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ULCERATIVE COLITIS A TEST OF PSYCHOSOMATIC HYPOTHESES
125 at the affected side, and the strip thus undermined is cut free and avulsed. A scalpel is introduced at the proximal end of the groove between nail-fold and nail-bed so as to bisect the angle between the two. It is pushed through to emerge from the lateral margin of the toe. Its point of emergence should be well down towards the plantar surface, so that the points of entrance and exit are at least half an inch apart. The knife is then advanced distally, cutting a flap consisting of the nail-fold and a substantial strip from the -Bide of the toe (fig. 8). The knife is then turned round, the flap is tapered off and amputated at its base, bevelling off the bare area proximally (fig. 9). The toe is wrapped tightly in a soft-paraffin gauze bandage, which is left for a fortnight, unless there are signs of gross sepsis. The tourniquet shown in the photographs is a great help though not essential.
ULCERATIVE COLITIS
passed beneath the nail
The
following points require special emphasis:
A TEST OF PSYCHOSOMATIC HYPOTHESES M.D. CONSULTANT
M. SIM Edin., D.P.M.
PSYCHIATRIST,
UNITED BIRMINGHAM HOSPITALS
B. N. BROOKE M.D. Birm., M.Chir. Cantab., F.R.C.S. READER IN
SURGERY,
UNIVERSITY OF BIRMINGHAM
ULCERATIVE colitis has been claimed to be a member of the psychosomatic group of diseases. According to Halliday (1943) a psychosomatic affection is " a bodily disorder whose nature can be appreciated only when emotional disturbances (i.e., psychological happenings) are investigated in addition to physical disturbances (i.e., somatic happenings) ". Apparently some workers regard the case as proven. Sullivan and Chandler (1932) reported a series which describe as of psychogenic origin, and Sullivan (1940) elaborated these findings with a paper on Psychogenic Factors in Ulcerative Colitis. Groen (1947) discussed not only the psychogenesis of the disease but also the use of psychotherapy in its treatment, and this theme has been supported by Daniels (1942), Lindemann (1945), Karush and Daniels (1953) and Craddock (1953). In this country Wittkower (1938) described personality studies in 48 unselected cases and found evidence that " ulcerative colitis is a disease of the mentally ill or maladjusted. Almost all the patients showed character disorders, obvious neuroses, or psychoses." With this view
they
(1) This operation is unsuitable for the adult type of
ingrowing toenail. (2) The knife enters
the angle between nail-bedand nailfold. The nail-bed is not cut in any way. (3) It is essential to remove enough soft tissue because the mobile pulp is always ready to roll round the phalanx and create a new nail-fold. Any excision less than that illustrated is likely to fail. Results
I have done this operation regularly for the past seven Paulley (1956) agrees. years. Properly carried out in appropriate cases, it is Several hypotheses have been advanced to explain the always successful. It produces no deformity of toe or psychosomatic nature of the condition, and these are well nail, no discomfort or loss of function, and no recurrence. reviewed by Engel (1955), who also illustrates (Engel There are no complications such as wound infection, 1954a, 1954b) the inadequacy of those hypotheses osteomyelitis, and recurrent nail spicules. The period of which depend on functional diarrhoea being a preliminary disability is reduced to a minimum because the operation feature. In his own series (Engel 1954b) of 32 patients can be done on outpatients on their first visit. Suppura22 presented originally with bleeding, and diarrhoea, when tion is no contraindication; indeed the operation is a most it did occur, was usually secondary. On the other hand, " effective way of terminating sepsis. After the bandages support for the " ejection-riddance theories has come have been changed on the fourteenth day, normal walking from Grace et al. (1951) who, from their studies of 4 is possible and the patient can return to sedentary or light patients with iistulae (2 with ulcerative colitis), conclude work. that " the colon of man is likely to participate in his Figs. 10-12 show the result two years after operation. reactions to threatening events in his life situation, The toes are the same ones illustrated in figs. 5-9. including those threats which arise out of problems of the of the nails still cuts corners the patient Although interpersonal adjustment. Changes involving colonic rather short, there is now no tendency to ingrowth, hyperfunctioning at first altogether functional and because the skin of the new nail-fold is almost level with transitory may when unduly sustained result in structural the nail-bed. change and disease." REFERENCES Though agreeing that personality changes are seen in Burrrows H. J. (1955) in Modern Operative Surgery (edited by G. G. Turner patients with ulcerative colitis, many do not regard these and L. C. Rogers); p. 78. London. Kemp, C. E. (1955) Postgrad. med. J. 31, 558. Lake, N. C. (1951) Brit. med. J. i, 1072. Nuttall, H. C. W. (1941) Lancet, ii, 100. Zadik, F. R. (1950) J. Bone Jt Surg. 32B, 66.
