THE TREATMENT OF HABITUAL CONSTIPATION. BY MAX EINHORN, M.D., New York. Instructor in Medicine and Physical Diagnosis, New York_ Post-Graduate Medical School and Hospital; Physician to the German Dispensary. REPRINTED FROM THE POST-GRADUATE, October, iBp6. THE TREATMENT OF HABITUAL CONSTIPATION. BY MAX EINHORN, M.D., New York. Instructor in Medicine and Physical Diagnosis, New York Post-Graduate Medical School and Hospital; Physician to the German Dispensary. THE TREATMENT OF HABITUAL CONSTIPATION.* BY MAX EINHORN, M.D., New York, Instructor in Medicine and Physical Diagnosis, New York Post-Graduate Medical School and Hospital ; Physician to the German Dispensary. I would like to discuss to-night the treatment of habitual con- stipation as this subject is quite interesting, and every practitioner has to deal with cases of this kind in his daily work. Constipation can arise either from some real organic trouble or some functional disorder. Those cases of constipation which are caused by real organic changes are few. You all know if there is a kind of stenosis in the intestinal tract that would certainly produce constipation. We also find constipation as a constant accompaniment of stenosis of the pylorus. But all these cases are very seldom met with. As a rule we have to deal with those cases where there is no organic change in the intestinal tract and where constipation is due to some other cause. It is not among the working class that constipation is most frequently found, but among the better classes. This shows that the mode of living has a great deal to do with this affection. If we would go a little more into detail and try to analyze cases of chronic constipation, we would learn that the patient had perhaps at first a great deal of worry or of mental strain. At that time his bowels did not move at the right time, but after a while the affec- tion became a little more developed and the patient experienced more and more difficulty, and began to take drugs, and after a short time he was not able to have a movement without such Often we find that after an acute gastric catarrh there was at first a little diarrhoea, which after a few days changed into constipation, which after a short time would have disappeared of itself, but the patient had no patience and took *Read before the New York Post-Graduate Clinical Society, May 15, 1896. 3 cathartics, thus upsetting again the normal state of the intes- tinal tract, in consequence of which constipation developed. Very frequently the patient has some trouble, perhaps a head- ache, and thinks the stomach is disordered, and begins to live on a one-sided diet, avoids vegetables, butter, fat—all substances which excite the peristaltic action of the bowels—and then constipation develops and becomes chronic. In this way you see that the etiology of chronic constipation is a quite manifold one. But from the start it has a great deal to do with the state of the brain—the mental faculties. This is the largest group of cases we have to deal with. But there are some others where constipation is really the consequence of some affection of the stomach. We know that many cases of hyper- chlorhydria are accompanied with constipation. In the same way there is also constipation in cases of too little secretion. With regard to treatment all these various groups have to be managed differently. If we may conclude that the stomach might in some way have to do with the affection, we must find out whether the gastric digestion is all right or not; in the latter instance the discovered anomaly has to be corrected. But in those cases where we do not find much trouble with the stomach, either from the symptoms or by the examination, we shall have to see how we can cure the constipation as such. Two questions might be answered before treating this affec- tion: i. Whether there is real harm in constipation lasting a long period of time. 2. Whether the symptoms which are usually complained of are really dependent upon constipation. You all know that patients complain of headaches or dizziness, which is usually attributed to constipation, and it would be advantageous to determine whether constipation, or perhaps some other affection is the real cause. For then we have to treat the patient not by trying to cure the constipation—by making the bowels move—but by curing the real trouble. Years ago it was believed that in cases of constipation ptomaines might be absorbed from the intestinal tract, and in this way give rise to intoxication, and it was thought that headache, dizziness and many other nervous phenomena were symptoms of the absorption of poison- ous matter from the intestinal tract. Lately it has been shown that this is not really the case, that an absorption could only arise when there is liquid fecal matter in the intestinal tract, and 4 an obstruction besides, producing stasis of the intestinal contents but where there is no real stricture or where the fecal matter is not thin there is no absorption of ptomaines. It was especially Dunin who made many experiments in this respect, and showed that there can be no intoxication or absorption of poisonous matter if the fecal matter is hard. If we try to determine whether constipation fora longer period