Dr. Theodore Potter, of Indianapolis: There is the old saying that pain is the cry of the nerve or blood. Which means that back of the nerve pains, as we call them, there is usually something. I think that any careful study of a considerable number of cases of sciatica will impress this fact strongly on one's mind, that in the vast majority of cases which we call sciatica there is something behind the sciatic nerve that is wrong, and the thing to do is to try to find out what it is. When we come to study the things we find back of the pain in the sciatic nerve in these cases we quickly and easily place them in two groups: The toxic things, the forms of poisoning, and the traumatisms; or local and constitutional things that irritate in some way the sciatic nerve. And so I am accustomed to say to medical students in the clinic, in the presence of a case of sciatica, to always remember to do two things above everything else; to make an examination for those things that may produce general poisoning, and a careful local examination, and these two things having been done, the case will clear up. Locally we may find disorders of the spinal column, of the pelvic bone, exostoses, affections of the rectum, piles, rectal ulcers, disorders of the urinary organs, in the pelvis, bladder, the pelvic organs in women; these disorders furnish causes of sciatica; and then the second group of disorders, the constitutional poisoning of Bright's disease, diabetes, cirrhosis of the liver and that group of degenerations which bring with them the toxemias. If one overlooks this important fact that back of the chronic sciaticas that persist for days and weeks and months, there is likely to be something producing a poisoning or irritation of that nerve, whatever relief he may temporarily get, he will be very apt to be disappointed in the real cure of the patient. I have within the last year met two cases which were at once cleared up by the discovery of diabetes. It is not uncommon, ás Dr. Bond said, for such patients with nephritis to complain of neuralgic pains about the head, brachial, sciatic, etc. These two things we want to bear in mind: The great majority of cases are easily explained by some discoverable local disorder or some constitutional disease like Bright's disease, etc.

Dr. A. C. Kimberlin, of Indianapolis: Whether we regard sciatica as due to mechanical or toxic causes it is interesting to the general practitioner to note the vast frequency with which we see it on the left side, as compared with the right.

Dr. Morris, closing: I attempted in my paper to differentiate between sciatic neuritis and sciatic neuralgia, and gave the symptoms of the two different conditions. They are exactly different, and this condition of sciatica, coming with diabetes, Bright's disease, etc., is not a neuritis, as you can demonstrate; it is a neuralgia that will be cured by correction of the underlying condition. The only cases which are not thoroughly examined, not only in regard to the urine, but in some cases as to the blood, are those where the examination is made after they are treated to relieve the pain. One of my ideas in presenting the paper was to insist on the fact that most of these cases escape us because we do not make a thorough examination, and it strikes me that this is one of our weaknesses that the osteopaths live on. There wouldn't any excuse on earth for their living and succeeding if they didn't have to make an examination absolutely thorough in order to make an impression the first time.

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MEMBRANOUS CATARRI OF THE INTESTINES.

BY ROBERT HESSLER, A. M., M. D., LOGANSPORT, IND.

The morbid condition generally called membranous catarrh of the intestines and characterized by the passage of slimy or membranous substance from the bowels, by abdominal pain, and by various disturbances of the alimentary tract and the nervous system, is an affection that is still ill-defined; little is known about the pathology, practically nothing regarding its etiology, and writers have not even agreed on a name. The synonymy is something wonderful. A study of the literature is interesting in many ways, but in this paper I shall give only a brief review, first in regard to the history of the affection and how it has been differentiated, next a mention of some of the receat writers and their views. After this follows a brief account of the affection as I have seen it.

Historical. Paulus Egineta, among the last of the old Greek physicians, speaks of the passage of mucus from the intestines. Moragni the Italian, about 150 years ago, mentions the passing of mucus at times in the form of ribbons or tape. Van Swieten, more than a hundred years ago, studied the affection in Vienna under the name of glutinous diarrhea. Mason Good, of England, nearly a hundred years ago, described it under the name of tubular diarrhea. Sireday of France, in 1869, described several cases, and came to the conclusion that it was a functional disturbance, a neurosis.

