tract, the tendency among practitioners now is to give it up too readily in favor of methods, such as frictions, which are much more irksome and difficult for the patient to employ, and the injection of soluble and insoluble mercurial compounds, the former being always troublesome in their method of application, and the latter painful and sometimes even dangerous. But physicians should know how to give mercury by the stomach, and they should remember that remedies to act must be given in solution; it should also be understood that when dissolved their efficacy is much greater in small and frequent doses than in a single large one.

Let us not then discard the gastric method in treating syphilis ; like all the others,-frictions, injections, etc., it has its indications, advantages, and usefulness. It appears to me likely always to render immense service in private practice with patients who cannot afford the expense of treatment by injections; but, in order that it may be sure to act, it is necessary, as far as possible (and this cannot be repeated too many times), to give the remedies not in pills, but in solution, and in small and frequent doses.

THE TREATMENT OF MUCOMEMBRANOUS

COLITIS.

A SPECIAL ARTICLE.

BY PROFESSOR ALBERT MATHIEU,
Physician to the Hospitals of Paris.

THERE has been considerable discussion as to whether mucomembranous colitis is due to an inflammation of the mucous membrane of the intestines or is a primary neurosis of these viscera. There is no doubt that neurotic symptoms, local as well as general, form an important part of the manifestations of the disease in many patients. I cannot think, however, that it has been demonstrated that the painful symptoms which are so prominent in this disorder are the direct expression of a disturbance only of the innervation of the gastro-intestinal tract, nor that the diarrhoeic symptoms are due to a secretory neurosis of the large intestine without inflammatory changes. It seems to me that the true basis of the disease is always an irritation of the intestinal mucous membrane. If the pain and the mucous hypersecretion, together with the spasmodic contractions of the colon, assume greater intensity when the neurotic condition is worse, or if, as is true, the mucomembranous colitis be more liable to occur and be more persistent in neurotic individuals, these phenomena manifest themselves only because under these circumstances the disease finds a soil more favorably disposed for its development. Whether or not the neurotic element plays a primary or a secondary rôle in the pathogenesis or symptomatology, especially of the severer forms of mucomembranous colitis, it is certain that any treatment to be successful must take account first of all of the neurotic elements in the case. All therapeutists agree that the treatment of the disease depends essentially on the successful therapy of the nervous condition of the patient.

The symptoms and etiological factors which furnish the prin

cipal indications for the treatment of mucomembranous colitis are the following: First, constipation is the rule, and it is often spasmodic. The diarrhoea, which occurs at irregular intervals, is always the result of an exacerbation of the disease or of a catarrhal complication. Second, in mucomembranous colitis a secretory irritation and desquamation of the mucous membrane of the colon always exist. Whether this secretory irritation is of nervous origin, or is due to a superficial inflammatory condition the lesions of which can be demonstrated histologically, is as yet in doubt. The third element in the etiology that gives us hints as to treatment is the special seriousness that mucomembranous colitis takes on in individuals who are predisposed to it by a preceding neurotic condition. In such persons the painful symptoms of the disease assume unusual intensity.

As a secondary element in this neurotic condition we must not pass over the existence of visceral ptoses, which tend to exaggerate the constipation and consequently the other symptoms of mucomembranous colitis, either by hindering the peristalsis of the gastro-intestinal tract or by inducing irritative conditions in the terminal nerve-filaments of the intestines, because of the way they are pulled upon, and thus causing reflex excitation of the large abdominal nervous plexuses. Locally the neurotic condition provokes or exaggerates a state of hyperesthesia in the walls of the large intestines. This induces spasmodic contractures; undoubtedly auto-intoxication from absorption of food before this has been properly prepared is another important feature of the disease.

The local condition and the general nervous state often react one upon the other. A vicious cycle is formed: the local symptoms cause an exaggeration of the general nervous condition, while the latter makes the localized pain more unbearable. Other elements in the vicious cycle are the consequent disturbance of digestion, the restriction of the amount of food assimilated, and also undoubtedly auto-intoxication from absorption of food before being properly prepared. All these unite to produce a progressive emaciation and anæmia with increasing nervousness. In turn the enfeeblement of the general system aggravates the local intestinal conditions. There is no doubt that mucomembranous colitis is often associated with gastric dyspepsia. Just how this association occurs is not clear, but it is important, when stomachic symptoms exist, not to

neglect them in the course of the treatment of the intestinal disorder.

