The administration of thymus in exophthalmic goitre / by R.H. Cunningham.

  • Cunningham, R.H.
Date:
1895
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Licence: Public Domain Mark

Credit: The administration of thymus in exophthalmic goitre / by R.H. Cunningham. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    mesorchium, so that it hangs freely on a pedicle, which, at any rate, is not fixed for some distance. This explains in itself the necessary anatomical conditions under which the twisting can be complete. Nicoladoni lays special stress upon this point, the absence of a short fixation, by a short mesorchium. The origin of this abnormal condition, which shows itself either as a too slender or too long, or as a complete absence of fixation, is to be traced back to early disturbances in the development of the processus vaginalis, and the shortening of the gubernaculum, which takes place at the same time.1 As the abnormal formation of the mesorchium allows great movement to the testicle, it can, hence, make difficult the entrance of the testicle into the inguinal canal, and in this way be the cause of late or incom- plete descent. Kocher has shown two examples of this kind.2 In fact, the majority of cases have been with incomplete descent, and in many of them this ab- normal condition has been mentioned. Nicoladoni says, “ The expressions ‘ absence of a mesorchium ’ and ‘ too long a mesorchium ’ do no not refer to oppo- site conditions, although apparently we might think so. In no case is there an ‘ absence ’ of the mesorchium, for as the testicle already has a peritoneal covering be- fore its descent, while in the posterior part of the ab- dominal cavity, the mesorchium cannot possibly be absent after it has descended. Hence, the cases de- scribed as ‘ absence of the mesorchium ’ mean only that the testicle is deprived of its normal fixation, while a ‘ too long mesorchium ’ relates as well to the cord as to the peritoneal covering both of itself and testicle.” Besides this, according to Lexer, we have another important predisposing factor, as well for the occur- rence of the torsion as for the impossibility of its un- twisting itself, especially when the testis is in the canal, and that is, its flattened shape, to which attention was drawn in several of the cases With this condition present it can be understood Kov^ertain, perhaps un- usual, movements of the body and lower extremities can become the direct cause of the torsion, and, if hav- ing once taken place, how difficult it would be for the testicle to resume its normal position. So, during heavy work, as in Nicoladoni’s second case, and in Lauenstein’s, after lifting a heavy piece of wood. It has been impossible, however, in all cases to dis- cover a direct cause, for although, besides these two, we find Whipple’s coming on after a strain, von Mey- er’s after sneezing, Johnson’s while blowing on a cor- net, Nash’s after boxing, Barker’s after straining at stool, and Owen’s after bowling at cricket, yet there are a number where nothing whatever unusual had happened, as in those of Keen, Davies-Colley, Page, Anders, Lexer, and in my own ; in fact, in several, the first symptoms appeared while the patients were asleep. In several, where the pain came on only some time after the accidents which were supposed to have caused them, it looks as if the torsion had perhaps commenced at the time of the accident, and had afterward been completed by subsequent bodily movements ; that is, completed sufficiently far to cause a disturbance in the circulation of the cord and testicle. For testes which lie in the scrotum the conditions would be different from those where they lie horizontally in the inguinal canal, and in this connection Meinhardt Schmidt has drawn attention to the fact that we have an analogue in the torsion of ovarian tumors, which certainly finds some causation in mechanical acts, such as changes in position from movements of the body and intestines. We naturally get more torsion with a long mesorchium than with a short one, but violence per se is not neces- sary. Any slight movement may complete the amount necessary to interfere with the circulation, which varies in the individual cases. Pathology.—As we have seen, in all cases where the vaginal process was opened there was a greater or less 1 Bramann : Archiv fur Chir., Bd. xl., S. 136. 2 Deutsche Chirurgie, 1887, p. 578. quantity of bloody serum and clots. The testis and epididymis were congested and swollen, of a dark or bluish-black color, and sometimes in a more or less ad- vanced state of necrosis. Sections of testis showed it filled with blood and clots, with sometimes no trace of tissue structure, as in Lauenstein’s case, while micro- scopically there was a true hemorrhagic infarction, a high grade of hemorrhage, or overfilling with blood of the entire organ, both of the lobules themselves and of the interlobular tissue. The necrosis, when present, was especially marked at the periphery. This condi- tion of hemorrhagic infarction is well explained by Miflet’s important work,1 in which is found the founda- tion for a complete understanding of the consequences of torsion, as far as is possible, by experiments upon animals. He used eighteen dogs, as follows : In seven he made artificial emboli ; in four he ligated the internal sper- matic artery ; while in five he ligated both the internal spermatic artery and veins ; and in two the veins alone. In two of the first seven the deferential artery was also stopped. These are his general conclusions and results : 1. The internal spermatic artery has, for the testis, the significance of a terminal artery. 2. Interruption of the flow of blood through the in- ternal spermatic artery, either by ligation or by embolus, is quickly followed by the formation of a hemorrhagic infarction, and these infarctions involve especially the superficial layers of the testis. 3. The glandular structure of the testis is especially sensitive to any disturbance in the circulation of the cord, not only when both the arteries and veins are in- terfered with, but also when the circulation through the veins is interrupted. The glandular tissue always disappears rapidly, which change takes place with more or less tissue proliferation. 4. The epididymis, which is supplied by the deferen- tial artery, is not at all affected by ligature, and very little by embolus. 5. If at the same time the circulation is disturbed in both the spermatic and deferential arteries, then the secreting tissue of the epididymis is also destroyed. As to the torsions themselves ; where stated, the acci- dent happened twelve times upon the right side, and nine times upon the left ; the greater length of the left cord, therefore, not having increased its liability, but, on the other hand, the twisted cord has always been abnormally short, the testis either lying within the inguinal canal or high up in the scrotum. The direction of the twist, however, when mentioned, has been nine times from without inward, and but three times from within out- ward. Lauenstein mentions this point, as resembling the idea brought forward by Kiistner, as regards the torsion of ovarian tumors, that the pedicle of the tu- mors of the right side had a left twist, and those upon the left side had a right twist. The degree of torsion sufficient to cause strangulation has varied greatly, from a half-turn in Keen’s and Nash’s cases, to two full turns in Defontaine’s and my own ; for, as we have seen, a long mesorchium would permit more twisting to take place, before the circulation would be interfered with, than a short one. Symptoms and Diagnosis.—In most cases there have been more or less well-developed symptoms of inflam- mation, such as pain, local swelling, and, in some in- stances, oedema, redness, and fever ; and when we find these conditions associated sometimes with constipa- tion and vomiting, together with absence of impulse in an irreducible swelling, developing suddenly, after per- haps some strain or exertion, we are naturally led to suspect a strangulated hernia. There are, however, some distinctions. With torsion of the cord the con- stipation may not be absolute. The vomiting, which is not apt to become stercoraceous, is not so persistent. 1 Ueber die pathologischen Ver'anderungen des Hodens, welche durch Storungen der lokalen Blutcirculation veranlasst werden. Lang- enbeck’s Archiv, Bd. xxiv., 23.