'Why, why did you have me treated?': the psychotic experience in a literary narrative.

In this paper, the authors suggest an approach that may be helpful in teaching medical humanities to medical students. In the context of an honours class on medicine and literature, students (1) read a novel on an illness, (2) interviewed a patient with the medical condition described in the novel and (3) wrote an essay on the biomedical, narrative and literary aspects of these sources of information. The authors compared the story of Chekhov's literary protagonist Kovrin in The Black Monk with the personal story of patient H., who was diagnosed with schizophrenia. The narratives of the two patients were compared, based on Chekhov's literary narrative and the narrative of the patient. Both patients appeared to somehow regret losing their symptoms, following various psychiatric treatments. Both narratives show the ambivalence between the gain and loss that adequate psychiatric treatment may bring. Studying novels and other literary sources may help in understanding the story of the patient better, with associated improvements in various aspects of medical outcome. Reading literary fiction may help to increase an understanding of patients' emotions, experiences, cognitions and perspectives. It may also reduce the emotional distance between the self and the patient. The educational approach that was explored in the authors' honours class may be helpful to others when developing methods for teaching medical humanities to (medical) students.

The perineorectal reflex The perineorectal reflex in health and obstructed defecation.

PURPOSE: Many females with obstructed defecation apply digital pressure on their perineum to facilitate defecation. This study investigated the impact of this maneuver on rectal tone. METHODS: Forty-five female patients with obstructed defecation were studied. Thirty-four patients (76 percent) regularly applied digital pressure on their perineum to facilitate defecation. Total colonic transit time was normal in 32 patients and prolonged in 13 patients. For comparison, 17 female controls were studied. With the subject in the left lateral position, a thin, "infinitely" compliant polyethylene bag was inserted into the rectum at 10 cm from the anal canal. Rectal tone was assessed by measuring variations in bag volume with a computer-controlled electromechanical air injection system. After an adaptation period of 15 minutes, digital pressure was applied to the anterior perineum by one of the authors (WRS). In a second recording session, the tonic response of the rectum to an evoked urge to defecate was examined. RESULTS: During the application of perineal pressure, all controls showed an increase in rectal tone (mean value, 52.8+/-19 percent). In the whole patient group, this response was significantly lower (mean value, 24.2+/-19 percent; P < 0.001). Eight of these patients (18 percent) showed no response at all. None of them applied perineal pressure. In the remaining 37 patients (72 percent), the perineorectal reflex was present but was significantly lower (mean value, 29.8+/-17 percent; P < 0.001). Thirty-four of these females (92 percent) stated that they applied perineal pressure on a regular basis to facilitate their defecation. All controls showed an increase in rectal tone during an evoked urge to defecate (mean value, 37.8+/-8 percent). In the patients, this response was significantly lower (16.7+/-6 percent). Eight of these patients showed no increase in rectal tone at all. These patients were the same patients in whom the perineorectal reflex was absent. Regarding the tonic response of the rectum to perineal pressure, no difference was found between patients with a normal colonic transit time and those with a prolonged colonic transit time. CONCLUSION: Digital pressure applied on the perineum results in an increase in rectal tone. This perineorectal reflex is present, although significantly lower, in the majority of females with obstructed defecation. This observation might explain why females with obstructed defecation frequently apply perineal pressure to facilitate defecation.

Rectal sensory perception in females with obstructed defecation.

PURPOSE: Parasympathetic afferent nerves are thought to mediate rectal filling sensations. The role of sympathetic afferent nerves in the mediation of these sensations is unclear. Sympathetic nerves have been reported to mediate nonspecific sensations in the pelvis or lower abdomen in patients with blocked parasympathetic afferent supply. It has been reported that the parasympathetic afferent nerves are stimulated by both slow ramp (cumulative) and fast phasic (intermittent) distention of the rectum, whereas the sympathetic afferent nerves are only stimulated by fast phasic distention. Therefore, it might be useful to use the two distention protocols to differentiate between a parasympathetic and sympathetic afferent deficit. METHODS: Sixty control subjects (9 males; median age, 48 (range, 20-70) years) and 100 female patients (median age, 50 (range, 18-75) years) with obstructed defecation entered the study. Rectal sensory perception was assessed with an "infinitely" compliant polyethylene bag and a computer-controlled air-injection system. This bag was inserted into the rectum and inflated with air to selected pressure levels according to two different distention protocols (fast phasic and slow ramp). The distending pressures needed to evoke rectal filling sensations, first sensation of content in the rectum, and earliest urge to defecate were noted, as was the maximum tolerable volume. RESULTS: In all control subjects, rectal filling sensations could be evoked. Twenty-one patients (21 percent) experienced no sensation at all in the pressure range between 0 and 65 mmHg during either slow ramp or fast phasic distention. The pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients with obstructed defecation (P < 0.001). In each subject, the pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were always the same, regardless of the type of distention. CONCLUSION: Rectal sensory perception is blunted or absent in the majority of patients with obstructed defecation. The observation that this abnormality can be detected by both distention protocols suggests that the parasympathetic afferent nerves are deficient. Because none of the patients experienced a nonspecific sensation in the pelvis or lower abdomen during fast phasic distention, it might be suggested that the sympathetic afferents are also deficient. This finding implies that it is not worthwhile to use different distention protocols in patients with obstructed defecation.

