return of the blood through the sperma- greater habitual pressure upon the left tic veins is retarded (1) by the interven- spermatic plexus. tion of an elaborate plexus, the plexus pampiniformis; (2) by their passage through the fibrous inguinal rings and canal, and the muscular cremaster and internal oblique, which closely invest the cord as it hangs over Poupart's ligament; and (3) by the length of the column of blood within them, reaching from the testis to the renal or caval veins high up in the abdomen. Now, in a perfectly normal condition, the elastic resiliency of the coats of these veins is such that the retardation is effectively controlled and modified. But slight imperfections are extremely common, and are evidenced in most individuals as an increase in the size of the left spermatic cord. In the surgery of the schools, this is commonly attributed to the fact of the left testicle being placed lower in the scrotum than the right, and to the opening of the left spermatic cord into the renal vein at right angles to the current of blood in the latter, and not, as on the right side, at an acute angle, with a course more parallel to the current in the inferior cava, and more adapted to the efficiency of the valve-action at the acute side of the angle. But a difference in length of column of about half or threequarters of an inch, or in the angle of junction to the extent of a right angle, do not, in normal conditions and in other situations (where they are common enough), produce undue dilatation of the veins. The other predisposing cause commonly assigned for this greater frequency on the left side, is, in my opinion, a much more powerful one; and that is the position of the sigmoid flexure of the colon across the front of the left spermatic plexus. The sigmoid flexure is the temporary receptacle of the fully formed fecal mass, until the habitual or convenient time for its expulsion has arrived. In civilized society there are frequent and unavoidable conventional causes for delay or neglect of Nature's indications; and constipation and consolidation of the feces is a common accompaniment of artificial modes of living. We have thus But along with these predisposing causes must coexist some other condition lying in the coats of the veins themselves, otherwise the same anatomical, mechanical, and conventional causes would operate alike in all individuals, which is notoriously not the case. Now, in a healthy vein, the middle coat is found under the microscope to contain abundantly muscular fibres of the same kind as those in the arteries. They are arranged both longitudinally and circularly in several successive layers, intermixed freely with white connective tissue, and with a smaller proportion of elastic fibres. In the larger veins of the abdomen, especially, the outer coat also contains, according to Remak, a considerable proportion of non-striated muscular fibres; and this peculiarity extends to a great extent into the spermatic veins. veins of the lower extremity have thicker coats than those of the upper, and the superficial veins thicker than the deep ones. The If you take a portion of the coats of a vein in a varicose condition and place it under the microscope, you will find that the hypertrophy depends chiefly upon the development of white connective tissue in the outer coat, while the muscular and elastic fibres are proportionately much less developed. The mechanical stress upon the vessels has promoted the development of the merely resisting material, and has atrophied by over-tension the contractile and resilient elements. In some cases, also, I have found a certain amount of amyloid or fatty degeneration of the muscular fibres. At a certain point of the lateral distension, the valves cease to be effective in closing up the tube against regurgitation, and they become finally shrivelled and atrophied from disuse. This promotes the stasis and accumulation of the blood within the vessel, and, longitudinal hypertrophy commencing, results in the coils and serpentine folds which are so characteristic of an advanced stage of varicose veins. We have, in fact, in varicose veins, a condition, mutatis mutandis, resembling, in the thickening of the outer coat and the diseased condition of the middle coat, that of true aneurism in the arteries. There can be no doubt that this predisposition of the venous system is, like so many other diseases, the result of hereditary transmission. Into the various points of the differential diagnosis of varicocele, I have scarcely time on this occasion to enter. I may, however, mention that the condition which is most difficult to distinguish from varicocele is the presence, in a narrow hernial sac, of an elongated portion of irreducible or adherent omentum, dragged out in the curious and perplexing way in which we sometimes see it, simulating a thickened spermatic cord, or a cyst, or even a testicle, almost perfect in shape. The most certain way of distinguishing them is to mark the effects of position in the recumbent posture, maintained for a length of time sufficient to empty the varicose vessels. Upon an adherent omentum this has, of course, little or no effect. But the coats of varicose veins are occasionally so thick in themselves that a considerable tumefaction remains, even after the blood has passed almost entirely out of them. In such cases, the only resource is in the tactus eruditus, which cannot be conveyed by words-the peculiar centrifugal dilating impulse which the cough impresses upon the varicocele, and which is different from the communicated impulse of an omental her nia. When the omental hernia is reducible, no difficulty should arise. The means of distinction given in books is to reduce the swelling while the patient is in a recumbent posture, and then placing the finger firmly upon the superficial ring, to let the patient assume the erect posture. If it be a hernia, the swelling does not return; but if it be a varicocele, it does so in a short time, but gradually. Fatty developments in the cord are usually persistent under any position; and, like omental hernia, doughy and inelastic to the feel, and, unless confined to so high a position in the inguinal canal as to contraindicate varicocele entirely, have not usually a cough impulse. Varicocele is often attended by an