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self of a trivial idea, but one adapted to my purposes) is the serous portion of the milk, from which is extracted the caseum and buttery portion. The spermatic artery runs in the central part of the cord, while the veins course in a serpentine manner on its external surface. A portion of a vein may therefore be cut without wounding the artery. In cures by injection or ligation of the spermatic vessels, those of the scrotum and dartos coming from the femoral and obturator arteries, join with those of the involucre of the testicle to support its vitality. We may not perhaps expect the secretion of the semen, on account of the smallness of these external vessels, or perhaps the blood of these vessels does not contain the prolific principles which form the elements of this fluid. In our case, of treatment by incision of the veins, where their action is simply secondary, and restricted to carrying the blood, already deprived of its principal elements, these vessels may, on account of their tenuity, carry on the function in substitution of the spermatic veins, when the latter are entirely destroyed. As the two veins correspond to one artery, each of which is larger than the artery itself, we must hence admit, that the venous circulation is more certain than the arterial. The compensation to the venous system may be the lymphatic vessels. Besides performing their own functions, these vessels may carry venous blood. From the experiments of Lippi, and the controversy of Rossi, we are informed that there exist direct communications between some of the venous and lymphatic vessels.
The operator and patient being agreed, it was decided to commence with the incision of the varicose veins alone, and to cut successively the artery and ras deferens, should the sacrifice of the testicle become indispensable.
Such an operation, sanctioned by a distinguished practitioner of this city, was in fact directed on the seventh of August, 1833, with the assistance of Dr. Trevesini, royal fiscal physician. A transverse portion of the integuments was elevated, from which a perpendicular incision about two inches in extent was made. Raising with a pair of forceps the fascia of the varicose veins, three incisions were made with a pair of scissors, for the purpose of exposing the veins which surround the vas deferens. The third incision was much the most painful, corresponding to the track of the vein, whose great pain induced the patient at any risk to submit to the operation. There was no necessity for ligatures on the vessels; the bæmorrhage being purely venous, ceased spontaneously. The wound was dressed with a linen cloth tempered with oil and lint, spread with a refrigerating ointment. No phenomena worthy of notice were de veloped, the pulse scarcely indicating fever. 'Forty-eight hours afterwards, the wound was dressed with little or no inconvenience to the patient. This could not be said three hours afterwards. Severe pains attacked the patient, ascending from the lower part of the wound to the region of the kidney, which were increased by the least motion of the body; so that the patient was reduced to a tetanic immobility imploring assistance. The pulse was depressed and jerking, subsultus tendinum, extremities cold; eyes sunk; hippocratic countenance, with cold sweats, were the symptoms presented. The calm through which he had passed for fifty-two hours, after the operation, did not indicate a scene so alarming. This sudden and violent attack was a speaking proof, that the deleterious influence of some morbid agent was acting upon the nervous system. Could it be the atmospheric air admitted for an instant during the last dressing? Assafætida with morphia internally; an embrocation of oil and morphia to the wound, with the application of guaiacum to the groin and to the renal region, were the means resorted to, during two days of great suffering; also, a blood letting with the application of leeches to lumbar region, as soon as vital reaction would permit. All the so-called nervous symptoms having subsided, about the third day, general inflammation attacked the wound and vicinity. Moderated by the abstraction of blood, digitalis and local applications, intended to reduce vascular action, a laudable and abundant suppuration put an end to the painful scene of this morbid process. The testicle which had remained safe during the storm, became also, by the affusion from the wounded part, inflamed, and was the seat of a collection of fætid pus, in the tunica vaginalis and albuginea, which discharged spontaneouslythrough the wound. From this time the ulcer progressed regularly, and the cicatrix was healed early in September. Sig. Morbiato returned to the duties of his office, and soon after to his usual habits.
I have now finished the historical part of the operation. It remains to add certain reflexions, as well on practical surgery, as on the special pathology of the veins. When the intolerable pains of our patient induced him to submit to the operation, we were not aware that others had performed it. The common practice, supported particulary by the authority of Boyer, has been the demolition of the testicle. In the history of medicine we learn that various varicose tumours have been extirpated by good surgeons. Petit has excised two, one of which he calls lymphatic sanguineous varicocele. The other, which was much less, he excised from the cord. A third was eradicated by my friend and colleague, Dr. Cumeno, of Trieste, from a French military surgeon, who does not speak of simple varices of the spermatic veins, but of varicose tumours. These tumours may form independently of the veins. We know that cancer from its nature produces varicose veins, and there is cancer of the varices. From the small vessels of the scrotal membrane, one of those inorganic fungous productions may arise, which may have but a superficial, or perhaps no attachment to the spermatic veins. If this were known it might be extirpated, leaving one of the two untouched. In order then to arrange the facts and suppositions above written, we have proved -
1st. That varicocele, under ordinary circumstances, is a disease of little inconvenience, yet occasionally it becomes so painful as to render it intolerable, and to demand the assistance of the surgeon.
2d. That varicocele may be radically cured by the excision of the varicose mass, without the destruction of the testicle, as was the practice of our predecessors.
