Neurotic Intestinal Affections

There is a whole series of intestinal affections dependent on nerve

influence that get worse and better under stress of emotion or relief

from it. Probably the commonest of these is constipation, which is

dealt with in a separate chapter. Often these nervous intestinal

conditions are associated with other neurotic manifestations. On the

other hand, patients are seen who are absolutely without any other

sign of the neur tic habit, and have nothing like hysteria, yet who

suffer severely and rather frequently from intestinal neuroses. Most

of the people who react symptomatically to the eating of strawberries,

or of shellfish, or of pork in any form, or cheese or other milk

products, also have a definite tendency to certain skin neuroses and

to suffer from intestinal troubles as a consequence of emotional

states. It is hard to trace real causation in many of these

cases, because it is so easy to accept the patient's expressions that

they must have taken cold, or they must have eaten something that

disagreed with them.





Neurotic Diarrhea.--But it must not be forgotten that nervousness

alone, without any additional factor, may produce a disturbance of the

functions of the intestines, and may even increase peristalsis and

bring about severe diarrhea. Anyone who has observed students going to

examinations has surely seen many examples of this. There are some

individuals--fortunately they are rather rare--who always suffer from

diarrhea when they have to take a serious examination. Some of these

cases are pitiable because the effects are quite beyond control, and

make it almost impossible for them to do justice to themselves.





Fright and Loss of Bowel Control.--Severe disturbance, such as

fright, may bring on this paralysis of proper regulation of

peristalsis, with consequent imperative intestinal evacuation. A

classical case in history is that of James II, for whom the Irish

soldiers invented a special name because of the tradition that he

suffered from an intestinal accident in one of the battles with

William of Orange. The imputation of cowardice on the last of the

unfortunate Stuarts has been completely wiped out by the investigation

of recent historians, and James' character for bravery has been

thoroughly vindicated. The fact that the story should have gained

credence shows that there is a general persuasion and popular

tradition that such intestinal incidents do occur from fright. An

incident told of the Franco-German War illustrates this, though I do

not vouch for the facts. Wishing to test the bravery of some soldiers

whom he was to send on a very dangerous expedition, and above all to

try how they would bear up even before the threat of instant death, an

officer of the French troops is said to have asked that half a dozen

brave men be sent to him. Without a word, he announced that there had

been treason in the ranks, and that the army needed an example. They

were condemned to be shot. A platoon of soldiers was drawn up, the men

were placed with their backs to a wall and they were asked whether

they wished to be blindfolded. They refused though they protested that

they did not know why they were being put to death. Then the word fire

was given. All of the men, excepting one, fell down, though the guns

of the firing party had been loaded with blank cartridges. The one who

remained standing was told that he was the man who would be selected

to go on the expedition, which, though perilous, was also of great

glory for himself and profit for his country. He said that he was

ready to go, but he asked permission to be allowed to change his

clothing, as he had not been able to keep as good control over his

intestinal muscles, as he had over his muscles of station.



Fright often has this effect in children. These stories and traditions

illustrate the influence of the mind and of deep emotions over the

intestines, and while only profound mental disturbance will produce

the most serious effects, there seems no doubt that lesser emotions do

interfere with normal function. This phase of the subject serves to

strengthen the contention that over-attention to the bowels may bring

about constipation by causing increased inhibition of peristalsis,

just as severe emotional disturbance may paralyze inhibition and so

bring about increased peristalsis with consequent diarrheal symptoms.







Habitual Diarrhea.--There are certain forms of chronic diarrhea,

usually considered most intractable, that owe their origin and

continuance to neurotic conditions of the intestine, rather than to

any gross organic lesion. In these cases the bowels acquire the habit

of emptying themselves two or three or more times a day, and the

stools are seldom formed. All sorts of physical treatment are employed

for these conditions, usually without avail, but whenever the

patient's mind can be set at rest, and his attention distracted from

his bowels by thorough occupation with some interesting work, the

intestinal disturbance gradually becomes less annoying. Ordinarily,

when stools have been frequent for a prolonged period, the case is

considered more or less unamenable to treatment. So far as ordinary

drug remedies go, this is true. What is needed is attention to the

patient's mind, to his habits of life, and to his worries, and the way

that he takes them. The illustrations given of the influence of the

mind over the bowels should make it clear that this therapeutic

principle can be of far-reaching significance and must be applied

deliberately and with confidence in the results.





