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An Address ON CHRONIC SPASMODIC AFFECTIONS OF THE COLON AND THE DISEASES WHICH THEY SIMULATE

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5492 DECEMBER 1, 1928. An Address ON CHRONIC SPASMODIC AFFECTIONS OF THE COLON AND THE DISEASES WHICH THEY SIMULATE. Delivered before the Sheffield Medical Society on Nov. 29th, 1928, BY JOHN A. RYLE, M.D., F.R.C.P. LOND., ASSISTANT PHYSICIAN TO GUY’S HOSPITAL. OF the problems which confront the physician and the surgeon few are more troublesome than those which require the interpretation of chronic or recur- ring abdominal pain. Frequently the diagnosis must be attempted in the absence of any conspicuous objective sign, and, with symptoms for guidance, a decision must be made between " organic " and " functional," or, what is more serious for the patient and more exacting in clinical judgment, between a surgical and medical plan of relief. Modern investi- gations do not always provide the clue. Discussions which serve, in however small a degree. to illuminate this dark field of diagnosis are therefore to be encouraged, and we should be very ready to share our observations and our difficulties. However great the triumphs of surgery may be in the acute abdominal catastrophes and in certain forms of chronic abdominal disease, none of us can feel content with the present position of abdominal surgery as a whole. We still see too many scarred abdomens with persistence of symptoms, too many " re-operations " and operations undertaken for pain, and it is disturbing to reflect upon the hours which must be lost annually to surgeons and their patients in the conduct of unrewarded appendicectomies, a considerable proportion of which have doubtless been advised by physicians. I would suggest that our shortcomings are less in respect of technique than of diagnosis, employing the term in its fullest sense of " thorough knowledge " of our cases. Such remarks as I shall have to make are to be regarded as a slender contribution to the study of a not uncommon abdominal disorder which is charac- terised by frequent and prolonged discomfort, or troublesome and even severe pain; which is unasso- ciated with any demonstrable organic change in the abdominal viscera; which sometimes simulates important organic disease ; and for which conse- quently operations and explorations are performed. The condition is variously referred to in the litera- ture as spastic constipation, chronic colospasm, spastic colon, and tonic hardening of the colon. For con- venience I shall refer to it as spastic colon. HISTORICAL. In Chapter IV. of his " Constipation and Allied Intestinal Disorders " Hurst gives a useful biblio- graphy of the subject and a concise account of the aetiology and important clinical features of the malady. It was first described by John Howship,2 2 surgeon to St. George’s Infirmary, London, in 1830, in a small and very readable book entitled " Practical Remarks on the Discrimination and Successful Treatment of Spasmodic Stricture in the Colon considered as an occasional cause of Habitual Confine- ment of the Bowels." He recognised that the com- plaint was due to " a deficient freedom of relaxation in some part of the intestinal canal," and both as a diagnostic test and a therapeutic measure advocated gradual distension of the bowel with a large warm gruel enema. Cherchewsky,3 who was unfamiliar with this account, redescribed the condition in 1883. Fleiner 4 wrote his first article on spastic constipa- tion in 1893. In this country Hawkins 5 wrote an admirably descriptive paper based on the study of 5492 35 cases of enterospasm in 1906, drawing particular attention to the frequent confusion of the disease with appendicitis. The subject has hitherto attracted more attention on the continent, but latterly there has been a revival of interest in England. Turner, g from the surgeon’s point of view, furnished an article to the Guy’s Hospital Reports in 1924. Dr. G. Evans made it the subject of a communication to the Asso- ciation of Physicians of Great Britain and Ireland in the present year. Stacey Wilson,7 who had pre- viously discussed the physiology of the pain in this disorder, has recently summarised his own views and wide experience in a book entitled " Tonic Hardening of the Colon." In this he discusses clinical features and advances his own therapeutic beliefs, but attri- butes, in my opinion, too long a list of physical and mental disturbances to the direct agency of tonic hardening. THE CLINICAL PICTURE OF SPASTIC COLON. The descriptions which follow are based on an analysis of 50 cases interrogated and examined by myself. The series includes 39 cases of spastic colon unaccompanied by mucus excess in the stools and 11 cases of the condition usually called muco-mem- branous colitis, or, better, mucous colic or muco- membranous colic, for cytological examination of the stools and the sigmoidoscope reveal no signs of ulceration and little or no evidence of active inflam- mation of the mucosa. The cases were taken from my file consecutively and with no special selection, excepting that those in which there was an element of doubt or obvious coincidental disease were excluded. The proportion of " spastic colon " cases to cases of " mucous colic " is, I believe, representative. The more detailed consideration of aetiology, symptoms, and physical signs is preceded by an account of an individual case portraying the more important features. CASE l.-A middle-aged professional man, of lean type and nervous constitution and liable to migraine, first started to have right-sided abdominal pain some 16 years ago. At one time and another cholecystitis and appendicitis were diagnosed, and finally, after careful investigation, the appendix was removed. He still, however, has the right- sided pain, and at times can feel for himself a sausage-like lump in the right flank. The attacks arrive especially in spring and autumn, and are precipitated by cold, fatigue, and mental worry. In a hot bath the pain is eased and the tumour fades away. The patient and his brother are both unable to face a cold east wind without developing abdominal pain. The pain shows a tendency to appear 2 hours after a meal. Examination revealed general right-sided tender- ness, and on one occasion the caecum or ascending colon became vaguely palpable. The descending colon was felt like a firm cord, and occasionally the transverse colon was also felt. There were no other signs of disease. The patient found that a good open-air holiday with exercise and mental rest was best calculated to bring relief. AETIOLOGY OF SPASTIC COLON. Sex Incidence.-In the present series of 50 cases there were 17 males and 33 females. Excluding the cases with mucous colic which, with rare exceptions, are confined to the female sex, there were 16 males and 23 females. Age Incidence.-The youngest patient was aged 19, the oldest 78. The average age was 39. Physical and Psychological Types.-Nineteen cases were specifically described in my notes as " lean," " thin," or " spare." " Wiry," " dark," " tall," and " pale " were other adjectives which occurred with conspicuous frequency. Twenty-seven cases were recorded as nervous, neurotic, worrying, or anxious. Migraine and asthma were entered against the patient or an immediate relative with sufficient frequency to suggest a more than coincidental association. The association with asthma is commented upon by Hawkins. 5 Family History.-In addition to these associations and general references to " nervous stock," there were two examples in my series of two brothers both suffering from spastic colon. The evidence for a constitutional or diathetic factor is thus fairly strong, and has, I think, usually been
Transcript
Page 1: An Address ON CHRONIC SPASMODIC AFFECTIONS OF THE COLON AND THE DISEASES WHICH THEY SIMULATE