amount of pain totally disproportional to the size of the tumour. It is probable that this proceeds from pressure or tension, during the initiative stages of the disease, upon the spermatic plexus which surrounds and embraces the veins, and supplies branches to their coats. The pain usually affects, also, the groin of the same side, and sometimes reaches the lumbar region, by an effect upon the renal plexus, from which part of the spermatic plexus is derived. In many cases, also, there is a morbid fixity of the attention of the patient to his condition, which is sometimes indicative of serious mental derangement. Atrophy of the testicle may be coexistent with varicocele, and in most cases is the result of the impaired nutrition consequent upon the continued congestion which results from the varicocele, as in the condition called varicose eczema in the legs. In most cases, an operation, if applied early enough, will prevent this atrophy; but sometimes the wasting goes on, and may even be considered by the patient as the effect of the operation. He should always, therefore, be informed beforehand of this possible result. The treatment that you have seen lately carried out by me, gentlemen, is an application of the principle of metallic wire pressure, applied subcutaneously, and with very little disturbance of the parts, by means of a new instrument which I have devised and carried out, with the help of Mr. Matthews, for the application of a continually acting spring traction. The very ingenious apparatus of M. Ricord was previously the most successful attempt to effect the same results; but it acted upon a silk or hempen ligature, applied in a peculiar manner round the vein, and had not the advantage of metallic pressure. This apparatus is ponderous, unwieldy, and requires screwing up afterwards. I have made many attempts, gentlemen, as you know, to obtain the advantages of continuous and unintermitting wire-pressure, so applied and self-acting that no subsequent interference by the surgeon or any screwing up of the apparatus, should put the patient to all or more of the pain of repeating again and again the original operation; so arranged that the wire could be at any time disengaged and removed with little or no pain to the patient, or disturbance of the parts; and so simple as to be easily managed by anybody, easily cleaned, and not liable to get covered for the escape of any discharge which may form, for which the shaft of the instrument and the wire form a direct conductor. I have found it better, also, so to arrange the punctures that the one through which the instrument passes shall be the most depending point in the track of the wire, so that no accumula out of gear. Well, the outcome of so tion of discharge is possible within the many trials seems simple enough when wound. This is a point of much imporyou look at it, as did the celebrated egg- tance to obviate any subsequent trouble. trick of Columbus. It is a strong, steel, It is also important, as I have proved exhighly tempered spring, acting like the perimentally, to provide that no pressure spring of a pair of dissecting forceps. or obstruction be placed at the puncture One limb carries at the end a thin round through which the wire emerges; but steel shaft, about an inch and a half long, that allowance be made for any swelling which ends in a transversely oval and of the parts around which may occur. obliquely placed eye, for transmitting the This is effectively provided for by the wire snare or loop which encircles the length of the steel shaft, and the elevavein. The other limb terminates in an tion of the counterpressure from the surarm or hook, round which the ends of face of the wound. Any instrument the wire are twisted and fastened. The which covers over, obstructs, and presses rings upon the two arms are for the upon the puncture in the skin, is objecpurpose of giving a firm hold to the fin- tionable for this reason. ger and thumb while compressing and closing the spring (as shown at the middle of the figure), till the ends of the wire are fastened upon the upper limb. The dotted lines at the outer part of the figure show the upper arm when at the extent of its action; and its distance from the closed arm shows the extent of transit of the wire to be more than is necessary to drag it clean through the inclosed vein. The steel shaft which carries the wire is pressed down close upon the vein through the puncture, at which the ends of the wire emerge. The puncture is left un In large cases, of course, a larger instrument and a stronger spring may be required. In small cases, a spring of twisted steel wire, somewhat like that of a mousetrap, has been found sufficient. Such an instrument I have found to act admirably in cases of varicose saphena. The wire used is the best and toughest iron wire, as thin as may be judged strong enough to bear the tension of the spring. It is first dipped in carbolized oil, and passed by means of a long needle in the ordinary subcutaneous way, first under the veins, and then back again over the veins, between them and the skin, entering, re-entering, and emerging through the same cutaneous apertures. The ends are then drawn as taut as possible; the loop sinks through its puncture into the tissues out of sight; and the spring-tractor is finally fixed by passing both ends of the wire through the oval eye, pressing down the spring firmly between the left thumb and forefinger, winding the wire tightly round the hook, and fixing it there. In most of the cases lately in the hospital, all of them men under the age of forty years, the spring-tractor was kept on for a week or ten days; but in one case, which is now in hospital under treatment, we had to deal with a very large varicocele, reaching down behind and below the testicle. In this instance, a pair of tractors and wire ligatures were applied, one above, and the other below and behind the testicle, and kept on for fourteen days. In none of these cases have the patients complained of any pain worth speaking of; there has been little or no discharge, and no formation of pus; and they have been discharged cured a few days after the removal of the wires. In the last-mentioned case, some time after the instruments and wires were withdrawn, we had a very small superficial abscess, but it occurred