BRITISH MEDICAL JOURNAL 8 JULY 1978 85

axilla with thin polyethylene film held in place with cotton-wool balls pharmacists report that if the mixture of aluminium chloride
and crepe bandage. After using this irksome regimen for six months hexahydrate crystals and absolute alcohol is left at room tem-
one patient reported that control of sweating was achieved just as perature and shaken occasionally a 20',( solution may be pro-
readily without occlusion. Accordingly we instructed our patients to duced in three weeks. A local chemist has also made the solution
apply the solution without an occlusive dressing, and subsequent without difficulty. Using absolute alcohol means paying excise
experience showed that this element of Shelley and Hurley's method
is unnecessary. The morning after application the axilla was washed duty, which increases the cost of the preparation. Thus we now
thoroughly with soap and water. Nightly applications were continued use a lower-proof spirit (95-99-5%/,), and initial results indicate
for one week, after which the patient applied the solution only when no diminution of effect.
necessary. Irritation of the axilla was the only side effect reported and
was almost always readily relieved by 1(( hydrocortisone cream.
Most of the patients were so delighted with the control of their
Results sweating that they would tolerate minor irritation for a few
hours every fortnight. Although the solution was highly acidic,
All the patients were followed up closely in the two departments, we received no complaints of damage to clothing. Nevertheless,
and after 12 months a questionnaire was sent to the Swindon group one patient reported total destruction of his passport when the
asking for their comments. Sixty-four patients were highly delighted bottle broke in his suitcase.
with the treatment and had achieved complete control of axillary We are now extending our work to include excessive sweating
sweating by periodic use of the solution. We felt that the high rate of at other sites and have had similar encouraging results with
return of the questionnaire in Swindon (41 out of 42 returned in two sweat reduction on the palms and soles and, in one patient, the
weeks) also reflected their satisfaction. After the initial period of
nightly treatment the interval between applications varied from two forehead. We are reporting these results as early as possible
days to one year. Most patients, however, had to apply the solution because we think that there is no longer any indication for
once every seven to 21 days to maintain control. The only side effect surgical treatment of axillary hyperhidrosis and that such
mentioned was irritation of the axillary skin, which we presume is operative procedures should be avoided.
caused by the high acidity of the solution. Twenty-nine experienced
some irritation, but 28 of these said that it was readily relieved by
applying 1 hydrocortisone cream on the morning after treatment.
Some of these patients also found that they could reduce the irritation References
by applying the solution more accurately to the area of excessive I
Cunliffe, W J, and Tan, S G, Practitioner, 1976, 216, 419.
sweating. One patient, who had the least severe hyperhidrosis, had to 2 Greenhalgh, R M, Rosengarten, D S, and Martin, P, British Medical
stop treatment because of unbearable irritation. Journal, 1971, 1, 332.
Hurley, H J, and Shelley, W B, Journal of the American Medical Asso-
ciation, 1963, 196, 109.
4 Jemce, B, ScandinavianyJournal of Plastic and Reconstructive Surgery, 1975,
Discussion 9, 44.
5 Ashby, E C, and Williams, J LI, British MedicalyJournal, 1976, 2, 1173.
This trial was highly successful, and we think that 20", 6 Ellis, H, British Medical3Journal, 1977, 2, 301.
aluminium chloride hexahydrate in absolute alcohol should be Shelley, W B, and Hurley, H J, Acta Dermato-venereologica, 1975, 55, 241.
Papa, C M, and Kligman, A M,Journal of Investigative Dermatology, 1967,
considered to be the treatment of first choice in axillary hyper- 49, 139.
hidrosis. In particular, the troublesome occlusive dressing 9 Gordon, B I, and Maiback, H I,Journal of Investigative Dermatology, 1968,
recommended by Shelley and Hurley7 was found to be unneces- 50, 411.
sary, which makes the treatment much more acceptable to the Sneddon, I B, British MedicalYJournal, 1976, 2, 1447.
Ryan, T J, Medicine, 1977, 32, 1871.
patient. Preparation of the solution has been described as
laborious,1" but this has not been our experience. Our hospital (Accepted 28 April 1978)