Rectal compliance in females with obstructed defecation.

PURPOSE: This study was designed to investigate whether rectal compliance is altered in females with obstructed defecation. METHODS: Eighty female patients with obstructed defecation and 60 control subjects were studied. Rectal compliance was measured with an "infinitely compliant" polyethylene bag. This bag was inserted in the rectum and inflated with air to selected pressure plateaus (range, 0-60 mmHg; cumulative steps of 2 mmHg with a duration of ten seconds) using a computer-controlled electromechanical barostat system. Volume changes at the levels of distending pressures were recorded. The distending pressures, needed to evoke first sensation of content in the rectum, earliest urge to defecate, and the maximum tolerable volume were noted. RESULTS: In all cases, the compliance curve had a characteristic triphasic (S-shaped) form. The mean compliance curve obtained from the patients was identical to that of the controls. However, the course of the compliance curve fell above the normal range (mean + 2 SD) in 14 patients. In ten (71 percent) of these patients, a large rectocele was seen at evacuation proctography. Such a rectocele was observed in only five patients (7.6 percent) with a normal compliance curve (P < 0.001). Eighty percent of the controls experienced earliest urge to defecate during the second phase of the curve. In 75 percent of the patients, this occurred in the third phase. The mean pressure threshold for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients compared with control subjects. Ten of the patients experienced no sensation at all in the pressure range between 0 and 60 mmHg. CONCLUSION: In females with obstructed defecation, the compliance of the rectal wall is normal.

The gastrorectal reflex in women with obstructed defecation.

This study evaluated the tonic response of the rectum to a meal in women with obstructed defecation. Fifteen control subjects and 60 women with obstructed defecation were studied. Total colonic transit time was normal in 30 patients (group I) and prolonged in the other 30 (group II). After over-night fasting an "infinitely compliant" polyethylene bag was inserted into the rectum. Rectal tone was assessed by measuring variations in bag volume with a computerized electromechanical air injection system. After an adaptation period of 30 min all subjects consumed a 450-kcal liquid meal. Postprandial recordings were continued for 3 h. In a second recording session we investigated the tonic response of the rectum to an evoked urge to defecate. In a third session rectal sensory perception was assessed. Following the meal all controls showed an increase in rectal tone (mean 74.8 +/- 17%). Patients in whom colonic transit time was normal showed a similar tonic response. In group II the increase in rectal tone was significantly lower (mean 27.8 +/- 10%; P < 0.001). Three patients of this group showed no response to a meal at all. All controls showed an increase in rectal tone during an evoked urge to defecate (mean 39.2 +/- 9%). In both groups this tonic response was absent or significantly blunted (mean 15.3 +/- 6% and 16.4 +/- 5%, respectively; P < 0.001). In both groups rectal sensory perception was significantly impaired. In conclusion, patients with obstructed defecation in whom colonic transit time is normal have an intact gastrorectal reflex. The increase in rectal tone after a meal is absent or blunted in patients with obstructed defecation in whom transit time is prolonged. The tonic response of the rectum to an evoked urge to defecate as well as rectal sensory perception are significantly impaired both in patients with a normal and in those with a prolonged transit time.

Rectal tone in response to bisacodyl in women with obstructed defecation.

