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A previous paper by Sutherland et al. (17) described the adaptation of patients to abdomino-perineal resection of the rectum with concomitant dry colostomy (the construction of an artificial anus in the abdominal wall). Feelings of inacceptability to others or self-hatred and withdrawal from social relationships were reported to some extent by every patient. On the basis of these findings it was concluded that the attainment of anal sphincter control in childhood is so fundamental in human socialization that the surgical destruction of anal sphincter control must result in a severe emotional and social disruption. This can only be alleviated by helping the patient to regain some measure of voluntary control over fecal evacuation and the expulsion of flatus. Although this has sometimes been attempted by a constipating diet and the wearing of a bag as a receptacle for spontaneous bowel movements, or by training patients to acquire regular evacuation habits, patients in this group were instructed to irrigate at periodic intervals.
Irrigation (the introduction of water into the colon through the colostomy opening) at periodic intervals to promote evacuation, therefore, constituted a substitute method of control over bowel function. In the interval between irrigations, however, patients are completely without voluntary control, a lack of mastery which results in the irrigation acquiring great emotional significance in the lives of patients. Sutherland et al. (17) have interpreted the significance of irrigation by stating, “The symbolic meaning of irrigation lies in the attempt to reestablish, by an external procedure, the destroyed inner control over bowel function” (p. 867). In order to maximize the effectiveness of this substitute method of control, patients instituted many compulsive practices, termed controls,