Effect of Psychoanalysis on theCourse of Peptic Ulcer

SAMUEL Z. ORGEL, M.D.

i H I S PAPER is concerned with the thera-peutic efficacy of psychoanalysis in relievingthe ulcer patient of his tendency to recur-rences and complications, as shown in 15 ulcerpatients treated by me in the past 25 years.

Diagnostic Groupings ofUlcer Patients

All my ulcer patients were neurotic, andwere found to fit into three psychiatric diag-nostic groupings: the greatest number, 7, werediagnosed as character neuroses; the nextnumber, 5, were obsessional neuroses; andthe remaining 3 were mixed psychoneuroses.There is no history of peptic ulcer in thefamilies of any of these patients.

Little or No AnalysisThree of these patients may be readily ex-

cluded from consideration, except to mentionwhat happened to them some 10 years or morelater.

Patient 15, A. J., received only an initialinterview in March, 1944, and refused treatment.He was a 41-year-old* married man diagnosed ashaving a character neurosis. His symptoms wereof 8 years' duration. He had three recurrences ofthe ulcer at about 2-year intervals and alwaysresponded to medical treatment. He refusedpsychoanalytic treatment, even though told his

Visiting Psychiatrist, Hillside Hospital, GlenOaks, N. Y.

Read before the Annual Meeting of the AmericanPsychoanalytic Association, Chicago, 111., May, 1957.

Received for publication October 1, 1957.* Age of patient used is that at the time of his first

interview.

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duodenal ulcer, as diagnosed by x-ray, mightnecessitate an operation. A follow-up visit in1954, 10 years after his first visit, elicited thefact that his typical ulcer symptoms recur aboutonce a year and are readily controlled by medicaltreatment.

Patient 14, S. S., seen in February, 1944, wasa 42-year-old married man and was diagnosed ashaving a mixed psychoneurosis. He had an ulcerhistory of 12. years' duration. At 36, 40, 41 Vz,and 42 years he suffered hemorrhages, had tarrystools, and vomited blood. The x-rays were al-ways positive for duodenal ulcer. Six monthsafter his attack he consented to psychoanalytictreatment, but left after 21 analytic visits. Sevenmonths after his last visit he again developed anulcer associated with bleeding which went on toperforation. A resection was performed and thepatient made a good recovery. On inquiry 11years later he reported that he had remainedsymptom-free for 1 year after the operation; sincethen he continues to have recurrent attacks, whichare temporarily relieved by diet, rest, and alkalies.

Patient 13, D. T., a 33-year-old married man,diagnosed as having a character neurosis, wasseen in 1943. His ulcer history dated back 9years and he had responded to medical treatment.At 31 and 31 V& years, he had a gastric hemor-rhage and tarry stools, and on both occasions agastric ulcer was demonstrated by x-ray. Sixmonths later his symptoms returned and he wasadvised to be analyzed. Not receiving any reliefof symptoms after 7 analytic visits, he discon-tinued his analysis. He was contacted in 1955,12 years later, and reported that his symptomscontinue to recur at 6-month intervals, and thatthey respond to diet, rest, and alkalies.

Deep Analysis

The 12 remaining ulcer patients received

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psychoanalytic treatment of the deep variety.They came 5 times a week and received a50-minute session each visit. The couch wasused and they were instructed in free associ-ation and allowed to develop a deep trans-ference relationship. Two of these patientsdid not complete their analyses, Patient 3stopping his after 138 visits over a period of7 months and Patient 7 stopping after 77visits over a 4-month period. These two casesand their follow-up will he briefly discussed.The remaining 10 patients all completed theiranalyses. The length of treatment varied from592 analytic hours during 3 years, to 942 ana-lytic hours over a period of 5 years.

Analysis Stopped

Patient 3, S. K., a 32-year-old married man,diagnosed as having a mixed psychoneurosis, wasfirst seen in 1932. His symptoms had been of6 years' duration and were relieved by alkalies.His symptoms became intense in 1932, 2 monthsbefore the analysis when his physician diagnoseda gastric ulcer which was confirmed by x-ray. Bythe end of 6 months he was free from symptomsand 1 month later, having had 138 analytichours, he stopped the analysis. On follow-up itwas learned that he had remained free fromsymptoms for 3 years when he had a recurrence.He had four more attacks between 1935 and1943, the last of which was associated with aperforation. A resection brought relief of symp-toms for 1 year after operation. Twenty-threeyears later a follow-up showed that he continuedto get symptoms which were controlled by milk,diet, and alkalies.

