Functional Constipation. By W. BLAIR STEWART, A. M., H. I)., Byrn Mawr, Pa. Reprint from New England Medical Monthly for April, FUNCTIONAL CONSTIPATION. BY W. BLAIR STEWART, A. M., M. D., BRYN MAWR, PA. Instructor in Therapeutics; Late Instructor in Practice of Medicine in the Medico-Chirurgical College. REPRINT FROM THE New England Medical Monthly For April, 1894. Danbury, Conn. THE DANBURY MEDICAL PRINTING COMPANY. 1894. FUNCTIONAL CONSTIPATION. BY W. BLAIR STEWART, A. M., M. D., BRYN MAWR, PA. Instructor in Therapeutics; Late Instructor in Practice of Medicine in the MedicorChirurgical College. Functional constipation is a symptom, not a disease, acute or chronic, dependent upon some dis- turbance of the physiological action of the intestinal tract or a disregard of the laws of nature and is recog- nized by abnormal, prolonged, in- definite periods of defecation and, frequently, constitutional symptoms secondary to it. Scarcely a day passes without some patient consult- ing us for the treatment of constipa- tion and, not infrequently, the dose is given with temporary relief only to be repeated time after time with uncertain results. Each case should be studied with a view of reaching the cause and producing permanent results. Functional constipation is most common among those who lead sedentary lives-old ladies, business men, seamstresses, laborers and society people, whose duties often place them in such positions that "they can not attend to the demands of nature without shocking their sense of propriety or that of their associates." Think of it! but it is a common excuse given. In fact every person is liable to constipation who does not attend scrupulously to the calls of nature or who greatly modifies his daily rules of life. Such causes as a misplaced uterus, organic obstruction of the bowels, foreign bodies, tumors, cancers and allied conditions are not applicable to functional constipation but pro- duce what might be termed organic constipation, which will not be con- sidered in this article, and belongs properly to the field of surgery. Neglect is probably the origin of ninety per cent, of the cases of func- tional constipation. What physio- logical action warrants this assertion? When nature has digested and as- similated a sufficient quantity of the food taken, the refuse passes into the flexures of the colon where it is deprived of a large portion of the liquids contained in it. It finally passes into the descending colon and sigmoid flexure until formed into an irregular soft mass, which, by its irritant action, causes involuntary muscular contraction from above which carries it into the rectum. This being a rather delicate structure in itself, as soon as it receives the fecal mass, is irritated; reflects that irrita- tion to the spinal and cerebral centers and produces a desire for defecation. As soon as that desire is made mani- fest the act of defecation follows at once, by voluntary muscular action, in lower animals irrespective of sur- roundings or circumstances, generally speaking. How different with man! The desire comes; he is too busy at the time to attend to this call; he wants to finish a letter; she may want to finish the last ruffle on her dress; she may be in the parlor with guests or in a crowd at a picnic. Probably it may be a child who does not want to take time from play or who is in the school-room under the care of some careless teacher. What is the result? The irritation of the rectum con- tinues for a few minutes or hours; it gradually subsides; the feeling of dis- comfort grows less and the fact is soon forgotten. Bed time comes and he retires without cognizance that his rectum is filled with feces. By morn- ing another fecal mass has descended and the desire is once more renewed but he has over-slept; breakfast is waiting; he must catch a train or hurry to work, and probably does not attend to nature for several hours or even days later. In time the sensi- bility of the rectum is so obtunded that it takes no cognizance of fecal matter unless it is present in very large masses and sometimes not then. Again, the rectum is so full or over distended that there is a weakening or partial paralysis of the muscles involved in the act of defecation together with inspissation of the fecal mass and defecation is painful, almost impossible or very difficult. Secondary to this accumulation there are headaches, nausea, coated tongue, anorexia, bad taste in the mouth in the morning, variable temper and sluggishness from reabsorption of ptomaines and refuse material. It does not end here, for the hard masses cause engorgement of the hemor- rhoidal veins and produce hemor- rhoids of all varieties; they press on the prostate gland and irritate it; they accumulate to such an extent that they often extend far up into the colon and irritate the mucous membrane so much that they cause catarrh, inflammation, ulcers or diarrhoea of constipation. These are some of the results, but are sufficient for the occasion. Impress upon your patients the necessity of immediately obeying the calls of nature. There is a tendency on the part of nature to perform her acts at regular intervals and a slight encouragement on the part of the individual is of great advantage. If one observes scrupulously a definite hour each morning and evening he can soon establish such regular habits that he will never know what constipation and its evils are; but let him infringe upon these hours and neglect them and he will soon realize how improper it is to neglect nature, and how soon the habit of constipa- tion can be acquired. Diet and Drink have their influence. A diet of salt meat, potatoes, beans, mush with coffee and tea tends to constipate. Fresh vegetables and fruits are laxative and should be used freely in season. Quite frequently it is possible to overcome the condition of constipation by adding a free fruit and vegetable diet to the regular routine albuminous meals. Canta- loupe, melon, peaches, pears, apples, cherries, stewed figs or oatmeal, taken before breakfast, tend to relax the bowels and overcome very obstinate cases. A glass of cold water flavored with a pinch of salt, taken before break- fast, aids in relaxing the bowels and also encourages regularity in the morning hour. Apolinaris, Vichy and other mineral waters, taken before meals, produce good results. The habit of excessive coffee and tea drinking forms a frequent cause of constipation among women. The indication for treatment in these casesis plain, viz: Reduce the amount of tea or coffee or absolutely pro- hibit it. All functional activity is increased by regular exercise. Functional con- stipation is rather rare among that class who exercise regularly, unless they neglect the calls of nature. If your patients are indolent, sedentary and inactive insist upon their taking regular daily exercise short of fatigue. Massage affords an active mechanical and therapeutic measure and is best practiced by kneading and pressure over the abdominal muscles, begin- ning at the right iliac fossa and fol- lowing the course of the colon. The process may be repeated daily. It stimulates and tones the abdominal muscles; increases peristalsis; im- proves circulation and favors in- creased secretion. Another method consists in placing a heavy metal ball on the centre of the abdomen and rolling it around over the course of the colon. In difficult or obstinate cases of constipation, the patient ex- periences some relief and aid by gentle pressure at the tip of the coc- cyx and can more readily empty the rectum. Electricity.