A. N. Smith

Clinical Effects of Whole-body Hyperthermia in Advanced Malignancy

Fifty-one patients in the terminal stages of cancer have been treated with whole-body hyperthermia either alone (38 cases) or in combination with chemotherapy (13 cases). Altogether 227 treatment sessions were held averaging four hours each. The most sensitive tumours were those of the gastrointestinal tract and sarcomas. Breast and genitourinary tumours did not respond, and lung tumours and melanomas were only partially responsive. Major complications were remarkably few.

Bile acids and colonic motility in the rabbit and the human.

Colonic motor activity was initiated by infusions of bile salts into the caecum or rectum of the anaesthetized rabbit. Primary bile acids were examined proximally and distally in the colon and elicited marked motor responses. Sinc dihydroxy bile acids are known to be potent inhibitors of electrolyte and water absorption in the colon, the secondary bile acid deoxycholic acid, the dihydroxyl compound most related to cholic acid which is the main bile acid in the rabbit, was examined distally and was also active, but to a lesser extent than cholic acid conjugates in this species. In man, a relationship was found between the faecal bile acid excretion and colonic motility: the introduction of bile acids directly into the human sigmoid colon and rectum also stimulated colonic motility. In man, the dihydroxy compound chenodeoxycholic acid was slightly more active than conjugates of cholic acid.

Outlet obstruction constipation (anismus) managed by biofeedback.

Fifteen subjects presenting with intractable constipation due to obstructive defecation, mean (SEM) duration 8.8 (1.8) years, had the inappropriate contraction and electromyographic changes in the pelvic floor muscles and external and sphincter typical of this condition. An electromyographically derived index was used to grade its severity. A self applied biofeedback device was used to allow electromyographic recording of the abnormal external anal sphincter. The subjects were encouraged to reduce the abnormal electromyographic activity on straining after instruction and training. The procedure was intended as a relearning process in which the non-relaxing activity of the pelvic floor was gradually suppressed. Biofeedback training was maintained on a domiciliary basis for a mean time of 3.1 weeks and resulted in a significant reduction in the anismus index (mean (SEM) 69.9 (7.8)% before biofeedback, mean 14 (3.9)% after biofeedback, p less than 0.01). There was an associated reduction in the time spent straining at stool and in the difficulty of defecation and an increased frequency of defecation. Defecatory video proctograms in six subjects showed improvements in the anorectal angle during straining and evacuation. The clinical benefit to the patients persisted after a mean follow up of 6.2 months.

Constipation associated with chronic spinal cord injury: the effect of pelvic parasympathetic stimulation by the Brindley stimulator

Ten subjects with severe constipation due to complete spinal cord injury (SCI) had prolonged oro-anal transit time (p<0.01), diminished faecal water content (p<0.05) and a reduced frequency of defaecation (p<0.01) compared to 10 non-SCI subjects. Paraplegics with an implanted Brindley S234 anterior sacral nerve root stimulator had a significant increase in frequency of defaecation (p<0.01), compared to the SCI group while the faecal water content was less although not significantly so. The Brindley stimulator group also showed a more rapid colonic transit than the SCI group but this did not reach statistical significance. SCI is associated with constipation which therefore appears to be favourably influenced by the Brindley S234 anterior nerve root stimulator. The effects produced are compatible with stimulation of left colonic motility, which facilitates the emptying of the distal colon, but also suggest that part of the response restricts transit in some areas of the colon or rectum. Since the motility changes induced by the Brindley stimulator do not affect the right colon a relatively greater residence time of the faecal bolus in this part of the large bowel would enhance water absorption.

Comparison of bran, ispaghula, and lactulose on colon function in diverticular disease.

Bran, ispaghula (Fybogel), and lactulose were given to three groups of patients with diverticular disease for four weeks. Faecal weights, bile acids, fat and electrolytes, transit time, and colonic motility were estimated before and after treatment. Stool weight increased, notably with Fybogel. Cereal bran had the greatest effect on the transit time, reducing it significantly. There were no changes in faecal bile acids, fat or electrolytes. Coarse bran reduced colonic motility and the number of high pressure waves after food; Fybogel increased the basal pressure and was without effect on the food-stimulated pressures; whereas lactulose influenced neither. All agents paradoxically equally alleviated symptoms.

