_Examples of Intestinal Tolerance_.--There is the famous case of the French army officer who, from his earliest years, did not have regular movements of the bowels, but secured evacuations of them by artificial aid once every two months or more. He lived to the age of past fifty, and then died from an intercurrent disease not connected with his intestinal condition, having in the meantime enjoyed good health. He was able to accomplish his duties as an officer without any special allowances, and he was on the sick list much less than many brother officers whose intestinal condition left nothing to be desired. This remarkable man succeeded in doing his life work without his condition being known by others to any extent, and it was only inconvenience, and not serious illness, that he suffered from. After his death, it was found that certain folds of the lower bowel were so large as to meet across the lumen of the bowel, making shelves and pouches in which fecal material gathered, preventing the movement of all material above.

In the Orient, it is said that many people, especially of the better cla.s.s, do not expect to have movements of their bowels every day. Some of them, indeed, do not encourage intestinal evacuations oftener than once a week, sometimes even more seldom. As their diet is more largely vegetable than ours, this is all the more surprising. This custom does not contribute to their good odor, but this they compensate for by using various Eastern perfumes. The average length of life of such people is not much below the Occidentals and the difference is probably accounted for to a great extent by other unhygienic practices, rather than this failure to have regular movements of their bowels. In the meantime, they do not suffer any particular inconvenience, and live life quite as free from the ordinary pains and aches as do the people of the West. Of course, in such cases the custom has been established early, and nature has grown accustomed to it. Nature seems to be able to stand almost anything, if she can only survive it long enough to neutralize its effects by some of her marvelous means of compensation.

A case under my observation some years ago deeply impressed upon me how thoroughly the human system can learn to get along in spite of extremely unfavorable conditions in the matter of intestinal evacuation. The case was that of a young woman suffering from some internal trouble and there was {272} a possibility of the growth of a tumor. Some charitable people had been interested in her case, and the question had arisen whether the tumor might not be physiological. Her story was a very curious one. She and her sister worked in a mill.

They came from a family that had been reduced in circ.u.mstances, and were much more sensitive, as regards the decencies of life, than were their fellow workers. In order to get to the toilet, the working girls had to pa.s.s a window of an office where a number of men were at work.

The other girls did not seem to mind it, but these two girls were so sensitive that they preferred not to use the toilet room at the factory. They had to leave home shortly after six o'clock in the morning. They did not get home until nearly seven. For a time, they succeeded in accomplishing their intestinal functions during the hours of their stay at home. Gradually, however, this habit was broken, and at first they went two or three days without an evacuation, then four or five days, and finally a week. It then became their custom to take a large dose of epsom salts on Sat.u.r.day night and spend most of the day on Sunday getting rid of the acc.u.mulated excrement.i.tious material of the whole week.

They taught Sunday School in the afternoons, and as the elimination of the acc.u.mulation of week-long material interfered with this, they gradually acquired the habit of doing their Sunday School work on alternate Sundays, each taking the other Sunday for evacuation purposes. It might be expected that this serious abuse of function would soon lead delicate girls, compelled to work full eleven hours a day, into rapid serious breakdown. But it did not. This state of affairs continued for more than a year. Then finally one Sunday, the more delicate of the two girls found it impossible to open her bowels at the end of two weeks, and though she stayed at home the next Sunday found it likewise impossible. Had not the directress of the Sunday School, who had become interested in them, succeeded in gaining their confidence, it is possible that they would not have consulted physicians even for some time longer, though about three weeks had pa.s.sed without an evacuation.

Probably every physician in active practice has women patients who have been constipated for successive periods of three or four days at a time, for several months, without much disturbance of the general condition. While, then, there are many nervous persons who are quite sure that they begin to notice definite symptoms within a few hours from the failure to have a motion of the bowels at the time when they had been expecting it, it seems certain that this is generally rather the result of anxiety and nervous worry than consequent upon any actual absorption of toxic materials--intestinal auto-intoxication--as these patients, with a nave liking for nice long names, find such satisfaction in describing their condition. A simple explanation of the complete lack of inconvenience that is found in so many cases of constipation, will neutralize the unfavorable auto-suggestion that exists, and make these people much less likely to suffer.

