"Thinking is the talking of the soul with itself." - Plato
 
 
    History notes that Dr. Mason Good gave one of the first communications in regard to the above disease, in 1825, under the name "Diarrhea Tubularis." Woodward collected the literature up to 1879, in the Medical and Surgical History of the War of the Rebellion, Vol.  I. Da Costa wrote in regard to the disease, as did also Leyden in 1892.  Nothnagel, in 1884, wrote an excellent essay on the disease, naming it colica mucosa.  In 1884 Krysinski, of Jena, wrote an inaugural thesis on the disease, detailing six cases, and sought to establish as its cause the presence and effects of microorganisms.  Leube thought it a nervous affection.  Pick has recently written a short essay on the subject.
    Many different names have been applied to this disease on account of the various views as to its causation.  If the disease consists of an epithelial inflammation, a catarrh, we may be satisfied with the designation, enteritis membranacea, but should there exist only increased mucous secretion, without inflammation, the terms colica mucosa would be more significant.  However, my studies on the subject have induced me to adopt the term, secretion-neurosis.  It is possible that there are two ill-defined affections in this field, one being an enteritis and the other a simple increase of the mucous secretion.  Autopsies are so rare on subjects dying of secretion-neurosis of the colon that no pathological basis is as yet definitely established.  An antemortem diagnosis must be confirmed by a postmortem examination before any pathology can be accepted or established.
    All observers agree that secretion-neurosis of the colon is indicated by the peculiar formation and evacuation of the stools.  The clinical symptoms are colicky pains and the evacuation of masses of mucus.  The mucous masses may consist of flat long bands (even membranes), ribbons, shreds or rolled tubes or scrolls.  Some portions assume a spiral form.  Some writers assert that the masses are fibrinous, but I have examined quite a number and have never observed fibrin.  The mucous masses are white, grayish white, or a color due to the mixing of mucus and feces, yellowish brown.  By placing the mucous masses in water they unroll and partially dissolve.  However, the peculiar form of the mucous masses may be retained if they are kept in bottles of water for several days, as we have noted in one case.  The quantities of these masses evacuated by some patients are enormous.  A female attended by Dr. Lucy Waite and myself. would occasionally evacuate nearly half a pint of mucous membranes, masses, bands, tubes or unformed substances.  In a male the evacuation showed more string or ribbon-like processes.
    All observers agree that women are the chief subjects of secretion-neurosis of the colon.  Litten estimates that 80 per cent are women, and according to Kitagawa 90 per cent are female subjects.  Dr. W. A. Evans says that of the many samples sent to the Columbus Medical Laboratory 80 per cent are from women.
    I had a typical case in a man 36 years of age, who had the disease for nine years.  Some report cases in men and children.  I never saw a typical case in a child.  Almost all writers agree that women who are subjects of secretion neurosis of the colon are neurotic, nervous, hysterical or hypochondriac.  The men possess a similar neurotic or hypochondriac tendency.  I have had several mild cases in men.
    Patients afflicted with secretion-neurosis of the colon have suffered from constipation for long periods previous to the outbreak of the former disease.  This accords with my view that constipation is a neurosis of the colon, or fecal reservoir.  The attacks of such patients are irregular, but recur for years.  Pain of a colicky nature may suddenly arise in the abdomen and continue until masses of mucus and occasionally feces are expelled.  The attacks of pain may be extremely severe, especially when large masses of mucus are evacuated.  So far as I can discover, the pain is chiefly located in the transverse and descending colon and the sigmoid flexure; in general, over the left abdominal region.  However, when the colicky pain is severe and continuous, the patient may complain of pain in the whole abdominal region.  Some of my patients complained of pain running down the legs.  Abnormal sensation may arise in the genitourinary organs.  After the evacuations of the mucous, slimy masses, especially the larger ones, the patients appear and report themselves to be entirely free from pain.  Generally, the larger the mucoid masses evacuated, the longer the patient remains free.  However. the colicky pains may be coming on for one or two days before the large masses are expelled.  If the evacuation be slight in quantity, the colicky pains are slight, but often continuous.      The appetite is generally good, except at the time of attack.  An enema will occasionally bring away very large masses of slime.  Also, there are patients who pass the mucous masses who do not report nor appear to suffer pain.  Hence two classes of patients present themselves, viz.: some pass mucous masses with colicky pains; others pass, mucous masses without colicky pains.
