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A CASE OF MEGACOLON
1013
CLINICAL AND LABORATORY NOTES The stomach appeared as an elongated organ extending from the left side to the extreme right of the abdomen ; it was situated high up, under the costal margin, and curved The passage of the over a huge distended coil of intestine. barium meal was not unduly delayed and in five hours it had reached the csecum. In 24 hours the barium was seen passing up the ascending colon into the transverse and
A CASE OF MEGACOLON OF MANY
YEARS’ DURATION
WITH UNUSUAL
ATTACKS OF PAROXYSMAL TACHYCARDIA.
BY H. J.
STARLING, M.D. LOND.,
HON. PHYSICIAN TO THE NORFOLK AND NORWICH HOSPITAL.
Electrocardiogram I ’
2.
THE essential lesion of the colon described in this case was a volvulus of the sigmoid flexure which had never become so complete as actually to occlude the lumen of the bowel. Gould’s " Medical Dictionary " defines volvulus (volvere, to roll) as " a twisting of the bowel upon itself so as to occlude the lumen.... " The patient was first seen by me in April, 1926 ; she was
then 48 years old. She had been delicate all her life and had suffered from constipation and sickness, especially in childhood. Her present trouble began at 24years when she nerves " ; no cardiac saw a consultant for constipation and abnormality was noted then. A few years later she had severe gastritis and the heart was said to be irregular and intermittent ; she rested for five years, with some improvement. At 31 she had a curious heart attack, said by one doctor to be functional but by another to be serious, and she was continually in bed after this. In 1914 she saw a London consultant who diagnosed a congenital heart lesion. When I saw her first she had been confined either to her room or to her bed for ten years. She was lying on a couch but, even so, showed slight dyspnoea. There was some pallor of the face, the general nutrition was good, and the teeth were sound, but there was marked pyorrhoea of the gums. The heart was slightly enlarged, there were no bruits, the sounds were tic-tac, the pulse-rate was 150 to 160, and the blood pressure 160/110. On standing up for some minutes the toes, then the feet, and then the legs became at first congested, then a deep red, then definitely cyanosed. This congestion gradually increased until at the end of ten minutes the upper part of the thighs was a deep red, and the colour increased downwards to a deep purple. The patient informed me that if she stood for much longer the congestion extended up as high as the upper part of the chest, when she would also have marked cedema of the left leg and slight oedema of the left hand and right leg. The abdomen was not dis"
(
.
, ’
, ’
’
tended hnt t.hv pereussion notp q,ll
over was
hyper-resonant.
descending parts, which also were situated above and around the aforementioned distended coils, but it did not reach the rectum until the end of 48 hours. A barium enema was then given, but the ordinary quantities failed to reach the ascending colon, and not until ten pints had been administered was this part of the colon filled. These distended coils were seen in all the films, but the barium was not observed to pass in or out of them at any time. On these findings a diagnosis was made of incomplete volvulus of the sigmoid flexure. The patient was seen by Sir Hamilton Ballance, who advised an exploratory laparotomy with a view to resection of the volvulus if this was found to be feasible, but the patient refused to undergo any operative procedure. As the result of treatment by colonic lavage, massage, liquid paraffin preparations, and dental extractions, the condition of the patient was greatly improved ; she was
able to be up and about to a limited extent, there was only oedema of the legs after being up for some hours, and only slight discoloration of the legs after standing still for ten minutes ; there was a loose action of the bowels either daily or every other day. It was remarkable that at no time did the contour of the abdomen suggest any undue distension. Palpation sometimes revealed a certain degree of tension, and the percussion note was I always tympanitic, especially in ’ the upper part of the abdomen and the lower half of the chest. This suggested that the pressure of the distended guts was exerted in a vertical rather than in an
slight
anteroposterior plane. The patient returned home in October and led a comparatively active life until March, 1926, when she began to have curious fainting attacks and periods of irregular tachycardia. She came
She
was only having two motions a week and these only with the aid of suppositories. In July, 1925, she was brought to a nursing-home and the first electrocardiogram was taken. This shows a left ventricular preponderance, T 3 inverted, and two extrasystoles in lead II. Whilst in the nursing home it became evident that there was something seriously wrong with the intestinal tract ; very large enemata failed to secure any ’, result, and the motions suggested that the intestinal contents were being held up in some part of the tract. X ray examinations were then made by Dr. J. S. Levack ’ of Norwich.
