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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 neurotic 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.





Next: Muco-membranous Colitis

Previous: Constipation



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