The first element of the disease that requires treatment is the constipation. Mucomembranous colitis is never satisfactorily relieved so long as constipation persists. It is important, moreover, to treat the constipation without provoking any reaction in the intestine, for this would readily lead to an increase in its irritative sensitiveness and to its hypersecretion and tendency to spasm. In this, as in all cases of habitual constipation, the ideal treatment is to bring about regulation of the evacuations by purely hygienic means. At least only physical factors should be employed and no cathartic should be given. Drastic purgatives inevitably make the disease worse and must be avoided at all hazards.

In cases of chronic constipation a diet rich in residual material is usually advised. Hence vegetables which are composed largely of indigestible detritus are recommended. These serve by their presence to excite intestinal peristalsis and so to bring about regularity of the stools. Von Noorden has particularly insisted on the usefulness for this purpose of green vegetables, of so-called graham or whole-wheat bread, and of vegetable substances generally that are rich in coarse cellulose material. Needless to say, most authorities are of the same opinion. On the contrary, for the treatment of mucomembranous colitis patients are usually advised to take food that leaves little undigested residue. The idea is that indigestible material will increase the irritation of the intestines If the prescription to take only bland substances be followed, however, the constipation is rendered persistent. It must not be forgotten that constipation is really one of the fundamental causes of mucomembranous colitis.

There is no doubt that in mild cases of mucomembranous colitis a vegetable diet that leaves abundant residue is of decided value. If the disease is of pronounced character, however, a dietary of this kind is often badly borne. The consumption of even slightly indigestible material excites attacks of pain, and these are followed, if the dietetic indiscretion is continued, by true colic and by diarrhoeic complications. Often even before the intestinal symptoms show the error of the diet the stomach has refused to co-operate in the digestion of this unsuitable material. Heart-burn, a feeling of pressure in the gastric region, and even crampy pains may occur.

Under these circumstances it is absolutely necessary to return to a dietary from which are eliminated as far as possible all cellulose substances, such as the shells of grains, vegetable fibres, and all other indigestible vegetable débris.

Von Noorden also advises an increase of the amount of fat in the dietary. Fresh butter, eaten cold or melted in mashed vegetables, seems especially suitable. This method of dietetic treatment succeeds very well, as a rule. Often in cases of mucomembranous colitis it becomes necessary to increase the amount of food taken. In their anxiety to avoid bringing on attacks of colic by eating, patients have acquired a sort of sitophobia, a fear of taking food. They have grown thin and as a consequence have become more and more nervous. It is important, then, to increase their nutrition, to make them regain the weight which they have lost and so to restore their former strength. For this purpose butter, when it is well borne, is excellent. It is an article of diet very rich in caloric and has at the same time a marked tendency to overcome constipation. One of nature's most effective materials for causing regularity of defecation is fat, and no fat is more digestible than the products of milk and none more easily obtainable than butter. This must be looked upon, then, as an important element in the treatment of the constipation which underlies all mucomembranous colitis. If the former can be overcome by simple dietetic measures, there is every reason to hope that in the course of time the latter will disappear.

For the constipation of mucomembranous colitis, as for constipation in general, massage is frequently recommended. It is not always well borne. As a rule, it should be employed in no case where it causes any pain. It is particularly contraindicated wherever hyperesthesia and painful contractions of the intestine are liable to take place. This method of treatment has been much abused. It may easily cause more harm than good and is likely to be of benefit only in mild cases.

Large injections of warm water or, better, copious washings out of the intestine are usually very beneficial. They represent one of the most important factors in the cure of mucomembranous colitis. Their action is not as simple as it may seem. By their warmth they have a calming effect on the mucous membrane and this tends to limit the muscular spasm. They often put an end