Proctocolectomy without ileostomy for ulcerative colitis

A G PARKS, R J NICHOLLS

British AMedical Journzal, 1978, 2, 85-88 This is drawn down through the denuded rectum and an
anastomosis created, via the per-anal approach, between
the ileum just distal to the pouch and the mid-anal canal.
Summary and conclusions A temporary ileostomy is made.
Out of eight patients so treated, five were available for
An operation has been developed that permits total assessment, and four of them were highly satisfied with
removal of all disease-prone mucosa in ulcerative colitis the result in improved health and function. The remain-
but avoids the need for a permanent ileostomy. The colon ing three were awaiting closure of their ileostomies.
and upper half of the rectum are excised and the remain-
ing inflamed mucosa is stripped from the rectal stump
down to the dentate line of the anal canal. A pouch is
fashioned from a triplicated loop of terminal ileum. Introduction
Ulcerative colitis is of unknown aetiology, and its treatment,
both medical and surgical, is empirical. Operative treatment will
remain an essential part of management until the cause of the
St Mark's Hospital, London EC1V 2PS and London Hospital, London disease is found and a specific cure discovered. Proctocolectomy
El 2AD is the commonest procedure used and eliminates colonic mucosa
Sir ALAN G PARKS, FRCS, FRCP, consultant surgeon in its entirety and thus the source of inflammation and potential
R J NICHOLLS, MCHIR, FRCS, senior surgical registrar
malignancy. The price paid, however, is a permanent ileostomy.
86 BRITISH MEDICAL JOURNAL 8 JULY 1978
Various alternative procedures have been tried, either to
improve the quality of life for a patient with an ileostomy or
remove the need for a stoma altogether. Of these, both colectomy
with ileorectal anastomosis and the Kock continent ileostomy
reservoir have won places in clinical practice. Each, however,
has disadvantages.'-5 For ileorectal anastomosis most surgeons
select patients according to strict criteria,4 thus limiting its
application. Furthermore, leaving part of the inflamed mucosa
may result in persistent disease, sometimes with severe exacer-
bations, and the risk of malignant change.4-7 The Kock pro-
cedure carries a morbidity and mortality and still includes an
abdominal stoma. The technical problems of making an inverted
nipple valve have been largely responsible for complications
requiring reoperation in nearly a third of the cases.' 2
Several attempts have been made to combine colectomy with FIG 1-Construction of ileal pouch from terminal 30 cm of small intestine.
removal of the inflamed mucosa from the rectum and preserve B, C, E, and the mid-point between D and E are points of folding. ABC is
intestinal continuity."8-0 These methods have not been generally the first fold. The final two folds will be complete when D and E are
accepted, however, because of unpredictable or unacceptable approximated.
functional results. After an ileoanal anastomosis, for example,
fewer than half the patients obtained satisfactory function.8
Two avenues of advance have now converged to allow a fresh
approach to be made to this problem. The first is the work of
Kock," who has shown that an ileal pouch is consistent with
normal intestinal function. The second is a resurgence of
interest in anorectal physiology, which has already enabled
advances in surgical technique to take place. In particular, it
has been shown that in such conditions as haemangioma of the
rectum'2 and extensive villous tumours of the rectum'3 the
colon may be introduced through the rectum denuded of its
mucosa and anastomosed to the anal canal with satisfactory
functional results. Rectal sensation is normal after these pro-
cedures and the anorectal reflex mechanisms remain intact. It was
therefore a reasonable assumption that if an ileal pouch was used
instead of the colon, normal sensation would be experienced as
it filled and the anorectal sphincter mechanism would maintain
continence.
FIG 2-Appearances of completed operation.