Patient 7, C. L., a 27-year-old woman, marriedand working as an attorney, was first seen in1934 Her diagnosis was an obsessional neurosis.She neglected her symptoms, until at 23 yearsof age she suffered a gastric hemorrhage andsevere ulcer pain. These responded to hospital-ization, rest, diet, and alkalies. X-ray revealed agastric ulcer. Similar attacks occurred at 26 and27 years of age, when she was referred for analy-sis. Her symptoms rapidly disappeared by theend of 4 months, when having had 77 analytichours, she stopped the analysis. In her follow-up21 years later she stated that from 1936 to 1941she had had three attacks of gastric hemorrhageand that the ulcer had perforated in the lastattack. A resection was performed and she re-

mained free from symptoms for 6 months, butsince she has had constant indigestion.

Analysis Completed

The 10 remaining patients completed theiranalyses. A summer vacation of 6 to 7 weeksinterrupted the treatment of these patients sothat they received approximately 220 analytichours a year. The follow-up of these patientshas shown no recurrences since the comple-tion of their analytic treatment, although 10to 22 years have passed. I would consider thesepatients cured. These cases will he brieflyreported.

Patient 1

Patient 1, J. 1V1., a 3o-year-old-married man,was referred to analysis in 1931. His psychiatricdiagnosis was character neurosis. His symptomsfirst occurred at 25 years of age, with pain andgnawing in the upper abdomen after meals.Three years later a definite diagnosis of gastriculcer was made clinically and by x-ray. He re-sponded to rest, diet, and alkalies, and made agood recovery. In 1931, 1 month before begin-ning analysis, he again evidenced clinical symp-toms of gastric ulcer which were confirmed byx-ray. After he had improved medically he con-sented to try psychoanalysis. His symptoms com-pletely disappeared after 1 year of analysis. Hisanalysis lasted 3V2 years, and he received 695analytic hours of treatment. During the latterpart of his analysis he was free from all gastricsymptoms. At the completion of his analysisthere was a marked improvement in his maritallife and sexual relationship. At work his diligenceand application increased and there was a dis-appearance of a constant need for praise fromhis superior. There was also a marked improve-ment in his interpersonal relationships. At thefollow-up visit in 1956, 23 years after the com-pletion of his analysis, he had retained his gainsfrom the analysis and had no recurrence of hisulcer symptoms, in spite of two business reversesand the loss of his wife in 1953.

Patient 2

Patient 2, P. G., seen in September, 1931,was a 25-year-old married man who had beensuffering with epigastric pains and pyrosis for8 years, and was treated by diet and alkalies andobtained relief. He suffered a gastric hemorrhagein 1931 which responded to rest, diet, and alka-

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lies. The x-ray and clinical diagnosis was a gastriculcer. Six months later, at the age of 25, hestarted psychoanalysis. His psychiatric diagnosiswas obsessional neurosis. He had progressed wellin analysis for 8 months when he had a returnof his symptoms, these responded to therapywithout medical intervention. At 14 months heagain had a return of symptoms. This, too, re-sponded to analytic therapy and he was com-pletely free from all symptoms by the end of thesecond year. His analysis continued for anotheryear, when, after receiving 592 analytic hourshe was discharged. At the completion of theanalysis he showed personality changes in rela-tion to his marital life and a marked change toa more normal sexual adjustment. At his placeof business there was a marked improvement inhis work adjustment. He was seen for a follow-upvisit in 1956, 22 years after completing hisanalysis, and reported his continued good healthand success in his home life and business.

