PEOPLE WHO INSTILLED FIBRE HYPOTHESIS IN BURKITTS MIND- PART 3 NEIL STANDFORD PAINTER, MS (London), FRCS, FACS (1923–1989)

Neil Standford Painter was born on 23 February 1923 in London. He was the only son of Robert Painter and Dorothy Matthews. His father was an engineer. He studied at St.Michael’s school, Otford Kent. He got a scholarship to join in Woodbridge School, Suffolk. After finishing school, he served as pilot from 1941 to 1946 in Fleet Air Arm.  On demobilization, he went to St Bartholomew’s Medical School, qualifying in 1952. He worked as a junior in various London hospitals, later he was appointed as prosector in the department of anatomy at the Royal College of surgeons under Professor G W Causey in 1955.

                                          

He passed FRCS in the following year and became registrar to the surgical professional unit of St.Bartholomew’s Hopsital under Sir James Paterson Ross and Professor G W Taylor.  In 1959, he became senior registrar at the Radcliffe Infirmary, Oxford. During this time, he measured the intraluminal pressure in the sigmoid colon in healthy patients and those with diverticular disease and undertook research into the effects of drugs on these pressures under the guidance of gastroenterologist Dr Sydney C Truelove. He was able to demonstrate the mechanism for the production of diverticula and published the results in Gut, his MS thesis and presented it in his Hunterian lecture in 1963.

Pictures taken from  John H. Cummings and Amanda Engineer. Denis Burkitt and the origins of the dietary fibre hypothesis. Nutrition Research Reviews (2018), 31, 1–15

Diverticula is protrusions of the inner lining of the bowel through the wall usually between thickened layers of muscle fibres . It is seen with increasing age. Painter showed that under resting conditions there were no differences in pressures between those with diverticulosis and healthy colons but when morphine was given there was a greater increase in pressure in those segments bearing diverticula.  Hence he pointed out that morphine should not be used to treat the the pain of diverticular disease.

Not much was known about the etiology of diverticular disease of the colon at that time. They used low fibre diet to treat them. However, Painter argued in his MS thesis and his Hunterian lecture to the Royal College of Surgeons in 1963 that diverticula are due to localised high pressures developing in segments of the colon.

Painter was aware from the literature that Africans seldom developed it, had wide colons and ate a bulky diet. Painter concludes in his thesis in 1962 by saying that ‘It maybe surmised that a low residue diet leads to narrowing of the colon and this allows segmentation and subsequent pressure production to occur more frequently. …From observation of African colon, which are usually more distended and do not get diverticular…It is therefore possible that a bulky diet lessens the probability of segmentation occurring and hence prevents onset of diverticulosis.’ He had clearly identified bulky diet as important.

He became a full-time consultant surgeon in Manor House Hospital in Golders Green London in 1965. He used Normacol to treat his patients.  Normacol, contains ‘sterculia’, a vegetable gum from the karaya tree that has established properties as a fibre laxative.  Like Painter used Normacol, Cleave had used bran to treat constipation in sailors in the Royal Navy. This shows they both had a common interest. They met in 1966 for first time, and Cleave asked Painter to write a chapter in the next edition of his book ‘Sachharine disease’ on Diverticular disease.

However, the second edition of Cleave’s book in 1969 had only two paragraphs from Painter’s hand concerning the neurophysiology of pressures in the colon that Painter had proposed as a result of his Oxford work. Cleave largely avoided the use of the term ‘fibre’ and talks about low-residue and high-residue diets. Painter did not contribute to the third edition of the book and disagreed with Cleave over the aetiology of both diverticular disease and varicose veins.  

However,in 1967 Cleave encouraged Painter to start a clinical trial of bran in the treatment of diverticular disease. This study started in December 1967, ended in March 1971 and was reported in the British Medical Journal in 1972. Though the study had many drawbacks, like no control group etc etc, but the outcome made sense and it was probably right so the paper was accepted for publication. This paper and Painter’s earlier work led to a significant change in the management of diverticular disease and it is one of the iconic papers in the fibre story. Today fibre is still recommended for the management of this condition.

His book, Diverticular disease of the colon, a deficiency disease of Western civilization, published in 1975 revolutionised the therapy of the disease. He travelled widely attending international meetings. He was elected as a Fellow of the American College of Surgeons.

His recommendation to treat diverticular disease with a high-residue (fibre) diet was a turning point since the mainstay of treatment for the previous 100 years had been a low-residue diet. Painter was the first to suggest to Cleave that fibre, more than just bran, was important in the diet while Cleave widened Painter’s horizons regarding a group of diseases that might have a common cause.

Painter undoubtedly contributed to the final fibre hypothesis and influenced Burkitt’s thinking. But before Cleave, Campbell or Painter had turned their minds to fibre there was a biochemist in South Africa who had started to study the importance of fibre beyond bowel disorders to include CHD and other diseases afflicting Western populations.

References:

1.     https://livesonline.rcseng.ac.uk/client. Royal College of surgeons of England. Plarrs’ Lives of the Fellows.

2.    John H. Cummings and Amanda Engineer. Denis Burkitt and the origins of the dietary fibre hypothesis. Nutrition Research Reviews (2018), 31, 1–15.

Next post we will see about the biochemist in South Africa who contributed to fibre hypothesis.

                                                                            Written by Dr.Priyavadhana.