A fair question is why someone would select the topic of “diarrhea and constipation?” When selecting a topic, an author would preferentially select a subject matter with little prior discussion, as if not, the proposed article would be a rehash of research already compiled by others. The topic of “diarrhea and constipation,” as seen through the eyes of science and of Torah, has not, as yet (at least, to my knowledge), been reviewed. Once the research process was started, interest - especially in the synthesis of Torah and science -  was motivational enough to propel the project.

The digestive tract is a mucous membrane-lined tube, beginning with the mouth and proceeding to the pharynx, esophagus, stomach, small intestine, and large intestine, terminating with the anus. Ingested food passes through this tube, in which it is digested to small molecules which pass through the inner lining of digestive tube and into the internal blood vessels. Digestion of food and uptake of nutrients occurs primarily within the small intestine. All undigested material eventually arrives in the large intestine, also termed the colon, where it can be further digested by the indigenous colonic microbiota.  The billions of bacteria that colonize the inner walls of the colon perform other beneficial activities, such as synthesizing vitamins B and K and metabolizing bile acids, sterols, and xenobiotics. The main function of the colon is the absorption of water and salts and the concentration of the undigested wastes (termed, feces or stool) into a substantial mass.  Every day, organs of the digestive system release up to nine liters of liquid secretions, primarily water, into the digestive system. Most of this water is reabsorbed into the blood from the colon. Muscles line the walls of the small and large intestines and squeeze the material through the tubes; this process of wave-like muscle contractions that sweeps over the intestines is termed peristalsis. Stool, evacuated at the rectum, consists of undigested wastes and bacteria, which constitute a significant presence in the feces (1-3).

Diarrhea and constipation are opposite sides of the defecation process, focusing activities within the colon. Diarrhea is the condition in which there is frequent defecation of loose, watery stool, usually due to irritation of the colon. As a result of the irritation, peristalsis increases and the materials move rapidly through the colon, preventing adequate absorption of water.  Common intestinal irritants include viruses and bacteria of the genera, Salmonella and Shigella. Tourists traveling in developing countries may develop “traveler’s diarrhea,” the phrase describing diarrhea resulting from ingestion of bacterial contaminated water and food by tourists traveling in countries with inadequate sanitary conditions (1, 2).  Severe bacterial infections may result in exudative diarrhea, in which blood and pus are present in the stool. Another type of diarrhea, termed osmotic diarrhea, occurs when too much water is drawn into the bowels from the body, commonly resulting from the consumption of excessive salt or sugar (4).  Diarrhea is more than just an uncomfortable situation. Excessive water loss may lead to dehydration, as well as loss of important ions, such as bicarbonate, calcium, potassium, and sodium. Prolonged diarrhea in an adult for more than 48 hours requires medication and in children and infants, diarrhea can be life threatening (1).  

In the Talmud, intestinal health issues are termed “choli me’ayim,” which includes several bowel diseases. However, according to Dr. Julius Preus (5), choli me’ayim refers primarily to diarrhea, which  apparently was accepted by Rabbi Avraham Steinberg (6).  A sign of choli me’ayim is the evacuation of abundant excrement (Sotah 42b). Choli me’ayim, common in those kohanim working in the Beis HaMikdash (Shekalim 13a), was related to their requirement to walk barefoot on the cold stone floor, their lack of warm clothing, as they only wore priestly vestments, and their consumption of huge quantities of meat (korbonos), e.g., the shelamin and the chatus offerings.  As it was forbidden to allow any sacrificial meat to be left uneaten past a designated time, the kohanim were under pressure to consume the korbonos within the same day as the sacrifice was performed. The kohanim were often ill. The situation required the professional assistance of the gastroenterologist, Ben Achiya. Being cognizant of herbal medicine, Ben Achiya formulated medicinal remedies for the kohanim (Shekalim 13b) (7). The kohanim, consuming large quantities of salted meats, may have experienced osmotic diarrhea.  In addition, beef probably was not readily consumed by the general population. Once a cow or bull was slaughtered, as there was no refrigeration to prevent microbial contamination, the entire animal needed to be consumed within a short time span. Thus, eating beef probably was an uncommon occurrence among the general populace, including among the kohanim when not working in the Beis HaMikdash. Possibly, kohanim consumed substantial quantities of beef only during the two week period that they were scheduled to work in the Beit HaMikdash.  The Talmud recognized that a change in life style, including of diet and even for the better, causes choli me’ayim (Nedarim 37b; Kesubos 110b). Even eating rich foods on the chagim may spoil one’s joy because of the resultant choli me’ayim (Sanhedrin 101a).

