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.