6050

AUG. 12, 1939

ADDRESSES AND ORIGINAL ARTICLES

VISCERAL NEUROSES

BY JOHN A. RYLE, M.D. Lond., F.R.C.P.REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF CAMBRIDGE ;

CONSULTING PHYSICIAN TO GUY’S HOSPITAL, LONDON

II*

(Esophageal NeurosesTHE two common neuroses of the gullet are heart-

burn and globus. Aerophagy is commoner, butit is a neurosis of swallowing, to some extent controll-able by the will, and involving the cooperation of thepharynx. It is attended by gastric as well as oeso-phageal discomforts. For these reasons it has beenexcluded from the present discussion. A third andmuch rarer neurosis is cesophagismus or functionalspasmodic dysphagia.

HEARTBURN

It is remarkable that the very familiar symptomof heartburn should still stand in want of satis-

factory physiological interpretation. Payne andPoulton (1923), on the basis of personal experi-ments with balloons, have associated it with peri-staltic activity and a rise in manometric pressure,but the quality of the symptom is unlike the qualityof pain or discomfort accompanying clinically or

radiologically demonstrable spasm in the gullet itselfor in other tubular organs. Except in stranguryand tenesmus there are few other examples of aburning visceral discomfort. It is, however, worthyof note that these two symptoms are associated withlocal sphincteric over-action, and that they affecta point of junction between a sensitive and an in-sensitive mucosa. The same is true of heartburn,which, although it may spread higher, is commonlyfelt in the neighbourhood of the cardia, where thesensitive oesophageal and insensitive gastric mucosaemeet.The older view that heartburn was due to acid

stimulation by regurgitated gastric juice also lackssupport, as Hurst (1911) has shown, in that it cannotbe produced with acids, although it is relieved byalkalis. Furthermore, it can occur in patients withnormal acidity, hyperchlorhydria, or achlorhydria.It has sometimes suffered confusion with acid eructa-tion, which is a separate phenomenon. The burningquality of the symptom is quite unlike the ache ormore positive pain of colonic or rectal spasm, and itis very different from the pain experienced on swallow-ing a large bolus or a hard fragment. This suggeststhe possibility that the mucosa is the seat of thesensation rather than the musculature, even thoughthere be a minor degree of associated spasm. Thereis no dysphagia or regurgitation of food accompanyingheartburn, and it may be momentarily relieved bythe act of deglutition-further arguments againstany considerable degree of positive muscular over-action. The rarity of heartburn in association withorganic disease of the stomach or gullet, its frequencyas an occasional symptom in otherwise healthypersons under conditions of rush, worry, or injudiciousfeeding, and as a more persistent symptom in personsof nervous type or faulty habits, or during emotional

* The second Croonian lecture, delivered at the Royal Collegeof Physicians on May 23, 1939. Lect. I appeared in our lastissue.

stress, and also in the later months of pregnancy,all justify its inclusion among the oesophagealneuroses. GEsophagitis is an unlikely explanation,for the symptom is not usual in alcoholics, and it isunaccompanied by hawking or regurgitation of mucusor immediate pain on swallowing. Radiologicalstudies give negative results.The symptom is described as a " burning dis-

comfort " rather than a "pain." It is felt along thecourse of the gullet anywhere between the manu-brium and xiphisternum but more often at the lowerlevel. It may last for seconds, minutes, or longerperiods. It comes on either immediately or an houror more after meals but bears a less precise relation-ship to food than do the organic dyspepsias. Somepatients relate it to certain foodstuffs, but no singletype of food is constantly incriminated. Curtail-ment of starches and fats is often beneficial. Ihave only rarely noted it in association with indisput-able allergic phenomena. It often accompaniesmental anxiety. One man repeatedly noticed itafter coitus. It is temporarily relieved by alkalis,particularly by sodium bicarbonate and aluminiumhydroxide. The most obstinate types of heartburnare those found in association with the later monthsof pregnancy and in highly nervous individuals.In each of these groups the symptom may causeconsiderable and prolonged distress. In the formerit usually disappears completely after parturition.Among 22 cases in which the symptom was suffi-

ciently troublesome to lead in itself to consultativeadvice there were 13 men and 9 women, 5 patientsbeing of Jewish extraction, 1 a Parsee, and 1 a

Persian. In 10 cases multiple nervous factors wereevident without any profound psychological inquiry.The following factors were incriminated by 9 patients :(1) alcohol, sauces, and afternoon tea ; (2) wine,acid fruits, and lobster ; (3) bacon and fats ; (4)whisky and cocktails; (5) sherry, celery, onions,and kippers ; (6) fats ; (7) whisky, cheese, pastry,some fats, and Indian tea ; (8) wines, condiments,and eggs ; and (9) liqueurs, cigarettes, and starchyfoods. In 7 of the 9 statements alcohol in some formreceives mention. Among the other substancesthere is no close conformity. One patient, a student,had been smoking forty cigarettes a day. In onecase a small cesophageal pouch was revealed radio-logically, but, although this must have been of

long standing, the symptom had been in evidencefor a short time only ; the patient was an asthmaticand admitted to recent worry.A mild and a severe case are here described.

CASE I.-Male, aged 49. Troublesome heartburnduring the past year, felt in the course of the gullet,coming two hours after food, and aggravated byalcohol, sauces, and afternoon tea. A well-conditionedman, too stout, living rather too well and taking noexercise. Nosophobia admitted. Reassured andadvised to cut out food with afternoon tea, to curtailfats and starches, and to take more exercise. Promptand lasting relief.

