Inner Hygiene: Constipation & the Pursuit of Health in Modern Society. (Reviews).

Inner Hygiene: Constipation & the Pursuit of Health in Modern Society. By James C. Whorton (New York: Oxford University Press, 2000. xvii plus 3l5pp.).

Though medical and cultural understanding of constipation has been overlooked by most historians of hygiene in the last decades of the twentieth century, Whorton shows that the subject was of considerable importance to medical practitioners, pharmaceutical manufacturers, health gurus, quacks and patients with costive bowels. These people were thoroughly dissecting the subject throughout the century. Given the volume of primary works on the matter, Whorton wisely chose to limit his treatment to particular themes in medical and popular understanding of the ailment as they were expressed in the United States and Great Britain from 1900 to 1999. He does provide two chapters at the beginning that give a necessary overview of Western understanding of the condition prior to the twentieth century, but the work focuses mainly on the period from 1900-1949. It concludes with two evocative chapters on late century developments in scientific and medical perception of constipation as a disease of industrial societies.

The basic approach of the work is in-depth coverage of varied themes related to the "culture of constipation" both as a disease of industrial society and its treatment as a medical condition. The goal is not to present a thesis-driven conclusive argument about the nature and direction of change within this culture, but to explore important components of contemporary understanding of it. Nonetheless there is a recurrent assertion that the concept of autointoxication, bodily pollution and degeneration caused by retained feces, first proposed by leading medical practitioners, has remained fundamental in popular thinking and pharmaceutical advertising despite being discredited in scientific circles. Whorton ably blends evidence from medical publications, popular journals, advertising, and the files of the American Medical Association's Bureau of Investigation to convincingly show that this was true for the medical profession and others in the business of selling constipation cures.

Whorton's work is particularly strong in its depiction of the ways in which those at the pinnacle of medical practice have altered their understanding of the causes, effects and, therefore, treatment of costive patients. He does this by looking thoroughly at the work of several leading practitioners, particularly Arbuthnot Lane, T.L. Cleave, and Denis Burkitt. Though he carefully contrasts the attitudes and ideas of these leaders to the practices of most physicians, the general approach is that of "great person" history where the earlier leaders are portrayed as misguided or self-deluded while more contemporary figures take on the stature of heroes in the fight against ignorance.

He also ably demonstrates how medical hucksters have adapted the ideas of the medical community to sell constipation cures and preventives to a general public already concerned with keeping their bowels open. He spells out how those in the business of marketing treatments have frequently played on the public's social values and general fear of disease to promote products as varied as laxatives, strenuous health regimens, and rectal dilators and vibrators. In his on-going discussion of the selling of constipation, he seems to be claiming that the public was duped into the false belief that a daily bowel movement was necessary for continued good health by misguided doctors, well-meaning health reformers, and greedy pitchmen. Indeed the evidence he marshals has given me new understanding of my paternal grandmother's daily regimen of cod-liver oil, bran, and yeast, as well as her propensity to comment on the shape, size and consistency of other people's feces.

His evidence for how thoroughly autointoxication was integrated into the health outlook of the vast majority is intriguing, but less convincing. To be fair, showing what ordinary people actually thought and did about hygiene is the most difficult task historians in the field face. Records of this are rare. Whorton tries to overcome this problem by incorporating personal testimony submitted to the AMA, pharmaceutical companies and health regimen reformers to illustrate that at least some members of the general public had embraced the concept of autointoxication by mid-century. He begins each chapter with intriguing stories from medical case records about the experiences of individual sufferers. Still, these records are not a representative sample of constipation sufferers and it seems likely that the majority of those who embraced laxatives and other regimens were simply seeking to relieve the discomfort of constipation and the potential pain of piles, as opposed to quaking in fear that retained fecal matter might cause cancer.

Another persistent claim of the work is that changing understanding of constipation by professionals and the public is linked to both the state of scientific knowledge and alterations in social values. This claim seems obvious, yet there is little in the work about the particular social values that influence this evolution in understanding. He provides a few thought-provoking paragraphs on the cult of efficiency and the tendency to seek a magic bullet cures or preventives. The one cultural claim that Whorton does repeatedly make is that industrial people more readily embraced easy answers to the problem of constipation and avoided the difficult, but more appropriate, approach of self-disciplined alteration of their lifestyles. Whorton uses words such as indulgent to describe the daily lives of modern British and American middle-class people. It is their unwillingness to embrace the discipline of low-fat, high-fiber diets, combined with regular exercise that makes constipation a problem.

This refrain seems slightly off key to me given the gruesome details he recounts of the nature of spa treatments, colonic irrigation, rectal dilators et al. Laxatives certainly were most often used and were an easy, but dangerous response, to constipation. Still, the other approaches, though simplistic, were neither comfortable nor easy. In repeating this accusation Wharton appears to have accepted the medical professions' tendency in the modern era to perceive that ailments are caused by complex interactions among biological and social phenomenan, but to place the responsibility for overcoming these societally created diseases on the shoulders of individual sufferers. The topic cries out for a more sophisticated treatment. Indeed, I would like to see a Freudian interpretation of social values related to constipation that particularly explores anal retentiveness and the use of dilators, vibrators and colonic irrigation as methods of prevention and cure.

Still, as a first foray into the subject of the bowels, Whorton's work is a fine effort. Wharton's willingness to interject himself into the text as both actor and scholar is a model more of us should follow. It is certainly a must read for scholars of hygiene and it is bound to make readers acutely aware of the functioning of their own lower intestinal tracts.