THE BUGABOO OF CONSTIPATION
Popular Superst.i.tions
In line with the taboos connected with the taking of food are the ceremonials attendant upon its elimination. Taking anxious thought about functions well established by nature is a feature of conversion-hysteria, the displacement of emotional desire from its psychic realm into symbolic physical expression. Whatever other symptoms nervous people may manifest, they are almost sure to be troubled with chronic constipation. It is true that there are many constipated people who do not seem to be nervous and who resent being cla.s.sed among the neurotics. Everybody knows that the occasional individual who has difficulty in swallowing his food is nervous and that the, trouble lies not in the muscles of his throat but in the ideas of his mind. But very few people seem to realize that the more common individual who makes hard work of that other simple process-elimination of his intestinal waste matter-is suffering from the same kind of disturbance and giving way to a nervous trick. When all the facts are in, the constipated person will have hard work to clear himself of at least one count on the charge of nerves.
An Oft-told Tale. Sooner or later, then, the neurotic, whether he calls himself a neurotic or not, is very likely to begin worrying over his diet or his sedentary occupation. He imagines himself the victim of autointoxication, afflicted with paralysis of the colon or dearth of intestinal secretions. He leaves off eating white bread, berries, cheese, chocolate, and many another innocent food, and insists on a diet of bran-biscuit, flaxseed breakfast-foods, prunes, spinach, cream, and olive-oil with doses of mineral oil between meals. In all probability, he begins a course of ma.s.sage or he starts to take extra long walks and to exercise night and morning, pulling his knees up to his chin and touching his fingers to his toes. When all these measures fail, he gives in to the morning enema or the nightly pill, in imminent danger of succ.u.mbing to a life-long habit.
The Truth About Constipation
What the Colon Is For. It is well, then to have a fair understanding of the structure and purpose of our intestinal machinery. Contrary to general opinion, the intestines are not a dumping-ground but a digestive organ. After the food is partly digested in the stomach, it pa.s.ses through a twenty-two foot tube (the small intestine) into a five-foot tube (the large intestine or colon) where digestion is completed, the nutriment is absorbed, and the waste matter is pa.s.sed on and out through the r.e.c.t.u.m. As the food pa.s.ses along the colon, pushed slowly ahead by the peristaltic wave, or rhythmic muscular contractions of the intestinal wall, it is seized upon by the four hundred varieties of friendly bacteria which inhabit the intestines of every healthy person, and is changed into a form which the body can a.s.similate. Digestion in the stomach and small intestine is carried on by means of certain digestive juices, but in the large intestine it is the bacteria which do the work. Without them we could not live.
Around the colon is a thick network of little blood vessels, all of which lead straight to the liver, the storehouse of the body. After the food is fully digested, it is pa.s.sed through the thin intestinal wall into these tiny vessels and carried away to liver and muscles for storage or for immediate use.
This process of absorption is carried on throughout the whole length of the colon. Not until the very end of the intestine is reached is all the nutrition abstracted. The bowel-content can properly be called waste matter only after it has reached the r.e.c.t.u.m or pouch at the lower end of the colon. Even then, this waste matter is not poison, but merely indigestible material which the body cannot handle.
Food, not Poison. The colon is not a cesspool but a digestive and a.s.similating organ. Its content is not poison but food. Active elimination is important not so much because delay causes autointoxication or poisoning as because too large a ma.s.s is hard to manage and irritates the intestinal wall. The problem is not so much one of toxicology as of simple mechanics. If Nature had put within the body five feet of tubing which could easily become a cesspool and a breeder of poison, it is not at all likely that she would have laid alongside an elaborate system of blood vessels leading not out to the kidneys but into the storehouse of the liver; and if civilized man"s changed manner of living had so upset Nature"s plans as easily to transform his internal machinery into a chronic source of danger, we may be sure that he would long ago have gone the way of the unfit and succ.u.mbed to his own poisons.
Possible Invasions. It is true that the intestinal tract, like the rest of the body, is open to attack by harmful bacteria. But in a great majority of cases, these enemy bacteria are either quickly destroyed by the beneficent microbes within or are immediately cast out as unfit. Any germs irritating to the intestinal wall cause the mucous membrane to produce an unusual flow of mucus which washes away the offending bacteria in what we call a diarrhea. [52]
[52] If the invading army proves obstinate and the diarrhea continues a day or so, it is wise to a.s.sist Nature by a dose of castor-oil, which gives an additional insult to the intestinal wall, spurs it on to a desperate effort, and hastens the cleansing process. In severe cases the more promptly the castor-oil is administered the better. Such emergency measures are very different from the habitual use of insulting drugs.
