VOL. VIII.

No. 1.

ORIGINAL ARTICLES.

Rectal Surgery in London, England.

REPORTED FROM LONDON BY J. M. MATHEWS, M. D., LOUISVILLE, KY.

To attend a clinic at St. Mark's Hospital is interesting from its novelty. As was stated in a former communication, no other city in the world has a similar institution, and too much credit can not be accorded to the late Mr. Salmon for founding, or to the surgeons in charge for their assiduous labor in keeping it up. A fact is noticeable here, that much more attention is given to rectal surgery than in America, and the list of distinguished surgeons who give it special attention embraces the names of Alling. ham, Curling, Cooper, Goodsall, etc. To their research and study much of the light on rectal surgery is due; and no class of disease can boast of as rapid advance in curative treatment as does this. Sir Astley Cooper once lost a Lord from hæmorrhage after an opera

tion for internal hæmorrhoids; no such thing is known or heard of to-day. Said Mr. Allingham a few days ago, "why, sir, we seldom see a patient bleed at St. Mark's after an operation, and should one do so, dilatation of the bowel is so easy and free from danger, that we would at once evert the bowel and tie any vessel that was bleeding." But to prevent this sequel after all operations, the rectum is plugged with cotton, so that no bleeding internally can take place. It will be well to mention bere that cotton wool is the only dressing used after operations. If a fissure or

ulcer is divided, a piece of wool is pushed down into the cut. If a fistula is cut through, a piece of wool is made to fit neatly in the wound, and if hæmorrhoids are ligated, a piece of dry wool is sometimes pushed back into the rectum, or to cover the anus. A surgeon remarked to-day, "if he were called upon to give up all other dressing for these wounds, he would hold to dry cotton wool." Some very interesting cases have presented themselves at the clinics in the hospital in the last few days, and refer

ence will be made to a few as taken from my note-book, hoping that they may be of some interest to your readers.

1. Mary E., aged eighteen years. Has been at St. Mark's two weeks. This girl was the subject of hip joint disease some fourteen months ago, and presented herself shortly after to Mr. Allingham, complaining of pain in the rectum, accompanied with some discharge. Upon examination an internal opening was found high up in the intestine, burrowing in the direction of the joint. A few days afterward quite a number of pieces of necrosed bone were taken from this

opening. It then healed, and now, after a lapse of so many months, she presents herself, complaining of the same symptoms, though no bone could be felt to-day.

2. J. S., a male; aged thirty-two, a journalist by profession, presents himself, complaining of slight pain in and around the anus, with slight discharge, though there is no particular distress. Upon examination a small external opening was found in the left buttock. But upon a careful examination, an in

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ternal opening is found extending into the perineum and reaching across the raphé. It was necessary in this case to make very extensive, cuts, and to trim off quite an amount of overlapping skin. The wounds were large enough to lay the hand into, yet after being dressed he called for his dinner, which he ate, half an hour after being operated upon. In all formidable operations ether is administered in lieu of chloroform, and this is preceded by nitrous oxide gas. It is claimed that it is much less dangerous administered in this manner, and that about one-third of the usual amount is inhaled. The patient spoken of above was under its influence for quite a while and yet but one ounce was taken.

3. A lady who has been twice operated upon for fistula comes, complaining of the same distress as preceded former operations; upon examination a deep sinus is seen extending up from old cicatrix. This was freely laid open by the surgeon and dressed with cotton wool.

4. Thomas D., aged eighteen years. This boy had been under treatment for a number of weeks at some general hos. pital. His affection diagnosed as con. dyloma and treated by local applica. tions. Upon examination he is found to have extensive mucous tubercles in

volving the anus, and to a circumference of some three or four inches. These were pronounced pathognomonic and the patient put upon a mercurial treatment. He has no chancre, nor has he had any.

5. Emma C., aged fifty-two. Complains of itching around the anus, with slight bloody discharge from the rectum. Has been treated by a respectable medical man for pruritus; applied local remedies, which did her no good. Examined by Mr. Edwards at St. Mark's, and found to be laboring under epithelioma of the rectum.

