I was on duty one night as an intern when a patient called the hospital’s emergency line. He was worried, he told me, because he wasn’t able to move his bowels. I looked at the clock. It was 4 A.M   I had been asleep for an hour or so. A number of things occurred to me to say in that situation, but I did not say any of them. Instead, I listened to the man. He seemed upset. Finally, I asked him when he moved his bowels last. “I haven‘t gone to the bathroom since midnight!” he said. On succeeding nights he telephoned the other interns on call. He made similar complaints. After a while, I was told, the house staff lost patience and went out to his home and “got him.”  We had a psychiatric unit at the hospital. Thinking back on the incident, I do not know  what kind of authority doctors had that allowed them to go into the community to round patients up, but I heard all kinds of stuff when I was an intern, and I was not inclined to question any of the stories people told me.

There are people who are concerned that ill health is creeping up on them. They are suffering from something called health anxiety. We call them health worriers. They look for signs that will allow them to go to a doctor and head off whatever physical calamity they feel may be approaching. More accurately, they suspect that they are already suffering some sort of obscure illness that the doctors have so far not been able to diagnose because the physical signs are not yet clear enough; so they are keeping a wary eye out. Patients have come to me to ask about the bags under their eyes, the “coating” on their tongues, their pulse, which may be too fast, or irregular, their breathing, which may have an odd sound to it, the color of their urine, and, most commonly, the character or frequency of their stool. They have read somewhere that “changes of bowel habit” may be a sign of cancer.

Sometimes people are concerned about the quality of their stool: too much, too little, the wrong color, and so on; but more commonly what concerns them is the frequency.  Some very real physical conditions present with multiple stools, such as irritable bowel syndrome or inflammatory bowel disease. It is true, also, that constipation can represent a real problem, especially in the elderly. In fact, there are many illnesses that can affect bowels and bowel function.  But I think the greater number of my anxious patients worry, like the gentleman referred to above, about going too long without a good bowel movement. (I don’t know exactly what a good bowel movement is, and I have chosen not to ask.)They think that if they do not evacuate all of their stool at proper intervals, toxins might be reabsorbed into the body. And the proper number of bowel movements is one a day. If I ask them how long they think it is possible to refrain from a bowel movement without endangering one’s health, they sometimes say two or three days, (although they really believe that would be too long.) A week boggles the mind.

The truth is many people normally move their bowels once a week. They cannot really be said to be constipated unless it is difficult or painful for them to pass a hard stool. But, then, I like to tell these worried patients about one man reported in the medical literature who moved his bowels very infrequently. I ask them to guess how infrequent. (Hint: the man had Hirshsprung’s disease, which is a lack of nerve endings in the colon.) The answer is, he moved his bowels once every six months. Every six months he spent a weekend in the bathroom and lost 35 pounds. He was healthy and did not otherwise suffer from this strange habit, although he may have been inconvenienced. No toxins were reabsorbed.

If it is possible that a real gastrointestinal problem is present, I encourage these patients to see a gastroenterologist. I discourage the indiscriminate, and usually frequent, use of laxatives. Chronic use of laxatives makes the underlying condition worse, since the bowel, after a while, will not respond normally to the usual sensations of fullness. And, of course, most of the time there is nothing wrong and nothing that needs treatment.

The underlying problem is not only an ignorance of proper bowel function; it is the idea that ordinary bodily functions need to be managed actively. Because they expect that ill health is just around the corner, they wish to supervise and enhance the way the body functions so that illness can be warded off. They do not understand that we are constructed in such a way that breathing, cardiac function and elimination take care of themselves.  

p.s. In a different context, I made a similar mistake. Having grown up in New York City, the only squirrels I ever saw were in Central Park. When I moved to Westchester County, I remember wondering who was feeding all the squirrels that were running about. It did not occur to me that they were capable of feeding themselves.(c) Fredric Neuman 2012   Follow Dr. Neuman's blog at fredricneumanmd.com/blog

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