lines of natural selection persisted. The same was true when the welfare unit became the tribe, and eventually the nation, but the relations between nations show only too clearly that there is still a step for man’s moral evolution to take in enlarging the welfare unit to encompass the whole of humanity. Man’s moral evolution is still incomplete."-Sir GAVIN DE BEER, The Listener, July 3, 1958, p. 12.
as
primary.
"
"
They adopt a common-sense view that a person with frequent diarrhoea and bleeding per rectum may well show secondary personality changes; if this were so it would prove a most powerful argument against the psychosomatic theorists. Two of the more "... With the evolution of man, characterised as it was by attractive hypotheses-those of Alexander (1952) and delay in development, great prolongation of childhood and Grace et al. (1951)-largely depend on diarrhoea being a resultant consolidation of the family, this pattern of altruistic reaction to frustration; and, since this symptom has behaviour must have acquired enormously enhanced importbeen shown by Engel (1954b) to be the less common ance. The size of the unit within which what may now be presenting feature of the disease, there is good reason called ethical conduct prevailed grew larger, from the family for further inquiry into a larger series. to the clan; but between clans the sub-human competition on changes
Method A retrospective inquiry into the incidence and order of appearance of each of six main symptoms was undertaken by means of a questionnaire, which was circulated to all 164 members of the Midlands division of the Ileostomy Association. 142 replied, and we attribute
126 INCIDENCE
OF
EACH
SYMPTOM IN ITS ORDER OF APPEARANCE; NUMBER OF PATIENTS WHO DID NOT HAVE
LAST COLUMN SHOWS THE SYMPTOM
excluded from the study. The replies from 120 patients form the basis of this report and are recorded in the
accompanying figure. Analysis of Data
Diarrhoea as a presenting symptom is only slightly morc common than bleeding (47:37, see table), and therefore the " ejection-riddance theory finds only very modest support. On the other hand, bleeding presents initially more commonly than most psychosomatic theorists would have us believe; perhaps therefore an alternative hypothesis is needed. Engel (1955) has elaborated one; but, since it depends on the fact that bleeding is the prime feature in the majority of cases, it cannot be considered this high return to the fact that the form, though designed adequate for the majority of the present series. He does, by ourselves, had been approved by the secretary ofthe however, stress that with a careful personal analysis of association and sent out to the members by their officers data (Engel 1954b) more patients admit to bleeding with an explanatory letter. as a first symptom than to diarrhoea, and it may be that There are disadvantages in this method; for retrospective the questionnaire did not supply this information surveys are less satisfactory than those planned in advance, accurately. This is a valid argument; but the value of the and in this particular investigation reliance has to be placed present method cannot be adequately tested by arguon the memory of patients for symptoms which in about a ment, but only by a carefully controlled prospective third of the series had begun five to ten years before. We inquiry, which we propose to do. soon realised did consider the perusal of case-histories, but Anxiety and depression are traditionally regarded as a no how these difference matter that, good may be, great exists between information obtained by various doctors and a important precipitating factors in the illness, yet they standardised series of questions designed to produce answers provide the first symptoms in only 23; these conditions in numbers. We chose the questionnaire, not only because of are so common in the general population that this may the greater ease in handling the data derived, but because we be a chance finding. On the other hand it is quite clear wanted to test the method itself. The active cooperation of a that affective disturbances are more frequent as third patient in a therapeutic trial has already been reported by and fourth symptoms, lending some support to the Hogben and Sim (1953), and an Ileostomy Association with a common-sense view that the mental changes follow membership of 164 consisting mainly of patients whose the physical changes. diagnosis had been confirmed at laparotomy appeared to us a Constipation appeared as a presenting symptom in most suitable medium for this type of investigation. series in 14 of his 32 patients. This is very Engel’s Of the 142 forms returned, 1 was unsigned. Confirma- different from the proportion in our series (24 out tion of the diagnosis was sought from the surgeons of 120) which seems to represent the subgroup whose concerned in all cases and was obtained in all but 3; disease started as proctitis or procto-sigmoiditis. A more a further 6 had not had ulcerative colitis. Of the 132 who striking feature regarding this symptom is the large had, 12 returned forms completed in an equivocal manner, number (80) who have not listed it at all. and though we had access to most of the information from other sources, we wanted to confine the investigation to Summary and Conclusion data derived from the questionnaire; these were therefore A method of inauiry into the presenting symptoms of ulcerative colitis is described, making use of an association of patients known as the Ileostomy "
"
"
Association. Diarrhoea
‘
initial symptom is only slightly than bleeding. There is little evidence therefore to support existing psychosomatic hypotheses of the origin of the disease. Anxiety and depression are commoner after than before diarrhoea and bleeding.
