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The Irritable Colon
Medical Clinics of North America Number January, 1942. Chicago NU111ber
THE IRRITABLE COLON M.D.· FRANK C. VAL DEZ, M.D.COLONIC dysfunction is the chief cause of abdominal pain or discomfort. For many years colitis was used to designate colonic irritation. Sippy very early recognized that this term tenn was not a proper one and used the designation "irritable colon" to describe such a noninflammatory disturbance. While I served as his assistant, my interest in this type of colon dysfunction was stimulated and the fundamentals emphasized in this paper were learned. ANATOMY AND PHYSIOLOGY
A knowledge of the anatomy and physiology of the normal colon is necessary for a fundamental understanding of the symptoms and treatment of an irritable colon. It is not within the scope of this discussion to describe in detail the anatomy. Morgan11 stated that the nervous mechanism of the colon is maintained by a balance of tonus between the vagus and the sympathetics and that local control is through Auerbach's and Meisner's plexuses. The normal physiology has been explained in a thorough manner by Laus22 •• With an understanding of the colon in its normal state one can apirt the progress preciate the importance of the time element itt of material through the ,gastro-intestinal gastro-intestinal tract in this very common condition. Adler, Atkinson and Ivys have recently reported a very interesting study of the motility of the human colon. They observe that under certain conditions the disorganization of the types of motility of the colon may be increased, and the syndrome of so-called "spastic" or "unstable" colon may oc~ur in the absence of easily recognized roentgenologic evidence. *'" Associate Clinical Professor of Medicine, Loyola University School of Medicine; Senior Attending Physician, 1\Ilercy Mercy Hospital. 227
228
VAL DEZ FRANK C. VAL
ETIOLOGY
everything that upsets The etiologic factors are legion, if everythin.g normal physiology is considered. However, there are a few very common causes that can be explained. Cathartics
My experience over a period of twenty years corroborates that of Collins and Van Ordstrand44 who found that cathartics play an important part in most of the cases. A well taken history reveals that the patient failed to have a bowel movement and, after waiting twenty-four to forty-eight hours, became alarmed and took a "strong" cathartic. This was followed by the passing of many stools, usually of watery consistency. After this he did not have a bowel movement normal funcbecause the colon was seeking to establish its nonnal tion. The cathartic was repeated and changed until many kinds were taken over a period of months and years. After taking such punishment for a long time the colon becomes so irritable that a typical distress develops and causes so much discomfort that the patient seeks medical advice. Enemas
The use of enemas, although probably not so common, causes a similar reaction. Small enemas are employed and if "sufficient" results are not produced, the size is increased and various kinds of irritants are introduced. The rectal tube is inserted to a higher and higher level in order to get a "high enema." Various positions are assumed in order to empty the "whole bowe1." Colon irrigations are not infrequently taken. It is surprising the amount of fluid a patient will use after he has become addicted to colon irrigations. One patient has come under my observation who used twenty-two gallons of salt water once a week in order to get a "thorough cleaning." Enemas may cause such a severe irritation that large quantities of mucus are passed in the stools. The mental reaction of the patient to large quantities of this mucus is at times astounding and an apprehension neurosis may develop, especially if he is not properly advised. It should be generally recognized that mucous surfaces pour out mucus to protect irritated membranes.
