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To judge by the frequency of advertisements for laxatives of various
kinds, constipation must be an extremely common affection. At least
one out of every three city dwellers suffers, it is said, from
constipation. Proper regard for the taking of food calculated to help
this important function, the formation of appropriate habits, and the
proper disposition of the mind so as to relieve worry and anxiety,
will cure the majority of these patients. There are some who need
additional treatment, pharmacal or mechanical, but these are few.
Undoubtedly the mind plays the most important role in the therapeutics
of the affection. It is influenced partly through instruction,
partly by the modification of unfortunate auto-suggestion, and partly
through auxiliary favorable suggestions of one kind or another.

Prophylaxis.--What is needed in most cases is such instruction as will
lead to a better observance of certain common-sense laws of health,
rather than the addition of remedies which eventually only complicate

Many people believe that unless they have an ample movement of the
bowels every day all sorts of serious results are likely to follow. If
they do not have the expected movement before noon, they suffer during
the afternoon from headache that is probably due more to worry than to
any physical cause. Ordinarily it is quite out of the question that
the retention of the contents of the lower bowel for a few hours
should produce any such serious effects as these patients immediately
begin to feel. Especially is this true when on the day previous there
has been, as is often the case, a sufficient movement of the bowels,
due to the use of medicine. Some people have become so anxious in the
matter that they foster the development of feelings of discomfort both
in their abdominal and intracranial regions.

This over-anxiety is all the more important because recent
observations have made it clear that over-occupation of mind actually
hampers peristaltic movements of the intestines, and thus prevents the
muscular action which would gradually pass the excrementitious
material on to the lower bowel, to be evacuated in the normal way. It
cannot be too often repeated that nature resents too close
surveillance of her functions and operations. Just as soon as the
over-anxiety is relieved, and patients are made to appreciate that if
they do not have a movement to-day they may wait without serious
solicitude till they have one to-morrow, the amount of medicine
required to bring about movements of the bowels is at once reduced.

The Mind and Peristalsis.--Analogous to Pawlow's ingenious
experiments, with regard to digestive secretion in the stomach, are
Kronecker's experiments at Berne upon the motor function of the
intestinal tract. Pawlow showed that the appetite depended, not on
physical conditions so much as on the mental state of the animal and
its desire for a particular kind of food. Kronecker, by isolating a
loop of intestine in which a metal ball was placed, showed that it was
possible to modify peristalsis very materially by affecting the
psychic condition of the animal. There was a distinct difference in
the movements of the intestine, in the passage of a metal ball, when
the animal was called and expected to go for a walk with its master,
than when it was threatened with punishment or rendered depressed for
some other reason. In animals, the psyche plays a very subordinate
role in inhibition and stimulation compared to that exercised by man's
higher nervous system, since in him this portion of the organism is so
much better developed than in the animal. The condition of the human
mind in its possibilities of unfavorable influence over the intestinal
function, is, therefore, extremely important.

The more one knows about the curious power of the mind even over so
material a function as intestinal peristalsis and movement, the more
is one convinced of the necessity for a properly disposed mind toward
intestinal function, if it is to be accomplished with regularity and
without disturbance. Many persons thoroughly under hypnotic influence,
who are told that they will have a movement of the bowels at a certain
hour the next day will have it. Indeed, this constitutes one way of
treating certain forms of constipation in nervous, preoccupied
people. There are many stories that illustrate the influence of
auto-suggestion upon the bowels. We have already mentioned Flaubert's
suffering as a consequence of realistic absorption in "Madame
Bovary's" poisoning by arsenic when he was writing that scene in the
book. Boris Sidis has told the story of a man who used to have a
disturbance of the bowels at every new moon, as the result of his
memory, acting unconsciously, reminding him of his mother's habit of
giving him a purgative about that time. These may be and doubtless are
exceptional cases, yet they illustrate the influence of mind and show
how much it must be the effort of the physician to use this effective
adjuvant just as much as possible in this very common and often
obstinate affection in which drugs so often fail, or are

So-called Intestinal Auto-intoxication.--Those who are anxiously
interested in the subject are likely to have read so much of
intestinal auto-intoxications, of which a great deal has been written
in recent years, that they will be quite sure the slightest delay in
intestinal evacuation may be serious, or at least may profoundly
disturb their economy. As a consequence, just as soon as the hour at
which they should have a movement passes, they begin to worry about
it. In a couple of hours they feel tingly all over, and they know that
there most be poisonous substances in their circulation. After two or
three more hours, they begin to have a headache. Then they have to
give up work, and still more devote themselves to concentration of
attention on the disturbed condition. Their sleep will be disturbed,
perhaps will be delayed; they wake unrested and fearful of the awful
effects of intestinal auto-intoxication. In most people this state of
feeling is entirely due to suggestion.

