Muco-membranous Colitis





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. At one watering place in France, Plombieres, 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.







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 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 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.





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