CASE 2.-Male, aged 32. Chronic heartburn forten years. A Jew much occupied with business, whichhe discusses at meals. Aggravation by wines, condi-ments, and eggs. A big starch-eater. Holidaysformerly brought relief but now do so no longer.Symptomatic relief with Jenner’s lozenges.

In the four cases which follow, as a separate group,there were so many associated personal and familialdisturbances of a kind generally classified as allergic

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that it is reasonable to inquire whether heartburnshould sometimes be regarded as a local manifesta-tion of a more general susceptibility.

CASE 3.-Male, aged 70. For years troubled byheartburn. One physician had diagnosed duodenalulcer, but the symptom was in no way characteristic,and X-ray examination did not confirm. He wasintolerant of vermouth and salt meats and said that" cigars did him no good." The symptom wasespecially bad every third day and arrived afterlunch and between 3 and 6 A.M., when it was some-times accompanied by hiccups and water-brash.He was lean and nervous and had well-markedfactitious urticaria. His mother and a maternaluncle were asthmatic.

CASE 4.-Male, aged 30. Heartburn from the ageof 16. The symptom was most in evidence at middlemorning, after lunch, and between 6 and 7 P.M.

He took alkalis regularly and was very careful withhis diet. His previous history included urticaria,hay-fever, and migraine. There was an allergic familyhistory on his mother’s side, and one of his childrenhad hay-fever, asthma, and urticaria. His mother

was intolerant of eggs. Full radiological and chemicalinvestigations were carried out but did not revealany evidence of organic disease.

CASE 5.-Female, aged 39. Married, with threechildren. Heartburn of long standing, which startedwith her pregnancies. Radiological studies of stomachand gall-bladder gave negative results, and she hadbeen subjected without benefit to a long period oftreatment for ulcer. She was also liable to migraineand to bouts of painful rectal spasm lasting twentyminutes. She was suspicious of tea, cream, and richfoods, and admitted to a cancer-phobia.

CASE 6.-Male, aged 26. Always nervous and" stomach-aches " frequent in childhood. A wastedleft arm from poliomyelitis. Complained latterly ofheartburn, fullness after food, and salivation duringand after food. For the past year he had beentroubled with repeated attacks of giant urticariaand angioneurotic oedema. The transverse andascending colon were unduly palpable. His paternalgrandfather, one brother, and one sister were asth-matic. He was inclined to blame milk for the angio-neurotic oedema. He developed much invalidismbut improved after encouragement and a period inhospital.

These allergic histories notwithstanding, it willbe seen that in three of the four cases there was apossible explanation in nervous unrest apart fromany food idiosyncrasy. I have not encounteredheartburn in human anaphylaxis or serum-sickness,and it is not a common association with asthma orcutaneous allergy when these are the presentingsymptoms. Perhaps the most that can be said atpresent is that skin tests and food-elimination testsshould be more worthy of a trial in obstinate casesof heartburn accompanying accepted allergic pheno-mena than in cases lacking these associations.

GLOBUS

The relationship of globus, or a sense of " lump inthe throat," to emotional disturbance needs no

emphasis. It is a common experience in thetransient sorrows of childhood and not rare with thegreater griefs of adult life. In the nervous patientit is both more frequent and more obtrusive and mayof itself become a cause of anxiety by creating abelief in local organic disease. Thus it may bothcause and be perpetuated by a nosophobia. It isfelt below the pomum Adami or retrosternally.It gives the impression of a small globular foreignbody lodged in transit. It is unaccompanied by pain,dysphagia, or regurgitation. A very similar dis-

comfort is sometimes described in the stomach, thecolon, or the rectum by the victims of neuroses

affecting these organs, and in the two last-namedsituations it may be associated with demonstrabletonic contraction of the bowel. It is difficult to avoidthe conclusion that a symptom so precise and localisedas globus has a physical basis. Because it has beencalled globus hystericus, we are not to suppose thatit is imaginary. A slight localised tonic contractionof the oesophageal musculature would best explainit. Such minor changes of tonus in this situationare not as yet susceptible of demonstration by ourspecial objective methods.Among 7 patients specifically referred for this

symptom 2 were Jewish and 1 Welsh ; 5 were womenand 1 a boy aged fourteen. A brief account of thesecases will help to typify related circumstances.CASE 7.-Female, married, aged 47, of Welsh

nationality and nervous. Eighteen months’ historyof "a lump in the throat," situated behind thesternum, present most of the time but sometimesabsent for two or three days. Nervous stresses wereliable to cause vomiting. On a recent holiday shehad felt quite well and happy and lost the symptom.She had a strong cancer-phobia.CASE 8.-Female, married, aged 43. An emotional

type, fond of admiration. Several months’ historyof a " lump in the lower chest " or epigastrium. Norelationship to food. Menopausal irregularity. Thispatient and her sister both suffered from spasmodicrhinorrhoea.

CASE 9.-Female, married, aged 60. Complainedof a feeling of a lump in the throat unaccompanied bypain or dysphagia. Also flatulence with belching,which sometimes relieved the globus. An air-swallower.