Operative technique
The operation may be considered in two parts. The first consists in dentate line using the per-anal route. Interrupted sutures of 3/0
total resection of the colon and upper rectum with the removal of all Dexon are used, each incorporating not only mucosa of the dentate
remaining rectal mucosa. In the second, an ileal pouch is fashioned and line but a deep bite of the internal sphincter and full thickness of the
anastomosed to the anal canal per-anally.14 A loop-defunctioning wall of the terminal ileum. A defunctioning loop ileostomy is fashioned.
ileostomy is made to protect this anastomosis. Two pelvic drains are inserted, one from above and the other through
The patient is placed in the position used for synchronous combined the perineum. A large-gauge catheter is passed through the anus into
excision of the rectum, with the legs raised. Through a long left the pouch and fixed by a suture to the perianal skin. The abdomen is
paramedian incision the entire colon is mobilised as for a total colec- closed. The completed operation is shown in fig 2.
tomy to include the rectum to a point in its middle third, just below Postoperatively the catheter is left on continuous drainage. This and
the peritoneal reflection. The dissection is kept close to the viscus to the urinary catheter are removed during the fifth to seventh post-
avoid damaging the pelvic autonomic nerves. The ileum is divided operative days. The patient is then instructed to pass a Kock catheter
just proximal to the ileocaecal valve; the rectum is transected, leaving per anum into the pouch at three-hour intervals during the day, the
a distal segment about 8 cm long, and the colon and upper rectum are pouch being left on free drainage at night. The intervals between
rehnoved routinely. catheterisation may be extended according to the patient's tolerance.
The ileal pouch is then constructed from the terminal 30 cm of the
small intestine; the terminal 5 cm is left untouched to act as a conduit.
The 25 cm segment is opened on its antimesenteric border and folded Patients
three times (fig 1). A continuous stitch of 2/0 Dexon is used to
approximate the full thickness of the adjacent edges followed by an The table gives brief details of the five patients available for study.
outer seromuscular layer of interrupted Dexon sutures. In this way a A further three patients underwent the operation but were awaiting
pouch consisting of three segments of ileum each about 8 cm long is closure of their ileostomies. All were unsuitable for colectomy with
created; 5 cm of ileum projects distal to the pouch. The procedure ileorectal anastomosis for technical reasons. In cases 1, 2, and 4 a strong
is not difficult as no attempt is made to create a valve. antipathy to a permanent abdominal ileostomy was the reason for
An assistant remains by the abdominal incision and the surgeon then performing the operation. In case 3 it was carried out for social
takes up a position seated facing the perineum. An anal retractor is reasons, and in case 5 because it was considered that the patient, who
passed and the entire rectal mucosa removed in strips from the dentate had Charcot-Marie-Tooth disease, would be unable to manage an
line up to the top of the divided rectum. This dissection is made ileostomy.
possible by injecting the submucosa with a solution of adrenaline in
physiological saline (1 in 200 000) to raise the mucosa off the under-
lying muscle. It is then relatively easy, using sharp scissor dissection,
to remove it. The abdominal operator then passes the terminal ileum Results
and distal half of the pouch down through the rectal stump; if the COMPLICATIONS
rectum is narrow or stenosed the muscle wall may be divided
anteriorly as far downwards as is necessary. The free edges of the There were no deaths.- The postoperative course of the pouch
ileum are grasped by the perineal operator and drawn through the procedure in cases 4 and 5 was uneventful. Two patients (cases 1 and
anus. An ileoanal anastomosis is then created at the level of the (3 developed a pelvic abscess, which was drained through the anastomo-
BRITISH MEDICAL JOURNAL 8 JULY 1978 87
Details of five patients available for assessment after closure of temporary ileostomy

Year of Months of Function

Case Sex and onset of Date of Complications follow-up after
No age disease operation closure of
ileostomy Evacuation Incontinence
1 M 39 1973 9 July 1976 Pelvic abscess; partial anastomotic dehiscence; 9 Catheter, 4 times No
anastomotic stenosis responding to dilatation daily
2 M 24 1972 21 Feb 1977 Chest infection; small-bowel obstruction 3 Catheter, 5-7 times No
(laparotomy, division of adhesions) daily
3 F 19 1969 4 April 1977 Pelvic abscess 3 Spontaneous, 2-3 No
times daily
4 M 33 1967 15 April 1977 None 2* Catheter, 5-6 times Slight
daily
5 F 38 1972 16 Nov 1977 None 1 Catheter, 6-8 times Slight at night
daily

*Pouch removed two months after closure of ileostomy.

