CLINICAL LECTURES ON SURGERY,

LONDON, SATURDAY, FEBRUARY 16.

opening this orifice,

CLINICAL LECTURES

ON

DELIVBRED AT THE

HOTEL DIEU, PARIS, BY

M. LE BARON DUPUYTREN,

tingency

FISSURES

MEANS

OF

OF

THE

ANUS,

TREATMENT,

1832-3.

THE

AND

an

operation, especially

in

only separated from the posterior commissure of the vulva, by a very delicate partition. The ulceration but rarely affects the entire of the mucous membrane. Its gravity then depends principally on the painful

USUAL

ON

of

making

a narrow

women, in whom this opening is frequently

[Revised, 4efore translation, by the Baron hiJnself.]

ON

and

the push cleft is perceived and slightly swollen and callous edges. But to appreciate its extent above, it is often necessary to introduce the finger into the rectum. Weobserve that it is more frequently situated on the sides, or behind, than before the anus, a circum. stance favourable as far as regards the con-

a little, SURGERY, down with red base,

During the lJl’esent Session,

[1832-33.

spasm of the constrictors of the anus. The fissure itself is indeed but an accidental thing, as is proved by the existence of the

THE

TREATMENT WITHOUT OPERATION.

painful spasm without

THE diseases which may affect the anus the ulceration; which, and its vicinity claim the minute attention according to some celebrated surgeons, of the practitioner ; considering their fre- occurs in the proportion of one to four of quency of occurrence, and the inconve- the constriction with fissure. This spasm nience dependent on errors in their diagno is such, that the introduction of the smallest sis. It is true that equal danger does not body is intolerable ; the point of the finger, result from the fissure of the anus, but it is the back of a syringe, exciting dreadful in general accompaniedby such violent pain, ’, pain. The resistance the anus affords to that to remedy this alone is a matter of the introduction of such small bodies is an great importance. These pains present to additional proof of the nature of the case. a certain extent a special character ; that of The causes of these anal fissures are nuincreasing gradually, and persistingfor a merous. Constipation disposes to its oclongtime after each expulsion of the faeces, currence. The hardened fseces, eroding sometimes being of a lancinatingkind, the mucous membrane, and distendine the usually burning, and described by the pa- canal beyond measure, explain the action of tients in highly exaggerated expressions, constipation. The awkward administration Ordinarily they compare them to red-hot of clysters, especially by metallic canuls*, iron penetrating the rectum. They dread rough or pointed, often directly induces so much the expulsion of the faeces, that they them. They are met with in persons afstruggle long before they yield to this im- fected with piles. The venereal virus, perious necessity, and they even go with- either deposed immediately on the margin out food in order to avoid its calls. of the anus as in unnatural coition, or havThese peculiarities enable us to detect ing trickled towards that opening from the the nature of the evil, and indeed by vulva, as often happens, is another common careful study of the special characters ofcause of the disease. the pain in various maladies of the recThe known inadequacy of almost all local tum, we shall find them to constitute excel- applications in this painful malady, has lent diagnostic indications. caused the majority of reputed curative or The fissure of the anus, consisting in anpaUIativemethods to be successively abanelongated ulceration, developed towards the doned, and an operation is generally emmargin of the anus in the radiated folds ofployed ; always free from danger, it is true, the mucous membrane of this part, claims,and invariably successful, but very painful as I have said, our especial attention. Ink in its performance. This operation con.-

I

!

No. 494.

642 sists in the incision of the sphincter ani, in one or more points of its circumference, with a bistoury, or in the cauterization of the ulcer with fused nitrate of silver. The mode of practising the incision is too simple and too well known to need description. It would be, doubtless, a true service to humanity, to discover some means of curing this malady without operation. The fol-

finger perceives at their seat a hard knotty chord, painful on pressure. They The

