its severest form is an exposed nerve, and that the spasmodic
contraction of the sphincter, excited by reflex irritation,
occasions the peculiar character of the pain.
Dr. Dolbeau is strongly in favor of forced dilatation of the
sphincter, originated by Recamier, in the treatment of anal
fissure ; in fact, he scarcely admits of any other method. He
says : —
*' The cure is thus complete after the operation, but it is
not a lasting one, relapses often occurring ; this is another
argument in favor of the neuralgic nature of the complaint."
A post-mortem examination was made in Paris, on a girl
who died of cholera within a few hours of having forcible
dilatation made for the cure of fissure. The surgeon whose
name I have forgotten, states that none of the fibres of the
sphincter muscles were in the least degree torn, though the
mucous membrane was slightly lacerated.
Although I had in several cases employed Dr. Dolbeau's
method, I found, as he had done, relapses were not uncom-
mon, and I further looked upon " forcible " dilatation as a
cruel operation. My first experience of this treatment was
gained in Paris, and I will describe literally what I saw, and
it was so repugnant to my feelings that I was greatly disin-
clined to it. A male patient was brought into the theatre
suffering from fissure of the anus. The surgeon introduced
one finger into the anus, and then another, until he gradually
but with much pressure, got the whole hand into the rectum;
he then made a fist of his hand and forcibly drew it out. The
cries of the patient were really heart-rending, and six or seven
assistants were employed in holding him down.
158 FISSURE AND PAINFUL
Now, during the past four years I have repeatedly dilated
the sphincter for the cure of fissure, and as I do it, the opera-
tion is not violent, and the result is, on the whole, very satis-
factory. The patient being thoroughly placed under the
influence of an anaesthetic, I introduce my two thumbs, one
after the other, taking care to press the ball of one thumb
over the fissure, and the other directly opposite to it ; this
prevents the fissure from being torn through and the mucous
membrane stripped off. I now gradually separate my
thumbs ; then I repeat the stretching in the opposite direc-
tion, /. ^., at right angles to my first ; then in other direc-
tions, until I have gone round the anus. I then apply con-
siderable pressure to the sphincter muscles all round, pulling
apart the anus with four fingers, two on each side, and
kneading the muscles thoroughly ; by thus gently pressing
and pulling, the sphincters completely give way, and the
muscle, previously hard, feels. like a well-beaten beef-steak,
or even putty. This will occupy at least five or six minutes,
to do thoroughly ; there is scarcely more than a drop or two
of blood seen, but you can see that the anus is bruised, and
for a few days extravasation is noticed, the part gradually
undergoing the changes of color usually observed in any
bruise. This operation is perfectly safe and almost painless.
I place in the rectum a suppository of half a grain of mor-
phia and apply cold. I am bound to say that since I have
dilated as above described, I have never failed to cure a
patient.
I saw, with Dr. Robert Mitchell, of Lewisham, a gentle-
man of more than eighty, who suffered greatly from a fissure
of long standing, in conjunction with some haemorrhoids.
He was too old to allow me to press a cutting operation, but
dilatation perfectly cured him in eight days, and he has con-
tinued in comfort until now.
I could relate a number of cases in which dilatation has
cured fissure and painful ulcer, as well as obstinate constipa-
tion from contraction of the sphincter muscles, and in such
cases I often employ it. I can remember that the late Mr.
Salmon was in the habit of treating constipation by passing
bougies, gradually increasing the size, until a very large one
could be introduced ; I have reason to know he was success-
ful. He used the same treatment as a preliminary step to
the operation on piles, and there, again, I am sure he gained
much advantage in lessening the pain after the operation —
a result which, as noticed in a previous page, can be accom-
IRRITABLE ULCER OF THE RECTUM. I59
plished by dilatation. There are still cases of fissure and
ulcer in which I prefer the knife, and shall continue to use
it ; but I am bound fo say my confidence in proper dilatation
is greatly increased, and I am, sure, when properly done, it
is very successful, though occasional relapses may occur-
Som.e years ago I frequently divided the sphincter subcuta-
neously for the cure of fissure, but I have ceased to practice
this operation, as possessing no advantage and not being cer-
tain in its results.
CHAPTER XVI.
IMPACTION OF F^CES.
