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Torsion of the testicle
TORSION OF THE TESTICLE CAPTAIN WILLIAM J. FOLEY MEDICAL CORPS, ARMY OF THE UNITED STATES
T
HIS chnical entity, although not by any means common, is certainly not as rare a condition as it was considered a decade or so ago; for although V. J. O’Connor,8 in 1919 reported a total of 124 cases on record, Abeshouse’ in his compIete review of the subject reported in 1936 a tota of 350 cases in&ding three cases of his own. This fuIly iIIustrates an increased awareness of the condition. However, faiIure of a Iarge number of these cases to be diagnosed promptIy and earIy, indicate that the diagnosis is not considered as soon as it shouId be. It is important that this diagnosis aIways be borne in mind because of the serious sequeIae both psychoIogica1 and physioIogica1 that may ensue, foIlowing an incorrect diagnosis or failure to institute proper treatment immediateIy after making the diagnosis. It is for the purpose of bringing to mind the possibility of this condition, that this case history and resume of the entity itseIf is reported. The etiology has been generaIIy recognized as being for the most part due to congenita1 anomaIies of both the scrotum and its contents and anomaIies in the descent of the testicIe itseIf. In general, the anomaIies are considered as being a hypermobiIity of the testicIe and its presence in an enIarged scrotum.3*4’7*g A question of hypermobility is best expIained on the basis of the anomaIous descent of the testicle in which the testicIe and the epididymis become compIeteIy surrounded by. the tunica vaginalis, aIIowing the testis, epididymis and the dista1 spermatic cord to become an intravagina1 body, without any IateraI or posterior attachments, being attached to the base of the scrotum onIy by the remnants of the gubernacuIum. The high attachment of the tunica vaginalis aIIows some of the lower fibers of the
cremasteric muscIe to be inserted inside the vaginal sac. Spasm of the muscle itseIf associated with a firmer contraction of one group of fibers may result in rotation of the spermatic cord, testicIe and epididymis inside the vagina1 sac, resulting in a torsion. Accepting this explanation as the cause of torsion, it is easy to comprehend why the condition may be reIieved spontaneously in some cases while in others the torsion may cause continued spasm of the cremasteric and thus maintain the torsion. This theory seems the most IikeIy one and was offered by Muchat’ in 193 I. It must be realized that in addition to the congenita1 anomalies present, extrinsic factors may pIay an important rBIe in inducing the condition. Of these factors, trauma and sudden muscular exertion appear to be predominant. The incidence of torsion in the fuIIy descended testicIe as against the undescended testicIe remains an undecided point, some authors cIaiming as high as 50 per cent of torsion cases being in the undescended testicIe.‘l It is in the fuIIy descended testicle, however, that the best resuIts can be obtained by earIy, correct diagnosis and treatment; yet it is in the fuIIy descended testicIe that diagnosis and proper treatment so often is delayed. The age at which torsion of the testicIe occurs is extremeIy variabIe for Hegner and Postma report a case occurring at the age of four months and WoIf13 reports a case at the age of sixty-eight years. V. J. O’Connor,8 in 1919, stated the average in the 124 cases, however, occurred at the age of or just before puberty.8 The diagnosis in the fully descended testicIe need not be too difficuIt just so Iong as the entity is borne in mind. In the case of the undescended testicIe, its absence from the scrotum makes the differentiation between torsion of the testicle and a
106
American
Journal
of Surgery
FoIey-Torsion