CASE 10.-Female, married, aged 45. Globus fornearly a year. A throat specialist, a general practi-tioner, and unorthodox opinion had been consultedin turn. The symptom had developed in the firstinstance at a time of great anxiety about a breasttumour, which proved, on excision, to be non-

malignant.CASE 11.—Female, married, aged 36. Discomfort

and a " choked-up feeling " in the gullet, which ledto frequent swallowing. Much depression, domesticoverwork, and, in the months preceding the develop-ment of the symptom, anxiety about her husband’sbusiness.

CASE 12.-Male, aged 36. A worrying nervous Jew.Had complained for four years of a feeling of "a alump behind the breast-bone which made him wantto swallow." Business worries and cancer-phobia.His mother had died of cancer.

CASE 13.-An intelligent nervous Jewish boy,aged 14. Had complained for fifteen months of a" lump behind his breast-bone," at first on swallowingonly but latterly more persistently. No pain,dysphagia, or regurgitation. Aggravation by excite-ment and examinations. Sometimes relief withbelching. Until the age of 12 he had been troubledwith enuresis.

In only one of these cases (case 8) was there anallergic association. In all of them nervous influenceswere pronounced.

SPASMODIC DYSPHAGIA

At one time I included in my index of diagnosesa separate cesophageal neurosis characterised eitherby pain in the course of the gullet or by a transitorydifficulty in swallowing. The association of thesesymptoms with a nervous temperament and a longhistory, the intermittency of the attacks, and thenegative results of clinical and radiological examina-tions had seemed to justify the opinion. Achalasia

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of the cardia, dysphagia with anaemia (the so-calledPlummer-Vinson syndrome), and an early carcinomaof the cardiac end of the stomach with an initial

negative X-ray report were familiar to me as differ-ential possibilities. Since then improvements in

radiological technique have revealed, and papersby Friedenwald and Feldman (1925), von Bergmannand Goldner (1932), and Hurst (1934) have described,a new cause of cesophageal dysfunction in the smallintermittent hiatus hernia of the cardiac end of thestomach. Reviewing my case-histories in the light ofthis new knowledge I must now exclude from thefunctional group several cases originally filed underthe heading of nervous cesophageal spasm. Hereis a case in point.CASE 14.-A woman, aged 69, was troubled during

a period of three years by a frequent burning sensationin the course of the gullet, to which were addedcurious spasms while eating in which " the foodwould not go down." At times she was compelled toleave the table and bring up food. These episodeswere sometimes followed by hiccups. Radiogramsshowed a normal gullet. A diagnosis of nervousspasm was made, and there was considerable ameliora-tion with a fuller diet, alkalis, and Luminal. A laterre-examination in special postures revealed a smallhernia of the stomach through the oesophagealopening.

Cases of this kind can sometimes be recognisedclinically by the association of the symptoms withstooping, sitting, or other postures or movementswhich increase intra-abdominal pressure. One patienthad been told by an observant daughter that sheought always to eat at a "snack-bar." Hiatushernia can also cause severe substernal pain and mayeven simulate angina or a coronary thrombosis.

After exclusion of all organic possibilities knownto us, however, there still remains a small group ofspasmodic dysphagias in which nervous factors alonewould seem to supply the cause.

CASE 15.-A nervous woman, aged 43, after a tiringday was seized with an inability to swallow whileeating fish. This inability persisted for ten hours,and she could not even swallow fluids or her saliva.There was no pain. During the previous four yearsshe had experienced the same symptom on severaloccasions, but it had only lasted for ten minutes orso. Eating fish when she was tired had been the chiefprecipitating factor. There was no radiologicalevidence of oesophageal disease.

McGibbon and Mather (1937) have discussed theradiological diagnosis of cases coming within thiscategory.Among the cesophageal neuroses of constant pattern

we may thus include heartburn, globus, and (withcareful reservations) nervous oesophagismus or spas-modic dysphagia. The organic states which may beerroneously attributed to an cesophageal neurosisare :-

(1) Achalasia of the cardia, shown by Rake (1927)to be associated with a degeneration of Auerbach’splexus and invariably accompanied by demonstrabledilatation of the gullet. Dysphagia and regurgitationare the main symptoms, but pain may be addedwhen the condition is complicated by secondaryulceration or by cosophagitis. Emotional factorscan undoubtedly aggravate symptoms in achalasia,although they cannot be claimed as its cause.

(2) The dysphagia with anaemia, described byKelly (1936). With this there is associated glossitis,a hypochromic anaemia, and sometimes splenomegaly.The dysphagia is at the pharyngo-oesophageal level.There is no pain.

(3) Intermittent hiatus hernia of the stomach.Dysphagia and sometimes severe pain induced by

sitting, stooping, or the reclining posture and relievedby standing, together with a barium X-ray examina-tion in the Trendelenburg position, supply thediagnosis in most cases.

In all of these conditions intermittency of symptomsand length of history may at first suggest a nervousdisorder, and special methods are needed to completethe diagnosis.

In the three neuroses reviewed, diagnosis is basedupon the character of the symptoms themselves, theabsence of all evidence of organic disease, and ageneral conspectus of the type and temperament ofthe patient and of the adverse circumstances of hislife, heredity, habits, and environment.

