VOLVULUS OF THE SPERMATIC CORD.

1055

oJ

alone." There is, I when the operator removing only the larger masses of growth in the hope that the remainder will atrophy, as is recommended in a recent work on the "Operations of General Practice." While, however, it is true that so-called recurrences are usually due to the growth of pieces of adenoid tissue which remain after incomplete operation, this does not finish the - question. It is generally agreed that under certain conditions recurrence may take place even after complete removal. By "complete"I mean, of course, macroscopically so-that is, that Luschka’s tonsil has been thoroughly removed, leaving a smooth raw surface free from all masses or tags of adenoid tissue. It is no doubt the case that there always remain minute, perhaps microscopic, collections of lymphoid tissue from which a regrowth of the tonsil may occur. One would expect, of course, a special liability to such recurrence during early life when the activity of the lymphoid tissues is so marked. Indeed the most important factor is probably the age of the child, and it must be admitted that in children under 4 years of age there is a decided risk of recurrence ; between the ages of 4 and 7 the chances of recurrence are slight, and after the age of 7 they are practically nil, always provided that the operation has been complete. The degree of recurrence which may occasionally be met with after what one may call complete removal is well - shown in the following case. About two years ago I removed from a little boy, 3 years of age, a large mass of adenoids. A full-sized StClair Thomson’s curette, which is wide enough to cover the whole vault of the naso-pharynx at this age, was used, and a mass representing evidently the entire hypertrophied naso-pharyngeal tonsil came away in one piece with the first sweep of the curette. No shreds of adenoid tissue appeared to have been left behind, and the roof and posterior wall of the naso-pharynx felt smooth and bare to the finger. The tonsils were at this time also much enlarged, but the parents, owing to a mistaken idea that their absence might interfere with the voice, would not allow me to remove them. Eighteen months later, however, which

can

am

sure, aims at

a

be

acquired by long practice

considerable risk of

recurrence

to be the rule rather than the ex(eption general condition is carefully treated. Lastly, is probably favoured by the presence of anterior nasal obstruction especially hyper-

recurrence seems

unless the recurrence

untreated trophic inferior turbinals, and is therefore apt to be met with in patients with high arched palates and narrow nasal cavities in whom removal of the adenoid does not lead to the establishment of free nasal respiration. All of these conditions have the feature in common that they tend to excite or maintain a state of chronic post-nasal catarrh, which should, therefore, wherever it is present, receive appropriate treatment if the risk of recurrence is to be reduced to a minimum. In conclusion, it may be remarked that a true recurrence is a somewhat rare event even in young children, and the fear of it is no argument against operation. Liverpool.

VOLVULUS

OF

CORD.1 (SEN. MOD.),

THE SPERMATIC

BY ADAMS A. MCCONNELL, B.A. M.B. DUB., F.R.C.S. IREL., ASSISTANT

SURGEON,

APPLIED

RICHMOND HOSPITAL, DUBLIN; LECTURER ON ANATOMY, MEDICAL SCHOOL, TRINITY COLLEGE, DUBLIN.

forward the report of this case for three reasons : I have been unable to discover any account of a similar case, either by verbal inquiry or by a search through the literature ; secondly, the symptoms present were markedly different from those found in the more usual lesion of torsion of the cord ; and thirdly, the conditions disclosed on operation were at first sight somewhat puzzling. The history of the case is as follows:I

BRING

first, because

The

patient,

a

boy, aged 15,

while at

school,

was

suddenly

seized with severe pain in the right groin. At the moment of onset he was sitting on his right foot with that leg crossed, tailor-fashion, beneath him. The pain was accompanied with a sensation of weakness and nausea. He was assisted outside the school, and during the process of an ineffectual attempt to micturate noticed a small swelling in the groin. The severity of the pain increased to such an extent that he was unable to stand on his feet. He was therefore carried home and put to bed, where he had several attacks of vomiting. A medical man then saw the boy, diagnosed a hernia, and sent him to the Richmond Hospital, to which he was admitted under the care of Mr. R. J. Harvey, to whom I am indebted for permission to operate and to report the case.

