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CHAPTER 27
spinal roots is of a different nature. In this event, the neural connections between the
spinal centre and sigmoid colon and rectum are cut off, and these parts of the intestinal
tract become autonomous. The paralysis is of lower motor neuron type, and the normal
response of sigmoid and rectum to distension and the tonicity of the external sphincter
is lost, the latter becoming patulous. The function of the levator ani is also impaired.
There will be progressive accumulation of faeces which become hardened resulting in
impaction. Moreover, owing to the complete loss of sensibility in the sacral area rectal
incontinence is not uncommon. Defaecation in this type of paralysis depends on the
volitional increase of intra-abdominal pressure and digital evacuation. During the second
stage, as long as the patient is confined to bed, this will have to be executed by the
nursing staff with the aid of suppositories and enemas. We have preferred to give the
enema in a lateral position. It is recommended that the rectal evacuation, whether with
or without enema, should be done preferably in the morning, either before or after
breakfast, to initiate the regular habit of defaecation in the patient.
The third stage (reconditioning of intestinal function)
In this phase of readjustment, the full co-operation of the patient in the planned defaeca
tion is of greatest importance to make the paraplegic socially acceptable, and the sooner
his upright position and standing is established the better the result. It is important at
this stage to carry out a thorough X-ray investigation of the gastrointestinal tract with
the aid of contrast means. This will give information about any congenital or acquired
abnormalities, such as enteroptosis, diverticulosis, megacolon, chronic gastric or duodenal
ulcer, etc., which may have adverse effects on the reconditioning of the intestinal tract
and need appropriate treatment. Unlike the bladder, the readjustment of the patient to
his intestinal dysfunction can be accomplished in the great majority of cases, provided
the patient's early instruction about his type of intestinal dysfunction and his systematic
training to adjust himself to his intestinal disturbance is instituted. The aim is to establish
a habit of regular and complete evacuation of the bowel once a day or every second day
at a specific time. It has become a custom for these patients to evacuate the bowels every
second day, but the patient and his attendant at home should really be advised to have
his bowels open every day. Naturally, his pre-paraplegic habit of emptying the bowels
will have to be taken into account. As a rule, the most suitable time for this procedure
is the period after a meal in the morning, when the gastro-colic reflex acts as an excitatory
stimulus to the peristalsis. In order to achieve a regular habit, enemas should be dis
continued as soon as possible, and automatic reflex evacuation in cord lesions, if necessary
with the help of mild laxatives and glycerine or bisacodyl (Dulcolax) suppositories,
encouraged. Early return of the patient's upright position, as already stressed, is of
great assistance. Moreover, in this stage of reconditioning, the patient must learn to
utilize certain afferent stimuli, such as gentle massage of the abdomen, bending forwards
to increase the intra-abdominal pressure or digital stimulation of the anal area. Stag
nation of the contents of the lower intestinal tract, which not infrequently develops in
later stages of cord lesions and may lead to constipation in these distal compartments, can
be counteracted by stool softeners, such as mineral or vegetable oil or Dioctyl forte
