Part 88

[54] [When the pain is considerable the camphorated liniment with morphia, laudanum, or belladonna, will be of great service. It should be rubbed upon the scrotum every four or five hours, avoiding of course injury to the inflamed testicle and epididymis. When the acute symptoms of the disease have subsided, under the treatment recommended in the text, the most efficacious practice is compression of the enlarged organ, by strapping it with the gum and mercurial plaster. Dr. Fricke of Hamburg pursues this plan in the very commencement of the inflammation, however severe, with the effect often of curing his patients in a few days. The plaster should be cut into narrow strips, not more than half an inch in width, and be applied in a circular manner round the testicle, which is to be previously drawn to the bottom of the scrotum. The first piece is to be placed round the insertion of the cord, just above the epididymis, and after the whole organ has been thus enveloped, another series of strips is to be applied from below upwards, to confine the first, and more completely equalise the pressure. Great care is to be taken not to pucker the skin, which should be previously divested of hair. “If the pressure of the plaster occasions pain or irritation, the strips are to be removed till the inflammation and sensibility are diminished. In many instances the patient experiences almost immediate relief from the application.” This remedy, which has been recently claimed by a European writer as new, appears to have been employed, with marked success, in the Pennsylvania Hospital, in the early part of the present century.—ED.]

[55] The principal objection to this method is, that it is not always successful, and that it requires, in some cases, to be repeated again and again before a sufficient amount of adhesive action is induced to obliterate the vaginal sac. Moreover, by carelessness on the part of the surgeon, the canula may slip out of the vaginal sac, and so allow the fluid to pass into the cellular substance of the scrotum, where, if it be not speedily evacuated by free incisions, it is sure to occasion gangrene. But this is not all. The operation, even when well performed, is sometimes followed by violent inflammation and suppuration; in one instance, indeed, I knew it to be productive of tetanus. The patient, a stout, robust mechanic, about twenty-six years of age, whom I saw twice in consultation, was doing apparently well during the first eight days after the operation; when, owing to exposure to cold, the symptoms of the disease in question manifested themselves, and in less than twenty-four hours the man expired. Upon examination after death, the vaginal tunic was found to be considerably thickened, and its cavity to contain several ounces of sero-sanguinolent fluid, intermixed with a small quantity of unhealthy-looking pus. No adhesions had taken place between the opposite sides of the sac. A case of a similar kind is alluded to by Sir George Ballinggall, in his “Outlines of Military Surgery.”

The operation by injection has, I know, many advocates, both in this country and in Europe; and, when well executed, is generally unattended with risk, if not always successful. The fact, however, that it may be followed by serious mischief, with occasional loss of life, should be sufficient to deter the practitioner from resorting to it, more especially when we reflect that we are in possession of another remedy, not only entirely devoid of danger, but always, so far as my observation extends, most effective. This remedy is the seton, which I have been in the habit of employing, in repeated instances, for some years past, and from which I have never experienced any other than the most happy results. The operation is perfectly simple, the amount of inflammation produced by the presence of the foreign body may be easily regulated, and there is no danger of sloughing of the scrotum, much less of the development of tetanus, or other mischief.

In performing the operation, a large round trocar is introduced at the usual place, and after the fluid has been thoroughly evacuated, the instrument is again conveyed along the canula to the upper and fore part of the scrotum, for the purpose of effecting a counter-opening, which should be from an inch and a half to two inches from the first. The trocar is now withdrawn, when an eyed-probe, armed with a skein of silk or piece of tape, is passed along the tube, upon removing which the operation is completed. The seton need seldom be retained longer than four or five days; during which period, as well as for some time subsequently, the recumbent posture should be enjoined, along with suspension of the scrotum, and the usual antiphlogistic means. When the inflammation, tenderness, and swelling have considerably abated, the reduction of the tumour may be promoted by the daily inunction of equal parts of iodine and camphorated mercurial ointment.—ED.

[56] In upwards of one hundred cases examined by Mons. Breschet of Paris, only one occurred on the right side. With this result, the experience of nearly every practitioner must coincide. Cirsocele may take place at any period of life, in the young as well as in the old; but it is most common, by far, within the first ten years after puberty, or during the period of the greatest excitement of the genital system. In twenty-seven cases observed by Mons. Landouzy, in which this subject was particularly noticed, seven occurred between the ages of nine and fifteen; seventeen between fifteen and twenty-five; three between twenty-five and thirty-five.