_Individual Variation_.--Another suggestive item of information that should be given those who are over-sensitive and anxious in the matter, is that different individuals vary very much in the need for intestinal evacuation. Perfectly healthy people have lived long and happy lives, having an intestinal evacuation only once every two days.

Whether it may not in exceptional cases be rarer than this without serious injury, immediate or remote, {273} experience has not definitely settled. Many of these people with infrequent intestinal movements, have gone on utterly unconscious of the frequency or infrequency of the calls of nature, paying no attention at all to the matter until by some chance remark or a newspaper health item, it is brought forcibly to their notice. They have not had a symptom before of any kind, but now they begin to note all sorts of symptoms because they try to order their lives after the supposed rule that they have heard or read.

_Anatomical Peculiarities_.--On the other hand, some people normally have two evacuations a day, and seem to require them if they are to remain in the best physical condition. While daily evacuation is to be considered normal, individual departures from it in either direction must be respected as quite within the bounds of good health. Sometimes there are anatomical reasons, as the capacity of the large intestine.

Sometimes there are physiological factors, as the amount of food taken, or the fullness or rapidity of function in the digestive tract.

Amount of Food as a Causative Factor.--Frequency, or infrequency, of bowel movements seems to depend to a great degree on the amount eaten.

It is well known that two men of the same weight and doing the same work often seem to require quite different amounts of food to enable them to accomplish their tasks. This is what might be expected, since it holds true also for the consumption of fuel in heat machines.

Engines built in exactly the same way often require quite different amounts of fuel in order to release the same amount of energy. Where men are large eaters, the amount of excrement.i.tious material left will usually provoke, if not actually demand, more frequent evacuation than where the amount eaten is small. Variety of food also has an important bearing. Men who live largely on beef, milk, eggs and food materials that do not leave much residue, do not require, indeed they cannot have, frequent evacuations. Those who live almost exclusively on vegetables, with large amounts of residue, will require more frequent evacuation of the bowels. Certain other dietetic habits, as the amount of fluid taken with the meal, or whether food is eaten in the solid state or cooked into purees, stews and the like, make a decided difference, the reasons for which are obvious.

Habit in Treatment.--For the regulation of the bowels and the proper treatment of constipation in nearly all cases, more weight must be given to the directions laid down for the patient's att.i.tude of mind and habits of life than to drug treatment. The patient must be made to realize that the directions given to him are much more important for the effective relief of his condition, than is the medicine prescribed. As a rule, medicine is meant only to afford relief from immediate inconvenience, in the hope that after a short time new habits will be formed which will remove the habitual constipation by correcting certain hampering conditions that have unfortunately become established.

_Habitual Evacuations_.--By far the most important element in the treatment is to make the patient realize that habit plays the largest role in the regular evacuation of the bowels. A child, even under two years, can, by tempting it at certain times to evacuate its bowels, be gradually brought to establish a habit that will save much inconvenience for nurses and the family. This has actually been done for most human beings now alive, and this same thing can be done at all stages of life. If a particular time be chosen, and the {274} individual habitually goes to the toilet at that time, results may be confidently expected. It is rather important that the time chosen be one when there is not much hurry nor anxiety, and when it is reasonably certain that the same time can be taken every day. It is surprising how much so simple a bit of advice as this will do for many people who have considered that they have been suffering great discomfort from habitual constipation. Between the persuasion that an occasional failure to have a movement is not serious and the definite habit of journeying to the toilet room at a particular time, whether the desire is felt or not, many cases of habitual constipation will disappear with, perhaps, only the necessity for the administration of such drugs as will prove laxative to a slight degree during the first two or three weeks.

Ingestion of Fluids an Important Influence.--After the suggestion of a habit and its extremely efficient influence, the most important idea that a patient suffering from constipation must be made to grasp, is the necessity for fluids. That there shall be easy movement of excrement.i.tious material in the digestive tract, there must be fluid enough ingested to keep the residue, after digestion, thoroughly moist, so as not to allow it to become dry and compact. To secure this, a reasonable amount of liquids must be taken. So much has been said in recent years about the actual and possible harm of taking much fluid with meals, because of the danger of diluting the gastric juice, dilating the stomach and the like, that many persons who eat under the control of their reasons rather than their instincts, have very materially lessened the amount of liquids taken at meal time. This is undoubtedly one of the reasons why constipation has become more common in the last half century. In the olden time considerable quant.i.ties of fluid were taken at meals. With people in our time deliberately diminishing the quant.i.ty, there is often not enough fluid ingested to keep the human economy in proper working order. Prof. Hawk's work shows how utterly wrong was this limitation.

