6049

[AUG. 5, 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

I* *

AN invitation to lecture before this College compelsa considered selection of subject, title, and materialwhich may in itself be held worthy of brief analysis.In my choice of subject I have been influenced partlyby developing personal interest and by the natureand quantity of the material within my reach, andpartly by a desire to examine accumulated obser-vations in such a way as to clarify my own thoughtand, where possible, to assist the thought and practiceof others. I have always preferred the appeal offamiliar phenomena to the excitation of the strangeor rare, and rightly or wrongly, but as time and theopportunity of a physician’s life dictated, have setmy training in recognition, description, and classifi-cation before the call to intimate or particularresearch. In my clinical philosophy the generalhuman problem and the special pathological problem,alike only in their complexity, have claimed, if notthe same attention at least an equal regard.’ Thetitle of these lectures is borrowed from a distinguishedpredecessor at Cambridge, one of our own most

scholarly Fellows, the late Sir Clifford Allbutt. In1884 Clifford Allbutt gave his Goulstonian lectureson the Visceral Neuroses. Many besides myselfmust have enjoyed and often re-read the slenderbooklet in which they were later published. The

fifty-five years which have since passed have witnessedgreat advances in the methods open to us for theobjective study of the normal and morbid physiologyof the viscera, and, although many of Allbutt’sobservations are as sound and instructive today aswhen they were first written, others would requirerevision in the light of our newer and more preciseknowledge. Although his understanding of men,women, and temperaments may still serve to correctour over-mechanistic interpretation of certain visceraldisturbances, modern chemistry, radiology, and

endoscopic technique, had they been then available,would certainly have traced some of his " neurosesto an organic defect.But we have advanced not only in the realm of

objective physical inquiry, for psychology too hasbegun to assist the elucidation of bodily discords ina more methodical way. Moreover, those peculiarhumoral disturbances now commonly called allergicare today regarded as capable of influencing otherstructures besides the bronchioles and the skin. Inthe scientific field the fundamental contributionsof two great physiologists, Pavlov and Cannon,have thrown light in dark places and given us

explanations and experimental proof of numerousphenomena which clinical study alone could neverhave unravelled.

It seemed to me, therefore, that the time wasripe for a reconsideration of Allbutt’s problem. IfI do no more than point the way to a clearerclassification and understanding and a better diag-nostic of the functional misdemeanours of certainorgans, my observations may yet serve a usefulpurpose and suggest fresh lines for future study.

* The first Croonian lecture, delivered at the Royal Collegeof Physicians on May 18, 1939.

My information has been mainly culled from thefiles of my private cases. Intimate personal histories,adequate family histories, careful symptom-analysis,and a systematic exclusion of organic possibilitiesare a necessary preliminary to the diagnosis of thevisceral disorders. These evidences are betterobtained in the atmosphere of the consulting-roomor the sick-room than in a ward or outpatientdepartment. It is probable too that the visceralneuroses are of more frequent incidence in those classeswhich do not earn their livelihood or control theirhomes by manual labour. Furthermore, the disa-bility accompanying a visceral neurosis, althoughoften prolonged and considerable, is not as a rule sosevere as to call for admission to hospital. Writingof the colonic neuroses Hawkins (1906) said : " Intes-tinal neuroses diminish in frequency as we descendthe social scale." The same’ can be said of theother visceral neuroses, although allowance must

always be made for the greater frequency with whichthe prosperous classes seek medical advice and fortheir better aptitude for describing symptoms.

NATURE AND DEFINITION OF VISCERAL NEUROSIS

The visceral neuroses may be held to embrace thosedisorders of visceral movement, secretion, or sensationwhich occur in the absence of organic disease. Ishall not include in my category mere anxiety aboutan organ in the absence of good evidence of suchdisorder. It is not rare for patients to presentthemselves in a state of anxiety about an organ onaccount of symptoms having no connexion with it,or because a suspicion of disease affecting it hasbeen created by the remarks of friends or an unwisemedical opinion. Although, therefore, anxiety mayand often does cause or contribute to a visceral neurosis,and although a visceral neurosis may in turn main-tain anxiety, the concept of such a neurosis shouldinclude some real disturbance of visceral function.To make our meaning more precise we must alsoexclude the operation of remote as well as local

organic disease, for disease in one viscus may propagatenervous impulses which disturb the function ofanother viscus, and blood-states or structural diseaseof the central nervous system may be expressed bydisorders of function in one or more of several intactorgans. Of such disorders the dyspepsia (as distinctfrom the primary gall-bladder pain) which accompaniescholecystitis, the cardiac dysfunction of ansemia, andthe vomiting of tabetic crises are familiar examples.