of time brings bad results with it, we must say that this is not the case. We know that we have sometimes to keep patients in bed for weeks without any movement of the bowels, and yet there are no bad effects. That is an experience which physicians make every day. The second question whether the symptoms, headache, dizzi- ness are caused by constipation or not, must be answered in the negative. The constipation, at least, does not cause all the symp- toms, but it is a part, it is one of the symptoms of a general nervous disorder. In treating these cases of habitual constipa- tion where we cannot discover any fault with the stomach, we must take care that the patient does not do too much mental work, and have to endeavor to draw the attention away from this affection. This can be done in different ways. You all know that the system becomes accustomed to certain habits, and if you miss the time of evacuation from whatever cause, if you are de- tained by some work, then irregularities will arise. We can make the system adapt itself to a certain time, and we must try and train the patient to this habit, by simply telling him to go to the watercloset every day at the same hour and simply to sit down and wait a little. If he has no evacuation he should do the same thing the following day. Simply tell the patient not to worry about his bowels, and not to take any cathartics. He may eat plenty of bread and a slight amount of cooked fruit, and go to the watercloset at certain hours every day. If this would not do in cases that are more pronounced, then you might give the patient very slight cathartics for a short period of time, perhaps for one, two, three weeks, twice a day; then let him take it only once a day, and then discontinue entirely. In many instances you might also apply massage either by telling the patient to exercise his abdominal muscles for five to eight minutes, or best by the cannon ball which Dr. Rose has recommended. 5 You also know that electricity has been recommended for the treatment of chronic constipation, by applying one pole in the rectum and going over the larger intestines with the other pole. That might also be done, but it is not necessary. The most important point is to regulate the mode of living of the patients. Tell them to eat slowly, to take time with their meals, not to work too hard in business, and to go out much in the fresh air. Not the walk alone will bring on a regular move- ment, but the state of mental freedom which we thereby produce. There are also cases, especially in people with a nervous tem- perament, where constipation is caused by some spasmodic con- traction of the large intestines. Here we can achieve a great deal by giving bromide to the patient. I usually give one gramme of bromide of sodium twice a day and keep it up for two or three weeks. The way you can recognize the spasmodic contraction is that the patient usually complains of pains in the lower part of the abdomen and the pains are relieved after an evacuation of flatus. Injections of sweet oil into the rectum, which have been recommended by Kussmaul and Fleiner, are best adapted for the treatment of these cases. The injections have to be made in the following way: You take about one pint of good sweet oil and heat it to the temperature of the body. Then take a fountain syringe provided with a soft rubber tube, and inject the oil into the rec- tum. Patient takes the injection while in bed, and it is better to have him retain the oil as long as he can. I usually order it to be taken in the evening, so that the patient will fall asleep at once and retain it over night. The following day the oil comes out again and an evacuation follows. If you treat the patient for two to three weeks with oil, the spasmodic condition will subside. The oil injections should then be given every other night for a period of two weeks, thereafter twice a week, for some time, then once a week for about a month. In treating these cases of chronic constipation, it is best to tell the patient not to take any drugs and not to get alarmed if he has no movement- for about a week. If the patient is afraid to be without a movement for so long a time, then you may allow him to have an injection of water once in two or three days. In conclusion permit me to submit the following statement to your kind consideration: 6 I. With regard to the prophylaxis of constipation, we should abstain from administering cathartics in slight transient disturb- ances of digestion; rather let nature take its own course. Never put a patient on a one-sided diet for too long a time; the exclu- sion of vegetables, fruits and starchy foods, in general, from the diet is frequently the cause of marked constipation, A hygienic mode of living, regular habits, less business strain and worry, and more out-door life and exercise are of greatest importance to pre- vent constipation. 2. The treatment of habitual constipation will be composed of the following factors: [a.) Of the just mentioned hygienic mode of living (A) Of correcting a faulty diet; increasing the amount of vegetables, fruits, starchy food and also fats (butter). (c.) Of impressing the patient with the importance of not worrying and not bothering much about his bowels. (