Worry as a Factor.--Very often it will be found that the diarrhea is

particularly bothersome on days when the patient is worried. In a

clergyman friend and patient who was building a church, the approach

of days on which bills and notes became due, was always the signal for

a diminished control over his bowels, and there were frequently three

or four stools in the day. On his vacations, when eating unusual

things, drinking unaccustomed water, exposed to changes of

temperature, all the factors that give many people diarrhea, he was

perfectly regular because the worries had been lifted from his mind.

In another case, where for fifteen or twenty years a writer living

much indoors had had tendencies to diarrhea, always made worse by

worries, self-discipline and the refusal to let troubles occupy him by

always turning to something else, did him so much good that he

considered himself cured. In his case the return of a manuscript from

a magazine would always affect his bowels unfavorably. If, as

sometimes happened, he found that the manuscript had been returned

only for some corrections, there would be an immediate relief of his

condition.





Change of Mode of life and Intestinal Control.--An interesting phase

of the neurotic or mechanical disturbance of peristalsis is found in

the interference with regular movements of the bowels when persons are

aboard trains for long distances, or for more than twenty-four hours.

There are very few people who are not bothered in some way by such a

journey. Those of a nervous temperament are likely to suffer from

diarrhea. This is usually attributed to catching cold because of

drafts, but in recent years, when well guarded Pullmans eliminate

drafts to a great extent, the bowel disturbance continues. For the

majority of people, however, constipation results. The cause of it

seems to be due to a disturbance of peristalsis in the line of

inhibition because of the vibration and jolting of the train. The more

or less conscious assumption of definite positions of the muscles of

the abdominal region in order to save the body from the action of the

unsteady movement of the train, seems to be reflected in the sphere of

peristalsis with consequent constipation. There are other features,

such as a lessened consumption of food and water and absence of

exercise, that seem also to have an influence. If the journey is for

several days patients should be advised to walk out during the longer

stops.







Mental Influence and Indifferent Remedies.--The best evidence that we

have of the influence of mind upon the intestinal tract, and the

importance of employing that factor for therapeutic purposes, is found

in the number of cases of various intestinal disturbances, often

apparently chronic in character, which have been cured by the

administration of quite indifferent remedies. Dr. Hack Tuke in his

"Influence of the Mind on the Body" reports a number of cases in which

bread pills were used with good effect. Pillulae micarum panis were

not an infrequent prescription in preceding generations. They are

usually supposed to have been effective only against the curious

symptoms that develop in hysterical women, but it must not be

forgotten that neurotic manifestations connected with the abdominal

region may occur very freely in men, and that treatment by suggestion

in connection with some remedy, real or supposed, is the most

efficient cure. The "British and Foreign Medical Review" for January,

1847, has a series of cases among naval officers which were reported

by a surgeon of long standing and wide experience. These cases include

painful intestinal psycho-neuroses, occasionally accompanied by

diarrhea, and sometimes by constipation and sometimes even by

dysenteric movements, all cured by bread pills when these were

administered in certain definite ways, and the patient's attention

concentrated on their expected effects. Bismuth lost its effect in one

case of repeated colic, opium was beginning to lose its effect. The

patient was then told that on the next attack he would be put under a

medicine which was generally believed to be most effective, but which

was rarely used on account of its dangerous qualities, and that would

not be used unless he gave his consent. At the first sign of his next

attack, a powder containing four grains of ground biscuit was

administered every seven minutes while within the hearing of the

patient the greatest anxiety was expressed lest too much should be

given. The fourth dose caused an entire cessation of pain. On four

other occasions, the same remedy was employed with equal success for

the same sort of attack. In a seaman who was suffering from obstinate

constipation which resisted even the strongest purgatives, including

Croton oil, pills consisting of two grains of bread were administered

every seven minutes, and the patient watched with very apparent

anxiety lest an overdose should be given. Within two hours he began to

have nausea at his stomach, which had been foretold as one of the

symptoms to be expected, and his bowels were freely open almost

immediately after. Apparently the administration of the bread pills

eventually cured his constipation.