All the functional disorders of the hollow organswhich we have in mind can, broadly speaking, beregarded as due to an interference with the nervousregulation which derives from the sympathetic andparasympathetic systems and controls the rhythm,quality, and quantity of the contractions in plainmuscle and the secretions, blood-supply, and sensa-tions of these organs. We must further refine ourconcepts when we come to consider dysfunction dueto chemical stimulation. Such stimulation must beaccompanied by local metabolic change although notby organic disease in the sense of persisting tissuemodifications, the avoidance of which is probablydue to the counteraction or reversibilitv of a chemicalchange. Chemical stimulation may be exogenous,as in the case of foods, poisons, and drugs, or endo-genous, as in the case of the secretions of the pituitaryor the suprarenal glands. We also accept, on

the basis of the researches of Loewi and Daleand their co-workers, that the nervous impulse

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itself, however initiated, is associated with a chemicaldischarge.Now, it is a remarkable but frequently confirmed

observation that certain clinical phenomena, such asangioneurotic oedema and bronchial spasm, can beprecipitated, on the one hand, by emotional causes,which presumably operate through the nerves, and,on the other, by an inhaled, ingested, or injectedforeign protein, which presumably operates throughthe tissue fluids. So specific in type are these clinicalor biological responses, that it is difficult to believethat the determining stimuli in the two instancesare widely dissimilar. In other words, whether weregard certain disturbances (among which we maycome to include some of the hollow-organ neuroses)as due to emotion or to allergy or sometimes to oneand sometimes to the other, we can simplify ourideas by supposing in each case the immediateinfluence of a similar or identical chemical stimulus.A nervous subject is sometimes but not necessarilyshown to be sensitive in the allergic sense. An allergicsubject is frequently, perhaps, but not always shownto be sensitive in both senses. His sensitiveness maybe increased or conditioned in many new ways withthe passage of time. The immediate or determiningstimulus, however, for his particular clinical or

biological response may for the present be presumedto be specific and chemical.

Finally, in so far as pharmacological counteractionof the visceral or vascular phenomena of emotion orof allergy is possible, we find that certain well-defined substances, such as atropine, eserine, andephedrine, are the most effective. There are observa-tions available, as Gaddum (1938) and Fraser (1938)have lately reminded us, which suggest that theinfluence of these substances is intimately relatedwith the interactions of certain endogenous substancesnow held to be the chemical determinants of thelocal muscular reaction to a nervous impulse. Thesesubstances include adrenaline with its counteragentamine oxidase and acetylcholine with its counteragentcholinesterase.

Briefly we are coming nearer to an understandingof clinical symptoms (or biological responses) variouslyand loosely attributed in the past to nervousness,idiosyncrasy, and allergy. Whether we includethese responses under the generic title of " neuroses "or invent a better name for them, we are findingexperimental and clinical justification for consideringthem together and not separately and for regardingthem, however originated, as dependent on specificphysiological disturbance rather than hypotheticalnervous influence or structural change. With veryrare exceptions the responses themselves, howeverfrequently and for however long a period they maybe repeated, remain uncomplicated by secondarystructural change, for the most careful examinationof the organs and tissues concerned reveals no lastingabnormality. In each episode, in fact, the eventualcounteraction of an excessive chemical stimulation iscomplete and perfect.

Analogies have been drawn between the visceralneuroses and stammering. Sir James Paget (1879)in a classical paper on " Stammering with otherorgans than those of speech," in which he discussesthe neuroses of the bladder in particular, wrote :" Stammering, in whatever organs, appears due to awant of concord between certain muscles that mustcontract for the expulsion of something, and othersthat must at the same time relax to permit the thingto be expelled." The result, as with the speechstammerer, is inhibition or disorderly action withdistress or, in the case of some viscera, actual pain.