THE IRRITABLE COLON
229 229
Diet
Diet may be an etiologic factor when it becomes excessively irritating. The normal colon will tolerate a great deal of irritation without manifesting it by abdominal distress. Healthy individuals have occasional bouts of pain after dietary indiscretion, but there is usually a rapid recovery. It is after these indiscretions are repeated that the various dietary fads are tried. After one is tried, another is suggested and usually many have been followed. Finally the colon becomes so irritable that almost all foods cause some discomfort. A most satisfactory sa~isfactory result can be obtained in this type of irritable colon if the proper treatment is followed. Emotional Upsets and Other Factors
Colon irritation as a result of emotional upsets is common. It is easily seen that this may include a multitude of conditions, few of 'which which can be discussed at this time, but family troubles, anxiety, fear, and frustrated social ambitions have to be considered in the successful management of an irritable colon. Other etiologic conditions are migraine, chilling of the body, allergy, menopause, hyperthyroid and, more often than is generally recognized, hypothyroid states. Inflammatory conditions such as gallbaldder disease and appendicitis may nl0re initiate colon irritability, but in my experience they more often aggravate a preexisting preexistiI1g irritation. Over a period of observation that rectal disease years it has not been my observatio·n alone causes abdominal pain. CLINICAL PICTURE
The clinical picture in irritable colon is fairly definite. The "{'he rnost most frequent complaint is a distress rather than a pain; however, it can be extremely painful. The site of occurrence is usually in the lower abdomen, but it may occur occur· any place in the abdomen. In pointing out the site of the distress the pat;ient usually passes his hand across the abdomen or folpa~ient lows the course of the colon. It is intermittent in type, varies in place of occurrence, occasionally radiates, and is accompanied by a feeling of distention or fulness. Rumbling and
230
C. VAL VAL DEZ FRANK c.
gurgling, nausea, passin'g passing of {latus, and occasionally a burning sensation across the center of the abdomen are not infrequently a part of the clinical story. The time of occurrence may be at any time if the colon irritation is of long standing but is usually while eating or very soon after the meal. It has been frequently explained that the gastrocolic reflex is responsible for the latter. It may occur during the night but this is rare and I am inclined to suspect some other cause when the patient is awakened in the middle of the night by abdominal pain. The distress does occur soon after arising and is not relieved by eating breakfast. Belching is a common complaint and becomes a bad habit which is difficult to overcome. Because by belching a relaxation of pressure on the colon is obtained, the patient encourages the habit. It may at times be necessary to carry the patient through a complete gastro-intestinal routine in order to prove to him that there is no gas in his stomach. Physical Examination
DIAGNOSIS
Physical examination should be carefully and thoroughly done in order to rule out any other condition. An irritable tender colon which in its descending porcolon will cause a te1lder tion can be rolled under the palpating finger like a rope. Superficial muscular tenderness may be misleading. This can be more accurately determined by having the patient lie on his head and heels while the abdominal wall is lifted or pinched. Laboratory Findings
The laboratory findings reveal a negative blood count except for a rather frequent low hemoglobin. Urine examination is negative. Inspection of the stools may reveal helpful information. The form and consistency should be noted. The ribbon-like and finger-size stools indicate a spastic condition. However, hard-fanned hard-formed or mushy and watery stools may be seen in the presence of a highly irritable colon. A stool that is mushy, full of bubbles, acid to litmus, and has a butyric fermentation. Microscopic examod or occurs when there is fennentation. odor
THE IRRITABLE COLON
231
ination of this stool reveals clostridia. In my opinion the bacteriologic examination of the stool only occasionally reveals anything of clinical value in an uncomplicated irritable colon. Blood in the stool is not a part of the picture in this syndrome. Mucus in varying amounts is very common. X-ray Examination
X-ray examination is routine, but it is not as important as it is in the presence of organic disease of the colon. It should be understood that filling the colon with barium may increase irritation, consequently the examination should not be the irr~tation, started until all other diagnostic work is completed. The preparation· for the examination differs from that followed preparation when organic disease is suspected. A cathartic should not be given to empty the colon, since the one cathartic that is most likely to empty the whole colon is certain to increase the irritation. An enema made with one pint of warm water is sufficient. Fluoroscopic examination is of most diagnostic value. As the barium enters the colon, contractions due to spasm may be seen which cause the haustrations to disappear. The colon may be finger size, but will fill to normal size as the enema patient, to indicate the site is continued. Not infrequently the patie,nt, of pain, will point to the area where the spasm is seen and state that the pain "is gone" when the spasm relaxes. Pain caused by the barium enema is relieved by expulsion of the barium, provided enough is expelled. i
