F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
441
by the subsequent consumption of the meal (Fig. 190). In another patient with a Thn
lesion there was no effect on visual impulses, but the patient did not find the food appetiz
ing. However, there was a definite response to eating.
Of special interest was the effect of distending the rectum on sigmoid motility, as
found in 12 patients with complete lesion and levels ranging from C6 to Li. All 7 patients
with spastic cord lesions (C6 to Ti2) showed a definite response which consisted in 6
cases of initial inhibition of sigmoid motility followed by a subsequent stimulation. The
response was most marked nearest to the point of stimulation. Figs. 1913, b illustrate
the responses to moderate and powerful rectal distension in a case of incomplete spastic
lesions below C6 but complete below T2, with co-ordinated automatic bladder and bowel
functions. In patients with cervical lesions, rectal distension elicited marked responses of
other autonomic mechanisms, in particular cardio-vascular response, as described
previously (Guttmann & Whitteridge, 1947), and in two cervical patients the study had
to be terminated because of rise in blood pressure to high levels. The flaccid low thoracic
and lumbar lesions and those cervical and mid-thoracic lesions who, following intrathecal
alcohol block, became flaccid, did not show responses to rectal distension, and on filling
the rectal balloon with larger amounts of water (200 ml) the balloon was extruded
passively.
These studies demonstrate the important function of the lower sigmoid colon for the
initiation of the defaecation reflex. It could be shown that stimulation of the bowel with
sigmoidoscope resulted in relaxation of the anal sphincters and passage of stool. On the
other hand, the usual response of the sigmoid to filling with a moderate amount of fluid
(100 ml) was an initial inhibition of activity. Only when the rectal pressure greatly
increased, following gross distension of the rectum due to a large amount of fluid (300 ml),
did an increased sigmoid activity follow. This could be explained as the result of an
mtestino-intestinal reflex to prevent the forwards movement of more faeces into an
already distended rectum (Connell, 1962). In this connection, it may be remembered
that, in the small intestines of the cat, distension of one segment results in inhibition of
neighbouring segments.
Clinical manifestations and treatment of intestinal dysfunction
Three main stages of intestinal dysfunction can be distinguished following complete
or severe incomplete lesions of the spinal cord and conus-cauda equina:
1
absence or depression of gastrointestinal function in the stage of spinal shock,
2 the stage of automatic reflex activity or autonomous function of the intestines,
3 the stage of intestinal reconditioning.
The initial stage
The immediate effect of spinal cord transection on intestinal function in upper thoracic
and cervical lesions is paralysis of the peristalsis, accompanied by faecal retention result
ing from the atonic state of the whole intestinal tract, which represents the cardinal
symptom in lesions of any level.