The victims of visceral stammering are of kindredtemperament with the speech stammerers. Visceraland speech stammering not infrequently occur inthe same person. Again and again we can trace thesymptoms of the visceral neuroses to a failure ofrelaxation or to a too precipitate contraction of plainmuscle, or to a loss of the normal tonic or peristaltichabit. Kennedy and Williams (1938) have also drawnattention to the association of stammering and theallergic disorders. From this we must rather concludethat there is an association between nervousness and

allergy than that stammering is an expression of

allergy. The terms " vagotonia " and " sympathico-tonia," associated with the names of Eppinger andHess (1917), sought to explain liability to many of thevisceral disturbances, but I am not satisfied that asimple separation into these reactive types is clinicallyjustifiable.

FUNCTIONAL AND ORGANIC

In considering, as we shall later do, the individualnature and symptomatology of the visceral neurosesit should be emphasised that, although generallydistinguishable by careful clinical analysis, they canand do imitate organic disease sufficiently closely tolead again and again to erroneous diagnoses. Therecognition of a visceral neurosis depends largely onthe recognition of its subjective phenomena, and wewould here do well to remind ourselves that all

subjective symptoms, whether due to structuraldisease or other physical cause or to nervous or

chemical unrest, express only a disturbance of func-tion, and that a similar disturbance of function mayresult from any one of these causes. A symptom, inother words, is specific for a disturbance of functionand not for its cause. A carcinoma or a nervousspasm may each cause colonic pain ; in both instancesthe pain accompanies abnormal tension, perhapswith attendant ischsemia, in the muscle-fibre. Cardiacpain may be due to emotional stimuli, to anaemia, orto sclerosis of the coronary arteries ; in each of theseinstances we believe the pain to be related to chemicaldisturbance arising from anoxia in the cardiacmuscle-fibre.To call an organic disease functional is an old and

regrettable error. It may be as grave an injustice toa patient to call a functional disease organic. It is

melancholy to contemplate the countless abdominaloperations which have been performed and thecountless physical treatments which have beenprescribed in the past for disorders affecting thestomach, the bowel, the heart, the uterus, and otherorgans, which are no more " organic " than bronchialasthma, extra-systoles, blushing, or blepharospasm.

Differential diagnosis must be decided partly, itis true, by the quality and degree of a subjectivesymptom, but partly also by associated phenomena,and by temperamental assessments and routine

objective tests. Without a physiological interpreta-tion of symptoms, however, all diagnosis remainsincomplete.

HISTORY AND LITERATURE

To attempt to combine a condensation of personalexperience with an adequate digest of the scatteredliterature of so wide a subject as the visceral neuroseswould be a difficult task. In a large but compactvolume running into 430 pages and with a biblio-

graphy of 150 pages Dunbar (1935) has lately reviewedand abstracted the literature relating to the psycho-somatic disorders covering the period 1910-30. Ofthis literature a considerable proportion is concernedwith the emotional disturbances of the viscera, butit must be allowed that the advancement of knowledge

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in a clinical regard within that period and since hasbeen neither very methodical nor very extensive.Cannon and Pavlov have given us basic knowledgeand a host of fruitful ideas, but these have notinfluenced contemporary medical thought as theyshould have done.

In recent years important observations on theinfluence of the emotions on the organs have beenmade by Wittkower (1935) and his collaborators,who have employed psychological experiment in

conjunction with physiological and radiological studiesand the psychiatric approach. More attention,however, is paid at present to the psychology andpsychiatry of these disorders than to their morbidphysiology, their symptomatology, and their differ-ential diagnosis from organic states. Careful descrip-tion and differentiation should surely anticipate orat least accompany therapeutic innovation. Wherepsychiatry will be as liable to failure as the thera-peutics of the physical school is in its omission to studythe type or mode of the physiological disturbancesconsequent upon emotion. Furthermore it has notbeen sufficiently emphasised that numerous factorsother than emotion may contribute to the establish-ment and perpetuation of a visceral neurosis.Perusal of the literature and contact with the

practice of the last quarter of a century reveal stagesof thought and changes of fashion in which sometimesthe organ, sometimes the nervous system, sometimesa mechanistic, sometimes an infective, emotional, orchemical hypothesis has focused attention for thetime being. Terms such as " vagotonia " or " organinferiority " have replaced local pathological conceptssuch as " colitis," and in the field of treatment surgicaltrial and error and other physical measures are makingway for psychiatric experiment. With patientwinnowing wheat may, it is true, be found among thechaff of much vague and unsatisfactory pathology.From close clinical study, however, and from suchstudy alone, emerges the prime necessity of observingand investigating the " whole man" if we are toreveal the pathogenesis and paint the true picture ofa visceral neurosis and effectively to assess, for

purposes of understanding and management, thecontributions of heredity, temperament, physique,environment, emotion, endocrine dysfunction, allergy,and the conditioned reflex. Together with such study,and not separately from it, we should seek, wheneverpossible, to employ such special methods as physiologyand psychology can prove to be effective.