Differential Diagnosis
Diagnosis of irritable colon is made by exclusion, not on direct or positive fiIldings. findings. Other gastro-intestinal disturbances should be ruled out first. It should be generally recognized that no other abdominal organ is likely to cause pain of daily occurrence over such a long period of time. Distress caused by a peptic ulcer is more localized, constant, has a gefinite pefinite time element as a rule, and is relieved by food or sufficient alkali to neutralize the free hydrochloric acid present. Roentgen ray examination of the stomach will reveal the casual lesion. s8
232
VAL DEZ FRANK C. VAL
Chronic gallbladder' gallbladder disease may challenge the ability of the most skillful diagnostician. It should be borne in mind that the presence of gallstones does not necessarily mean that they are causing symptoms. In the acute attacks of gallbladder disease the severe, localized pain with localized tenderness and muscular rigidity are helpful. It also has an inflammatory background, the evidences of inflammation being a rise in temperature and leukocytosis. The gallbladder dye may help. In acute appendicitis there is a sudden onset with a definite severe pain. In most cases there is also localized tenderness and muscular rigidity, elevated temperature, and leukocytosis. It is certainly being more generally recognized today that chronic appendicitis is not of frequent occurrence. If more attention is given to the diagnosis of irritable colon, chronic appendicitis will become a comparatively rare diagnosis. Genito-urinary disease can be ruled out by a carefully obtained history, which should not be a forgotten art, and the necessary investigative procedures. Organic disease of the colon, such as polypi, carcinoma, ulcerative colitis and other ulcerations may be complicated by the picture of an irritable colon but they can be diagnosed if the history, proctoscopic examination, stool examination and roentgen findings are carefully evaluated. migraine,the In migraine, ·the classical history is usually obtained, and in hypothyroidism the slow pulse, nail changes, blood pressure, dry skin, speech and metabolism should make the diagnosis very definite. MANAGEMENT
If the patient with irritable colon is seen reasonably early, its management may be easy and satisfactory results are the rule. Some of the very late cases will challenge th,e the ability and patience of the most expert. Diet is the fundamental part of the treatment. It seems to me desirable to classify patients who appear for treatment into three types: (1) those with "constipated" stools; (2) those with normal stools, and (3) those with watery stools.
THE IRRITABLE COLON
233
I. Patients with "Constipated" Stools
Constipation is diagnosed on the basis of hard-formed stools that are difficult to to expel, whether the condition occurs daily or irregularly. The popular treatment for such a patient is to allow plenty of vegetables and a large quantity of fruit. Again my experience agrees with Collins and Van Ordstrand that such a diet is contraindicated. In the obser- , vation of more than 3000 cases, a low residue diet, omitting all fruits, and the use of 2 to 4 ounces of warm oil as a retention en,e111a enema each night until the distress has definitely improved, have given the best results. An evacution enema made with not more than 1 pint of warm water may be used if necessary. As the distress impro,ves, improves, one vegetable at a time may be added. When the distress is not troublesome and the stools are not soft formed, fruit may be added and is tolerated better ter' after taking food than before. It should be understood that no one diet will 'be be satisfactory for all aU patients. As a rule, corn, cabbage, cucumbers, sauerkraut and highly seasoned foods are most irritating and should be added cautiously, if at all. All cathartics are forbidden. 2. Patients with Normal Stools
The dietary management of this type is not as a rule difficult. It is usually possible to start with the bland foods and one to three cooked vegetables daily, such as string beans, spinach, asparagus and carrots, omitting any vegetables that the history may have indicated as irritating. Baked beans, sweet potatoes, peanuts and lima beans are omitted if the passing of flatus is a complaint. Additions are made as the distress lessens. It is usually necessary to use heat on the abdomen and to administer an antispasmodic drug. 3. Patients with Watery Stools
The patient with an irritable colon who is having mushy or watery stools is given small feedings at two-hour intervals, consisting of gruels, boiled milk, poached or soft boiled eggs, and milk toast. As the diarrhea improves, other bland foods are added and three meals daily are allowed. As the stool
234
FRANK C. VAL DEZ
