49 Legros and Onimus, Journal de l'Anat. et de la Phys., t. vi. pp. 37 et 163. Ringer says one grain of ipecacuanha taken while fasting each morning will relieve constipation from torpor (Therapeutics, New York, 1882, p. 438).
These remedies are slow-acting, and in the mean while the bowels must be moved artificially, methodically, and taught to act at stated hours. For this purpose a small enema of cool or cold water at the same hour every day after breakfast does well. It is irrational to distend the bowel, already weakened by distension, with large enemata of warm water. Recourse should not be had to this until all hopes of effecting a cure are gone, or only as an occasional remedy in impacted accumulations where the mass must be softened before it can be removed. If the enema does not in time empty the colon sufficiently, laxatives will have to be taken with some regularity until the habit is created. A tumblerful of water with or without a teaspoonful of salt, or a tumblerful of any alkaline water charged with carbonic acid, taken on rising in the morning, may prove effective. A tablespoonful of sweet oil at night acts well as a lubricator and softens the feces. If these more simple means fail, it becomes unfortunately necessary to give a purgative drug: any one of this class can be combined with strychnia, belladonna, vegetable tonics, and iron. Those to be preferred are aloes, colocynth,50 and podophyllin. The compound podophyllin pill or a pill of one-sixth of a grain of belladonna and podophyllin at night or three times daily, the pill of aloes and myrrh, or the Lady Webster pill, are well-approved forms of administration. A compound rhubarb pill acts well if taken after dinner.
50 A few drops of the Prussian tincture of colocynth several times daily is advised by Ringer (Therapeutics, New York, 1882, p. 642).
If one desires to select a purgative which will probably increase the outflow of bile, selection can be made from the following drugs: podophyllin, aloes, rhubarb, colchicum, euonymin, colocynth, calomel, jalap, sodium sulphate, potassium sulphate, cream of tartar; and among the rarer alkaloids iridin, sanguinarin, physostigma, and juglandin. These, according to Rutherford, Vignal, and Dodds, increase the secretion of bile in fasting animals. Ox-gall and pig-gall are laxatives only; they have no effect on the liver, but can be added to other purgatives in pill forms.
Salines largely diluted may be given to strong adults: Epsom or Rochelle salts quite early in the morning, a solution of sulphate of magnesia with dilute sulphuric acid, to which dried sulphate of iron may be added, are quite popular; and of the bitter waters, Hunyadi Jânos, Friedrichshall, or Pullna water serves the purpose. One grain of sulphate of quinia added to a saline will increase its effect. The milder laxative waters are to be preferred to the bitter waters. The Saratoga waters, Congress, Geyser, Hathorn, answer the purpose taken early in the morning, or among the European springs those of Kissengen, Plombières, Marienbad, Homburg, Seltzer, or Leamington in England, are not too active in their effects. In atonic constipation, the form now under consideration, the laxative chalybeate waters are indicated where there is anæmia or debility. These are represented by the Columbian, Pavilion, Eureka, and Excelsior Rock among the Saratoga waters, and by the Bedford Springs water.
It is well to administer a number of drugs in rotation in habitual constipation, as the susceptibility to a particular drug is lost after continued use. Increase of the dose is the usual method to offset this result, but it is irrational to meet exhaustion by over-stimulation. Rest of the part stimulated by using a remedy which brings about the result in a different way is the wiser course. The dose should be gradually reduced, tempting the bowel to act more and more without aid. Among the laxatives which can be borne in mind in alternating treatment the following list includes some which can be used with advantage: the fluid extracts of rhamnus (buckthorn) and cascara sagrada; alum, which is called for in certain forms of atony; sulphur in the form of confection or sulphur with guaiacum51 (half a drachm of each in powder at night); the wine of colchicum (five drops or more three times daily), advantageously used in gouty or rheumatic persons; the infusion or tincture of euonymus; the tincture of benzoin; senna in fluid extract and in the compound powder of liquorice.
51 Fuller, Lancet, London, April 23, 1864, p. 459.
Infants and children should be cured of constipation without purgatives if possible. Attention to the diet of the infant, and close inspection of the stools to see the effect of the food given, will guide to a proper system of feeding. Breast-milk is the best remedy; next, a food which most nearly resembles mother's milk—cow's milk properly diluted with barley-water, oatmeal-water, or rice-water—stands first. Condensed milk, given in barley- or oatmeal-water, is a second and excellent substitute in cities. Antacids prevent a too rapid coagulation of the casein and the formation of curdy lumps. Lime-water with milk or bicarbonate of potassium or of sodium may be administered with the food or before it. The quantity of food must be lessened until the child can digest all it takes.
The infant should be taught to empty the bowel at the same hour daily by always placing it at this hour in a position favorable to and suggestive of defecation. Dilating the sphincter at the same time with the soap suppository or the small end of a Davidson's syringe, or just touching the margins of the anus, will excite the necessary reflex movement. If defecation is painful, examine the inner edge of the anus for small cracks or for eczema ani.52 Over-stretching the sphincter with the finger in cases of rigid or spasmodic contractions will sometimes produce permanent relief.
52 Betz, "Eczematous Proctitis," Memorabilien, iv., Dec. 28, 1859, S. 190.