The ordinary excretion of water through the kidneys should be at least three pints, another pint is exhaled from the lungs--the quant.i.ty is even more than this in steam-heated houses where no provision for moistening inhaled air is made--and probably still another pint is needed for other purposes, perspiration, nasal and ocular secretion, and the like. Two quarts and a half to three quarts of liquid must be daily ingested then, and unless special care is taken to see that this amount is consumed the system may have to get on with much less, but as can readily be understood, not without difficulty. The ordinary gla.s.s of water does not contain half a pint; the ordinary tea cup probably holds not more than from four to six ounces. A gla.s.s of water and a cup of tea or coffee is about the limit of consumption of fluids at meals for ordinary people, and some take even less. Except in hot weather, comparatively few regularly take any fluids between meals. At the most, then, three or four pints of liquid is taken, instead of five or six, and the consequence is that the intestinal contents are deprived of their fluids by the call of the system for more liquids.

Peristalsis has, therefore, to overcome the sluggish movement of the excrement.i.tious material, which usually does not contain as much liquid as would make its movement easy and normal.

Residual Material.--The next most important consideration after the amount of fluid in the intestines, is the amount of the residuum which the lower bowel has to move. Evacuation of the intestines is to a great degree {275} a mechanical arrangement. When sufficient material is contained in the lower bowel, it pushes on ahead of it the matter that has been gathered there during the immediately preceding time, and so leads to an acc.u.mulation in the r.e.c.t.u.m that brings about reflex evacuation. It is only indigestible material that is thus excreted. If sufficient indigestible material is not taken with the food, there will not be sufficient residue left after digestion to call for the exercise of the evacuant function of the intestines, and the consequence will be sluggishness and failure to bring about daily movements. Originally nature provided food materials so arranged that the amount of indigestible material was sufficient for the exercise of peristaltic function; or rather perhaps, the regularity of peristaltic movement is of itself a development from the habits that were gradually formed in moving the residue that is normally left from food materials in the state in which they are produced by nature.

Food materials are no longer taken to any great extent in the form in which they are provided by nature. We have learned to eliminate the coa.r.s.er indigestible portions. Bread used to be made of the whole wheat, and of rather coa.r.s.e flour, leaving a large residue for peristalsis to exercise itself on. Now only fine white flour is used, leaving a minimum undigested. Vegetables used to be taken with much more waste material attached to them than is the case now. After being baked, potatoes were often eaten with the skins on, apples and other fruits were eaten unpared and many of the coa.r.s.er vegetables, turnips, carrots, beets, and greens of various kinds that leave large proportions of waste were much more commonly used. Movements of the bowels depend on this residue. If it is not present the bowel movements will not take place with the regularity observed when food with more residue is consumed.

Diet--Prof. Otto Cohnheim, in his lecture before The Harvey Society in New York, December, 1909, emphasized the necessity for a mixed diet.

The less vegetables are taken, the less cellulose remains undigested to stimulate peristalsis. Liquids find their way through the intestines by a system of percolation, and do not excite peristaltic movements. Meat, if well digested, is almost entirely dissolved in the stomach and becomes a fluid. Vegetables are pa.s.sed on to the intestines as a rather thick paste. Occasionally, in the midst of this paste there are portions of food of good size. Those excite peristalsis; hence the necessity for vegetables in the diet, if peristaltic movements and regular evacuations are to take place. This physiological law is poorly understood. Patients have heard so much about the indigestibility of starches, that whenever they have any uncomfortable feelings in their abdominal region, supposed to be due to indigestion, they commonly eliminate vegetables from their dietary with the consequence that their disturbed condition is likely to be emphasized rather than improved.

