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.

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.