Cirsocele appears to be occasionally hereditary. Professor Blandin of Paris, in an able article on this disease, in the “_Dict. de Medicine et Chirurgie Pratiques_,” refers to three brothers with whom he was personally acquainted, who were all exempted from military duty on account of the existence of this malady: the father was similarly affected. An analogous case is mentioned in an inaugural dissertation published a few years ago at Paris.

The causes of cirsocele are, venereal excesses, masturbation, protracted exercise on foot or horseback, contusions of the scrotum, inflammation of the testicle, and mechanical obstacles to the return of the blood to the spermatic veins, whether produced by the presence of a tumour, fatty accumulations of the omentum or mesentery, or the wearing of tight and ill-constructed trusses. Of these the first two are probably the most frequent and influential. Indeed, I am persuaded, from considerable experience, that this is the case. How these causes act in developing this affection admits of ready explanation. Their tendency is not only to determine an abundant afflux of blood to, and consequent congestion in, the genital organs, but to produce more or less fatigue in the muscles of those parts, especially in the cremaster and dartos, together with a loss of nervous innervation, which diminish their power and contractile energy. The testicle being thus insufficiently sustained sinks down, by its own weight, into the scrotum, which, with the spermatic vessels, is thereby kept in a state of constant relaxation. Heat acts in a similar manner, and produces similar results. Hence cirsocele is more frequent in hot than in temperate climates, and worse in summer than in winter.—ED.

[57] [Although the symptoms of this affection are usually well marked, yet it is sometimes liable to be confounded with other lesions. The malady for which it is most apt to be mistaken is inguinal hernia, especially that variety of it in which the omentum is concerned. The best way in such cases is to place the patient on his back, and hold up the scrotum until the vessels are entirely emptied of their contents; the finger is then applied against the external ring and the patient requested to rise, when, if the disease be cirsocele, the spermatic veins will immediately refill, while, if it be hernia, the bowel will be unable to descend.

The progress of this disease is usually tardy, years elapsing before it causes much suffering or inconvenience. In some instances, however, it increases with great rapidity, and gives rise to severe local disorder, with more or less constitutional derangement. One of the most serious and unpleasant effects of this disease is atrophy of the testicle and epididymis, produced by the pressure of the enlarged veins; it may exist in various degrees, from the slightest softness and diminution of volume to almost entire wasting of the organ, and occasionally, though rarely, affects both sides simultaneously. A gloomy and melancholy state of mind, sometimes bordering upon alienation, frequently attends this condition of the testicle.—ED.]

[58] [The least objectionable operation, in my opinion, is that of tying the affected veins, after having carefully separated them from the spermatic artery, vas deferens, and nerves of the testicle. The vessels may be ligatured at one or more points, according to the extent of the enlargement; and, by carefully excluding the structures just mentioned, there will be no danger of cutting off the nervous and vascular supply, as must necessarily happen, in some degree, in the proceeding recommended by Mr. Liston, and which must therefore lead to further wasting of the testicle; a circumstance which should be most sedulously avoided. The external incision need not exceed an inch and a half in length.

I am induced to subjoin the following account of a novel but harsh operation for the cure of cirsocele, lately devised by Mons. Breschet of Paris, not from any belief or hope that it will be generally adopted, but because it has made some noise in the surgical world. It is founded upon the anatomical arrangement of the part, or the facility with which the varicose vessels can be isolated from the spermatic artery and vas deferens, and afterwards compressed so as to obliterate their calibre. This is effected by means of a forceps with flattened plates, which are worked by a screw. The pressure is applied in a gradual manner, but with sufficient force to destroy the vitality of the scrotum and of the affected vessels. The instrument is usually removed in from six to eight days, during which the patient is left on his back, cold lotions are applied to the scrotum, and the case treated on general principles. When the sloughs are detached, the edges of the sore are approximated by adhesive strips, and the person is permitted to walk about. In this way Mons. Breschet is said to have operated successfully in more than a hundred cases; the average period required for a complete cure being twenty-three days. I have never performed this operation, the severity of which is such as to induce the belief that very few persons in this _republican_ country would submit to it. An American surgeon, Dr. F. Hamilton, of New-York, has recently recommended castration for the relief of this affection, and has published several cases in which he performed the operation in illustration of its efficacy. This is certainly a _radical_ mode of doing business, but in my opinion a very objectionable one.—ED.]