May, 1927. She described
very
vividly three different types
of heart attacks. The first type she called " barge-poling "; during this phase the pulse was extremely irregular, the whole chest heaving with the violence of the heart’s action, and the rate varying between 140 and 170. The next type " was described as quick-beating," at a rate of 196. The third type was known as " hitching," and very aptly so. The first type was the most uncomfortable, but was brief and transitory, leading to type 2, during which she was able to be up and about, write letters, and do other work at a slow The pace, or to type 3, during which she had to rest. second type was the most prolonged and sometimes lasted
T2
1014 From the close conjunction of the distal and long as 24 hours. The three types are represented in electrocardiograms 2, 3, and 4. proximal ends of the volvulus it would appear that During the next three years these attacks of tachycardia the operation for its removal, as suggested in 1925, slowly but surely increased in frequency, duration, and severity. In spite of them the patient kept up and about would have been comparatively safe and probably effectual, especially since the volvulus was remarkably free from adhesions to surrounding structures. Electrocardiogram 3. The electrocardiograms are of unusual types. The first, taken in 1925, shows a normal sinus rhythm and left ventricular preponderance. In lead Il. are two extrasystoles, each of a different type and both occurring after a normal P-wave, thus replacing the usual ventricular sequence. In the second, leads I. and II. show a normal sinus rhythm of 135-140 per min., but lead III. shows an anomalous paroxysmal tachycardia of a rate of 217 per min. The third, taken in 1927 during an attack of paroxysmal tachyas
the minor attacks and in the brief interludes between the bad ones, and even during the severe attacks she was able to do much writing, resting on a couch. Quinidine sulphate and digitalis, singly and combined, in large doses and for many days at a time, failed to bring any relief, but the French tinct. iodi, taken in milk in ten-minim doses thrice daily for a month at a time, proved to be of great value. The bowels were relieved by enemata, but as time went on the amount of fluid had to be increased to5 pints or more before they were effectual. During her last stay in the nursing-home in November, 1929, during the course of her daily massage, she had a severe fainting attack followed by general convulsions and loss of consciousness for some hours, due probably to a cerebral embolus. In the early part of 1930 the attacks of tachycardia were almost continuous, and early one morning in April she was found to have died quietly about one hour after she had been seen to be sleeping peacefully. A partial post-mortem was allowed. On opening the abdomen and thorax the following disposition of the viscera was observed (see Diagram). A
during
..
double loop or volvulus occupied the greater part of the abdomen, the distal part arising from the sigmoid flexure and the proximal part ending close to the distal The end, in the lower part of the ascending colon. descending and transverse parts of the colon were twice
Electrocardiogram
4.
Diagram showing disposition of viscera post
(and in parts three times) the normal size and the latter was lying high up under the costal margin. Above this again was seen the stomach, the major portion of which was on the left ’I
mortem.
cardia, shows a rate of 195 per min. The ectopic focus is evidently the same as that which caused the second extrasystole in lead II. of the first tracing. From the occurrence Of a probable P-wave after each R-wave in lead I. and in the up-stroke of each S-wave in lead III. the focus is probably in the auriculoventricular node. The only other explanation is that the focus is in the left ventricle and that the P-waves The fourth shows a bigeminal are retrograde beats. paroxysmal tachycardia, an example of re-entry with a rate of 195 per min. ; it is fundamentally the same as the preceding type, but each alternate beat is replaced by an extrasystole arising from a different focus, probably the same as that which caused the first extrasystole in lead II. of the first electro-
cardiogram.
side at the level of the fifth to the seventh ribs, but the These types persisted until the last records taken in duodenal portion was enormously elongated, stretching 1929. The only type not recorded was one described across to the right seventh rib in the mid-clavicular line. The upper limit of the diaphragm on the right side was at as a " slow hitch," during which the pulse-rate was the third rib, the liver occupying the space below this, and 60 to 80 ; the patient was completely incapacitated, on the left side was at the fifth rib. The heart was slightly and venous polygraphic record the suggested a larger than normal, the muscle appeared to have a good flutter at a very high rate. colour and consistency, and the valves were normal.