Hospitalized patients frequently are constipated, possibly due to intake of various medications, especially strong pain relievers, such as narcotics, antidepressants, and iron pills. Thus, soft stool would be a sign of healing.  According to the Talmud (Berachos 57b) diarrhea, provided it is not dysentery, is a favorable prognostic sign in the ill. Patients with diarrhea emit an unpleasant odor and, in Talmudic times, it was customary to place a pan of incense under their bed (Moed Katan 27b). Today, a room deodorant would be used. The Talmud enumerated numerous food items that induce diarrhea, including dates (Kesubos 44b; Gittin 70a), isparagus (spinach?) made in beer (Berachos 44b, Sanhedrin 64), barley bread, fish brine, and beer (Shabbos 108a).  The Ph’listim had the strange custom of honoring their idol, Pe’or, by defecating in front of it. Rashi (Sanhedrin 64a) made note that the Ph’listim would consume beets and fresh beer, which acted as laxatives, to loosen their bowels to defecate before Pe’or.

In Shabbos (110a) an aqueous solution is noted that, on the surface, appears to be similar in effectiveness to the liquid consumed by present-day patients prior to undergoing a colonoscopy. The diarrhetic drink is produced from water of a spring that passed between two telai palm trees. Drinking one cup loosened the fecal matter within the intestines and drinking two cups induced the purging of all fecal material. If one drank a third cup, the liquid evacuated from the colon was clear.  Today, a popular laxative prior to undergoing a colonoscopy is the ingestion of a solution of magnesium citrate. The spring that passed between the two telai palm trees may have had an elevated content of a similar salt with laxative properties. 

Talmudic remedies for diarrhea included external rubbing of the abdomen with oil and wine (Shabbos 134a) or the application of heat (Shabbos 40a). Ingestion of an Egyptian concoction of barley, safflower, and salt was used as a binding agent for patients with diarrhea. A variant version of this binding concoction substituted wheat for barley (Shabbos 110a). Today, kaopectate, a suspension of kaolin, a clay mineral, and pectin, a high molecular weight carbohydrate in fruit, is an over-the-counter medication commonly used to treat diarrhea. Bananas, rice, apples, and toast are foods with  antidiarrheal properties. Rambam mentioned pomegranates, quinces, apples, and small pears are binding foods (Mishneh Torah, Sefer Madda, Hilchos De’os, chapter 4, Halacha #6).  Apple wine older than seventy years is helpful for choli me’ayim (Avodah Zarah 40b). There is an interesting controversy regarding the medicinal properties of ingesting fine flour and eggs.  One thought (Rashi) was that it induces diarrhea and the other thought (Tos. HaRosh) was that it is a binding agent. On the morning of the eve of Yom Kippur, the kohan gadol was given fine flour and eggs, so that he would not need to relieve himself on the day of Yom Kippur - either because his intestines already were purged prior to Yom Kippur or because he was constipated on Yom Kippur and would not need to relieve himself (Yoma 18a).

Whereas it is a mitzvah to visit the sick (bikur cholim), the Talmud (Nedarim 41a) noted that this does not apply to visiting an individual with diarrhea. Such visits may embarrass the sick person when he needs to relieve himself. Additionally, those with intestinal disorders emit offensive odors which will further embarrass the patient. The Talmud (Nedarim 41b) further elaborated to avoid visiting a sick person who contracted bordam, described as a bloody diarrhea (possibly, dysentery - an inflammatory disorder of the lower intestinal tract, usually caused by a bacterial or protozoan infection) or bleeding hemorrhoids (discussed later). Bloody diarrhea is indicative of several health issues, including bacterial infection of the intestines (8). As contagion was possible, avoiding individuals with bloody diarrhea due to microbial contamination was helpful as it limited spread of the infection. II Chronicles (21:14-18) noted that King Jehoram suffered from severe dysentery or, perhaps, colorectal cancer (8), causing his bowels to fall out and resulting in his death.

Constipation, difficult or infrequent fecal elimination, is the opposite of diarrhea. Constipation, one of the most common gastrointestinal complaints in the United States, occurs when the colon absorbs too much water or when the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools can become hard and dry (1). Constipation can be caused by various personal life-style factors, including the habitual consumption of highly refined foods, of low-fiber foods, and of the low intake of liquids, a sedentary life-style, a lack of exercise, and lack of access to toilet facilities coupled with the consistent suppression of the urge to evacuate the colon (9).  The symptoms of constipation include infrequent bowel movements, the sensation of incomplete bowel evacuation, and difficulty during defecation, described as straining during more than 25% of bowel movements (10). Straining can led to hemorrhoids. Severe constipation, which includes the inability to pass intestinal gas and fecal impaction, can progress to bowel obstruction and become life-threatening (11).  Rav Elazar ben Azaryah explained that constipation was as difficult as the day of death and relieving it was as difficult as the splitting of the Sea of Reeds (Pesachim 118a).  

