Psychotherapy

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.

CHAPTER VII

MUCO-MEMBRANOUS COLITIS

Probably the severest, certainly the most interesting of the neurotic conditions of the intestines, is muco-membranous colitis. The only lesions discovered are those which point to a functionally increased secretion of tenacious mucus from the lower bowel. No definite pathological changes are known. The colic seems to be due to nothing more than the effort of the large intestine to push off the thick mucus which has been secreted, and which in many cases clings to the bowel walls. This may be of such consistency that it is passed from the bowel in the shape of tubular casts. These casts have often been seen in place in the lower bowel. While the word membranous used in connection with the disease has produced the impression that this might be a form of diphtheritic affection, it is now known that it is only due to an abnormally increased function, and not to any structural pathological condition or infection of the lower bowel. The membranous material is often gelatinous, and so the casts may hang together in long pieces.

Neurotic Etiology.—It might be thought that such a cast could not be formed, remain in situ in the lower bowel for a considerable period, and then be passed as a whole, or in quite long portions, without causing serious tissue disturbance in the mucous membrane. As Sir William Osier says, in spite of the apparent improbability, the separation may and usually does take place without any lesion even of the surface of the mucous membrane. The epithelium seems to be left intact. Owing to the curious nature of the stools, the disease has been recognized for a long time and the descriptions of this disease by the older authors are very interesting. Muco-membranous colitis occurs mainly in nervous individuals, and is much more frequent in women than in men, but it is not limited to women. Some of the severest cases have occurred in men, and Woodward, in the second volume of "The Medical and Surgical Reports of the Civil War," has an exhaustive description of the disease as it occurred among soldiers. It is particularly those who are worried and run down from overwork and excitement who are likely to suffer from it, but it occurs typically in people who, faute de mieux, worry about themselves. Most of its victims are self-centered, though not hysterical.

Recent Increase in Number of Cases.—According to all the authorities, there has been a considerable increase in the number of cases in recent years. At one watering place in France, Plombiêres, which has acquired the reputation for relieving, or even curing the disease, about 400 cases had been under treatment during the course of about two years. This increase was attributed by Boas of Berlin to two causes. First the struggle for life has become much more intense in our day, and the nervous conditions which are practically always the basis of muco-membranous colitis, have as a consequence become more frequent. Not only this, but mild cases that were not called to the attention of physicians in the past, have become so emphasized by the nervous worries of the strenuous life that now they seldom escape the physician's attention. Besides our generation is getting away from the old-fashioned idea of patiently standing many pains and aches, and refusing to call in a physician unless the condition persists or seems to be producing serious results. There are more cases of the disease, but physicians also see more of the cases than formerly because patients come for treatment for slighter causes.

Dr. Boas considered that, besides the strenuous life, there was another prominent factor in the increase of the disease. This is the abuse of laxatives and purgatives. Many of these have their principal effect on the lower bowel. In consequence the nervous mechanism of this structure has been irritated to a point where occasionally explosions of nerve force take place. This causes an increase of the secretion, and a tendency to cramp-like contractions. While there is undoubtedly much of truth in this, there is no doubt that the most important factor in the disease is the patient's nervous condition. Only those who are inclined to be introspective, to worry much about themselves, and who are constantly examining their stools for the presence of mucus, suffer severely from the affection.

Very few cases have been seen among the working classes. Most of the cases have hypochondriacal symptoms that sometimes go to the extent of real melancholia and the full persuasion that they have an incurable disease, a visitation on them for some real or fancied lapse from the laws of health in earlier years. The affection usually lasts a long time, or has been in existence for some years when the physician is asked to see it, and patients are made most miserable by it.

Unfavorable Suggestion and Over-attention.—The pathological physiology of this disease, for, as has been said, it has no pathology in the proper sense of the word, is in many cases a problem of mental influence. For some reason, the patient gets his or her lower bowel on his or her mind. There is so much talk of constipation and its evil effects in the newspapers, in advertisements and by suggestion from bill-boards and in the magazines as well as, sad to relate, in parlors, drawing-rooms and even dining-rooms, that it is easy for those who are introspective and nervous about themselves, and who have some little tendency to constipation already, to become much worried about it. If, then, as was suggested by Boas, they take laxatives in profusion, the irritation set up further fixes the attention on this portion of the body. After a while, in these people, a goodly portion of the waking hours are spent in thoughts with regard to the lower bowel. The morning thought is the possibility of a stool to-day, followed by conjecture as to its character. After the stool has taken place, if there seems anything abnormal about it, comes a morbid dread of the consequences of having such stools.

