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by means of the catheter, and directed an enema of infusion of senna and tinct. of aloes,
On the morning of the 12th, Dr. Noble saw him in company with Dr. B., and myself; his pulse was 96; he had had his bowels evacuated by the enema and had passed his urine ; his mind was somewhat affected ; sensation natural; constant restlessness and desire to be moved. We directed sixteen ounces of blood to be taken, by cups to the spine, and a repetition of the enema. At 1 o'clock, P. M., his pulse was 120; skin hot and dry. I passed a tube into his stomach, and injected a gill of milk and water; he said he felt refreshed; from this time he sank rapidly ; his breathing became hurried and stertorous, and at 7 P. M., he died, about 50 hours after the first appearance of disease.
A post mortem examination was made thirty-six hours after death, by Dr. Bibighaus and myself-Dr. Noble being absent from the city. We opened the spinal column in the lumbar region, and found it filled with transparent serum; the theca was somewhat softened, and there was atrophy of the medulla spinalis. We were not able to examine the condition of the brain and other viscera.
On the Treatment of Young Permanent Teeth, that require
Plugging. By J. F. B. FLAGG, M. D. In the course of a series of microscopic observations upon the hunan teeth, in which I have been engaged for more than two years past, I was early led to observe the striking difference of density in the bony portions of teeth of different ages; particularly in their more external parts, as the bone approaches either toward the enamel or cortex.
In two preparations, consisting of transverse sections at the neck, one, an adult tooth, the other of the age of eight years, I
ve observed this peculiar development most decidedly illustrated. A section of the older tooth being prepared sufficiently to allow the light to pass between its pores, when subjected to a powerful lens, presented a uniformly fibrous, or striated appearance, from the edge bordering upon the chamber of the nervous pulp, quite to its outer surface, with the slight exception of the cortex at this part of the tooth; that being beautifully defined by its clustering stars.
A similar section of the young permanent molar, although it appeared equally opaque as the other at its inner portion, yet it gradually became less so, for about two-thirds of the way towards its outer circumference, when all its fibrous appearance was lost, and the external third became perfectly translucent,
Much difficulty has been experienced in the practice even of our best operators in regard to saving these early permanent teeth. It is not unfrequently necessary to fill the same cavity twice or three times, at periods varying from one to three years, before we can confidently pronounce it to be an operation lasting and permanently useful. The probable reason for this is the change which is constantly progressing within the tooth, necessary to its growth and full development; the capillary tubes, in the immediate vicinity of the cavity so filled, evidently acting to its detriment. I think it reasonable to suppose that this condition may be superinduced by vital action being in contact with a foreign substance. Be this as it may, having pursued the following practice with uniform success, I recommend it to others desirous of benefiting the condition of young sufferers in this respect.
After removing every particle of decay, I devote as much tiine to burnishing the bony surface as is necessary to close the mouths of the tubuli opening into the cavity. This should be done with a smooth instrument, capable of reaching every portion of exposed bone, and with sufficient strength to cause the bone to present under the instrument somewhat the feeling of enumel; then wipe dry, and fill full, solid, and finish.
On the radical cure of Varices, deduced from the prorimate cause.
Explained and demonstrated in Two Memoirs, by Dr. TOMMASO RIMA ; Ordinary Member of the Athenoum, Senior Surgeon to the Civil Provincial Hospital of Venice, formerly Chief Surgeon of the Navy, Clinical Professor, and Surgeon in Chief to the Military Hospital, of the late Kingdom of Italy. Rewarded with the Golden Medal of S. M. I. R., Ferdinand First, from the Royal Institute, for the invention of permanent and moveable swimming baths, &c., &c., &c. Second Edition, with an appendix by the Author. Translated from the Italian, by JAMES BRYAN, M, D., Lecturer on Surgery, &c., &c.
On Varicocele. In the classification of the innumerable disorders to which the human organism is subject, some are alterations of tissue, which sooner or later according to the importance of the part attacked, tend to the destruction of life; others are so circumscribed in their effects, that they occasion only a slight alteration in the function of the organ or viscera where they are seated. Thus they sometimes disappear spontaneously, instead of increasing with advancing years.
But some of these occasionally remain within certain limits, and produce an amount of suffering disproportioned to the actual extent of the organic lesion. Of this number is Varicocele. This consists, as is well known, in a morbid enlargement of the veins which con
vey the blood from the testicle to the general circulation, coursing, enclosed and covered by the scrotum, along the spermatic cord, commonly in an irregular serpentine matter.
It will not be in place here to speak of the essential character of this disease, of the degree of alteration which the membranous tissues of the spermatic veins undergo, of the mode of distinguishing it from hernia of the omentum, or of other diseases with which it may be confounded. We will merely state, to fix it in its place, not to verify the disease, as all writers have asserted, one characteristic sign of Varicocele, which will distinguish it from omental hernia: it is, that the former developes itself from the testicle towards the abdominal ring, while the latter, or epiplocele, descends from the inguinal canal to the scrotum. A theory which is well proved by physiological and pathological laws, is not always established by a clinic, at the bedside of the patient. There is no doubt but that an epiplocele must descend from above, and pass the inguinal canal into the scrotum. But we cannot so certainly say that a varicocele must pass from below upwards, from the testicle to the ring. If we admit (for the moment) a new supposition, that the blood in varicocele may descend from the vena cava and renal veins, and
oppose that which naturally ascends from the testicle to the spermatic veins. This symptom would cease to be pathognomic, and the obscure would become diagnostic. We will return to the argument when it becomes necessary to prove that such a supposition may be demonstrated by facts.