_Limitation of Diet_.--Just as soon as a patient's attention is attracted forcibly to any tendency to constipation, he is almost sure to conclude that this is a symptom of indigestion and he proceeds to put into practice all the rules which he has heard and read for the treatment of indigestion. The first of these is elimination from the diet of all indigestible food products, including most of the vegetables. The result is a vicious circle of cause and effect by which constipation is rendered worse than before. This needs {276} to be explained to intelligent patients in order to make them understand that some of the new habits which they have been forming and which they are p.r.o.ne to think highly hygienic, of cutting off all food containing indigestible material, are really important factors in the causation of further intestinal disturbance. It will often be found that the real reason for patients' inability to have daily evacuations of the bowels, is that they have become persuaded that various forms of food are either indigestible on general principles, or else are indigestible for them. For this reason they have eliminated from their diet most of nature's ordinary and quite natural provocations to intestinal evacuation, only to have to subst.i.tute artificial means to the same end in the form of the various laxatives.

It is important to talk this matter over with patients; otherwise the true cause of their constipation may be missed. For instance, from the very beginning of human life an excess of fat acts as a lubricant of the intestine, and as a material by means of which other and more concentrated objectionable matter that needs to be eliminated is carried out with as little friction as possible. Mother's milk contains from one-fourth to one-third more fat than the baby can use in its economy. This is meant to furnish a lubricant for the large intestine. It is a residue that will aid in securing movements of the bowels at regular intervals.

_Fats_.--Many people who come to their physicians complaining of habitual constipation have been told, or have read, that fat is rather indigestible, and, as a consequence, they have eliminated from their dietary all fatty materials. Even b.u.t.ter they use but sparingly, and they exchange the cream in their tea or coffee for plain milk; they carefully remove as much as possible of the fat of meat and they abstain from all sauces in which fat is employed. Such practices make normal, natural, regular evacuations of the bowels extremely difficult.

_Sugars_.--Another food material that is a valuable aid to nature for the stimulation of peristalsis is sugar. In its digestion, a certain amount of fermentation takes place, and the gas from this stimulates peristalsis. Of course, there may be excessive fermentation, and then harm rather than good, is done. Ordinarily a certain amount of sugar is demanded by nature and practically all the food materials, even the meats, contain it. All the starches from vegetables have, as the end products of their digestion, various forms of sugary material. These are just the cla.s.ses of foods that many nervous persons, suffering from constipation and anxious about their digestion, eliminate from their diet under the mistaken notion that they are indigestible, or are productive of undesirable fermentations. When they do so, it is not surprising that their constipation should be emphasized and that they should have to ingest other irritant materials, laxatives, to replace the sugars. It is probable that where constipation exists in the bottle-fed infant, the addition of a little brown sugar to the water with which the milk is diluted, is the safest and most natural way of correcting the sluggishness of the intestines.

_Supposed Idiosyncrasies_.--The physician will in many cases meet with the objection that some of these materials that he is recommending disagree with his patient. Most of the presumed idiosyncrasies in the matter of food are founded on extremely insufficient evidence.

Not infrequently young persons who are thin and inclined to be {277} constipated, and who need to take fats plentifully, do not care at all for b.u.t.ter. Sometimes this is founded on nothing more than the fact that at some time or other the b.u.t.ter provided for them was rather poor, and they got out of the habit of eating it. Now they a.s.sume that their disinclination is physiological. In this regard, as with milk, a little careful persistence will usually convince the person that there is no natural obstacle and no good reason why they should not partake, in moderate quant.i.ties at least, of this extremely valuable article of food.

Often the supposed idiosyncrasy against a food is due to no better reason than that on a single occasion it disagreed, owing to its preparation, the circ.u.mstances under which it was eaten, or the materials with which it was a.s.sociated. An aversion, for instance, to so nutritious and so valuable a food-stuff as hog-meat will be acquired for no better reason than that fried ham or bacon disagreed with the patient on one or more occasions. Such people when told that ham, boiled so thoroughly that it crumbles in the fingers, is a favorite mode of giving meat to convalescents in European hospitals and that it agrees very well with them, will often be tempted to try it. Then they find they have been harboring an illusion as to their supposed idiosyncrasy for hog-meat. Nearly the same thing is true of bacon. A trial or two of crisp bacon, with the fat so thoroughly cooked out of it that it may be eaten out of the fingers without soiling them, will often convince those who doubt of their ability to eat it, how tasty a nutriment it is. Bacon is one of the most precious dietetic adjuvants in the treatment of constipation.