This constant attention sends down a lot of impulses to the lower bowel. Anyone who has studied the psychology of attention knows how much influence can be exerted on the skin, or on the mucous surface by mental influence. Hyperemia is produced, and this leads to over-action of the glands of the large intestine. These glands secrete a glairy mucus which is necessary to protect the bowel from the offensive material that is always present, and from the hardened material that is so often there when there is a tendency to constipation. This mucus is secreted in large quantities, while at the same time a hyperemia of the colon tends to interfere with peristalsis and consequently to delay the passage of contents and to keep the mucus in place. An accumulation goes on for some time, until irritation is set up by the presence of such a large quantity of material in the intestine, and then colicky efforts for its removal are occasioned. All of this process is accompanied by suggestive reactions upon the mind that further complicate the case. This story of the affection points out the indications for treatment. Unless the patient's mind can be diverted from its constant attention to the lower bowel, the possibility of cure is distant, and even after such diversion any return of attention is likely to bring on a relapse.

Treatment.—The treatment of this affection emphasizes its neurotic origin. We have had any number of cures for it and each one has actually relieved many patients. The more trouble the cure involves, and the greater the impression produced on the patient's mind the more likely is there to be a relief of symptoms. All sorts of drugs have been employed. Many of them have for a time been heralded as more or less specific. The important thing, however, was that the patients should come predisposed to believe that they were going to be improved, and then that suggestion should be made at frequent intervals—a combination of auto-suggestion through the administration at regular intervals for a long period of simple remedies with the confident suggestion of the physician that the patient will get better. Local treatment of various kinds has been reported to bring about improvement. The more difficult this is, and the longer it takes, as well as the more bother it involves for the patient and the attendant, the better the response to it is likely to be. Long rectal tubes were found beneficial in many cases, though they failed in many others, and most physicians have seen relapses occur in spite of the continuance of the treatment that at first did much good. High injections of water containing various drugs, and of olive oil sometimes bring improvement though they afford no guarantee against a relapse. Mineral waters do good only in the suggestive environment of the spring.

Surgery and Suggestion .—The symptoms have sometimes been so severe and the complaints of the patients have been so great that even surgery of serious character has been recommended and tried in some of these cases. The making of an artificial anus in the right inguinal region, so that for a time the feces are not allowed to pass over the colon mucous membrane has been tried. This gives decided relief from the symptoms, but when the artificial anus is allowed to close, recurrences often take place. It has been suggested, therefore, that the artificial anus should be allowed to stay open for months, but even this seems to afford no guarantee against a relapse. In recent years the appendix has been taken out through the opening in the right inguinal region, and a portion of it allowed to remain through which, when fastened to the abdominal wall, injections might be made into the colon. In these cases ice-water has been found probably of more effect than any drug solutions. This rather serious surgical procedure is, however, as yet on trial, and we do not know enough about the after-course of the cases to be sure that it has any permanent effect.

A strong suggestion is involved in the removal of the appendix, and the use of the stump of it as an irrigating tube. When the treatment consists of something that is so strongly excitant of feeling as ice-water, applied directly to the colon, it is easy to understand that suggestion reaches the limit of its possibilities. No wonder these cases improve, though we are not sure as yet what happens after the appendix opening is allowed to close, or is deliberately sutured. I should expect a recurrence of symptoms, if ever a time came when the patient was run down in weight and worried by external conditions, introspection, and above all by concentration of attention on the intestines.

Direct Suggestion .—The question is whether suggestion can be used to advantage in these cases without employing any of the radical measures that have been suggested. There is no doubt that at certain watering places where a specialty is made of this disease, and to which patients go, sure that they are going to be much better than before, and where they see patients all round them who are improving, they often get complete relief. This is only what might be expected. Whether a similar effect can be produced by simple suggestion when the patient is thoroughly convinced that the physician understands the case, and that if they will respond he can cure it, remains to be seen. I know that mild cases improve rapidly under simple hygienic measures, with a renewal of confidence in the possibility of relief, and with the diversion of the patient's mind from the intestinal difficulty. This is the most important factor in the treatment, as it is the most important factor in pathology. If the patient's nerve centers can be kept from sending down impulses causing exaggerated action of the glands, then there is some hope of relief. A habit has been formed in the matter, and a habit can only be broken by a series of acts, just as it was formed. It is not effort for a few days nor a week that counts in these cases, but diversion of mind for long periods, until normal function is restored. It is usually quite impossible to keep up this improvement constantly in nervous patients. There are setbacks, but then this is true in every form of nervous affection. It is, then, that the renewed suggestion of the physician is needed.

Resort Cures and Suggestion .—Physicians often tell patients that muco-membranous colitis is incurable, or at least emphasize strongly that it is very refractory to treatment, and that it is prone to relapse even after improvement. After a certain number of physicians have insisted on these points, it is inevitable that patients should not respond readily to treatment, and that they should be solicitous about themselves, even when improvement does come.

It is most important then to bring about the neutralization of these unfavorable suggestions. This is what is particularly accomplished at the health resorts where muco-membranous colitis is successfully treated. At these the patients see other sufferers from the disease who proclaim how much better they are and some at least who are entirely cured. The waters used at these health resorts are not nearly so efficient when used at a distance because of this lack of additional suggestion.