Richter’s hernia we11 nigh impossibIe in cases producing Iike symptoms. Cardinal symptoms of torsion in the fuIIy descended testicIe are a sudden onset of pain, the retraction of the testicie upward in the scrotum, swehing and tenderness. There may be nausea and vomiting and occasionaily some chiIIs with fever of a miId degree. Laboratory tests are negative at the onset unIess there is concurrent disease. The differentia1 diagnosis presents its main probIem in the consideration of an acute epididymitis. The lack of a history of infection, the sudden onset without temperature or increase in bIood count, pIus the physica findings wifi usuaIIy ruIe out an epididymitis. In addition, the testicIe itself is tender and swoIIen in a case of torsion which is not the ruIe in a case of epididymitis at the onset. A usefuI diagnostic point between these two conditions is Prehn’s sign,“*‘O namely, that in torsion cases the more the scrotum is eIevated, the greater is the severity of the pain; which contrasts with the reIief of pain with elevation of the scrotum in epididymitis. Orchitis and tumor of the testicIe offer a simiIar differentiation. PhysicaI examination of externa1 rings will ruIe out a stranguIated hernia when negative. The condition encountered in an acute case of torsion which is not reIieved immediateIy corresponds to that seen in a stranguIated hernia. The vesseis are deepIy congested and prominent, smaI1 petechia1 hemorrhages are visibIe and the epididymis and testicIe are swoIIen, and as the time interval increases, the coIor passes through the stages of cyanosis to that of compfete gangrene. The testicIe and epididymis then undergo an aseptic necrosis with softening of the parenchyma folIowed by a gradual repIacement of the structures with fibrous tissue. The treatment of acute torsion is decidedIy surgical, although cases have been reported in which earIy manua1 detorsion has been successfuI.12 The torsion is, of course, prone to recur and the process of detorsion is not aJways successful because
of TesticIe
OcToeeH. ,945
it is impossible to determine accurateIy the number of degrees which the torsion has undergone and the direction in which it has occurred. If detorsion is successfu1, the pain is immediateIy relieved; but again a partia1 detorsion may cause a marked reduction in pain and yet strangujation is present as is shown in the case presented here. SurgicaI treatment, if instituted earIy, offers the only certain method of saving the testicfe. The technic of surgica1 interference is variabIe, but must satisfy the two requirements of compIete detorsion and attachment of the testicIe to the scrotum in such a fashion as to preclude recurrence. If surgica1 treatment has been deIayed and detorsion does not resuIt in restoration of circuIation and normal coior, orchidectomy shouId be performed. Many men have advocated the prophyIactic expioration of the opposite testicIe and surgica1 correction of anomaIies predisposing to torsion if present.2*4*6,g The Ioss of one testicIe results in no great physioIogica1 change so Iong as the opposite is norma and functioning; but in an individua1 who has previousIy Iost the function of the other testicIe, torsion is a major catastrophy. PsychoIogicaIIy, the Ioss of even one testicIe is of major importance to the individua1. CASE
REPOKT
A soldier, age twenty-four, white, admitted to the hospital August 13, 1944, with the diagnosis of non-union of the left clavicle. The patient was injured in September, 1943, when he feII and fractured the Ieft clavicIe. Since that time he had moderate pain in the Ieft shoulder region and tenderness over the junction of the middIe and outer third of the left cIavicIe. Since the injury, he experienced diffrcuIty in Iifting and in doing heavy work. His past history was essentially norma except for attacks of tonsillitis and a fracture of the right cIavicIe in 1932. PhysicaI examination revealed onIy moderate, biIatera1 enlargement of the tonsiIs and a small enlargement of the right testieIe which was considered a smaI1 hydroceie. There was a deformity over the
NEW SERIES
VOL. I.XX, No. I
FoIey-Torsion