Exercise.--There is always a serious difficulty in the treatment of constipation in stout people. To counsel fats and starches and liquids in the quant.i.ties necessary to bring about regular natural movements of the bowels, through the mechanical presence of a sufficient amount of residue, will often add greatly to their weight. For them, exercises are needed. Not exercise in general, for many a man who takes abundant exercise may be constipated. I have patients with this complaint who are letter carriers, expressmen, even stevedores, and the like. The mere absence of a sedentary occupation will not guarantee against constipation. Motormen and conductors not infrequently suffer from it. What is needed particularly is exercise directed to the strengthening of the abdominal muscles, and the increase of peristalsis.

For this certain leg exercises that can be readily and easily done in less than five minutes each day will be found useful. A patient may be directed to lie on his back, lift up the leg as high as possible in the extended position, and do that with each leg an increasing number of times every day. At the end of a month he is able to lift each leg up forty or fifty times at each trial. This exercise twice a day, morning and evening, just before and after sleep, will usually relieve the constipation. The bringing up of the thigh on the abdomen as far as possible, not only acts as a sort of ma.s.sage upon the abdomen itself, but the bellying of the large muscles within the pelvic and abdominal regions mechanically helps the movement of the intestinal contents. If, in addition to this, the patient gradually accustoms himself to rise to a sitting from a lying position, the constipation will almost invariably yield. In stout people, the presence of fat in the abdominal wall seems to weaken the muscles so that the intestines are not compressed as they should be in ordinary conditions, and peristalsis seems to be thus interfered with.

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A heavy wooden (bowling) ball rolled on the surface of the abdomen, beginning low down in the right lower quadrant up towards the liver, across just above the umbilicus, and then down on the left is often advised. It is a good remedy but not better than the simple exercises of the leg and abdominal muscles suggested. The use of the ball has the advantage of novelty, and of distinctly adding to the suggestive value of the exercise treatment. It is particularly valuable for women. All of these exercises have a distinct value from their suggestive side. If thus twice a day for three minutes people are made to recall while doing the exercises the necessity for taking an abundance of fluid, forming a habit with regard to movements of the bowels and eating so as to encourage peristalsis, a definite good effect will be produced. In the treatment of stout people particularly, it is important to remember that the use of sufficient salt, and then of certain of the natural salts, as Carlsbad or Hunyadi Janos, may be of distinct advantage for their obesity. If taken regularly in small amounts, that is, just enough to help to a movement of the bowels, and if varied from time to time and occasionally interrupted while some other form of laxative is taken, much good may be done. It is as well to take simple irritants of this kind as some of the irritant foods that will have a tendency to add to their acc.u.mulation of fat, though they may increase peristalsis.

Influence of Position.--Little things may mean much in the matter of the regular movements of the bowels. In my student days in France, our little hotel in the Quartier had the old-fashioned water-closets consisting of a hole in the floor in one corner, and a place to put one's feet properly beside it, thus reverting to the old-fashioned natural method of bowel evacuation. Some of the American students found it an uncomfortable proceeding at the beginning, but, on the other hand, some of them who had suffered from constipation in America were no longer troubled that way. I have found in quite a few cases of younger men that the suggestion to revert to this natural mode of evacuation helped in the formation of the habit of having bowel movements at a regular time. How much of the effect was physical and how much was mental seemed hard to decide. The suggestion was particularly valuable in my experience with patients of the better educated cla.s.ses.

CHAPTER VI

NEUROTIC INTESTINAL AFFECTIONS

There is a whole series of intestinal affections dependent on nerve influence that get worse and better under stress of emotion or relief from it. Probably the commonest of these is constipation, which is dealt with in a separate chapter. Often these nervous intestinal conditions are a.s.sociated with other neurotic manifestations. On the other hand, patients are seen who are absolutely without any other sign of the neurotic habit, and have nothing like hysteria, yet who suffer severely and rather frequently from intestinal neuroses. Most of the people who react symptomatically to the eating of strawberries, or of sh.e.l.lfish, or of pork in any form, or cheese or other milk products, also have a definite tendency to certain skin neuroses and to suffer from intestinal troubles as a consequence of emotional states. It is hard to trace {279} real causation in many of these cases, because it is so easy to accept the patient's expressions that they must have taken cold, or they must have eaten something that disagreed with them.