    Nothnagel, my honored teacher, the ablest of all writers on the subject, shields himself by adopting the term colica illitcosa et enteritis incinbranacca.  He acknowledges that a variety of pathological processes are here included.  Krysinski and Mathieu are both inclined to consider the affection an enteritis and Krysinski endeavors to show that certain low organisms are the primary cause.  It does not seem probable that microorganisms would persist for years; and besides, were the disease caused by microorganisms we ought to be able to cure it.  Krysinski describes patients who simply gave a desire for stool without colicky pains, i. e., merely "bearing down pains."
    Much interest is manifested by writers, in the stools in secretion-neurosis of the colon.
    Microscopically, the evacuation consists of membranous or tubular gray masses.  They may resemble croupous membrane from the respiratory passages.  The mucous masses may be transparent like slime, or opaque like fibrin, of a grayish white, or a dirty color with pigment in it.  Sometimes the masses consist of large, wide and thick leathery-like membranes; at other times, long ribbon-like bands or rope-like coils.  The mucous masses nearly always come away alone, unmixed with feces.  Sometimes they resemble the swollen jackets of baked potatoes.  By careful manipulation in water the masses of slime will generally unfold into membranes; hence the term, membranous colitis.  They may resemble fascia or tendons, or one may be deceived by milk coagula.
    Microscopically, the mass substance represents a hyaline body, which can be preserved only a short time in air, alcohol or water.  Degenerating cylindrical epithelia of almost any grade can be noted.  The slimy mass represents a glassy, unformed, transparent substance.  If acetic acid be added it assumes a wavy, striped or ground glass appearance.  Glandular epithelia are almost always found, shrunken, swollen or vacuolated.  Sometimes vast numbers of microbes are present, cholesterin crystals, triple phosphates, fecal masses, pigment and occasionally round cells.
    Chemical examination reveals mucin, or mucin-like material, as the chief constituent.  This may be considered as definitely established, as it is confirmed by Clark, Thompson, Perrond, Da Costa, Hare, Pick, Nothnagel, Furbringer, Hirsch, Walter, V. Jaksch, Krysinski, Kitagama, Rothmann, Littre, Vanni, Leube and Pariser, a sufficient number of investigators to settle the question.  Some authors assert that mucin is the chief constituent with other albuminous bodies.  The only author we have found who claims that fibrin exists in the evacuations of secretion-neurosis of the colon is P. Guttmann, who apparently based his support on doubtful microscopical examination.
    Pathological records are rare, on account of the scarcity of material on which to establish them.  Nothnagel reports a case of secretion-neurosis; Rothmann, one which was examined by C. Ruge.  Ruge reported that "in spite of careful examination of the whole intestinal tract, nothing abnormal was discovered." The above patient of Rothmann presented a typical picture of colica mucosa, but died from a duodenal perforation.
    Rothmann had another case that died of carcinoma at the base of the skull.  The patient was in the hospital from June 14 to Nov. 2, 1892.  By taking an enema the patient evacuated large masses of mucus without pain.  He made no complaint.  The autopsy showed in the transverse colon (where it did not contain feces) and the strongly contracted parts of the descending colon, injected and folded mucosa.  Between the folded mucosa lay products, partly membranous, partly strand-formed.  The parts of the colon filled with membranes contained no feces.  In the ascending colon there were no mucous masses, but feces, with reddened mucosa.  In the sigmoid the membranes could be torn from the reddened mucosa without loss of substance.  Feces were found in the small intestine, which had reddened mucosa.  The chief mucous masses were found in the left half of the transverse colon, descending colon and sigmoid.  The microscope demonstrated the mucous masses in the lower colon to consist of mucin, not fibrin.  In this case there can be no doubt of the existence of catarrh. just on this point of catarrh or no catarrh, investigators are divided.
    We have, then, three opinions in regard to the nature of secretion-neurosis of the colon, viz.:

    1.  That it is an enteritis (catarrh).
    2.  That it is simply excessive secretion of mucus (mucous colic).
    3.  That it is secretion-neurosis (nervous).
 
    In general visceral neuroses we have, (1) motor neuroses (motus peristalticus); (2) sensory neuroses (hyperesthesia and anesthesia); and (3) secretary neuroses (excessive, deficient and disproportionate secretion).  In secretion-neurosis of the colon we have to deal with a patient who has all three secretory disturbances, i. e.: deficient, disproportionate and excessive secretion.  These patients have generally been long sufferers from constipation (deficient secretion).  Then follows disproportion-secretion, but that is not so evident, as it simply produces fermentation.  Finally comes the formation of the habit of excessive secretion of mucus.  Now, this excessive secretion of mucus arises from the unfortunate habit which the mucus cell had formed during the early but prolonged state of constipation.  The mucus cell had learned a bad, persistent, nervous or irritable habit of excessive secretion.  After a long-continued bad habit of secreting excessive mucus, the cells were unable to change their mode of life and assume normal action.  Hence, as one of the etiological factors of secretion-neurosis of the colon, we will assume the depraved cell habit from reflex irritation.