This study investigated the tonic response of the rectum to topical application of bisacodyl in women with obstructed defecation. Forty-five women with obstructed defecation, and 15 female controls were studied. Total colonic transit time was normal in 35 patients, and prolonged in 10. For the purpose of this study an "infinitely compliant" polyethylene bag was inserted into the rectum. Rectal tone was assessed by measuring variations in bag volume with a computerized electromechanical "barostat" system. After an adaptation period of 30 min, a suppository containing 10 mg bisacodyl was inserted into the rectum. Recording was continued for 90 min. In a second recording session rectal tone in response to an evoked urge to defecate was assessed. In a third session we investigated rectal sensory perception. After a mean time interval of 30 +/- 15 min following intrarectal application of bisacodyl, all controls showed a significant increase in rectal tone (mean value: 68.2 +/- 12%). In patients with a normal transit time, a similar increase was observed. In patients with prolonged transit time, the tonic response of the rectum to bisacodyl was significantly lower (mean 21.1 +/- 11%; P < 0.001). Five of these patients showed no response at all. In the second recording session, all controls showed an increase in rectal tone during an evoked urge to defecate (mean 36.3 +/- 7%). In both patient groups this tonic response was absent or significantly blunted (mean 19.2 +/- 6%) (P < 0.001). In both patient groups rectal sensory perception was impaired significantly. In conclusion, rectal tone increases significantly after topical application of bisacodyl in controls as well as in patients with obstructed defecation in whom transit time is normal. This tonic response is absent or significantly blunted in patients with a prolonged transit time. Both the tonic response of the rectum to an evoked urge to defecate and rectal sensory perception are significantly impaired in patients with a normal and those with a prolonged transit time.

Treatment of enterocele by obliteration of the pelvic inlet.

PURPOSE: Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This hernial sac contains either sigmoid colon or small bowel. It is well known that enteroceles are associated with symptoms of pelvic discomfort. It is unclear whether enteroceles contribute to evacuation difficulties. Controversies also exist regarding their treatment of choice. The aim of the present prospective study was to evaluate the impact of obliteration of the pelvic inlet on evacuation difficulties and on symptoms of pelvic discomfort. METHODS: From October 1994 to August 1996 20 females (median age, 53; range, 41-73 years) with symptomatic enterocele diagnosed on evacuation proctography underwent obliteration of the pelvic inlet with a nonabsorbable Mersilene mesh. All patients presented with pelvic discomfort, characterized by feelings of prolapse (n=20), pelvic pressure (n=16), lower abdominal pain (n=13), and false urge to defecate (n=15). Symptoms of obstructed defecation were noted in 15 patients. Six months after repair, evacuation proctography with opacification of the small bowel and the vagina was repeated. RESULTS: The median duration of follow-up was 25 (range, 10-34) months. A persistent or recurrent enterocele was observed in none of the patients. All symptoms of pelvic discomfort disappeared except feelings of a false urge to defecate, which persisted in 27 percent of cases. Symptoms of obstructed defecation persisted in all patients with evacuation difficulties. CONCLUSIONS: In patients with pelvic discomfort enterocele should be considered as a possible causative factor. It is unlikely that this abnormality contributes to the problem of obstructed defecation. In patients with a symptomatic enterocele, obliteration of the pelvic inlet with a Mersilene mesh is an adequate treatment.

Rectal wall contractility in response to an evoked urge to defecate in patients with obstructed defecation.

PURPOSE: The aim of this study was to examine rectal sensory perception and rectal wall contractility in response to an evoked urge to defecate and to identify differences between control subjects and patients with obstructed defecation. METHODS: Twenty control patients (10 men; median age, 47 (range, 17-78) years) and 29 female patients with disabling obstructed defecation (median age, 48 (range, 18-70) years) entered the study. Under radiologic control, an infinitely compliant barostat balloon was inserted over a guide wire into the proximal part of the rectum. Additionally, a latex balloon was introduced into the distal part of the rectum. This latex balloon was inflated until an urge to defecate was experienced. Simultaneously, rectal wall contractility was assessed by measuring the variations in barostat balloon volume. These variations were expressed as percentage changes from baseline volume. RESULTS: By comparing controls and patients with obstructed defecation, a significant difference was found regarding mean distending volume required to elicit an urge to defecate (135 +/- 38 vs. 214 +/- 87 ml of air; P < 0.001, Mann-Whitney U-test). In all controls, the evocation of an urge to defecate induced a pronounced increase in rectal tone, proximal to the distal stimulating balloon. By comparing controls and patients, the increase in rectal tone was found to be significantly higher in control subjects (35 +/- 10 vs. 9 +/- 10 percent; P < 0.001). Twenty-five patients (86 percent) showed no or only minimum (<20 percent) increase in rectal tone during the perception of an urge to defecate. In 14 of these patients, the threshold for this perception was increased. Only four patients (14 percent) showed a relatively normal increase (>20 percent) in rectal tone. However, their threshold for perception was greatly increased. CONCLUSION: The assembly used in this study provides a useful tool for investigation of rectal evacuation. In all of our patients, obstructed defecation was associated with abnormal rectal sensory perception and/or altered rectal wall contractility.