middle third of the Ieft clavicIe with motion at the fracture site. The x-rays showed a nonunion, middIe third of left clavicle with a pseudo-arthrosis. The patient had an inIay bone graft of the left clavicle on August 23, I 944 Progress was uneventfu1 unti1 October 16, I 944. At 3. 00 A.M. October I 6, I 944, the patient awakened from his sIeep and started to get out ‘of bed to go to the Iavatory when he experienced a sharp pain in the right scrotum, became nauseated, and started vomiting. He was examined at 3.15 A.M. at which time the physica findings were a IocaIized tenderness of the right testicle which was sIightIy enIarged. Pressure on the testicle made the patient even more nauseated and brought on a speI1 of vomiting. There was no redness or inflammation present. A diagnosis of torsion of the testicIe was made. Upon rotating the right testicIe IateraIIy (counter-cIockwise) the pain increased, but on rotating it mediaIIy (cIockwise) the pain Iessened. The right testicIe was rotated 180 degrees mediahy and the pain and nausea disappeared. The patient feIt comfortabIe. At 4.30 A.M., the patient had a recurrence of the origina pain with nausea and vomiting. Examination at this time showed a drawing up of the right testicIe with markedly increased tenderness of the testicIe over the previous examination, and a beginning tenderness of the cord just beIow the externa1 ring. The testicle did not appear any Iarger than on the previous examination. EIevation of the scrotum did not reIieve the patient’s pain. An attempt was made at detorsion but there was no decrease in pain on rotation of the testicIe through 180 degrees either counter-cIockwise or cIockwise. Because of the marked nausea and vomiting, a flat plate of the abdomen was taken to rule out an atypical uretera stone. This was negative. FolIowing the x-rays, the patient’s nausea and vomiting decreased and it was believed that the patient should be observed. The testicIe was stiI1 very tender. His genera1 condition improved in the next twenty-four hours but there was stiI1 an occasiona speI1 of nausea and vomiting. Examination on October 17, showed simiIar findings with an increased enjargement of the right testicle and increased tenderness of the cord below the externa1 ring. He was operated upon October i7th, under IocaI procaine anesthesia. The incision was made in the right
of TesticIe
Amcricsn
Journal
of Surgery
107
scrota1 sac. Upon incising the tunica vaginalis, the testicIe was found to be rotated 360 degrees counter-cIockwise and was found to be an intravagina1 body. The testicIe was markedly discoIored from dusky red to definitely bIue and bIack areas. The torsion was reduced and the testicIe observed over a period of twenty minutes when it showed a marked increase in circuIation with a beginning return to normal coIor. Due to the return of circulation, it was thought that orchidectomy was not indicated. Andrew’s bottIe operation for hydroceIe was performed. In addition, a mattress suture of silk was introduced through the lower poIe of the testicIe which was anchored to the dependent portion of the right scrotum. The scrotum was then closed Ieaving a smaI1 penrose drain in the dependent portion of the wound. ConvaIescence was uneventful with the exception of a localized edema of the prepuce which Iasted unti1 October 24th. The drain was removed on October 20th. The patient was up and around on November 2, 1944, with the wound compIeteIy healed. The testicIe had not quite returned to norma size and no pain was experienced on compression. He was seen on December 19th and the testicle was found to be about the same size as the one on the Ieft. There was tenderness on compression of the epididymis on the right but none on compression of the right testicle which was quite firm in consistency. Aspiration of the right testicle was done under IocaI anesthesia and the laboratory reported in the stained smears “evidence of spermatogenesis, severa ceIIs were identified with rudimentary tails which were thought to be spermatids undergoing transformation to spermatozoa.” SUMMARY I. Torsion of the testicIe is not a rare condition and the diagnosis shouId always be considered in cases of testicuIar pain. 2. SuccessfuI treatment of torsion is immediate surgery with detorsion and fixation of the testicIe to prevent recurrence. 3. Orchidectomy may be avoided by earIy diagnosis and the institution of immediate surgery avoiding all procrastination. 4. In cases of doubt as to the absoIute certainty of the diagnosis, surgica1 expIoration under IocaI anesthesia of the involved testicIe is advised.
108
American Journal of Surgery
FoIey-Torsion
5. A case of torsion
of the right testicIe in which manuaI detorsion was unsuccessfu1 and in which surgica1 detorsion accompanied by fixation of the testicIe was successfu1 is presented for record.