-Faradization or gal- vanization of the abdominal muscles tends to overcome constipation on the same principle as massage. If the negative pole be introduced into the rectum by an appropriate elec- trode; the positive pole placed-on the perineum or abdominal walls and a gentle current passed, the results are almost immediate and very satis- factory. Rectal Injections.-A method too often neglected and abused, but one far superior to all others in most cases of functional constipation. The fountain or gravity syringe is most satisfactory; insures the best results and, if properly used, can do no harm. All classes of force and bulb syringes can not be regulated to advantage for the flow is more or less spasmodic, (except in the hands of an expert) too strong and produces a desire for defecation long before a sufficient amount has been injected. There is nothing better for injection than pure boiled water at a temper- ature of 98° to 103° F. This can be medicated if desired but it is usually not advisable to add anything unless it be a small quantity of castile soap or bicarbonate of soda. The rectum and colon of an average adult will hold from one to six quarts by in- jection and this amount can be retained from five minutes to three or four hours without great discom- fort by those who have used the method some time. The quantity must be regulated by the individual. An injection is best given when in the recumbent position. The hips should be higher than the shoulders and the patient should lie on the back or slightly on the right side. The nozzle of the syringe should be annointed with pure lard or oil and introduced without force. Elevate the reservoir of the syringe only high enough to allow a flow of water into the bowel. This should cause no uneasiness. If there is great dis- comfort with a desire to defecate it indicates too much force in injection, too hot or cold injecting fluid, too strong medication of an over- distended colon. Insist that he lie quiet and retain the fluid as long as possible as most beneficial results follow its long retention. This method cleanses the rectum and colon of ptomaines and fecal masses, stimulates peristalsis and is usually followed in some hours by a natural passage. One injection may suffice but use as often as necessary. This fact, however, must be remem- bered: a prolonged daily practice of rectal injections obtunds the sensi- bility of the mucous membrane of the rectum and colon and nature will, after a time, refuse to act without this artificial stimulant. When fecal masses are solidly impacted in the rectum injections often fail. In such cases it is necessary to remove them by direct mechanical means. Constipation seems to depend upon a spasmodic or organic contraction of the sphincter ani muscle in some cases and permanent cures have been reported from the forcible dilatation of this muscle. There is still one more feature to be considered and that is the rela- tion existing between- the gases formed in the intestines and the func- tion of defecation. Nature permits the formation of a limited amount of gas in the healthy intestinal tract for a two-fold purpose, viz.: (i) All gases are diffusible through an animal membrane, hence the gases of the intestinal canal diffuse through the walls of the capillaries and lacteals and, according to their nature and amount, aid in the nutritive, phy- siological or pathological conditions of the blood and tissues. (2) All gases are expansile and, by virtue of this property, keep the intestines dis- tended, move obstructing and fecal masses, stimulate peristaltic action, assist defecation and preserve the normal rotundity of the abdomen to an extent. The practice of habitually "breaking wind," passing gases per rectum, is pernicious not only from an aesthetic stand-point but for the physiological reason that it is dis- posing of one of nature's means of preventing constipation. If great dis- comfort is caused by their retention they should not be held. This may seem light to the casual observer but, if viewed scientifically, its utility is evident. Medicinal Measures.-From the pre- ceding considerations it is evident that the average case of functional constipation is not a subject for much medicine. Here the physician must exercise his own judgment and be guided by conditions. Probably the salines are as valuable as any drugs. They consist of pulv. effervescens comp., sulphate of magnesia, liq. magnesii cit., sodii phosphas., and are best given in the morning before breakfast. Such laxatives as syrup of figs, tamarind, sulphur, magnesia, prunes and fruits are most desirable for children or delicate adults. A large anhydrous glycerine supposi- tory will frequently produce copious stools in course of an hour or more. In those cases dependent upon ob- tunded sensibility of the rectum, the preparations of aloes are best. The following- pill has proved of excep- tional value in my hands: 3 Aloini, gr. y. Ext. cascarae, gr. ss. Podophyllin, Ol. menth pip., aa gr. M. Ft. pil. No. j. Sig. One night and morning for several days when the morning pill is dropped and one continued at bed time. In a few days give one-half pill at bed time and finally reduce the amount until it can be entirely discontinued. Another favorite formula is one called "Brown's Mixture." B Pulv. aloini, vss. Sodii bicarb., 3 xij. Aq., O viij. Mix and macerate four weeks; de- cant and give one teaspoonful to a tablespoonful three times daily. This makes a bad tasting dose, but its good results are so uniform that the objectionable taste is not con- sidered. Many other drugs have their indi- cations but, as it is my desire to put most stress upon caustic factors, the remaining drugs and methods will not be considered in this paper.