Changes in bowel function after hysterectomy.

PURPOSE: It has been suggested that hysterectomy has a disturbing influence on bowel function. To assess the incidence and nature of these changes, we performed a retrospective study. METHODS: A retrospective study was performed in all 593 women who had undergone hysterectomy between 1989 and 1993. A control group consisted of 100 women who had undergone laparoscopic cholecystectomy. RESULTS: The response rate was 90 percent (n = 531; median age, 45 (range, 18-84) years). Of the responding women, 315 patients (59 percent) indicated a normal defecation pattern before hysterectomy. Of these women, severe deterioration in bowel function was reported by 98 patients (31 percent), whereas 36 women (11 percent) mentioned a moderate change after hysterectomy. Most frequent symptoms were severe straining (90 patients), incomplete and/or digital evacuation (83 and 50 patients, respectively). According to most patients, the changes in bowel function were reported to have started within one month after hysterectomy. With advancing age, fewer complaints were recorded (P = 0.008). No significant difference was found in the incidence of disturbed bowel function between the different types of operation (abdominal, vaginal, supravaginal, or radical hysterectomy). In the control group, the response rate was 96 percent. Median age of these women was 46 (range, 25-78) years. Fifty-eight patients (60 percent) reported normal bowel function before laparoscopic cholecystectomy. In this group of patients, disturbed bowel function after surgery was reported by five women (9 percent), which figure is significantly (P < 0.001) lower compared with that in the corresponding hysterectomy group. CONCLUSION: Hysterectomy seems to play an important role in the pathogenesis of disturbed defecation.

Anismus: fact or fiction?

PURPOSE: Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question. METHODS: During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position. RESULTS: The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs. 32 percent; P < 0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement. CONCLUSION: Based on these findings, we doubt the clinical significance of anismus.

Role of defecography in predicting clinical outcome of rectocele repair.

PURPOSE: The aim of this study was to evaluate the role of defecography in predicting clinical outcome of rectocele repair. METHODS: Between January 1988 and July 1994, 74 consecutive patients (median age, 54 (range, 35-81) years) with a rectocele and symptoms of obstructed defecation were studied prospectively. After preoperative evaluation by a standardized questionnaire, physical examination, and defecography, a combined transvaginal/transanal rectocele repair was performed. At follow-up, all patients had defecography. Long-term results were qualified by an independent observer after a median follow-up of 58 (range, 14-89) months as "excellent," "good," or "poor." RESULTS: Rectocele repair was considered excellent in 37 patients and good in 13 patients. Defecography six months after surgery did not show persistent or recurrent rectocele in any of the patients. Size of the rectocele, barium-trapping in the rectocele, internal intussusception, rectal evacuation, and perineal descent did not appear to influence clinical outcome. Radiologic evidence of anismus did not correlate with long-term results of rectocele repair. CONCLUSIONS: Combined transanal/transvaginal repair of rectocele is an efficient therapy in patients with obstructed defecation. Various defecographic parameters (size of rectocele, internal intussusception, rectal evacuation, perineal descent, radiologic signs of anismus) do not appear to influence clinical outcome of surgery. The main value of defecography is the objective demonstration of rectocele and any associated abnormalities such as an enterocele preoperatively and again in objective assessment of the postoperative results.

Inability of Lactobacillus casei strain GG, L. acidophilus, and Bifidobacterium bifidum to degrade intestinal mucus glycoproteins.

BACKGROUND: Lactic acid bacteria have been suggested for use in the prevention of relapse of ulcerative colitis and of recurrent pouchitis. These strains may not damage the protective intestinal mucus glycoproteins. METHODS: Lactobacillus casei strain GG and strains isolated from a commercial fermented product (Lactobacillus acidophilus, Bifidobacterium bifidum, and a mesophylic lactic culture) were cultured in vitro on hog gastric mucin and human intestinal glycoproteins. Furthermore, germ-free rats were mono-associated with Lactobacillus GG and poly-associated with the other strains. Glycoproteins were isolated from rat distal ileum, cecum, and colon. Mucus degradation was established by assaying carbohydrates (hexosamines, hexoses, pentoses), proteins, and blood group antigenicity. RESULTS: All strains colonized the intestinal mucus but were not found in the deep crypts. Degradation of mucus glycoproteins was observed neither in vitro nor in vivo. CONCLUSION: The tested strains do not break down intestinal mucus glycoproteins and thus far are safe to use for therapy.