[59] [Of 5376 calculous cases mentioned by Civiale,[60] 2416 were children, 2167 adults, and 793 old persons. Of these 1946 occurred before the age of ten, 943 from ten to twenty, 460 from twenty to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, and 17 after eighty.

Children are more subject to this affection in certain districts than in others; and the same is true in regard to adults. The greater proportion of calculous cases in Wirtemberg, in the mountains of Switzerland, the Neapolitan States, and some of the provinces of England, occur in young persons, from causes which have not hitherto been explained. In the United States a larger number of children are afflicted with this disorder in Kentucky, Tennessee, and Alabama, than perhaps in any other sections. In very warm or cold latitudes, on the contrary, adults, and, above all, old people appear to be most liable to it.

Whether this affection is actually hereditary or not is not yet fully decided. Facts certainly warrant the inference that it is. Thus, Civiale relates the case of a man on whom he practised lithotrity, whose mother had had the stone, and one of whose children died of it. He also performed the operation on two brothers, whose grandfather and two uncles had laboured under the disorder. Prout speaks of a family of which the grandfather and father were affected with uric acid calculi, and who had a son, aged thirteen years, that was very much predisposed to the same disease.—ED.]

[60] Treatise on Calculous Affections: MS. translation by Dr. Colescott.

[61] [In comminuted fractures of the lower jaw, it sometimes happens, in spite of our best-directed efforts, that the ends of the fragments cannot be maintained in contact. Under these circumstances it may become necessary to tie the pieces together by means of a gold or silver wire, or to make the patient wear a thin metallic plate, adapted to the shape of the jaw, and interposed between the cheeks and dental arches; to the latter of which it should be immoveably fixed.—ED.]

[62] [The bones, owing to falls, blows, or other external violence, are occasionally _bent_, with or without partial fracture. Within the last few years a considerable number of cases of this accident have been reported by American and European practitioners. The first regular account of it was published in 1810, by Professor Jurine of Geneva; and in 1821 a very able article on the subject appeared in the American Medical Recorder, from the pen of that distinguished surgeon, Dr. John Rhea Barton, of Philadelphia.

Simple bending is most common in the radius and ulna, though it is by no means confined to them. For obvious reasons it happens only in children, before the completion of the ossific process, or in whom there still exists a predominance of animal matter. In older persons the bones more readily break than bend. The diagnostic signs of the accident are, pain and deformity at the seat of the injury, loss of power in the limb, want of displacement of fragments, and absence of crepitation. The deformity consists in an unnatural curvature, which can be made to disappear under pressure and extension, but recurs, to a certain extent, when the limb is liberated. When attended with partial fracture, the symptoms are the same, excepting that, instead of a curvature, there is angular deformity opposite the seat of the accident. When the injury occurs in the forearm, and only one bone is implicated, extension generally produces no change in the appearance of the limb. The treatment, in both cases, is to be conducted upon the same principles as that of fractures. The attempts to remove the curvature by extension should neither be too violent nor long continued, otherwise they must prove injurious. Mr. Mantel of England, distinguished alike as an able surgeon and an accomplished geologist, thinks that the application of leeches and the usual antiphlogistic means should alone be trusted to when there is much pain and swelling, alleging that the action of the muscles will ultimately restore the limb to its natural form.—ED.]

