Probably the severest, certainly the most interesting of the neurotic conditions of the intestines, is muco-membranous colitis. The only lesions discovered are those which point to a functionally increased secretion of tenacious mucus from the lower bowel. No definite pathological changes are known. The colic seems to be due to nothing more than the effort of the large intestine to push off the thick mucus which has been secreted, and which in many cases clings to the bowel walls. This may be of such consistency that it is passed from the bowel in the shape of tubular casts. These casts have often been seen in place in the lower bowel. While the word membranous used in connection with the disease has produced the impression that this might be a form of diphtheritic affection, it is now known that it is only due to an abnormally increased function, and not to any structural pathological condition or infection of the lower bowel. The membranous material is often gelatinous, and so the casts may hang together in long pieces.

Neurotic Etiology.—It might be thought that such a cast could not be formed, remain in situ in the lower bowel for a considerable period, and then be passed as a whole, or in quite long portions, without causing serious tissue disturbance in the mucous membrane. As Sir William Osier says, in spite of the apparent improbability, the separation may and usually does take place without any lesion even of the surface of the mucous membrane. The epithelium seems to be left intact. Owing to the curious nature of the stools, the disease has been recognized for a long time and the descriptions of this disease by the older authors are very interesting. Muco-membranous colitis occurs mainly in nervous individuals, and is much more frequent in women than in men, but it is not limited to women. Some of the severest cases have occurred in men, and Woodward, in the second volume of "The Medical and Surgical Reports of the Civil War," has an exhaustive description of the disease as it occurred among soldiers. It is particularly those who are worried and run down from overwork and excitement who are likely to suffer from it, but it occurs typically in people who, faute de mieux, worry about themselves. Most of its victims are self-centered, though not hysterical.

Recent Increase in Number of Cases.—According to all the authorities, there has been a considerable increase in the number of cases in recent years. {287} At one watering place in France, PlombiÊres, which has acquired the reputation for relieving, or even curing the disease, about 400 cases had been under treatment during the course of about two years. This increase was attributed by Boas of Berlin to two causes. First the struggle for life has become much more intense in our day, and the nervous conditions which are practically always the basis of muco-membranous colitis, have as a consequence become more frequent. Not only this, but mild cases that were not called to the attention of physicians in the past, have become so emphasized by the nervous worries of the strenuous life that now they seldom escape the physician's attention. Besides our generation is getting away from the old-fashioned idea of patiently standing many pains and aches, and refusing to call in a physician unless the condition persists or seems to be producing serious results. There are more cases of the disease, but physicians also see more of the cases than formerly because patients come for treatment for slighter causes.

Dr. Boas considered that, besides the strenuous life, there was another prominent factor in the increase of the disease. This is the abuse of laxatives and purgatives. Many of these have their principal effect on the lower bowel. In consequence the nervous mechanism of this structure has been irritated to a point where occasionally explosions of nerve force take place. This causes an increase of the secretion, and a tendency to cramp-like contractions. While there is undoubtedly much of truth in this, there is no doubt that the most important factor in the disease is the patient's nervous condition. Only those who are inclined to be introspective, to worry much about themselves, and who are constantly examining their stools for the presence of mucus, suffer severely from the affection.

Very few cases have been seen among the working classes. Most of the cases have hypochondriacal symptoms that sometimes go to the extent of real melancholia and the full persuasion that they have an incurable disease, a visitation on them for some real or fancied lapse from the laws of health in earlier years. The affection usually lasts a long time, or has been in existence for some years when the physician is asked to see it, and patients are made most miserable by it.

Unfavorable Suggestion and Over-attention.—The pathological physiology of this disease, for, as has been said, it has no pathology in the proper sense of the word, is in many cases a problem of mental influence. For some reason, the patient gets his or her lower bowel on his or her mind. There is so much talk of constipation and its evil effects in the newspapers, in advertisements and by suggestion from bill-boards and in the magazines as well as, sad to relate, in parlors, drawing-rooms and even dining-rooms, that it is easy for those who are introspective and nervous about themselves, and who have some little tendency to constipation already, to become much worried about it. If, then, as was suggested by Boas, they take laxatives in profusion, the irritation set up further fixes the attention on this portion of the body. After a while, in these people, a goodly portion of the waking hours are spent in thoughts with regard to the lower bowel. The morning thought is the possibility of a stool to-day, followed by conjecture as to its character. After the stool has taken place, if there seems anything abnormal about it, comes a morbid dread of the consequences of having such stools.{288}

This constant attention sends down a lot of impulses to the lower bowel. Anyone who has studied the psychology of attention knows how much influence can be exerted on the skin, or on the mucous surface by mental influence. Hyperemia is produced, and this leads to over-action of the glands of the large intestine. These glands secrete a glairy mucus which is necessary to protect the bowel from the offensive material that is always present, and from the hardened material that is so often there when there is a tendency to constipation. This mucus is secreted in large quantities, while at the same time a hyperemia of the colon tends to interfere with peristalsis and consequently to delay the passage of contents and to keep the mucus in place. An accumulation goes on for some time, until irritation is set up by the presence of such a large quantity of material in the intestine, and then colicky efforts for its removal are occasioned. All of this process is accompanied by suggestive reactions upon the mind that further complicate the case. This story of the affection points out the indications for treatment. Unless the patient's mind can be diverted from its constant attention to the lower bowel, the possibility of cure is distant, and even after such diversion any return of attention is likely to bring on a relapse.

