BMJ 2000;321:1586-1589 ( 23 December )
Civilisation and the colon: constipation as the "disease
of diseases"
James Whorton, professor
of history of medicine. Department of Medical History and
Ethics, University of Washington School of Medicine, Box 357120, Seattle, WA 98195-7120, USA
jwhorton{at}u.washington.edu
The publication in April 2000 of the results of a clinical
trial that found high fibre cereals had no protective effect against colorectal adenomas stirred up considerable media attention and shook a
cherished tenet of popular health culture.1 After all, boxes of All-Bran have been assuring us for nearly two decades that
they contain "at last, some news about cancer you can live with,"2 and the manufacturers of high fibre cereals have
enjoyed unprecedented profits thanks to the assumption that their
products provide insurance against colon cancer. What will happen to
"the high fibre feeding frenzy"3 that has possessed
Americans for the past 20 years now that that assumption has been
challenged?
|
Summary points
Throughout human history, bowel irregularity has been considered
to be dangerous to health
In the 19th century medical scientists formulated a theory of
"intestinal autointoxication" self poisoning from one's own
retained wastes
The public became prey to marketers of anticonstipation foods, drugs,
and devices; All-Bran was introduced in the early 1900s to combat
autointoxication
Recent clinical evidence suggests that cereal rich in fibre does not
have a protective effect against bowel cancer, but because constipation
has a historic hold over the public mind, people may continue to
believe that bran is protective
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 |
Constipation has always been feared |
Not much, most likely. It isn't just that the epidemiologists
continue to remind us that there are many observational studies of
population groups that show a correlation between consumption of a
bulky diet and low incidence of colorectal cancer,4
or that the gastroenterology authorities continue to recommend
daily ingestion of a minimum of 30 grams of fibre.5
More important than anything the experts have to say, I would
wager, is human intuition, which has seen bowel irregularity to be
dangerous from as far back as health literature can be traced. The
oldest complete "book" in existence is an Egyptian pharmaceutical
papyrus of the 16th century BC that offers as a basic explanation of
disease the notion of poisoning of the body by material released from decomposing waste in the intestines.6 The intuition was
that disease is a process of internal putrefaction (as evidenced by the
voiding of vomit, diarrhoea, mucus, etc) and that putrefaction can most
easily be initiated by the contents of the colon, foul matter that is
always undergoing a process of degeneration.
This compelling suspicion shaped medical theory for more than three
millennia; the personal physician to Louis XV of France in the 18th
century was merely echoing the Ebers Papyrus when he warned that
disease was the result of blood turned "faeculent" by contamination
with "the depraved remains of concoction" in the
intestines.7 From the late 1700s onward, moreover,
European and American physicians were convinced that constipation was
becoming ever more common because of changes in diet, exercise levels, and pace of life associated with urbanisation. By the beginning of the
19th century, there was a medical consensus that constipation was the
foremost disease of civilisation, a universal affliction in
industrialised societies that engendered the full range of more serious
human ailments. As a popular American health manual warned in the
1850s, "daily evacuation of the bowels is of the utmost importance to
the maintenance of health"; without the daily movement, "the entire
system will become deranged and
corrupted."8
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Constipation and the germ theory: "autointoxication" |
Surely such simplistic pathology should have been consigned to the
rubbish heap once the modern germ theory of disease came in during the
last quarter of the 19th century but, in truth, bacteriology only
buttressed the ancient intuition that faecal decay triggers physical
decay. First of all, the discovery that germs cause infection was an
outgrowth of Pasteur's studies demonstrating that germs cause
putrefaction of animal and vegetable material outside the body. The
first practical application of Pasteur's findings, the introduction of
antisepsis into surgery by Joseph Lister in the 1860s, further
confirmed the germ-putrefaction connection; Lister used a caustic
chemical, carbolic acid, to suppress surgical wound infection because
he thought of wound inflammation as a putrefaction induced by germs,
and carbolic acid was known to inhibit putrefaction in sewage. But what
was the colon if not a sewage pit teeming with bacteria, a cesspit that
was not being sanitised with antiseptics nor, in people with
constipation, being regularly emptied? Might not its germ-infested
foulness spread out somehow into the rest of the body?
A more elegant rationale for colonic corruption of the body became
available in the mid-1880s, when bacteriologists came to realise that
intestinal flora broke down protein residues in faeces into several
compounds that showed pronounced toxicity when injected into animals.
Reasoning that putrescine and cadaverine and similar ptomaines
generated in the bowel could be absorbed into the bloodstream, late
19th century medical scientists formulated the theory of intestinal
autointoxication, or self poisoning from one's own retained wastes.