In the majority of cases, varicocele remains latent and innocuous. It is, for the most part, by mere accident that the most careful discover it under the fingers. It generally appears as a group of worms, covered by the integuments of the scrotum, merely inducing a sense of weight in the testicle, a dull sense of stretching in the region of the kidney, and this not constantly. The patient, half mechanically, supports his scrotum for relief. With this precaution he walks, rides, dances and undergoes any
es and undergoes any other gymnastic exercise without pain.
Our predecessors limited their prescriptions to a suspensory bandage, local astringents, bathing and cold water. The cure was merely palliative. We do not speak of certain empirical ministers of Hygeia, who applied various pharmaceutical preparations, whether sanctioned by experience and reason, or not, to all diseases.
All surgeons, who are not entirely unknown, will occasionally have patients present themselves to be relieved of varicocele. Some apply to us to relieve them of a varicocele, which is neither voluminous, nor incompatible with the uses of life. Here, it will not be difficult to convince the patient, that greater harm will result from the operation, than the benefit which can be hoped for. Though it is true that this is the ordinary course of the disease, yet
it is very certain that, in some rare cases, pains and other symptoms arise where it is permitted to push the knife beyond the limits which antiquated scholastic precepts have in vain imposed on an illimitable art. The following is a case in point:- Antonio Morbiato, of Venice, writer under the royal pretorship, in the parish of Cadore, came to this country in July, 1833, to place himself under my care for a varicocele in the left testicle—a more frequent seat of this disease than the right.
He had arrived at the thirty-second year of his age, and had no appearance of want of health. For ten years past the varicocele had been so decided as to exempt him from military duty. But it continued so mild as not to interfere with his running over the Alpine rocks of the Cadorino in the chase, which was his favourite amusement. Not until November of 1822, (writes the patient) did the first painful sensation pass along a varicose and tortuous vein, which had ascended towards the testicle, swelled so visibly as to exempt me from military conscription, for the six months previous.
On consulting a physician he recominended to me the use of cold bathing in water and vinegar, with the occasional use of the suspensory bandage. He did not, however, give up his favourite exercise, the chase, or restrain himself from indulgence in that which his vigorous age inclined him to. Fortunately, not withstanding this violent exercise, after a tiine the painful sensation left him so completely, that he was enabled for seven years to follow his Alpine course.
The slight pain was confined entirely to the enlarged vein, whose swelling increased by exercise, and particularly during four or five days in the spring of the year. With this slight variation, the life of our patient continued up to 1833. It must be recollected that in March the disease increased continually, but with little pain. The means first resorted to, with repeated leeching, were insufficient to impede its progress, so that in the middle of July he writes, his life had become burdensome, since he was constantly confined to his bed, full of pain and fit for nothing.
The cure was not completed on the 20th of July. The infusion of digitalis and guaiacum, locally applied, diminished for a time his sufferings, but was not sufficient to induce me to expect a cure, without the repetition of leeches. Scarcely had he abandoned the horizontal position, ere his pains recommenced. It appeared, and was a fact, that the blood, in opposition to the natural laws of the circulation, was not moved by the abundance of that passing through the spermatic veins of the testicle, but condensed into one column, in a manner to compress materially by its mass the spermatic nerve. Hence came the unpleasant sensation about the kidney, and not by the other filaments of the mesenteric plexus of the great sympathetic and of the lumbar nerves. To the advantage of the horizontal position, he added, temporarily, that of cold, and of the constant application of
guaiacum. This, operating as a mechanical astringent, must necessarily corrugate the vascular tunic on the slow moving column of blood, diminishing its volume and the capacity of the tunic. Such an impression of cold diminishes the chief pressure on the nerves. The sensation is reduced by the action of this agent to an unpleasant sensation of weight and stretching. Changing the supine position of the body exacerbates the suffering. To the most painful, excruciating, and insufferable physical sufferings of the patient, are added severe mental distress; hence, he writes that he is tired of his existence. He is in such a state that he demands succour and efficacious relief. The destruction of the testicle offers, according to the usual practice, the only hope of a cure, but with a painful sacrifice.
The patient will not object, nay, he will implore the operation. But the surgeon of the nineteenth century should not perform it. The radical cure of varices of the leg has been practiced by us in different ways, and repeatedly during the last twenty-six years. In
, spite of incision, ligature, and the excision of a portion of the saphena, though the result has not corresponded entirely in all, varying in different cases, yet it is proved that the venous circulation has received no harm. This reflection has induced the idea, that as in the great saphena, so in the spermatic veins, no harm can occur. It is true, that these being isolated by a very slight adhesion to the cellular tissue of the scrotum, do not present the most favourable combination in connection, with an infinite number of smaller ramifications. We might fear that if varicocele were formed by a morbid alteration of both the spermatic veins, with the excision of a portion of these the blood of the testicle could pot be conducted into the current of the general circulation. As a consequence we might have the disorganization of the testicle. We must be prepared for this accident. But why be not willing to trust the hazard of the operation? The following reflections have induced me to attempt it.
Scarpa has demonstrated, in a masterly manner, in the arterial apparatus, the system of compensation which nature adopts when a vessel has been obliterated, either artificially or by disease. There is reason to believe that, to a certain extent, this physiological and anatomical law is also active in the venous system. If the rule be correct, that greater evils follow the lesion of an artery than that of a vein, it will apply with much more force to operations on the spermatic vessels. There are two veins devoted to this function, besides the artery. This carries the blood for the nutrition of the testicle, and also the principle of which is composed, and from which is elaborated, the first element of life, the semen. The veins have but a secondary office, that of carrying again into the current of the general circulation the residuary blood, in order to be deprived of its carbon and to reacquire its lost oxygen. The venous blood (to avail my