Sometimes the wrong kind of bacteria do persist, causing anemia, rheumatism, sciatica, or neuritis. When these disorders are not the result of infection from teeth, tonsils, or other sources of poison, but are really caused by intestinal bacteria, I have found that a diet of b.u.t.termilk (lactic acid bacteria), with turnip-tops or spinach to supply the necessary mineral salts, often succeeds in planting the right bacteria and driving out the disturbing ones. These disorders are invasions from without, like tuberculosis or malaria, and are as likely to attack the person with easy bowel movements as the one with the most chronic constipation.
Autointoxication. A good deal of the talk about autointoxication is just talk. It sounds well and affords an easy explanation for all sorts of ills, but in a large majority of cases the diagnosis can hardly be substantiated. Uninformed writers of newspaper articles on the care of the body, or purveyors of purgatives or apparatus for internal baths are fond of dilating on the "foulness of the colon" as a leading cause of disease. As a rule, they advise either a strict diet, some kind of cathartic, or an elaborate process of washing out the colon to clear the body of its terrible acc.u.mulation of poisons.
Cathartics and Enemas. He who makes a practice of flushing out his intestinal tract with high enemas and internal baths is like a person who eats a good dinner and then proceeds to wash out his stomach. In the mistaken idea that he is making himself clean, he is washing what was never intended to be washed and robbing the body of the nutrition which it needs. And the man who persists in the pill habit is making a worse mistake, adding insult to injury and forcing the mucous membrane to toughen itself against such malicious attacks.
Cathartics and Operations. Even in emergencies, the use of purgatives as a routine measure is happily decreasing year by year. For many years I have deplored the use of purgatives before and after operations. That other pract.i.tioners are coming to the same conclusion is witnessed by a number of papers recently read in medical societies condemning purgation at the time of operation.
Among the most favorably received papers of the California Medical Societies have been one by Emmet L. Rixford, surgeon of the Stanford University Medical College, read before the Southern California Medical Society at Los Angeles December 8, 1916, and one by W.D. Alvarez at the California Medical Society, Del Monte, 1918,-both condemning the use of purgatives as a routine measure before operations. An article ent.i.tled the "Use and Abuse of Cathartics" in the "Journal of the American Medical a.s.sociation" admirably summarizes the disadvantages of purgation at such a time. [53]
[53] "1 Danger of dissemination of infection throughout the peritoneal cavity, in case localized infection exists.
"2 Increased absorption of toxins and greater bacterial activity by reason of the fact that undigested food has been carried down into the colon to serve as pabulum for bacteria, and that liquid feces form a better culture medium than solid feces.
"3 Increased distention of the intestine with gas and fluid, when it should be empty....
"4 Psychic and physical weakness produced by dehydration of the body, disturbance in the salt balance of the system, and the loss of sleep occasioned by the frequent purging during the night preceding the operation. As Oliver Wendell Holmes says: "If it were known that a prize fighter were to have a drastic purgative administered two or three days before a contest, no one will question that it would affect the betting on his side unfavorably. If this be true for a powerful man in perfect health, how much more true must it be of the sick man battling for life."
"5 Increase in postoperative distress and danger: thirst, gas pains, and even ileus...."-Journal of American Medical a.s.sociation, Vol. 73, No. 17, p. 1285, Oct. 25. 1919.
Four years ago I was called to a near-by city to see a former patient who two days before had had a minor operation,-removal of a cyst of the breast. She was dazed, almost in a state of surgical shock and very near collapse. I found that she had been put through the usual course of purgation before operation and starvation afterward, and I diagnosed her condition as a state bordering on acidosis, or lowering of the alkaline salts of the body. I ordered food at once. She rallied and recovered.
A few months later this same woman had to undergo a much more serious operation for multiple fibroids of the uterus and removal of the appendix. This time I advised the surgeon against the use of any purgative, and he took my remarks so seriously that he did not even allow an enema to be given. This time the patient showed no signs of exhaustion and had very few gas pains. I firmly believe that the day will soon come when a patient under operation, or a patient after childbirth, will no longer be depleted by a weakening and dehydrating cathartic and by a period of starvation, at a time when he needs all the energy he can summon.