Da Costa of this country, in 1871, gave the first classical description of the affection, in the American Journal of the Medical Sciences. He regarded it of nervous origin and recognized the importance of and advised the use of diet, exercise and fresh air. Whitehead of England, in the same year, described it as mucous disease or mucous affection of the intestines; he insisted on proper

diet, quality rather than quantity, and the importance of exercise. Leyden of Berlin, in 1882, directed special attention to its occurrence in Germany, where from now on it was extensively studied. Nothnagel of Vienna, in 1884, attempted to make sharp distinetions between enteritis membranacea or mucous colitis, on an anatomic basis, and mucous colic, on a functional basis; the latter alone he regarded as being of nervous or neurotic origin. The term colica mucosa is the same as mucous colic, or membranous catarrh of the intestines. Potain of France, in 1887, inclined to the view that it is a superficial catarrh of the mucous membrane of the large intestine, caused and kept up by coprostasis. This seems to be the most generally accepted view among the French writers; the assumption of an arthritic or neuroarthritic diathesis among them should also be mentioned.

Vanni, of Italy, in 1888, regarded it as a myoangio-neurosis of the intestine with hypersecretion of mucus; his view is said to have modified the treatment of the affection. Edwards, of our own country, in 1888, gave a good account, adopting the name given by Da Costa; he dwells on the nervous phenomena. Von Leube of Germany, writing in 1889, regarded it as a neurosis of secretion. Rothman, in 1893, published the first report of an autopsy, in the Berliner Clinische Wochenschrift; he found much mucus in the large intestine and the tubular glands.

Since then many have written on the subject, most writers following along the beaten path; but occasionally some one would have something new. Of the many writers I can make mention of only a few, and I desire to bring out the idea that in our country the affection is not simply a bowel condition, but that the nervous features are of the highest importance.

In 1900 Mannaberg (Wiener Med. Wochenschr, Oct., 1900,) reviewed the literature and the opinions concerning pathogenesis and pathologic anatomy. He came to the conclusion that there is a diversity of opinion in regard to the frequency of the disease; there is a lack of a generally accepted pathology; there is insufficient consideration of the clinical picture. He brought out the fact that there are three sets of views held by investigators: (1)

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That it is an organic disease of the intestine, principally of the large bowel. (2) That it is a secretory and motor neurosis of the intestines. (3) There are two entirely different conditions-(a) an inflammatory disease of the intestinal mucous membrane with the production of an extraordinary amount of mucus; (b) a purely nervous disease without any organic disease in the bowel. A few writers believe there may be a combination of the above types.

Mannaberg concludes from his comparative studies that there are two different pathologic entities that have been confused under the name and he agrees with Nothnagel in differentiating colica mucosa from enteritis membranacea. The latter is at form of enteritis marked by profuse mucoid and membranous stools and caused by chronic diarrhea, tropical dysentery, typhoid fever, hemorrhoids, intestinal tumors, irritating enemas (especially of silver nitrate, vinegar, alum, tannin and glycerin), anthelminties and drastics. The former (colica mucosa) he regards as a disease sui generis; it is not connected with any of the above causes, but is apt to occur in nervous cultured people who are usually constipated and suffer from some lesion of the genitalia, enteroptosis, and achylia gastrica. The cause may be sought for in vain, although constipation and enteroptosis have been thought to be of casual influence. Mannaberg thinks there may be an indirect connection between constipation and colica mucosa, brought about by the fact that mucus is amassed in an empty, contracted, and for a considerable time inactive part of the large bowel, to be expelled later on by more or less colicky contractions. He believes a larger number of pathologic examinations are necessary to determine and differentiate; a correct diagnosis is of scientific interest, and treatment depends upon it.

On going over the recent literature within my reach and comparing the writings of German, French, English and American observers, I came to the conclusion that the former emphasize the importance of the bowel condition and minimize the nervous manifestations; the French attach special importance to the arthritic or rheumatic and neuroarthritic diathesis; the English more nearly approach in their views those of our own writers, who attach