OCTOBER. ,945
of TesticIe
5. HEGNER, C. F. and POSTMA, G. S., Torsion of the spermatic cord. Am. J. Surg., 47: 121-123, 1940. 6. KINNEY. WILLARD H. Torsion of the soermatic cord. 3. Ural. 34: 470, 1935. 7. MUSCHAT, MAURICE. The pathologica anatomy of testicular torsion. Surg., Gynec. @ Obst., 54: 758, 1932.
8. O’CONNOR, REFERENCES
of the spermatic cord. Ural. @ Cut. Rev., 40: 6gg, 1936. 2. BAILEY, HAMILTON:Torsion of the Fully Descended Testis, Emergency Surgery. P. 474. BaItimore, 1944. WiIIiams & “Wilkik. 1. CAMPBELL. MEREDITH F. Torsion of the soermatic cord. Surg., Gynec. u Obst., 44: 31 I, 316, 1927. 4. COLBY, FLETHER H. Torsion of the spermatic cord with gangrene. New England J. Med., 203: 16,
9.
I. ABESHOUSE, B. S. Torsion
1930.
10.
11. 12.
V. J. Torsion of the spermatic cord. Surg., Gynec. @ Obst., 29: 580, IgIg. ~ENHEIMER, E. J. and BIDGOOD,C. Y. TesticuIar fixation in torsion of the spermatic cord. J. A.-, M. A., IOI: 116-119, 1933. PREHN, DOUGLAS. A new sign in the differentia1 diagnosis between torsion of the spermatic cord and epididymitis. J. Ural., 32: 191, 1934. ROCHE, A. E. Clin. J., 57: 577, 1928. SMITH, R. E. Torsion of the testis. Clin. J., 63: 250,
1934. ‘3. WOLF, MONROE. Torsion Surg., 27: 483, 1942.
of the testicle.
IT is of the highest importance that prostatectomy shouId neither be attempted in the presence of gross infection nor unti1 it has been proved that renal function is adequate. Preliminary Iigation and division of the vasa deferentia has banished the troublesome complication of post-operative epididymo-orchitis. From “A Short Practice of Surgery” by Hamilton Bailey and R. J. McNeil1 Love (H. K. Lewis & Co. Ltd.).
Am. J.
T
HIS chnical entity, although not by any means common, is certainly not as rare a condition as it was considered a decade or so ago; for although V. J. O’Connor,8 in 1919 reported a total of 124 cases on record, Abeshouse’ in his compIete review of the subject reported in 1936 a tota of 350 cases in&ding three cases of his own. This fuIly iIIustrates an increased awareness of the condition. However, faiIure of a Iarge number of these cases to be diagnosed promptIy and earIy, indicate that the diagnosis is not considered as soon as it shouId be. It is important that this diagnosis aIways be borne in mind because of the serious sequeIae both psychoIogica1 and physioIogica1 that may ensue, foIlowing an incorrect diagnosis or failure to institute proper treatment immediateIy after making the diagnosis. It is for the purpose of bringing to mind the possibility of this condition, that this case history and resume of the entity itseIf is reported. The etiology has been generaIIy recognized as being for the most part due to congenita1 anomaIies of both the scrotum and its contents and anomaIies in the descent of the testicIe itseIf. In general, the anomaIies are considered as being a hypermobiIity of the testicIe and its presence in an enIarged scrotum.3*4’7*g A question of hypermobility is best expIained on the basis of the anomaIous descent of the testicle in which the testicIe and the epididymis become compIeteIy surrounded by. the tunica vaginalis, aIIowing the testis, epididymis and the dista1 spermatic cord to become an intravagina1 body, without any IateraI or posterior attachments, being attached to the base of the scrotum onIy by the remnants of the gubernacuIum. The high attachment of the tunica vaginalis aIIows some of the lower fibers of the