[63] [A comparison of the results of the different kinds of treatment of disunited fracture, furnished by Dr. Norris of Philadelphia, in an able and elaborate article in the American Journal of the Medical Sciences, for January, 1842, leaves no doubt as to their relative value. Of forty-six cases in which the _seton_ was employed, thirty-six were cured, three partially relieved, five not benefited, and two died. In twenty-one the seton was introduced with, and in twenty-four without, previous incision: of the former seventeen were cured, two improved, one failed, and one died; of the latter eighteen were cured, one was benefited, five failed, and one died. In reference to the seat of the fracture, the cases stand as follows:—

13 for the femur, of which 9 were cured. 10 ” leg, ” 10 ” 16 ” humerus, ” 10 ” 6 ” forearm, ” 6 ” 1 ” jaw, ” 1 ”

The average period of the existence of the fracture in the above cases was nearly twelve months and a half, the longest ten years, the shortest six weeks. The mean period of the retention of the seton was seven weeks and three days. In one instance—that of a fractured humerus—it was left in thirteen months, notwithstanding which it finally failed. The average time required for the cure was nearly three months, the longest eight months, the shortest three weeks. Arterial hemorrhage occurred in two of the cases; in ten, severe fever, erysipelas, or profuse suppuration.

Of thirty-eight cases in which _resection_ was performed, twenty-four were cured, one improved, seven failed, and six died. The seat of the injury was as follows:—

12 were in the femur, of which 7 were cured. 6 ” leg, ” 5 ” 12 ” humerus, ” 6 ” 7 ” forearm, ” 5 ” and 1 improved. 1 ” jaw, ” 1 ”

The longest period of the existence of the fracture in these cases was five years, the shortest ten weeks, the average thirteen months and nineteen days. The average time required for effecting a cure was four months, the shortest one month, the longest thirteen months. In seventeen of the cases other methods of treatment had been ineffectually tried: in six the resection was followed by erysipelas, in one by phlegmasia dolens, and in two by profuse suppuration and abscesses.

Of thirty-six cases healed by _pressure and rest_, twenty-nine were cured, one improved, and six failed. The seat of fracture was:—

In 13 cases in the femur, of which 9 were cured. ” 7 ” leg, ” 7 ” ” 12 ” humerus, ” 9 ” ” 4 ” forearm, ” 4 ”

The average duration of the fracture in the above cases was five months and twelve days, the longest twenty-two months, the shortest four weeks. The mean period required for a cure was nine weeks, the longest nine months, the shortest eighteen days. In one of the cases the treatment was productive of excoriations, in three of severe pain and inflammation.

_Cauterization_ of the ends of the fragments, after free exposure of them by the knife, was successfully employed in six cases; in two others it completely failed. The article most frequently used was the caustic potash. Frictions succeeded in eleven cases.

From a careful analysis of all the circumstances connected with the preceding cases, one hundred and thirty-nine in number, and of which the above is an abstract, Dr. Norris has deduced the following conclusions:—1. That non-union after fracture is most common in the thigh and arm. 2. That the mortality after operations for its cure follows the same laws as after amputations and other great operations on the extremities, the danger being in proportion to the size of the limb and the proximity of the injury to the trunk. 3. That failures after operations are more frequent in the humerus than in other bones, and in middle-aged and elderly persons than in young ones. 4. That the seton, variously modified, is safer, speedier, and more successful than resection or caustic. 5. That incising the soft parts previously to introducing the seton augments the danger, but renders the cure more certain and expeditious. 6. That allowing the seton to remain in for a long time exposes to accidents, and does not facilitate the cure. 7. That the seton is least successful in the femur and humerus.—ED.]

INDEX.

Abdomen, affections of, 412 injuries, 438, 440

Abscess, 31 lumbar, 441

Adhesion, 25

Albugo, 264

Amaurosis, 275

Amputation, 612 arm, 624 fingers, 619 foot, 628 forearm, 622 hip-joint, 631 leg, 628 shoulder-joint, 625 thigh, 630

Anchylosis, 73

Aneurism, 118, 121 by anastomosis, 127 popliteal, 125, 541 axillary, 389 osseous, 158

Aneurismal varix, thigh, 542

Anthrax, 63

Antrum maxillare, inflammation of, 317

Anus, pruritus, 460 artificial, 434

Arterial system, diseases, 116, 121

Articular cartilages, atrophy and hypertrophy, 75

Artificial anus, 433, 434

Artificial pupil, 287

Ascites, 435

Axillary aneurism, 389

Bladder, inflammation of, 469 irritable, 470

Blennorrhœa, 247

Bone, diseases, 94 fractures, 552

Brasdor’s operation, 126

Bronchocele, 377

Bruise, 610

Bubo, 197

Bubonocele, 416

Bunnion, 544

Burns, 211

Bursæ, diseases of, 80 inflammation of, 543

Calculus, in the female, 530 salivary, 336 vesicæ, 508

Carbuncle, 63

Carcinomatous tumours, 142

Caries, 96

Castration, 507

Cataract, 277, 279, 280

Chancre, 201

Chemosis, 259

Chest affections, _see_ Thorax.