more
as an
common
This inquiry could not have been made without the fullest cooperation of the Midland Ileostomy Association, and we should like to record our sincerest thanks to the members, and to all those surgeons who kindly answered our inquiry regarding diagnosis of their patients. REFERENCES
Alexander, F. (1952) Psychosomatic Medicine. London. Craddock, C. C. (1953) Psychosom. Med. 15, 513. Daniels, G. E. (1942) New Engl. J. Med. 226, 178. Engel, G. L. (1954a) Amer. J. Med. 16, 416. (1954b) Psychosom. Med. 16, 496. — (1955) Amer. J. Med. 19, 231. Grace, W. J., Wolf, S., Wolff, H. G. (1951) The Human Colon. —
London.
Groen, J. (1947) Psychosom. Med. 9, 151. Halliday, J. L. (1943) Lancet, ii, 692. Hogben, L., Sim, M. (1953) Brit. J. prev. soc. Med. 7, 163. Karush, A., Daniels, G. (1953) Psychosom. Med. 15, 140. Lindemann, E. (1945) Arch. Neural. Psychiat. 53, 322. Paulley, J. W. (1956) Lancet, ii, 215. Sullivan, A. J., Chandler, C. A. (1932) Yale J. Biol. Med. 4, 779. (1935) Amer. J. dig. Dis. 2, 651. Wittkower, E. (1938) Brit. med. J. ii, 1356. —
Order of appearance of
6. symptoms
in 120
patients with
ulcerative colitis
ULCERATIVE COLITIS
passed beneath the nail
The
following points require special emphasis:
A TEST OF PSYCHOSOMATIC HYPOTHESES M.D. CONSULTANT
M. SIM Edin., D.P.M.
PSYCHIATRIST,
UNITED BIRMINGHAM HOSPITALS
B. N. BROOKE M.D. Birm., M.Chir. Cantab., F.R.C.S. READER IN
SURGERY,
UNIVERSITY OF BIRMINGHAM
ULCERATIVE colitis has been claimed to be a member of the psychosomatic group of diseases. According to Halliday (1943) a psychosomatic affection is " a bodily disorder whose nature can be appreciated only when emotional disturbances (i.e., psychological happenings) are investigated in addition to physical disturbances (i.e., somatic happenings) ". Apparently some workers regard the case as proven. Sullivan and Chandler (1932) reported a series which describe as of psychogenic origin, and Sullivan (1940) elaborated these findings with a paper on Psychogenic Factors in Ulcerative Colitis. Groen (1947) discussed not only the psychogenesis of the disease but also the use of psychotherapy in its treatment, and this theme has been supported by Daniels (1942), Lindemann (1945), Karush and Daniels (1953) and Craddock (1953). In this country Wittkower (1938) described personality studies in 48 unselected cases and found evidence that " ulcerative colitis is a disease of the mentally ill or maladjusted. Almost all the patients showed character disorders, obvious neuroses, or psychoses." With this view
they
(1) This operation is unsuitable for the adult type of
ingrowing toenail. (2) The knife enters
the angle between nail-bedand nailfold. The nail-bed is not cut in any way. (3) It is essential to remove enough soft tissue because the mobile pulp is always ready to roll round the phalanx and create a new nail-fold. Any excision less than that illustrated is likely to fail. Results
I have done this operation regularly for the past seven Paulley (1956) agrees. years. Properly carried out in appropriate cases, it is Several hypotheses have been advanced to explain the always successful. It produces no deformity of toe or psychosomatic nature of the condition, and these are well nail, no discomfort or loss of function, and no recurrence. reviewed by Engel (1955), who also illustrates (Engel There are no complications such as wound infection, 1954a, 1954b) the inadequacy of those hypotheses osteomyelitis, and recurrent nail spicules. The period of which depend on functional diarrhoea being a preliminary disability is reduced to a minimum because the operation feature. In his own series (Engel 1954b) of 32 patients can be done on outpatients on their first visit. Suppura22 presented originally with bleeding, and diarrhoea, when tion is no contraindication; indeed the operation is a most it did occur, was usually secondary. On the other hand, " effective way of terminating sepsis. After the bandages support for the " ejection-riddance theories has come have been changed on the fourteenth day, normal walking from Grace