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