F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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The second stage (automatic or autonomous function)
The return of peristalsis and bowel sounds varies from case to case but, as a rule, the
first sounds appear within 2 or 3 days of cord transection at higher level, commensurate
with proper management. The anal and bulbo-cavernosus reflexes, which at first are
absent, will return early in cord lesions above the thoraco-lumbar junction, provided, no
longitudinal damage affecting the spinal centre of defaecation has occurred. Once
peristalsis has returned and the reflex activity of the isolated cord has started, intermittent
automatic reflex defaecation occurs in cord lesions above the thoraco-lumbar junction.
It is then the time to start planned defaecation.
Various factors may influence the establishment and efficiency of rectal reflex stimu
lation in the spinal man:
1
Positioning of the patient. Prolonged recumbency has certainly an adverse effect on
the establishment of early and efficient reflex defaecation. During the Second World War,
when the comprehensive management of spinal paraplegics arid tetraplegics was not fully
understood, this was conspicuous in paraplegics treated with prolonged recumbency in
plaster casts. Some of these patients were admitted to Stoke Mandeville not only with
over-loaded rectum but also with extreme faecal retention in all other compartments of
the large bowels which had become hardened. These patients were often suffering from
intermittent diarrhoea as a result of contractions of the overdistended colon and rectum
(diarrhoea ex constipatione, diarrhoea paradoxa, overflow diarrhoea), and some of these
patients were suffering from the effect of colonic distension on other autonomic mechan
isms, as have been described as a result of bladder distension. However, this autonomic
hyperreflexia as the result of colonic distension was found, as a rule, less pronounced as
compared with the effects of bladder distension, owing to the greater elasticity of colon
and rectum. Throbbing headaches may sometimes represent the leading symptom of
intestinal distension. Regular turning day and night from the supine to the lateral
positions facilitates bowel movement, whilst the patient is confined to bed. Exercises with
chest expanders and gentle massage of the abdomen have also proved helpful in this
respect.
2 The chemical and physical qualities of food certainly affect the rate of passage through
the intestinal tract. Food of low residue, such as meat, rice, white bread, etc., progress
more slowly than those with high residue, such as cabbage, bananas, animal and mineral
fats; moreover, fruit juice, yoghourt and lactose act as mild laxatives.
3 The reflex activity of the isolated cord, both hypo- and hyperreflexia, may influence
reflex defaecation. In lesions above T6, in which the abdominal muscles are involved in
the spastic contractions of the muscles below the level of the lesion, these contractions
may interfere with the propulsive activity of the various compartments of the intestinal
tract, and may lead to increased activity of certain segments only. This in turn may lead
to inadequate bulk being propelled to the distal colon. Moreover, it must be remembered
that, in the stage of hyperreflexia, the tonicity of the external anal sphincter is greatly
increased and, therefore, its resistance to the expulsive function of sigmoid and rectum is
magnified.
Constipation in lesions resulting in destruction of the lumbo-sacral cord or of its