5492

DECEMBER 1, 1928.

An AddressON

CHRONIC SPASMODIC AFFECTIONSOF THE COLON

AND THE DISEASES WHICH THEY SIMULATE.

Delivered before the Sheffield Medical Society onNov. 29th, 1928,

BY JOHN A. RYLE, M.D., F.R.C.P. LOND.,ASSISTANT PHYSICIAN TO GUY’S HOSPITAL.

OF the problems which confront the physician andthe surgeon few are more troublesome than thosewhich require the interpretation of chronic or recur-ring abdominal pain. Frequently the diagnosis mustbe attempted in the absence of any conspicuousobjective sign, and, with symptoms for guidance, adecision must be made between " organic " and" functional," or, what is more serious for the patientand more exacting in clinical judgment, between asurgical and medical plan of relief. Modern investi-gations do not always provide the clue. Discussionswhich serve, in however small a degree. to illuminatethis dark field of diagnosis are therefore to beencouraged, and we should be very ready to shareour observations and our difficulties.However great the triumphs of surgery may be in

the acute abdominal catastrophes and in certainforms of chronic abdominal disease, none of us canfeel content with the present position of abdominalsurgery as a whole. We still see too many scarredabdomens with persistence of symptoms, too many" re-operations " and operations undertaken for pain,and it is disturbing to reflect upon the hours whichmust be lost annually to surgeons and their patientsin the conduct of unrewarded appendicectomies, aconsiderable proportion of which have doubtless beenadvised by physicians. I would suggest that ourshortcomings are less in respect of technique than ofdiagnosis, employing the term in its fullest sense of" thorough knowledge " of our cases.Such remarks as I shall have to make are to be

regarded as a slender contribution to the study of anot uncommon abdominal disorder which is charac-terised by frequent and prolonged discomfort, or

troublesome and even severe pain; which is unasso-ciated with any demonstrable organic change in theabdominal viscera; which sometimes simulatesimportant organic disease ; and for which conse-quently operations and explorations are performed.The condition is variously referred to in the litera-

ture as spastic constipation, chronic colospasm, spasticcolon, and tonic hardening of the colon. For con-venience I shall refer to it as spastic colon.

HISTORICAL.In Chapter IV. of his " Constipation and Allied

Intestinal Disorders " Hurst gives a useful biblio-graphy of the subject and a concise account of theaetiology and important clinical features of themalady. It was first described by John Howship,2 2

surgeon to St. George’s Infirmary, London, in 1830,in a small and very readable book entitled " PracticalRemarks on the Discrimination and SuccessfulTreatment of Spasmodic Stricture in the Colonconsidered as an occasional cause of Habitual Confine-ment of the Bowels." He recognised that the com-plaint was due to " a deficient freedom of relaxationin some part of the intestinal canal," and both as adiagnostic test and a therapeutic measure advocatedgradual distension of the bowel with a large warmgruel enema. Cherchewsky,3 who was unfamiliarwith this account, redescribed the condition in 1883.Fleiner 4 wrote his first article on spastic constipa-tion in 1893. In this country Hawkins 5 wrote anadmirably descriptive paper based on the study of

5492

35 cases of enterospasm in 1906, drawing particularattention to the frequent confusion of the diseasewith appendicitis. The subject has hitherto attractedmore attention on the continent, but latterly therehas been a revival of interest in England. Turner, gfrom the surgeon’s point of view, furnished an articleto the Guy’s Hospital Reports in 1924. Dr. G. Evansmade it the subject of a communication to the Asso-ciation of Physicians of Great Britain and Ireland inthe present year. Stacey Wilson,7 who had pre-viously discussed the physiology of the pain in thisdisorder, has recently summarised his own views andwide experience in a book entitled " Tonic Hardeningof the Colon." In this he discusses clinical featuresand advances his own therapeutic beliefs, but attri-butes, in my opinion, too long a list of physical andmental disturbances to the direct agency of tonichardening.