cremasteric muscIe to be inserted inside the vaginal sac. Spasm of the muscle itseIf associated with a firmer contraction of one group of fibers may result in rotation of the spermatic cord, testicIe and epididymis inside the vagina1 sac, resulting in a torsion. Accepting this explanation as the cause of torsion, it is easy to comprehend why the condition may be reIieved spontaneously in some cases while in others the torsion may cause continued spasm of the cremasteric and thus maintain the torsion. This theory seems the most IikeIy one and was offered by Muchat’ in 193 I. It must be realized that in addition to the congenita1 anomalies present, extrinsic factors may pIay an important rBIe in inducing the condition. Of these factors, trauma and sudden muscular exertion appear to be predominant. The incidence of torsion in the fuIIy descended testicIe as against the undescended testicIe remains an undecided point, some authors cIaiming as high as 50 per cent of torsion cases being in the undescended testicIe.‘l It is in the fuIIy descended testicle, however, that the best resuIts can be obtained by earIy, correct diagnosis and treatment; yet it is in the fuIIy descended testicIe that diagnosis and proper treatment so often is delayed. The age at which torsion of the testicIe occurs is extremeIy variabIe for Hegner and Postma report a case occurring at the age of four months and WoIf13 reports a case at the age of sixty-eight years. V. J. O’Connor,8 in 1919, stated the average in the 124 cases, however, occurred at the age of or just before puberty.8 The diagnosis in the fully descended testicIe need not be too difficuIt just so Iong as the entity is borne in mind. In the case of the undescended testicIe, its absence from the scrotum makes the differentiation between torsion of the testicle and a
106
American
Journal
of Surgery
FoIey-Torsion
Richter’s hernia we11 nigh impossibIe in cases producing Iike symptoms. Cardinal symptoms of torsion in the fuIIy descended testicIe are a sudden onset of pain, the retraction of the testicie upward in the scrotum, swehing and tenderness. There may be nausea and vomiting and occasionaily some chiIIs with fever of a miId degree. Laboratory tests are negative at the onset unIess there is concurrent disease. The differentia1 diagnosis presents its main probIem in the consideration of an acute epididymitis. The lack of a history of infection, the sudden onset without temperature or increase in bIood count, pIus the physica findings wifi usuaIIy ruIe out an epididymitis. In addition, the testicIe itself is tender and swoIIen in a case of torsion which is not the ruIe in a case of epididymitis at the onset. A usefuI diagnostic point between these two conditions is Prehn’s sign,“*‘O namely, that in torsion cases the more the scrotum is eIevated, the greater is the severity of the pain; which contrasts with the reIief of pain with elevation of the scrotum in epididymitis. Orchitis and tumor of the testicIe offer a simiIar differentiation. PhysicaI examination of externa1 rings will ruIe out a stranguIated hernia when negative. The condition encountered in an acute case of torsion which is not reIieved immediateIy corresponds to that seen in a stranguIated hernia. The vesseis are deepIy congested and prominent, smaI1 petechia1 hemorrhages are visibIe and the epididymis and testicIe are swoIIen, and as the time interval increases, the coIor passes through the stages of cyanosis to that of compfete gangrene. The testicIe and epididymis then undergo an aseptic necrosis with softening of the parenchyma folIowed by a gradual repIacement of the structures with fibrous tissue. The treatment of acute torsion is decidedIy surgical, although cases have been reported in which earIy manua1 detorsion has been successfuI.12 The torsion is, of course, prone to recur and the process of detorsion is not aJways successful because
of TesticIe
OcToeeH. ,945
it is impossible to determine accurateIy the number of degrees which the torsion has undergone and the direction in which it has occurred. If detorsion is successfu1, the pain is immediateIy relieved; but again a partia1 detorsion may cause a marked reduction in pain and yet strangujation is present as is shown in the case presented here. SurgicaI treatment, if instituted earIy, offers the only certain method of saving the testicfe. The technic of surgica1 interference is variabIe, but must satisfy the two requirements of compIete detorsion and attachment of the testicIe to the scrotum in such a fashion as to preclude