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1846.]

SUBMUCOUS DIVISIONS OF THE SPHINCTER.

265

of uric acid and soda, thus creating a demand for these elements in that fluid, and thereby bringing about an absorption, as it were, and solution of the superfluous lithate of soda which is deposited in the white tissues." In all the cases adduced, when little acid had been before observed in the urine, it disappeared under the use of the phosphate, while, instead of the lateritous deposit usually seen at the period of convalescence, this fluid continued limpid-the eliminated lithate of ammonia and phosphate of soda being soluble. The rapid disappearance of lithic acid from the urine in cases wherein this salt is administered, leads to the conclusion that it must prove an eligible remedy for uric acid calculus.

Dr. Buckler does not propose the salt as an exclusive and empirical remedy, but employs simultaneously, various means for combating serious symptoms, until the healthy condition of the blood is restored.-American Journal Medical Sciences, Jan.

ON THE SUBMUCOUS DIVISION OF THE SPHINCTER IN AFFECTIONS OF THE ANUS. By M. DEMARQUay.

The division of the sphincter, as practised by Boyer, frequently fails, and is not devoid of danger; but all its advantages may be obtained and inconveniences obviated by operating upon it beneath the mucous membrane. MM. Guerin, Velpeau, Blandin, and the author, have employed this modification with great success, and it is the object of this paper to spread a wider knowledge of the proceeding by detailing several of the cases which have been treated by the two last.

Submucous myotomy is especially calculated for the relief of spasmodic action and contraction of the sphincter ani. It is often difficult to say where one of these affections ends and the other begins, for they are so intimately connected that the one may be said to be a consequence of the other: for if the same irritating causes which induce spasmodic contraction of the muscle continue in operation, this will then become permanent. When the contraction is wellmarked the anus seems deeper seated than ordinary, the borders of the external sphincter being seen projecting and the plaits of the region well marked. If hæmorrhoids or mucous membrane has become engaged within the sphincter, the compression gives them a violet colour, and they may even become gangrenous. The finger is introduced with difficulty, and with pain to the patient, and is much constricted by the muscle.

Spasmodic contraction, requiring the operation, may manifest itself under various circumstances, but it is especially in its prevention of the extraction of foreign bodies from the rectum, that it comes under our notice. It may also manifest itself in two very important affections, viz., prolapsus of the rectum and the sudden appearance of large hæmorrhoids. In this last case, the constriction may be so considerable as to induce gangrene, or at all events prevent the return of the protruded parts.

Contraction of the sphincter plays an important part in three affections, viz., constipation, old hæmorrhoids, and fissure of the anus.

(1.) Prolonged and obstinate constipation not unfrequently gives rise to it. The indurated matters contained in the gut irritate it, and induce, first spasmodic and then more permanent contraction; and anthors have certainly sometimes mistaken the effect for the cause, in regarding the constipation as produced by the contraction. In mentioning constipation as a cause of contraction, it is not intended to recommend combating it by a surgical operation. It is a complex condition of which this contraction only forms a portion.

(2.) When hæmorrhoids have long existed, and become frequently congested

and inflamed, it is by no means rare to find contraction induced. In this case they are forced out at stool, but can only be partially returned. They inflame; defæcation becomes more and more difficult, and fissures and hæmorrhages result. Several examples are given in which this state of things was effectually relieved by the submucous section.

(3.) Fissure of the anus is so intimately connected with contraction of the sphincter that Boyer regarded them as the same disease. But we have already seen contraction may exist without fissure, and the question is, when the two affections co-exist, which has preceded the other. In the great majority of cases a more or less obstinate constipation, a state often giving rise to contraction, has preceded the fissure. Authors, however, have stated that they have observed fissure without contraction, and if they are correct we may explain such cases by the varieties of the disease admitted by M. Blandin. He states that the fissure may be seated above, opposite, or below the sphincter. In the last case it may exist without contraction.

anus which have been They amount to 53, of Of these persons, 30

The author has analysed all the cases of fissure of the published, as far as he knows, since the time of Boyer. several of which very insufficient particulars are given. were men and 23 women, in opposition to Boyer's assertion that, females are most liable to the disease. In six instances the fissure was double, triple, or quadruple. The age is only recorded in 42 cases, the disease being most common between 20 and 30, and 30 and 40. In 26 of the cases constipation, and in six cases hæmorrhoids, are described as existing.