Treatment.—The treatment of this affection emphasizes its neurotic origin. We have had any number of cures for it and each one has actually relieved many patients. The more trouble the cure involves, and the greater the impression produced on the patient's mind the more likely is there to be a relief of symptoms. All sorts of drugs have been employed. Many of them have for a time been heralded as more or less specific. The important thing, however, was that the patients should come predisposed to believe that they were going to be improved, and then that suggestion should be made at frequent intervals—a combination of auto-suggestion through the administration at regular intervals for a long period of simple remedies with the confident suggestion of the physician that the patient will get better. Local treatment of various kinds has been reported to bring about improvement. The more difficult this is, and the longer it takes, as well as the more bother it involves for the patient and the attendant, the better the response to it is likely to be. Long rectal tubes were found beneficial in many cases, though they failed in many others, and most physicians have seen relapses occur in spite of the continuance of the treatment that at first did much good. High injections of water containing various drugs, and of olive oil sometimes bring improvement though they afford no guarantee against a relapse. Mineral waters do good only in the suggestive environment of the spring.

Surgery and Suggestion.—The symptoms have sometimes been so severe and the complaints of the patients have been so great that even surgery of serious character has been recommended and tried in some of these cases. The making of an artificial anus in the right inguinal region, so that for a time the feces are not allowed to pass over the colon mucous membrane has been tried. This gives decided relief from the symptoms, but when the artificial anus is allowed to close, recurrences often take place. It has been suggested, therefore, that the artificial anus should be allowed to stay open for months, but even this seems to afford no guarantee against a relapse. In recent years the appendix has been taken out through the opening in the right inguinal region, and a portion of it allowed to remain through which, when {289} fastened to the abdominal wall, injections might be made into the colon. In these cases ice-water has been found probably of more effect than any drug solutions. This rather serious surgical procedure is, however, as yet on trial, and we do not know enough about the after-course of the cases to be sure that it has any permanent effect.

A strong suggestion is involved in the removal of the appendix, and the use of the stump of it as an irrigating tube. When the treatment consists of something that is so strongly excitant of feeling as ice-water, applied directly to the colon, it is easy to understand that suggestion reaches the limit of its possibilities. No wonder these cases improve, though we are not sure as yet what happens after the appendix opening is allowed to close, or is deliberately sutured. I should expect a recurrence of symptoms, if ever a time came when the patient was run down in weight and worried by external conditions, introspection, and above all by concentration of attention on the intestines.

Direct Suggestion.—The question is whether suggestion can be used to advantage in these cases without employing any of the radical measures that have been suggested. There is no doubt that at certain watering places where a specialty is made of this disease, and to which patients go, sure that they are going to be much better than before, and where they see patients all round them who are improving, they often get complete relief. This is only what might be expected. Whether a similar effect can be produced by simple suggestion when the patient is thoroughly convinced that the physician understands the case, and that if they will respond he can cure it, remains to be seen. I know that mild cases improve rapidly under simple hygienic measures, with a renewal of confidence in the possibility of relief, and with the diversion of the patient's mind from the intestinal difficulty. This is the most important factor in the treatment, as it is the most important factor in pathology. If the patient's nerve centers can be kept from sending down impulses causing exaggerated action of the glands, then there is some hope of relief. A habit has been formed in the matter, and a habit can only be broken by a series of acts, just as it was formed. It is not effort for a few days nor a week that counts in these cases, but diversion of mind for long periods, until normal function is restored. It is usually quite impossible to keep up this improvement constantly in nervous patients. There are setbacks, but then this is true in every form of nervous affection. It is, then, that the renewed suggestion of the physician is needed.

Resort Cures and Suggestion.—Physicians often tell patients that muco-membranous colitis is incurable, or at least emphasize strongly that it is very refractory to treatment, and that it is prone to relapse even after improvement. After a certain number of physicians have insisted on these points, it is inevitable that patients should not respond readily to treatment, and that they should be solicitous about themselves, even when improvement does come.

It is most important then to bring about the neutralization of these unfavorable suggestions. This is what is particularly accomplished at the health resorts where muco-membranous colitis is successfully treated. At these the patients see other sufferers from the disease who proclaim how much better they are and some at least who are entirely cured. The waters {290} used at these health resorts are not nearly so efficient when used at a distance because of this lack of additional suggestion.

The most efficacious treatment of muco-membranous colitis then is to bring the patient up to normal weight, for they are often thin people, quiet their solicitude about themselves, give them a bland and irritating diet and get them away from worries or anxieties about themselves or others. I know cases in physicians where the effect of worry of any kind can be traced very clearly in the increased symptoms of their colitis and the greater frequency of attacks. It is particularly important not to give habit-forming drugs in these cases for they always do harm. Where the pain is much complained of the coal-tar anodynes are useful, but ice in the rectum or even suppositories of gluten, or of cocoa butter without any medication often prove useful. Most of these patients watch prescriptions that are given them rather carefully and make up their mind beforehand whether they are likely to do them good or not and the event usually follows their premonition. They often have habits of self-drugging which must be stopped and always carefully inquired into for they will sometimes continue to take things for themselves in spite of being under the doctor's care. If they have heard of surgical treatment for their affection they are likely to think that they will have to come to it eventually and this prevents a favorable attitude of mind towards their affection. Unless this is secured no treatment will prove efficient. With it almost anything that keeps up the suggestion will greatly relieve and often will actually cure the condition.