-3d. That the serious consideration of surgeons should be directed to the theory of varices, to know whether generally, or in some solitary cases, the disease takes place, or is maintained by the blood which flows back from the great veins. This should be suspected by writers on varicocele, as I have sufficiently demonstrated in a letter of December 29th, 1825, speaking of varices of the lower ertremities. Whilst I operated on the seventh of August, 1833, Siz. Dufresne published, on the 27th February, of the present year 1836, in the Journal Hebdomadaire, a memoir containing various operative processes for the radical cure of varicocele. He refers to the practice of the ancients, who tied the vein above or below the varicose group; he does not analyse this operative process and give the rule, but merely writes it as a historical fact.
We learn from this memoir that the learned physician, our colleague and friend, Professor Delpech, the unhappy victim of the ingratitude of men, has operated several times, with happy results, by the excision of the varicose spermatic veins Never. theless, one is surprised that he adheres to the opinion of Boyer, preferring semi-castration. The result is certainly not less doubtful, and the sacrifice is too painful, especially if the patient be in the bloom of life. He then proceeds to give us the opinions and various processes of Breschet, Velpeau, Friche. They attempt in various ways to obtain their purpose without cutting the integuments of the scrotum, and without exposing the vein. Breschet uses a pair of pincers, which somewhat resembles the compressor of Assalini. The vein and a portion of the integuments of the scrotum being introduced between its two branches, they are pressed together so as to bring the parietes of the vein in contact. The others use a needle to perforate the vein, and carry a thread to act as a seton, allowing it to remain two or more days. Others with a greater probability of success, on a needle which has passed through the integuments of the scrotum, under the vein, twist a thread in the figure of 8 form, or else retain the vein in constant compression between the needle and the thread, as is done in hare-lip.
Several cures have been obtained by these processes. He cites among others as authority, the name of Velpeau. But they seem to us not to unite the cito, tuto et jucunde of Celsus, and should
not supersede simple excision. It is certain that this pricking terrifies the patient, nor when accomplished is the pain relieved. By incision the pain is transient, and the operation decisive, and is finished in a few seconds. We cannot say so much of the strangulation of the vein between the needle and thread. This occasions a little pain at first, but the pain must of necessity continue to increase, indeterminately, for several days; nor can we know in anticipation or perhaps in reality, to what extent, and how long a time it will continue and excite inflammation, as we will not have the power of limiting it to the simple grade of adhesion. The excited sensibility of the vein does not remain circumscribed to the point compressed. It extends easily along the vein, and there is danger that phlebitis will extend to the larger trunks, endangering
the life of the patient. Nor is the inflammation confined to the vein. The integument and other parts which sympathise with it are likely to participate. It is not uncommon for gangrene to attack the integuments which surround the points compressed, and killed, by the pincers or by the needle and thread.
Resection, on the other hand, induces some loss of blood, which depends upon the operator favoring it or not, so that the inflammation of the wounded part may be circumscribed, which cannot be done with compression. Strangulation of the vein does not give confidence to the patient, who perceives always the uncertainty of the cure, without knowing the extent of suffering. Nor should we be surprised if after three or four days the sufferings of the patient should induce the surgeon to relax the compression, leaving him exposed to all the results of the experiment, which are not only useless in effect, but always pernicious, and may induce grave consequences.
In excision, the patient may be compared to a ship in a troubled sea, the wind having ceased to blow ; while compression may be compared to a vessel which leaves the shore, throwing itself into an ocean, soou to suffer all the effects of an inevitable tempest, whose duration or termination canot be surmised.
Should the patient have enough of courage and patience to resign himself to events; uncertain whether adhesion will take place, or how much time must pass ere its accomplishment, well; if not, he will consider the operation a total loss. If it is performed in a place which may be obliterated, we may not obtain cure on account of the anastomosis of the obliterated vessel. If the varicocele is in both veins, the operation must be performed the second time, uncertain still whether compression is applied to the remaining vessel or to that which has been operated upon. Facts, in fine, in the cure obtained by strangulation, have proved, as has been said by Dr. Dufresne, that we always have more or less suppuration. Nor can we guarantee the patient from the danger of secondary hæmorrhage, which, without the degeneration of the wound, cannot take place after excision of the vein. Subjected to an impartial examination, and placed in opposition to the advantages we may hope for, and the dangers we may fear, it appears to us that excision of the varicose veins merits the preference without regard to the choice of the patient.
Clinical teachers, who reason upon and compare the different methods, are authorized by experience, to form a judgment which will serve as a guide to the novice in the noble art of surgery.
On Diseases of the skin. By ERASMUS Wilson, F. R. S., Con
sulting Surgeon to the St. Pancras Infirmary; Lecturer on Anatomy and Physiology in the Middlesex Hospital School of Medicine, etc. etc. Second American from the second London edition. Svo. pp. 439. Lea & Blanchard. Philadelphia: 1947.
Although we have many works on Dermatology, we can hardly be said to have yet arrived at any great degree of accuracy in our diagnosis of the various affections, and, as a consequence, their treatment remains for the most part empirical and often unsatisfactory. The greatest confusion exists in the classifications of authors. Affections are described as distinct diseases, which often co-exist, or become blended, so as to bid defiance to all attempts at satisfactory diagnosis. With some, the topographical system, which divides the diseases according as they affect the head or the body generally, has been prefixed; but more generally the system of Plenck, modified and improved by Willan, was for a long time adopted. It consists of six orders, characterized by the appearance of the eruption, which, instead of constituting the disease, is in fact merely one of its products. To this succeeded the so-called natural system of Alibert, which embraced all cutaneous diseases in one