Colonic Neuroses

In this section attention will be devoted to thoseneuromuscular disturbances of the colon which havebeen variously designated chronic colospasm, spasticconstipation, spastic colon, and tonic hardening ofthe colon. In the past these disorders have commonlyreceived the erroneous diagnosis of " colitis." Toits most aggravated form, which is characterised bypain and an excessive output of coagulated mucuswith the stools, the label of mucomembranous colitishas been applied, but here also, as Hurst (1938) hasshown, there is no evidence of a true inflammatorylesion of the colonic mucosa,A considerable literature has grown up round the

subject of spastic colon-the name which I shall,for brevity, employ-and yet the condition continuesto pass undiagnosed or to be misdiagnosed and to betreated erroneously in consequence. There is prob-ably no other single condition which has led to somuch unwise local treatment and to so many needlessabdominal operations. As long ago as 1906, Hawkinswrote of the intestinal neuroses : " They are at thismoment particularly worthy of study, owing to theadvance of abdominal surgery, not because they areamenable to surgical treatment, but rather becausethey need protection." This sound advice is stilltoo little heeded.The condition of spastic colon was first described

in 1830 by Howship. Cherchewsky (1883), Fleiner(1893), Hawkins (1906), Hurst (1919), Turner (1924),and Stacey Wilson (1927) have all added noteworthydescriptions. I reported on it myself ten years agoand have paid particular attention to the genesisof the pain which is the most frequent and trouble-some symptom (Ryle 1936). My earlier analysiswas based on a study of 50 cases. For this occasionthe notes of 321 cases have been examined. Thislater series included 169 females and 124 males in the" spastic colon " group and 28 female patients in thegroup with excessive output of mucus, which somewould prefer to classify separately under the headingof mucous or mucomembranous colic. Of the needfor such separation I am not satisfied. The smallergroup differs only in the severity of symptoms, in thequantity and special character of the bowel dis-

charges, in the greater degree of the nervous instabilityof its victims, and in the fact that they are almost allwomen. Cases with evident organic disease of theabdominal viscera were excluded from this series, andthere were no instances of plumbism.The age-distribution of these cases at the time of

consultation is of some interest. Into the seconddecade fell 2 per cent. of the cases ; into the third16 per cent. ; into the fourth 29 per cent. ; into thefifth 26 per cent. ; into the sixth 19 per cent. ; intothe seventh 7 per cent. ; and into the eighth 1 percent. Thus 90 per cent. of the patients were between

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the ages of twenty and sixty ; 74 per cent. betweenthirty and sixty ; and 55 per cent. between thirtyand fifty. There is therefore a preponderance ofcases in that period of life in which work, anxiety,economic stress, and domestic adjustments are

dominant. A similar age-distribution is observedin the cardiac neuroses and in certain organic condi-tions, notably duodenal ulcer, which seem to be related,at least in part, to anxious temperaments and thenervous stress of modern life. In a random series of321 consecutive cases (excluding those with spasticcolon) 70 per cent. were between the ages of twentyand sixty ; 63 per cent. between thirty and sixthand 43 per cent. between thirty and fifty.

Of other aetiological factors, the case-historiesand the sampled statements which follow give ageneral indication. They can convey no adequateidea of the qualitative and quantitative value of theseveral contributions. Only the most intimate

personal histories and after-histories can allow suchestimates. It need hardly be mentioned that

multiple factors of diverse type, but all capable ofacting as

" irritants," are often recorded in the samecase. The patients and their colons are alike sensitiveto various forms of adversity. Among the abbreviatedentries from the fuller stories taken from my tabulatedlists were the following: fatigue, cold, and worry " ;"a Jew, anxiety, worry " ; nerves, worries, pork,salads, fruit"; "alcoholic husband, devoted ’hanger-on,’ cancer-phobia, cold " ; " death of parents,childless marriage and " nuts, fruit, laxatives,worry."Among the 321 cases a clear history of worry,

anxiety, domestic unhappiness, or other emotionaldisturbance was noted in 188 cases. Fatigue wasspecifically recorded in 30 cases. Cold (with particularemphasis on east winds in several instances) wasmentioned in 37 cases. Evident abuse of purgatives,although a much larger number habitually employedthem, was mentioned in 13 cases ; tobacco excess in16 ; aggravation by walking, motoring, or jolting in14. Of food idiosyncrasies, vegetables, nuts, or

fruit were specifically noted in 23 cases and chocolatein 5. There was a history of antecedent dysenteryor other acute bowel infection in 9 cases.

Of associated neuroses the following were recorded :migraine in 28 cases ; asthma in 16 ; hay-fever orspasmodic rhinorrhcea in 9 ; oesophageal neurosesin 8 ; proctalgia in 6 ; cardiac neuroses in 5 ; dys-menorrhoea in 5 ; urticaria in 3 ; epilepsy in 2 ; andangioneurotic oedema in 1 case. There were 2 exampleseach of associated vaginismus, bladder neurosis, andspeech stammering. There was a family history ofasthma in 14 cases ; of spastic colon in 5 ; of urticariain 2 ; and of angioneurotic oedema in 1 case. The

frequency of all these personal and familial associa-tions may be regarded as an underestimate, for Ihave only in late years pressed my inquiries in thesedirections, and in the fullest routine histories patientsoften omit evidence which does not at the time

appear to them relevant or interesting. In a randomseries of 321 consecutive cases (excluding those withspastic colon) there were 19 cases of migraine, 3 ofasthma, and 3 of urticaria.There was a history of appendicitis with operation

in 13 cases (4 per cent.). In no less than 86 cases(26 per cent.) the appendix had been removed withoutgood historical evidence of appendicitis and commonlyfor symptoms similar to or identical with those stillcomplained of by the patient. I have for some yearsbeen at pains to enter " appendicitis " and " appendi-cectomy " as distinct events in my case-histories.