CRITERIA OF ALLERGIC PHENOMENA

In describing some of the visceral neuroses I shallhave occasion, as already indicated, to consider thepossible contribution of natural sensitivity or allergy.The list of manifestations attributed to allergy hasalready been unduly expanded. Many of the neweradditions have been made with little justification.The term itself is providing a new cloak for ignorance.I suggest that no visceral, cutaneous, or vascularsymptoms should be held to be allergic unless some,and preferably several, of the following postulatesare fulfilled:

(1) The symptoms should bear close comparisonwith symptoms observed in human anaphylaxis orserum-sickness. I

. (2) There should be a history of " idiosyncrasy " ,

in respect of some food, beverage, tobacco, drug, or iother extraneous substance, or a well-defined responseto specific cutaneous tests.

’

(3) There should be observed in conjunction withthe suspect phenomenon, whether coincidentally or at 1other times, other accepted allergic phenomena, such asasthma, hay-fever, urticaria, and angioneurotic oedema. (

(4) There should be a family history of thesedisorders.

(5) The disturbances should show some suchintermittency or periodicity as obtains in thesedisorders.

(6) Every care should have been- taken to excludethe presence of irreversible structural disease.

(7) As additional tests Hurst (1933) mentions afavourable response to adrenaline and the presenceof eosinophilia.The only final proof of allergic sensitiveness is a

specific response to a specific allergen, but we mustrecall that this is by no means universally obtainedeven in such conditions as bronchial asthma andurticaria ; hence its absence in other conditions neednot be held to exclude them. The clinical observationsreported hereafter suggest that we have latterly, inour clinical assessments, attached too much import-ance to the idea of specific sensitivity, and that theso-called allergic response is only one of many expres-sions of a hypersensitiveness to adverse stimuli(whether physical, chemical, or psychological) whichattaches to certain types of human constitution. Itis a common observation that the same individualmay manifest the same intestinal intolerance to afood-stuff, an east wind, fatigue, or a mental problem.Angioneurotic oedema, although it may be inducedby a bee-sting or the injection of a serum, is oftenevoked by emotion. The general and nervous healthor balance of the individual at the time of exposureto an adverse stimulus may also determine theappearance or non-appearance of the specific response,much as other forms of reflex activity may beheightened or diminished by an attendant butunrelated circumstance. Nervous unrest and allergyare often partners ; both may be capable of evokingthe same symptoms in the same patient; but itremains for us to discover the nature of the relation-ship and the reason for the similarity of their effects.The primary evidence for these statements is to befound in the daily experience of the clinic ; the finalexplanation of the observed phenomena will only beattained by experimental methods.

.

SCHEME OF INQUIRYI propose to confine myself to a consideration of

functional disorders affecting certain of the holloworgans. Of the solid organs the liver particularly mayalso have its nervous disturbances, but these have notyet acquired clear definition, the nature of the dis-turbances is uncertain, they are rarely painful affec-tions or locally manifest, and they seldom lead toserious misinterpretations. Nor shall I consider therespiratory neuroses. Asthma is too large a subject.Other disturbances of respiratory rate or rhythmunder the influence of the emotions are scarcelyvisceral in the true sense. Of the hollow organs Ishall review in turn the gullet, the colon, the rectum,the urinary bladder, and the heart. The uterus,for lack of special knowledge, although its spasmodicneuroses are well known, I have left out of account.Omission of the stomach may seem a peculiar decision,but I have to confess that, although much of mytime and thought have been devoted to gastricphysiology and pathology, and although gastricneuroses are common enough, the difficulties of

separating them from organic states, from associationsof organic change with functional super-additions(including the effects of aerophagy), or from reflexdisorders of gastric function due to organic diseasein neighbouring structures, remain so considerablethat I have preferred to concentrate on other viscera.Alvarez (1930), in America, with his sensible physi-;ianly approach, has made valuable contributions to