Patient 4

Patient 4, M. F., seen in 1932, was a 36-yeai-old married man who had been suffering withdaily gnawing pains and pyrosis for 8 years.Vomiting occurred once or twice a week. Dietand alkalies gave slight relief but never con-trolled the symptoms. In 1931, his symptomsbecame intensified and duodenal ulcer was diag-nosed clinically and by x-ray. The response torest, diet, and alkalies was very slow, and analy-sis was suggested. This he began in January,1932. The psychiatric diagnosis at this time wasobsessional neurosis. He progressed well in analy-sis and all symptoms disappeared after 4 months.However, as strong emotionally tinged materialbegan to emerge in the tenth month of his analy-sis, his ulcer symptoms returned and persistedup to the fourteenth month when they disap-peared. No medical treatment was given andthe patient was allowed to live on a normal dietwithout restriction His analysis continued foranother 3W yeais without any recurrence of hisulcer symptoms. He was in analysis for 5 yearsand received 942 analytic hours of treatment,during which he evidenced mild psychotic symp-toms, and might rightly have been diagnosed asa borderline schizophrenic psychosis. At thecompletion of his analysis, marked personalitychanges had taken place. His marital life andhis sexual adjustment to it were within the norm,so that both his wife and he were content. Hiswork adjustment had markedly improved, as had

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his financial status He still had mild difficultyin his interpersonal relationships. He was seenfor a follow-up visit in 1955, 19 years after thecompletion of his analysis, when he reportedthat he had been exceedingly healthy and hadnot needed any medical care. The gains from theanalysis had continued, for during that time hisfamily had increased, and he had had a hardstruggle making his new business venture suc-ceed.

Patient 5

Patient 5, S. G., seen in November, 1932, wasa 33-year-old married woman, childless, andworking as an executive. For the past 10 yearsshe had been suffering daily with pain, gnawing,pyrosis, and occasional vomiting in the morningon arising. The symptoms had been partly con-trolled by diet, milk, and alkalies. At the timeof referral in November, 1932, her symptomshad intensified and a duodenal ulcer was diag-nosed clinically and on x-ray. Medical treatmentof diet and alkalies were continued for the first2 months of the analysis. The psychiatric diag-nosis was character neurosis. She responded well,until deeper emotional material began to comeinto consciousness, and she had a hemorrhagewhich on x-ray proved to be from a recurrenceof a duodenal ulcer. Hospitalization was foundunnecessary and the analysis continued withoutrecurrence for another 2 years, making a total of3VS years of analysis, and 620 analytic hoursThroughout the analysis a marked evolution wasnoted as infantile activity was replaced by moreacceptable adult activity. At the completion ofthe analysis changes had taken place in hermarital and sexual adjustment, as well as herwork adjustment. In 1955, 20 years later, at thefollow-up interview she reported that there hadbeen no recurrence of any ulcer symptoms or anyother illness. She had two normal pregnancies,18 and 15 years ago, and gave birth to normalchildren, a boy and a girl. She laughingly re-marked that after the birth of her second child,the girl, she had stopped work and acceptedbeing a wife and mother.

Patient 6

Patient 6, B. H , seen in October, 1933, was a40-year-old married man, who had for 15 yearsbeen suffering with abdominal pains occurringmostly at night. In 1927, a clinical and x-raydiagnosis of gastric ulcer was made which re

120 PSYCHOANALYSIS IN PEPTIC ULCER

sponded to medical treatment. A recurrence in1930 and again in 1933 was diagnosed clinicallyand by x-ray as gastric ulcer. He was placed ondiet and alkalies and advised to take psycho-analytic treatment, which he began immediately.The psychiatric diagnosis at the time of the initialinterview was character neurosis. His progresswas slow and his symptoms persisted for the firstyear of the analysis. He remained in analysisfor 4 years, receiving 730 analytic hours oftreatment. He showed slow but continuous evo-lution and at the completion of his analysisshowed marked improvement in his marital life,sexual adjustment, work adjustment, and in in-terpersonal relationships. His follow-up interview19 years later showed him to have continuedwell without any recurrence of his ulcer or ulcersymptoms In the interim his wife had givenbirth to two healthy boys, who are now 17 and15 years old. His oldest daughter had married5 years ago and has given him two grandchildren.

Patient 8

Patient 8, C. P., seen in September, 1935,was a 29-year-old single man living at home withhis parents, an older brother, and two oldersisters. He had been suffering for 7 years fromabdominal distress, which had been clinicallydiagnosed as gastric ulcer. These symptoms hadresponded to medical treatment. In 1934, andagain in 1935, his symptoms recurred with in-creased intensity and a gastric ulcer was demon-strated by x-ray. He was advised to try psycho-