The result of prolonged constipation may be a collection
of clayey faeces formed in the caecum or in any part of the
colon, but the term " impaction " is generally used when the
accumulation takes in the pouch of the rectum immediately
above the internal sphincter muscle. This is its most fre-
quent situation, and here a very large deposit, more or less
globular in shape, is often found. It occurs in females more
commonly than in males ; old women, and women shortly
after their confinements, being especially liable to it. In
aged people very often one of the first indications of failing
nerve power is loss or diminution of the contractile force of
the colon and consequent inaction of the bowels, leading to
impaction.
I have seen some cases of impaction in hysterical young
girls and in middle-aged females, I have also met with it
in elderly men, but until recently I never had a well-marked
example of this disorder in a young man, but I have found it
occur more than once in children ; I saw a little boy, only
three years of age, who had a veritable impaction which
gave a dood deal of trouble, but when it was removed the
bowel soon regained it tone, and regular action was afterwards
easily kept up.
The cause of the accumulation I believe nearly always to
be, primarily, a loss of power of the muscular coat of the
rectum. This loss of power may have been produced by
the pressure of the child's head, during a long protracted
labor, or by over-distention of the bowel through habitual
l6o IMPACTION OF F7ECES.
neglect of the calls of nature, in which case the collection
may be the result of months' costiveness, and the condition
of the rectum much resembles that of a bladder paralyzed
from retention of urine.
Spasm of the sphincter has been said to be a cause of
impaction, but I have more often thought the reverse was
the case, and the impaction the cause of the spasm. I must,
however, acknowledge that spasm is often the cause of the
constipation which is the forerunner of impaction. In impac-
tion spasm of the sphincter always exists, in some instances
to such a degree that when the patient strained I have
observed the anus protrude like a nipple, and an injection
return in a fine stream, as if coming out of a squirt. I have
certainly met with cases of idiopathic spasm of the sphincter,
occurring for the most part in elderly, nervous, single women,
and though no impaction was present, there was always more
or less constipation.
The symptoms of impaction are not uncommonly very
obscure, and the malady may be mistaken for something
else. I was once call to see a lady laboring under impac-
tion, and found that an eminent physician had recently
declared her to be suffering from neuralgia of the bowel,
and had ordered her quinine and steel, and I have heard of
another case which was treated as gout in the rectum. I
have met with several patients who were supposed to be the
subjects of malignant disease of the caecum or sigmoid
flexure from the fact of there being a tumor present, and
from the patient's aspect, which is frequently very suggestive
of cancer. I had a very marked case of impaction in a girl,
thirteen years of age, which was supposed to be enlarged
mesenteric glands, and was being treated with steal and cod-
liver oil. I attended a gentleman who was believed by his
physician to have incipient disease of the brain, so much
nervousness and hypochondriasis resulted from a very loaded
colon and impacted rectum. I had a case in a young lady
which was said, by more than one medical man, to be phthisis,
constant cough being present, with hectic at night, and much
emaciation. And lastly, a very common but sad error is
often committed ; these patients are treated for diarrhoea,
with tenesmus, as a considerable fluid discharge from the
bowel is not at all incompatible with great retention of solid
faeces.
A very interesting case was sent me by Dr. Frodsham.
The patient was an elderlyperson from thc'country, who was
IMPACTION OF F^CES. l6l
placed under Dr. Frodsham's care. She had been for a long
time ill with severe pains in the bowels, of a colicky charac-
ter, not especially restricted to one part of the abdomen,
which was much swollen. No tumor could be detected.
She was subject to hiccough and flatulence. This was
attended with dyspnoea and palpitation of the heart. She
had on several occasions fainted away, and fears were enter-
tained that the heart was not sound. Always, or nearly so,
in conjunction with the abdominal pain she had diarrhoea,
copious colored watery stools ; for the correction of this she
had been prescribed opium with carminatives ; a few doses
generally gave her much relief. Her appetite was bad, and
she had frequent retching and sometimes vomiting. Dr.
Frodsham not being satisfied with the case sent her to me.
She was fifty years of age, not ill-nourished, her face wore
an anxious expression, and the complexion was muddy.
