EPIDIDYMITIS

490 studies of the after-history of perforation cases are useful. Harrison and Cooperl have analysed 57 cases. Of these, 16 died in hospital, the fatality rising from 13% in those operated on within ten hours of perforation to 46% in those in whom operation was delayed for up to 24 hours. Of the 41 patients who left hospital all were followed up after periods ranging from one to twelve years, and it was found that only 7 (17%) had remained free from symptoms. Of the remainder, 2 had died and most of the other 32 had had only a short period, averaging 1-8 years, free from symptoms after leaving hospital; the one who had the longest asymptomatic period had this abruptly terminated by a second perforation. Very few of the patients had strictly followed any course of medical treatment after their operation. These figures, besides exploding a dangerous misapprehension, serve to emphasise the fact that the treatment of chronic peptic ulcer can never be surgical alone, and that to extract any good from the evil of perforation requires not only early diagnosis and skilled surgery but a warning to the patient that this disaster is but an incident in a condition which requires care throughout life ; suture after perforation is not a final cure for a " simple ulcer," but the saving of a life from an acute complication in a chronic constitu-

Lately

tional condition. EPIDIDYMITIS

GONORRHOEA is the commonest cause of acute epididymitis and the chronic form is most often tuberculous. Occasionally, however, tuberculous involvement of the epididymis may manifest itself in an acute form and cause confusion in diagnosis. The differential points of value are summarised in the Army Medical Directorate Bulletin for July (p. 6). In tuberculous cases the onset is more gradual and pain and tenderness are less severe.; the epididymis and vas may present nodules which become adherent to the scrotum and later break down to form sinuses. In addition, there may be evidence of involvement of other parts of the genito-urinary tract amd it may be possible to demonstrate tubercle bacilli in the urine. In gonococcal cases the epididymis is smooth, very tender and uniformly enlarged ; the vas is not nodular and the scrotum is not adherent. Although urethral discharge usually abates abruptly with the onset of the epididymitis, the urine often still contains shreds. The response to adequate chemotherapy is another point of value-gonococcal epididymitis rapidly subsides while tuberculous cases fail to respond. Since both types of case may be sent to the VD wards in the first place, the venereologist must keep the possibility of tuberculous epididymitis in mind if he is to avoid delay in starting appropriate treatment. PULMONARY

EMBOLISM

BY AMNIOTIC

FLUID

IN the past few years much attention has been paid to fat-embolism as a cause of shock symptoms in patients with fractures and severe trauma, such as are caused by motor accidents and air-raids. An analogous condition has been shown’ by Steiner and Lushbaugh2 to play an important part in the pathology of " obstetric shock." In 9 patients who died during labour or within eight hours after delivery they found multiple embolism of the small branches of the pulmonary arteries. The material forming the emboli appeared to be particles of foetal products which had been floating in the amniotic fluid during the labour. Mucus from meconium, and squames, vernix caseosa and lanugo from the foetal skin, were all recognised as constituents of the emboli. In addition there was often heavy infiltration of the emboli with leucocytes, even within an hour of the first onset of symptoms. The mucinous emboli were long and were usually impacted in arteries about 1 mm. in diameter ; the embolism by squames and vernix was usually in 1. Harrison, C. and Cooper, F. W. Ann. Surg. 1942, 116, 194. 2. Steiner, P. E. and Lushbaugh, C. C. J. Amer. med. Ass. 1941, 117, 1245 and 1340 ; Amer. J. Obstet. Gynec. 1942, 43, 833.

small arterioles and capillaries. The manner in which the liquor amnii gains access to the uterine veins is not clear. In one of the cases there was rupture of the uterus, and in another case caesarean section had been performed through the placental site. In the remaining cases the uterus was intact ; it is presumed that a tear had occurred through the membranes and into the uterine veins, but such a tear has not actually been demonstrated. Clinically the usual course in these patients had been as follows. The patient was a rather old multipara with a large foetus past term, possibly dead in utero, and with meconium in the amniotic fluid. The labour pains were strong and sometimes tetanic. During labour or very soon after delivery there was a sudden onset of shock with chill and restlessness, dyspnoea and cyanosis, and sometimes vomiting. The syndrome presented similarities with an anaphylactic reaction to foreign protein. Sometimes there was oedema of the lungs, and sometimes there was some post-partum atony of the uterus with moderate haemorrhage. Death usually occurred in from 1 to 11 hours after the first onset of these shock symptoms. These 9 cases are all fatal ones, for at present direct evidence on the matter can only be obtained at autopsy. Nevertheless it seems probable that some non-fatal cases of obstetric shock are due to this cause. Steiner and Lushbaugh examined the lungs of 34 women who died of other conditions during late pregnancy or the puerperium ; these controls were all negative. Subsequently, however, they examined the lungs of a woman who had rupture of the uterus and severe shock at the’time of delivery but survived until the seventh day of the puerperium. In this case there were pulmonary emboli in a healing stage, the mucinous emboli being infiltrated by macrophages and the emboli of particulate matter showing a well-marked foreign body giant-cell reaction. Further evidence was obtained by the intravenous injection of human amniotic fluid and meconium into dogs and rabbits. The immediate clinical and pathological effects were much the same as in human patients. A satisfactory study of the later pathological changes in animals was unfortunately prevented by bacterial contamination of the injected material. It is rather astonishing that so striking a lesion as this should have been overlooked by all previous workers on obstetric shock. SIGNS IN SUBARACHNOID HÆMORRHAGE BEFORE the introduction of lumbar puncture cases of subarachmoid haemorrhage from an aneurysm of the circle of Willis were classed as "apoplexy" and no further diagnosis was sought. Lumbar puncture reveals a blood-stained cerebrospinal fluid in some of these patients, and if this is coupled with a cranial nerve palsy and rigidity of the neck the diagnosis is not often in doubt. The ophthalmoscope is a useful accessory to diagnosis, for examination of the retina will show haemorrhages into the eye in most cases. Post-mortem examination of the orbit often reveals that the optic nerve is surrounded by blood, due, it was supposed, to direct extension from the cranial cavity, the blood having passed through the optic foramen and down the prolongation of the cranial membranes which surrounds the optic nerve. It was also thought that the blood inside the eye came there by direct extension from the subarachnoid cul de sac behind the globe. Riddoch and Goulden,l however, after a critical examination of five patients suffering from this disease, concluded that while the blood could track through the optic foramen and down the sheath of the nerve it could not pass from the sheath of the nerve into the eye, and that where intraocular haemorrhage occurred, it did so by the same mechanism as operates in papillcedema-the central retinal vein is compressed as it passes through the subarachmoid space some 10-12 mni. behind the eye, and by this means EYE

1. Riddoch, G. and

Goulden, C. Brit. J. Ophthal. 1925, 9, 209.

.