Membranous Catarrh Of The Intestine (Colica Mucosa) And Its Treatment

I. Pathology. a. Various Views Expressed

Colica mucosa (syn. colitis pseudomembranacea, membranous catarrh of the intestine, myxoneurosis coli) is difficult to characterize and to classify among the chronic disorders of the intestine either from a theoretical point of view or from the standpoint of systematic nosology. Notwithstanding the fact that numerous dissertations on this subject, some of them by very competent authors, have been published within the last two decades, and in particular within the last five or six years, the disease that we call membranous catarrh of the bowel has not so far attained an established and generally recognized nosological position. After the papers by Nothnagel ⁽¹⁾ Marchand ⁽²⁾, Leube ⁽³⁾ and others appeared, there seemed to be a consensus of opinion among clinicians to the effect that the disease was a secretory and motor neurosis of the intestine. The more recent dissertations on the subject, however, by Einhorn ⁽⁴⁾, Boas ⁽⁵⁾, Ebstein ⁽⁶⁾, Schütz ⁽⁸⁾ and others disagree in numerous essential points with this interpretation of the symptom complex of colica mucosa without at the same time agreeing satisfactorily among themselves. All the more recent publications on colica mucosa have only this in common that they concede the role of inflammatory processes in the genesis of the majority, if not of all, the cases of this affection. This view differs radically from the old idea and is important both from a theoretical and a practical standpoint; for it is clear that the prognosis and the treatment of the disease must be largely determined by the interpretation of its pathogenesis, just as in corresponding affections of the stomach the existence of a catarrhal or a nervous form of dyspepsia determines the interpretation and the treatment of the disease. As long as only the two symptoms of colica mucosa that are indicated in the name of the affection, viz.: the passage of mucus and the pain, are considered, we can hardly expect to arrive at a satisfactory unification of ideas on the subject; for both these symptoms appear in a great variety of diseases of the intestine that have nothing in common with each other and that call for altogether different treatment. The excretion of mucus, and pain, are particularly common as symptoms or as consequences of affections of the bowel that are unquestionably inflammatory in character, particularly of inflammatory lesions of the lower portions of the intestinal tract. As the excretion of mucus with pain may vary in intensity and extent at different periods of these in flammatory affections, just as any other symptom may, we are certainly justified, from a purely symptomatic standpoint, in calling paroxysmal exacerbations "colica mucosa."

There are a number of very valuable post mortem reports on record that demonstrate positively that a diseas e-picture corresponding to colica mucosa (and that I will describe more fully below) may actually be observed in cases of genuine enteritis (M. Rothmann: Zeitschrift f. Klin. Medicin, Vol. 22, 1893, and J. C. Hemmeter, Diseases of the Intestine, Vol. 1, pag. 486, 1901). Other case reports by Boas ⁽⁵⁾, Einhorn ⁽⁴⁾, Schütz ⁽⁸⁾, Krysinski ⁽⁹⁾, and finally a considerable number of observations that I have made myself, all demonstrate without doubt that this is actually the case. The occurrence of the symptom complex of colica mucosa in genuine enteritis seems so unquestionable and self-evident to us that it is hardly worth while to adduce more evidence to strengthen this view.