THE CLINICAL PICTURE OF SPASTIC COLON.The descriptions which follow are based on an

analysis of 50 cases interrogated and examined bymyself. The series includes 39 cases of spastic colonunaccompanied by mucus excess in the stools and11 cases of the condition usually called muco-mem-branous colitis, or, better, mucous colic or muco-membranous colic, for cytological examination ofthe stools and the sigmoidoscope reveal no signs ofulceration and little or no evidence of active inflam-mation of the mucosa. The cases were taken frommy file consecutively and with no special selection,excepting that those in which there was an elementof doubt or obvious coincidental disease were excluded.The proportion of " spastic colon " cases to cases of" mucous colic " is, I believe, representative. Themore detailed consideration of aetiology, symptoms,and physical signs is preceded by an account ofan individual case portraying the more importantfeatures.CASE l.-A middle-aged professional man, of lean type

and nervous constitution and liable to migraine, first startedto have right-sided abdominal pain some 16 years ago.At one time and another cholecystitis and appendicitis werediagnosed, and finally, after careful investigation, theappendix was removed. He still, however, has the right-sided pain, and at times can feel for himself a sausage-likelump in the right flank. The attacks arrive especially inspring and autumn, and are precipitated by cold, fatigue,and mental worry. In a hot bath the pain is eased and thetumour fades away. The patient and his brother are bothunable to face a cold east wind without developing abdominalpain. The pain shows a tendency to appear 2 hours aftera meal. Examination revealed general right-sided tender-ness, and on one occasion the caecum or ascending colonbecame vaguely palpable. The descending colon was feltlike a firm cord, and occasionally the transverse colon wasalso felt. There were no other signs of disease. The patientfound that a good open-air holiday with exercise and mentalrest was best calculated to bring relief.

AETIOLOGY OF SPASTIC COLON.Sex Incidence.-In the present series of 50 cases

there were 17 males and 33 females. Excluding thecases with mucous colic which, with rare exceptions,are confined to the female sex, there were 16 malesand 23 females.Age Incidence.-The youngest patient was aged 19,

the oldest 78. The average age was 39.Physical and Psychological Types.-Nineteen cases

were specifically described in my notes as " lean,"" thin," or " spare." " Wiry," " dark," " tall," and" pale " were other adjectives which occurred withconspicuous frequency. Twenty-seven cases were

recorded as nervous, neurotic, worrying, or anxious.Migraine and asthma were entered against the patientor an immediate relative with sufficient frequency tosuggest a more than coincidental association. Theassociation with asthma is commented upon byHawkins. 5

Family History.-In addition to these associationsand general references to " nervous stock," therewere two examples in my series of two brothers bothsuffering from spastic colon.The evidence for a constitutional or diathetic factor

is thus fairly strong, and has, I think, usually been

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1116 DR. J. A. RYLE : CHRONIC SPASMODIC AFFECTIONS OF COLON.

remarked by those interested in the condition. Con-versely I would suggest that it is extremely rare tomeet with spastic colon in fair-haired, blue-eyed,healthy-complexioned types with placid dispositionsor in robust individuals. In my own experiencespastic colon is more common in private than inhospital practice. As Hawkins remarks, " Intestinalneuroses diminish in frequency as we descend thesocial scale."

Predisposing Illnesses and Intoxications.-Dysen-tery, as might be expected from the habit of irrita-bility which it engenders in the bowel, may befollowed by spastic colon, and this even for yearsafter the active infection has subsided. Three casesoccurred in my series. Hurst also refers to theinfluence of lead and tobacco, and to colonic spasmreflexly induced by gall-stones, ureteric calculus, orother irritative visceral lesions, or due to tabesdorsalis. It is very difficult to assess the part playedby tobacco. I would suggest that it is rarely the soleor main factor. Most of my male patients weresmokers, and four of them really excessive smokers.On the other hand, the majority of the women werenon-smokers. Occasionally I have seen patientswith spastic colon in association with other mani-festations of tobacco excess, such as sweating,dizziness, and palpitation. Plumbism and such coinci-dental diseases as appendicitis, diverticulitis, gall-stones, and tabes were, so far as possible, excluded.The causal or contributory effect of purgatives mustbe given due prominence. Thirty of the cases wererecorded as constipated, and of these the majoritywere taking laxatives or purgatives occasionally orhabitually. It cannot be doubted that undue irrita-bility of the neuro-muscular mechanism of the bowelis present in these cases, and that the majority of thepopular purgatives, however mildly so, are irritants.Furthermore, not a few of the patients are well awarethat their pain may be aggravated by brisk purgation.

CospaoM.—How far constipation is to beregarded as a cause or a consequence of the spasm itis difficult to say, but, as already mentioned, it waspresent in 30 (60 per cent.) of the cases. Neverthelessit is important to recognise that pain and tonichardening of the colon are consistent with regularand apparently normal bowel function. Attacks of" diarrhoea " are a constant feature in mucous colic.Diarrhoea, occasional or constant, was also recordedin seven cases of simple spastic colon. In some cases,both costive and otherwise, it is tempting to believethat a low grade colonic infection is at work, but wehave no certain information on this point. The casesare not pyrexial.