Other operations undertaken for symptoms attribu-table, so far as could be judged, to the colonicdysfunction were nephropexy, cholecystectomy, hys-terectomy, ovariectomy, an exploration, and multipleoperations-each in one instance.As illustrative of physical or psychological type,

the following adjectives were often encountered inmy notes : lean, thin, spare, dark, pale, wiry, anxious,nervous, tense, neurotic. Many patients sufferedfrom " dead fingers " in cold weather. Conversely,we find that spastic colon is rarely recorded in fair-haired blue-eyed plump healthy complexioned typeswith good circulation and placid dispositions. Itsvictims are industrious and conscientious and do not,as a class, give way to symptoms unduly or make ofthem an excuse for invalidism, even though theymay appreciate them-as they appreciate their othertroubles-more sharply than the common herd. Theirsymptoms are, indeed, very real and often a serioushandicap to busy lives.We have evidence for the sensitivity of their

colonic mucosa and musculature to local irritantssuch as nuts, raw fruits, vegetables, and purgatives;to nicotine in some cases ; and in many to the generaleffects of fatigue, cold, and physical jolting. But thecentral, if often submerged, irritations of care, fear,and conscience would seem to playa more importantpart than any of these. Immediate fear can precipitatedefaecation in the herbivora or in soldiers beforebattle. It is not, perhaps, surprising that anxiety,which is a low-grade and protracted form of fear,operating through the preoccupied mind of civilisedman, who has learned to inhibit his external displayof emotion, should sometimes provoke disturbancesof visceral tone and peristalsis. In the case of thebowel sometimes pain and sometimes diarrhcearesults. A medical man, himself a sufferer fromspastic colon, once told me that he knew of no betterlaxative than an anxious day’s work ahead of him.It is repeatedly mentioned by patients that theircolonic pain is worse after defsecation, and that theyare more comfortable when constipated, so readilywith them does tonic action pass into over-action.

Constipation is described in approximately halfthe cases. The remainder have a normal functionor bouts of looseness. Mucus in the stools is oftenmentioned. In the cases of " mucous colic " thereis a true and a spurious diarrhcea, the stools beingeither loose and frequent or, more commonly,scybalous and frequent. Both in simple spasticcolon and in " mucous colic " the dejecta are com-monly fragmentary, hard, and likened by the patientto those of sheep or rabbits. This fragmentationis but another sign of the tonic and peristaltic over-activity of their intestinal musculature.

Passing now from aetiology and associated disordersto the malady itself, we find that the usual complaintis of discomfort or actual pain in some portion orportions of the large bowel. Ascending or descendingcolon is most commonly indicated (and the gesturemay be very exact) with the palm of the hand lyingin the course of the affected part in one or otherflank or iliac fossa. Less frequently the transversecolon is indicated by drawing the ulnar margin ofthe hand across the abdomen at the " watch-chain "

level. In other cases a lower abdominal pain withoutthis precise linear distribution is described. Thediscomforts are likened to a " ball " a "lump,"a " bar of lead " or described as " a feeling of stop-page." The pain is a continuous wearing ache;not rhythmical or griping as in the pain of purgation,enteritis, or intestinal obstruction ; and lacking the

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immobilising sharper quality and soreness of visceralor peritoneal inflammation. It may last for hoursand be present day after day. Very occasionally,however, colonic spasm comes in acute attacks andmay cause pain of great intensity, simulating oneof the major crises which signal a stone in the ureteror the bile-duct.

Physical examination in the chronic type oftenreveals an unduly palpable colon in one or more

of its three accessible parts. A contracted colonis often felt in health in the left iliac fossa, but itbecomes a more hard and rigid structure in a stateof tonic spasm, and in the condition under reviewit may often be felt in its transverse and ascendingportions. Shortening and straightening accompanythe rigidity. In the region of the caecum thesechanges may be felt, or even seen in the bath, bythe patient himself like a tumour or " cricket ball "in the right iliac fossa. The bowel may be tenderto palpation and is generally so in the cases of" mucous colic." Radiological examination after abarium meal (the results varying with the state ofthe bowel at the time) show an intensification ofthe normal haustrations of the colon, a thin stringof barium in the affected portions, or, more rarely,a strictly localised spasmodic constriction. Thebarium enema, usually to be preferred in colonicstudies, may in these cases be less informative thanthe meal as it distends the walls of the gut in passage.

Sigmoidoscopy is often difficult and is apt to beunusually painful on account of the spasm. Thelumen of the bowel can be seen to narrow down toa pin-point before the advancing instrument. Afirm ring-contraction is sometimes felt during a

digital examination of the rectum.These and other observations leave small room

for doubt that the pain is an expression of exaggeratedtonus in the bowel musculature. The condition hasbeen called " asthma of the colon," and indeedbronchial and colonic spasm, in their behaviour,chronicity, and intermittency, have much in common,apart from the fact that they may coincide in thesame patient or in a family. In extreme contractionthe colon has been seen on the operating-table tobecome white and hard, and it is not impossiblethat the attendant ischaemia and anoxia may bethe immediate cause of the pain.

