Constipation is due to many causes, which are separate or combined, and every case requires examination before dietetic treatment can be considered. It is very commonly present in association with gastric disease of all kinds, often owing to the diet which is necessary in such disease, sometimes perhaps owing to an atonic intestinal condition which is associated with a similar state of the stomach. Generally speaking it is more common with hyperacid than anacid conditions. It may depend on defects of any of the intestinal secretions. It occurs in all manner of conditions in which the general health and nutrition is impaired, as anaemia, fever, neurasthenia and debility. Painful conditions of the anus produce it. In some cases one can hardly doubt from the history that it has been present from birth, and is the outcome of a congenital neuro-muscular defect in the colon. It is often aggravated by enteroptosis. Its association with mucous colic and enterospasm is referred to elsewhere. But constipation produced by these and such-like causes forms a very small part of the disease. As a rule it is the direct result of a defective diet, and contributory causes are to be found in other avoidable adverse conditions, such as a sedentary unhealthy life and matutinal hurry.

The main error is one of diet. The condition of the nervous mechanism on which defaecation depends is a matter of the greatest importance. In some cases we must conclude that it has been sluggish from birth. More commonly it shows signs of failure in early adult life. Sometimes it seems to become defective only in old age. We have no certain means of raising its excitability and power, but much can be done by an appropriate diet to provide an increase of stimulus to its action.

For the due performance of the function certain things are necessary. We may presume that the actual cause of peristalsis is either, (1) direct excitation of movement by mechanical distention of the bowel by solids, fluids or gas, or (2) a local reflex action (subject to central nervous control) set up by chemical stimulation of the sensory nerves in the mucosa. Probably both forms of stimulus are at work. For the former a certain bulk of residue after digestion is necessary, and this will obviously vary greatly on different diets. Of milk 2,438 grm. produced 96 grm. of faeces with a dry residue of 24.8 grm.; of meat 1,435 grm. produced 64 grm. with a dry residue of 17.2 grm.; of black bread 1,360 grm. (roughly 46 oz.) produced 815 grm. with a dry residue of 1158 grm. (Rubner). Rapid distension of the bowel excites strong peristalsis, and is often attended with pain. As regards chemical irritation, there is every reason to believe that the acids produced by bacterial fermentation of carbohydrates and cellulose are the important factors. Certainly, as is mentioned in connexion with diarrhoea, violent and painful peristalsis may be produced by excessive acidity. But probably the products of the decomposition of protein by bacteria, which normally occurs in the colon, are also to be regarded as stimulants of peristalsis in that part of the bowel. And it is a noteworthy fact in this relation that, as Strasburger has shown the average daily weight of dried bacteria in the stools is only 5.5 grm. in constipation, as compared with 80 grm. in health. Perhaps it may be concluded from this observation that protein-decomposition is actually less in constipation than in health. This is certainly in agreement with clinical experience. I think the evil effects of constipation, the toxaemia, anaemia and malnutrition which are often ascribed to it, are greatly exaggerated. There are no facts which will justify the use of the term " autointoxication" in this connexion.

Though no statistics are available, it will be generally allowed that constipation is increasingly prevalent in the upper classes. It is probable that this tendency is mainly due to the steady intentional elimination from food-stuffs of all particles which are not nutritious. In this way the bulk of the residue is diminished. Further, it is possible that there has been an undue substitution of protein for carbo-hydrate material, which results in a decreased formation of organic acids and gas.

That defective diet is an important factor in the production of common constipation is shown by the good result which sometimes quickly follows the resumption of simple and less artificial food. But such an immediate result is seen only in slight cases of short duration. In the majority of patients who seek help the trouble is of long standing, aperients have been freely used, and the reflex is blunted or lost. In such cases no immediate benefit results from the establishment of a proper diet, and it is consequently often dropped as useless. It is wise, therefore, to be beforehand and to explain to the patient that the diet will at first produce no obvious effect, but that it must nevertheless be considered (with slight variations) as a permanent regime, while dependence is placed on massage, electricity and improvement of life-conditions to wean him from aperients.