The constipated person, French physician Charles Bouchard declared,
"is always working toward his own destruction; he makes continual
attempts at suicide by
intoxication."9
Autointoxication not only bore the imprimatur of the most modern
medical science, it met a clinical need to come up with an explanation
and diagnosis for all those exasperating patients who insist that they
are sick but are unable to present the physician with any clear organic
disease to prove it. Thus even though autointoxication was, to
paraphrase Pudd'nhead Wilson, nothing more than constipation with a
college education, it became its era's catchall diagnosis, the
pigeonhole into which cases of headache, indigestion, impotence, nervousness, insomnia, or any number of other functional disorders of
indeterminate origin could be placed. The diagnosis was not restricted
to such relatively benign complaints, however, for heart disease and
cancer and other deadly ailments did not always have obvious causes
either. Given enough time, it seemed, toxins absorbed from the torpid
bowel could wreak just about any degree of havoc anywhere in the body.
Indeed, from 1900 into the 1920s autointoxication was regarded by much
of the medical profession and most of the public as the most insidious
disease of all, since it was, in essence, all diseases. In books such
as The Conquest of Constipation, The Lazy Colon,
and Le Colon Homicide physicians on both sides of the
Atlantic warned that the contents of the colon were "a burden,
fermenting, decomposing, putrefying, filling the body with poisonous
substances" and creating "sewer-like blood"10; that
autointoxication "is the cause of ninety per cent of disease"; and
that "constipation shortens
life."11
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Prevention and treatment of autointoxication |
Physicians were also generous with advice on preventing
constipation, but recommendations to eat more fruits, vegetables, and
whole grains; to be more active physically; and always to respond
promptly to nature's morning call to evacuate seemed to many people to
require more self discipline and sacrifice than they cared to exercise.
The public, anxious about autointoxication, thus fell easy prey to all
manner of marketers of anticonstipation foods, drugs, and devices.
All-Bran was introduced in the early 1900s precisely to combat
autointoxication, as were any number of other bran cereals such as the
so subtly named DinaMite. Yeast was a heavily promoted dietary
preventive of constipation, and yogurt acquired its reputation as a
health food when recommended in the first decade of the century to
forestall autointoxication.
Still more popular were laxatives. The 1920s and '30s were the golden
age of purgation as literally hundreds of brands of bowel cleansers
competed for consumer dollars with lurid advertisements such as the
Cascarets warning of the dangers of "Bowel Bloat" (fig 1).
Phenolphthalein, introduced as a cathartic in 1900, quickly claimed the
position of best selling of all laxatives on the strength of its
marketing campaign to rescue innocent children from the clutches of
autointoxication. Indeed, the manufacturers of brands running from best
selling Ex-Lax to the onomatopoeic Zam Zam laid down a relentless
advertising barrage aimed at frightening parents into giving their
children daily doses of chocolate-coated or otherwise pleasantly
disguised phenolphthalein, making it sound as if the chief source of
paediatricians' income must be epidemic laxative
deficiency.
A horde of device salesmen swept over the land as well, peddling
an astounding collection of merchandise: enema and colonic irrigation
equipment, abdominal support belts, abdominal massage machines
(fig 2), electrical stimulators, rectal dilators (fig 3), and
so on and on. Not the least intimidating of the cures for
autointoxication was surgery, colectomy to be precise, popularised by
the renowned surgeon of London's Guy's Hospital, Sir William Arbuthnot Lane (fig 4). Between 1900 and 1920, Lane extirpated the
colons of hundreds of constipates, maintaining that his streamlining of
the human "drainage scheme" was "the most satisfactory result of
surgery known to us at the present time."12
| |
Constipation related to "civilisation" |
A number of experimental studies in the 1910s cast doubt on the
possibility of bowel toxins leaching into the circulation, and
autointoxication slowly faded from professional acceptance during the
1920s. Fear of constipation continued to be exploited by laxative and
other manufacturers, of course, but more pertinent was Arbuthnot
Lane's persistent belief in constipation as a disease exclusive to
urban, industrial civilisationas, in fact, "the disease of
diseases," as he dubbed it, "the cause of all the hideous sequence
of maladies peculiar to civilisation."13 Lane had a distinctive theoretical argument for identifying constipation as a
disease of civilisation, explaining how the living habits of people in
the developed world distorted the colon's anatomy in a way not
suffered by "savage races."14 More important in the
long run, however, was the epidemiological justification for his
contention that constipation was the true white man's burden. Although
he did none of the sophisticated statistical comparisons of disease