Relief of pain is obtained by warmth, the hotbottle and hot bath being especially helpful; bybelladonna in adequate dosage, but not in everycase; and a warm gruel enema, according to

Howship (1830), may also bring comfort. All thesemeasures tend to counteract spasm. In some casesthe pain develops late after food and is relieved byfood and so prompts a suspicion of duodenal ulcer.In most cases sleep is not disturbed, the bodily andmental relaxation seeming to extend their beneficenceto the troubled organ.

In the differential diagnosis such possibilities as

appendicitis, peptic ulcer, diverticulitis, carcinomacoli, ulcerative colitis, intestinal starch indigestion,renal colic, and ovarian or tubal disease may haveto be considered. In the great majority of cases

the history and especially the length of the history,the type and durability of the pain, the temperamentof the patient, and a careful examination shouldlead to a correct opinion. Where doubt remains fuller

investigation must be employed, and in appropriatesubjects carcinoma coli and diverticulitis are

particularly to be excluded.Of the erroneous labels which are liable to be

attached to these cases chronic appendicitis and

colitis are the commonest. Both lead to undesirable

physical treatments, and both tend to fix the patient’smind unduly on the complaining part of his anatomy.The disappointment which follows futile surgery onlyaccentuates his physical and mental misery. Hereare some illustrative cases.

CASE 16.-A highly nervous and anxious profes-sional man, aged 60, was seen in 1932 and 1934 forright-sided abdominal pain. He described his caecumas "blowing up" at times and feeling " like a

sausage." He had had a life full of worries and hadrecently lost his wife after a long illness. During thesummer and during two holiday periods he lost hissymptoms. Latterly the pain had begun to wakehim at 2 A.M., but he would immediately drop offto sleep after a bromide and belladonna draught.He had begun to entertain fears of cancer.CASE 17.-A medical student, aged 21, who gave

a history of diarrhoea and vomiting after eatingturbot in 1927, of appendicectomy without relief ofpain in 1929, and of nocturnal pain with diarrhoeaand sickness in 1930, was seen in 1931 for a draggingpain in the right iliac fossa, across the epigastrium,and below the left rib margin. He was tender alongthe course of the ascending and descending colon.Two of his brothers had colonic symptoms, and onehad been admitted to Guy’s Hospital as a case ofintestinal obstruction but was found to have anintense spasm only of the descending colon. Investi-gations of the alimentary tract gave negative results.Full reassurance and rational treatment were followedby a disappearance of symptoms, and a year laterhe was reported as in very good health.CASE 18.-A man who had lived in the east for

many years but had had no dysentery complainedof flatulent discomfort in the right and left iliacfossae and the epigastrium and of a feeling of " windin the bowel which would not pass." He stated thatfried foods and beef disagreed and that " pork waspoison." Symptoms had first appeared ten yearspreviously at a time of great overwork and worry,when his " nerves were bad." He recognised thatworry or emotion in anticipation of small troubleswas the chief precipitating cause. He was lean,nervous, muscular, and wiry. His reflexes were verybrisk. His caecum at the examination was firm andcontracted like a sausage. The sphincter gripped thennger during a rectal examination. His mother wasliable to angioneurotic oedema if she ate strawberries.

CASE 19.-Multiple neuroses. A young man, aged26, had had cyclical vomiting in childhood, for manyyears hay-fever, and for one year asthma. He wasalso liable to migraine and was brought to see mepartly for these symptoms and partly for " spasticcolon " with excess of mucus in the stools. In theprevious year he had been given a vaccine for thebowel condition and promptly developed an anaphy-lactic attack, with oedema of the face and dyspnoea,relieved by adrenaline. His bowels were erratic andoften loose. He had observed that he was betterwithout alcohol and when he took exercise. His caecumwas bulky, he was lean, and he had a low blood-pressure, but there were no signs of any organicdisease.

CASE 20.-" Mucous colic." A small nervous under-sized married woman, aged 35. Seen in 1931, 1932,and 1933 for left-sided abdominal pain, constipation,and the passage of much mucus. In 1926 she had hadher appendix removed and ovarian cysts were saidto have been cauterised on account of her symp-toms, which persisted. Aggravation by cold. Acancer-phobia also played its part. In 1933, aftershooting on a very cold day in December, she had afebrile attack, with vomiting and diarrhoea, leavingpain again in the transverse and descending colon.There was tenderness in the course of the colon, whichat times could be felt in contraction under the pal-pating hand. The domestic situation was profoundly

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unsatisfactory, for she was unhappily married to achronic alcoholic whom she could not divorce forreligious reasons and was also embarrassed by adevoted admirer.

Now, although, as has been shown, the familiarallergic states are commonly associated with thecondition of spastic colon, and although food idio-syncrasy sometimes plays a part, we have scarcelyas yet enough evidence to include this particulardysfunction in the allergic category. Children withallergy are sometimes stammerers, but it would bean unwarrantable extension of the use of the termto describe stammering as an allergic manifestation.Is there any more reason so to describe the stammeringcolon ? ’1 Occasionally, however, cases of acute colonicdisturbance are seen in which the arguments for allergyare stronger. In these cases the associated phenomenamay synchronise with the attack instead of appearingseparately and at other times. They may includevomiting, diarrhoea, angioneurotic oedema, and shock-like symptoms. Of such cases I have given an

account elsewhere (Ryle 1936). A specific cause orgroup of causes may or may not be discoverableby careful inquiry and food-elimination or cutaneoustests.