    A second factor that perhaps plays a chief role is genital disease.  Secretion-neurosis of the colon is nearly always manifested in neurotic persons of the female sex.  Such subjects nearly always have pelvic disease.  Every gynecologist knows from actual experience that pelvic disease produces constipation, a fore-runner of secretion-neurosis.  Constipation may be secondary to genital disease, which, through reflex action, produces in the bowel deficient, excessive or disproportionate secretion.  Disproportionate secretion induces fermentation, causing gases which distend the bowel, resulting in atony and deranged nerve action in the epithelial cell.  Irritation from the diseased genitals induces the development of toxins.  The toxins affect the tissues locally, inducing colitis, if not epithelial catarrh.  Besides, the absorption of toxins induces neurasthenia.  The diseased genitals reflexly lead to a train of conditions which induce defective nutrition and excretion.  The evacuation of glassy, viscid mucus, subsequently followed by grayish shreds, extraded with pain, is pathognomonic of secretion-neurosis of the colon.  Gynecologists frequently observe these conditions except the grayish shreds and mucomembranous layers.  The pain on defecation may be but slight.
    The first step in the cure of such patients is to relieve the afflicted genitals, when improvement often supervenes.  In one of my patients suffering from chronic pelvic disease and also typical secretion-neurosis of the colon, many complex neurotic symptoms of an intense character would occasionally arise at the time of the evacuations.  She presented paroxysms of pain, intense colic, profound hysterical or neurotic symptoms, rapid pulse, disturbed respiration; all of which subsided very slowly after the evacuation of mucus.  Reflex neuroses of an intense character were present.  In the intervals she was quiet, presented none of the acute egoism of the hysteric, and apparently had no desire for attention or notoriety.
    The differentiation of the pathological process in secretion-neurosis of the colon may be aided by (a) the anatomic pathologic findings in autopsies; (b) by analysis of clinical cases; (c) by examination of the evacuations; and (d) by comparison with analogous processes in other mucosa.  We have spoken of the findings of the autopsy and in the evacuations; but too much cannot be said in regard to the correct clinical symptoms.  The numerous names applied to the disease show that its clinical symptoms are not definitely agreed upon.
    Colica flatulenta is a close relative of secretion-neurosis, as is also the motor neurosis (motus peristalticus) of the digestive tract.  They consist of invisible derangements of the sympathetic nerve.  Secretion-neurosis occurs in subjects who can in almost all cases be demonstrated to be neurotics.
Comparison with similar processes in analogous structures may not clear up the pathology very much.  In bronchitis crouposa chronica, a similar disease in a similar structure (mucosa), as in secretion-neurosis of the colon, there is no anatomical change in the bronchial mucosa, as noted by B. Littre, and there is no fibrin present.  Klein, Neelson and Beschomer claim that the bronchial membrane and coagula in bronchial croup are thickened mucus or slime.  That keen and able observer, Nothnagel, vigorously asserts as a comparison that the membranes of chronic croup speak against the fibrinous product and inflammatory nature of colica mucosa.  However, conflicting opinions still exist in regard to the nature of the membranes in bronchial croup.
    Do we receive any light in secretion-neurosis of the colon by comparing it with dysmenorrhea, which was first described by Morgagni in 1723, and colpitis membrancea by Farre in 1858?  The number of terms applied to membranous dysmenorrhea, as endometritis exfoliativa, endometritis dessicans and decidua mesenteralis, signifies conflicting opinions.  There are at least two irreconcilable opinions in regard to membranous dysmenorrhea, the inflammatory and the non-inflammatory conditions.  It appears to the writer that a third view should be introduced, viz., that it is a secretion-neurosis of the endometrium.