CLINICAL AND LABORATORY NOTES The stomach appeared as an elongated organ extending from the left side to the extreme right of the abdomen ; it was situated high up, under the costal margin, and curved The passage of the over a huge distended coil of intestine. barium meal was not unduly delayed and in five hours it had reached the csecum. In 24 hours the barium was seen passing up the ascending colon into the transverse and
A CASE OF MEGACOLON OF MANY
YEARS’ DURATION
WITH UNUSUAL
ATTACKS OF PAROXYSMAL TACHYCARDIA.
BY H. J.
STARLING, M.D. LOND.,
HON. PHYSICIAN TO THE NORFOLK AND NORWICH HOSPITAL.
Electrocardiogram I ’
2.
THE essential lesion of the colon described in this case was a volvulus of the sigmoid flexure which had never become so complete as actually to occlude the lumen of the bowel. Gould’s " Medical Dictionary " defines volvulus (volvere, to roll) as " a twisting of the bowel upon itself so as to occlude the lumen.... " The patient was first seen by me in April, 1926 ; she was
then 48 years old. She had been delicate all her life and had suffered from constipation and sickness, especially in childhood. Her present trouble began at 24years when she nerves " ; no cardiac saw a consultant for constipation and abnormality was noted then. A few years later she had severe gastritis and the heart was said to be irregular and intermittent ; she rested for five years, with some improvement. At 31 she had a curious heart attack, said by one doctor to be functional but by another to be serious, and she was continually in bed after this. In 1914 she saw a London consultant who diagnosed a congenital heart lesion. When I saw her first she had been confined either to her room or to her bed for ten years. She was lying on a couch but, even so, showed slight dyspnoea. There was some pallor of the face, the general nutrition was good, and the teeth were sound, but there was marked pyorrhoea of the gums. The heart was slightly enlarged, there were no bruits, the sounds were tic-tac, the pulse-rate was 150 to 160, and the blood pressure 160/110. On standing up for some minutes the toes, then the feet, and then the legs became at first congested, then a deep red, then definitely cyanosed. This congestion gradually increased until at the end of ten minutes the upper part of the thighs was a deep red, and the colour increased downwards to a deep purple. The patient informed me that if she stood for much longer the congestion extended up as high as the upper part of the chest, when she would also have marked cedema of the left leg and slight oedema of the left hand and right leg. The abdomen was not dis"
(
.
, ’
, ’
’
tended hnt t.hv pereussion notp q,ll
over was
hyper-resonant.
descending parts, which also were situated above and around the aforementioned distended coils, but it did not reach the rectum until the end of 48 hours. A barium enema was then given, but the ordinary quantities failed to reach the ascending colon, and not until ten pints had been administered was this part of the colon filled. These distended coils were seen in all the films, but the barium was not observed to pass in or out of them at any time. On these findings a diagnosis was made of incomplete volvulus of the sigmoid flexure. The patient was seen by Sir Hamilton Ballance, who advised an exploratory laparotomy with a view to resection of the volvulus if this was found to be feasible, but the patient refused to undergo any operative procedure. As the result of treatment by colonic lavage, massage, liquid paraffin preparations, and dental extractions, the condition of the patient was greatly improved ; she was
able to be up and about to a limited extent, there was only oedema of the legs after being up for some hours, and only slight discoloration of the legs after standing still for ten minutes ; there was a loose action of the bowels either daily or every other day. It was remarkable that at no time did the contour of the abdomen suggest any undue distension. Palpation sometimes revealed a certain degree of tension, and the percussion note was I always tympanitic, especially in ’ the upper part of the abdomen and the lower half of the chest. This suggested that the pressure of the distended guts was exerted in a vertical rather than in an
slight
anteroposterior plane. The patient returned home in October and led a comparatively active life until March, 1926, when she began to have curious fainting attacks and periods of irregular tachycardia. She came
She
was only having two motions a week and these only with the aid of suppositories. In July, 1925, she was brought to a nursing-home and the first electrocardiogram was taken. This shows a left ventricular preponderance, T 3 inverted, and two extrasystoles in lead II. Whilst in the nursing home it became evident that there was something seriously wrong with the intestinal tract ; very large enemata failed to secure any ’, result, and the motions suggested that the intestinal contents were being held up in some part of the tract. X ray examinations were then made by Dr. J. S. Levack ’ of Norwich.
