( Originally Published 1936 )
Contributory Causes. Delayed or incomplete function of the colon may arise from several causes, and in the study of any single instance a careful investigation should be made of the general health of the patient. Where the muscle of the bowel wall is thin naturally or where its tone is lessened by age or lowered general nutrition as observed in acute nutritional diseases (anemia), normal function may not be experienced. Then too where a hypersensitive nervous system is present and reflexes are abnormally produced, no action may be observed. An irritable or irritated bowel may not respond to normal stimuli when residue accumulates. The natural movements of the second half of the colon may be lost in more or less of a spastic state that follows nervous or physical irritation. The lack of sufficient residue, essential to awaken reflexes in hollow organs, is one of the outstanding causes today. The absence of certain chemical constituents found in residue-producing foods—namely, fruits, vegetables, and whole grains, may be considered as well as the small bulk. Physical obstruction resulting from growths within the bowel or in organs pressing upon it, adhesions, mechanical disturbance of the form of the bowel, and injured pelvic or abdominal musculature should be listed among other disposing causes.
Dietary Treatment. In planning the treatment of constipation we should first consider causes that may be present and plan for their treatment or removal if indicated. Supposing no evident cause exists except a slowly and poorly functioning digestive tract, then the treatment is largely dietary. In preparing an anti-constipation diet one must choose foods that,
(a) will promote normal function of the stomach and small intestines, and a free flow of digestive juices;
The effect of palatable food on the secretion of the digestive juices has already been mentioned in another chapter. A natural flow of these promotes stomach and intestinal digestion, and contributes to the content of the stool itself. Poorly chosen and poorly prepared foods, particularly highly seasoned foods, excessive use of fried foods, or the excessive use of tea and coffee, should be avoided. Frequently alcoholic beverages disturb the natural function of the digestive organs.
The cellulose content of the diet today in the United States is small because people are living on more refined foods than they used fifty or more years ago. The following foods which form a large part of our diet, contain very little residue.
The grains or cereals, such as wheat, oats, rye, corn, rice, etc., prepared as they are today as breakfast foods, and fine white flour for bread and pastry have had most of the indigestible residue removed. They are almost completely digested and absorbed before reaching the colon.
Meats, including fowl, fish, and shell-fish, are almost completely digested and absorbed in the stomach and small bowel, the only residue being possibly some undigested portion and hard fiber.
Eggs are almost completely digested and absorbed before the colon is reached.
Sugar leaves no residue. At the present time we are using ten times as much sugar, as sugar, than was used one hundred years ago.
Fats and oils of vegetable or animal origin are digested and absorbed in the small intestine unless excessive quantities have been used.
These five groups of foods together with combinations of them are those upon which most people live today. The result is inevitable. Those using them as a large part of their diet may not and usually do not have natural movements of the bowels because the colon and rectum do not fill adequately.
The residue-containing foods are the fruits, vegetables, and whole grain products. All fruits,fresh, dried, or canned, are valuable because of their high cellulose con-tent. The juice fruits such as oranges and grapefruit, while they do not contain as much residue as some others, are valuable because the organic acid content seems to stimulate peristalsis. Vegetables may be placed into two groups; those that grow above the ground, and those that grow below the ground. The leafy vegetables which grow above the ground, such as spinach, lettuce, chard, greens of all kinds, and string beans contain generous amounts of residue. The root vegetables, such as the potato, car-rot, beet, and parsnip which grow beneath the ground, do not contain as much cellulose. However, they should be included in the diet freely because of other important food substances which they contain. Whole grains contain cellulose of very good quality. Advantage can be taken of this best when whole grain products are used. It seems to us that bran probably should not be used in greater concentration than is found in whole wheat, lest it produce a condition or irritation similar to that caused by cathartics.
Some of the salts and chemical constituents found in fruits and vegetables have a stimulating effect on intestinal elimination. A few persons may have such sensitive bowels that fruits and vegetables must be used in limited amounts, partly because of chemical contents and partly because of the amount of residue present. Phytin, found in wheat bran has a marked effect in hastening this function. Recent investigations lead to the belief that vitamin B found in these foods also plays an important role in promoting activity of the muscles of the digestive tract.