CASE 21.-In a case which has been of great interestto Sir Arthur Hurst and myself, a woman, aged 34,with a strong family history of asthma and hay-fever,and herself liable to hay.-fever and digestive dis-turbances, developed, at intervals, severe abdominalattacks with the following characters : acute lowerabdominal pain; a frequent desire to defsecate ;the passage of long mucous casts and, in the worstattacks, of much bright blood from the bowel. Thesigmoidoscope, however, revealed no ulceration ofthe bowel, even during active bleeding. Skin testsshowed her to be sensitive to pork. She recognisedherself as intolerant of pork and eggs. One of theworst attacks started after she had become very coldat a race-meeting and had drunk coffee. When allother measures had failed to relieve the symptoms ina severe attack, Hurst found that 1 drachm of castoroil at night and 1 drachm of sodium sulphate in themorning brought immediate relief.

In connexion with these rare cases of acute

hoamorrhagic (non-infective) " colitis " it is worthremembering that Dean and Webb (1924) produceda very similar condition in experimental anaphylaxisin dogs.

Rectal Neuroses

Although less frequent than the neuroses thus farconsidered there is one rectal neurosis so definite incharacter and circumstance and often so painfulthat it is a matter for surprise that it has receivedsuch scant notice in the literature. Under the nameof proctalgia fugax Thaysen (1935), apologising for themixed derivation, drew attention to a painful formof rectal spasm which came on in the absence of

any discoverable organic cause and which must

long have been familiar to physicians and proctologists.The usual complaint is of a severe ache-of tooth-

ache quality, rapidly crescendo and sometimesreaching an unbearable intensity-which is locatedin the rectum and sometimes gives the impressionthat the coccyx is being forcibly bent forwards orbackwards. The pain may be so bad as to causepallor and fainting. Its duration is usually fromfive to fifteen minutes, very rarely longer. Althoughit may also come on in the day, the common accountis that the symptom arrives, usually at long intervals,during the night, and especially towards the early hoursof the morning. As a rule it bears no relation todefsecation, and in this it is distinct from the pain

of rectal carcinoma, anal ulcers, and fsecal impaction.Occasionally, however, it may succeed defsecation.In the early moments of an attack there is a

desire to defsecate or to pass flatus, and relief is

sought in this way without success. The rectal crisesof tabes dorsalis should be readily excluded by acareful history and routine examination of thenervous system. Some patients describe a muchmilder sensation of rectal globus. Proctalgia or

rectal spasm has a close association with mentalworry and fatigue. Colonic spasm is a common

accompaniment, and in a minority of cases thereis an attendant history of migraine or other allergicdisorder. In a group of 15 cases it was associatedin 1 with migraine and a family history of migraineand asthma ; in 1 with spastic colon and urticaria;in 1 with spastic colon and migraine; and in 6 withspastic colon only. The average age of the patientswas forty-five. There were 9 females and 6 males.In no less than 8 cases a very unsatisfactory or

unhappy psychological situation was revealed, or

the patients were recorded as of excessively worryingand introspective type. One patient recorded greatrelief from distension’of the rectum by immediateinflation with air from a Higginson’s syringe. Other.wise there is no treatment for the immediate attack,and, indeed, the treatment should correctly be directedto the underlying causes and includes especiallythe counteraction, when possible, of anxiety andfatigue.

CASE 22.-A masseuse, aged 41, complained ofa dull aching pain in the right iliac fossa, which wokeher between 2 and 4 A.M. and sometimes lasted allday. She was able to feel a hardened contractedcolon on the right side. For some years before thisshe had been liable to painful cramps in the rectum,lasting up to a quarter of an hour, and occurringboth by night and day. There was a history ofurticaria following lobster and strawberries. Shesmoked fifteen cigarettes a day. Family historynegative. A firm ring-contraction was felt during adigital examination of the rectum.

CASE 23.-A married woman, aged 46, complainedof left-sided colonic pain and of severe nocturnalattacks of rectal spasm, in one of which she fainted.Coitus seemed to predispose. She smoked twentycigarettes a day.

CASE 24.-A woman, aged 50, was subject tointermittent abdominal attacks characterised by adiscomfort " as though food had stuck " and locatedeither in the epigastrium or the flanks. At intervals,for many years, she had also been liable to violentattacks of rectal pain, chiefly at night but sometimesin the day. The pain would continue for as much ashalf an hour. Relief was obtained by inflating therectum with air.

CASE 25.-A woman, aged 46, complained ofterrible attacks " of pain starting sometimes inthe sacral region, sometimes in the vagina, andending up with a feeling " as though the lower spinewere being pushed out." The attacks were mainlynocturnal and would last for a quarter of an houror even as long as three-quarters of an hour. Therewas a desire both to defsecate and to micturate.There were varying intervals between attacks, andshe might be free for two months. She had had manyoperations, and the symptoms succeeded the lastone, soon after which her husband had been acci-dentally killed. Her doctor had seen her " writhingin pain " in an attack. She was liable to migrainousheadaches. Sigmoidoscopy and cystoscopy revealedno abnormality.

CASE 26.-Rectal globus. A young dental surgeon,liable to migraine, and previously seen for lowerabdominal pains, complained of a troublesome rectal

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discomfort " as though the bowel wanted to move."At first it was associated with standing. Later thesymptom occurred between midnight and 2 A.M.