et al. (1951) who, from their studies of 4 is possible and the patient can return to sedentary or light patients with iistulae (2 with ulcerative colitis), conclude work. that " the colon of man is likely to participate in his Figs. 10-12 show the result two years after operation. reactions to threatening events in his life situation, The toes are the same ones illustrated in figs. 5-9. including those threats which arise out of problems of the of the nails still cuts corners the patient Although interpersonal adjustment. Changes involving colonic rather short, there is now no tendency to ingrowth, hyperfunctioning at first altogether functional and because the skin of the new nail-fold is almost level with transitory may when unduly sustained result in structural the nail-bed. change and disease." REFERENCES Though agreeing that personality changes are seen in Burrrows H. J. (1955) in Modern Operative Surgery (edited by G. G. Turner patients with ulcerative colitis, many do not regard these and L. C. Rogers); p. 78. London. Kemp, C. E. (1955) Postgrad. med. J. 31, 558. Lake, N. C. (1951) Brit. med. J. i, 1072. Nuttall, H. C. W. (1941) Lancet, ii, 100. Zadik, F. R. (1950) J. Bone Jt Surg. 32B, 66.
lines of natural selection persisted. The same was true when the welfare unit became the tribe, and eventually the nation, but the relations between nations show only too clearly that there is still a step for man’s moral evolution to take in enlarging the welfare unit to encompass the whole of humanity. Man’s moral evolution is still incomplete."-Sir GAVIN DE BEER, The Listener, July 3, 1958, p. 12.
as
primary.
"
"
They adopt a common-sense view that a person with frequent diarrhoea and bleeding per rectum may well show secondary personality changes; if this were so it would prove a most powerful argument against the psychosomatic theorists. Two of the more "... With the evolution of man, characterised as it was by attractive hypotheses-those of Alexander (1952) and delay in development, great prolongation of childhood and Grace et al. (1951)-largely depend on diarrhoea being a resultant consolidation of the family, this pattern of altruistic reaction to frustration; and, since this symptom has behaviour must have acquired enormously enhanced importbeen shown by Engel (1954b) to be the less common ance. The size of the unit within which what may now be presenting feature of the disease, there is good reason called ethical conduct prevailed grew larger, from the family for further inquiry into a larger series. to the clan; but between clans the sub-human competition on changes
Method A retrospective inquiry into the incidence and order of appearance of each of six main symptoms was undertaken by means of a questionnaire, which was circulated to all 164 members of the Midlands division of the Ileostomy Association. 142 replied, and we attribute
126 INCIDENCE
OF
EACH
SYMPTOM IN ITS ORDER OF APPEARANCE; NUMBER OF PATIENTS WHO DID NOT HAVE
LAST COLUMN SHOWS THE SYMPTOM
excluded from the study. The replies from 120 patients form the basis of this report and are recorded in the
accompanying figure. Analysis of Data
Diarrhoea as a presenting symptom is only slightly morc common than bleeding (47:37, see table), and therefore the " ejection-riddance theory finds only very modest support. On the other hand, bleeding presents initially more commonly than most psychosomatic theorists would have us believe; perhaps therefore an alternative hypothesis is needed. Engel (1955) has elaborated one; but, since it depends on the fact that bleeding is the prime feature in the majority of cases, it cannot be considered this high return to the fact that the form, though designed adequate for the majority of the present series. He does, by ourselves, had been approved by the secretary ofthe however, stress that with a careful personal analysis of association and sent out to the members by their officers data (Engel 1954b) more patients admit to bleeding with an explanatory letter. as a first symptom than to diarrhoea, and it may be that There