•analysis, which he began immediately. His psy-chiatric diagnosis at the time of his initial visitwas obsessional neurosis. His symptoms graduallysubsided under combined medical and analytictreatment. His treatment was a stormy one besetwith continued doubts of getting well and beingable to care for himself. His symptoms wouldgradually diminish for a few months and thenflare up again. After 2 years his symptoms gradu-ally subsided, without the aid of diet or alkalies.He remained in analysis for 4 years, receiving740 hours of analytic treatment. He evidencedcontinued improvement in his sexual adjustment,as well as work and in his interpersonal relation-ships. His follow-up interview in 1956, 18 yearslater, showed him to have had no recurrence ofhis ulcer symptoms. He married 2 years aftercompleting his analysis. His wife has given birthto two children, both boys. His adjustment tohis marital life and family is excellent, as is his

relationship with his two sisters and brother. Thepatient reacted normally to the death of hisparents 5 years ago.

Patient 9

Patient 9, G. N., seen in September, 1939,was a 43-year-old married man who had beensuffering with ulcer symptoms for 10 years. In1934, and again in 1937, he was hospitalizedand treated for bleeding ulcer of the stomach.He made a good recovery and remained well for2 years, when his symptoms recurred and werediagnosed clinically and by x-ray as being dueto a duodenal ulcer. He was advised to trypsychoanalysis before resorting to surgery. Hebegan his analysis in the fall of 1939 with apsychiatric diagnosis of mixed psychoneurosis.His symptoms gradually improved under diet andanalytic treatment. One and a half years afterthe beginning of his analysis his ulcer recurredas deeper material of emotional significance beganto emerge. His symptoms gradually disappearedwithout the help of a diet, and he remained wellthroughout the rest of the analysis, which lastedfor three years; he received 615 analytic hours oftreatment. He showed marked improvement inhis marital and sexual adjustment, as well as inhis work and interpersonal relationships. At thetime of his follow-up interview in 1956, 15 yearslater, he had had no recurrence of his ulcersymptoms in spite of a business reverse in 1943,2 years after completing his analysis. He alsoweathered the death of both his parents in 1946.His adequate adjustment at home, work, and theoutside world has continued to date.

Patient 10

Patient 10, H. R., seen in September, 1938,was a 2.9-year-old married man who had beensuffering for 12 years with gastric symptomswhich were controlled by diet and alkalies. InJuly, 1938, he had a gastric hemorrhage whichwas diagnosed clinically and by x-ray as aduodenal ulcer. He was immediately placed ona rigid diet, rest, and alkalies. At the end of 3months, because his symptoms had not dis-appeared, psychoanalysis was advised, which heaccepted. His initial interview in September.1938, showed him psychiatrically to have acharacter neurosis. He was continued on hisulcer diet and alkalies and his symptoms grad-ually disappeared, so that at the end of 6 monthshe was symptom free. In the next 3 monthsof his analysis he gradually discontinued his diet

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and alkalies but refused to give up his dailyconsumption of 4 glasses of milk. He finally, inhis 13 months of analysis, did discontinue themilk. For the next 9 months, as intensely chargedemotional material from his early childhoodcame to the surface, he reverted to drinkingmilk. This he discontinued by the end of hissecond year of analysis. He remained wellthroughout the remainder of his analysis, whichlasted -i,Vi years, having received 650 analytichours of treatment. His growth was evident inhis marital and sexual life, as well as at workand in his interpersonal relationships. Whenseen for his follow-up in 1956, 14 years later,he had sustained his gains from analytic treat-ment. In the interim his parents had died, hiswife had given birth to their third child, and hehad received two promotions at work so that hewas now the director of his department.

Patient 11

Patient 11, R. B., seen in February, 1940,was a 27-year-old single man, living at homewith his parents and two younger sisters, whohad been suffering daily with pain, pyrosis, andgnawing in the abdomen for 10 years. He hadthree recurrent attacks of duodenal ulcer asdiagnosed clinically and by x-ray at the age of20 years, at 24 years, and at the time of referralfor analysis at 27 years. In all these attacks hehad responded to rest, diet, and alkalies. In hislast attack, though placed on the same treatment,psychoanalysis was advised, which he accepted.His psychiatric diagnosis at the time of theinitial interview was obsessional neurosis. Hisdiet and alkalies were continued and he re-sponded rapidly. He got along excellently with-out the need of diet and alkalies, until emo-tionally toned infantile material of an aggressiveand destructive nature began emerging 15months later. His symptoms and ulcer recurredas confirmed by x-ray. He was not given anymedical treatment and the ulcer healed underthe analytic treatment. He remained wellthroughout the remainder of his analysis, whichlasted for 3V4 years, having received 642 hoursof analysis. His growth and evolution evidenceditself by the marked improvement in relation tohis parents and sisters. He left home, but con-tinued to help support his parents. His sex lifeimproved as did his work and interpersonal re-lationships. In 1956, 13 years later, he was seenfor a follow-up report, and was found to havecontinued well since his last attack during

