F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
445
(sodium sulfosuccinate). The latter has proved particularly useful. The laxatives used at
Stoke Mandeville are Sennacot tablets or granules, Cascara Elix, Syrup of Figs or
Dubhalac liqu. (Lactulose), and their dosage as well as type has to be varied on occasions
to achieve an optimal effect. Drastic laxatives should be avoided as far as possible, and
liquid paraffin should be used only temporarily, because of its preventative action of
carotine and fat absorption. In cervical lesions of higher level, evacuation of the bowels
will have to be carried out by an attendant, preferably with the patient lying in lateral
position, while tetraplegics below
Cj
and especially C8 have learned to open their bowels
on the toilet.
In conus-cauda equina lesions, evacuation of the bowels depends on the severity
of the lesion. In those cases where the parasympathetic connections to sigmoid and
rectum are not completely interrupted, the peristaltic function of these intestinal compart
ments is still active, and the external rectal sphincter maintains its reflex function, although
the external anal sphincter may be flaccid. Therefore, conditioned reflex function of
these patients, as described above, is still possible. In more severe or complete conus-
cauda equina lesions, where all connections between sacral cord and sigmoid and rectum
are severed, rectal evacuation depends on the compensatory function of the intramural,
autonomous innervation and the expulsive force of intermittent efficient intra-abdominal
pressure by the action of diaphragm and abdominal muscles. The ability of the sigmoid
to act as a reservoir is still present, and the efficient expulsive forces of abdominal pressure
will evacuate the bolus into the rectum. However, digital evacuation by gloved finger will
be necessary to avoid both constipation and incontinence. Colostomy, as recommended
previously (Munro, 1952) to prevent rectal incontinence in these patients has not been
found necessary in any of our conus-cauda equina lesions.
The development of haemorrhoids and anal fissures is a complication in later stages,
in particular of conus-cauda equina lesions. While the latter is certainly the result of
mucosal damage by careless and faulty digital evacuation, the former is the result of
chronic constipation and prolonged strong abdominal pressure during faecal evacuation.
However, this complication can, as a rule, be controlled by phenol injections, and only
very seldom are more extensive operative procedures necessary. The same applies to the
mucosal prolapse of the rectum as a result of intensive abdominal pressure and weakness
of the levator ani.
Before the paraplegic or tetraplegic is discharged from hospital treatment, his atten
dants at home should receive information and guidance by the medical officer and nurse
in charge of the case about the patient's intestinal dysfunction, to ensure his proper
management after discharge.