indescribable tenesmus at stool, which when the fseees are expelled. These are covered with purulent mucus, and stained with blood at the side corresponding to the fissure. The ulceration of internal hemor. rhoids generally causes this kind of fissure. Lastly, the fissures on a level with the lowing method, though not always success- sphincter are the most serious of the three, suceeed- and it is to these that the distressing sympful, has, nevertheless, ed, as to entitle it to be practised, at any toms first described more particularly ap. rate, in the great majority of cases, before ply. The two first generally get well withproceeding to the operation. We have said, out operation, some by means of lint and that the spasmodic constriction was the true ! charpie covered with simple cerate, opiated lesion; the elongated ulcer, crack, or fissure, cerate, cucumber ointment, unguentum pois only a secondary complication. By cur- puleum, or mercurial applications; others emollient and narcotic lotions, composed ing the constriction, then, yon terminate the disease. The application of belladonna of decoctions of marsh-mallow, poppyheads, is consequently an obvious indication, and dulcamara, hyosciamus, belladonna or by combining it with the acetate of lead, as stramonium, &c. Amongst other patients, in the following formula, it is found to be a cardinal was cured by these rectal douches. But in the third kind, the surest and of great advantage. cure is effected by the operation promptest :ij;. Fresh lard 6 scruples ; of Boyer, which requires only a common Acet. lead 1 ditto ; bistoury, and a bistoury with a button ex. Ext. belladonna 1 ditto. cause

ceases

so frequently

by

A pledget of moderate size is smeared with this ointment, and the volume of the pledget gradually increased, until it acquires the size of the index finger. The continued use of this ointment for a few days often completely removes the pain, and spares the patient the torment of an operation. Thus it happened in the case of a young woman of stout, well-formed person, who, four months after her confinement, experienced for some weeks intense pain in the anus. At the water-closet, and especially when the faece$were indurated, the pain was beyond description. At first, it only lasted a few minutes; but gradually it increased in duration, and at length lasted for several hours together. The application of this ointment cured her in fifteen days. This case proves, then, that we must not be in too great haste to practise incision or canterisation of the sphincter, and that we should, previously, at least give the belladonna a fair trial. Before adverting to the ultimate remedies in more detail, it is desirable to notice the differences’presented by the fissures themselves, on account of the seat they occupy. Those formed below the sphincter of the anus, interesting only the cutaneous tissue, and not the anal mucous membrane, determine itching in different degrees, but occasion little impediment to defecation, induce 110 constriction of the sphincter, and are painful, but in a trifling degree. These are generally caused by the venereal virus. The fissures above the sphincter affect the mucous membrane ; the eye cannot distinguish them without the assistance of the speculum.

tremity.

A man, setat. 30, for four months laboured under the symptoms of this disease to such an extent, that he used only to yield every third or fourth day to the necessities of nature. He had a minute excrescence at the circumference of the anus, spasmodic con. The excrescence striction, nssure, &c. was removed by a stroke of a scissors, and the anus divided in the fissure itself. A pledget covered with cerate was then introduced into the rectum, and placed between the lips of the incision. It is important to note this fact, that the incision should be practised on the fissure itself, and not at a distant point of the rectum. The division thus practised, at once puts an end to the pain, permits the fissure to cicatrize, and ensures a certain cure. This rule has, however, one exception, namely, in the case where the fissure is seated anteriorly towards the urethra in the male, and the vasina in females. When this affection, simple in itself, is of very long standing, it becomes complicated with local disorders of more· or less importance, and with an alteration of the constitution which may even endanger the patient’s existence, as in the following Case.-Angelica Delabaye, aetat. 24, of good constitution, regular courses, the mother of several children, entered the Hotel Dieu to be treated for numerous anal fissures with cushion-like excrescences. The evil was of several years existence. At first it occasioned little inconvenience, and made but slow progress ; but when she entered the hospital the anus was contracted, several fissures existed in it

643

circumference, as well as a cushion of crescences, which, however, offered no

exun-

favourable character. The stools were rare, but accompanied with horrible torments, which were prolonged for severalhours after each evacuation. The patient voluntarily abstained from food in order to diminish the number of evacuations. The stercoral matters were usually mixed with a great quantity of blood and mucus. The constitution of the patient was getting weak, she was full and puffed up especially in her face. i She was frequently feverish. She denied ever having had any syphilitic affection, and could assign no cause for the disease. After two or three days preparatory treatment, the excrescences were excised, and the fissures divided. Each tumour was seized with a dissecting forceps, and removed with a single stroke of a curved scissors. A