Skin and Intestinal Sympathy.--Curious intestinal conditions are, as I

have said, often associated with neurotic manifestations of other

kinds. Attacks of hives and other neurotic skin disturbances are

common in association with nervous diarrhea. Sometimes the attack of

hives precedes the intestinal disturbance; sometimes it accompanies

it. Soon after eating the offending material, the skin manifestations

may begin and other symptoms follow. Only a few minutes elapse, even

when the patient does not know that the offending material has been

eaten, because it is concealed in some combination, yet the reaction

takes place evidently not from digestive absorption, but from

intestinal reflex. Very often there is vomiting, as well as diarrhea.

It is not hard to understand that in these cases there is produced an

irritation of the intestinal mucosa, corresponding to that seen in the

skin. Whenever this occurs, it is not surprising that there

should be evacuation of the contents of the digestive tract in every

way that nature has provided for removing irritating material. The

simple nervous diarrhea is often spoken of as an "intestinal blush,"

as the neurotic disturbance of the bladder which causes frequent

urination is spoken of as a "vesical blush." Blushing is certainly the

external manifestation that corresponds most closely to the

disturbance that is probably the basis of these curious

manifestations.





Urticaria and Diarrhea.--Patients who suffer from urticaria readily

are almost sure to have other neurotic disturbances, and their

intestines seldom escape. On the other hand, those who have an

idiosyncrasy for certain kinds of food are almost sure to have other

nervous neurotic disturbances, which emphasize the fact that these

curious idiosyncrasies are of reflex nervous origin, rather than due

to any chemical irritation.



Some of these lesions of the intestinal tract related to urticaria may

affect, either primarily or secondarily, the biliary structures. Under

these circumstances there may be symptoms resembling true biliary

colic with some jaundice and pain that radiates toward the right

shoulder. Whether these bile symptoms are due to the occurrence of

actual urticarial lesions in the bile duct, or so close to the papilla

of entrance of the gall passages into the intestine as to occlude it,

is doubtful. Practically all the symptoms of the presence of biliary

calculus may be thus simulated. The differential diagnosis can only be

made by the rapid clearing up of the symptoms, and by the history of

the case. As a rule, where there is the story of repeated attacks of

neurotic intestinal disturbance, the physician and especially the

surgeon, should be slow to conclude as to the presence of a serious

pathological condition anywhere in the intestinal tract, unless the

symptoms are absolute. This is all the more necessary because now, in

patients' minds, the words appendicitis or biliary calculus are

associated with the thought of operation. This thought sometimes gives

rise to so much dread as to seriously disturb the appetite and still

further predispose the patient to the repetition of neurotic

intestinal trouble.



In the chapter on Abdominal Discomfort, the necessity for absolute

assurance of some definite lesion before there is any question of

operation, is insisted on. Here the disturbing mental influence of

suggestion, with regard to certain serious abdominal conditions, may

be emphasized. Many painful conditions in the abdomen are either

primarily or secondarily due to appendicitis. Most of these are quite

acute, and practically all amenable to definite diagnosis. There is,

however, a tendency to exaggerate the place that this organ holds in

the pathology of chronic cases. Many women who suffer from nothing

more than hysterical abdominal conditions are told by someone that

they have recurrent attacks of appendicitis, though there is nothing

except their suggestive complaints of pain on which to found such a

diagnosis, and then it becomes extremely difficult to remove this idea

from their minds, and contrary suggestion applied over a long period

is the only therapeutics that favorably affects them.





Intestinal Idiosyncrasies.--I have had the opportunity to see a series

of cases of intestinal idiosyncrasy in a family that has been an

interesting study for many years. One of the members has the most

exquisite case of susceptibility to various articles of food that I

think I have ever seen or heard of. Even the eating of a little

unrecognized pork in sausage will give rise to a diarrhea so intense

that there is no peace for hours, and slight movements take place

every few minutes. Towards the end of the attack, there is always

considerable blood in the stools. Often the attack is preceded by

vomiting. While in most people the idiosyncrasy is limited to one

article of food, this patient has it for all of the articles that are

usually the subjects of idiosyncrasy. Besides pork, shell-fish will

produce vomiting and diarrhea within a few minutes, strawberries act

detrimentally at once, and cheese produces an almost immediate

reaction.