On examination, about two hours after the onset of the symptoms, the boy looked distinctly ill-his face pale and covered with cold sweat. In the line of the right inguinal canal a swelling was found ; it was tense, fixed, yielded no impulse on coughing, and was tender on palpation. It corresponded, in position, to the inner half of the inguinal canal and came to an end at the external abdominal ring. The right testis was slightly larger than the left, and the spermatic cord on the affected side was more definitely

than on the other, but in neither of these structures there any pain, nor did palpation elicit tenderness. The bowels had acted that morning as usual, and there had been no motion from the time of onset of the symptoms. He did not vomit after admission to hospital. Temperature 98’ 60 F., pulse 88. I diagnosed strangulation of an incomplete inguinal hernia and proceeded to operate forthwith, with the assistance of my colleague, Mr. H. de L.

palpable was

Reproduction of photograph showing A, adenoid removed from a boy three years of age, and B, adenoid removed from the same patient eighteen months later. the tonsils had still further increased in size, attacks of tonsillitis had occurred, and Dr. C. J. Macalister, who had originally referred the case to me, suspected some secondary enlargement of the bronchial glands. I therefore removed the tonsils and found at the operation to my surprise a considerable amount of adenoid tissue again present in the naso-pharynx. This I removed. It happened that I had preserved as a good museum specimen the mass of adenoid removed 18 months previously from the same case, and it was therefore possible to appreciate the amount of regrowth which had taken place during that period. (See

figures.)

.

Apart from the influence of age, it is certain that recurrence is much favoured by an attack, within a short time of the operation, of one of the specific fevers, especially measles or whooping-cough. Again, according to Charles Parker, in children who are the subjects of congenital syphilis

Orawford.

The ordinary oblique incision was made over the swelling. The external oblique aponeurosis and the external abdominal ring having been defined, what appeared to be the fundus of The a hernial sac presented between the pillars of the ring. aponeurosis was divided, laying bare the rest of the sac, which was seen to extend along the whole length of the inguinal canal. On opening the sac, which was lined by serous membrane, what we took to be a coil of intestine appeared ; it was covered by peritoneum and was intensely congested, being of a dark purple colour. I passed my finger towards the internal ring and found that the sac came to an end at that point, and that no patency of the ring existed ; neither did the coil of supposed gut pass to the region of the ring, 1 A paper read before the Surgical Medicine in Ireland, on Dec. 8th, 1911.

Section, Royal Academy of

1056 but seemed rather to emerge through the posterior wall of the inguinal canal after the fashion of a direct hernia, but no aperture leading to the general peritoneal The finger cavity could be found in this region. could be passed freely downwards into the tunica vaginalis. We now pulled up the testis and found that when the spermatic cord was thus slackened, what had hitherto seemed to be a coil of intestine was really formed by a loop of the spermatic cord twisted on itself for two turns and rendered purple in colour by greatly distended This loop of cord had bulged into the funicular veins. portion of an infantile type of scrotal sac, and had thus obtained a serous covering. All the constituents of the cord, including the vas deferens, were included in this twisting of the loop, to which I think the term volvulus" may be

applied

with accuracy.

(See figure.)

Regarding the treatment resorted to in this instance, if the veins of the cord had alone been involved we should have resected them after the fashion adopted in the treatment of varicocele, but on discovering that all the constituents of the cord were implicated it was considered wiser to remove the testis. Inspection of the parts removed showed that the cord was of abnormal length and that its components were more spread out than is usually the case. The testis and epididymis with their peritoneal connexions appeared absolutely normal, with the exception that the testis itself was of a slightly bluer colour than usual. -

Dublin. _______________

THE TREATMENT OF THE EARLY STAGES OF SENILE CATARACT. BY HENRY SMITH, M.D.R.U.I., V.H.S., LIEUTENANT-COLONEL,

I.M.S.

