The use of agar (a dried seaweed from the East) in constipation was first suggested as late as 1905 by Prof. Adolf Schmidt, of Dresden, Germany. Since then a wide experience has extended its use in every civilized country. A search of the medical literature of the subject fails to find any dissenting opinion against its proper use. Dud-ley Roberts in International Clinics 2 says it sometimes happens that the ingestion of agar causes stomach discomfort when it is taken before the flakes are slightly softened by admixture with semi-solid food. Aside from this no disturbances have been observed from its use.
It should be pointed out, however, that when it is taken in too coarse a form and hurriedly swallowed before it is thoroughly softened, it has a tendency in some cases to irritate the throat. To avoid this the substance should be cut fine enough so that the longest piece is less than a quarter inch in length. Another difficulty to be overcome, and frequently not realized is the slowness of its progress along the intestinal tract. This is no fault of the agar but a consequence of the stasis from which the patient is suffering. Many people have experimented with the sub-stance only to reach a hasty conclusion that it has no value for them. As a matter of fact before reaching such a conclusion four or more days should be allowed to elapse before discontinuance. In such cases instead of discontinuing the agar the bowel up as far as the cecum should be relieved by coloclysters or “high” enemas, at a temperature where the health is good, of 80°, a section of the colon at a time. The overloaded colon is not infrequently in a condition so bad as to cause a block and furnish a big surprise to even intelligent people.
In order to overcome this condition and give the agar a fair start Kellogg says that the quantities of fecal matter removed in these cases is sometimes enormous; and not infrequently putrefying masses, semi-hardened by long retention, make their appearance after a free coloclyster (irrigation of the whole colon) has been thoroughly administered every day for a week or more, showing that a single irrigation of the colon, no matter how thorough-going, is not sufficient to establish the fact of its thorough cleansing. As long as the patient complains of gaseous distension and fetid flatulence the coloclyster should be administered daily. Care should be exercised against using an excessive quantity of water at once. The amount need never exceed two quarts and the quantity should be reduced from day to day. The warm enema can cause a distention of the bowel. If used at a temperature of 92° to 95° it should be followed by a pint of water at a temperature of about 70° and retained as long as possible as a tonic to the bowel. If the patient reacts well a regular temperature of 80° is recommended after which the cooler water need not be used. The temperature of the clyster when the purpose is to flush the portal circulation (to the liver) and at the same time relieve the alimentary canal should be from 90° to 100°, followed by the cooler water as above.
With its progress through the colon thus facilitated the agar should make pretty nearly normal progress and in-crease the fecal bulk until the colon by its contractions and peristaltic movements is able to successfully engage it. (The technique of the enema is more fully treated elsewhere.) In cases where the constipation is due to the so-called “greedy colon,” agar or bran is indispensable. In such cases the colon has acquired the power to eat up large quantities of the cellulose of the food so that it is very difflcult to increase the bulk by the use of green vegetables. This is the reason for the disappointment of many who hoped to find in the free use of lettuce and like green foods a panacea for their intestinal ills. Agar has been found as a rule to be indigestible. It should be taken at meals up to an ounce in cereal, coffee, fruit juice, stewed fruit so as to be thoroughly mixed with the food, or stirred into a glass of water and quickly swallowed. When food cannot be taken, and when there is no appetite, agar can be taken in place of food in fruit juice or fresh stewed fruit and an extra dose can be taken be-fore going to bed. In this way the intestinal rhythm is maintained by keeping material in the intestine.
Studies made in the laboratory of Mendel, at Yale, showed that agar in great part was excreted unchanged and could be readily recovered. The agar easily retains water in the alimentary residue and prevents the formation of the hard masses. It was this property together with the resistance of the agar to bacterial decomposition, with the production of gases or other noxious products, which led to the suggestion of its use as an element in the diet. But the experiments may not have been extensive enough to arrive at final conclusions. No claim is made that it will produce permanent cures but it is harmless and brings about a condition that approximates natural functions.
One objection to agar, which is a Japanese and Ceylon seaweed, is that it is shipped to this country in coarse bags under sanitary conditions that are not the best, and without being properly cleansed. Various cleansing processes are practiced by the different producers, some of them seriously objectionable. When properly prepared pretty high prices are asked, up to 75 and 80 cents per quarter pound. Also some producers attempt to doctor the article by adding licorice or other substance to change
its taste, although in its clean form it has no taste worth mentioning. It melts at the temperature of boiling water and jellies at a temperature above 120° in which condition Kellogg says it makes an excellent substitute for objectionable animal gelatine.