Effects of hysterectomy on bowel and bladder function

A case control study compared the bowel habit of 91 post-hysterectomy women with paired controls from the same family doctor practice. More cases had an abnormal bowel frequency, a firmer stool consistency and assessed themselves as having abnormal bowel function, predominantly constipation after hysterectomy, than controls. Significantly more cases than controls had consulted a doctor because of constipation but there was no significant difference in laxative usage. There was a significant short-term association between decreased bowel frequency and increased urinary frequency after hysterectomy. This became highly significant in those patients who developed chronic symptoms. Oophorectomy, unilateral or bilateral, did not significantly affect bowel habit other than to intensify the change in stool consistency. The hypothesis is discussed that the post-hysterectomy effects on bowel and bladder function may have a common aetiology in a degree of autonomic denervation of both viscera.

Submucosal collagen changes in the normal colon and in diverticular disease

Full thickness specimens of normal colon (n=15), and colon from patients with diverticular disease (n = 5) were obtained at operation or autopsy. In the isolated submucosa the ultrastructure of the constituent collagen fibres was examined by transmission electron microscopy. Collagen fibrils in the left colon become smaller (p < 0.001) and more tightly packed (p< 0.001) than those in the right colon with increasing age. This difference is accentuated in diverticular disease (p<0.01). Factors which contribute to the development of colonic diverticulosis, such as raised intraluminal pressure, may be responsible for premature change in submucosal structure.

The action of Cisapride on the chronic constipation of paraplegia

Paraplegic patients have intractable constipation associated with prolonged colonic transit time. The agent Cisapride significantly reduced the colonic transit time from 7.7 days to 5.1 days. It also improved the intraluminal tone in the rectum, resulting in a significant reduction in maximal rectal capacity from 305.8 ml to 224.3 ml. There was a reduction in residual urine volume from 51.5 ml to 27.7 ml. The increased number of stools containing transit markers showed that intraluminal mixing was increased by cisapride. Faecal water remained unchanged. A side effect was retention of urine in one subject after sudden withdrawal of the drug but this was avoided by its gradual reduction over 2 days.

Use of the pudendo-anal reflex in the treatment of neurogenic faecal incontinence.

An electrical stimulator has been devised to treat neurogenic faecal incontinence caused by pudendal nerve neuropathy and works on the basis of repeated stimulation of the pudendo-anal reflex arc. Although conduction in the pudendo-anal reflex arc may be prolonged, and is so in neurogenic faecal incontinence, it must be shown to be present before the method can be used. This stimulation results in an immediate rise in the pressure in the anal canal and a significant increase in the electromyographic activity of the external anal sphincter. Maintenance of the stimulus over a two month period raised the mean resting pressure significantly in the anal canal and increased the reflex and voluntary responses of the external anal sphincter to coughing and squeezing actions respectively. The length of the sphincter was not affected. There was widening of the mean motor unit potential duration, though this was not significant. The resting electromyogram was enhanced after the course of treatment, indicating greater spontaneous activity in the external sphincter. The changes led to seven of the eight patients studied becoming continent at the end of the treatment.

Intestinal streaming patterns in cholerrhoeic enteropathy and diverticular disease

Streaming of gastrointestinal contents depends on the demonstration of differential rates of recovery of equal doses of two synchronously fed markers. There was no significant difference in the rate of throughput of polyethylene glycol (a liquid phase marker) and chromium sesquioxide (a solid phase marker) in healthy volunteers (n = 7) and hospital inpatients (n = 5) with normal bowel habit, so that streaming does not usually occur. In cholerrhoeic enteropathy (n = 5), however, the rate of throughput of polyethylene glycol was increased. In colonic diverticular disease (n = 7) the rate of throughput of polyethylene glycol was significantly lower. In cholerrhoeic enteropathy the liquid phase marker was excreted 1·5 times faster than the solid phase, but in the diverticular disease group the liquid phase was excreted 0·75 times more slowly than the solid phase marker. This may reflect the effects of colonic hypersegmentation on the relative distribution of the liquid and solid phases.