to the twentieth day, leaving a. wound which may be easily kept up. It is not my business to speak to ypu minutely respecting the places where -the cautery should be applied. It is sufficient to say that we should select parts abundantly provided with cellular tissue, at a distance from osseous projections, tendons, or the centres of muscles. There are, how-

eighth

ever,some places of preference, of w hic I may say a word. Thus, at the arm, we ordinarily choose the slight depression at the inferior insertion of the deltoid muscle. At the

thigh we place the cautery at some fingers breadth above the internal condvle of the femur, on the cellular line which bounds any teriorly the inner portion of the crural muscle, and posteriorly the third adductor and gracilis. The preferable place for the leg is the space comprised between the straight button-pointed bistoury having inner edge of the tibia and the correspondbeen then introduced into the rectum, seve- ing border of the gemelli muscle, below ral incisions were practised, each from three the tendinous expansion formed by the sarto four lines deep. Little blood was lost, torius and gracilis. during the operation, and a tent of charpie, It is useful in a great number of cases to the size of the finger, was introduced, indetermine slowly the formation of eschars order to prevent the re-union of the in- on the skin, so that the irritation produced cisions. by the prolonged action of the fire should The same day a copious stool took placebe more intense, and penetrate more deeply. with a considerable discharge of blood, butThe most suitable mode of fulfilling this inwithout the horrible pain previously suf-dication is by the use of the moxa. fered. A tent of charpie was again intro. Both these varieties of cautery give rise duced. This dressing was renewed daily,, to a wound or ulcer, which suppurates fora and whenever a stool was passed. Calmlimited time with more or less abundance, To prevent this was now restored, the young woman againi and which then heals. became plump, and in 22 days after the healing, and keep up a continued suppuraoperation she left the hospital perfectly tion, it is customary to introduce into the cured. sore, peas either natural, or made of iris wood or orange, or any other foreign sub. stance. This method is sometimes good, PRACTICAL CONSIDERATIONS ON THE USE OF!I but I have often seen it occasion serious acCAUTERIES AND 1B10Xae. cidents, as well as increasing those it was The application of cauteries and moxm is intended to remove. The extreme irritafollowed by the happiest effects in diseases tion thus produced propagates itself to the of the bones and articulations. Its imme- articulation, and the diseased parts of the diate effects are, pain more or less intense, bones. The patients are a prey to fever, the formation of a dry or humid eschar, pro- thirst, and sleeplessness, symptoms which duced ty the disorganized tissues, whether only cease when the foreign substances are combined or not with the cauterizing sub- removed. Practitioners thus frequentfy The secondarv results are are. persuaded that these phenomena are attristance. vulsive irritation produced by the pain de- butable to the excitories, fear to employ termined on the skin. Soon after this there them again, and thus deprive themselves of is an inflammation which I have called 11 eli- a valuable remedy. Convinced that the minatory," followed by a loss of substance substances introduced into the wounds were and an abundant suppuration proceeding the sole cause of the symptoms in question, from the subcutaneous cellular tissue. After f have, for several years, discontinued their six or seven hours the action of the cautery employment. After having applied the is entirely exhausted, the dressing may be cautery or moxa, I allow the eschar to fall removed, for the eschar is formed. This is off, and the wound to suppurate, without bf a deep-yellow or brown colour, and the stimulating it. When the ulcer is healed, circumference moderately red, swelled, and I immediately reapply new cauteries in its painful. In some days this swelling sub- vicinity, until I have obtained the good. sides, and the separation of the eschar, com- effects desired. I have, in this manner, all mencing from the circumference towards the advantage, and none of the inconveui. the centre, is usually completed from the ence of these powerful revulsives. -

-

i

644 the intestine, would have to lift up the mesocolon, in order to find this issue. One much less difficult is presented to it. It tends towards the crural arch and ingui. nal ring. In this case a mistake would be with difficulty avoided, did we not clearly recollect the distinctive signs of the hernias and congestive abscesses with which this disease may be confounded. Let us add, ON ABSCESSES IN THE RIGHT ILIAC FOSSA. that, it is in this part the alimentary matCase i.-A man was received last vear ters, taking the excrementitial character, (1832) into the Salle S.Marthe, with sýmp. are compelled to circulate contrary to the toms of a disease to which the attention of laws of gravity, and that it is in this part