The most interesting feature of this case is that occasionally an

attack of diarrhea that is extremely severe, will occur merely as a

consequence of a strong emotional stress. Any great anxiety will have

this effect. The knowledge that someone has a telegram for her whose

contents she can not ascertain for a time, will act as a cathartic.

She also has other neurotic manifestations, especially of an

urticarial character, that are equally interesting. On a number of

occasions, when she has particularly prepared for some special event

such as a wedding or reception, for which a new gown has been provided

and preparations made with considerable solicitude to the end that she

shall appear at her best, she has suffered from a severe attack of

angio-neurotic edema affecting either her lips or her eye-lids so that

it was absolutely impossible for her to be present at the social

engagement. This has happened to her over and over again. On the first

two occasions, one eye was closed completely by the edema. In each

case she attributed it to the sting of an insect. There was no sign of

any sting, there was no itching or inflammation, the condition

presented all the signs of angio-neurotic edema, had come without

warning, and disappeared in from 36 to 48 hours without leaving any

mark or trace of its origin.



There is absolutely not a sign of hysteria in this individual, nor is

there any tendency to what would be called an emotional neurotic

condition. On the contrary, she is lively and sensible, the life of

her friends when they are ill, their consolation when they are in

trouble, and she herself has shown the power to bear trials and

difficulties. It is only the peripheral circulation in the intestinal

mucosa, and in the skin, that passes from under her control. She

neither laughs nor cries without reason and she has no other

exaggerated nerve reactions. Even more interesting is the fact that

the angio-neurotic condition can be traced in the preceding

generation, while the tendency to an intestinal neurosis complicated

by diarrhea exists in a sister in this generation. Examinations are

always a source of grave distress to the sister. Although she is a

bright intelligent woman she does not do justice to herself because of

her nervousness. Usually she has a vomiting spell in the morning

before the examination, and rather serious intestinal disturbance

during the day. That this is entirely neurotic is clear from its

constant disappearance immediately afterwards, and its constant

reappearance whenever there is this form of emotional stress.



In certain of these cases of supposed neurotic, intestinal troubles,

one cause of the condition sometimes fails of recognition. Many of

these people are found on inquiry to be taking much more salt than

usual. It is hard to understand how this occurs, but I have seen it in

a number of cases, sometimes in men, but much more frequently in

women. Some sort of a vicious circle has been formed: probably

their original tendency to diarrhea led to a craving for salt, because

of the excessive serous evacuations. Somehow, then, the habit of

taking more salt was formed and its presence reacted to produce

irritative conditions in the patient, which, combined with neurotic

tendencies, produced the intestinal disturbance. I have seen chronic

diarrhea, mucous diarrhea, and even mucous colitis, associated with

the over-free taking of salt. When salt was eliminated from the diet

the cases at once improved. We now realize the value of a salt-free

diet for many conditions disturbing osmosis, and the presence of serum

where it should not be. It is probable that most people take more salt

than is good for them.





Intestinal Troubles Due to Air.--One of the most annoying intestinal

troubles due to a neurosis is the passage of air from the intestines,

or in some people a rumbling through them, which is distinctly of

neurotic origin. It is increased under emotional stress or whenever

there is anxiety with regard to it. This is much more common in the

old than in the young, as if relaxation of tissues had much to do with

it. Old men seldom complain of it to their physicians, but for obvious

conventional reasons, we are rather often asked to control it in older

women, and are occasionally asked to treat poignant cases of it in

young women. The older women are often stout, of flabby constitution,

and one has almost to accept the conclusion that the real trouble is

such a relaxation of the intestinal walls that the empty intestines do

not fall together as they used to, but rather tend to lie apart from

one another with the production of spaces into which gases, perhaps by

diffusion from the blood, find their way and are expelled. Usually

these patients were stouter than they now are.



Often after these patients have walked outside for some time,

especially if they have become quite tired, and then sit down inside

and become warm, the expansion of the air in the intestines leads to

some rumbling and the production of flatus. This experience is so

common with elderly people, when they come in in cold weather, that

they do not feel quite right unless it actually happens. The odor of

the flatus is seldom offensive.