becomes soft formed, vegetables are added. Fruits are usually added last. The antispasmodic drugs are of definite help in most cases, e.g., tincture of belladonna in doses of 10 to 20 minims three to four times daily. It is recognized that the tolerance for this drug varies widely in different individuals, but in my experience large doses for a short time give a better result than small doses for a longer period of time. Trasentin will give satisfactory results in many cases. In the mild diarrhea, tannagen, grains 10 three to four times daily, and kaolin with or without amphogel may be used. Sippy used a combination of calcium phosphate, calcium carbonate carbon'ate and bisnmth bismuth subcarbonate in 60-grain doses; this is effective in a large number of cases. F or the irritable colon accompanied by a stubborn diarrhea, paregoric or tincture of deodorized opium may be used with satisfactory results. It must be understood that the opium preparations are habit forming. Bromides in 10 to 15 grain doses and the barbiturates in small doses are helpful in all three types to control the nervous reactions. Emotional individuals, or those who have been commonly E1110tional called neurotics, will require a studied application of what was at one time called the art of medicine. When properly used it will suffice in most cases, but much patience is required. Rarely there may be a psychiatric problem. If so, it is best to refer the patient to a competent psychiatrist, and in my experience a satisfactory improvement has usually resulted. It is generally recognized that the individual with an irritable· able colon who remains on a restricted diet for a long time should be given sufficient vitamins to assure him the recognized daily requirement. Vitamin C should not be forgotten. CONCLUSIONS
1. A knowledge of the anatomy and physiology of the normal colon is essential for a fundamental understanding of irritable colon. 2. The etiologic importance of cathartics, enemas and diet was discussed.
THE IRRITABLE COLON
235
3. A method of treatment that has given satisfactory results was outlined. BIBLIOGRAPHY
1. Morgan, W. S.: Etiology and Treatment of Spastic Colon. Southern M. J., 20: 380-382 (May) 1927. 2. Laus, Clark J.: The Irritable Colon Syndrome. Radiology, 24: 572-590 (May) 1935. 3. Adler, Harry F., Atkinson, A. J. and Ivy, A. C.: A Study of the Motility of the Human Colon. Am. J. Digest. Dis., 7: 197-202 (June) 1941.
c.:
4. Collins, E. N. and Van Ordstrand, H. S.: Cleveland Clinic Quarterly, 8: 67 (April) 1941.
THE IRRITABLE COLON M.D.· FRANK C. VAL DEZ, M.D.COLONIC dysfunction is the chief cause of abdominal pain or discomfort. For many years colitis was used to designate colonic irritation. Sippy very early recognized that this term tenn was not a proper one and used the designation "irritable colon" to describe such a noninflammatory disturbance. While I served as his assistant, my interest in this type of colon dysfunction was stimulated and the fundamentals emphasized in this paper were learned. ANATOMY AND PHYSIOLOGY
A knowledge of the anatomy and physiology of the normal colon is necessary for a fundamental understanding of the symptoms and treatment of an irritable colon. It is not within the scope of this discussion to describe in detail the anatomy. Morgan11 stated that the nervous mechanism of the colon is maintained by a balance of tonus between the vagus and the sympathetics and that local control is through Auerbach's and Meisner's plexuses. The normal physiology has been explained in a thorough manner by Laus22 •• With an understanding of the colon in its normal state one can apirt the progress preciate the importance of the time element itt of material through the ,gastro-intestinal gastro-intestinal tract in this very common condition. Adler, Atkinson and Ivys have recently reported a very interesting study of the motility of the human colon. They observe that under certain conditions the disorganization of the types of motility of the colon may be increased, and the syndrome of so-called "spastic" or "unstable" colon may oc~ur in the absence of easily recognized roentgenologic evidence. *'" Associate Clinical Professor of Medicine, Loyola University School of Medicine; Senior Attending Physician, 1\Ilercy Mercy Hospital. 227
228
VAL DEZ FRANK C. VAL
ETIOLOGY
everything that upsets The etiologic factors are legion, if everythin.g normal physiology is considered. However, there are a few very common causes that can be explained. Cathartics
My experience over a period of twenty years corroborates that of Collins and Van Ordstrand44 who found that cathartics play an important part in most of the cases. A well taken history reveals that the patient failed to have a bowel movement and, after waiting twenty-four to forty-eight hours, became alarmed and took a "strong" cathartic. This was followed by the passing of many stools, usually of watery consistency. After this he did not have a bowel movement normal funcbecause the colon was seeking to establish its nonnal tion. The cathartic was repeated and changed until many kinds were taken over a period of months and years. After taking such punishment for a long time the colon becomes so irritable that a typical distress develops and causes so much discomfort that the patient seeks medical advice. Enemas
The use of enemas, although probably not so common, causes a similar reaction. Small enemas are employed and if "sufficient" results are not produced, the size is increased and various kinds of irritants are introduced. The rectal tube is inserted to a higher and higher level in order to get a "high enema." Various positions are assumed in order to empty the "whole bowe1." Colon irrigations are not infrequently taken. It is surprising the amount of fluid a patient will use after he has become addicted to colon irrigations. One patient has come under my observation who used twenty-two gallons of salt water once a week in order to get a "thorough cleaning." Enemas may cause such a severe irritation that large quantities of mucus are passed in the stools. The mental reaction of the patient to large quantities of this mucus is at times astounding and an apprehension neurosis may develop, especially if he is not properly advised. It should be generally recognized that mucous surfaces pour out mucus to protect irritated membranes.