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the clinical study of the gastric neuroses, but theyawait a more intimate investigation. The organschosen for consideration in these lectures are lessliable than the stomach to inconspicuous inflamma-tions and ulcerations and to reflex disturbances andcan be more certainly passed as free from organicdefect by modern methods of investigation. We shall,perhaps, be in a better position to segregate thegastric neuroses when gastroscopy has added to

radiology and chemical analysis a more direct andreliable knowledge of the living mucosa. In themeantime the principles which should govern theirclinical study differ in no essential from those to bedescribed in the case of other organs.The descriptions and discussion which follow are

based upon a perusal of the records of 33 cases ofoesophageal neurosis, 321 of colonic neurosis, 15of rectal neurosis, 2 of serious bladder neurosis (theminor neuroses of the bladder being too numerousfor analysis and not separately indexed in my files),and 63 of cardiac neurosis. Many of the descriptionswill be familiar; others may seem to have gainedsomething through added detail and a closer symptom-analysis than is usually accorded them. Among thevisceral neuroses some are of indefinite type andsome of more constant pattern. It is with the second

group that my descriptions will be chiefly concerned.The more constant the clinical pattern the more likelyis it that we are confronted with a specific physio-logical error. To attempt an analysis of the indefinitetypes of visceral neurosis would scarcely as yet provea fruitful labour. In classifying results I debated atfirst whether it would be better to take each organseparately and to consider its important neuroses orunder the several aetiological headings to considerexamples of various visceral manifestations. Themore I considered my case-histories the more pro-nounced became their setiological complexity, eventhough competence for the recognition and siftingof likely causal factors in the individual may beallowed to have increased with experience. It wasalso clear that different stimuli repeatedly causedor appeared to cause the same response. For thesereasons and because anatomical classifications inmedicine still have their uses the first plan appearedthe only reasonable one to adopt. Brief mention willbe made, in passing, of organic states which may beconfused with the neuroses and particularly certainstates which have recently been given distinctive

portraiture by improved methods of objective study.Multiple neuroses often coexist in the same patientand are among the best evidences of a general oremotional cause. To these associated neuroses

frequent reference will be made.

2ETIOLOGY

Certain general setiological considerations mustclaim our attention before the particular neurosesare passed in review. When a patient presentshimself with a complaining organ, when no evidenceof structural change in that organ is forthcoming,and when symptom-analysis and the circumstancesof his life and temperament suggest that he mayproperly be regarded as a victim of a visceral neurosis,diagnosis in the full sense still remains incompleteuntil we can suspect an exciting stimulus and haveobtained demonstration or at least framed a reasonablephysiological explanation of the mechanism of theneurosis. Clinical, radiological, and other objectiveinvestigations have done much to explain the morbidphysiology of the hollow organs and can discoveror exclude organic states with increasing certainty.Intimate clinical histories and hypothesis based upon

them and strengthened by the work of Cannon andby Pavlov’s classical experiments on the conditionedreflex can at least carry us a stage further in thestudy of aetiology and may at present be held tojustify the following conclusions in regard to the

origins and perpetuating causes of the visceralneuroses.

(1) The origin of a visceral neurosis may be foundin a previous but finally departed organic injury.Thus a past dysentery may leave in its wake a spasticor irritable colon, or a cystitis be followed by a nervousfrequency. In similar fashion a bronchitis is isome-times succeeded by asthma, or a conjunctivitis byhabitual blinking. " Conditioned irritability " would,perhaps, be an apt definition of such a neurosis. Ineach example quoted the local inflammatory irritationhas passed, but the habit of irritability remains. Ineach example a central or peripheral irritation, some-times minimal and often far to seek, is required todetermine the active dysfunction.

(2) The origins of a visceral neurosis may be foundin an inborn, or more rarely an induced, sensitivenessor allergy. In such case the " irritability " is condi.tioned by a " humoral " instability, while the activedysfunction is determined by specific stimuli. Aswith asthma, however, the passage of time mayresult in a more ready determination of attacks byboth old and new stimuli. The sensitiveness becomesless specific. The active irritation, as distinct fromthe irritability, is determined in new ways. As willbe shown, colonic and rectal neuroses, which are

sometimes associated in the same individual withasthma, urticaria, hay-fever, or migraine, can rarelybe traced to a single specific cause.