sis and perineal drain site respectively. A clinically detectable defect difficulty in passing the catheter and suffered from tenesmus, faecal
in the anastomosis was observed only in case 1. The subsequent soiling, and a frequent desire to evacuate the pouch. These problems
stricture responded to dilatation. In case 2 the patient developed a were overcome by a postanal repair of the pelvic floor to restore the
chest infection immediately after the operation and small-bowel angle between pouch and anal canal. Three weeks later he could
obstruction due to adhesions two months later. After laparotomy he tolerate intervals of four to five hours between catheterisations. He
made an uneventful recovery. was not prepared to continue self-catheterisation, however, having
developed an aversion to the procedure. On his insistence the pouch
was removed and a terminal ileostomy fashioned on 20 August 1977.
He recovered well and when seen one month later was in good health.
FUNCTION There was no obvious metabolic derangement in these patients after
The duration of follow-up after closure of the ileostomy ranged from closure of the ileostomy. Details of the biochemical values will be
one to nine months. When last seen, four of the patients had obtained given later.
a good result. They were well satisfied with the operation, not only
because of their improved health, increased weight, and general
well-being but also with respect to the functional outcome. Pressure in Discussion
the perineum, apparently similar to the normal feeling, is the signal to
empty the pouch. Estimations of pouch volume made from contrast Total excision of the colon and rectal mucosa with conserva-
enema examinations in cases 1, 2, and 3 ranged from 300 to 600 ml tion of the anal sphincter is not a new procedure. Nissen (1933)
(fig 3). is reputed to have been the first to describe a proctocolectomy
In case 3 spontaneous evacuation was occurring four or five times a with ileoanal anastomosis,8 and there have been several reports
day, the patient not needing to pass a catheter at all. In case 1 the
patient catheterised the pouch two to four times during the day. The of its use in ulcerative colitis.15-18 A successful functional result
stool was semi-formed and he suffered no urgency. In case 2 the occurred in only 40%0 of these cases.8 More recently a technique
patient passed the catheter four to seven times a day. He experienced was described in which ileorectal continuity was restored after
some urgency on occasions, especially when the stool was liquid. These removal of the rectal mucosa by curettage.9 10 Out of 12 patients
patients could last throughout the night without needing to void. In so treated, seven were said to be leading normal lives,10 although
case 5, one month after closure of the ileostomy the patient was no detailed information on function was given. The rectal
passing the catheter six to eight times a day. Minor faecal incontinence mucosa appeared to regenerate after this procedure and it
at night and urgency, which troubled her for the first two weeks, later
improved.
therefore seems likely to be subject to the same risks as occur
The outcome in case 4 was unsuccessful. Technically both the after ileorectal anastomosis.
construction of the pouch and closure of the ileostomy were satis- Valiente and Bacon8 constructed a double-loop pouch in dogs
factory. After the ileostomy was closed, however, the patient had that was anastomosed end to end to the anal canal. Two animals
survived with satisfactory bowel function. Kock later showed
that an ileal reservoir is feasible in man.1' Continence is main-
tained by means of an inverted nipple valve of ileum distal to the
pouch. There is now considerable experience of this operation,
and out of 138 patients followed up by Kock,3 90 did not need
to wear an ileostomy appliance. These results, however, were not
matched by others, 1 2and the technical problems arising from
this approach to reconstructive surgery are in large part due to
the valve.1-' Hence we decided to create a pouch without a valve
and to rely on the sphincter mechanism to maintain continence.
The results were possibly better than expected, with four out
of five patients well satisfied with the outcome. It would
naturally be desirable for the patient to be able to defecate
spontaneously and the reason why catheterisation is necessary
is not clear. The length of the ileum between the pouch and
anastomosis may be important. With further experience,
however, we hope that the factors enabling spontaneous evacua-
tion to occur will become clear. The detailed results of physio-
logical studies on these patients will be reported separately.
The lower rectum is not mobilised in this operation for three
reasons. Firstly, damage to the nerves supplying the pelvic
floor, bladder, and generative organs is avoided. Secondly, the
muscles of the pelvic floor are left undisturbed. Thirdly, the risk
of a pelvic haematoma and therefore pelvic sepsis is reduced.
FIG 3-Contrast-enema radiograph of pouch. Great importance is attached to the last factor because an
88 BRITISH MEDICAL JOURNAL 8 JULY 1978

