Constipation, dietary fibre and the control of large bowel function.

Abstract

Goodhart's brief cameo of late Victorian life in England is a reminder of the disproportionate influence which trivial changes in bowel habit may have on people's lives, and of the long-held belief that regularity in these matters is the sine qua non of healthy and effective living. Today constipation is unfairly equated with the refined habits and indolent lifestyle of the late twentieth century, when in fact it is a symptom with many causes, recognized by the lay-public and doctors alike, and clearly described in the very earliest of medical and historical writings. The enigma of constipation lies not so much in its diagnosis but in its pathophysiology and management. These aspects of constipation have occasioned the writing of a number of classic texts on the subject, starting in 1840 with 'A treatise on the causes and consequences of Habitual Constipation' by John Burne. In his discussion of the causes of constipation, in addition to the usual pathologies that we recognize today, Burne is at pains to point out that '.... inattention to the calls of Nature... the civilised life... sedentary habits and occupations... and literary pursuits...' are all important causes. He is forthright about matters which we perhaps avoid discussing with our patients today when he says 'A misplaced sense of delicacy, an absolute disregard of the calls of nature, some engagement from which persons do not at the moment liberate themselves, the inconsiderate or ill-planned situation of the closet, or of the out-of-door cabinet d'aisance, all conspire to counteract the operations of nature and to originate constipation. How often does it happen that ladies, feeling it not quite convenient to retire to the closet at the moment they experience an admonition, defer it till a more favourable opportunity; but this opportunity having arrived their efforts are powerless; the bowel will not then act and disappointment and discomfort ensue.' In 1909 a detailed and comprehensive 340-page account of constipation was written by Arthur Hertz (later Sir Arthur Hurst) entitled Constipation and Allied Intestinal Disorders in which he 'attempts to determine what part of the intestines is to blame in different forms of constipation by tracing with the Xrays the passage of food mixed with a bismuth salt through the alimentary canal'. In this book the idea of slow-transit constipation, and allied motor disorders is born. Most recently in 1972 a distillation of new knowledge of the causes and treatment of constipation was published in Management of Constipation by Sir Francis Avery Jones and Edmond Godding. The popularity of this book was due partly to its timeliness, coming as it did when there was a revival of interest in dietary fibre, and to its practicality, containing the clinical experience of one of the most outstanding gastroenterologists of his time. Although having written nothing on this subject before 1972, Sir Francis recognized in the mundane problem of constipation and its treatment by dietary fibre the start of a new understanding of colonic physiology. In Management of Constipation he writes 'It is also possible that the fibre-containing foodstuffs may favourably influence the bacterial activity in the colon. The influence of diet on bacteria is one which is probably of great importance to bowel activity . . .'. The truth of these words is already evident only 10 years after they were written both in the context of the management of constipation and of colonic function overall.