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analysis. Three years after completing theanalysis he had married and has had two chil-dren. In 1953 his parents died; their deaths wereseparated by 3 months. Through all this, he hasnot regressed and has felt capable of meetinghis difficulties.

Patient 12

Patient 12, D. E., seen in March, 1942, was a34-year-old married woman with one child, whohad been having repeated episodes of ulcer dis-tress of increasing intensity for the past 5 years.In 1942, 1 month before being referred for psy-choanalysis, she had a hemorrhage by mouthwhich proved to be, both clinically and by x-ray,due to a bleeding gastric ulcer. She was placedon a strict diet, rest, and alkalies, but respondedpoorly. She was advised to try psychoanalytictreatment before having recourse to surgery. Herpsychiatric diagnosis at the time of the initialinterview was character neurosis. Her medicaltreatment was continued during the first 6months of the analysis without bringing aboutany change. This, I believe, was due to difficultyin developing sufficiently strong transference tothe analyst because of her strong attachment toher medical physician. Her medical treatmentwas discontinued. In the next 3 months, thepatient grew worse and the medical treatmentwas reinstituted. The improvement in the next3 months was so slight that again medical treat-ment was discontinued. For the next year, theanalytic sessions were a growing battle becauseof the patient's insistence that the analysis satisfyher infantile needs and desires. Finally, by theend of her second year of analysis some definiteprogress was evident. All her symptoms graduallydisappeared with the relinquishing of her infan-tile drives. She continued to remain symptomfree and showed a progressive evolution in heremotional life to the end of her analysis, whichlasted for 3V4 years and consisted of 657 analytichours. She showed a marked improvement in hermarital and sexual life, as well as improvementin her interpersonal relationships with her familyand friends. She was seen for a follow-up visitin December, 1955, 10 years after the comple-tion of her analysis, and reported herself as well,having had no recurrence, and that she washappy and contented. There had been no recurrence after the shock of her mother's death 3years ago, nor after the business reverse of herhusband 5 years ago.

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Discussion

All 15 cases were referred for psychoanalysisin the hope of a cure specifically for pepticulcer. The psychiatric examination of all thesepatients showed them to be suffering from aneurosis in addition to their ulcer, though notall were suffering from the same neurosis. Insome cases, the referring physician did notrealize that his patient was also suffering froma neurosis. Some did not believe that theneurosis and the peptic ulcer were part of thesame illness, but considered them as two sep-arate illnesses. In my cases it was evident thatthe psychoneurosis and ulcer were parts ofthe same illness, and not two unrelated con-ditions. These patients exhibited both somaticand emotional symptoms. In all cases, passivedependency wishes were found to be presentbut unacceptable, and thus strongly repressed.This would agree with Alexander's1 formula-tion of the ulcer conflict. However, Alexanderalso felt that ulcer patients would not respondto formal long-term analyses. Yet 10 of mycases accepted and completed a psychoanalysis,while the remaining 5 accepted it in varyingdegrees. All my patients were burdened withother psychoneurotic manifestations besidestheir peptic ulcer, and were willing and ableto accept psychoanalytic treatment.

For simplicity I shall first discuss the 5patients who did not complete their analysesand then the remaining 10. In the first groupthe ages varied from 27 years to 42 years, 1was a married woman and the remaining 4were married men. The onset of their gastricsymptoms varied from 4 years to 12 yearsbefore they began their psychoanalytic treat-ment. This group was psychiatrically com-posed of 2 mixed psychoneuroses, 2 obses-sional neuroses, and 1 character neurosis.Hemorrhages occurred in all 5 patients, 3went on to perforation, which necessitated aresection. Two of these 5 patients hemor-rhaged both before and after their short treat-ment, and 1 perforated. One hemorrhagedbefore treatment and responded to medica-tion. In the 3 resected cases symptoms returnedin from 6 months to 1 year after operation.

