The diet in this condition is an important part of the treatment. From the evidence I think we must regard the conditions as a perversion of secretion, a secretion-neurosis. If any actual change in the colon-wall occurs, it is of secondary origin. But, as is seen from the synonyms above mentioned, the alternative view of an inflammatory origin was held at one time, and perhaps it is still in existence. From the dietetic point of view this difference of opinion is of some importance. On the inflammatory hypothesis one could hardly recommend the coarse diet which experience shows is often of service.
The belief in the neurotic explanation is founded on the peculiar temperament which (like that associated with asthma) is characteristic of the patient, on the known fact that an attack of mucous colic may be precipitated by shock or emotional disturbance, on the negative findings in the few cases in which an opportunity for post-mortem examination has arisen, and on the fact that in no definite inflammation of the colon is there any such abundant appearance of mucus as is commonly seen in even slight cases of this disease. The inflammatory explanation arose from the & priori idea that excess of mucus must mean catarrhal inflammation.
Mucus is the natural lubricant of the colon, and its secretion in due amount is necessary for the passage and expulsion of faeces. I think a diminution or absence of mucus is a small contributory factor in some cases of constipation. Mucus is often seen in small thin pellicles upon hard scybala, and in such cases its excessive secretion may be taken as a natural purposeful process, and it is not disease. Excessive mucus-secretion becomes a disease when it is purposeless and out of proportion to any lubricating effect required. In many cases painful entero-spasm is associated with this secretory perversion.
Without attempting to describe the whole condition, it may be said in brief that two classes of cases can be recognized. The distinction is useful in determining the line of treatment. These two classes, however, are not separate. They represent the two extremes of one scale. There are intermediate grades, and in regulating the diet the position of individual patients must be appreciated. In nearly all cases constipation is a prominent feature.
In the first class are cases which may be considered as a pure secretion-neurosis. With obstinate constipation there is the passage from time to time of considerable quantities of mucus, generally as small sheets, pellets or masses, seldom as tubular casts. There is discomfort or aching in some part of the course of the colon, generally on the left side, seldom amounting to actual pain, which if it is long continued obtrudes itself more and more upon the consciousness, and may induce hypochondriasis. Such a condition is often of long duration; it may be continuous for months at a time, and sometimes, with intervals of peace, it is spread over several years. In this case constipation is the main trouble, and it is aggravated by most aperients.
In the second class are cases to which the term mucous colic is more correctly applied. With the secretory perversion there is associated motor and sensory disturbance. There is added evidence of violent spasm of colon, probably combined with inhibition in other sections of the bowel. The case presents a history of attacks of pain, generally on the left side, always severe, sometimes so severe that colotomy has been performed. With each attack is the production and passage of large quantities of mucinoid material, often in tubular casts, sometimes in rods, which on transverse section and microscopical examina-tion show evidence of having been subjected to compression. The stools at this point may be exceedingly frequent. Some oozing of blood may occur as the casts are detached. True intestinal sand (mostly calcium carbonate and phosphate) is occasionally found in the stools. After long treatment by a coarse cellulose diet this appearance of sand may be imitated by vegetable residue. Such attacks last for a few days, and occur at varying intervals. During the intervals there may be fair health, but constipation is generally a source of trouble.
Two opposed lines of dietetic treatment are recommended by different schools in this condition, viz. : a coarse cellulose diet (von Noorden), on the one hand, and a diet leaving a scanty residue on the other. This apparent divergence of practice seems to be explained by the differences which have been mentioned in the form of the malady. At one end of the scale we have cases of constipation and mucus-passing, in which the constipation is the most important matter. At the other end are cases which, though they are in other respects identical with the first group, present pain as the prominent feature, such pain, moreover, as would legitimately need morphia for its control in any other than this neurotic class of patient. I think that both plans, the coarse diet and the bland diet, have their uses, and that each case must be treated according to its prevailing character.
If the case approximates to simple constipation with mere excess of mucus and little or no evidence of spasm, a diet such as is recommended in constipation may be found equally suitable here. And the same diet may sometimes be used during the quiescent intervals of fair health in those patients who suffer from paroxysms of pain and mucus-passing, if these intervals are of sufficient duration. In all cases an attempt should be made to diminish the use of meat and to substitute a larger allowance of fat, and it is important to ensure that an abundance of fruit is taken.
I doubt if many cases occur in which it is wise to employ von Noorden's diet in its full severity. It consists of " half a pound of Graham bread, all manner of leguminous vegetables, including the husks and all vegetables containing much cellulose, fruits, especially those which have thick skins and seeds, such as currants, gooseberries and grapes, with large quantities of fat, butter and bacon." With such a diet he reports a permanent cure in 50 per cent and incomplete success in 28 per cent.
