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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

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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