FREQUENCY OF PREVIOUS APPENDICECTOMY.In 18 (36 per cent.) of my cases the appendix had

been removed. In one of these it was removed duringa laparotomy which I myself advised (vide Case 3).In only three instances was it specifically noted thatthe appendicectomy was undertaken for acute appen-dicitis. In several instances the operation was under-taken for relief of pain not dissimilar from that for Iwhich relief was again sought. In one case therehad been two further explorations. In other casesa diagnosis of " chronic appendicitis " had beensuggested.

THE PATIENT’S SYMPTOMS.The leading complaint is usually of discomfort or

pain in the lower abdomen. The discomforts arevariously described as a feeling of stagnation or" stoppage," as

" a ball " or

" a lump," or as a

sensation " like a bar of lead " ; the direction of thisbar may actually correspond with some part of thelarge bowel, and the description is remarkable forthe nicety with which it interprets the tonic rigiditypresent in the affected segment. The pain is usuallya dull continuous ache, sometimes " gnawing " or

" like a toothache," never rhythmical or griping asin the colic of purgation, acute enteritis, or intestinalobstruction, and even in the severe cases unlike therelentless, immobilising pain of an acute inflammatorylesion. It varies in severity from something quite

trivial to an intensity-as will be described later-sosevere as to simulate the major colic of a uretericcalculus, and to call for the administration of mor-phine. These severe cases are fortunately rare.

Diagnosis even in the attack may be extremelydifficult. In a case of average severity the pain is attimes troublesome enough to interfere seriously withwork or pleasure, although it is noteworthy that sleepis seldom lost on account of it. It is usually referredwith accuracy to the part of the colon involved, andI must differ from Stacey Wilson 7 8 when he statesthat the distribution is segmental. A common

gesture is the application of the palm of the right orleft hand to the corresponding iliac fossa, when theproximal or distal portions are affected. In the caseof the transverse colon the course of the pain istraced with a finger or shown with the ulnar borderof the hand. For purposes of brevity I tabulated thecaecum and ascending colon as " nrst part"; thetransverse colon as " second part " ; and the colonfrom the splenic flexure to the commencement of therectum as "third part." Of the cases in whichobservations of the part affected were noted the firstpart was indicated in 26, the second in 14, and thethird in 21. Rectal pain was also recorded in a fewcases. Some patients could only describe a vaguelower abdominal " stomach-ache." Variations in thesituation of the pain are spontaneously described.Associated pyloric spasm and, in women, bladderdiscomfort and frequency are not rare.

" Deadfingers " are a common complaint. With the painthere is often mental depression or irritability andphysical inertia. Both onset and relief may be abruptand occur for no apparent reason. The duration ofthe pain varies from an hour or less to many hoursor even days.

Of aggravating or precipitating factors I wouldparticularly mention cold and fatigue, each of whichwere specifically recorded in 14 instances; joltmg,such as results from games or digging, horse-riding ormotoring over rough roads, and even walking;mental stress or worry ; purgatives ; tobacco ; and,in women, the menstrual cycle. The more irritablecases of mucous colic are very susceptible to fruit.Patients are sometimes more, sometimes less, comfort-able when their bowels are confined, but aggravationof pain immediately after the act of defsecation iscommon. Warmth, rest, hot baths, and open-airholidays with freedom from cares are among therelieving factors. Food sometimes gives temporaryrelief.

PHYSICAL FINDINGS.To these disturbed sensations certain objective

information can be added in a high proportion ofcases, more especially if the opportunities for examina-tion are frequent. The physical sign of the diseaseis an unusual palpability of some part or parts of thecolon ; this depends upon tonic rigidity, shorteningand straightening of the affected loop. The coloncan often be felt in the left iliac fossa in healthypersons or in patients without colonic disease, andsimple palpability in this region cannot be regardedas pathological. In spastic colon it is felt as an

unduly hard cord of small calibre. It is doubtfulif the colon is ever palpable in its proximal or trans-verse portions in perfect health. In the conditionof spastic colon, however, either of these portionsmay be felt as a firm rod or sausage-like tumour.This is sometimes, but by no means always, tender.The.degree of palpability varies from time to time,and even in the course of a single examination, andis more likely to be remarked when symptoms are

present. In those cases in which undue palpabilitywas noted in my series the first part was affected in18 instances ; the second part in 8, the third partin 9. The first and third parts were simultaneouslyfelt in 3, and all three parts in 4 cases. What StaceyWilson aptly likens to a " cartilaginous ring " maysometimes be felt on inserting the finger into therectum. Occasionally attacks of ballooning of thecaecum are observed behind a spastic ascendingcolon.

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1117DR. J. A. RYLE : CHRONIC SPASMODIC AFFECTIONS OF COLON.