Chimney-sweeper’s Cancer, 495

Choroiditis, 274

Cirsocele, 417

Club-foot, 545

Compression, 226

Concretions, salivary ducts, 336

Concussion, 218

Congestion, 23

Corectomia, 287

Corneitis, 261

Corodialysia, 288

Corotomia, 287

Coxalgia, 81

Croup, 354

Cynanche trachealis, 354

Deafness, 375

Delitescence, 26

Dislocations, 588 ankle, 606 carpus, 599 clavicle, 592 elbow-joint, 596 fingers, 599 hip-joint, 600 congenital luxation, 604 lower jaw, 591 patella, 605 radius, 597 shoulder-joint, 592 tarsus, 606 wrist-joint, 598

Distortion of the feet, 545 varus, 547 valgus, 548 pes equinus, 548 calcaneal, 549

Ear, diseases of, 373 foreign bodies in, 375

Ear, polypus, 375

Eburnation, 75, 113

Ectropion, 254

Eczema rubrum, 211

Emprosthotonos, 183

Empyema, 410

Encanthis, 252

Encysted tumours, 151, 336, 406 of eyelids, 253 of the breast, 406

Enterocele, 415

Entero-epiplocele, 415

Entropion, 255

Epiphora, 247

Epiplocele, 415

Epispadias, 495

Erethismus, 211

Erysipelas, common, 55 hospital, 57 phlegmonous, 56

Erythema, 55

Excision, diseased bone, 632 of joints, 634

Exomphalos, 415

Exophthalmia, 266

Exostosis, 153 of distal phalanx, 551

Eye, diseases, 245

Fever, hectic, 42 inflammatory, 19 irritative, 43

Fistula lachrymalis, 248 in ano, 449, 450 in perineo, 472

Fractures, 552 clavicle, 564 cranium, 227, 558 compound, 553, 556 disunited, 586 face, 558 femur, 575 humerus, 569 metacarpal bones, 574 olecranon, 571 patella, 581 pelvis, 574 phalanges, 574 radius, 572 ribs, 566 scapula, 565 shoulder, 567 simple, 553 spinal column, 560 sternum, 567 tarsus, 584

Fractures of the tibia and fibula, 583 ulna, 710

Frænum linguæ, division of, 334

Fragilitas ossium, 110

Fungus hæmatodes, 147

Furunculus, 62

Ganglia, 401

Gangrene, 43

Genital organs, affections of, 461

Glaucoma, 277

Gonorrhœa, common, 462 in females, 531 præputialis vel spuria, 490

Gonorrhœal lichen, 532

Gums, inflammation, 337 tumours, 337

Gunshot wounds, 180

Hare-lip, 323

Hæmatocele, 503

Hemorrhage, 129, 166

Hemorrhoids, 445 distinct varieties, 445

Hectic fever, 42

Hernia, 412 of the iris, 264 cerebri, 233 congenital exomphalos, 415 scrotal, 413 crural, or femoral, 416 infantilis, 414 inguinal, direct, 415 oblique, 416 scrotal, 416 umbilical, 430 humoralis, 467

Hospital gangrene, 191

Humeral artery, 394

Hydatic tumours, 161

Hydrocele, 417 of the neck, 381

Hydrops articuli, 68

Hydrophthalmia, 266

Hydrothorax, 410

Hypopium, 273

Hypospadias, 495

Incontinence of urine, in females, 489

Inflammation, 13

Injuries of the head, 215

Iritis, 272

Irritation, 20

Irritative fever, 43

Joints, diseases of, 67 growths from synovial membranes, 79 hip-joint disease, 81, 91 loose cartilages, 80 neuralgic affections, 78 scrofulous disease, 77