Bran has several very important advantages over agar. It is very much cheaper, cleaner, and has the very desirable quality not possessed by agar, of not packing. The principal good quality of agar is that it is an indigestible and non-irritating dried seaweed that increases greatly in bulk in the presence of moisture. But bran has all these qualities and the additional ones mentioned above. As impaction of the colon contents in chronic constipation is the most serious condition to provide against, it has been demonstrated that a substance like bran, which disintegrates the contents of the colon, and at the same time greatly increases their bulk, performs a service not secured from agar. In addition the disintegrated mass does not lie closely against the wall of the intestine like agar and therefore is not so much subjected to the loss of its moisture by absorption, a very important point. The key to its successful use is to take it in ample quantity after each meal instead of once a day.
The best bran is produced, it is believed, by large and responsible milling concerns, where it is handled under good hygienic conditions, sterilized and carefully packed in pound and a quarter containers, which retail for about sixteen cents, a twentieth of the price of good agar.
Some producers cook it beyond the point of sterilization but this is not recommended as the bran crumbles to some extent and thus loses some of its most desirable qualities. Other producers grind it too fine. Examined under a magnifying glass it will be seen that each particle looks as if it were removed entirely, or almost whole, from the grain of wheat. There are several layers in the bran, the inner ones being nutritious. On the inside a white sub-stance clings that is a part of the gluten of the grain. Probably half of these flakes after use curl up into thin, elongated spirals to which the adjective spicate is applied (spear shaped). These inside layers are thoroughly digested down to the outside hull. It should not be taken on an empty stomach. A pound of whole wheat contains 37 grains of potash. A pound of bran contains 119 grains of potash (thus showing that a large percentage of the wheat potash is in the bran), while a pound of fine flour contains only 11 to 12 grains of this important food element. Bran contains one-twentieth of its weight of salts, one-thirtieth of its weight of phosphate of potash and 7 to 11 times as much valuable salts as are found in fine flour. Ordinary bran contains nearly one-fifth cellulose, 37 to 100 times as much as does fine flour and about 43 per cent of starch and sugar, while of mineral matter and fat there are 9% per cent. The use of bran can be greatly facilitated by its inclusion in muffins, biscuits, griddle cakes, mashed potatoes, mush, potato and onion soup, cookies, and macaroons. Contrary to misinformed public opinion in certain quarters, carefully fostered by producers of white flour at an excessive price, bran and graham flour are not irritating. In an article on the subject in the Journal of the American Medical Association 2 in its department of Therapeutics, the following important statement is made:
“Bran is chiefly to be looked on as a form of almost indigestible carbohydrate which is endowed with considerable laxative value, not only because it adds by its bulk to the distention of the intestine but also because of the spicate shape of its particles. Excessive irritation does not result from these, for when properly moistened and heated, bran becomes as soft and pliable as wet paper and produces merely a gentle titillation, and is usable even by patients with a tendency to colic.”
One of the easiest and simplest ways of taking bran is to first decide upon the proper amount needed, not in weight but in bulk. Rubner 3 has found that the average weight of the feces of a meal made up of fine white flour is 132.7 grams; of bread from coarse flour 252.8 grams; and from brown bread 317.8 grams. The average of these weights is 234.4 grams, or about half a pound. A proper mixture of bran in a chronic condition of serious impaction (note the qualification) in such a bulk is an 8 ounce glass nearly full a day. Frequently the amount must be decreased and sometimes in bad cases, increased. This can be divided into as many portions as there are meals. With three meals one-third of this amount should be taken with each meal either with the food, or within an hour after a meal, stirred in a glass of water and quickly swallowed in large draughts. Many uninformed writers advise teaspoonfuls of bran. Such small portions have little effect. This practice explains why so many people fail to get results from bran that are easily possible. It should be taken as food is taken, in liberal quantities. Bulk is a fundamental requirement. With it a normal condition is present as in primitive man. Without it the colon contents become impacted and dry and the colon inert it does not have sufficient material to work on. Then follows the delaystasiswhich develops into a chronic state. Unless such a condition is fully realized and capably met there is little or no hope of worthwhile relief.
One of the most obstinate and common forms, spastic constipation, accompanies colitis (inflammation of the mucous membrane of the colon characterized sometimes by colicky pain, constipation or diarrhea and the passage of mucus and membranous shreds). This form derives its name from the fact that its cause is spastic (spasm) con-traction of the colon, acute or chronic, usually below the splenic flexure. Because this condition accompanies colitis it is often thought that bran and other roughage should be avoided. This is an error, says Kellogg. Roughage is more needed in this form of constipation than any other. Bran is of signal benefit in such cases. It is of most importance that the colon membrane should be kept clean. For this reason the colon should be emptied once or twice a day by an enema at not less than 1000-102° to clean and relax the bowel. When colitis and spasm are not present this should be followed by a cool irrigation at 70° to 85°. Paraffin oil as a lubricant is useful, as spas-tic contractions vary from day to day. Rough palpation (with the fingers on the surface) sometimes produces a violent and painful contraction, while gentle friction may cause relaxation.