THE IRRITABLE COLON
229 229
Diet
Diet may be an etiologic factor when it becomes excessively irritating. The normal colon will tolerate a great deal of irritation without manifesting it by abdominal distress. Healthy individuals have occasional bouts of pain after dietary indiscretion, but there is usually a rapid recovery. It is after these indiscretions are repeated that the various dietary fads are tried. After one is tried, another is suggested and usually many have been followed. Finally the colon becomes so irritable that almost all foods cause some discomfort. A most satisfactory sa~isfactory result can be obtained in this type of irritable colon if the proper treatment is followed. Emotional Upsets and Other Factors
Colon irritation as a result of emotional upsets is common. It is easily seen that this may include a multitude of conditions, few of 'which which can be discussed at this time, but family troubles, anxiety, fear, and frustrated social ambitions have to be considered in the successful management of an irritable colon. Other etiologic conditions are migraine, chilling of the body, allergy, menopause, hyperthyroid and, more often than is generally recognized, hypothyroid states. Inflammatory conditions such as gallbaldder disease and appendicitis may nl0re initiate colon irritability, but in my experience they more often aggravate a preexisting preexistiI1g irritation. Over a period of observation that rectal disease years it has not been my observatio·n alone causes abdominal pain. CLINICAL PICTURE
The clinical picture in irritable colon is fairly definite. The "{'he rnost most frequent complaint is a distress rather than a pain; however, it can be extremely painful. The site of occurrence is usually in the lower abdomen, but it may occur occur· any place in the abdomen. In pointing out the site of the distress the pat;ient usually passes his hand across the abdomen or folpa~ient lows the course of the colon. It is intermittent in type, varies in place of occurrence, occasionally radiates, and is accompanied by a feeling of distention or fulness. Rumbling and