The stools as a rule show nothing very charac-teristic excepting in the group to be separately con-sidered under the heading of mucous colic. In thelarger group there is no mucus excess or occasionalvery slight excess ; no blood ; and the colour varieswithin normal limits. There may, however, befragmentation, and, in the presence of anal spasm,narrowing of the fsecal mass. If purgatives are beingused the motions may, of course, be

" loose," " messy,"and unsatisfactory.Siqmoido8cOPY is often both difficult and painful on

account of spastic narrowing of the rectal andsigmoid lumen which is further stimulated by passageof the instrument. Fluctuations in the degree ofspasm can be witnessed simultaneously with varia-tions in the pain complained of by the patient. Themucosa looks perfectly healthy.

Less is to be gleaned from X ray examination thanmight be supposed. In the first place, the spasticstate is intermittent and may not coincide with theexamination. In the second place, a barium enema,which is commonly used in preference to the bariummeal in colonic cases, may by its gradual introductionand gentle distension overcome existing spasm, justas Howship was able to bring relief in painful spasmwith a large gruel enema ; in the third place, whenviews are taken after evacuation of the bulk of themeal or enema, it is necessary to distinguish theappearances of a normal but partly emptied segmentfrom a segment with spastic narrowing of its lumen.Examination after a barium meal is more likely togive positive evidence. In extreme cases the affectedlength of bowel appears as a thin thread or streak ofbarium, sometimes with a sharp line of demarcationfrom the better filled portions (vide Figs. 1 and 2).Normal haustrations, deepened with lesser degrees ofspasm, become obliterated when the spasm is verypronounced. In some cases the whole transverse ordescending colon or a longer portion is involved ; inothers, but less frequently, the spasm is localised toan inch or two. The localised spasms cause a moreintense pain. Two other departures from the normalare important and will be discussed later. These areshortening and straightening of the affected loop.

MUCOUS OR MUCO-MEMBRANOUS COLIC(Muco-membranous Colitis).

I see no valid reason for placing these cases in aseparate category. The abdominal pains described,the aggravating and relieving factors, and the radio-graphic appearances are identical. The chief differ-ences are as follows : (1) the sex incidence, the casesbeing almost all in women ; (2) the passage in attacks(usually after a period of constipation, chilling,anxiety, or fatigue) of large quantities of coagulatedmucus, sometimes in casts or shreds or envelopingsmall scybalous fragments; (3) the more evidentneurotic associations ; (4) an exaggerated colonictenderness with flinching and hyperalgesia but lessdefinite palpability of the bowel. The sigmoidoscopicfindings are as described in simple spastic colon.The mucosa is smooth and, at the most, slightlyredder than normal.

DIFFERENTIAL DIAGNOSIS.

Judging by my own difficulties and those experi-enced by colleagues who have referred cases to me,the following conditions are among those which aresimulated or suggested by the " spastic colon " :(1) appendicitis, acute and chronic, (2) duodenalulcer, (3) diverticulitis, (4) colonic carcinoma, (5) renalcolic, (6) intestinal obstruction, (7) ovarian or tubaldisease, (8) neurasthenia and hypochondriasis, (9)faecal tumours. Finally (10) the cases with mucusexcess seem not infrequently to conjure doubts aboutthe possibility of ulcerative colitis, or have beenvaguely classified as " colitis."

(1) Appendicitis.-In one of my cases the hardlump in the right iliac fossa formed by the contractedcolon during an attack of pain had led a surgeon toa provisional diagnosis of appendicular abscess. More

usually the persistence of symptoms leads to appen-dicectomy for a so-called " grumbling appendix."In simple spastic colon there is, as a rule, no pyrexia,guarding, vomiting, or cutaneous hyperalgesia. Inacute exacerbations of mucous colic there may, how-ever, be slight pyrexia, flinching (rather than guard-ing), superficial soreness, deep tenderness, and evensickness; but the previous history, the patient’spsychology, and inspection of the stools generallyestablish the diagnosis. In simple spastic colon theinterrogation, particularly in regard to the nature,duration, and localisation of the pain, and carefulpalpation along the course of the colon are usuallyadequate. (2) Duodenal ulcer may be simulated,firstly, because of associated pyloric or gastricspasm with food relief ; and, secondly, becausethe colonic pain itself, although differently situated,may develop late after meals and be relieved byfood. If there is any suspicion of duodenal ulceras an alternative or additional diagnosis a fullinvestigation should be advised. (3) Diverticulitis.In the left-sided cases particularly this possibilitymust be borne in mind, but the type of individualaffected is usually different, the victim of diver-ticulitis being commonly well nourished and lesscommonly neuropathic. The inflammatory tender-ness and thickening of pericolitis and pyrexia duringexacerbations are distinctive. X ray examinationafter a barium enema should be made in case of doubt.(4) Colonic carcinoma has frequently been feared incases of spastic colon because the patient himself orhis physician has discovered a hard lump in thecourse of the colon. The smoothness of the tumour,its sausage or rod-like formation, its mobility in thecase of the ascending or transverse colon, its varia-tions in size and hardness, or complete disappearanceunder observation or in a hot bath are helpful pointsin differentiation. The absence of obstructive symp-toms on the one hand, and of diarrhoea or passage ofblood on the other, and generally a very long historyof abdominal discomforts are reassuring features. Ifdoubts persist the aid of the radiologist, sigmoidoscopy,and chemical and cytological examination of the stoolsshould be invoked. (5) Renal colic is only likely tobe simulated in the occasional cases with very severepain (vide Case 3, in which the hardened colon wasmistaken by myself and others for the left kidney).(6) Intestinal obstruction was feared in Case 4, in whichthe complication of csecal distension was present.(7) Ovarian or tubal disease. At one time it was notuncommon for operations on one or both ovaries, butespecially the left, to be performed for spastic colon.The fallacy probably arose from the aggravation ofcolonic pain which sometimes accompanies the periodand from the association with dysmenorrhoea. (8)Neurasthenia and hypochondriasis may appear appro-priate labels in some cases of spastic colon, but theydo not embody an adequate explanation of the painand physical findings. (9) Fcecal accumulations canbe disposed of with enemata. (10) " Colitis " is aninaccurate pathology. I have had several cases ofmucous colic referred to me with a diagnosis ofulcerative coliiis, but the two conditions bear littleresemblance to one another. In the more seriousdisease an ill and frequently anaemic and wastedpatient gives a history of watery diarrhoea andpassing blood and mucus, commonly with a febrile,dysenteric onset. The diagnosis is completed withthe sigmoidoscope.