6. Frank K., a boy aged sixteen. Has been in a general hospital for some weeks. Appearing to get no better, he

is sent to St. Mark's by the house-surgeon. Complains of the greatest distress around the anus. Pain unbearable. No discharge, no "coming down of body," no abnormal condition whatever of the parts, save a small external hæmorrhoid, which the surgeon let out with a lance, and the patient expresses himself as greatly relieved.

7. A lady aged forty-five presents herself, complaining of a "bearing-down" sensation in the rectum, though there is no prolapsus and no discharge. Upon inserting the finger into the bowel, a hard substance is felt which might be thought impaction of fæces, but for the absence of the characteristic "doughy" feel. Upon closer inspection it is found that this tumor is not in the bowel, but uterus; and the case is at once pronounced fibroid tumor of the uterus, and the patient sent to another hospital.

REMARKS.-I have related these cases in detail, because they are typical of those met with in rectal surgery. The first case being interesting because of so rare an occurrence as bone taking this course of exit; and again, that no more serious trouble was caused. The second case shows how often a superficial examination of these cases confuses the surgeon and damages the patient's safety. The third case brings to mind a difference among surgeons as to the propriety of laying open all sinuses. Dr. Van Buren, of New York, in his very valuable book on "Diseases of the Rectum," says: "There is nothing

Rectum," says:

gained by searching for an opening into the bowel at the end of a fistulous tract; if an opening exist there it would be unsafe to incise the whole tract. If the incision be made through the communication usually found just above the external sphincter, the freedom of the depending opening will affect the consolidation of the undivided sinus." Yet here is a case in which this advice has been twice followed and proved futile.

Mr. Allingham assures me that patients of this kind are frequently seen, and that nothing short of a full cut of the whole extent of the sinus will cure the patient.

Case four brings up a mooted question, viz: Can the eruption of secondary syphilis make its appearance without there having been first a sore? This patient states that no chancre whatever has existed. Mr. Cooper states that this. may be true, but that the case is one of specific origin, and that in a short time. the eruption will appear. He has at this time no other symptom but the mucous tubercles. The surgeon prescribes no local application, but puts the patient upon mercurial treatment. The question might be asked, "how long can syphilis lie dormant in the system?" This patient had been affected eight

months or more.

Case five shows what might be a very damaging diagnosis to a medical man's reputation, at the same time prove serious to his patient.

Case six shows that in these cases, as in many others, no reliance can be placed upon what patients tell you as to diagnosis. Also proves how little care is given by the profession at large in examining these cases.

Case seven would suggest how often uterine disease is confounded with rectal symptoms, and with what superficial examination medical men pass these cases. American physicians would do well to take pattern after their English friends, and give more study to this class of diseases. Its frequency must be admitted, as must the fact that this class of patients fall generally into the hands of irregulars, because the regular profession seem to care so little for their welfare, or else know so little of the treatment in these cases.

THE deaths registered in London last week numbered 1,448.

Quinia as a Parturient.

BY W. W. DOW, SOMERVILLE, MASS.

This is a subject that is now attracting a great deal of attention among medical men. When we consider the importance of the subject we will not be surprised that it is now eliciting so much comment. A great deal has been said and written on this subject within the last few years; still it (the subject) is far from being a stale or a thread-bare one. It is to me a matter of much surprise that professional opinion is so divided on this subject. Men of high professional standing claim that they bave frequently witnessed the oxytocic powers of this drug. While on the other band, men of equal prominence and of long experience and most accurate observers have witnessed no such results. After a careful perusal of all the literature on the subject to which I have had access, I am of the opinion that the mass of the profession think quinia "incapable of originating expulsive uterine contractions," either at the full term of uterogestation or of producing abortion. Cazeaux, in his "Theoretical and Practical Treatise on Midwifery," is of the opinion that it is the disease for which quinia is administered and not the drug that causes the abortion when it occurs during the administration of quinia in the treatment of malarial fever. He thinks it "not only an innocent remedy, but one of the surest means of preventing abortion when it is imminent in consequence of the fever." It has been claimed by some that quinia acts specially on the sympathetic nervous system, causing in virtue of this property contraction of the non-striated muscular fibres of the (which are supplied by the sympathetic nerve) walls of the blood vessels, intestinal canal, urinary bladder, and uterus, and in consequence of this property it should be classed with such