incidence in developed and developing countries that became the norm in
the second half of the 20th century, he read widely in the publications
of European physicians practising in India and in African nations, and
he became convinced that both constipation and a number of ailments
common to Europe and America existed at very low levels among
"uncivilised" populations. Lane was particularly adamant that colon
cancer was so rare in pre-industrial peoples because their bowels moved
frequently due to a diet of whole grain cereal foods: "the whiter
your bread," he liked to say, "the sooner you're
dead."15
| |
The dietary fibre hypothesis and "Western diseases" |
One sees in Lane the germs of the dietary fibre hypothesis and the
concept of "Western diseases" developed most notably by English
surgeon Denis Burkitt in the 1970s and '80s. Burkitt told me in
conversation that he was unaware of Lane's work until he was well
along in the formulation of his own ideas about fibre. Yet a link
exists none the less, as Burkitt was inspired by the "saccharine
disease" theory of British naval surgeon T L Cleave, who drew on the
observations of Sir Robert McCarrison, a British physician in India
during Lane's day. McCarrison's reports of the rarity of colon
cancer, appendicitis, and gastric and duodenal ulcer among the
grain-eating Hunza of northern India were used by Lane as the
cornerstone of his theory. Burkitt too saw that "constipation is the
commonest Western disease,"16 and his exhortations to
Westerners to consume more dietary fibre to ward off colon cancer and
other ailments of industrialised societies, an obituarist observed,
"was to change the breakfast tables of the western
world."17
| |
Conclusion |
I would guess that, given the historic hold of constipation
on the public mind, most of those tables will stay changed no matter
how many clinical trials deny that Burkitt and Lane were right about
bran and colon cancer. People instinctively appreciate the wisdom of an
elderly Scottish physician who used to consult with another Guy's
Hospital surgeon, Sir Astley Cooper, in the early 1800s. "Weel,
Mister Cooper," he would say just before entering the sick room,
"we ha' only twa things to keep in meend, and they'll searve us for
here and herea'ter; one is always to have the fear of the Laird before
our ees, that'll do for herea'ter; and the t'other is to keep your
booels open, and that will do for
here."18
| |
Acknowledgments |
This subject is discussed at much greater length in Whorton JC.
Inner Hygiene: Constipation and the Pursuit of Health in Modern Society (New York: Oxford University Press, 2000). The photographs are reproduced from that book.
| |
Footnotes |
Competing interests: None declared.
| |
References |
| 1.
|
Alberts DS, Martinez ME, Roe DJ, Guillen-Rodriguez JM, Marshall JR, van Leeuwen JB, et al.
Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas.
N Engl J Med
2000;
342:
1156-1162[Abstract/Free Full Text].
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| 2.
| Foltz K. Policing the health ads. Newsweek 1984 Nov
26:75.
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| 3.
| Gilman M. Fiber mania. Psychology Today 1989 December:33.
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Byers T.
Diet, colorectal adenomas, and colorectal cancer.
N Engl J Med
2000;
342:
1206-1207[Free Full Text].
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Kim Y.
AGA technical review: impact of dietary fiber on colon cancer occurrence.
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The Papyrus Ebers.
Copenhagen: Levin and Munksgaard, 1937:30-32.
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Lieutaud J.
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Philadelphia: Parker, 1816:21.
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Root HK.
The people's medical lighthouse.
New York: Ranney, 1856:114.
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Bouchard C.
Lectures on auto-intoxication in disease or self-poisoning of the individual.
Philadelphia: Davis, 1906:15.
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Bilik SE.
The trainer's bible.
New York: Athletic Trainer's Supply, 1928:88.
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Stemmerman W.
Intestinal management for longer, happier life.
Asheville, NC: Arden, 1928:25, 28.
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Lane WA.
An address on chronic intestinal stasis.
BMJ
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Lane WA.
Blazing the health trail.
London: Faber and Faber, 1929:74.
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| 14.
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Lane WA.
The operative treatment of chronic constipation.
London: Nisbet, 1909:36-37.
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| 15.
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Lane WA.
Against white bread.
JAMA
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|
Burkitt DP, Trowell HC, eds.
Western diseases: their emergence and prevention.
London: Arnold, 1960:427.
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Fergusson A.
D P Burkitt [obituary].
BMJ
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|
Cooper AP.
The lectures of Sir Astley Cooper.
Boston: Lilly and Wait, 1831:56.
|
© BMJ 2000
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