230
C. VAL VAL DEZ FRANK c.
gurgling, nausea, passin'g passing of {latus, and occasionally a burning sensation across the center of the abdomen are not infrequently a part of the clinical story. The time of occurrence may be at any time if the colon irritation is of long standing but is usually while eating or very soon after the meal. It has been frequently explained that the gastrocolic reflex is responsible for the latter. It may occur during the night but this is rare and I am inclined to suspect some other cause when the patient is awakened in the middle of the night by abdominal pain. The distress does occur soon after arising and is not relieved by eating breakfast. Belching is a common complaint and becomes a bad habit which is difficult to overcome. Because by belching a relaxation of pressure on the colon is obtained, the patient encourages the habit. It may at times be necessary to carry the patient through a complete gastro-intestinal routine in order to prove to him that there is no gas in his stomach. Physical Examination
DIAGNOSIS
Physical examination should be carefully and thoroughly done in order to rule out any other condition. An irritable tender colon which in its descending porcolon will cause a te1lder tion can be rolled under the palpating finger like a rope. Superficial muscular tenderness may be misleading. This can be more accurately determined by having the patient lie on his head and heels while the abdominal wall is lifted or pinched. Laboratory Findings
The laboratory findings reveal a negative blood count except for a rather frequent low hemoglobin. Urine examination is negative. Inspection of the stools may reveal helpful information. The form and consistency should be noted. The ribbon-like and finger-size stools indicate a spastic condition. However, hard-fanned hard-formed or mushy and watery stools may be seen in the presence of a highly irritable colon. A stool that is mushy, full of bubbles, acid to litmus, and has a butyric fermentation. Microscopic examod or occurs when there is fennentation. odor
THE IRRITABLE COLON
231
ination of this stool reveals clostridia. In my opinion the bacteriologic examination of the stool only occasionally reveals anything of clinical value in an uncomplicated irritable colon. Blood in the stool is not a part of the picture in this syndrome. Mucus in varying amounts is very common. X-ray Examination
X-ray examination is routine, but it is not as important as it is in the presence of organic disease of the colon. It should be understood that filling the colon with barium may increase irritation, consequently the examination should not be the irr~tation, started until all other diagnostic work is completed. The preparation· for the examination differs from that followed preparation when organic disease is suspected. A cathartic should not be given to empty the colon, since the one cathartic that is most likely to empty the whole colon is certain to increase the irritation. An enema made with one pint of warm water is sufficient. Fluoroscopic examination is of most diagnostic value. As the barium enters the colon, contractions due to spasm may be seen which cause the haustrations to disappear. The colon may be finger size, but will fill to normal size as the enema patient, to indicate the site is continued. Not infrequently the patie,nt, of pain, will point to the area where the spasm is seen and state that the pain "is gone" when the spasm relaxes. Pain caused by the barium enema is relieved by expulsion of the barium, provided enough is expelled. i
Differential Diagnosis
Diagnosis of irritable colon is made by exclusion, not on direct or positive fiIldings. findings. Other gastro-intestinal disturbances should be ruled out first. It should be generally recognized that no other abdominal organ is likely to cause pain of daily occurrence over such a long period of time. Distress caused by a peptic ulcer is more localized, constant, has a gefinite pefinite time element as a rule, and is relieved by food or sufficient alkali to neutralize the free hydrochloric acid present. Roentgen ray examination of the stomach will reveal the casual lesion. s8
232
VAL DEZ FRANK C. VAL
Chronic gallbladder' gallbladder disease may challenge the ability of the most skillful diagnostician. It should be borne in mind that the presence of gallstones does not necessarily mean that they are causing symptoms. In the acute attacks of gallbladder disease the severe, localized pain with localized tenderness and muscular rigidity are helpful. It also has an inflammatory background, the evidences of inflammation being a rise in temperature and leukocytosis. The gallbladder dye may help. In acute appendicitis there is a sudden onset with a definite severe pain. In most cases there is also localized tenderness and muscular rigidity, elevated temperature, and leukocytosis. It is certainly being more generally recognized today that chronic appendicitis is not of frequent occurrence. If more attention is given to the diagnosis of irritable colon, chronic appendicitis will become a comparatively rare diagnosis. Genito-urinary disease can be ruled out by a carefully obtained history, which should not be a forgotten art, and the necessary investigative procedures. Organic disease of the colon, such as polypi, carcinoma, ulcerative colitis and other ulcerations may be complicated by the picture of an irritable colon but they can be diagnosed if the history, proctoscopic examination, stool examination and roentgen findings are carefully evaluated. migraine,the In migraine, ·the classical history is usually obtained, and in hypothyroidism the slow pulse, nail changes, blood pressure, dry skin, speech and metabolism should make the diagnosis very definite. MANAGEMENT
If the patient with irritable colon is seen reasonably early, its management may be easy and satisfactory results are the rule. Some of the very late cases will challenge th,e the ability and patience of the most expert. Diet is the fundamental part of the treatment. It seems to me desirable to classify patients who appear for treatment into three types: (1) those with "constipated" stools; (2) those with normal stools, and (3) those with watery stools.