(3) The origins of a visceral neurosis may be foundin a psychological instability unassociated with theconditioning factors named above but manifest as

anxiety or other emotional unrest. Prominent amongthe perpetuating factors is the patient’s fear that thevisceral symptoms may be due to organic disease.

(4) As with bronchial asthma, so with the disordersof the abdominal viscera any or all of the provocativefactors named may operate simultaneously or at onetime or another in the same individual and mayserve as reinforcing stimuli. A humoral state mayprovide the condition for an emotional reaction, oran emotional state for a humoral reaction. Anasthmatic tendency based on a native allergy, andthe asthmatic attack itself due primarily to pollenor some other specific factor, may, as the years pass,undergo aggravation or be occasioned by a varietyof other factors, physical or psychological, andincluding dust, fatigue, locality associations, or

emotional repressions. A similar evolution mayeventually be found to be true for the neuroses

affecting the abdominal viscera.(5) Whatever conditioning or determining causes

we invoke, we have good reason to suppose fromstudies of temperament, physique, and family historythat hereditary predisposition is a main foundation

upon which the visceral neuroses are based. Bothconditioning and determining extraneous stimuli-e.g., a past inflammation or present irritation-operate frequently but with little or no effect inpersons lacking the nervous or humoral predispositionor diathesis. In most cases of visceral neurosis thereis a history of nervousness on one or both sides ofthe family. The inherited tendency or diathesis isbest regarded as a biological variation. Variationsmay be observed in degree as well as kind. Correlatedvariations, here as elsewhere in nature, are common.

(6) Finally (although such cases cannot strictlycome within our category) an organic state incapable

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of producing symptoms under favourable conditionsmay, in the presence of anxiety, lead to visceraldisorder. Thus, I have seen achalasia of the cardiawith pronounced oesophagectasia causing small incon-venience in quiet times or even under the crudestdietetic conditions in times of holiday, but under theworrying conditions of professional life, domestic

infelicity, or international crisis occasioning a returnof the usual troublesome dysphagia and regurgitation.Anxiety may also perpetuate angina pectoris, whichwill again disappear with relief of mind, even thoughwe have good reason to suppose that the primarybasis of the pain was organic coronary artery disease.

I have thought it well to formulate these viewsrelating to aetiology in advance of the evidence onwhich they are based. This evidence has been soughtand must be sought again in clinical experience whichconstantly checks and modifies its own conclusions,in the frequent re-reading of case-notes, and, wherepossible, by "follow-up " inquiry. I believe and shallhereafter support the belief that the classification ofcauses outlined above, although it may stand in needof fuller proofs, is a useful one, if only as an aid tothe management of cases and as a reminder that thevisceral neuroses are not all or wholly emotionalin origin, not all or wholly implanted in allergic soil,and not all or wholly a consequence of physicalfactors in the shape of present or past organicirritation.The whole man and his environment will remain

an essential part of the study of the visceral neuroses,whatever refinements of knowledge may accrue fromphysiological, biochemical, or psychological inquiry.

REFERENCES

Allbutt, T. C. (1884) On Visceral Neuroses, London.Alvarez, W. C. (1930) Nervous Indigestion, London.Dunbar, H. F. (1935) Emotions and Bodily Changes, New York.Eppinger, H., and Hess, L. (1917) Vagotonia, 2nd ed., New York.Fraser, F. R. (1938) Brit. med. J. 1, 1249, 1293, 1349.Gaddum, J. H. (1938) Ibid, p. 713.Hawkins, H. P. (1906) Ibid, 1, 65.Hurst, A. F. (1933) in Price’s Text Book of the Practice of

Medicine, London.Kennedy, A. M., and Williams, D. A. (1938) Brit. med. J. 2, 1306.Paget, J. (1879) Clinical Lectures and Essays, 2nd ed., London.Wittkower, E. (1935) J. ment. Sci. 81, 534.