All 5 cases have continued to have their gas-tric symptoms, which are controlled by rest,diet, and alkalies. Their neuroses are stillpresent.

The 10 patients who completed their analy-ses varied in age from 25 years to 43 years;this group consisted of 2 married women and8 men, of whom 2 were single and the re-maining 6 married. The onset of their gastricsymptoms varied from 5 years to 15 yearsbefore they began their analytic treatment.Psychiatrically this group consisted of 5 char-acter neuroses, 4 obsessional neuroses, and1 mixed psychoneurosis. Hemorrhages oc-curred before analysis in 4 of these 10 patients,and in only 1 did hemorrhage occur duringtreatment. They were in analysis for from3 years to 5 years, and received 592 to 942analytic hours of treatment. The analyses hadbeen completed from 11 years to 22 years be-fore the follow-up interview. All these patientshave remained well; there has been no recur-rence of any of their former gastric symptomssince the completion of their analyses, eventhough situations have occurred which previ-ously would have precipitated an attack. Allhave been on a normal diet and have eatenwhatever they desired. At no time has therebeen any necessity for a return to a diet orantacids. It is because of this continued stateof freedom from the type of peptic ulcer symp-toms which they had previously suffered, aswell as the fact that no new ones have ap-peared, which might indicate the existence oftheir former neuroses, that I believe these 10peptic ulcer patients to be cured.

Since at this time I am not concerned withan attempt to illuminate the problem of thebasic etiology of peptic ulcer, I have notdelved into the detailed psychodynamics ofeach individual case. The inevitable conclu-sion I have reached is that in those cases ofpeptic ulcer successfully treated by me, thelesion of the upper gastrointestinal tract isbut one manifestation of an emotional illnessinvolving the total personality. Since psycho-analysis is the optimum type of therapy thatcan be applied to an emotional illness, I be-lieve that when a peptic ulcer is found to be

PSYCHOSOMATIC MEDICINE

ORGELa manifestation of an emotional illness in-volving the total personality, psychoanalysisshould be the treatment of choice. In all 15cases of proved peptic ulcer, the fact that Ifound it to be occurring in severely neuroticpatients persuaded me that psychoanalytictreatment was indicated. I could not find anycontraindications to such treatment in mydiagnoses. Like Alexander, I was aware ofthe possible dangers of the development oftoo strong a transference and its possibly lead-ing to an interminable analysis, but preferredto face this danger in striving for the greatestgain of health over permanent illness. Mystudy is not a large one and I have no con-trols since all these patients were treatedprivately. It is, however, the largest group ofcured patients reported to date that has had acareful follow-up for a period as long as 22years after the completion of psychoanalysis.In all these 10 cured cases, peptic ulcer symp-toms had ceased to exist at least 1 year beforethe completion of their analysis. The timeelement of cure is, therefore, from at least 10years in one case to the maximum of 22 yearsin others.

In the 10 analyzed cases the results of psy-choanalytic treatment in this psychosomaticdisorder have proved to be strikingly good,and thus tend to confirm a basically emotio-genic etiology. There is every indication thatthe 10 cured cases have developed a greatlyimproved capacity to cope with their emo-tional disturbances. No doubt constitutionalas well as emotional factors were active in

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producing the disease in my patients. If weaccept this as the case, then we must say thatthe psychoanalytic treatment favorably influ-enced the emotional components of the dis-ease, and was thus sufficient to beneficiallyaffect the ulcer.

Summary and Conclusions

1. This has been a report on the psychoana-lytic treatment of 15 peptic ulcer patients.

2. Five of these patients received inade-quate psychoanalytic treatment and were notmaterially benefited by it.

3. Ten of these 15 patients pursued theirpsychoanalytic treatment to its conclusion andhave remained well for 10 to 22 years, asdetermined by follow-up interviews.

4. While this group is small, being limitedactually to 10 cases, I feel I am justified inbelieving that patients suffering from pepticulcer and also a neurosis can be cured by thetreatment of their neurosis.

5. The concept of the disease is that, in mycases, the lesion of the upper gastrointestinaltract was one manifestation of an emotionalillness involving the total personality.

667 Madison AvcNew York 21, N. Y

Reference

1. ALEXANDER, F. The influence of psychologicfactors upon gastro-intestinal disturbances' Asymposium. Psychoanalyt. Quart. 3.501, 1934.

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