The following is an outline of a modified cellulose diet: -
Half an hour before breakfast, 8 oz. of hot water. Breakfast . . . Milk, 8 oz. (or cocoa made with milk.
Graham or whole-meal bread or toast, 3 oz.
Butter, 1 oz.
Honey, 1/2 oz.
One egg (or fat bacon).
A baked apple (or fruit in season, pears, currants, gooseberries, blackberries, raspberries, grapes). Lunch . . . . Scrambled eggs (or savoury omelette).
Bread or toast as above, 2 oz.
Butter, 1/2 oz.
French beans, 4 oz. (or artichokes, beet-root, parsnips, turnips, cabbage).
Water plain or aerated, 8 oz. 5 p.m..... Freshly made tea with half milk, 8 oz.
Bread or toast, 2 oz.
Butter, 1/2 oz. Dinner .... Milk-soup, flavoured with celery or turnip, 6 oz.
Fish (sole, plaice or whiting), 3 oz.
Vegetables as at lunch.
Apple-fritters or puree with cream (or stewed apples, prunes, figs).
Bread or toast, 2 oz.
Butter, 1/2 oz.
Water as at lunch (or whisky diluted 6-1). Bed time . . . Water plain or aerated, 8 oz.
Toast or whole-meal biscuit.
In the more severe type of case in which pain is the chief • feature, occurring either continuously or in frequent attacks, I think that the diet must be modified so as to lessen the amount of residue that shall enter the colon. In such cases a very coarse cellulose diet will sometimes even precipitate an attack, or at any rate is apt to increase the discomfort. Milk should be used in some quantity. The following scheme may be of use : -
Half an hour before breakfast, 8 oz. of hot water.
Breakfast . . . Milk (perhaps slightly diluted), 8 oz.
White bread or toast, 3 oz. Butter, 1 oz. Honey, 1/2 oz. Baked apple with cream.
II a.m..... Milk hot or cold, 8 oz.
Lunch .... Milk soup flavoured with vegetables, 8 oz.
Milk-pudding, especially rice, tapioca or macaroni (or custard), 2 oz.
Bread or toast, 2 oz.
Butter, 2/3 oz.
Water plain or aerated, 6 oz. 5 p.m..... Freshly made tea with half milk (or cocoa), 8 oz.
Bread or toast, 1 oz.
Butter, 1/3 oz. Dinner .... Lentil-soup (or milk-soup), 6 oz.
Fish, 3 oz.
Potato-puree (or potato-salad with oil), 2 oz.
Spinach or cauliflower, 2 oz.
Milk pudding with cream (or blancmange with fruit-juice), 2 oz.
Bread or toast, 1 oz.
Butter, 1/3 oz.
Water plain or aerated, 6 oz. Bed time . . . Milk, 6 oz.
Finally, there are cases of still greater severity. Paroxysms of pain and mucus-passing are long and frequent. The outlook is sometimes so hopeless that a right-side colotomy has been performed. Periods will then occur in which the diet must be still more simple, and the residue entering the colon must be still further reduced, although constipation is thereby increased. Milk diluted with lime-water or as blancmange, or flavoured with coffee should be the main article of diet. It may be strengthened with plasmon. Eggs lightly-boiled or as custard may be taken in some cases, with carbo-hydrate food, in the form of toast, rusks, arrowroot, rice or tapioca.
Though the principles involved in the preparation of the diet in cases of this disease may be theoretically correct, the practice is beset with difficulty. Modifications must often be made to suit individual patients. The difficulties are often greatest in those who are least ill. As in the case of common constipation, the expectation entertained by the patient as to immediate benefit from the diet is usually placed too high. This should be explained at the outset. Some patients, for whom the full cellulose diet would seem entirely suitable, are unable to continue it owing to the flatulence produced. Other points must be considered and allowed for, or in some cases disregarded. The general state of nutrition must be considered. These patients are generally ill-nourished, but continued loss of weight may require at first a simple diet of milk, carbo-hydrates and fat (with massage), to which articles containing much cellulose may be subsequently added by degrees. In some cases there is associated with the colon-condition a gastric neurosis, of such a character that genuine pain in the stomach is produced by all but the simplest and most digestible articles of food. Considerable inanition and feebleness of body and mind may follow. A gain of weight is a hopeful sign. Moreover, the patient who suffers from this colon-neurosis in its slighter grades is the very type of person who quickly declares that such and such articles of diet cannot be taken but always disagree. While a real idiosyncrasy as regards food-stuffs does certainly exist, in most cases these likes and dislikes are due to preconceived and baseless ideas. They are the more troublesome, inasmuch as the patient's wish to get well is often curiously ill-developed, and they must then be ignored. Finally, an insuperable difficulty may be met with in the association of such a degree of gastroptosis as will forbid any attempt at a curative diet.