FREQUENCY OF SPASTIC COLON.

Taking all grades of the condition, allowing for itsvaried appellations and deceptions, and judging byinformation received from colleagues in generalpractice, I can only conclude that spastic colon is acommon disorder. On the basis of consulting andhospital experience I should say that it ranks highamong the causes of chronic abdominal distress.Numerically in my index it is more frequent thangastric ulcer, but less frequent than duodenal ulcer,conditions which are far more likely to be referredfor a second opinion.

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1118 DR. J. A. RYLE : CHRONIC SPASMODIC AFFECTIONS OF COLON.

NATURE OF THE DISORDER.

"Spastic colon" falls into the category of thevisceral neuroses. Its association with certainphysical and psychological types ; its intermittentbehaviour ; its aggravation by circumstances whichdepress or harass the higher centres ; and the absenceof all evidence of an associated organic lesion, givecredence to this view. It is a close ally to bronchialasthma, in which an inherited irritability of thebronchial centres and a sensitiveness to certain local,psychic, and peripheral stimuli are, on Hurst’s 9

showing, so apparent. Just as with asthma so withspastic colon cases occur in which spasm aloneis the outstanding feature, and others in whichmucorrhoea is superadded. Asthma is sometimescoincident with colonic spasm in the same patient orrecorded in a near relative. The stimuli which mayprovoke and perpetuate an attack of colonic spasminclude (1) local stimuli (purgatives, constipation),(2) central nervous stimuli (worry), (3) externalperipheral stimuli (cold). The same irritability ofplain muscle is often simultaneously manifest as

bladder frequency and even bladder pain, especiallyin female sufferers from spastic colon ; in pyloricspasm ; spasmodic dysmenorrhoea ; and in thevascular spasm which gives rise to " dead fingers."

NATURE OF THE SPASM AND PAIN.In obstructive or irritative lesions of the colon

there is increased peristaltic activity with more orless rhythmical griping due to the passage of wavesof contraction involving successive groups of circularfibres. In spastic colon no such rhythmical move-ments are provoked, but the tonus or posture of themuscle-fibres, including the longitudinal fibres, ismodified in such a way as to impart a sustainedshortening, with rigidity and narrowing of thelumen, to portions of the bowel wall often many

inches inFIG. 1. extent. The

equally thestraighteningand shorteningof the affectedloop cannot beotherwise ex-

plained. I wasat one timepuzzled byfinding a hard-ened and hori-z o n t a trans-verse coloncrossing theepigastrium,foralthough this isits anatomicalsituation Iknew that theradiologistmore fre-quently showedthis structure

Tonic spasm of transverse colon withballooning of csecum (erect).

as a festoon in the middle or lower abdominal planesand sometimes even in the true pelvis. Examinationof Figs. 1 and 2, copied from radiograms in mypossession, will show what remarkable straighteningmay occur and at once explains the clinical observa-tion. Surgeons sometimes witness the phenomenonof tonic hardening in the course of a laparotomy whenthe affected loop becomes rigid, pale, and erect inthe wound. I know no clinical condition whichbetter supports the hypothesis that visceral painoriginates in the viscus and is due to increased tensionin the muscle-fibre than spastic colon. With noinflammatory disease to involve the other coats ofthe bowel or neighbouring tissues, and so to confusethe issue, it is possible to demonstrate in these casesat once a complete absence of somatic hyperalgesiaand well-defined pain and tenderness in the affectedbowel itself, a pain and tenderness which increase

when the hardening increases and diminish when itdiminishes. The sustained and aching character ofthe pain accords well with this durable modificationof tonus or posture, and contrasts with the sharper,transient agony of peristaltic colic.

ILLUSTRATIVE CASES.CASE 2.-Illllstmting the influence of cold, the simulation

of a]J]Jcnd.icitis, and the cause of the pain.-A young andathletic lady, aged 25, developed pain in the right iliac fossaon a long voyage.The ship’s doctor Fig. 2.diagnosed appen-

..

dicitis, but would l’ B B Inot operate on

board. On arrivalin England herown medicaladviser and a

surgeon saw herand concurred inthe diagnosis, butfreely admittedthat the appendixwhen removed was" disappointing."The other organswere healthy. Thepains recurred andshe was broughtto see me. Iobtained an

earlier history ofmany attacks ofsudden and in-tensely severe painearning on tenanizz2<tes aft.sr a long’swiz2, in which shewas doubled up,

Tonic spasm of descending colon (same caseas Fig. 1) twenty hours later (supine).

