The road to Rome

Medical diagnosis generally requires observed anatomical or physiological abnormalities. Description of the illness and criteria for its diagnosis follow naturally. Recognized symptoms can then be attributed to the observation, and a diagnosis predictably follows. In the case of the functional disorders, such a process is impossible. As there are no observed defects, we only know of the existence of these disorders through the words of our patients. Hence there can be no animal model. Parrots may talk, but are not likely to discuss their bowels. The need to define these disorders of unknown pathology represents a major paradigm shift, a substantial change in thinking for doctors whose training concentrates on basic science and palpable evidence. As more than half of the gut disorders encountered by gastroenterologists and primary care doctors are functional, we must face the reality that scientific evidence to explain these disorders does not exist, and develop alternative methods to identify disease. For too long, functional diseases have been described by what they are not, rather than as real entities. Yet they are real enough to our patients. Not only does this exclusive approach fail to provide the patient with the dignity of a diagnosis, but it also generates needless tests and consultations. The fruitless pursuit of an anatomical cause renders functional disorders diagnoses of exclusion. Their very numbers and cost demand a more positive approach. There are many references to gut dysfunction in the ancient and early European literature. However, the first credible English language descriptions of irritable bowel syndrome (IBS) appeared in the early 19th century. One such description of the IBS in 1818 drew attention to the three cardinal symptoms of IBS; abdominal pain, “derangement of. digestion” and “flatulence. ” A few years later, Howship described a “spasmodic stricture” of the colon reflecting the enduring, but still unsubstantiated belief that functional gut disorders are somehow the product of gut spasm. Mid century brought more sophisticated treatises (and very unsophisticated cures such as purging and “electrogalvanism”). In 1849, Cumming asks incredulously: “the bowels are at one time constipated and at another lax in the same person. how the disease has two such diVerent symptoms I do not propose to explain. ” Were Dr Cumming to return to a modern consensus meeting, he would discover that this enigma remains unexplained! Cumming’s treatise contained one other comment in line with modern thinking about IBS, “One can tell, without more minute examination what the nature of the complaint is. ” The authors of this supplement agree with Cumming’s notion of a positive diagnosis, even though many doctors persist in recognizing IBS and the other functional gut disorders only after the patient has undergone extensive investigation. Medicine’s understanding of the IBS progressed little during the next 120 years. Indeed, it may have lost ground! In Edwardian times, functional disorders were considered diseases of the wealthy. In fact, only the aZuent could aVord to be the patients of the Harley Street doctors who published their observations in the medical literature. Through the writings of MetchnikoV and Arbuthnot Lane, constipation became associated with uncleanness. The quaint notion of “autointoxication” resulting from colon contents prompted an urge to purge that persists to this day. In the 1920s and 1930s pejorative descriptors such as “psychogenic,” “neurogenic,” and “The Abdominal Woman” did little to help patients with functional gut disorders. Proctalgia fugax was long thought to be a disease of young professional men, because only doctors had the temerity to describe their symptoms in letters to the editor of the Lancet. Use of terms such as “spastic colitis” and “hyperacidity” inferred etiologies that do not exist for these disorders. The first systematic attempt to bring discipline to this area was a 1962 retrospective review of patients with IBS seen at Oxford by Chaudhary and Truelove. From this experience, the authors were able to report many of the features that we recognize as those of the IBS (or the irritable colon syndrome as they termed it). They even separated IBS from what we now call functional diarrhea, and noted that one quarter of their patients’ complaints began with an enteric infection. Their report ushered in a new era, and scientific publications on functional disorders increased rapidly thereafter (fig 1). The first attempt to classify all the functional gastrointestinal disorders appears in the index of my book The Irritable Gut, published in 1979. In 1978, led by Ken Heaton, Adrian Manning and I reported results obtained by questionnaire administered to Bristol outpatients with abdominal pain and disordered bowel habit. The six of 15 symptoms we found more common in the IBS than organic gut disease (as determined by a chart review a year later) are now known as the Manning Criteria. (see C. Functional bowel disorders and D. Functional abdominal pain in this supplement). In 1984, Kruis and colleagues from Germany reported a similar study. Their report recalls the three cardinal IBS symptoms of pain, bowel dysfunction, and flatulence mentioned by Powell in 1818. If all three were present, IBS was highly likely. Kruis et al stressed chronicity and other symptoms as well, but their major contribution was to quantitate the alarm symptoms that should alert the physician to organic disease. These two discriminant function studies in addition to epidemiologic data provided by Drossman and Whitehead are the basis of the Rome criteria. The inspiration for the Rome criteria followed the 12th International Congress of Gastroenterology held in Lisbon in 1984. I chaired one of the earliest international symposia on the IBS, and my panel and the organizers of the Congress were astonished that despite untranslated presentations in three languages, the attendees far outstripped the capacity of the assigned room. One of the panel members was Professor Aldo Torsoli, an organizer of the next international congress to be held four years later in Rome. Over coVee in Portugal, we discussed the need for Figure 1 Results of a Medline literature search for irritable bowel syndrome (IBS) and irritable colon syndrome (ICS) by decade, for the 30 years ending with 1997. Note the rapid rise in publications, and the relative decline in the use of the term irritable colon. 1000