Neurotic Diarrhea.--But it must not be forgotten that nervousness alone, without any additional factor, may produce a disturbance of the functions of the intestines, and may even increase peristalsis and bring about severe diarrhea. Anyone who has observed students going to examinations has surely seen many examples of this. There are some individuals--fortunately they are rather rare--who always suffer from diarrhea when they have to take a serious examination. Some of these cases are pitiable because the effects are quite beyond control, and make it almost impossible for them to do justice to themselves.

_Fright and Loss of Bowel Control_.--Severe disturbance, such as fright, may bring on this paralysis of proper regulation of peristalsis, with consequent imperative intestinal evacuation. A cla.s.sical case in history is that of James II, for whom the Irish soldiers invented a special name because of the tradition that he suffered from an intestinal accident in one of the battles with William of Orange. The imputation of cowardice on the last of the unfortunate Stuarts has been completely wiped out by the investigation of recent historians, and James' character for bravery has been thoroughly vindicated. The fact that the story should have gained credence shows that there is a general persuasion and popular tradition that such intestinal incidents do occur from fright. An incident told of the Franco-German War ill.u.s.trates this, though I do not vouch for the facts. Wishing to test the bravery of some soldiers whom he was to send on a very dangerous expedition, and above all to try how they would bear up even before the threat of instant death, an officer of the French troops is said to have asked that half a dozen brave men be sent to him. Without a word, he announced that there had been treason in the ranks, and that the army needed an example. They were condemned to be shot. A platoon of soldiers was drawn up, the men were placed with their backs to a wall and they were asked whether they wished to be blindfolded. They refused though they protested that they did not know why they were being put to death. Then the word fire was given. All of the men, excepting one, fell down, though the guns of the firing party had been loaded with blank cartridges. The one who remained standing was told that he was the man who would be selected to go on the expedition, which, though perilous, was also of great glory for himself and profit for his country. He said that he was ready to go, but he asked permission to be allowed to change his clothing, as he had not been able to keep as good control over his intestinal muscles, as he had over his muscles of station.

Fright often has this effect in children. These stories and traditions ill.u.s.trate the influence of the mind and of deep emotions over the intestines, and while only profound mental disturbance will produce the most serious effects, there seems no doubt that lesser emotions do interfere with normal function. This phase of the subject serves to strengthen the contention that over-attention to the bowels may bring about constipation by causing increased inhibition of peristalsis, just as severe emotional disturbance may paralyze inhibition and so bring about increased peristalsis with consequent diarrheal symptoms.

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Habitual Diarrhea.--There are certain forms of chronic diarrhea, usually considered most intractable, that owe their origin and continuance to neurotic conditions of the intestine, rather than to any gross organic lesion. In these cases the bowels acquire the habit of emptying themselves two or three or more times a day, and the stools are seldom formed. All sorts of physical treatment are employed for these conditions, usually without avail, but whenever the patient's mind can be set at rest, and his attention distracted from his bowels by thorough occupation with some interesting work, the intestinal disturbance gradually becomes less annoying. Ordinarily, when stools have been frequent for a prolonged period, the case is considered more or less unamenable to treatment. So far as ordinary drug remedies go, this is true. What is needed is attention to the patient's mind, to his habits of life, and to his worries, and the way that he takes them. The ill.u.s.trations given of the influence of the mind over the bowels should make it clear that this therapeutic principle can be of far-reaching significance and must be applied deliberately and with confidence in the results.

_Worry as a Factor_.--Very often it will be found that the diarrhea is particularly bothersome on days when the patient is worried. In a clergyman friend and patient who was building a church, the approach of days on which bills and notes became due, was always the signal for a diminished control over his bowels, and there were frequently three or four stools in the day. On his vacations, when eating unusual things, drinking unaccustomed water, exposed to changes of temperature, all the factors that give many people diarrhea, he was perfectly regular because the worries had been lifted from his mind.

In another case, where for fifteen or twenty years a writer living much indoors had had tendencies to diarrhea, always made worse by worries, self-discipline and the refusal to let troubles occupy him by always turning to something else, did him so much good that he considered himself cured. In his case the return of a ma.n.u.script from a magazine would always affect his bowels unfavorably. If, as sometimes happened, he found that the ma.n.u.script had been returned only for some corrections, there would be an immediate relief of his condition.