Her general symptoms had existed over two years. The
tongue was quite clean and too red. On examination, the
heart and lungs were found sound. The abdomen was
much distended and the diaphragm forced upward, causing
dyspnoea when she lay down. The abdomen was globular,
and there was no particular prominence in any one part.
The skin was not shiny; on manipulation the abdomen felt
doughy; it was also tender, so that she could not bear much
kneading, but after a little pressure the transverse colon
started into action, and it was felt to be very large. A flex-
ible tube was easily passed eighteen inches, and on with-
drawal it was, in parts, smeared with faeces; on introducing
the finger into the rectum the latter was found filled with
clayey faeces. The diagnosis was great fecal accumulation
and slight impaction. I ordered her a pill of podophyllin,
calomel, belladonna, and pil. colocynth co. three times in
the day, and every morning an injection of a pint and a half
of thin gruel, with two ounces of fresh ox gall in it. On the
third morning of this treatment she passed an enormous
motion, more than enough to fill an ordinary chamber uten-
sil. The same pills and enema were continued now every
day, and were followed by several enormous evacuations. I
really may say that the quantity of fecal matter she parted
with would, to most persons, appear incredible. After ten
days the medicine was changed to a combination of laxa-
tives and tonics, which she continued for some time, but at
the termination of three weeks all her discomforts were gone,
and she was quite slender, as regards the abdomen.
l62 IMPACTION OF F^CES.
In the history of these cases it is not rare to find that
severe pains have been experienced in the right lumbar and
left inguinal regions; this sympton points to the fact that the
caecum had been the seat of obstruction and distention, and
that when this was removed the faeces again lodged in the
rectal pouch. The symptoms of impaction might be expected
to be generally those of obstruction, and resemble in many
respects those of stricture of the rectum, and sometimes this
is so, but the absence of any jelly-like or coffee-ground dis-
charge is an important point to be noticed in the diagnosis.
The patient often really complains of a tendency to diar-
rhoea, liquid motions beingfrequently passed, especially after
an aperient, but without any sense of relief, and on assuming
the erect position, straining, severe, continuous and irresisti-
ble, takes place. On lying down this generally gradually
passes off.
Dyspepsia, irritability of temper, nervousness and dis-
pondency, the patient supposing herself to be suffering from
an incurable malady, a very muddy-yellow skin, suggestive
of malignant disease, morning vomiting, and a loathing of
all food as soon as a few mouthfuls have been taken, exces-
sive and very painful thirst, are among the common symp-
toms of this disorder. A peculiar ringing, barking cough,
particularly in women, and also night sweats, are not uncom-
mon. In both men and women I have seen very obstinate
retention of urine, caused by impaction. All these symptoms
may continue more or less urgent for months, and aperients
and injections may be given, without affording more than
temporary relief.
When examining a patient, if you make careful palpation
over the abdomen, tumors may be felt in the caecum, the
transverse colon, or the sigmoid flexure; under any circum-
stances, in the majority of cases, if you look at the anus,
youVill see that it is nipple-shaped, and if you feel around the
anus you will find the sphincter muscle tightly contracted
and almost as hard as a piece of wood. It is only with dif-
ficulty that you can introduce your finger into the bowel, and
having done so, you will find a ball of hardened, clayey
faeces filling up the rectal pouch. This ball I have seen
almost as large as a foetal head, and quite movable, so as to
admit of liquid or thin motion passing round by the sides of
it, thus giving rise to the impression that diarrhoea rather
than constipation existed. So deceptive is the feeling this
mass gives to the finger, that I have more than once thought
IMPACTIOiSr OF F^CES. 1 63
I must be touching a tumor; and I have been called in con-
sultation several times, by medical men, who had discovered
the impaction, but could not believe that what they felt was
only a collection of faeces.
In bad cases you must commence the treatment of this
malady by thoroughly breaking up the ball of faeces.
The best mode of accomplishing this is first to put the
patient under an anaesthethic, and then forcibly but slowly
dilate the sphincters by introducing both your forefingers,
well oiled, and separating them in the antero-posterior
direction, then again toward the tuberosities of the ischiia.
You need not tear the mucous membrane, but you so stretch
the muscles as to paralyze them for a time; this done, you
can get at the interior of the rectum without any difficulty, and
break up the mass with your finger or a lithotomy scoop, or
the handle of an old-fashioned silver spoon. The spasm of
the sphincters being thus overcome, you can do a great deal
at one sitting, in fact, quite empty the rectum.