Milk is usually looked upon by most people as either a constipating food or as having no effect upon the bowel movement. For the majority of people this is an erroneous idea. There are those who are sensitive to milk and who experience an allergic reaction which interferes with normal reflexes of the colon. It is believed that most of the sugar in milk escapes digestion in the small intestine and passes unchanged into the colon in normal adults. If an adequate amount of milk sugar reaches the colon, then the milk-sugar-loving, harmless lactic acid bacilli will thrive there. It is true that the colon bacilli can also thrive on milk sugar, but apparently in the presence of adequate milk sugar the lactic acid bacilli produce sufficient lactic acid to retard the growth of the colon bacilli. Some have believed for a long time that the ideal intestinal bacterial growth should be of the lactic acid producing or aciduric type. These organisms are not gasforming. They do not produce toxic substances from protein as do colon bacilli and other putrefactive organisms.
In the past attempts have been made to change the intestinal flora by giving living cultures of lactic acid bacilli by mouth, or by implanting them in the colon by way of the rectum. Apparently the best way to ensure a lactic acid flora in the colon is to give an adequate amount of milk sugar in the form of milk. Often more satisfactory progress can be made by giving, in addition, about two ounces of milk sugar per day. This supplies the medium best suited for the growth of the aciduric organisms. Once a proper intestinal flora has been established it can usually be maintained by the use of milk alone.
Some recent work seems to show that the lactic acid bacilli thrive even better on soy bean milk. In the Orient where milk is not available to the masses, soy bean products are used in many forms. It is probable that in this way and without milk, such nations have maintained a favorable intestinal flora.
An anti-constipation diet should therefore contain generous amounts of fruits, vegetables, whole grain products, and milk in addition to other foods. The fruits, vegetables, and whole grain products furnish the necessary fiber, certain chemical elements, and vitamin B, while the milk sugar of the milk maintains a favorable intestinal flora—all helpful in the proper treatment of this condition.
Other Important Aids. In addition to dietary treatment, certain other practices should be observed. Regularity of meals as well as a variety of food at each meal is important. We favor using fruit regularly for breakfast, and fruits and vegetables in some form with the other two meals. Following meals the gastro-colic contractions which work to move the colonic contents are experienced. The regular use of a convenient hour of the day for evacuating the bowel establishes a habit which should be formed in early childhood. Natural impulses are likely to be overlooked if one lives with a program of constant irregularity. Habit formation relieves one largely of any annoying nervous response along with the impulse to move the bowels. A composed nervous state is very essential in the normal digestive and eliminative acts of the body. Reasonable exercise, particularly for persons of sedentary habits, acts as a tonic to the body muscles generally, and often aids mechanically in promoting strong reflexes and effective functioning of the muscles in the digestive tract.
Artificial Aids. There is a common disposition to make use of artificial means in the treatment of constipation without attempting any of the methods which we have discussed. Among them may be mentioned mineral oil and agar preparations, salts of various types, concentrated vegetable extracts, certain irritating mineral sub-stances, and oils such as castor oil and croton oil. Mechanical aid is often sought in the use of enemas and irrigations.
Mineral oil and various preparations containing it are widely used. It is not absorbed from the alimentary tract, hence, eventually one ounce of mineral oil produces one ounce of stool. It increases the intestinal rate so that a stool usually appears within forty-eight hours. There is some evidence that mineral oil interferes with the absorption of food, and possibly the activity of certain vitamins, so its continued use is not advised.
Agar-agar is essentially pure cellulose. It has the property of combining with very large amounts of water. One ounce of agar-agar will actually make more than 100 ounces of agar jelly. When comparatively small amounts of agar are taken by mouth together with plenty of fluid, the bulk of the stool is materially increased.
When several ounces of mineral oil are taken each day it frequently leaks from the anus soiling the clothing and bedding. It is for this reason that agar has been combined with mineral oil to form an emulsion. There are numerous combinations of. these on the market today, varying in oil content from about 20 to 65 per cent.
Psyllium seeds and other seeds of this type have the property of taking up fairly large amounts of water, as does agar, thus increasing the bulk of the stool.