    However, it appears quite certain that there are two conditions classed as membranous dysmenorrhea, viz., in one case the membrane consists of fibrin, lymphoid cells and red blood corpuscles - a secretion-neurosis - and in another, the membrane consists of a cellular infiltrated endometrium - an inflammatory process.  The second process throws off the endometrium with its bloodvessels, cell infiltration and utricular glands.  Hence, under the general term, membranous dysmenorrhea, we are dealing with inflammatory processes (endometritis), and a secretion-neurosis (a fibro-lymphoid membrane enclosing accidentally red blood corpuscles from diapedesis at the morrthlv congestion).  The last process is a perverted nerve-action - a secretion-neurosis of the endometrium.
    In an intensely lymphatic organ like the uterus we would expect more lymphoid elements in the membrane than in the colon.  This would account for the fibrin and lymph-cells.  Also red blood corpuscles are found in the evacuations of colica mucosa; and thev are simply more numerous in the membrane of membranous dysmenorrhea, because of the intense endometric congestion, proceeding to rupture (diapedesis).  Again, secretion-neurosis of the endometrium, like secretion-neurosis of the colon, evacuates the mucous membranes with or without pain, and at irregular intervals, showing a sustained comparison.
    To say that the above diseases of the colon and uterus are forms of mal-nutrition or deranged innervation means but little.
    In secretion-neurosis of the colon an explanation of the string and netformed stools may be made from the contracted condition of the irritable muscle of the colon, which is thrown into folds, recesses and grooves, which allow the moulded form of the retained secreted mucus to persist.  It may be mentioned that some confusion in diagnosis may arise by the so-called colica mucosa and enteritis coexisting.  In other words a catarrh and secretion-neurosis of the colon may exist together.
    The prognosis of secretion-neurosis of the colon, is, for life, favorable, but for recovery, doubtful.  I have known the disease to continue for nine or ten years, with but slight changes.  However, it is very variable in its attacks, and very erratic in its occurrence.
    The treatment of secretion-neurosis of the colon must be directed to the nervous system, by habit, diet, physical and mental exercise, and general moral influences.
Regular daily bowel movements should be secured by very slight use of cathartics, considerable use of drinking fluids, and diet that leaves a large residue.  Baths (medicated) twice weekly are very helpful.  I have made some patients happy and helpful to themselves, by urging them to return to their regular business, which have been stopped by other physicians.  Clysters, and high rectal and colonic irrigations, aid wonderfully in evacuating the mucus.  Intestinal antiseptics (HgCl,), slight massage and long rests at night are beneficial.  Much moral influence and helpful courage is given a patient, when he is told he will not die from the trouble; for thought concentrated on the disease makes him much worse - produces pathologic physiology - particularly because he is almost always a neurotic.  Electricity aids physically and mentally.  Sexual activity should be especially limited. Clothing should be carefully regulated to avoid sudden changes.
 
CONCLUSIONS.
 
    1.  These diseases should be termed secretion-neurosis or enteritis. The first is   of neurotic origin and course.
    2.  Both secretion-neurosis and enteritis may co-exist.
    3.  Secretion-neurosis of the colon occurs chiefly in neurotic females.
    4.  It is closely associated with genital disease.
    5.  It is frequently preceded by constipation.
    6.  The continuation of the disease is partly due to an irritable, vicious habit of excessive epithelial activity.
    7.  The disease is characterized by colicky pains with the evacuation of mucous masses.
    8.  It is non-fatal, variable, capricious and erratic in attacks, with impossible prognosis as to time.
    9.  Microscopically, the evacuations appear as membranous, yellowish-white masses of mucus.
    10. Microscopically, one sees hyaline bodies, cylindrical epithelium, cholesterin crystals, triple phosphates, round cells, various micro-organisms and pigment.
    11.  Chemically, the evacuations consist of mucin and albuminous substance.
    12.  Secretion-neurosis of the colon is comparable to the secretion-neurosis of the endomitrium (dysmenorrhea membranacea) or bronchial croup.
    13.  Secretion-neurosis of the colon appears to be limited chiefly to the part of the colon supplied by the inferior mesenteric ganglion, i. e., to the fecal reservoir.
    14. It is a disease of the sympathetic secretary nerves and is analogous to disease of the motor and sensory nerves of the viscera.
    15.  Its treatment consists of removing the neurosis, which lies in the foreground, and regulating the secretion, which lies in the background.
    Regulation of diet - especially limited to cereals, vegetables, milk, eggs, exercise in open air, and systematic "visceral drainage" are the essentials in treatment.