"Keep the head cool, the feet warm and the bowels open." - Hermann Boerhaave, 17th-century physician. The number of jokes about a medical problem is usually proportional to how awkward it is to broach the subject with a doctor.
While patients have no problem discussing nausea, vomiting and abdominal pain, it seems that symptoms associated with the tail end of the digestive system have a higher joke index and a greater ability to induce embarrassment.
A man with bad constipation is prescribed a course of suppositories. However, after two weeks, there had been no movement. "Have you been taking them regularly?" the doctor asks. "Of course I have," the patient snaps back. "What do you think I've been doing - sticking them up my arse?"
But, joking aside, chronic constipation is a bothersome symptom, with an ability to make one's quality of life quite miserable. Patients who complain of constipation have difficulty passing a bowel motion or infrequent passages of hard stools, or both. One survey of almost 600 constipated patients found that 79 per cent were bothered by the straining involved, hard stools bothered 71 per cent, while 57 per cent complained of infrequent bowel movements.
Anything between three times a day to three times a week is considered a normal bowel motion frequency. Constipation is medically defined as passing stool less than three times a week. While the obsession with bowel regularity has diminished somewhat in recent years, there is a historical perspective to this human preoccupation. It might also be driven by an innate intuition that retaining waste products inside our bodies is not a good thing.
The notion of decomposing waste causing internal putrefaction was first recorded in ancient Egypt. The idea of poisoning the body by material released from decomposing waste in the bowel gathered pace from the late 1700s onwards. By the beginning of the 19th century, there was a medical consensus that constipation was a disease of industrialised society brought about by changes in diet and exercise levels.
Rather than helping the situation, the germ theory of infection pioneered by Louis Pasteur encouraged a notion of a colon as a sewage pit teeming with bacteria which, if not emptied regularly, threatened to spread inside the body. And so the theory of intestinal auto intoxication was formulated. The constipated individual was thought to be on a treadmill of self poisoning.
Soon physicians warned that constipation created "sewer-like blood" and that it was "the cause of 90 per cent of disease". Cue the purgative industry, with advertisements advocating a cure for "bowel bloat" and a raft of new medical devices from abdominal massage machines to rectal dilators.
All-Bran was introduced early in the 20th century to combat auto-intoxication; another brand of bran cereal was rather subtly named Dina Mite. The 1920s and 1930s were the golden age of purgation, with phenolphthalein the best selling laxative. Parents in particular were frightened into pouring daily doses of products such as Ex-Lax and Zam Zam into their children.
Science eventually prevailed with studies showing it was most unlikely that bowel toxins could leak into the circulation. But some eminent doctors were not about to give up. Sir William Arbuthnot Lane, a surgeon at Guy's Hospital, London, spent 20 years removing the colons of constipated patients. He considered colon cancer rare in pre-industrial populations because their bowels moved frequently thanks to a wholegrain diet. "The whiter your bread, the sooner you're dead," was his favourite catchphrase.
The ongoing popularity of laxatives suggest we are still bothered by slow-moving bowels. Some 12 million prescriptions for laxatives were written in England in 2001, while laxative sales in the US are projected to exceed €850 million annually by 2010.
Another sign of our continuing preoccupation is the popularity of complementary therapies, such as colonic irrigation or bowel washouts.
A number of myths and misconceptions persist around constipation. Increasing dietary fibre may actually make the situation worse. For someone who is not clinically dehydrated, drinking eight glasses of water a day will not help constipation. But exercise has been shown to help, especially in older people.
If you have difficulty passing hard, dry stools, try a stool softener. If the problem is more one of infrequent bowel emptying, then a bulk laxative such as methylcellulose or phyllium may speed things up. However, if you suffer an abrupt onset of constipation and you are over 60, it's best to have a check-up. Other symptoms that should not be ignored or self-treated are passing blood from the back passage and weight loss of three kilogrammes or greater.
Finally, we have the wisdom of an elderly Scottish physician who in the early years said to a consultant colleague in Guy's Hospital: "We ha' only two things to keep in mind, and they'll serve us for here and hereafter: one is always to have the fear of the Lord before our eyes, that'll do for the hereafter; and t'other is to keep your booels open, and that will do for here."
Dr Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries. Medical Matters
Muiris Houston