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 {279} 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.{280}

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.{281}

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 {282} 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. {283} 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 {284} 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 {285} 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 {286} 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.