Air Swallowing.--There seems to be no doubt that a certain amount of

air is swallowed, that it finds its way along the intestines, and

then, with the change of temperature on coming into the house,

expansion takes place and the air finds its way out. In certain

patients the habit of swallowing air may grow, and the necessity for

its evacuation, either by eructation or flatus, may be a source of

great discomfort. The latter form of relief may be impossible owing to

conditions, though it is quite as natural as other forms of the

evacuation of the bowels, and it must not be considered pathological

unless it becomes too frequent. People of other civilizations than

ours are not so sensitive in this matter. A late distinguished Chinese

Ambassador to this country relieved himself of an accumulation of gas

in his lower bowel quite as indifferently as he would have of gas in

his stomach--but without so much as "by your leave" and evidently

without a thought of anything unseemly in the act--apparently to his

own great satisfaction, though sometimes to the consternation of the

bystanders. Utterly failing to understand why he should not permit

himself this satisfaction, he peremptorily refused to conform to our

Western refinements in this matter.



In many of these cases habit may add to the necessity for relief of

this kind, and habit may require considerable self-discipline

and training of organs to overcome it. To attempt to control this form

of intestinal trouble by ordinary intestinal remedies, and especially

by carminatives, is almost sure to increase it rather than do any

good. It is the patient's mental attitude toward the affection that

must be modified, and the intestinal bad habit must be brought under

control.





Intestinal Uneasiness.--In young women the cases are much more

serious, for the presence of gas in the intestines sometimes leads to

such dread of physical events over which they fear they may have no

control, that it makes it impossible for them to carry on their

ordinary occupations, hinders their conformance with social usages, or

even their association with any but very near friends. The cases are

not frequent, but are poignant when they occur. Many young women

suffer from rumblings in the intestines whenever more than four hours

have passed since their last meal. This phenomenon is not likely to

manifest itself unless they are nervous, excited and worried over

something, but is particularly likely to be troublesome when they are

with persons whom they are most solicitous to impress favorably. The

manifestation is undoubtedly associated with emptiness of the

intestines and relief will usually be afforded by taking something to

eat, even something so simple as a glass of milk and some crackers,

shortly before the time when the rumblings are usually heard. Dread of

this annoyance plays a large role in it, and it is due to an

exaggeration of peristalsis with the consequent crowding into larger

masses of small quantities of air that ordinarily would find their way

much more slowly along the intestinal tract. Milk of bismuth will do

more than anything else, though the presence of a certain quantity of

food is probably the best prophylactic and remedy.



Besides these cases, there are some that are even more annoying. These

occur in young women who have all the symptoms of an approaching

intestinal evacuation, and then find when they have excused themselves

that there is nothing but gas to be passed. This gas is nearly always

quite inoffensive, and is evidently air that has been present in the

intestines for some time, and has in the midst of the excitement of

peristalsis been forced on into the rectum and gives the sensation of

an approaching stool. These cases are coming into notice much more

commonly since young women have taken up business occupations. The

symptoms are worse in those who are constipated, though sometimes in

these cases there are recurring attacks of diarrhea showing that the

normal function of the intestine is disturbed. It is more annoying

just before and during menstruation than at any other time.





Physical Basis.--Whenever the patients are run down in weight there

is a distinct exaggeration of the condition. Whether the loss of

weight, by removing fat from within the abdomen, does not tend to make

the intestines more ready to take up air and to produce these

manifestations is a question worth considering. The most annoying

cases that I have seen were in people who had lost considerable weight

and though there had been some tendency to the condition before they

lost weight, it was doubtful whether the symptoms were greater than

those often seen and which are not productive of special annoyance

except in very sensitive people. In three of these cases that have

been under my observation in recent years, improvement came promptly

when weight was put on. The presence of an abundance of fat in

the abdominal cavity seemed properly to balance the intestines and to

dampen peristalsis.



Reassurance, absence of worry, occupation of mind with interests that

keep it from putting such surveillance on the intestinal tract as will

surely be resented, must be the chief care of the physician. Without

these any relief afforded will be only temporary. With psychotherapy

relapses will occur, for these individuals are in a state of unstable

intestinal equilibrium, but practically all the successful remedies of

the past have been founded on it and its effect may be renewed over

and over again under various forms.