Cathartics and Childbirth. The article referred to in the "Journal of the American Medical a.s.sociation" cites the experiences of Dr. R. McPherson of the Lying-in Hospital of New York, "who showed that the routine purgation after confinement is not only useless but harmful. Of 322 women who were not purged, only three had fever (and one of them a mammary abscess); most of them had normal bowel movements and those who did not were given an enema every third day. Of 322 women who were delivered by the same technique and the same operators but were purged in the usual routine manner, twenty-eight had some fever." This experience of one physician is corroborated by that of others who find that the more we tamper with the natural functions in time of stress the harder do we make the recuperative process. There are certainly times when catharsis is necessary but "one thing is certain, the day for routine purgation is past." [54] Even in emergencies we need to know why we administer cathartics and in chronic cases we may be sure that they are always a mistake.
[54] Ibid, p. 1286.
"An Old Trick." Before we make a practice of interfering with Nature"s processes, it is well to remember how old and stable those processes are. As long as there has been the taking in of food, there has been also the casting out of waste matter. The sea-anemone closes in on the little mollusk that floats against its waving petals, a.s.similates what it can and rejects the rest. In the long line from sea-anemone to man, this automatic process of elimination has gone on without a hitch, adapting itself with perfect success to the changing habits of the varying types of life. So old a process is not easily upset. And, be it noted, in the human body this automatic, involuntary process still goes on with very little trouble until it reaches a point in the body where man, the thinking animal, tries to control it by conscious thought.
A Question of Evacuation. Much of the misconception about constipation arises from the mistaken idea that this is a disorder of the whole intestine or at least of the whole colon. As a matter of fact, the trouble is almost wholly in the r.e.c.t.u.m. There is no trouble with the general traffic movement, but only with the unloading at the terminus. In my experience, the patient reports that he feels the fecal ma.s.s in the lower part of the r.e.c.t.u.m, but that he is unable to expel it. Examination by finger or by X-ray reveals a ma.s.s in the rectal pouch. If there is a piling up of freight further back on the line, it is only because the unloading process has been delayed at the terminus.
So long as the bowel-content is in the region of automatic control, there is very little likelihood of trouble. An occasional case of organic trouble-appendicitis, lead-colic, mechanical obstruction, new growths or spinal-cord disease-may cause a real blockade, but in ninety-nine cases out of every hundred there is little trouble so long as the involuntary muscles, working automatically under the direction of the subconscious mind, are in control. By slow or rapid stages, on time or behind time, the bowel-content reaches the upper part of the r.e.c.t.u.m and pa.s.ses through a little valve into the lower pouch. Here is where the trouble begins.
Meddlesome Interference. In the natural state the little human, like the other animals, empties his bowel whenever the fecal ma.s.s enters the lower portion of the r.e.c.t.u.m. The presence of the ma.s.s in the r.e.c.t.u.m const.i.tutes a call to stool which is responded to as unthinkingly as is the desire for air in the taking of a breath. But the tiny child soon has to learn to control some of his natural functions. At the lower end of the r.e.c.t.u.m there is a purse-string muscle called the Sphincter-ani, an involuntary muscle which may with training be brought partly under voluntary control. Under the demands of civilization, the baby learns to tighten up this muscle until the proper time for evacuation. Then, if he be normal, he lets go, the muscles higher up contract and the bowel empties itself automatically, as it always did before civilization began.
There is, however, a possibility of trouble whenever the conscious mind tries to a.s.sume control of functions which are meant to be automatic. Under certain conditions necessary control becomes meddlesome interference. If the child for one reason or another takes too much interest in the function of elimination; if he likes too much the sense-gratification from stimulation of the rectal nerves and learns to increase this gratification by holding back the fecal ma.s.s; if he gets the idea that the function is "not nice" and takes the interest that one naturally feels in subjects that are taboo; or if he catches from his elders the suggestion that the bowel movement is a highly important process and that something disastrous is likely to happen unless it is successfully performed every day; then his very interest in the matter tends to interfere with automatic regulation, and to cause trouble.