Constipation keeps fecal material in the colon for a prolonged time span. A little discussed issue regarding the potential hazard of stool remaining longer in the colon than necessary is the connection between constipation and colorectal cancer. Researchers investigated the prevalence and incidence of colorectal cancer and benign neoplasms in 28,854 patients with chronic constipation and 86,562 controls without chronic constipation. Chronic constipation is defined as the condition of infrequent bowel movements - typically fewer than three bowel movements a week - and the difficult passage of stool. Both colorectal cancer and benign neoplasms were more prevalent in chronic constipation patients compared to the control population free from chronic constipation. The researchers postulated a causal link between constipation and increased colorectal cancer risk; in patients with chronic constipation the longer transit times increased the duration of contact between the inner wall of the colon (colonic mucosa) and concentrated carcinogens, such as bile acids, in the lumen of the colon (12).  Specific intestinal bacteria, such as Streptococcus gallolyticus and Clostridium septicum, play a casual role in colorectal cancer. Prolonged residency of fecal material in the colon would allow for greater bacterial metabolic conversion of dietary molecules to carcinogens (13).  As will be noted below, Rambam was particularly concerned about constipation in his patients.  

In the general population, constipation is treated by changes in dietary habits and in life-style and by stool softeners, laxatives, and enemas (10).  Dietary changes include an increase in the intake of water and in the intake of fiber, which increases the weight of the stool and enhances its movement through the intestines.  The importance of sufficient hydration was noted in the Talmud. One who ate but did not drink, his eating is tantamount to shedding his own blood, as this is the beginning of choli me’ayim (Shabbos 41a). Eating and drinking plenty of water prevent choli me’ayim (Berachos 40a). An important life-style change is to exercise, as physical activity increases muscle activity in the intestines. As stated in the Talmud (Shabbos 41a) walking 4 cubits after the evening meal prevents intestinal disorders, as the food “rots within him.” A person should not ignore the urge to have a bowel movement. Chazal taught that a person must properly care for evacuation of feces and that withholding or delaying this function was detrimental to health (Berachos 55a, 61b; Shabbas 33a; Gittin 70a; Nedarim 49b).  Laxatives are pharmaceuticals and herbal products that stimulate the bowel muscles to undergo peristaltic contractions or that direct more water into the bowel to relieve constipation (2).  The Talmud (Gittin 70a; Ta’anis 9b; Pesachim 88a) made note that dates are effective laxatives. An interesting approach to treating constipation was provided by Rav Yaakov Emden. The dangers of cigarette smoking were then unknown and he thought that smoking would be medically beneficial for relieving constipation. Hence, he permitted cigarette smoking on Tisha B’Av because of its laxative effect (14).

A search on the world wide web (www) with the key phrase “matzah and constipation” listed numerous articles and blogs on how to limit matzah-induced constipation. Matzah is prepared by mixing flour with water, which is immediately baked to form a crisp very dry type of “bread” with a high fiber content. Matzah consumption on Pesach has been associated with the induction of constipation. To show the comparative water absorbing capacity of matzah versus bread the following experiment was suggested. Place a slice of bread in a bowl, pour room temperature water over the slice, until it becomes soft and falls apart. Do the same with an equivalent-sized piece of matzah. It will require 2-3 times the amount of water to soften the matzah as to soften the bread slice. The same happens within the colon, in which a solid, firm mass of semi-digested high fiber matzah is formed, which will be difficult to evacuate. Ingestion of prunes and apricots are suggested to counteract matzah-induced constipation (15).

Rav Elazar ben Azaryah observed constipation to be as difficult as the day of death and relieving it as difficult as the splitting of the Sea of Reeds (Pesachim 118a).  The following Talmudic aphorisms of choli me’ayim focus on it causing much pain and, thus, appear to be more applicable to constipation than to diarrhea. Because of their intense pain, patients with choli me’ayim are forgiven for their sins (Eruvin 41b). Therefore, it is a good omen for a deceased person to have died of choli me’ayim, as most pious people suffer from it (Kesubos 103b). Rav would rather suffer from any illness but not choli me’ayim, which was very painful (Shabbos 11a). Tears in the latrine following strongly forced stool elimination are not good tears (Eichah Rabbah 2:15).  One who ate but did not drink, his eating is tantamount to shedding his own blood, as this is the beginning of choli me’ayim (Shabbos 41a). Eating when coupled with drinking plenty of water prevents choli me’ayim (Berachos 40a).