Seven cases of fissure operated upon by M. Blandin are given, in all of which complete and immediate relief succeeded to the most intense suffering. Prior to commencing the operation the rectum should be well cleared out, so as to obviate the necessity of going to stool shortly after it. An assistant must raise the side of the buttocks opposite to that on which the section is about to be made. This last is always practised at one of the sides of the anus, so that the sphincter may be divided through its middle. An ordinary tenotome may be used, or a bistoury which M. Blandin has contrived. The former is however not long enough, and its point is not sufficiently guarded, so that there is danger of penetrating the mucous membrane with it. M. Blandin's bistoury is protected by a moveable sheath, and he can either use it for puncture or incision, or as a flattened probe, accordingly as he wishes to divide parts, or merely to pass it between the muscle and mucous membrane. Whichever may be selected, the operation is simple. 1. Make a small opening in the skin. 2. Introduce the finger into the rectum, at the same time that the skin on each side of the anus is stretched. 3 Pass the tenotome between the mucous membrane and the sphincter. 4. Divide the latter. The puncture of the skin is most conveniently made at from 8 to 12 lines from the anus. The instrument must be passed in very gently so as to detach parts as little as possible. When the division has been made a kind of crack is heard, and the finger which is in the rectum feels the space between the two divided portions of the muscle. Although not absolutely necessary, the patient had better keep his bed for a few days after; and he should live very abstemiously, as it is desirable he should not go to stool for three or four days, after which there is no fear of rupture of the cicatrix. Occasionally the section of the sphincter on one side only is insufficient. The fissure does not after the section of the muscle require any special treatment.—Archives Générales, April.

(When the dreadful and prolonged suffering incident to fissure of the anus is considered, the substitution of this simple operation for that of Boyer's must be regarded as of one of the most valuable applications of myotomy.-—Rev.)

1846.]

CONTAGIOUSNESS OF PUERPeral Fever.

267

QUININE IN ACUTE RHEUMATISM.

Three years have elapsed since M. Briquet communicated the success which attended the use of quinine in cases of acute articular rheumatism at the Hôpital Cochin. Several practitioners have resorted to it with the same result; but its employment has become by no means general, partly in consequence of too large doses being given at first, and various accidents in consequence ensuing. M. Briquet formerly gave from 4 to 6 scruples in the 24 hours, but now gives but from 1 to 4, discontinuing it when any sign of prostration manifests itself. He employs the neutral salt rendered soluble by sulphuric acid. From the first or second night sleeplessness disappears, and a little later there is a more or less marked diminution of the pain and swelling of the joints. From the third to the sixth day the rheumatism may become cured; but when the cure is so prompt as this there is usually some return of pain, with or without swelling, again requiring the use of quinine. As a general rule the patients are cured or notably relieved from the ninth to the twelfth day of treatment.-Gazette MédicoChirurgicale, No. 17.

CONTAGIOUSNESS OF PUERPERAL FEVER.