While on the one hand these preparations do increase the size of the stool, and are undoubtedly better than medicinal cathartics, on the other hand they contain none of the vitamins or mineral foods which are found together with cellulose in the fruits, vegetables, and whole grain products.
A drastic cathartic empties the whole intestinal tract causing one or more watery stools. The patient is satisfied with the result. The next day he usually does not have a stool, but is not alarmed because he has had such a "good bowel movement" the day before. The following day he may still have no stool, and one may not be expected because even if he is taking a proper diet the colon has not yet had time to fill. He has been told that a daily movement of the bowels is necessary for health and on the evening of the second day he usually takes another cathartic. Thus, a habit is formed. Many persons take some form of cathartic daily or every other day, never permitting the bowels to fill and act naturally. The use of laxatives quickly leads to an habitual dependence upon these artificial stimuli.
It may be in place to comment here that the continued action of cathartics results in a degree of irritation of the bowel. Frequent straining will tend to increase this even when the drug used is mild. Many of the cathartics act directly by irritation of the bowel; others which contain salts, draw water to themselves, thus loading the bowel with useless fluid which is expelled. Even the so-called "herbs" used as laxatives function by causing local irritation in the digestive tract and should be avoided.
At times enemas may be useful helps, but their continued use encourages laziness of the bowel. Solutions such as soap suds have been shown to destroy large numbers of cells in the wall of the rectum and colon. Likewise, flushing the bowel with prepared solutions is not best. Some of the mucus so removed and often pointed to as a reason for irrigations, is the natural product of the cells of the colon wall.
Legitimate Use of Artificial Aids. It must not be understood from the foregoing discussion that cathartics and enemas have no place in the practice of medicine. They should be used in any case where intestinal poisoning is suspected. Spoiled and infected foods, especially the latter, often cause severe abdominal distress, which is sooner or later followed by diarrhea. Enemas and cathartics should be used freely to eliminate as rapidly as possible this material. Cathartics are often considered favorable in infectious diseases, especially those associated with fever, bringing about an elimination of toxins with a thorough emptying of the alimentary tract. Patients may be especially constipated in the presence of fever, due probably to the abnormal binding of water in the body. Again mild laxatives have a place following surgical operations, especially upon the alimentary tract, when it is often unwise to fill the bowel with masses of indigestible residue. Surgical patients oftentimes needlessly continue the use of cathartics after their recovery. It is the habitual and not the occasional use of cathartics which causes serious damage. In the routine treatment of constipation all cathartics and enemas should be stopped.
Adapting Treatment to Condition Found. If the colon is sore from the unwise use of cathartics or enemas, the initial diet should consist of either all cooked fruits and vegetables or at least the majority of the fruits and vegetables should be cooked. Sometimes it is necessary to make the diet even more bland by sieving some of the vegetables. A diet of cooked foods cannot be kept up in-definitely, because the cooking destroys vitamin C.
In the beginning of a course of dietary treatment for constipation, some patients complain of a "stuffed" feeling. Whereas in the past the abdomen has been kept unnaturally empty, it is now restored to a natural state. Others find difficulty in consuming an adequate amount of fruits and vegetables, because the stomach has become abnormally small; however, the stomach also will early resume its natural capacity, which is in the neighborhood of three pints, if an attempt is made to eat a proper amount. Many individuals become impatient and are unwilling to wait the necessary length of time for the bowels to act unaided. It may be that a natural movement is prevented because the rectum is filled with an impacted mass of feces. It is often advisable during the first few days of treatment, which may be termed the "weaning stage," to use some artificial help to empty the rectum only. The oil retention enema is used for this purpose. The injection is made by means of a rectal tube and funnel, or with a plunger syringe. Three to six ounces of cottonseed oil or mineral oil are injected into the rectum upon retiring and retained until the next morning when the softened fecal matter is easily expelled. Sippy formulated the following rules governing the use of the oil enema: "The oil enema should be used at bedtime, when there has been no stool during the entire day; or when the stool that day has been hard and dry. If the oil enema has been neglected in the evening, and there is no inclination to go to stool the next morning, a bowel movement may be obtained by using a glycerin suppository or the injection of one-fourth to one-half pint of normal salt solution. If this is not sufficient, a pint may be used, but a copious flushing must not be taken." The normal salt solution is prepared by the addition of one level tea-spoonful of table salt to a pint of warm water.