After you have thoroughly broken up the impacted mass
you may administer injections of soap and water and oil,
and in this way you will often get rid of enormous quanti-
ties of faeces. When the ball occupying the rectal pouch
is cleared away, other masses generally come down, and I
have seen as much as would fill two or three chamber utensils
passed at one operation.
I have found, in several instances, the rectum so much
dilated that the upper part of the bowel opened into the
pouch like a pipe into a bladder.
It is often a considerable time before the rectum recovers
its power after its great distention, and, therefore, you must
take care that no reaccumulation takes place. Injections of
cold water, kneading the abdomen, and the exhibition of the
compound decoction of aloes with nux vomica, will be found
useful. As soon as the bowel is thoroughly cleared out I am
in the habit of prescribing the following pill, which is very
effective in restoring power to the colon and rectum, thus
inducing a regular action of the bowels :
]^ . Ferri Sulph. Exsice gr. J-
Quiniae Sulph gr. j
Extracti Nucis Vomicae gr. i
Ext. Aloes aq gr. j
Extr. Taraxaci q. s. ut fiat pil. M.
Take one three times in the day, after meals.
164 IMPACTION OF FiECES.
Faradization is most advantageous in these cases.
Persons of sedentary habits are especially liable to these
attacks, exercise in the open air must, therefore be taken
daily.
' The diet should not be too liberal. An elderly lady was
a patient of mine on three occasions, with impaction and
loaded caecum, and I am sure it was because she was a very
hearty eater and never took any exercise. I could neither
persuade her to walk more or to eat less.
Inpactions have, as I have mentioned, been often mistaken
for malignant abdominal tumors, but the diagnosis is usually
not difficult if observations be carefully made. There are two
points of distinction which may always be noticed: ist. An
examination from time to time will show that the tumor
differs in size and shape; this the patient will often be the
first to remark. 2d. A very careful manipulation will detect
that the tumor is irregularly soft and has a decidedly doughy
feeling. When the tumor is in the sigmoid flexure or rec-
tum the introduction of the finger will at once clear up the
doubt, if there be any.
Concretions in the bowels are rarer than impactions,
and they differ from these in that they are often formed
round some foreign body and are usually cylindrical in
shape. Concretions consist of animal and vegetable fibres
matted together round a nucleus, which may vary according
to circumstances. In one case a quantity of human hair
formed the core; the patient had been in a lunatic asylum,
and in a fit of mania had swallowed the hair. She had
suffered from attacks of intestinal obstruction for months,
and she always said there was something in the bowel which
would not pass through the anus. She was brought to me
at St. Mark's Hospital. I forcibly dilated her sphincter and
with a lithotomy scoop and my finger succeeded, after some
trouble, in removing a conical-shaped mass, more than six
inches in length by two and a quarter inches in diameter; it
was covered with pus and extremely fetid. On cutting
through it, as I have mentioned, the centre was found to
consist of human hair.
Another patient of mine, an elderly gentleman, had an
obstruction of the rectum which I thought was an ordinary
impaction, but it was not globular in form, and when I tried
to break it up I could not do so, as it slipped away and was
too tenacious. After dilating the sphincters I was able to
get hold of it with a pair of lithotomy forceps and gradually
IMPACTION OF F^CES. 165
draw it out. The nucleus was a large biliary calculus, and
aVound it were vegetable and animal fibres and dried faeces;
the whole was covered by a thick coating of mucus and
pus. Eighteen months before he had suffered from an
attack of gall stones, and no doubt this calculus had been
lodged in the bowel, probably in one of the sacculi of
the colon.
I have already related another case of this kind.
One more case I will record, as it is peculiar; here a sov-
ereign formed the nucleus. The patient, a woman, came to
St. Mark's Hospital suffering from stricture of the rectum;
when I dilated the stricture I found a large mass above it.
Purgatives and enemata not effecting its removal, I eventu-
ally brought it down with a scoop and my finger; it was
cylindrical in form. On tearing it up to examine its struc-
ture I found in its centre the coin I have mentioned. Quite
fifteen months before the woman had swallowed a sovereign,
and she had sought for it in her motions, but failed to find it;
she had not any idea that it had not passed. I think it very
likely that at that time she had incipient stricture of the rec-
tum, and consequently the piece of money did not escape
from the bowel.