recurrence. If surgica1 treatment has been deIayed and detorsion does not resuIt in restoration of circuIation and normal coior, orchidectomy shouId be performed. Many men have advocated the prophyIactic expioration of the opposite testicIe and surgica1 correction of anomaIies predisposing to torsion if present.2*4*6,g The Ioss of one testicIe results in no great physioIogica1 change so Iong as the opposite is norma and functioning; but in an individua1 who has previousIy Iost the function of the other testicIe, torsion is a major catastrophy. PsychoIogicaIIy, the Ioss of even one testicIe is of major importance to the individua1. CASE
REPOKT
A soldier, age twenty-four, white, admitted to the hospital August 13, 1944, with the diagnosis of non-union of the left clavicle. The patient was injured in September, 1943, when he feII and fractured the Ieft clavicIe. Since that time he had moderate pain in the Ieft shoulder region and tenderness over the junction of the middIe and outer third of the left cIavicIe. Since the injury, he experienced diffrcuIty in Iifting and in doing heavy work. His past history was essentially norma except for attacks of tonsillitis and a fracture of the right cIavicIe in 1932. PhysicaI examination revealed onIy moderate, biIatera1 enlargement of the tonsiIs and a small enlargement of the right testieIe which was considered a smaI1 hydroceie. There was a deformity over the
NEW SERIES
VOL. I.XX, No. I
FoIey-Torsion
middle third of the Ieft clavicIe with motion at the fracture site. The x-rays showed a nonunion, middIe third of left clavicle with a pseudo-arthrosis. The patient had an inIay bone graft of the left clavicle on August 23, I 944 Progress was uneventfu1 unti1 October 16, I 944. At 3. 00 A.M. October I 6, I 944, the patient awakened from his sIeep and started to get out ‘of bed to go to the Iavatory when he experienced a sharp pain in the right scrotum, became nauseated, and started vomiting. He was examined at 3.15 A.M. at which time the physica findings were a IocaIized tenderness of the right testicle which was sIightIy enIarged. Pressure on the testicle made the patient even more nauseated and brought on a speI1 of vomiting. There was no redness or inflammation present. A diagnosis of torsion of the testicIe was made. Upon rotating the right testicIe IateraIIy (counter-cIockwise) the pain increased, but on rotating it mediaIIy (cIockwise) the pain Iessened. The right testicIe was rotated 180 degrees mediahy and the pain and nausea disappeared. The patient feIt comfortabIe. At 4.30 A.M., the patient had a recurrence of the origina pain with nausea and vomiting. Examination at this time showed a drawing up of the right testicIe with markedly increased tenderness of the testicIe over the previous examination, and a beginning tenderness of the cord just beIow the externa1 ring. The testicle did not appear any Iarger than on the previous examination. EIevation of the scrotum did not reIieve the patient’s pain. An attempt was made at detorsion but there was no decrease in pain on rotation of the testicIe through 180 degrees either counter-cIockwise or cIockwise. Because of the marked nausea and vomiting, a flat plate of the abdomen was taken to rule out an atypical uretera stone. This was negative. FolIowing the x-rays, the patient’s nausea and vomiting decreased and it was believed that the patient should be observed. The testicIe was stiI1 very tender. His genera1 condition improved in the next twenty-four hours but there was stiI1 an occasiona speI1 of nausea and vomiting. Examination on October 17, showed simiIar findings with an increased enjargement of the right testicle and increased tenderness of the cord below the externa1 ring. He was operated upon October i7th, under IocaI procaine anesthesia. The incision was made in the right
of TesticIe
Amcricsn
Journal
of Surgery
107
