85 axilla with thin polyethylene film held in place with cotton-wool balls and crepe bandage. After using this irksome regimen for six months one patient reported that control of sweating was achieved just as readily without occlusion. Accordingly we instructed our patients to apply the solution without an occlusive dressing, and subsequent experience showed that this element of Shelley and Hurley's method is unnecessary. The morning after application the axilla was washed thoroughly with soap and water. Nightly applications were continued for one week, after which the patient applied the solution only when necessary. ResultsAll the patients were followed up closely in the two departments, and after 12 months a questionnaire was sent to the Swindon group asking for their comments. Sixty-four patients were highly delighted with the treatment and had achieved complete control of axillary sweating by periodic use of the solution. We felt that the high rate of return of the questionnaire in Swindon (41 out of 42 returned in two weeks) also reflected their satisfaction. After the initial period of nightly treatment the interval between applications varied from two days to one year. Most patients, however, had to apply the solution once every seven to 21 days to maintain control. The only side effect mentioned was irritation of the axillary skin, which we presume is 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 by applying the solution more accurately to the area of excessive sweating. One patient, who had the least severe hyperhidrosis, had to stop treatment because of unbearable irritation. DiscussionThis trial was highly successful, and we think that 20", aluminium chloride hexahydrate in absolute alcohol should be considered to be the treatment of first choice in axillary hyperhidrosis. In particular, the troublesome occlusive dressing recommended by Shelley and Hurley7 was found to be unnecessary, which makes the treatment much more acceptable to the patient. Preparation of the solution has been described as laborious,1" but this has not been our experience. Our hospital pharmacists report that if the mixture of aluminium chloride hexahydrate crystals and absolute alcohol is left at room temperature and shaken occasionally a 20',( solution may be produced in three weeks. A local chemist has also made the solution without difficulty. Using absolute alcohol means paying excise duty, which increases the cost of the preparation. Thus we now use a lower-proof spirit (95-99-5%/,), and initial results indicate no diminution of effect.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 sweating that they would tolerate minor irritation for a few hours ever...

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Haemorrhoidal disease is the consequence of distal displacement of the anal cushions, which are normal structures with an important role in continence. The causes of haemorrhoidal disease are unknown; constipation and abnormal bowel habit are commonly blamed despite largely contrary evidence. The most consistently demonstrated physiological abnormality is an increased maximum resting anal pressure. Most evidence points to this being a secondary phenomenon rather than the cause of haemorrhoidal disease. Among the many unexplored areas are the function of the longitudinal muscle in relation to haemorrhoidal disease, the description and pharmacological responsiveness of the anal subepithelial muscle, and the clinical role of specific pharmacological agents that might reverse some of the observed physiological changes.

Background-Some patients with faecal incontinence are not amenable to simple surgical sphincter repair, due to sphincter weakness in the absence of a structural defect. Aims-To evaluate the eYcacy and possible mode of action of short term stimulation of sacral nerves in patients with faecal incontinence and a structurally intact external anal sphincter. Patients-Twelve patients with faecal incontinence for solid or liquid stool at least once per week. Methods-A stimulating electrode was placed (percutaneously in 10 patients, operatively in two) into the S3 or S4 foramen. The electrode was left in situ for a minimum of one week with chronic stimulation. Results-Evaluable results were obtained in nine patients, with early electrode displacement in the other three. Incontinence ceased in seven of nine patients and improved notably in one; one patient with previous imperforate anus and sacral agenesis had no symptomatic response. Stimulation seemed to enhance maximum squeeze pressure but did not alter resting pressure. The rectum became less sensitive to distension with no change in rectal compliance. Ambulatory studies showed a possible reduction in rectal contractile activity and diminished episodes of spontaneous anal relaxation. Conclusions-Short term sacral nerve stimulation notably decreases episodes of faecal incontinence. The eVect may be mediated via facilitation of striated sphincter muscle function, and via neuromodulation of sacral reflexes which regulate rectal sensitivity and contractility, and anal motility. (Gut 1999;44:407-412)

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