The alterations which are generally necessary in the diet are an increase of cellulose, a decrease of meat, an increase of fat, a sufficiency of water, and an avoidance of astringents.

Consequently Graham or whole-meal bread should be substituted for white bread. Porridge is useful, especially Scotch oatmeal and Quaker oats. Vegetables such as cabbage, sprouts, scarlet runners, tomatoes, haricots blancs, salsify, Spanish onion and asparagus should be freely used, though the two last are unsuitable in some cases. Fruit should be taken at least three times a day, the most useful varieties being apples, baked or raw, pears, currants, raspberries, cranberries, prunes, dates and figs. Butter should be taken at all meals. An increase of fat in the dejecta is a material aid. Many people have a strong aversion to oil. If it can be taken, olive oil is certainly of use, even in such small quantity as is commonly employed with salads. But if there is no such aversion, it should be taken more freely either with salads or alone. I think that the patient is fortunate, though rare, who can take one or two tablespoonfuls of olive oil three times a day. The free use of water should be insisted on. It is thought by some that cold water is more efficient than hot. Tea should be avoided. There is no reason to forbid alcohol, but the choice should be limited to whisky diluted with soda-water, or Hock or Moselle wine, and even these latter may well be diluted with one-sixth of soda-water. Cider is often recommended, but it is not always welcome at meals. Light lager beer is a harmless drink.

An outline of a wholesome diet is appended. But in the treatment of constipation it is necessary to suit the diet to the patient and to make allowance for idiosyncrasies which we can recognize without understanding. It is quite possible at first to overdo the alteration in the diet and to forget that a cure must be the work of time. Though many patients can take vegetables and fruit in abundance, others experience considerable discomfort from the intestinal flatulence engendered by bacterial action upon the cellulose. Though this is not an unmixed evil, it may necessitate some modification in the diet. Again, if obesity co-exists with constipation, as often happens, the carbo-hydrate allowance must be reduced, and protein, and if possible more fat must be added. Further, it is obvious that the dietetic treatment of constipation may be rendered difficult or impossible by the co-existence of some form of dyspepsia or actual gastric disease.

Diet For Constipation

Half an hour before breakfast 10 fluid oz. of hot water with a small dose of Carlsbad salt (dissolved in it) insufficient to produce an obvious aperient effect: or the juice of an orange made up to 10 oz. with cold water.

Breakfast . . . Coffee with milk and sugar, 10 oz. (or cocoa).

Graham or whole-meal bread or toast, 3 oz. Porridge with milk or cream (2 oz. of Scotch oatmeal). One egg (or fish or fat bacon). Butter, 1 oz.

Honey, 1/2 oz. (or treacle or home-made marmalade). Two apples baked or raw (or bananas, pears, and other fruit in season). Lunch .... Bread or toast as above, 2 oz. (or whole-meal biscuits). Fish, 2 oz. (or chicken or meat). French beans, 4 oz. (or Spanish onion, celery, cabbage, Brussels sprouts). Salads with oil, 2 oz. (lettuce, potato, tomato, beetroot). Stewed fruit with cream, 2 oz. (prunes, figs, apple-charlotte or puree). Butter, 1/2 oz. Lager beer, 10 oz. (or cider, Hock, Moselle, Berncastler).

5 p.m..... Coffee, milk, and sugar, 8 oz.

Bread, toast or whole-meal biscuits as above, 2 oz.

Butter, 1/2 oz. Dinner .... Clear soup, 6 oz.

Otherwise as lunch. Bed time . . . Water plain or aerated, 10 oz.

Whole-meal biscuit.

A Diet Recommended By Wegele Is As Follows

Morning .... Milk and coffee, 200 grms.

Butter, 30 grms.

Honey, 30 grms. Forenoon . . . Buttermilk, 300 grms. Noon..... Bouillon, 200 grms.

Mutton, 200 grms.

Cabbage, 300 grms.

Plums, 200 grms.

White wine or cider, 300 grms. Afternoon . . . Buttermilk, 300 grms. Evening . . . Meat, 150 grms.

Butter, 30 grms.

Stewed apples, 300 grms.

Graham bread, 250 grms. After evening meal Lager beer, 750 grms.