scrota1 sac. Upon incising the tunica vaginalis, the testicIe was found to be rotated 360 degrees counter-cIockwise and was found to be an intravagina1 body. The testicIe was markedly discoIored from dusky red to definitely bIue and bIack areas. The torsion was reduced and the testicIe observed over a period of twenty minutes when it showed a marked increase in circuIation with a beginning return to normal coIor. Due to the return of circulation, it was thought that orchidectomy was not indicated. Andrew’s bottIe operation for hydroceIe was performed. In addition, a mattress suture of silk was introduced through the lower poIe of the testicIe which was anchored to the dependent portion of the right scrotum. The scrotum was then closed Ieaving a smaI1 penrose drain in the dependent portion of the wound. ConvaIescence was uneventful with the exception of a localized edema of the prepuce which Iasted unti1 October 24th. The drain was removed on October 20th. The patient was up and around on November 2, 1944, with the wound compIeteIy healed. The testicIe had not quite returned to norma size and no pain was experienced on compression. He was seen on December 19th and the testicle was found to be about the same size as the one on the Ieft. There was tenderness on compression of the epididymis on the right but none on compression of the right testicle which was quite firm in consistency. Aspiration of the right testicle was done under IocaI anesthesia and the laboratory reported in the stained smears “evidence of spermatogenesis, severa ceIIs were identified with rudimentary tails which were thought to be spermatids undergoing transformation to spermatozoa.” SUMMARY I. Torsion of the testicIe is not a rare condition and the diagnosis shouId always be considered in cases of testicuIar pain. 2. SuccessfuI treatment of torsion is immediate surgery with detorsion and fixation of the testicIe to prevent recurrence. 3. Orchidectomy may be avoided by earIy diagnosis and the institution of immediate surgery avoiding all procrastination. 4. In cases of doubt as to the absoIute certainty of the diagnosis, surgica1 expIoration under IocaI anesthesia of the involved testicIe is advised.
108
American Journal of Surgery
FoIey-Torsion
5. A case of torsion
of the right testicIe in which manuaI detorsion was unsuccessfu1 and in which surgica1 detorsion accompanied by fixation of the testicIe was successfu1 is presented for record.
OCTOBER. ,945
of TesticIe
5. HEGNER, C. F. and POSTMA, G. S., Torsion of the spermatic cord. Am. J. Surg., 47: 121-123, 1940. 6. KINNEY. WILLARD H. Torsion of the soermatic cord. 3. Ural. 34: 470, 1935. 7. MUSCHAT, MAURICE. The pathologica anatomy of testicular torsion. Surg., Gynec. @ Obst., 54: 758, 1932.
8. O’CONNOR, REFERENCES
of the spermatic cord. Ural. @ Cut. Rev., 40: 6gg, 1936. 2. BAILEY, HAMILTON:Torsion of the Fully Descended Testis, Emergency Surgery. P. 474. BaItimore, 1944. WiIIiams & “Wilkik. 1. CAMPBELL. MEREDITH F. Torsion of the soermatic cord. Surg., Gynec. u Obst., 44: 31 I, 316, 1927. 4. COLBY, FLETHER H. Torsion of the spermatic cord with gangrene. New England J. Med., 203: 16,
9.
I. ABESHOUSE, B. S. Torsion
1930.
10.
11. 12.
V. J. Torsion of the spermatic cord. Surg., Gynec. @ Obst., 29: 580, IgIg. ~ENHEIMER, E. J. and BIDGOOD,C. Y. TesticuIar fixation in torsion of the spermatic cord. J. A.-, M. A., IOI: 116-119, 1933. PREHN, DOUGLAS. A new sign in the differentia1 diagnosis between torsion of the spermatic cord and epididymitis. J. Ural., 32: 191, 1934. ROCHE, A. E. Clin. J., 57: 577, 1928. SMITH, R. E. Torsion of the testis. Clin. J., 63: 250,
1934. ‘3. WOLF, MONROE. Torsion Surg., 27: 483, 1942.
of the testicle.
IT is of the highest importance that prostatectomy shouId neither be attempted in the presence of gross infection nor unti1 it has been proved that renal function is adequate. Preliminary Iigation and division of the vasa deferentia has banished the troublesome complication of post-operative epididymo-orchitis. From “A Short Practice of Surgery” by Hamilton Bailey and R. J. McNeil1 Love (H. K. Lewis & Co. Ltd.).
Am. J.