Functional Bowel Syndrome: Also a “Crohn” Disease?
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Burrill R. Crohn (1884–1983), a pioneering gastroenterologist, is best known for a manuscript published in 1932 in the Journal of the American Medical Association, coauthored with Leon Ginzburg and Gordon Oppenheimer entitled “Terminal Ileitis: A New Clinical Entity” . In this publication, he described 14 cases of a granulomatous inflammation of the distal ileum. Although descriptions of the condition had arguably been published previously, this landmark paper described clinical findings in the largest group of patients with inflammatory bowel disease at that time, and was the source of our current use of the author’s name for the disease.
Dr. Crohn was an interesting man who practiced medicine into his 90s, primarily at the Mount Sinai Hospital in New York, where he worked for over 40 years. A true polymath, he also painted and studied Civil War history. Like many of his contemporaries, who worked when the field of gastroenterology was still in its infancy, his career was devoted to the understanding and management of a variety of vexing conditions, including peptic ulcer disease, gastrointestinal cancer, and functional bowel disorders. Dr. Crohn’s premise underlying his description of functional bowel disorders, republished in this issue of Digestive Diseases and Sciences , is that the gastrointestinal tract is a target for “external forces” including stress, personal problems, and family history that ultimately predispose to the development of what Dr. Crohn termed the “neurotic stomach.” Based on contemporary understanding of functional bowel disorders, this expression has a certain quaintness, as it reflects the prevailing interest in psychoanalytic theory. At the time of this manuscript’s publication, Sigmund Freud’s picture had already appeared on the cover of Time, and Freud’s name comes up twice in the article, beginning with its introductory sentence. Although our current understanding of functional bowel disorders includes a number of more recently appreciated non-psychiatric factors associated with the pathophysiology of these conditions, including intestinal dysbiosis, dysregulated gastrointestinal neurotransmitters, and distorted brain-gut activities, Dr. Crohn’s article contains many insights that remain relevant to the care of these patients in the twenty-first century.
Functional disorders are described as occurring from “psychic shock” in persons inclined towards neurosis. Unfortunately, in promoting this aspect of his theory, Dr. Crohn actually disagrees with his contemporaries who suggest that these conditions are an “autonomic nervous system imbalance,” terminology that would fit closely with the current understanding of functional GI disorders. Instead, he views these conditions as gastrointestinal manifestations of well-described psychiatric conditions including “anxieties, hysterias, somatic neurosis, neurasthenias, and hypochondriases.” Using estimates from an article published in 1928 entitled “Insanity Equivalents and the Gastro-Enterologists,” he reminds the reader that “one percent of the population…is emotionally and physically unfit,” connecting this fact to the likelihood of a hereditary basis for “gastro-intestinal neuroses.” Within this context, he notes that patients seem to develop their problems in early adulthood, aggravated by worries when “the individual first faces his stark environment…or after a child takes sick and sleepless night are followed by convalescence. Soon one finds neurotic symptoms…furtive hunger, belching, constipation, pains, insomnia.” Current literature confirms that functional GI conditions most commonly occur in adolescence and early adulthood.
The personality of these patients is described in detail. Qualities identified in his patients with functional GI conditions include timidity, fear, poor sense of self-esteem, and irrationality. Social problems include domestic difficulties, poor relations with peers, and sexual disorders. Although some of these descriptors appear to fit patients in our current medical practices, others seem less familiar. Nonetheless, we would agree with Dr. Crohn who bemoans the fact that economic pressures prevent appropriate time away from work and leisure activities, which he views as vital to patients wellbeing.
In describing a case of an unnecessary cholecystectomy in a women with marital disharmony as a source of her functional GI symptoms, Dr. Crohn remarkably identifies a problem that remains today, when cholecystectomy in patients with irritable bowel syndrome (IBS) occurs at three times the rate of patients without the condition .
In his discussion of the diagnosis of functional GI conditions, Dr. Crohn’s approach is extraordinarily similar to today’s practice of medicine. He advises that “a thorough and careful examination for organic disease is necessary before the acceptance of the first impression becomes a final conclusion.” Gastroenterologists continue to follow the practice of performing a careful history, physical examination, and appropriate additional testing for organic diseases prior to diagnosing functional GI disorders .
Most importantly, Dr. Crohn reminds the practitioner what we know in the present day, that a trusting physician–patient relationship is the most important aspect of care for patients with functional GI conditions , demonstrating his own astounding appreciation of the art of medicine. In his words, “the one single powerful means at the disposal of every physician, of every general practitioner, is his capacity for understanding, for sympathy and advice.” Reading this, one can appreciate that Dr. Burrill B. Crohn was a giant, under whose shadow gastroenterologists proudly stand today.