( Originally Published Early 1925 )
Spasticity in the sense used here is spasmodic contraction of the large bowel, acute or chronic. Patients suffering from this condition are generally thin, more or less neurotic (nervous) individuals, many being definitely neurasthenic (lack of nerve balance or tone) and a few hypochondriacal (melancholic).
There is always a long history of the condition which often becomes more obstinate in attacks which may recur for many years and last, with short intermissions, for a few days or a few months. Attacks are frequently brought on by overwork, worry and sometimes by a definite shock. They are often relieved by occupying the mind, so that mild exercise, if it is of a congenial nature, generally produces relief. Strenuous exercise tends to aggravate the condition. Aperients invariably cause pain and are often quite ineffective. The feces are hard, dry and small; they are often coated with mucus as a result of secondary inflammation of the interior surface of the colon. They may be quite flat or narrowed to the diameter of a pencil but more often small, round scybala are passed (small, hard masses). The former type, which was regarded by Fleiner as the distinguishing characteristic of spastic constipation, is produced by spasm of the anal sphincter and not by spasm of the colon, as material molded into thin forms higher in the intestines tends to be agglomerated into larger masses in the rectum. If sufficiently soft they may again be moulded into thin strips on their passage through the contracted anal canal. Successful defecation is often painful, as the spasm of the colon is generally accompanied by spasm of the anal sphincter. The spasm at the pelvi-rectal flexure (sigmoid or S-shaped bend of the colon immediately behind the rectum-the lowest section of the bowel) also obstructs the entry of an enema into the colon; when fluid has been introduced by pressure it is often retained in spite of every effort to evacuate it.
There is often dull ache in the abdomen which does not amount to actual pain but may be wearing on account of its long duration. Sometimes the attacks of severer constipation are accompanied by more or less pain. This is often situated in the left or right pelvic region and occasionally it moves from side to side or is central. Some rigidity of the abdominal muscles is often present. When the pain is situated on the left side the whole of the descending and pelvic colon, or the latter alone, can be felt as a thin, hard and tender cord, which is sometimes retracted upon a row of small round, hard fecal masses. In some cases the contracted pelvic colon can be felt by pressing deeply above the pubes (central, frontal bony foundation of the abdomen). When the pain is in the right side, the ascending colon is sometimes felt as a similar but rather thicker cord in the flank, the cecum being distended with soft material or gas. The transverse colon can rarely be felt but occasionally the whole colon is palpable.
The condition of the colon in spastic constipation has been investigated by Singer and Holzknecht with x-rays. Their conclusions coincide with those of Hurst, that feces generally pass along the first part of the colon either at the normal rate or more frequently at an abnormally rapid rate, delay only occurring in the part beyond the splenic flexure (see diagram) or at the pelvirectal flexure (sigmoid). The contracted part of the bowel generally begins at some point between the hepatic flexure (see diagram) and the end of the descending colon, the pelvic colon being most often affected. By observing the colon after a barium enema in spastic constipation Singer and Holzknecht found that the last part, in which delay occurs, has a diameter one-quarter or one-half smaller than normal.
The obstruction is not of a mechanical nature, as the x-rays show that there is generally no delay in the passage through the contracted segment. The colon immediately above is often not dilated, though the cecum (see diagram) is frequently distended with gas and visible and palpable peristalsis is never present. Moreover Boas has shown that the spasm can easily be overcome by inflation of the colon with air and water but it re-turns as soon as they are passed. He has also pointed out that the contracted colon can often be felt for several weeks after treatment has led to complete disappearance of the constipation. The actual cause of the disorder appears to be the absence of normal, orderly, propulsive activity of the intestine, which is replaced by irregular, spasmodic contractions of some parts while others remain almost completely inactive, defecation being also rendered difficult by the spasm of the pelvirectal flexure (sigmoid) and the anal sphincters.
As spasticity of the colon is a not infrequent form of constipation the following interesting case is given in detail by Hurst:
William K., a highly neurotic (nervous) man of 48 had done much hard work as a farmer in Australia with poor living and financial anxiety. He complained of abdominal pain, which came on in paroxysms lasting for a half hour or more. Attacks were aggravated by exercise. The pain occurred in different parts of the abdomen. It was occasionally brought on by meals, but the chief variations corresponded with the severity of the constipation, from which the patient habitually suffered and from which relief was obtained by purgatives. Defecation was generally followed by pain. Vomiting occurred occasionally and the patient lost 28 pounds in the 5˝ years since his illness began. Immediately after eating he sometimes experienced suffocation attacks, also neuralgic pains in the head and irritability of the scalp and feet.
On examination he was found to be thin but fairly muscular. Abdomen somewhat retracted with considerable rigidity but with very little tenderness. Rectum empty and normal. The patient was very pessimistic and much worried about himself.
The long history, the mental condition of the patient, the paroxysmal nature of the attacks and their association with constipation led to a diagnosis of enterospasm (increased, irregular and painful peristalsis—spastic constipation). The patient was given belladonna and codein and his bowels were kept open by olive-oil injections, as purgatives had no effect beyond causing great pain. Though the constipation was relieved by the oil enemata the pain could only be controlled by keeping the patient in bed on a milk diet. Increase in the diet or a short time out of bed was always followed by a severe attack. These began even when the patient was interested in a book or engaged in an exciting game of chess, so that I began to doubt the nervous origin of the attacks. This doubt became stronger when, at the end of the first month, a small horizontal tumor could be felt just above and to the right of the navel in the situation where most pain was now experienced. An exploratory operation developed that the apparent tumor was a tightly contracted transverse colon.
When constipation is associated with intestinal spasm it is often necessary to begin the treatment with a period of rest. The patient should go to bed early and it is advisable at first to have breakfast in bed, allowing the patient to get up only in the middle of the morning. In severe cases, especially when loss of appetite and emaciation are present, the patient should remain in bed from two to four weeks, but should get up each morning in order to open the bowels. If enough food is given, the rest often results in rapid recovery from the constipation without any local treatment, although hydrotherapy (water applications, external or internal) massage and electricity, which should all be given in a mild form, often hasten improvement. In uncomplicated cases belladonna is the most useful drug for combating spasm, dose 1/2 to 2 grains,' but in many cases very small doses of bromide should also be given to diminish the irritable condition of the nervous system. When the pain is severe it may be necessary to add codein s to the belladonna. The self-centered state of the patient's mind should be discouraged. Irrigation should be by normal saline solution (see index) only when necessary; and injections of soap and water, antiseptics and astringents avoided.
Spastic constipation is made worse rather than better unless any pressure is extremely gentle. Ordinary massage can, however, be applied to all parts of the colon, such as the cecum, which shows lack of tone and is not abnormally contracted, but it should never be employed if there is any evidence of serious inflammatory symptoms.