Just as people often find it hard to let go the bladder muscle and urinate when in a hurry or under observation, and just as an apprehensive woman in childbirth tightens up the purse-string muscle of the womb, so the little child, or the grown up who catches the suggestion of difficulty in the bowel movement, loses the trick of letting go. Instead of merely exercising control by temporarily inhibiting the function, he tries to carry through the process itself by voluntary control-and fails. Constipation is a perfect example of the power of suggestion, and of the troublesome effect of a fear-idea in the realm of automatic functions.
Food and Constipation
Since the waste matter from all foods finally reaches the r.e.c.t.u.m, and since constipation is merely a difficulty in the forces of expulsion, it is hard to see how any normal food in the quant.i.ties usually eaten could have the slightest effect on the problem. When we remember that it takes food from twelve to twenty-four hours to reach the r.e.c.t.u.m, and that it has during all that time been subjected to the action of the powerful chemicals of the digestive tract, it is hard to imagine a piece of cheese, of whatever variety, strong enough to stop the contraction of the muscles of the upper r.e.c.t.u.m or to tie the sphincter-muscle into a knot. It would be difficult to find a food which could pa.s.s without effect through twenty-seven feet of intestinal tubing only to become suddenly effective on the wall of the r.e.c.t.u.m. If the wrong kind of food is the cause of constipation, why does the r.e.c.t.u.m prove to be the most refractory portion of the tube? On what principle could a piece of chocolate inhibit the call to stool or contract the sphincter muscle? On the other hand, even if it should be conceded that constipation were the result of lack of lubricating secretions in the colon, how could two tablespoonfuls of mineral oil be a sufficient lubricant after being mixed with liquid and solid food through many feet of the intestinal tract?
An Adaptable Apparatus. The lining of the intestines has plenty of secretions to take care of its function. It is as well adapted to the vicissitudes of life as are the other parts of the body. The muscular coat is no more liable to paralysis or spasm than are the voluntary muscles. As the skin adapts itself to all waters and all weathers, and as the lungs adjust themselves to varying air-pressures, so the intestinal wall makes ready adaptation to any common-sense demands, adjusting itself with ease to an athletic or a sedentary life, and to the normal variations of diet. What man has eaten throughout the centuries man may eat to-day. If you will but believe it, your intestines will make no more objection to white bread, blackberries, and cheese, along with all other ordinary articles of food, than the skin makes to varying kinds of water. Naturally, the suggested idea that a food will constipate tends to carry itself out to fulfilment and to prevent the call to stool from rising to the level of consciousness; but the real force lies not in the food but in the suggestion.
The Bran Fad. It is when we try to improve on the normal human diet that we really insult the body. He who leaves off eating nourishing white bread and takes to bran m.u.f.fins is simply cheating his body. Bran has a small food value, but the human body is not made to extract it. Not only does bran fail to give us any nourishment itself, but it lessens the power of the intestines to care for other food. [55] The fad for bran is based on the well-known fact that we need a certain quant.i.ty of bulk in order to stimulate the intestinal wall to normal peristalsis. We do need bulk, but not more than we naturally get from a normal and varied diet including a reasonable amount of fruit and vegetables.
[55] See an article ent.i.tled "Bread and Bran," Journal of American Medical a.s.sociation, July 5, 1919, p. 36.
It is true that the suggestion of the efficacy of bran, dates, spinach, or any other food is frequently quite sufficient to give relief, temporarily, just as ma.s.sage, manipulation of the vertebrae, the surgeon"s knife, or mineral oil may be enough to carry the conviction of power to a suggestible individual. But who wants to take his suggestions in such inconvenient forms as these?
Change of Water. Another popular superst.i.tion centers around drinking-waters. There are people who cannot move from one town to another, much less take an extensive trip, without a fit of constipation-or a box of pills. If they only knew it, there is no water on earth which could make a person constipated. A new water, full of unusual minerals, might hasten the bowel movement, but on what possible principle could it r.e.t.a.r.d it? Constipation has nothing to do with food or with water, but solicitous care about either can hardly fail to create the trouble which it tries to avoid.