Dr. Kneeland has contributed an interesting paper upon this subject to the American Journal of Medical Sciences. He does not bring forward any new cases in elucidation of the question; but, from a careful examination of facts and authorities on both sides of the Atlantic, arrives at the following conclusions:"1. From the confinement of cases to the practice of single physicians and nurses in populous cities; from the fatal results attending post-mortem examinations; from its ravages in hospitals; that puerperal fever is contagious; that it may have other modes of propagation in certain states of the atmosphere, and among strongly predisposed individuals; but that the fact of its conveyance by practitioners attests its contagiousness. 2. That it may be propagated by direct inoculation with the fluids of the living and dead; by the effluvia arising from the bodies of the sick, inhaled in the very chamber of death (as in the wards of a hospital) or carried about by the person of the physician; by clothes, bedding, which have been in contact with a diseased individual. 3. That the order of propagation from the physician to the patient, and the regular succession of cases, show that the epidemics of puerperal fever are, in almost all cases, the effects and not the causes of contagion. 4. The contagion acts according to the frequency of communication between the physician and nurse (in whose practice are cases) and lying-in-women, independently of insalubrity of places, wretchedness of patients, or the neighbourhood of dwellings-for, although poverty and misery seem to predispose to it, communication is none the less fatal to the higher classes. 5. A case, to all appearance sporadic, may communicate the disease; a mild case may communicate a severe disease, and vice versa. 6. Immunity proves nothing against contagion; it may be the effect of an acquired or temporary inaptitude. It is equally inexplicable in all contagious diseases. 7. The rapidity of its propagation shows that it is contagious at the commencement; the fatal results of attending autopsies indicate this character after death. 8. That a physician should not make or be present at an autopsy of this disease; or if he does should take proper measures to cleanse himself and dress, for the safety of his next patient that if a case (or several cases) occur in his practice, he should consider himself, in the language of Dr. Holmes, a 'private pestilence,' and regulate his conduct accordingly-that persons who have washed, or have other wise handled the clothes or bedding soiled by the discharges of this disease,

should not approach, much less nurse, a woman after delivery. 9. That when the disease is prevalent, a prompt removal from possible intercourse with a pestilential' physician, and a strict attention to ventilation, cleanliness, quiet, proper food, &c., are the dictates of a reasonable fear."

(So overwhelming is the testimony in favour of the contagious character of this disease, and so truly frightful have been the consequences which have frequently resulted from neglecting the precautions this should have furnished, that we think a medical man persisting in attending successive cases of midwifery after a well-marked instance has broken out in his practice, should be made amenable to the criminal tribunals of his country. A woman has confided her life and safety to his skill and honour, and he enters her chamber, and approaches her person, the bearer of what he knows is reputed to be by some of the wisest of his profession a deadly poison, the escaping from the effects of which she is to owe to her own idiosyncracy and not to his humanity. Medical men are doubtless unconsciously the propagators of other diseases; but their instrumentality is here so well marked, and has been so often exemplified, and the consequences are so commonly fatal, that every one possessing a spark of conscience should at once resolve to relieve himself from this dreadful responsibility, at whatever sacrifice, while such as choose to persist in so criminal a course should not be allowed to do so with impunity. This is not one of the hundreds of instances of difference of opinion in the profession where each person is as likely to be as right in the long run as the other. The practical results are fearful, and it is of the last importance for the honour of our profession that we do not convert our blessed ministration into a curse and a scourge. It is to be regretted that an authoritative and combined declaration of opinion has not been expressed upon the subject, and a rule of proceeding laid down; for we every now and then hear of men consulting their brethren and temporarily abandoning their practice only after they have lost several patients in succession; and Dr. Jackson of Philadelphia, our author states in his paper, began to be "seriously alarmed on the score of contagion," when he had had seven cases of puerperal fever in uninterrupted and rapid succession (five of which were fatal,) and women whom he had been engaged to attend fled from him as from a pest. Mere ablution or change of dress will not suffice. Midwifery should be entirely abandoned for several months. The sacrifice would sometimes be great, but it would not be without its compensation.—Rev.)

ON THE QUESTION OF THE REMOVAL OF CANCEROUS BREASTS. By M. VELPEAu.