It was in abeyance on holidays. There were no signsof organic disease. He was over-anxious, had previ-ously had a cancer-phobia and was working very hardand smoking too many cigarettes. After reassuranceand adjustments in his life, cessation of smoking,and luminal at bedtime he lost his symptoms andgained 9 lb. in a month.

Vesical Neuroses

The neuroses of the bladder, although commonlyconsidered trivial, are both numerous and familiar.Some of them cause much mental distress. Precipi-tate and involuntary micturition is a recognisedresponse to acute fear in man and animals. A

frightened flock of sheep affords a good demonstrationof emotional evacuation both of bowel and bladder.The recruit before battle may be unable to containhis urine. During the European crisis of September,1938, I was questioned about a nervous man whowas similarly afflicted. The nocturnal enuresis ofchildren, notwithstanding the multiple explanationsand physical treatments which have been appliedto it, is now generally accepted as a-nervous pheno-menon, a view which is well supported by its highincidence in the nervous offspring of nervous parents,its aggravation by rebuke and punishment, and itsgood response to sensible handling and time. Thediurnal frequency of nervous women, occurringeither without evident cause or as a sequel of a

departed cystitis, is also common and can generallybe distinguished from frequency due to an organicpolyuria or pollakiuria by the finding of a normalurine and by the fact that it is in abeyance at night.Apprehension of the desire to micturate during socialengagements when opportunity is lacking is probablyone of the reasons why many women of anxious typerestrict their fluid intake unduly. In men nervousinhibition of micturition is a familiar experience ofthe consulting-room and the life-assurance examina-tion, and there are many who cannot pass waterin a public urinal. The initial retention of urinewhich follows abdominal and rectal operations mayreasonably be attributed to reflex irritation and incon-venient posture. Its persistence is often abettedby anxiety. A new and useful remedy in thesecases is available in Doryl (carbaminoylcholinechloride).The more serious nervous incontinences and

retentions are comparatively rare and are accompani-ments of graver anxiety states. Sir James Paget(1879) described the case of a man who developeda nervous retention while walking with a lady friendand declined ever to go walking with her again,because he knew the association of ideas would betoo strong for him and would again invite the samedisability. He also related the case of a clergymanwho always passed a catheter before going into thepulpit, because on one occasion, having experiencedan urgent desire to micturate during a sermon, hefound himself unable to perform the act when thesermon was over.

Nervous incontinence may cause misery as greatas nervous retention and, in the two cases whichfollow, complicated other visceral neuroses of emotionalorigin. I have observed no special association betweenbladder neuroses and the allergic state.CASE 27.-A young woman, who had been liable to

gastric and colonic disturbances since childhood andhad experienced a few severe attacks of rectal spasm,developed great urinary frequency and was unable

to hold her water if she heard a tap running and some-times, when paying social calls, had urinary incontin-ence on the door-step. A severe psychic trauma hadpreceded the aggravated phase of this neurosis.CASE 28.-A young married woman, nervous and

hypersensitive, at a time of anxiety in connexionwith domestic and social affairs, developed diarrhoeaand bladder incontinence. She also suffered fromvaginismus, experienced bowel and bladder painafter evacuation of these organs, and was liable toincontinence in cold weather. She was troubled withnightmares always in connexion with lavatories andfor a long time was harassed by multiple phobias andanxieties.

If we except the acts of blushing and fainting,the conditioned reflex in daily life is, perhaps, betterillustrated by the disturbances of micturition thanby any other bodily dysfunction. Even in goodhealth modifications of natural habit by circumstanceare frequent. The old device of turning on the

tap to encourage micturition must clearly be relatedto the environmental associations of the act or tothe sound of running water.A physician became aware of a curious conditioning

of the desire to micturate. After examining a patientin his consulting-room it was his invariable customto take the specimen of urine to test in his laboratory,carry out the test, and then pass on to the lavatoryto wash his hands. At this stage, with the tapsrunning, he repeatedly had an inclination to passwater, although he had experienced no desire a

moment before. As time went by he noted withinterest, although he had continued to pay scantattention to the phenomenon, that the reflex hadbecome antedated, and that lighting the Bunsenburner to test the patient’s urine now induced thedesire.

If similar sequences may be held to obtain inthe case of the more troublesome visceral over-actions-e.g., bronchial and colonic spasm, urinary fre-quency, and tachycardia-we discover at once an

accessory explanation for their chronicity and fortheir seemingly inconsequent recrudescence indepen-dently of any observed external agency or immediateemotional stimulus.

Clearly, quite trivial actions and mental associations,conscious and subconscious, are responsible for a

great many of man’s visceral irregularities anddisturbed sensations and may become, in course oftime, important determining stimuli. It is a part ofthe function of general therapeutics and psychiatryto investigate and direct the removal or counteractionof such stimuli.

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Bergmann, G. von, and Goldner, M. (1932) Funktionelle Patho-logie, Berlin.

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170, 263.Hawkins, H. P. (1906) Brit. Med. J. 1, 65.Howship, J. (1830) Practical Remarks on the Discrimination

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Hurst, A. F. (1911) The Sensibility of the Alimentary Canal,London.- (1919) Constipation and Allied Intestinal Disorders,2nd ed., London.- (1934) Guy’s Hosp. Rep. 84, 43.- (1938) The British Encyclopædia of Medical Practice,

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