Rambam (Hilchos De’os, chapt.4) provided several recommendations for a healthy life, amongst which were suggestions regarding healthy bowel movements. Many of his recommendations parallel current medical protocol. In Halacha #1 he stated, “It is obligatory for man to avoid things which are detrimental to the body and to acclimatize himself to things which heal and fortify it. These are as follows: a person should never eat except when he is hungry nor drink unless he is thirsty. He should not postpone his eliminations for even a single moment, rather every time that urination or defecation becomes necessary he should respond thereto immediately.” In Halacha #5 mention is made of various food items that enhanced fecal elimination (e.g., figs and grapes) and others that caused constipation (e.g., apples and pears).  In Halacha #13 Rambam noted, “Man should always strive to have this intestines relaxed all the days of his life and his bowel function should approximate a soft stool. This is a fundamental principle in medicine, namely, whenever the stool is withheld or is extruded with difficulty, grave illnesses result. An active life style as related to adequate bowel movements is noted in Halacha #14. “Another major principle of bodily health, physicians’ state, is that as long as a person labors and becomes greatly fatigued and does not satiate himself and keeps his bowels soft, no illness will befall him and his strength becomes fortified, even if he eats detrimental foods.” Halacha #15 seems to be from a current medical textbook, “Anyone who lives a sedentary life and does not exercise or he postpones his excretions or whose intestines are constipated, even if he eats good foods and takes care of himself according to proper medical principles - all his days will be painful ones and his strength will wane.”

Rambam was a physician and many of his recommendations probably were derived from hands-on clinical cases that he treated. Additionally, many of his recommendations were gleaned from the Talmud, in particular, the mediating effects of dietary habits and life style choices on illnesses of the intestines. For example, Rambam’s recommendation of not to withhold the urge to defecate or to postpone defecation is suggested in the following incident in Nedarim (49b). [Noting, however, that the Talmud often exaggerates and that there are hidden meanings to various passages], the following incident was related. A Sadducee questioned Rav Yehudah concerning the reason for his radiant, luminous face. Rav Yehudah replied that there were twenty four lavatories between his home and the beit medrash and he would enter each one.

The following incident is recorded in Shabbos (82a). Rav Huna questioned his son, Rabbah, on why he was not sitting as a disciple before Rav Chisda, whose teachings are sharp? Rabbah responded to his father that Rav Chisda related mundane matters, rather than Torah.  For example, Rav Chisda discussed behavior when in a latrine - one who enters a latrine to relieve himself should neither sit down forcefully and nor should he overly stain himself to eliminate, for the rectum is supported by three “teeth” (i.e., the internal and external sphincter muscles). Sitting down forcefully and overly straining may cause the “teeth” of the rectum to become dislocated. Rav Huna explained to his son that Rav Chisda was dealing with issues that impact the lives of people and if he discussed matters of such importance, certainly he should go to him to study. Rashi (as explained in note #6 of the Artscroll edition of Shabbos, 82a) noted that sitting down forcefully or staining too much when evacuating the bowels can cause the rectal orifice to open wider than normal, weakening and tearing the sphincter muscles and causing the rectum to protrude through the anal opening. This condition, termed rectal prolapse, can make it impossible to defecate and is prone to infection. Today, it is known that most patients with rectal prolapse have a long history of constipation and that prolonged, excessive and repetitive straining during defecation may predispose a person to rectal prolapsed, which itself causes functional obstruction (16).

Hemorrhoids are blood vessels in the rectal area, that serve as cushions to assist in control of the evacuation of stool. However, when the blood vessels are swollen or inflamed, the condition is termed hemorrhoidal disease, which, internally may manifest as rectal bleeding and externally may cause pain. Constipation is the prime causative factor of hemorrhoidal disease. Treatment for cases of mild to moderate hemorrhoidal disease include increasing the dietary intake of fiber, ingesting fluids to maintain hydration, and taking pain relief medication; surgery may be recommended for serious cases of hemorrhoidal disease (11). Rambam, an authority on hemorrhoidal disease, viewed surgery as the last resort and preferred to advise the patient to undergo changes in life style and diet to soften the stool (17).