I looked green and ill, but was relieved by brandy. Sincethe operation there had been a slight looseness of thebowels. She had noticed aggravation by fatigue, cold, andby fruit and green vegetables. During my examination Iwas able to demonstrate a hardening of the colon in theright iliac fossa which came and went, the pain coming withthe " lump " and disappearing as it " faded." Thediagnosis had been made easier for me by the negativeoperation findings, but the earlier history of precipitationby cold was instructive.CASE 3.-Ill1/strating difficulties in diffe1’ential diagnosis,

the occasional severity of the pain, and aggravation by anenema, jolting, &c.-An infantry officer, aged 41, consultedme on Feb. 25th, 1926, for severe pain in the left subcostalregion passing through to the back at the same level. Hehad also felt the pain in mid-epigastrium where he had beentender. He had suffered similar symptoms a year and alsofive months previously, but less severely. The pain was

liable to come one or two hours after food, and was some-times relieved by eating. Jolting definitely aggravated it.His actual sensations he likened to " a lump,of dough stuckand swelling as though about to burst." He was lean,tense, and tremulous, and very tender in mid-epigastrium.I made a provisional diagnosis of gastric ulcer and put himinto a nursing home for observation. On Feb. 27th he hada very severe attack of pain below the left rib margin andradiating down towards the groin. The pain immediatelyfollowed an enema. Morphine was given on more than oneoccasion. He was tender under the left ribs and I queriedfeeling the kidney. Jarring the loin also caused pain.Urine normal. His wife then remembered that for yearshe had had an occasional day in bed for left-sided pain.While I was away for a week-end, the patient, my deputy,and the nurses all noted the presence of a lump below theribs which was gone on my return. I now decided to regardthe symptoms as renal. A surgical colleague who saw himwith me concurred, but cystoscopy and pyelography werenegative. The pain continued, and he was explored onMarch 14th, all investigations having proved negative andall medical treatment unavailing. A slightly fibroticappendix was removed, and adhesions between the duo-denum and gall-bladder were freed. No ulcer, gall-stones,growth or other abnormality were demonstrable. He wasnot relieved of his symptoms by the operation, althoughreassured in his mind by the findings. I was then able tosatisfy myself that both the pain and the lump were colonicand due to tonic contraction. I have seen only a few othercases in which the pain was so severe and none so deceptivein symptomatic associations. I saw this patient, whoremains on duty, recently, and was able to feel thehardened colon to the left of the navel. He is quiteclear that jolting and cold, which I had come in the

Page 5: An Address ON CHRONIC SPASMODIC AFFECTIONS OF THE COLON AND THE DISEASES WHICH THEY SIMULATE

1119DR. W. YEOMAN : ARTHRITIS OF THE SACRO-ILIAC JOINT AND SCIATICA.

interval to recognise in other cases as important aggravatingfactors, are very definitely so in his case. I should clearlyhave paid more attention in his first bad attack to theinfluence of the enema.

CASE 4.-Illustrating the occasional severity of symptoms,ballooning of the caecum, the shortening and straightening ofthe colon, and the accuracy of localisation by the patient’sgesture.-I was consulted in May of the present year by awoman aged 40. From girlhood she had suffered from con-stipation and a liability to nausea, and had been preventedby her poor health from taking up work in which she wasinterested. In 1921 she had acute gangrenous appendicitis.Since then she had, in the words of her medical adviser,had three or four attacks " almost like a partial obstruction."These start with feelings of pain and weight in the cascalregion where a big bulge appears. In her last attack shecould " feel the bowel like a lump," and was in pain for fouror five hours continuously. The pain also passed straightacross her abdomen to the left. Lesser attacks were broughton by work in the garden, and could be cut short by lyingdown. There was aggravation by purgatives and her painwas worse after defalcation. On palpation I was able tofeel a hardened colon which again " faded " under my hand.The radiograms showed an extreme degree of colonic spasmaffecting first the transverse and later the descendingportion. During the examination she surprised the radio-logist by accurately tracing the course of the transverse colonby her sensations. This straight course from hepatic tosplenic flexure is well shown in Fig. 1.

TREATMENT.Most patients with " spastic colon " have been

walking in fear of organic disease ; many of themhave been told that they have organic disease ;cancer-phobia is frequently present ; operations mayhave been advised or already performed. The firstduty of the physician is therefore full reassurance.With this must be combined a simple explanationas to the nature of the disorder and the mode oforigin of the pain. Under general hygienic measuresthe importance of mental and physical relaxation, ofholidays, of moderate exercise, of warmth, and asensible mixed diet must be enumerated. Often thediet has been cut too low and fruit and vegetableshave been too rigorously excluded. The bulkystarchy foods, potatoes, beans, and peas, whichpredispose to intestinal flatulence, are better avoided,but fruits of all kinds, excepting those with toughskins and seeds, and the softer green vegetablesshould be liberally prescribed together with whole-meal bread and farm produce as a natural treatmentof the costive tendency. Tobacco may requirerestriction or even be forbidden for a long test-period. Purgatives must be entirely forbidden, butlubricants may be given. Belladonna or hyoscyamusin full pharmaeopceial doses helps to relax the spasm.Bromides should be reserved for the anxious and"

