Constipation

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 m jority 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

conditions.



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

unsatisfactory.





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

bowels.





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

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

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

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

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 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

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 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.