An interesting case of hemorrhoidal disease is presented in I Samuel. In chapter 4 the following incident unfolds. Against the advice of the prophet Samuel, the Jews go to battle against the Ph’listim and are defeated, suffering a loss of 4,000 soldiers. A revised plan for a second battle was formulated by Chafni and  Pinchus, Eli HaKohen’s sons. In this plan, the Ark of the Covenant was to lead the troops into battle. The ensuing battle was disastrous, with the Ark captured and Eli’s two sons, along with 30,000 Jewish infantrymen, killed. In chapter 5 the Ph’listim brought the captured Ark and situated it next to Dagon, their idol.  The following day, noting that Dagon had fallen, the Ph’listim returned it upright. Yet, the next morning the Ph’listim found that Dagon had fallen once again, but this time its head and two palms of its hands were severed. The Ph’listim remained steadfast and still acknowledged that their idol was powerful and was the source for their victorious defeat of the Jews. HaShem struck them with an embarrassing, humiliating, and painful pathology - hemorrhoids (5).  To add insult to injury, while the Ph’listim evacuated their bowels, mice would enter their bodies and pull out their colon (Rashi to I Samuel, chapter 5, verse 6).

According to Chazal, there are 10 causes of hemorrhoidal disease, related either to specific dietary habits or to defecation habits. For example, eating insufficiently cooked salted fish or leaves of reeds or vines caused hemorrhoids. Remembering that toilet paper was not, as yet, invented, [eople used smooth stones to clean the anal region. The Talmud mentioned that hemorrhoids may be caused by wiping the anus with lime, with clay or pebbles previously used by others, or with fresh grass (Berachos 55a; Shabbos 81a; Kesubos 101a). Hemorrhoids may result from prolonged sitting and limited walking (Kesubos 111a) and by anger (Nedarim 22a). By contrast, several dietary measures may eliminate hemorrhoids (Berachos 51a; Kesubos 10b). Dates, having laxative properties, are helpful to treat hemorrhoids (Kesubos 10b).

Today, a colonoscopy is a common medical procedure that permits the physician to examine the inner lining of the large intestine and the terminal portion of the small intestine. A camera is attached to a thin, flexible tube, the colonoscope, which is moved up the colon to identify areas of pathology, such as those with colon polyps (or, precancerous lesions), ulcers, tumors, and areas of bleeding. In the time of the Talmud, a variant diagnostic procedure - the turmita egg  - was utilized (Nedarim, 50b). The turmita egg is prepared as follows: the egg is place into hot water a thousand times and then into cold water a thousand times, until it has shrunk so that it may be swallowed whole. An individual with a gastrointestinal illness swallows it. If the person has such an illness, a residue forms over the egg. Upon excretion, the egg is examined and the physician will know which medication is needed to heal the patient. Israeli technology has upgraded the turmita egg to the pillcam, or capsule endoscopy. The pillcam is a pill encapsulating a tiny camera that is capable of transmitting high quality images. The patient swallows the pillcam and images, in real time, of the entire gastrointestinal tract are transmitted for analysis (18, 19).

An individual either with constipation or diarrhea should be knowledgeable of the various halachos that are triggered. Below, is a small sample of these halachos. In Talmudic times, medications were made by grinding herbs, spices, and other natural products into usable forms. As a result, Chazal forbad acts of healing on Shabbos, out of concern that a person might prepare a medication which involved the me’lacha of tochen (i.e., grinding).  Thus, a person with mild constipation would not be permitted to take laxatives on Shabbos. Normative behaviors, although they may have health benefits, were allowed (Shabbos 109b). Thus, a person with mild constipation would be permitted to drink prune juice, as that is something done by healthy people. However, if his constipation is bad enough to place him in the category of a non-seriously ill person, laxatives would be permitted. A person suffering from hemorrhoids may take medication on Shabbos to prevent constipation, as the laxative is intended as a means to prevent further injury to the hemorrhoids.  On Shabbos, an individual with severe constipation may be given an enema (20), the process of pushing a liquid into the colon through the anus and, thereby, to deliver medicines to treat constipation (2).  On Shabbos, if a person’s whole body suffers from diarrhea or if he is confined to bed, he is allowed to drink anti-diarrheal medications even if he is not seriously ill (Mishnah B’rurah 328:118). After evacuation of one’s bowels, he is obligated to recite the b’racha of Asher Yatzar. If a person has diarrhea and still feels an urge to relieve himself again, immediately afterwards, then he should wait and say one b’racha of Asher Yatzar (Mishna B’rurah 7:2). 

It is worthwhile to cite Halacha #14 in Rambam’s Hilchos De’os (chapter 4) in which this important rule is presented: “As long as one exercises, does not eat too much, and has soft bowel movements (i.e., is not constipated), no illness will come upon him and his strength will be great, even if he eats bad foods.” 

Acknowledgement

Appreciation is expressed to Samuel (“Shimshon”) Koslowsky, an alumnus of M.T.A. and Y.C., for reviewing this manuscript.

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