A great number of persons affected with maladies of the joints of the shoulder, hip, or vertebral column, have, for many years, been treated at the Hotel Dieu in this man. ner. The majority have experienced the happiest effects, and many have been completely cured.

the students was then specially directed, that in numerous diseases, inflammatory and which has since been the subject of ex- alterations are met with. May we not then cellent memoirs by MM. Husson, Dance, , legitimately conclude, that all these dispoand Meiniere. The individual in question sitions, natural and morbid, elucidate the was about 40. He had considerable pain occurrence of these engorgements outside and circumscribed swelling in the right the intestine, and explain their frequency iliac fossa. Applications of leeches, emol- in tberio’ht iliac fossa. lient cataplasms, with slight laxatives, The appearance of these tumours is some. times preceded by precursory symptoms. succeeded in obtaining a perfect cure. A long time has elapsed since I have After some error of diet, constipation, diar. made known the fact of the development ofrhoea, colic, more or less habitual. Sometumours in the right iliac fossa, having an times, without any of these circumstances, apparently intimate connexion with the pa- the patient experiences colics and intestinal rietes of the caecum. These tumours are pain, tending to concentrate in the right frequently accompanied by remarkable iliac fossa, or radiatingin the great intesderangement in the functions of the large tines, or disseminated over the abdomen. intestine. In a great number of cases they Ordinarily, these colics are accompanied by terminate in resolution-sometimes by an constipation; in some cases by vomiting. abundant suppuration-and sometimes,they The duration of these previous symptoms is constitute the point of origin of a gene- very various-six weeks, two months, or tal peritonitis. Thus, in every point ofonly a few days before the appearance of the view, they should be carefully studied. local inflammation. Moreover, they have One of the first questions, then, which only a relative degree of importance, as presents itself is-Why do they almost in- they often occur without any tumour super. variably form in the right iliac fossa? Why vening. is the left iliac fossa so rarely their seat ? The symptoms peculiar to the disease are The answer can only be found in the form the fixity of the pain in a very limited point bf the intestine and its surrounding parts. of the iliac fossa, andthe tumefaction of this Plunged in a mass of cellular tissue, theI point. If this region be examined, it is caecum presents at its point of reunion with found more tense or resisting, and we often succeed in circumscribing a tumour the small intestine, so marked a constriction, that various foreign substances are apt to of variable volume, considerable hardness, accumulate there, and sometimes become more sensible to the touch than the rest of themselves the determiningcause of these the abdomen, and apparently reposing on abscesses-in the same way as pins, shells, the caecum. The patient complains of con&c., stop at the pylorus, or at the extremity stipation and colic. The emission of sterof the rectum. The case is different at the coral gases is impeded. Sometimes the left side. where the sigmoid flexure of the fever is rather intense, but in the uncomplicolon presents no constriction whatever. cated cases no general symptoms of imIf it be required to explain the difference of portance usually occur. issue these abscesses obtain in the right and The predisposing cames are of different left side, let us remember the anatomical kinds. The adult age has an incontestable dispositions of the parts, and we shall un- influence. Of sixteen patients, eleven were do stand that at the right side the want of under thirty years. The constitution preperitoneal covering behind, presents at this sents nothing very remarkable. It is otherpoint less resistance to the effort of the pus, wise with respect to sex, the registers of and that its thinned, corroded, ulcerated the Hotel Dieu showing that men are much edges, must there yield with facility. To more frequently attacked than women. The the left, on the contrary, hermetically shut same has been found in private practice. up in the peritoneum, protected by this The season of the year seems to have no membrane and the aponeurotic expansion of direct influence, but still the end of summer the iliac muscle, the pus, in order to reach and beginning of autumn afford the greatest i