THE IRRITABLE COLON
233
I. Patients with "Constipated" Stools
Constipation is diagnosed on the basis of hard-formed stools that are difficult to to expel, whether the condition occurs daily or irregularly. The popular treatment for such a patient is to allow plenty of vegetables and a large quantity of fruit. Again my experience agrees with Collins and Van Ordstrand that such a diet is contraindicated. In the obser- , vation of more than 3000 cases, a low residue diet, omitting all fruits, and the use of 2 to 4 ounces of warm oil as a retention en,e111a enema each night until the distress has definitely improved, have given the best results. An evacution enema made with not more than 1 pint of warm water may be used if necessary. As the distress impro,ves, improves, one vegetable at a time may be added. When the distress is not troublesome and the stools are not soft formed, fruit may be added and is tolerated better ter' after taking food than before. It should be understood that no one diet will 'be be satisfactory for all aU patients. As a rule, corn, cabbage, cucumbers, sauerkraut and highly seasoned foods are most irritating and should be added cautiously, if at all. All cathartics are forbidden. 2. Patients with Normal Stools
The dietary management of this type is not as a rule difficult. It is usually possible to start with the bland foods and one to three cooked vegetables daily, such as string beans, spinach, asparagus and carrots, omitting any vegetables that the history may have indicated as irritating. Baked beans, sweet potatoes, peanuts and lima beans are omitted if the passing of flatus is a complaint. Additions are made as the distress lessens. It is usually necessary to use heat on the abdomen and to administer an antispasmodic drug. 3. Patients with Watery Stools
The patient with an irritable colon who is having mushy or watery stools is given small feedings at two-hour intervals, consisting of gruels, boiled milk, poached or soft boiled eggs, and milk toast. As the diarrhea improves, other bland foods are added and three meals daily are allowed. As the stool
234
FRANK C. VAL DEZ
becomes soft formed, vegetables are added. Fruits are usually added last. The antispasmodic drugs are of definite help in most cases, e.g., tincture of belladonna in doses of 10 to 20 minims three to four times daily. It is recognized that the tolerance for this drug varies widely in different individuals, but in my experience large doses for a short time give a better result than small doses for a longer period of time. Trasentin will give satisfactory results in many cases. In the mild diarrhea, tannagen, grains 10 three to four times daily, and kaolin with or without amphogel may be used. Sippy used a combination of calcium phosphate, calcium carbonate carbon'ate and bisnmth bismuth subcarbonate in 60-grain doses; this is effective in a large number of cases. F or the irritable colon accompanied by a stubborn diarrhea, paregoric or tincture of deodorized opium may be used with satisfactory results. It must be understood that the opium preparations are habit forming. Bromides in 10 to 15 grain doses and the barbiturates in small doses are helpful in all three types to control the nervous reactions. Emotional individuals, or those who have been commonly E1110tional called neurotics, will require a studied application of what was at one time called the art of medicine. When properly used it will suffice in most cases, but much patience is required. Rarely there may be a psychiatric problem. If so, it is best to refer the patient to a competent psychiatrist, and in my experience a satisfactory improvement has usually resulted. It is generally recognized that the individual with an irritable· able colon who remains on a restricted diet for a long time should be given sufficient vitamins to assure him the recognized daily requirement. Vitamin C should not be forgotten. CONCLUSIONS
1. A knowledge of the anatomy and physiology of the normal colon is essential for a fundamental understanding of irritable colon. 2. The etiologic importance of cathartics, enemas and diet was discussed.
THE IRRITABLE COLON
235
3. A method of treatment that has given satisfactory results was outlined. BIBLIOGRAPHY
1. Morgan, W. S.: Etiology and Treatment of Spastic Colon. Southern M. J., 20: 380-382 (May) 1927. 2. Laus, Clark J.: The Irritable Colon Syndrome. Radiology, 24: 572-590 (May) 1935. 3. Adler, Harry F., Atkinson, A. J. and Ivy, A. C.: A Study of the Motility of the Human Colon. Am. J. Digest. Dis., 7: 197-202 (June) 1941.
c.:
4. Collins, E. N. and Van Ordstrand, H. S.: Cleveland Clinic Quarterly, 8: 67 (April) 1941.