May, 1927. She described
very
vividly three different types
of heart attacks. The first type she called " barge-poling "; during this phase the pulse was extremely irregular, the whole chest heaving with the violence of the heart’s action, and the rate varying between 140 and 170. The next type " was described as quick-beating," at a rate of 196. The third type was known as " hitching," and very aptly so. The first type was the most uncomfortable, but was brief and transitory, leading to type 2, during which she was able to be up and about, write letters, and do other work at a slow The pace, or to type 3, during which she had to rest. second type was the most prolonged and sometimes lasted
T2
1014 From the close conjunction of the distal and long as 24 hours. The three types are represented in electrocardiograms 2, 3, and 4. proximal ends of the volvulus it would appear that During the next three years these attacks of tachycardia the operation for its removal, as suggested in 1925, slowly but surely increased in frequency, duration, and severity. In spite of them the patient kept up and about would have been comparatively safe and probably effectual, especially since the volvulus was remarkably free from adhesions to surrounding structures. Electrocardiogram 3. The electrocardiograms are of unusual types. The first, taken in 1925, shows a normal sinus rhythm and left ventricular preponderance. In lead Il. are two extrasystoles, each of a different type and both occurring after a normal P-wave, thus replacing the usual ventricular sequence. In the second, leads I. and II. show a normal sinus rhythm of 135-140 per min., but lead III. shows an anomalous paroxysmal tachycardia of a rate of 217 per min. The third, taken in 1927 during an attack of paroxysmal tachyas
the minor attacks and in the brief interludes between the bad ones, and even during the severe attacks she was able to do much writing, resting on a couch. Quinidine sulphate and digitalis, singly and combined, in large doses and for many days at a time, failed to bring any relief, but the French tinct. iodi, taken in milk in ten-minim doses thrice daily for a month at a time, proved to be of great value. The bowels were relieved by enemata, but as time went on the amount of fluid had to be increased to5 pints or more before they were effectual. During her last stay in the nursing-home in November, 1929, during the course of her daily massage, she had a severe fainting attack followed by general convulsions and loss of consciousness for some hours, due probably to a cerebral embolus. In the early part of 1930 the attacks of tachycardia were almost continuous, and early one morning in April she was found to have died quietly about one hour after she had been seen to be sleeping peacefully. A partial post-mortem was allowed. On opening the abdomen and thorax the following disposition of the viscera was observed (see Diagram). A
during
..
double loop or volvulus occupied the greater part of the abdomen, the distal part arising from the sigmoid flexure and the proximal part ending close to the distal The end, in the lower part of the ascending colon. descending and transverse parts of the colon were twice
Electrocardiogram
4.
Diagram showing disposition of viscera post
(and in parts three times) the normal size and the latter was lying high up under the costal margin. Above this again was seen the stomach, the major portion of which was on the left ’I
mortem.
cardia, shows a rate of 195 per min. The ectopic focus is evidently the same as that which caused the second extrasystole in lead II. of the first tracing. From the occurrence Of a probable P-wave after each R-wave in lead I. and in the up-stroke of each S-wave in lead III. the focus is probably in the auriculoventricular node. The only other explanation is that the focus is in the left ventricle and that the P-waves The fourth shows a bigeminal are retrograde beats. paroxysmal tachycardia, an example of re-entry with a rate of 195 per min. ; it is fundamentally the same as the preceding type, but each alternate beat is replaced by an extrasystole arising from a different focus, probably the same as that which caused the first extrasystole in lead II. of the first electro-
cardiogram.
side at the level of the fifth to the seventh ribs, but the These types persisted until the last records taken in duodenal portion was enormously elongated, stretching 1929. The only type not recorded was one described across to the right seventh rib in the mid-clavicular line. The upper limit of the diaphragm on the right side was at as a " slow hitch," during which the pulse-rate was the third rib, the liver occupying the space below this, and 60 to 80 ; the patient was completely incapacitated, on the left side was at the fifth rib. The heart was slightly and venous polygraphic record the suggested a larger than normal, the muscle appeared to have a good flutter at a very high rate. colour and consistency, and the valves were normal.