"... The world of today is suffering from a crisis ofdisillusion and resentment against reason, simply becauseit believed too much in it before. Human life can onlystand one homeopathic dose of reason at a time. In lovewith logical perfection, and also afflicted by the injusticesand inequalities of everyday life, the men of the nineteenthcentury tried to force the pace of human progress byestablishing the perfect society ruled by rationalist justice.This noble effort was the dream of the French Revolution.Under the Revolution itself human life turned withunheard-of violence against the domination of rationalisedlogic, and the world saw this strange paradox: the

triumph of the most unbridled irrationalism in the nameof the most rigid reason. This affliction has gone on invarious forms during the whole of the nineteenth century,and it is even today the keynote of many happenings,both large and small, which we see around us.... ButEngland never took part wholeheartedly in this rationalisticmania of our epoch.... However much she might be inlove with ideas, she always retained a certain reserve forthe unexpected, the errors of men, and the ways ofunfathomable nature. As an external and positive symbolof this attitude, England never gave the first place in herpublic life to the intellectual or the thinker. But, actuallybecause of that, the intellectual and the thinker stilloccupy the high place in England that they have alwayshad, while one sees them dethroned and persecuted incountries that have suffered from an excess of intellec-tualism, and where political advance was wont to be

. preceded by philosophical standard-bearers."-SALVADORDE MADARIAGA, " The Island of Commonsense," in TheLi8tener, July 20, 1939, p. 110.

ENCEPHALOMYELITIS FOLLOWING

ADMINISTRATION OF SULPHANILAMIDE

BY J. H. FISHER, M.B. Sydney, M.R.C.P.A MEDICAL CHIEF ASSISTANT AT THE ROYAL INFIRMARY,

MANCHESTER; LATE MEDICAL REGISTRAR AT THESOUTHEND-ON-SEA GENERAL HOSPITAL

With a Note on Histological FindingsBY J. R. GILMOUR, M.R.C.P.

JUNIOR ASSISTANT DIRECTOR OF THE BERNHARD BARONINSTITUTE OF PATHOLOGY, LONDON HOSPITAL

NUMEROUS toxic manifestations are known tohave followed the use of sulphanilamide. Manyof these are not serious; for example cyanosis,dermatitis, febrile reactions, nausea, vomiting, andenteritis. Others, which are uncommon but moreimportant, are ansemias, agranulocytosis, and hepatitis.Their cause seems to be an idiosyncrasy to the drug,for they develop very rarely, and often after onlysmall amounts of the drug have been taken. Toxiceffects on the central nervous system have seldombeen recorded. In the two following cases symptomsof encephalomyelitis appeared after administrationof small quantities of sulphanilamide.

The First Case

A woman of 33 was admitted to the Southend-on-Sea General Hospital on Sept. 7, 1937.History.-Four years previously she had begun

to suffer from arthritis of the fingers, ankles andknees, and for this she was treated with gold injections.Six months later she developed lupus erythematosus.Examination.-The lupus erythematosus affected

chiefly the nose, face, ears and back of the hands.The rheumatoid arthritis involved the fingers, wrists,knees and ankles, and she complained of pain inthe affected joints. There was moderate ansemia, theblood-count being : .

Red cells ....

4,096,000 Polymorphs.... 70 %

White cells.. 5700 Lymphocytes 26%Haemoglobin .. 65 % Large mononuclears.. 4 %Colour-index .. 0-8

Progress.-The temperature rose occasionally to99° or 100° F. On Sept. 28 treatment with sulphanil-amide was started, and she was given 0’5 grammetwice daily. Even on this small dose she becamecyanosed on the second day, but as she was in noway distressed, administration of the drug wascontinued. On Oct. 11 the temperature rose to101’50 and she had a slight headache. Next day thetemperature was 104° and the headache more severe.The drug was stopped. Two days later (Oct. 14) shesuddenly developed complete flaccid paralysis ofboth legs, her neck was a little stiff, the knee- andankle-jerks and the abdominal reflexes were absent,and the plantar reflexes were not elicited. Sensationfor light touch was lost up to the level of the iliaccrests, and sense of position in the feet was also lost;but pain and vibration sense remained.The cerebrospinal fluid (C.S.F.) removed on Oct. 14

was turbid and under increased pressure. Cells16,000-almost all polymorphs, with a few red blood-cells. Protein 100 mg. per 100 c.cm. Chloride 660 mg.Globulin, marked excess. No tubercle bacilli seen,and culture sterile. Leucocytes 4700 (polymorphs70 per cent., lymphocytes 27 per cent., large mono-nuclears 2 per cent., eosinophils 1 per cent.).On Oct. 15 sensation was completely lost up to

the level of the fifth thoracic segment, and retentionof urine developed. On the 17th the anaesthesia hadascended to the second thoracic segment, and therewas consolidation at the bases of both lungs. Shedied on the 18th.