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The New England Journal of Medicine
Volume 343:820-821 September 14, 2000 Number 11

By James C. Whorton. 332 pp., illustrated. New York, Oxford University Press, 2000. $39.95. ISBN 0-19-513581-4.

Inner Hygiene: Constipation and the pursuit of health in modern society

The subject of this book concerns everyone in one way or another. When nature calls regularly, one should be grateful. But when such calls are irregular and one suffers from headache, distention of the abdomen, disagreeable breath, and furred tongue, then something has to be done. According to 18th-century doctors, retained bile would cause fever, in the 19th century putrefaction and bacterial infection were feared, and now we are frightened by autointoxication and cancer.

The belief that retained feces can poison the body has a long history. A passage in the Ebers papyrus suggests that undigested food produces poisonous substances that overflow into the body and initiate putrefaction in vital organs. Similar ideas are to be found in the 18th and early 19th centuries. Germ theory transformed the consequences of constipation into an even greater menace: autointoxication. By the 1880s, it had become apparent that bacteria decompose proteins in the large intestine into a number of compounds that have pronounced toxicity when injected into animals. Despite the lack of scientific proof that these substances are actually absorbed from the colon into the circulation, the concept of autointoxication turned out to be of great importance in the 19th and early 20th centuries.

Ever since antiquity, well-timed evacuation and repletion have been considered one of the six res non naturales, along with air and light, food and drink, sleep and watching, motion and rest, and the passions of the mind. In each case, health was to be achieved by moderation, regularity, and the balance of opposites. Constipation viewed in contrast to cleanliness was also a leading idea in the process of civilization.

Filth was omnipresent in urban life before the sanitation-reform movement. Putrefaction and foul smell foreshadowed disease, decay, and death. Feces were seen — and smelled — in "nightstools" (whence the usual euphemistic term was derived), in chamber pots and privies, and in cesspools and the streets, and it was natural to suspect that the retention of this material in the body would have bad effects. Street cleaning and drainage, the removal of refuse, and the construction of efficient sewer systems, including the toilet, promoted not only environmental cleanliness but also loathing and fear of every kind of filth. The idea of a coexisting inner rottenness and outer cleanliness was hardly tolerable. Thus, the counterpart of sanitation reform as a medical and political movement was the individual fight against constipation, the "mother of all diseases."

It was convenient to suspect civilization as the cause of constipation. Since the last third of the 18th century, Europeans and Americans had been made intently aware of the widening gulf between their manner of living and that of their ancestors. There were many dangers in modern life, including lack of time to obey the call of nature. The fight against constipation became the centerpiece of efforts to counter the debilitating effects of urban life, not only by means of purgatives, enemas, irrigation, and even surgery but also through massage, ingestion of "roughage" and black bread, and perfect mastication.

James Whorton, a professor in the Department of Medical History and Ethics at the University of Washington in Seattle, has analyzed a host of British and American sources on the costive bowel. He explores the theories and practices of intestinal purity, a subject that, considering its prominence in medical and popular culture from antiquity to the present, he considers the most neglected element in the history of hygiene. After establishing the context in two chapters about the 19th century, Whorton concentrates his discussion on the 20th century. Six chapters examine the period from 1900 to 1940, when the theory of autointoxication was at its zenith and prominent physicians were its propagators. The two final chapters bring us to the end of the 20th century, when the old idea was revived as the basis for the dietary-fiber movement in the fight against colon cancer, scientifically supported by the "bran man," Denis Burkitt (1911–1993), a surgeon, oncologist, and epidemiologist.

A fascinating and well-documented story that is fluently written, sometimes with a wink and sometimes with humor, Inner Hygiene is at once a record of timeless hypochondriacal preoccupation and an instructive account of the evolution of medical thought and its shaping of popular beliefs about health and behavior. The author has done his job "in as cleanly a Manner, as the Dirtiness of the Theme will admit," and there is no doubt that his book will leave the reader with a very salutary "bowel consciousness" if not "bowel wisdom."


Urs Boschung, M.D.
University of Bern
3012 Bern, Switzerland

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