in a different part of the scrotum, towards the opposite side, and resulted, apparently, from the pressure of the cross strapping used to sustain the scrotum. It was opened by the house-surgeon, and gave thenceforth no more trouble. In all the cases we have had a very great amount of thickening from fibroid deposit in the track of the wire ligature, producing a great amount of lateral support to the weakened vessels, and persistent for a considerable time, as you may have seen by the patients who have returned for inspection, at a period of many months subsequent to their discharge from the hospital. In patients whom I have seen years after a precisely similar operation, effected by means of an instrument acting with wire in the same manner, but upon a different principle, which I then employed, the veins have remained quite impervious, with a hard, firm, constricted portion, or indurated ring, at the site of the operation. In most of the cases, I have withdrawn the wire before it has quite cut through all the included tissues, and the results have been equally good as in those in which the loop has cut its way clean through. I believe, therefore, that it is not always necessary to prolong the cure by waiting for this result, inasmuch as a great deal of fibrous tissue, not forming part of the venous channels, is necessarily included in the ligature, and often prolongs the process of separation after the veins have been entirely occluded. A dense, hard, and resisting ring of fibroid tissue is formed around the veins by the action of the ligature, which resists the pressure of the blood outwards, and prevents redistension. And not the least of the advantages of the apparatus I have described is the power that it gives us of withdrawing the ligature without pain or disturbance, when it it evident that the desired result has been arrived at, as ascertained by the deposit of fibrin and the small length of the wire yet remaining engaged in the tissues. In this method, gentlemen, it appears to me that we have all the advantages of subcutaneous treatment and thin metallic pressure, combined with a continuous and equable traction, by which we obtain a division of the diseased veins without danger of hemorrhage, with little or no pain to the patient, without the repetition of a most excruciating process of tightening or screwing up the ligature upon the inflamed tissues; and we get, in a short course of treatment, complete division or occlusion of the veins, no open sore (which, in such cases, is very often very slow to heal), and no suppuration which may endanger the entrance of pus into the veins. And this is combined with the power of disengaging the wire compress; with little pain and no disturbance of the parts, which might set up the process of disintegration of the clot or suppuration of the vein; and with a simplicity of construction and ease of manipulation which leaves little to be desired in the way of improvement.—Brit. Med. Journ., Sept. 16, 1871. Lecture on the Treatment of Smallpox. tality in the different hospitals has been Delivered at Homerton Fever Hospital. as follows: Hampstead, 19.1 per cent.; By ALEXANDER COLLIE, M.D., Resident Stockwell, 17.6; Homerton, 17.1; Mrs. The patient's bed may consist of feath- Se In the mild variety of smallpox treatment is not of importance. "Il ne faut que demeurer en repos." The patient should be kept in bed until crustation is completed, should be fed on light and easily digestible food, and should have his linen changed daily and fresh cool air in abundance. No drugs will be required, except perhaps a purgative pill or a little castor oil. In the black smallpox all treatment is useless, and our efforts should be directed simply towards palliating the patient's sufferings. Cold water will probably be most grateful, and that ought to be given freely. An egg beaten up in a little whiskey-and-water will relieve sensations of exhaustion, but beyond this our art is powerless. Large doses of stimulants are simply wasted. In the severe or confluent smallpox, however, treatment is of the highest importance. Here our management will sometimes determine the result. The patient should be placed in a large, wellventilated room, a room with opposite windows if possible, and these should be kept open by night and by day and in all seasons. If the weather is very cold, keep a good fire in the room, and let the patient have an extra blanket, but keep the windows open; and if the weather is mild, treat the patient absolutely in the open air. Nothing is of so much importance as pure air, and that in unlimited quantities. In this hospital we have kept our windows open constantly by night and by day throughout the months of February, March, April, &c.; and this has been attended with the very best results, for our mortality is the lowest of all the smallpox hospitals in London, and we were receiving our patients from the same sources, and some time before the epidemic reached its height. Including every death, our mortality is only 14.6 per cent.; and if we were to strike off those who died of sequelæ, and those who died six, twelve, and twenty-four ter. Always combat this notion. There hours after admission, it would be considerably less. Up to July 22 the mor Do not place your patient on low diet. That a patient about to undergo the exhausting labour involved in an attack of smallpox should be starved is, in my opinion, of all medical absurdities the most absurd. Your patient will not be able to take food in the same form as in health, but he must and should have the same in quantity, if not, indeed more, although in a different form. Let your patient have milk in abundance, as many raw eggs beaten up with a little whiskey as can be stuffed into him, beef-tea, arrowroot, sago, tapioca, &c. Ordinary tea and coffee, of moderate strength, you will find pleasant stimulants, and these should be given, remembering, however, that if given in too large a quantity they have a tendency to prevent sleep. To relieve thirst, cold water is usually the best and the most pleasant to the patient, and he ought never to be refused this. You will find, however, amongst some nurses and patients' friends a decided objection to giving much cold wa is nothing more pleasant to a parched mouth and a dry tongue than pure cold |