CHAPTER XII. IMPACTED F^CES AND FOREIGN BODIES. (Part 1)

CHAPTER XII. IMPACTED F^CES AND FOREIGN BODIES. Impacted Faeces. — Intestinal Concretions. — Diagnosis and Treatment of Impaction. — Foreign Bodies Swallowed. — Results which may Follow the Swjdlowing of a Foreign Body. -^Ulceration and Abscess.— Foreign Bodies Introduced per Anum, — Cases. — Prognosis. — ^Treatment. — Dangers of Attempts at Re- moval. — Laparotomy for Removal. — Cases Successful. Impaction of Fceces. — The impaction of fsBces may be due to several causes, but is most generally a symptom either of intestinal atony in old people or of some paralytic affection such as locomotor ataxia. It not infrequently occurs in women as a result of the entire neglect of the function of defecation for which they are perhaps unjustly celebrated; ^nd they may follow a partial paralysis of the rectum from the long-con- tinued use of large enjgmata, or the pressure of the foetal head in child- birth. They may also be formed as a consequence of a painful affection such as a fissure which renders each act of defecation an ^gony to be avoided by every possible means. The disease is generally one of old people, of hysterical girls, and of careless women; but it has been seen in children, and as a result of improper diet may occasionally be encoun- tered in young and healthy men. Intestinal concretions may be composed entirely of hardened and ■stratified or clayey masses of faeces, or they may contain within them as a nucleus a biliary calculus, or indigestible substances which have been hastily swallowed, such as peach-pits, cherry stones, etc. Molliere calls attention to the presence of magnesia which favors the aggregation of faecal matters, and which also may act as the nucleus of a scybalus; and the frequency of impaction during the famine in Ireland in 1846, when potatoes, and those of a very poor quality, were the only article of diet, is a well known historical fact.* In Scotland, where oat-meal is a favorite article of diet, faecal accumulations are said to be of frequent occurrence. Certain other drugs besides magnesia, such as chalk, sulphur, and powdered cubebs have been blamed as the cause of intestinal concretions. Intestinal calculi have been seen which were composed of pure cholesterin or of a biliary calculus coated with cholesterin. ' For description of these cases see article by Dr. Papham in the Lancet, 1850. IMPACTED FjfiK)£8 AND FOKBIGN BODIES. 253 The usual location of a mass of impacted faeces is the rectal pouchy but it may be situated anywhere between the caecum and this point. Tho symptoms to which it gives rise are generally suflSciently well marked to enable the practitioner to reach a correct diagnosis if he be on his guard. The pains which it causes will generally be obscure and may be located anywhere in the abdomen or in the lower extremities; and the signs of disturbance in digestion are not in themselves suflSciently marked for diagnosis, but the one symptom which is characteristio is diarrhoea. Just as the practitioner has to learn that incontinence of urine may be a sign of a distended and not an empty bladder, so he may have to learn by a disagreeable error in diagnosis that a diarrhoea is sometimes a result of an overfilled and obstructed rectum. This diarrhoea is peculi- arly foetid in character, and the matters discharged may be entirely free from faeces and consist entirely of mucus. In some cases there may be an approach to a daily natural evacuation. The act of defecation is always attended by straining and pain as the faecal ball is pressed down against the perineum and rises again when the muscular effort ceases. To these symptoms AUingham adds a peculiar ringing, barking cough, morning vomiting (particularly in women), and night-sweats. Of course errors in diagnosis are easy in such a condition as this, and a mass of faeces in the colon may be mistaken for any and every sort of tumor in the pelvis or abdomen. Liver, spleen, stomach, uterus, and ovaries have again and again been supposed diseased in these cases when a simple digital examination of the rectum, or in women even of the vagina, could not fail to make the diagnosis clear. Unfortunately for diag- nosis, the general practitioner is not fond of making rectal examinations, and these cases are not infrequently treated with bismuth and opium as a consequence. The following instructive case was reported by Dr. Griffith.' In the autumn of 1876, I was hurriedly summoned to an old lady, who had within a few days of my seeing her met with a severe accident in the city, having been knocked down by a hansom as she was crossing the street. All her friends had given her up to die. She was so power- less to move, so prostrated, and so large a tumor, they stated to me, had made its appearance since her injuries. Her age (80) seemed to exclude all hope of recovery; and I was asked to see her — more that it should not be said she had died incapable of making her will and to witness her signature to it, than with any idea that I could benefit her. I examined the abdomen, and while doing so learned from her that she thought she had been larger on the left side for some time before the accident. I found considerable enlargement of the entire abdomen from flatulent distention, and oh the right side a tumor, hard and apparently * Faecal Accumulations Stimulating Utero-Ovarian Tumors, Edinburgh Med- icalJoumal, May, 1877. 