The normal stool should be soft but formed, of about the consistency of putty at average room temperature, and should weigh approximately five or six ounces. Many patients are not satisfied with a stool of normal size, but expect the copious cathartic stool to which they have been accustomed. One need not worry if there has been no stool on any particular day, provided the subsequent stool is soft and formed. On the other hand, two or three movements may be had in the day, provided they are of this proper consistency.
If a person has a general understanding of the anatomy and physiology of the alimentary tract, and observes simple health rules, and uses a well balanced diet, he should have no difficulty in achieving normal intestinal elimination.
ELIMINATION THROUGH THE KIDNEYS
While the residue expelled from the bowel is gross in its form it is true that the expulsion of residues from other organs is equally important in the health of the individual. The excretion of the kidneys, called urine, is very complex in its composition. Its volume varies from one to two quarts daily. It is slightly greater in density than water, and straw colored generally, although as it is more concentrated its color may become a dark reddish brown. Its reaction is commonly observed to be acid. We believe that when a balanced diet is used and digestive function is normal, the reaction will be close to neutral. Each day about two ounces of solid material is excreted in solution composed of organic and inorganic sub-stances which are end products of metabolism. Among the inorganic substances we would mention sodium chloride, sulphates, phosphates, potassium, and calcium compounds, and among the organic—urea, uric acid, and creatinine. When we find regularly that the blood contains more than an average of these substances we reason that the kidneys are not doing their work properly. It is believed that normal kidneys are capable of excreting several times the amount of wastes usually eliminated through them. So when there are evidences of failure in function, it is usually where already a marked degree of damage has been done. The appearance of either albumin (protein), sugar, or acetone in the urine is an important finding indicating conditions of health that need immediate care. The appearance of these substances is of sufficient importance that the advice of a physician should be sought whenever they may be found.
Arteriosclerosis, poisons, and bacterial infection are conditions which frequently injure the delicate cells lining the kidney tubules, allowing the proteins of the blood plasma to pass. A very slight trace of albumin after heavy exercise may be a normal finding. In certain diseases such as diabetes mellitus, sugar may rise in the blood stream and be lost through the kidneys. The appearance of sugar in nursing women should always be studied carefully as it may be lactose associated with activity of the mammary glands. Acetone and related substances are abnormal being found in severe uncontrolled diabetes, or where starvation has led to an unnatural waste of body tissues.
ELIMINATION THROUGH THE SKIN
Many think of the skin as a covering for the body only. It is this and more. It is a very important organ in the regulation of body heat, and functions somewhat in eliminating certain types of wastes. In average temperatures over a pint of liquid is eliminated daily via the skin, largely as a means of body heat regulation. Over 99 per cent of the sweat is water. Sodium chloride is excreted; also a small amount of urea. In severe kidney injury this latter substance may be excreted vicariously in a much greater amount. A small amount of carbon dioxide is lost through the skin. This may be a result of the activity of the sweat glands, being thus a loss through metabolic changes rather than an actual excretion.
ELIMINATION THROUGH THE LUNGS
The lungs bring about an exchange of poisonous gases resulting from metabolic processes within the body for oxygen from the fresh air constantly breathed in. In-spired air contains approximately four per cent of oxygen more than expired air; and expired air contains approximately this amount more of carbon dioxide. The blood carries more oxygen than a fluid such as water would carry under the same conditions. This is made possible by the presence of hemoglobin in the red blood cells. This substance is the active ingredient in carrying oxygen to the tissues, and carrying carbon dioxide from the tissues to the lungs where it is given up. These gases are carried in a loose chemical combination. Any increase of carbon dioxide in the air of the air sacs in the lungs leads very promptly to increased depth and rate of respiration. This change is brought about by an increase of carbon dioxide in the blood circulating about the nerve centers of the brain which regulate the mechanism of breathing. Persons who live in higher altitudes have an increased number of red cells which permits a proper exchange of gases between the blood and rarefied air. Other gases in small amounts may be exhaled from the lungs. These, however, are variable in amount and should be thought of more as incidental rather than the usual wastes eliminated in respiration.