Boas is of the opinion that these positive findings in regard to the anatomic changes in the mucous lining of the bowel are "without doubt of much greater importance than any negative findings." Personally we are inclined to maintain precisely the opposite; we consider it to be much more interesting and much more important that the typical disease-picture of colica mucosa may occasionally be observed in cases that reveal a perfectly normal condition of the intestinal mucosa on autopsy. To this category belongs the case reported by O. Rothmann (Deutsche Med. Woch. 1887, No. 27); Hemmeter (1. c. pag. 486) reports similar instances from his experience. The latter subjected certain portions of the colon that were covered with a thick layer of mucus to careful macroscopic and microscopic examination and failed to find any histologic evidence of inflammation. He therefore agrees with Nothnagel, who says that for this reason the disease merits more the name of "colica mucosa" than "colitis mucosa." In another case that N. Jagic (Wiener Klin. Rundschau, 1901, No. 41) published and that was carefully studied by this author, small anomalies were discovered in the epithelial layer of the mucosa, but the changes differed in several respects from those found in genuine enteritis. The case occurred in my service (von Noorden). The scanty anatomic material at our disposal, therefore, teaches us, on the one hand, that colica mucosa may be one of the symptoms of genuine enteritis and, on the other hand, that this affection may also occur without any essential anatomic lesion of the mucous lining of the intestine or even without any anatomic lesions whatever. The latter occurrence, i. e. the appearance of the symptom complex of colica mucosa without corresponding anatomic lesions in the bowel, is decidedly the most important observation from the point of view of pathologic anatomy. The clinician will be still more inclined to attach particular importance to this phenomenon, for clinical observation in the majority of cases and particularly in the cases that run a typic course, negatives the existence of any anatomic disease of the intestine.

Nothnagel ⁽¹⁰⁾, recognizing the duplex character of colica mucosa, i. e. realizing that there are two forms of the disease, the one with, the other without inflammatory phenomena, strictly separates the two forms and even calls them by different names; thus he speaks of enteritis membranacea on the one hand and of colica mucosa on the other. He teaches that only the latter form is of neurotic origin. It would not be correct, of course, to consider only the production of mucus and to speak only of a secretory neurosis; the symptom complex moreover - provided we wish to adhere to the conception of a neurosis - amounts to a combined secretory, motor and sensory neurosis. This dual-istic view that Nothnagel advocates dominates, as I have already said, all the literature on the subject that has appeared since his publications. Whereas, however, several authors, as v. Leube, Rosenheim ⁽¹¹⁾, Fleischer ⁽¹²⁾, Hemmeter and I myself, are inclined to see the characteristic features of Nothnagel's colica mucosa in the great majority of the cases that come under observation, other authors are inclined to consider enteritis membranacea (in the sense of Nothnagel) to be the rule and simple colica mucosa to be the exception.

We find the first attempt to depart from the dualistic view enunciated by Nothnagel in v. Leube, for the latter says: "However well established the fact may be that the formation of a membrane occurs in the course of certain varieties of enteritis, it is also true beyond cavil that this formation of membrane is dependent on some nervous affection. Almost all the sufferers from this disease that I have had occasion to observe were at the same time hysterical, and all medication directed towards improving the catarrh of the bowel, even though it was continued for months, remained without effect. I cannot help believing that the majority of these cases of intestinal disease that are accompanied by the formation of a membrane are in reality secretory neuroses of the bowel." According to this view colica mucosa may, so to say, develop as a nervous complication on the basis of enteritis. This conception overthrows the dualistic view of Nothnagel. H. Westphalen ⁽¹³⁾ emphasizes this Unitarian point of view still more forcibly than v. Leube, for this writer condemns the separation of enteritis membranacea into two etiologically different groups altogether. He denies the justification of distinguishing between enteritis membranacea of inflammatory origin and colica mucosa or a neurosis of the bowel in the sense of Nothnagel. According to this author, the formation of the so-called enteritic membrane is always due to nervous hypersecretion of mucus. If we are dealing, in any given case, with an uncomplicated secretory neurosis, then abnormally large quantities of amorphous mucus are poured out; if the case is complicated by the appearance of spastic conditions of the bowel, then the over-abundant quantity of mucus is compressed and strand-like masses are evacuated; if these masses are evacuated with violent pain then we must assume that a sensory neurosis exists at the same time. A genuine catarrh, as Westphalen correctly assumes, may be present at the same time (in this he agrees with Boas), but in such a case it is not the catarrh but the neurosis that must be made responsible for the production of excessive quantities of mucus, i. e. for the most characteristic feature of the disease. The excellent monograph of Westphalen treats of this subject in a most exhaustive manner and I recommend a perusal of his paper to every one who wishes to instruct himself in regard to the pathogenesis and the diagnosis of colica mucosa.