I will not occupy more space on this subject; the cases
are somewhat rare and the treatment simple enough. When
the mass comes down near the anus it must be removed
bodily; you will find itso tenacious that you can not break it
pu like an ordinary impaction. Unless you dilate the sphincter
you will have very great difficulty in extracting these con-
cretions; in fact, it will be almost impossible to do so.
It is very curious how, sometimes, small substances fail
to traverse the alimentary canal safely, and how, at other
times, very large bodies pass without producing any severe
or dangerous symptoms. There are cases related by Sir
James Paget, Mr. Henry Smith, and others, where a con-
siderable portion of a set of false teeth, mounted in gold,
was swallowed and not arrested anywhere in the intestines.
There is one thing we should recollect when such a case
comes before us, that is, never give a purge. You may tell
your patient to eat very freely of solid material, such as suit-
pudding, bread, and the like, so as to form full-sized cohesive
motions.
These cases must not teach us to lightly estimate the
danger of swallowing foreign bodies ; many cases are on
record where such a simple matter as a cherry stone has
l66 ULCERATION AND STRICTURE OF THE RECTUM.
caused death, by setting up ulceration and perforation of the
bowel, usually the caecum or vermiform appendix.
I saw, some time back, a case, with Dr. Nash and Mr.
Clover, of a fine young lad who lost his life from peritonitis
caused by perforation of the appendix vermiformis. The
foreign body appeared to be a small portion of wood, around
which fecal matter had deposited, augmenting its size to
about that of a small date stone, but pointed at each end.
The symptoms were at first not very pronounced, but the
fever was soon great and accompanied by much delirium.
No operative interference was resorted to, the diagnosis
being that the obstruction to action of the bowels was caused
by peritonitis, the result of probable perforation of the caecum
or its appendix. The post mortem verified the diagnosis.
CHAPTER XVII
ULCERATION AND STRICTURE OF THE RECTUM.
Ulceration extending above the internal sphincter, and
frequently situated entirely above that muscle, is not a very
uncommon disease ; it inflicts great misery upon the patient,
and if neglected, leads to conditions quite incurable, and the
patient dies of exhaustion, unless extraordinary m*eans are
resorted to. In the earlier stages of the malady, careful,
rational, and prolonged treatment is often successful, and
the patient is restored to health ; I wish I could say the
same of the severe and long-standing cases. Ulceration of
the rectum can be mistaken only for maUgnant disease ; but
when the symptoms are carefully considered, and the finger
is well educated, there can but very occasionally be any error
in diagnosis committed. As the earlier manifestations are
fairly amenable to treatment, it is of the utmost importance
that the diaease should be recognized early. Unfortunately,
it rarely is so ; the symptoms are obscure and insidious, the
suffering at first but slight, and thus the patient deceives, not
only himself, but his medical attendants, by the little heed he
gives to the complaint.
In the majority of these cases the earliest symptom is
morning diarrhoea, and that of a peculiar character ; in my
ULCERATION AND STRICTURE OF THE RECTUM. 167
Opinion it is quite indicative of the disease, and can be con-
founded only with similar symptoms due to cancer. The
patient will tell you that the instant he gets out of bed he
feels a most urgent desire to go to stool ; he does so, but the
result is not satisfactory. What he passes is generally wind,
a little loose motion, and some discharge resembling " coffee
grounds " both in color and consistency ; occasionally the
discharge is like the " white of an unboiled egg ; " or " a
jelly-fish ; " more rarely there is matter. The patient in all
probability has tenesmus, and does not feel relieved ; there
is a somewhat burning and uncomfortable sensation, but not
actual pain ; before he is dressed, very likely, he has again
to seek the closet ; this time he passes more motion, often
lumpy, and occasionally smeared with blood. It may also
happen that after breakfast, hot tea or coffee having been
taken, the bowels will again act ; after this he feels all right,
and goes about his business for the rest of the day, only,
perhaps, being occasionally reminded, by a disagreeable sen-
sation, that he has something wrong with his bowel. Not
by any means always, but at times, the morning diarrhoea is
attended with griping pain across the lower part of the