Not getting his hands dirty

If you haven’t been watching the BBC2 comedy Quacks, you’re missing a treat. It’s set in the world of mid-Victorian medicine, an era when the discipline was beginning its dramatic metamorphosis into a rigorous science. Anaesthesia had just arrived on the scene, and a younger generation of surgeons and physicians was eager to discard outmoded thinking and replace it with something new.

A lot of historical knowledge has clearly gone into Quacks, but more importantly it’s very funny, well written and has an unusually excellent cast. There’s a particularly droll cameo by Rupert Everett, who plays Dr Hendrick, the hospital’s senior physician. He’s the embodiment of fusty medical tradition: a remnant of the eighteenth century, he is far too grand to examine a patient at first hand, preferring to offer his diagnoses with Olympian detachment.

Even the ridiculous bits of Quacks often turn out to be historically accurate, and Dr Hendrick’s demeanour is one of them. Not long after watching the last episode I came across this report, which was published in the Medical Observations and Inquiries in 1771:

painful constipation from indurated faecesThe writer is not identified, although the article was later attributed to the physician John Fothergill. The subject is the edifying one of constipation caused by impacted faeces; it’s clear that, like Dr Hendrick, the author was not a fan of getting his hands dirty.

It is known, that from many causes, from the use of the bark especially, it happens, such quantities of hardened faeces are sometimes collected in the rectum, as nature, without assistance, is unable to expel.

By ‘the bark’ the anonymous writer means cinchona bark, usually known at this date as Peruvian bark. A source of quinine, it was used to treat fevers.

I shall relate one single case particularly, as some useful hints may be collected from it, as well as from some other cases of the like tendency, sufficient, I hope, to lead the young practitioner into a method of distinguishing this disorder from others, which, though in some appearances the same, are diametrically opposite.

The  author then gives a case history:

Not long since I was desired to visit an elderly gentleman, labouring, as it was supposed, under an obstinate diarrhœa. He was in the country, under the care of a very sensible and experienced apothecary, who, from the patient’s and attendants’ complaints and informations, was induced to believe it a diarrhœa, and had treated it as such, in a very proper manner.

Apothecaries, who prepared and sold drugs, are often thought of (correctly) as the equivalent of the modern pharmacist. But until the nineteenth century they also functioned as general practitioners.

The gentleman had very frequent motions to stool, and the motions extremely urgent. Some thin excrement was always discharged on these occasions: the pains gradually lessened for a time, and then returned with the like violence and the same effects. Rhubarb, testacea, demulcents, anodynes, had been occasionally given.

Rhubarb was traditionally used to treat intestinal complaints, both diarrhoea and constipation. Testacea was powdered oyster shells, recommended in Hunter Lane’s Compendium of Materia Medica and Pharmacy for “diarrhoeas depending upon acrimonious secretions; sprinkled over burns when the inflammation has subsided, [and] ulcers discharging thin ichorous matter.” Demulcents and anodynes were preparations intended to reduce inflammation and relieve pain respectively.

But the disorder still continued, and the pains and discharges, though rather less frequent, seemed to be more violent. From the violence of these returns, 1 began to suspect they proceeded from some obstruction in the rectum. The pains were previous to the discharge; a tenefmus always succeeds it.

‘Tenesmus’ is one of those wonderful archaic words that deserves a revival. It means a painful straining to empty the bowels.

The patient told the doctor that he had always suffered with constipation, and that he had not managed to pass a stool for over a fortnight. The physician guessed that the current symptoms were in fact caused by an obstruction somewhere in the lower gut.

I requested the apothecary’s servant, who was in waiting, to dip his finger in oil, introduce it into the rectum, and try to discover if my suspicions were well founded…

One wonders whether this task was part of the unfortunate servant’s job description.

…and if they were, to endeavour to break the hardened scybala, and bring them away, either by his finger, or a narrow spoon, the best instrument we could then find.

‘scybala’ = a hardened mass of faeces. Now you know.

It proved as I had suspected, and the young man performed his part so well as to bring away a very large lump of hardened faeces, which could not by any other means have been discharged.

I very much hope the spoon was discarded rather than being washed and returned to the cutlery drawer.

Emollient clysters [enemas], and oily relaxing draughts, soon brought away the rest, and our patient was effectually relieved from that moment.

So: a successful outcome. As further illustration, the unnamed author adds a second similar case. It’s not worth reproducing in its entirety, except for one telling detail. After hearingthe patient’s history, the doctor felt that further investigation was called for. But he did not condescend to examine her himself; once more, he made an unfortunate assistant do the dirty work:

The apothecary, at my request, examined the rectum again with his finger; but found no faeces. He then introduced a small tallow candle, and pushed it gently past the compressed part. Upon drawing it out, he observed some excrement sticking to it. This induced him to pass it again to the obstructing place, and, by degrees, he dislodged a very large mass of hardened excrement, which fell into the rectum, and being there broke with the finger and the scoop, was extracted.

Dr Hendrick, take a bow.

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