The British Medical Journal, Feb. 22, 1936
Before beginning the treatment of a case of alleged constipation one should ascertain whether the patient really is constipated or only believes himself to be so. He should therefore be instructed to stop all aperients for three days, taking only a teaspoonful or two of paraffin at night to keep the contents of the bowel soft. If at the end of that time there has been no proper relief, constipation may be diagnosed. If the rectum is full of faeces it is a case of dyschezia; if not, of Colon constipation, of which there are two varieties: (1) atonic; (2) spastic.
Atonic Constipation
General Management
Insist on the patient’s making a regular daily attempt at evacuation and giving enough time to the act. See also that the seat is not too low nor the closet too cold. It may be necessary to advise more exercise, especially such as is calculated to strengthen the abdominal muscles. Massage is often useful if the abdomen is flabby and distended. It may be done by the patient himself lying on his back in bed night and morning and following the course of the colon by deep rotary movements of the hand from right to left ; or a rubber ball filled with shot may be rolled round and round the abdomen instead.
Diet
The food should contain a sufficiency of “roughage,” of water, and of the laxative principles contained in fruits. Green vegetables and fruits, especially cooked fruits and raisins, should therefore be taken freely, and wholemeal bread substituted for white. If the motions are dry the consumption of water should be increased, and if the local water is hard a distilled (for example, Salutaris) or natural water (for example, Malvern) substituted for it. Fats also are helpful when the motions are small and dry, and may be taken in the form of bacon fat, butter, and olive oil.
On the other hand, all foods which have a constipating effect, either from their leaving a small residue or from their containing an excess of such astringents as lime or tannic acid, should be avoided. Milk, eggs, strong tea, and red wines come under this head. It is only in the slighter cases of constipation that dietetic treatment alone is likely to succeed, and if it fails it may aggravate the trouble by producing a ‘large and bulky residue which the enfeebled bowel has difficulty in propelling.
Drugs
These are usually indispensable, but patients are sometimes reluctant to take them regularly. It may be necessary, therefore, to point out that, rightly used, their object is to educate the bowel into acting by itself, and this can only be achieved by persevering in the use of the medicine. One should aim, if possible, at producing a natural and formed motion. There is an immense number of aperients and laxatives, but for practical purposes they may be grouped thus:
Salines
These include the sulphates of magnesium and sodium, the tartrates of potassium, the citrate of magnesium, and the phosphate of sodium. For habitual use the sulphates are usually employed, either in the form of a natural water (Hunyadi, Aquaperia, etc.), in the effervescing form, or as one of the numerous proprietary preparations. They are specially suitable in plethoric subjects or where there is a tendency to hepatic or portal congestion, but should be avoided by old, debilitated, or nervous subjects. They suit men better than women, and are best given before breakfast and well diluted.
The Anthracene Group
This includes such well-known drugs as aloe, cascara, senna, rhubarb, and phenolphthalein. These are among the most suitable of all aperients for regular use, but it is well to “ring the changes” on them, as the bowel readily becomes accustomed to any given drug and ceases to respond to it. Idiosyncrasy also plays a part, and an aperient which suits one patient does not necessarily suit another.
Aloe is the active ingredient of many “dinner pills” and proprietary remedies. It is an admirable tonic laxative, but is slow in action. It should be avoided in cases of piles and of pregnancy. Cascara is best given in liquid form (for example, cascara evacuant), so that the patient can regulate the dose for himself. It acts quickly enough if given at bedtime. Senna is best used in the form of the pods. An infusion of these for three hours in cold water will contain the laxative principle and does not gripe. It is well suited to women. Lixen (A. & H.) is a ready-made preparation derived from the pods. Rhubarb enters into many official preparations — for example, pil. rhei co. and pulv. rhei co. It is specially useful in children and where there is a tendency to excessive mucus secretion in the bower.
Mechanical Aperients
These act either as lubricants (for example, paraffin) or by swelling up and stimulating the bowel by their bulk (for example, agar-agar). In theory they are the most “natural” of all laxatives, but they may fail in the more severe cases. Paraffin may be given either as the pure oil or as one of the numerous emulsions on the market, or made up with malt extract, in which form it is specially suitable for children. It should be avoided in the case of “bilious” subjects. Some patients object to it because of “seeping.” This is less likely to happen if it is taken in a little warm milk after meals and distributed throughout the day. Of the purely mechanical laxatives which act by increasing the bulk of the faeces one has a choice of various agar preparations or of normacol (a vegetable mucilage known as bassorin) or isogel, or a French preparation coreine. These are all very similar in action, and are given in doses of 1 to 2 teaspoonfuls after each meal.
Other aperients, not belonging to any of the above groups, are sulphur and castor oil. Sulphur is given as the confection or in lozenge form. It has the property of making the motions soft, and is therefore often prescribed, with or without the addition of confection of senna, in cases of haembrrhoids and anal fissure. It also enters into the composition of compound liquorice powder, which is a useful regular laxative in children. Castor oil is more of use as an occasional purgative than as a regular laxative. It often acts well, however, for the latter purpose in the case of constipation in elderly patients. It may be given either in capsules (20 minims), two or three at bedtime, or mixed with an equal quantity of glycerin in such dose as is found suitable.
Spastic Constipation
General Management
As this form of colon disorder tends to occur especially in neurotic subjects with irritable or exhausted nervous systems, rest is usually indicated. In severe cases it may be necessary to send the patient to bed with hot applications to the abdomen to allay pain. In milder cases it may suffice to send him away for a holiday or merely to rearrange his day so that he gets more rest. Abdominal massage is contraindicated.
Diet
The diet must be the reverse of that for the atonic form of constipation, all “roughage” being as far as possible eliminated. Raw fruit and vegetables should therefore be avoided, and cooked vegetables taken only in puree form; cooked fruits should be sieved. White bread must take the place of brown. Fats are useful, and should be taken freely if the patient can tolerate them.
Drugs
The mechanical aperients are the most suitable, or one of the milder of the antliracene group, such as an infusion of senna pods. Belladonna should be given to relax spasm, beginning with 5 minims of the tincture two or three times daily and increasing it if necessary. It may also be given in the form of the extract, 1/2 grain in pill, night and morning.
Enemata
If the spasm is in the sigmoid an enema of 6 oz. of paraffin or olive oil. may be run into the bowel and left there all night, a pad being worn to prevent soiling. It may be gently washed out next morning with warm normal saline.
Dyschezia
Dyschezia or rectal constipation enters into most obstinate cases of the disorder, especially in women in whom the abdominal wall has been left weak after childbirth. Such patients can only empty the bowel if its contents are first made fluid by a large dose of aperient. In order to avoid this one should only prescribe such a dose of laxative as is sufficient to bring the contents of the bowel down into the pelvic colon and then remove them either by the aid of a glycerin suppository or by the injection of not more than half a pint of plain warm water, which may be done either with a pear-shaped rectal syringe or a ball syringe.
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