645 This coincides perfectly iHence numerous fistulæ result; the introof the air and decomposition of the frequency of abdominalc In such a case I would are permitted. affections, and seems to strengthen the pus the opinion of those who think that in this dis-Irecommend the patients to lie on the belly, ease there is a pre-existing lesion of the iin order to make the opening the lowest The occasional causes point of the abscess. mucous membrane. These abscesses are remarkable in this are numerous and important. The influence of trade, by means of lesions thus producedrespect, that the pus may escape into the in the digestive tube, has been very oftenintestine without the stercoral matter enobvious. House-painters, colour-grinders, tering the abscess. The first reason for is the gradual emptying of the abscess, I this copper-turners, incessantlyexposed to and the emanations of certain irritatingand the abdominal pressure preventing any metals, have experienced colics and diar- vacuum in its interior, by means of which jhma which, after the lapse of more or less the fasces might enter. ’1 he second reason time, induced the formation of the tumour. is the obliquity of the opening. The third Several persons, much occupied by study, is the valvular adhesion of the intestine to wall of the abscess. have also been similarly affected. The place of residence is also a cause ofLastly, in some circumstances, happily importance. Wehave seen several patients very frequent, the inflammation rapidly in whom a brief residence in Paris , extends to the peritoneum ; sometimes to to induce this state of suffering. It is easily r! the post-peritoneal cellular tissue. Death understood how great this influence may be may be the consequence of this extenin a native of the country who quits it for of the disease. These notions being the first time for a city life. The food of established, let us now cite some casesprothe poor workmen, especially during the per to lend them illustration. fine season, is so bad, that the majority adCase 2.—A young man, aged 23, fair, mitted to the hospital with gastro-enteritis,weak, of scrofulous aspect, and very indusowe their disease to the diet they have been 1trious, experienced during the month of compelled to follow. Now all causes ofDecember, 1828, symptoms of entero-coirritation of the digestive mucous which, at first left to themselves, were are eauallv causes of the phlegmon of the treated with purgatives. The paafterwards iliac fossa. Drinks are as capable as food moreover, would not confine himself to of inducingthese accidents, and the history any par ticular diet. A phlegmonous tumour of the cases shows, that the majority of having developed itself in the right iliac it was treated by topical emollients. patients have made use of alcoholic liquors, rendered irritating by the addition of some)When he came to the Hotel Dieu, the ab. acrid substances. Several other patientsscess had nearly opened spontaneously. I An had taken purgatives in excessive doses. incision, however, was practised behind The progress and termination of these tu-the iliac crest, towards the insertion of the The mours are not always uniform. lumborum, where was felt a flucfavourable and most common is resolution. tuation, corresponding with that of the antumour. A bistoury was plunged in Of 16 cases, M. Meiniere found 11 to and the pus flowed copiously, but in this manner under suitable This resolution is usually slow, and leaves was not completely voided, and the tumour a deep-spated hardness indicating the seat of in the crural arch continued to increase. the engorgement. In other and very fre- The counter opening was practised, but quent cases, a pulsating pain is felt within without effecting a favourable change in the the swelling, which enlarg-s, softens, and patient. His strength diminished, the right breaks into the interior of the intestine. lower extremity became mdematous, diarThis favourable termination is announced rhaea and hectic supervened, and he died by a pressingnecessity to e’o to stool, fol- after five months illness. lowed by purulent alvine evacuations, coin- The opening of the body displayed a ciding with decrease of size in the tumour. large focus, having its seat in the cellular The cure is usually quick. Sometimes these tissue surrounding the caecum, with burabscesses open at ouee into the caecum and rows extending according to the direction bladder, or into the vagina, but at other of the psoas and iliac muscles. In some times, as in the case of M. Malus, to whom points the osseous surfaces were bare. The I was called by M. Nacquart ; and in some caecum did not communicate with the abother cases I have seen, the opening took scess, but it was manifestly thinned behind. place externally. This termination has been The mucous membrane was thick, rather usually unfortunate, for the base of the ab- so’tened, and
number of cases. with the greater

] duetion

dust,

the iI

I seemednot

I.B’

sion

I

membrane,litis,

Itient, thefossa,

mostquadratus endterior

treatment.deeply,

"

towards the highest point, the evacuation of thf pus can only be slow and incomplete.

lobes of the lungs. lower Case ’,.-The

patient,

a

young man,

646

tailor, ætat. j4(, presented the modifica. tion of various fistulous openings, evacua.

a

Here

pus.rejected by the anus.