254 DI8EA8ES OF THE RECTUSC AND ANUS. irregular, extending from the left hypochondriac into the left iliac fossa and passing a little way to the right of the median line. At first, I thought it might be enlarged spleen, or a left ovarian dropsy, or an extrauterine fibroid, which had been unnoticed, and was now observed, solely because attention was directed to the left side, where the patient had been struck by the yehicle. I could not at this, my first visit, make a very minute examination, owing to the extreme prostration and de- pression; but at my second visit, having in the interval built her up and cheered her all I could, I examined very carefully per vaginam, and with equal care explored by the rectum. I then came to the conclusion that there was neither ovarian nor uterine tumors, and that I had to deal with an accumulation of f sBceS^-even though the bowels were moved every day, as the attendant informed me, and that the accumulation had com- menced previous to her accident; forming, no doubt, the enlargement which she told me she had noticed before her injury, and which, as the accumulation increased, culminated in the enlargement I found. I swept out the bowels by free purgation, kept up for some days, while I sustained her with light and easily digested nutrients, allowing as stimu- lant only good tea and coffee. The next case is also from the same author: Mrs. G., aged twenty-five, mother of three children; the last being about four months old when I was first in attendance. I was called up to her on the night of 18 th June, 1876, "as she was suffering acute pain in the left side, which she could endr.e no longer." On examining the abdomen, I found a hard, irregular, exceedingly tender tumor, from which she was enduring great agony, and which was almost as large as an infant's head. I made no further examination that night, contenting myself with ordering her one-half grain morphia suppositories, to relieve not only the pain, but likewise the tenesmus and the passing of mucus. The discharge from the bowels was quite fluid, but distinctly fascal, occasionally a scybalous mass making its appearance. Next day, the morphia having taken good effect, I examined with the finger by the vagina, but could make out neither ovarian nor uterine tumor; the sound in utero enabled me to make certain that there was no intrauterine growth; but movement of the uterus with the sound in the interior of it was attended with the movement of the mass, which I found lay outside the womb, yet connected to the left and upper portion of it — in fact, attached to it. I gave it as my opinion that, whatever the mass was, it was outside the uterus, and was adherent to it, and that it was not ovarian. I did not, however, express the opinion at which I arrived after the above examinations and after thoroughly exploring by the rectum, viz., that it was a case of impacted and accumulated faeces, which, having set up great irritation, had occasioned inflammation, effu- sion of lymph, and matting or gluing of the bowel to the left and upper portion or cornu of the uterus, that organ being still enlarged, its invo- IMPACTED FAECES AND FOSEIOK BODIES. 255 lution after delivery being not yet completed, probably owing to the irritation, inflammation, and subsequent adhesion to which I have referred. Taking this view of the case, I purged freely and continu- ously for some days, till at length, after the lapse of six weeks, I had the satisfaction of hearing from my patient — for I did not attend her contin- uously during this period — that the tumor was all gone, and she was quite well; facts I verified by careful manipulation when she last visited me. The iodide of potassium had been combined with the aperients, as had also anodynes — the former in hope of dissolving adhesions, the latter with a view to ease pain. I would add, to show the diflSculties which sometimes behedge the diagnosis in these cases, that this patient had previously had pronounced to her by three medical men that operation alone (gastrotomy) could do her any good; and of this she had a mortal dread, so that all through I buoyed her up with the hope that the knife might never be required. The swelling had commenced to be noticed about twelve or fourteen days after the birth of her child, was chiefly confined to the left side, though sometimes it seemed to enlarge, and to extend higher up and across the middle line towards the right, and was so large that it was as though she was at her full time, and when walking, even across her room, she required a towel to support the abdomen; at other times it would subside, preserving, however, the same shape; these alterations in size were synchronous with the action of the bowels, and gave me a valuable clue. The agony had been very great, and she told me nothing had relieved her for any length of time till she had used the morphia suppositories. At no period was there a discharge of matter indicative of any internal abscess; nor any flux of water either into the abdominal cavity or into the bladder, or any way externally, which would demon- strate the existence. and rupture of an ovarian or other cystic growth; therefore, the only diagnosis at which I could arrive was that the bowels had become blocked during the confinement period, had not emptied themselves fully, that an accumulation occurred and became greater and greater, being, however, occasionally partially lessened by the aperient action of the bowels themselves, which accounted for the diminution of and subsidence that had been noticed in the swelling. The treatment of impaction is simple, and consists first of all in the entire removal of the mass. In cases of paralysis, where the accumulation has not been allowed to reach any very great amount, and the scybala are small and not very hard, this may sometimes be accomplished by the use of injections with a long tube and the assistance of the finger of the operator. In women very effectual aid may be rendered under similar conditions by pressure from the vagina, by which small