The patient before us is one upon whom we cannot operate, for, on examining the breast, we find little knots extending even to the edge of the great pectoral; moreover the nipple is implicated, and it is an instance of disseminated cancer, which for us is a true noli me tangere. We do not mean to say that the wound would not cicatrize and the patient recover of the operation itself, but we have acquired the desolating conviction that this species of cancer, as well as the ligneous scirrhous, invariably relapses.

Many descriptions of cancer should not be removed, and this is a very important point, as many practitioners, unaware of it, injudiciously undertake an operation. Among the varieties liable to return, all do not re-appear however with the same tenacity. Among those whose return is certain may be named that form in which the skin becomes horny or leathery, and in which the indurated integuments and the nipple are retracted; that ligneous variety in which the indurated parts are formed into layers like bark; and that in which the dis

1846.]

VELPEAU ON NEURALGIA OF THE BREAST.

269

ease does not commence with one tubercle under the skin but with several at once, in which case we may be certain that there are others there also. In all these, relapse is certain. In this last named variety we need not be surprised at a return, for how are we to be certain of the removal of cancerous grains so small as to elude sight and touch.

Melenic cancer is rare in the breast, or co-exists in other parts of the body. Nevertheless, if a simple tumour of this kind appears in this part, it should be removed, as it is not always reproduced. Colloid cancer may be placed in nearly the same category. Scirrhus also admits of operation, except when it is branching, i. e sends out roots in different directions, whence its name cancer. In this case it is usually reproduced, its distinct limits being ascertained with difficulty. Encephaloid is a bad species, because it is usually simultaneously developed in one or several other organs. If, as far as we can ascertain, no other deposition exists, we have a chance of success by operation. We have cured some fifteen out of those we have operated upon; but when we recollect that these tumours may become developed in some internal organ without any symptom thereof, we can see how uncertain any prognosis must be. There are some curious facts connected with this subject. I recollect a man of robust habit and apparently in vigorous health, from whose lip I removed an encephaloid tumour. He died in four days, and at the autopsy we found thousands of little encephaloid tumours in the liver. Are we to suppose these became developed in so short a period after the operation? If we believe that they existed simultaneously with the disease of the lip, how do we explain the excellent health of a person having so large a quantity of cancerous tumours in his liver? It will be seen that cancerous tumours in general, and those of the breast in particular, demand classification and distinction from each other; and until classification is perfectly established, and the same one employed by all practitioners, they will continue to misunderstand each other.-Gazette des Hôpitaux, No. 55.

This excellent surgeon published some interesting observations in the same journal last year upon Neuralgia of the Breast, so frequently mistaken by women for cancer of the organ. If the surgeon is not on his guard when he examines the breast, he observes, he may confirm instead of dissipating the error. The organ is composed of numerous lobules which are far from always offering the same consistence. In different women, too, there is great variety in the configu ration of the thorax as regards its flatness or projection, which imparts a different sensation to the hand engaged in examining the mamma. Again, if we take hold of the breast at the side as if to compress it, and then feel it with the other hand, it will be difficult to persuade oneself it does not contain a tumour: and without having made the experiment the different density of the organ, according as it is pressed in one direction or another, cannot be conceived. If to this we add that the gland is more or less developed, and the breast more or less resisting, more or less pendent, in different persons, we can see there are many shades of difference met with.

Women who suffer severe pain always believe that cancer exists, and have submitted themselves unnecessarily to amputations and severe treatment. Attacked by a species of hypochondriasm, they are annoyed if you doubt the importance of their malady; and although you may deny that they suffer from the disease they suppose, it would be unjust and inhuman to forget they do suffer much. The pains felt are sometimes only the result of the attention being unduly directed to unpleasant sensations and the mind dwelling upon them; but at others result from a true neuralgic affection of the breast. It is of course important to distinguish this from cancer, and we must remember that in general true tumours do not cause pain at their commencement, and that, when the patient has long complained of violent pain without any tumour being apparent, there is no tumour at all in the case. In examining the breast we must never take hold of

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