again the

prognosis is not unfavourable, since expe. rience has shown the cure to be not less

ting pus and faecal matter. Serious constitu. tional symptoms supervened, but he reo perfect here, than in resolution simply. If general peritonitis supervene, death is covered in some months. Thefourth case presents no very remark, to be dreaded, because the devolopment of able feature. The patient was cured ir this disease is the signal of the rapid increase of the primitive affection, and over eight months. Tbeffth case is equally devoid of special the re-union of these two maladies art has interest. The patient was also cured. Ir no control. a sixth case the abscess opened into the The treatment should at first be preservative. When called in time, we almost always caecum, and the patient also recovered. - The diagizosis of these engorgements anc either prevent the formation of the tumour, phlegmonous abscesses is so important a,4 or at least impede and render abortive its to deserve particular notice. It is not rare progress. When pain in the iliac region is to observe in the right or left iliac fossl accompanied by alternate diarrhcea and con. indistinct engorgements seemingly having stipation, when by the touch we recognise the same seat as that above described, bu a deep-seated and ill-defined swelling, local they are really developed in the cellula bleeding, emollients, and slight laxatives in tissue connecting the psoas and iliac mus- drink or lavement, will put a stop to the

cles, and below the aponeurosis called the symptoms. Absolute rest, numerous and iliac fascia. This is a variety of the affec. prolonged baths, will be very efficacious, tion termed ’° psoitis" by different authois and strict diet is equally indispensable. After accouchment, engorgements are ofter If the tumour have already acquired a cera enough met with in the iliac fossae, bui tain volume, we must hasten to stop its inthey appear in the substance of the roune crease ;and to succeed in this, local and geligaments, or originate in the cellular tissue neral bleedings are necessary. If the sub. interposed between the broad ligaments o: ject be robust, and the febrile movement the uterus, and may thence extend to all th( considerable, bleeding from the arm should cellular tissue in the vicinity, and project at once be practised. A great number of in the iliac fossa. Sometimes these abscesses leeches should be applied to the tumour, ppen into the womb; sometimes through the and this afterwards covered with a large ca. sides of the vagina. taplasm. Emollient clysters should be admi. Under some circumstances the ilia( nistered morning and evening. The patient fossae may be the seat of purulent collections should drink several bowls of veal broth the source of which is very distant from containing sulphate of soda or magnesia. these regions, such as abscesses sympto- Oily juleps, especially, should be given at matic of caries, or of inflammation of the night. The application of leeches must be ligaments. The pus creeps along the psoas repeated as often as the state of the pulse, and iliac muscles, and the tumour induced the vigour of the patient, and the degree of is soft and fluctuating from the first. This inflammation of the tumour, seem to reremark suffices to distinguish these puru. quire. lent collections from all those previously When the diminution of pain, and the dedescribed. Errors of diagnosis may, how- creasing volume of the tumour, announce ever, be still committed in this case. 1 the commencement of resolution, it will be have thus seen this inflammation taken for enough to favour it by emollient applicaan.internal strangulation, or for hepatitis, tions, rest, and regimen. If, on the conIn two cases off trary, the tumour preserveits form, voor metritis, or peritonitis. Ihis description, the exact circumscriptioni lume, and sensibility, despite the means of the disease in the right iliac fossa, theem’ployed, fluctuation soon becomes perretention of stercoral matters, and the com-. ceptible ; obscurely at first, then more eviparative appreciation of other symptoms,, dent. The practitioner should then promote served to rectify the error, and the evacua-- its reabsorption by continuinghis antiphlotion of the pus by the rectum, almost at the! gistics, if the state of the patient permit day predicted, confirmed the justice of thethem, or confine himself to local emollients -

until the opening of the abcess takes place. The prognosis is not in general bad, since’ In this state some patients derive benefit in sixteen cases there was only one death.. from laxatives which stimulate gently the Obvious symptoms indicate a speedy cure.. contractions of the intestines and promote When, on the contrary, the accidents per.the evacuation of the pus. Finally, if insist, when the tumour increases despite off flammation of the peritoneum seem to be the means employed, when it becomes the’ imminent, we combat this grave complicaseat of fluctuation, first obscure, then moretion according to the well-known method. apparent, and of pulsations with excruciating pain, in this case we must expect to see the

diagnosis.