masses may be extruded one after another, each with a certain amount of pain, but without laceration of the mucous membrane at the anus. This plan of treatment will often constitute one of the regular duties of the attendant upon a case of paral- 256 DISEASES OF THE BECTUM AXD ANUS. ysis — a disagreeable duty which must be attended to at certain regular intervals. In cases of longer standing, however, these means may be entirely in- adequate and all injections, no matter what their supposed solvent virtues, will be of no avail even if they are not at once ejected. In such cases the operation of breaking up and removing the mass must be begun by the administration of ether and dilatation of the sphincter. This accom- plished, the mass may be attacked with the fingers, an iron spoon, or a pair of lithotomy forceps, and removed piece by piece. When this has been done, an injection may be administered through the long tube and more matter will generally come down from the sigmoid flexure. The impacted mass is often as large as the fist, and sometimes as a foetal head, and the amount in the sigmoid flexure and colon may be much greater though not as hard; so that at a single sitting an enormous amount may be removed. After such an operation as this, the patient must be treated by injec- tions and a daily laxative, as will be described in speaking of constipation, till the over-distended rectum has recovered its tone. This may require a considerable time. Foreign bodies which have been swallovjed, — Medical literature is full of curious cases in which foreign bodies have been swallowed, either acci- dentally or by design, and have in some cases passed the full length of the alimentary canal, and been safely voided with the faaces, or in others have become entangled in the mucous membrane, and given rise to much trouble. Every practitioner is familiar with cases of peach-stones and coins which have been accidentally swallowed, and knows how generally such substances take care of themselves, and cause no symptoms after once passing the oesophagus. Much larger substances, such as whole or partial sets of false teeth, and the various things with which performers in travelling shows entertain an audience, may also be passed in safety. To show what nature is capable of in this line, it may be well to enu- merate the substances which were swallowed and safely voided by a cer- tain lunatic now become famous. The patient stated that she had been - swallowing nails, etc., and a dose of castor oil brought away two pieces of faience, one or two centimetres long and about the same breadth, two nails, and a pebble. During the following six weeks she passed nineteen large pointed nails, a screw seven centimetres long, numerous fragments of glass and china, a piece of a needle, two knitting needles, fragments of whalebone, etc., amounting in all to three hundred grammes. During all this time the patient ate and drank as usual, and seemed in ordinary health.* Prof. Agnew " saw in the dissecting room of the Philadelphia School of Anatomy, a female subject, afterwards learned to have been insane, in. > Lancet, 1866, Vol. i , p. 23. IMPACTED FJECE8 ANH FOREIGN BODIES. 257 whose intestinal canal from jejunum to rectum were found three spools, of cotton partially unwound; two roller bandages, one of them 2^ inches wide and one inch thick, the other was partially unrolled, one end being in the ileum, the other in the rectum; a number of skeins of thread, a quantity being packed tightly in the cascum; and finally a pair of sus- penders." Prof. Gross records the " case of a man who swallowed a bar of lead, ten inches long, upwards of six lines in diameter and one pound in weight, whilst performing some tricks of legerdemain," which was removed by gastrotomy and the patient recovered in two weeks. He also mentioned another case in which a teaspoon was swallowed, whilst the patient was in a paroxysm of delirium, which was removed from the ilium by entero- tomy, recovery taking place in a few weeks.* " Henrion, called Cassandra, born in Metz, in 1761. Not satisfied with the various trades which he followed in his youth, he began to force himself, at the age of twenty-two years, to swallow pebbles. Some- times he swallowed them whole and without any preparation, and some- times he broke them between his teeth, after having first heated them red-hot and then suddenly plunged them into cold water. In this manner he palmed himself off as an American savage. For several years he had fixed his residence at Nancy, and there continued the same habits which he had not interrupted, swallowing daily a large number of pebbles, sometimes as many as thirty or forty. The largest pebbles equalled in volume a large nut, but they were usually smaller, and Hen- rion demonstrated their presence in the stomach by the collision which he obtained by percussing the epigastric region. With the aid of salts, he passed them in twenty-four hours, and often made them do duty for the next day. He also swallowed live mice, though only one in the course of a day, as well as crabs of moderate size, after their claws had been cut. When the mice were introduced into the mouth, they threw themselves into the pharynx, in which they were soon suffocated, and their deglutition was then facilitated by that of a nail. Upon the follow- ing day it was passed from the rectum, flayed, and covered with a mucous substance. At another time three large pennies were successively put to the same use, and Henrion found them later, scraped clean and mixed with faecal matters. He continued this calling until 1820. At this time he swallowed some nails, and then a plated iron spoon measuring five and a half inches in length and one in breadth, for a