The Cure
Taking off the Brakes. Since constipation is wholly due to the acceptance of a false suggestion, the only logical cure must be release from the power of that suggestion. "He is able as soon as he thinks he is able"; not that thought gives the power, but that the right thought releases the inhibition of the mistaken thought. As soon as the brakes are taken off, the internal machinery is quite able to make the wheels go round. The bowel will empty itself if we let it. The function of elimination is not a new trick learned with difficulty by the aged, but a trick as old and as elemental as life itself. Like balancing on a bicycle, it may not be done by any voluntary muscular effort, but it just does itself when one learns how.
Once the sense of power comes, once the mind forgets to be doubtful or afraid, then the old automatic habit invariably rea.s.serts itself. Meddlesome interference may throw the mechanism out of gear, but fortunately it cannot strip the gears. Constipation is an inhibition or restraint of function, but is never a loss of function. No one is too old, no one is too fixed in the bad habit to relearn the old trick. I have had a good many patients with chronic constipation, but I have never had one who failed to learn. Real conviction speedily brings success, and in many cases success seems to outrun conviction. So efficient is Nature if she has only half a chance!
Some People Who Learned. Unless you are over ninety-two, do not despair. One old lady of that age, a sort of patient by proxy, was able to cure herself without even one consultation. Her daughter had been a patient of mine and had been cured of the constipation with which she had been busy for many years. The mother, who believed her own bowel paralyzed, had been in the habit of lying on the bed and taking a copious enema every second day of her life. When, however, she heard of her daughter"s cure, the bright old woman gave up her enemas and let her bowels do their own functioning. She stayed cured until her death at ninety-five.
A Fifty-year Habit. Another old lady was not quite so easily convinced. She ridiculed the idea that her son of fifty, who had been "constipated in his cradle" could be cured of his lifelong habit, but he was cured. As long as there is life and the light of reason, so long may Nature"s functions be reestablished.
The Whole Family. Nor is any one too young to learn. A tiny baby is easily taught. There came to me for two consultations a mother and her two babies, all three constipated. The four-year-old child, mentally deficient, had been fed on milk of magnesia from his infancy, and the four-months-old baby had been started on the same path. I explained to the mother the mechanism of elimination, told her to give up cathartics, and to set a regular time for herself and the baby, but was a little dubious about the mentally deficient four-year-old. However she soon reported that they had all three promptly acquired the new habit. Four years later she told me that they had never had any more trouble.
A Record History. When Miss H. first came to my house, she told a story that was almost incredible. She said that for many months she had been taking eight tablespoonfuls of mineral oil three times a day besides a cathartic at night, and an enema in the morning. No wonder she was a little dubious over such mild treatment as mine seemed to be!
Constipation was only one of this young woman"s troubles. She could not sleep and was so fatigued that she believed herself at the end of her physical capital. When she first came to me she had tears in her eyes most of the time and used to confide to various people that she was sure she was a patient that I could not cure,-a very common belief among nervous invalids! She was sure that I did not understand her case, and that she could not get anything out of this kind of treatment.
It was only a very short time, however, before her bowels were functioning like those of a normal person. She lost her insomnia and her fatigue and went away as well as ever. When she got back to her office, she found that her old position, which she had believed secure to her, had been given to another. She had to go out and hunt a new job and face conditions harder than she had had before, but she came through with flying colors. A short time ago Miss H. came back to see me,-a happy, robust young woman, very different from the person I had first known. She a.s.sured me that she had never had any return of her old symptoms and that she was as well as a person could be.
Living up to a Suggestion. Mrs. T. had not had a natural movement of the bowels in twenty-five years. After the birth of a child, twenty-five years before, her physician had told her that her muscles had been so badly torn in labor that they could not carry through a natural movement. After that she had never gone a day without a pill or an enema. I explained to her that when any muscle of the r.e.c.t.u.m is injured in childbirth, it is the sphincter-ani, and that since this is the muscle whose contraction holds back the bowel content, its injury would tend to over-free evacuation rather than to constipation. She saw the point and within two or three days regained her old power of spontaneous evacuation.
Practical Steps. The first step, then, in acquiring normal habits is the conviction of the integrity of our physical machines and a determination not to interfere by thought, or by physical meddling, with the elemental functions of our bodies. After this all-important step, there are a few practical suggestions which it is well to follow. Most of them are nothing more than the common-sense habits of personal hygiene which are so obvious as to be almost axiomatic, but which are nevertheless often neglected:
1 Eat three square meals a day.