abscess, besides causing morbidity, may impair the functioning Addendum

of the pelvic floor. Two of the patients awaiting closure of the ileostomy have
The importance of temperament when selecting patients is now had the operation. The early results are good. A patient
well shown by case 4. Although the operation was technically
uncomplicated and the patient obtained satisfactory function with familial polyposis and carcinoma of the upper rectum has
(after initial difficulties), he was unable to cannulate the pouch also been treated with an excellent functional result. In this case
for psychological reasons. In retrospect probably he was unsuited the indication was again total refusal to accept a permanent
to the procedure from the start; however, such an assessment is ileostomy.
difficult to make preoperatively.
It must be emphasised that the colonic and rectal mucosa,
which in ulcerative colitis is alone the site of the disease, is totally References
eliminated by this operation, the risk of further inflammation Goligher, J C, and Lintott, D, British Journal of Surgery, 1975, 62, 893.
and of malignant change thus being removed. Therapeutically, 2 Beahrs, 0 H, Diseases of the Colon and Rectum, 1976, 19, 192.
therefore, it is as effective as proctocolectomy. Moreover, there 3Kock, N G, Diseases of the Colon and Rectum, 1976, 19, 200.
has been no indication that operative risk and complications 4Jones, P F, Munro, A, and Ewen, S W B, British Journal of Surgery, 1977
will be greater than in any other major pelvic operation. The 64, 615.
5 Aylett, S, Archives Francaises des Maladies de l'Appareil Digestif, 1974, 63,
severity of the disease in the rectum is of no great importance; 585.
the procedure may be carried out in the presence of ulceration, 6 Adson, M D, Cooperman, A M, and Farrow, G M, Archives of Surgery,
stenosis, or even a rectovaginal fistula. An adequate anal 1972, 104, 424.
sphincter mechanism is, however, necessary. Gruner, 0 P N, et al, Scandinavian Journal of Gastroenterology, 1975, 10,
641.
Provided these initial results are maintained and reproducible 8 Valiente, M A, and Bacon, H E, American Journal of Surgery, 1955, 90,
this operation may offer a satisfactory alternative to procto- 742.
colectomy with a permanent ileostomy. Even at this early stage it 9 Oppolzer, R, Diseases of the Colon and Rectum, 1964, 7, 537.
seems desirable for it to be known that preservation of anal Hampton, J M, Diseases of the Colon and Rectum, 1976, 19, 133.
Kock, N G, Archives of Surgery, 1969, 99, 223.
function is feasible. The plea is therefore made that the rectum 12 Parks, A G, in Clinical Surgery-Abdomen, Rectum and Anus, ed C Rob,
be retained when operating for colitis so that the patient may be R Smith, and C N Morgan, p 545. London, Butterworths, 1966.
given a chance, should he wish it, to lose his ileostomy. It 13 Jeffery, P J, Hawley, P R, and Parks, A G, British_Journal of Surgery, 1976,
would, however, be wise in the first instance to confine this 63, 678.
14 Parks, A G, Proceedings of the Royal Society of Medicine, 1972, 65, 47.
procedure to those who have an active antipathy to an ileostomy. 15 Ravitch, M M, Surgery, 1948, 24, 170.
They will be prepared to pay the price of any initial difficulties 16 Devine, A, Surgery, Gynecology and Obstetrics, 1951, 92, 437.
that may occur in order to avoid a stoma. 17 Best, R R, Journal of the American Medical Association, 1952, 150, 637.
18 Drobni, A, Diseases of the Colon and Rectum, 1964, 7, 416.
Requests for reprints should be addressed to: Sir Alan Parks, St
Mark's Hospital, City Road, London EC1V 2PS. (Accepted 28 April 1978)

Comparison between subjective and ultrasound assessments

of fetal movement
A GETTINGER, A B ROBERTS, S CAMPBELL

British Medical Journal, 1978, 2, 88-90 Introduction

The mother's assessment of fetal movement is used to indicate
fetal wellbeing.'-5 Pearson and Weaver2 and Sadovsky et all 6
Summary and conclusions equated low counts of fetal movement with poor fetal outcome,
Forty pregnant women participated in a study to and most workers now accept that there is a good correlation
compare subjective with ultrasound assessments of between the true amount of fetal movement and the "kick
fetal movements. A real-time ultrasound scanner was counts" noted by the mother.6 Sadovsky et al used an electro-
used. Movements were recorded for 45 minutes in all magnetic measuring device and reported that on average
cases. There was a significant positive correlation patients felt 870o of the observed movements. We have carried
between the number of movements recorded by the out a study of subjective and objective assessments of fetal
two methods, but the 95% confidence limits were wide movement using a good-resolution real-time ultrasound scanner.
and no correlation was found in those patients who We report here the results.
recorded fewer than 20 movements in the study period.
Thus "false-positive" information may be obtained
from purely subjective data, and in patients reporting Patients and methods
low "kick counts" fetal activity should be assessed from
real-time ultrasound recordings. Forty pregnant women between 25 and 40 weeks' gestation agreed
to participate in the study. Thirty were clinically normal, five had
raised blood pressure, three had growth-retarded fetuses as determined
by serial ultrasound measurement of the circumferences of the head
Department of Obstetrics and Gynaecology, King's College Hospital and abdomen,7 and two complained of diminished fetal movement.
Medical School, London SE5 8RX Ultrasound examination using an ADR real-time scanner (Tempe,
A GETTINGER, BSC, research assistant (now medical student, Dartmouth Arizona) was performed with the patient semi-recumbent. The
Medical School, Hanover, New Hampshire, USA) transducer was positioned to include a transverse section of the
A B ROBERTS, MB, MRCOG, Rank research fellow
S CAMPBELL, MB, FRCOG, professor fetal trunk and both legs and held in place with a Kretz Technic
clamp. In this way we observed most of the fetal movements, though