THIS is a subject of supreme importance both to the patient himself and to every member of the profession who

Diagram of condition found. All the constituents of the cord are included under " spermatic cord." H

Considering that the condition of the vessels would be incompatible with the maintenance of the blood-supply of the testis, and having regard to the fact that necrosis of the latter often ensues after untwisting the cord in cases of torsion, I ligated the spermatic cord above the site of the lesion and removed the testis. The split aponeurosis of the external oblique muscle was then sutured, and the wound closed. The patient made an uneventful recovery, and left hospital on the ninth day after operation. I should like to refer briefly to the diagnosis and treatment

has to deal with him. I have again and again been asked, "Can you do nothing to prevent the development of cataract, to cause it to disappear in its early stages, or to " Until recently my answer has been stay its development ? in the absolute negative ; that no such remedy is known to science. Some months ago a European lady came to me from a station 800 miles away complaining that she could no longer see to read or write, and that her vision for distance On examination 1 found a was becoming rapidly useless. thin nebula on the front of each cornea in the pupillary I dilated her area, the result of old-standing trachoma. pupils with homatropine and observed that the nebulas were only partially the cause of her failing sight, as she had incipient cataract in both eyes. I explained to her that we hoped to clear the nebulse which were very thin, and that thus we might improve her vision a little, but that she had cataract, which I would advise her to have operated on a little later. I gave her a subconjunctival injection of cyanide of mercury (20 111 of 1 in 4000). She had to leave two days after, but wrote to me about a month later that the result was marvellous as she could now see distance as well as ever and could thread a cambric needle with her ordinary presbyopic glasses. The corneal haze having cleared up was not sufficient to explain this considering the condition of the lens. It was only explicable on the understanding that the hypersemia induced had acted on the lens as well as on the cornea. How this came about I leave to pathologists to

of this condition. One would expect that twisting of a loop of the spermatic cord would give rise to practically the same symptoms as torsion of that structure. In torsion or axial rotation the testis is often imperfectly descended ; in this case the testis explain. I then determined to try this remedy on the early stages of occupied its normal position in the scrotum, nor was there evidence forthcoming that at any period it had been other- cataract in patients whom I could keep under observation for a sufficient length of time. The following list is a small one, wise situated. In the second place, torsion of the cord has usually resulted which I hope to supplement at a later date, but in such in such a swollen and acutely tender condition of the testis, experimental work the ordinary illiterate villager is unsatisoften combined with redness and oedema of the scrotum, factory as it is difficult to detain him in hospital long enough that a diagnosis of epididymo-orchitis has been made. While for observation, and it is equally difficult for a busy man to in those cases in which strangulated hernia has been diagnosed follow him up when he has left hospital. It is also extrait was the swollen testis that was mistaken for strangulated ordinarily unusual to get any details of vision from an gut, in every instance in which strangulation of an incom- illiterate villager with any degree of accuracy. The following cases, which include Europeans and plete hernia had been simulated the testis of the corresponding side was absent from the scrotum. In the present educated natives, show that in some cataracts the result case the testis was apparently normal and could be palpated is phenomenally successful, in others it has not been without pain or tenderness, and the skin of the scrotum successful or only partially so. The varieties in which showed no pathological change, while a distinct swelling of treatment is not successful I may be able to define at a later other origin than the testis simulated strangulated intestine. date. I am disposed to consider that vision that has been The absence of any history of strain is, I think, of little significance in excluding either torsion of the cord or strangulated hernia, though one would expect such a history to be

present in the former condition, and

would remark its absence in the latter. We must conclude, therefore, that the usual symptoms indicating torsion of the cord are not those of volvulus of that structure, though both lesions would, from a priora reasoning, manifest themselves in a similar manner. In drawing this conclusion, however, from observations made in one case we are falling into the logical fallacy of arguing from the particular to the universal. The only explanation that I can offer for the absence of testicular swelling is that in all probability the arteries and veins had been occluded simultaneously, and that consequently marked venous congestion could not take place.

reduced by half or less for distance is amenable to treatment. If reduced over a half there is little hope of improvement. The most promising cases are those in which distant vision has been reduced by about 30 per cent. or under. CASE 1.—Native soldier, aged 56. Vision formerly normal. Left eye on ophthalmoscopic examination showed immature cataract; normal fundus. Vision : 6/60 and Jaeger V. Oa Jan. 10th. 1912, a subconjunctival injection of cyanide of mercury (20 1TJ. of 1 in 4000) was given in the left eye. On the 15th he could make out half the letters of 6/12. On the 31st conld make out all the letters of 6/12, and with a + 2 D. presbyopic spectacle could read Jaeger II. CASE 2.-Parsee, aged 60. The right eye had a slowly sclerosing lens with a history of three years’ progress ; fundus apparently normal ; opacity central, a little more developed towards the temporal than the nasal side. He could