are disadvantages in this method; for retrospective the questionnaire did not supply this information surveys are less satisfactory than those planned in advance, accurately. This is a valid argument; but the value of the and in this particular investigation reliance has to be placed present method cannot be adequately tested by arguon the memory of patients for symptoms which in about a ment, but only by a carefully controlled prospective third of the series had begun five to ten years before. We inquiry, which we propose to do. soon realised did consider the perusal of case-histories, but Anxiety and depression are traditionally regarded as a no how these difference matter that, good may be, great exists between information obtained by various doctors and a important precipitating factors in the illness, yet they standardised series of questions designed to produce answers provide the first symptoms in only 23; these conditions in numbers. We chose the questionnaire, not only because of are so common in the general population that this may the greater ease in handling the data derived, but because we be a chance finding. On the other hand it is quite clear wanted to test the method itself. The active cooperation of a that affective disturbances are more frequent as third patient in a therapeutic trial has already been reported by and fourth symptoms, lending some support to the Hogben and Sim (1953), and an Ileostomy Association with a common-sense view that the mental changes follow membership of 164 consisting mainly of patients whose the physical changes. diagnosis had been confirmed at laparotomy appeared to us a Constipation appeared as a presenting symptom in most suitable medium for this type of investigation. series in 14 of his 32 patients. This is very Engel’s Of the 142 forms returned, 1 was unsigned. Confirma- different from the proportion in our series (24 out tion of the diagnosis was sought from the surgeons of 120) which seems to represent the subgroup whose concerned in all cases and was obtained in all but 3; disease started as proctitis or procto-sigmoiditis. A more a further 6 had not had ulcerative colitis. Of the 132 who striking feature regarding this symptom is the large had, 12 returned forms completed in an equivocal manner, number (80) who have not listed it at all. and though we had access to most of the information from other sources, we wanted to confine the investigation to Summary and Conclusion data derived from the questionnaire; these were therefore A method of inauiry into the presenting symptoms of ulcerative colitis is described, making use of an association of patients known as the Ileostomy "
"
"
Association. Diarrhoea
‘
initial symptom is only slightly than bleeding. There is little evidence therefore to support existing psychosomatic hypotheses of the origin of the disease. Anxiety and depression are commoner after than before diarrhoea and bleeding.
more
as an
common
This inquiry could not have been made without the fullest cooperation of the Midland Ileostomy Association, and we should like to record our sincerest thanks to the members, and to all those surgeons who kindly answered our inquiry regarding diagnosis of their patients. REFERENCES
Alexander, F. (1952) Psychosomatic Medicine. London. Craddock, C. C. (1953) Psychosom. Med. 15, 513. Daniels, G. E. (1942) New Engl. J. Med. 226, 178. Engel, G. L. (1954a) Amer. J. Med. 16, 416. (1954b) Psychosom. Med. 16, 496. — (1955) Amer. J. Med. 19, 231. Grace, W. J., Wolf, S., Wolff, H. G. (1951) The Human Colon. —
London.
Groen, J. (1947) Psychosom. Med. 9, 151. Halliday, J. L. (1943) Lancet, ii, 692. Hogben, L., Sim, M. (1953) Brit. J. prev. soc. Med. 7, 163. Karush, A., Daniels, G. (1953) Psychosom. Med. 15, 140. Lindemann, E. (1945) Arch. Neural. Psychiat. 53, 322. Paulley, J. W. (1956) Lancet, ii, 215. Sullivan, A. J., Chandler, C. A. (1932) Yale J. Biol. Med. 4, 779. (1935) Amer. J. dig. Dis. 2, 651. Wittkower, E. (1938) Brit. med. J. ii, 1356. —
Order of appearance of
6. symptoms
in 120
patients with
ulcerative colitis