So much has been said in recent medical literature of the influence of
absorption of poisonous substances from the intestinal tract--the
so-called intestinal auto-intoxication--that it is a surprise to learn
how little we know, definitely and absolutely, about this subject, and
how many theories have come and gone. Arthur Hertz, in his
"Constipation and Allied Intestinal Disorders" (Oxford Medical
Publications, 1909), reviews the whole subject very interestingly but
shows that we are entirely without any definite conclusive evidence
for what has been talked about so much. The idea had often occurred,
and been expressed vaguely, in medical literature in the old time, but
began to have its great vogue when the high-sounding Greek term
copremia (literally "excrementitious-substances-in-the-blood") was
invented, toward the end of the first quarter of the nineteenth
century. Naturally this had a strong suggestive effect. Bouchard took
it up a generation later, and then intestinal auto-intoxication,
another mouth-filling term, came to occupy much attention as an
explanation for various vague conditions, and especially nervous
discomforts of many kinds. Bouchard's method of proving his theory by
showing how much toxic material was reabsorbed from the intestines,
using the urine for injection into animals, was open to many
objections. Now it has been quite discredited.

Bouchard's disciples exaggerated and theorized even beyond their
master, until intestinal auto-intoxication became the same sort of a
refuge for the puzzled physicians of our time--like rheumatism or the
uric acid diathesis, for those of a score of years ago. Various
methods of demonstrating the toxicity of substances absorbed had a
vogue for a time, but they have now lost their significance. There are
only a limited number of people who seem to suffer from the
symptoms attributed to such reabsorption. Some people who are quite
constipated have none of the symptoms at all, while a delay of an hour
or two in the evacuation seems to affect other people very much. These
latter are especially nervous persons. It now seems very clear that
the liver acts as a safeguard against the absorption of poisonous
materials from the intestinal tract, and that neither degenerate
proteid materials, nor bacterial toxins, are allowed to affect the
system to any serious degree. After all our study, as Dr. Hertz
insists, we have as yet no evidence that poisons are absorbed.

Reassurance as an Element in Treatment.--The most important element in
the rational treatment of constipation is to make patients understand
that under ordinary circumstances the symptoms of auto-intoxication,
of which so much is said, do not develop until there has been
long-continued accumulation of excrementitious material and under
conditions favoring absorption. Even then nature learns to protect
herself against untoward conditions. We have some very striking
examples of good health in spite of even very rare movements of the

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

In the Orient, it is said that many people, especially of the better
class, 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 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 circumstances, 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 pass 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 Saturday night and spend most of the
day on Sunday getting rid of the accumulated excrementitious material
of the whole week.

They taught Sunday School in the afternoons, and as the elimination of
the accumulation 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
passed 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 naive 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, 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 excrementitious 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 attitude 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

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
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
excrementitious 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 quantities of
fluid were taken at meals. With people in our time deliberately
diminishing the quantity, 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 quantity 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
glass of water does not contain half a pint; the ordinary tea cup
probably holds not more than from four to six ounces. A glass 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
excrementitious 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 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 accumulation in the rectum 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
coarser indigestible portions. Bread used to be made of the whole
wheat, and of rather coarse 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 coarser 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 passed 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 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 prone 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 substitute 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 butter 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

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 classes 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
constipated, and who need to take fats plentifully, do not care at all
for butter. Sometimes this is founded on nothing more than the fact
that at some time or other the butter provided for them was rather
poor, and they got out of the habit of eating it. Now they assume 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 quantities at least, of this extremely valuable article of

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 circumstances under which it was eaten, or the
materials with which it was associated. 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 quantities 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 massage 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.

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
accumulation 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 classes.

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