jumpy " patients, and withheld in the case of themore jaded and depressed. There is commonly rest-lessness with a furrowed brow, and hypertonus ofskeletal muscles. Psychotherapy plays an importantpart in the treatment of such cases. Jackson 10 hasdescribed a method of treatment by " progressiverelaxation " in which clinical improvement is shownto coincide with a return to normal in the colonicradiograms and a diminution in the briskness of theknee-jerks. The good sleep enjoyed by most patients,even when suffering bad pain by day, is probably dueto the relief afforded by natural muscular repose. Insome cases the sallow complexion and lassitude anda furred tongue during the attacks seem to suggestan element of what-for want of a more preciseterm-we must continue to refer to as intestinaltoxaemia. I think it must be in these cases especiallythat Stacey Wilson obtains his successes by exhibitingliquor hydrarg. perchlor. with liquor ferri perchlor.I have not tried his prescription extensively, butin one case it seemed to bring about a remarkableimprovement when other remedies had failed andthe patient was begging for an exploration. In caseswith severe pain and in exacerbations of mucouscolic, initial large warm enemata administered veryslowly, both to give lavage and to overcome thespasm, and rectal injections of warm liquid paraffin(4 or 5 oz.) to be retained overnight, are useful. Thedisorder, being like asthma and migraine, so largely

dependent on constitutional factors, is difficult to" cure," but repeated reassurances and rationaltreatment will often mitigate symptoms even in badcases. In milder cases there may be complete relief.

CONCLUSION.I have attempted a somewhat detailed analysis of

the clinical picture of spastic colon because thediagnosis of the condition should generally be possibleon clinical grounds. Furthermore in functional dis-orders of this kind special investigations inevitablygive a high percentage of negative results. Therecognition of spastic colon as an occasional causeof very severe abdominal pain and as a commoncause of persisting or recurring pain in the rightiliac fossa is, I believe, especially worthy of emphasis.Writing of these visceral neuroses in 1906 Hawkinssaid, " They are at this moment particularly worthyof study, owing to the advance of abdominal surgery,not because they are amenable to surgical treatment,but rather because they need protection." I thinkit should be accepted that they still need protection,and that for this and other reasons they are stillworthy of study.

REFERENCES.1. Hurst, A. F. : Constipation and Allied Intestinal Disorders,

London, 1919.2. Howship, J. : Practical Remarks on the Discrimination and

Successful Treatment of Spasmodic Stricture in theColon, London, 1830.

3. Cherchewsky : Rev. de M&eacute;d., 1883, iii., 876 and 1033.4. Fleiner, W. : Berl. Klin. Woch., 1893, xxx., 60 and 93.5. Hawkins, H. P. : Brit. Med. Jour., 1906, i., 65.6. Turner, P. : Guy’s Hosp. Rep., 1924, lxxiv., 55.7. Wilson, T. Stacey : Brit. Med. Jour., 1922, i., 944.8. Same author : Tonic Hardening of the Colon, London, 1927.9. Hurst, A. F. : Medical Essays and Addresses, London, 1924.

10. Jackson, E. : Arch. of Internal Med., 1927, xxxix., 433.

THE RELATION OF

ARTHRITIS OF THE SACRO-ILIACJOINT TO SCIATICA,

WITH AN ANALYSIS OF 100 CASES.*

BY W. YEOMAN, M.B. LOND.,HONORARY PHYSICIAN, ROYAL BATH HOSPITAL, HARROGATE.

THE part which the sacro-iliac joint plays inlumbago " and " sciatica " has long been a sourceof speculation, and in America " sacro-iliac strain "or subluxation is a common diagnosis. My attentionhas been drawn to the apparent frequency of a spuror irregularity of bone at the lower end of the sacro-iliac joint, and the analysis of a number of cases maybe of some value. The series consists of 100 casesadmitted to the Royal Bath Hospital, Harrogate,with a diagnosis of sciatica, in all of which radiogramsof the sacro-iliac and lumbo-sacral joints had beentaken. In all radiograms the hip was included, andin most some or all of the lumbar vertebrae wereshown.

-

Anatomy of the Joint.In order to obtain a clear conception of the role

which the sacro-iliac joint plays in the causation ofsciatica it will be necessary to summarise briefly theanatomy of the joint and its relationship with thelumbo-sacral cord.

In addition to descriptions in standard text-booksof anatomy, reports on a series of dissections of thejoint have been made by Albeel and Brooke.2 In50 specimens Albee found a perfect joint with synovialmembrane, cartilage, joint cavity, and well-formedcapsule. The joints before being opened were injectedwith methylene-blue, which showed that the synovialmembrane distended and retracted along the anteriorinferior aspect of the joint during movement. Thelumbo-sacral cord was found in close proximity to thelower third of the joint. Brooke based his findingson 200 dissections, and confirmed Albee’s work. Hefound that many males in late middle and advanced

* Abstract of paper read before the Harrogate Medical Society.


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