Billeder på siden


retrograde change which nature has no chance to repair with this impediment in the local circulation. The integrity of the testicle is in marked cases reduced and atrophy with structural degeneration is a sequelæ.

The symptoms are pain in the testicle and cord, vesical and urethral distress, lumbar and iliac pain, and in those affected with genito-phobia fancied sexual perversions are common, and melancholia with real digestive and nutritive disturbances follow.

No definite relation exists between the severity of the venous engorgement and the subjective symptoms. Marked hypochondriosis may be associated with but a mild development of the trouble, particularly when the individual has obtained his information upon his malady from the paid advertisements in the daily press. This leads to the first remedial measure, which may be called moral treatment.

Clear explanations of the functions which belong to the genital organs, directing the patient's attention to the harmlessness of a mild varicocele with advice which will lead to the removal of existing causes often leads to satisfactory improvement.

The palliative treatment consists in hygiene of the bowels and genital organs, the use of dietary and medicinal measures which promise the best general nutrition, systematic exercise, regular rest, the cold douche to the scrotum which gives benefit by stimulating the circulation and the tone of the dartos muscle. The cold sound, vesicle irrigation, and mechanical support are supplementary measures of value. The suspensory bandage to be really useful should be accurately and neatly applied.

When the palliative measures fail to give relief, and the veins are distinctly varicose, radical steps are indicated. Of the radical measures but three will be mentioned as offering the most certain relief with a minimum of danger.

First. The subcutaneous ligature may be applied after complete asepsis of the scrotum has been accomplished by first separating the vas deferens from the veins, then transfixing with a Peasley's needle, the scrotum from before backward, when the needle is withdrawn sufficiently to allow the veins to fall back past the point of the needle when it passes outside of the vein and again makes exit at the posterior juncture. The needle is then withdrawn and the silk snugly tied, the skin pulled away from the juncture points when the operation is completed. This plan is comparatively simple and good results should follow, but it seems objectionable in that some connective tissue is included within the ligature, and some difficulty may be found in making sufficient pressure to promptly occlude the veins.

The open operation seems most surgical at this period on account of the accurate technique which it affords. The incision is made an inch and a half long, beginning an inch below the external ring. The vas is displaced posteriorly and the veins all readily reached. Care should be exercised to avoid injuring the veins, and when they are well exposed, an aneurism needle armed with catgut is passed beneath the vessels which are pulled out of the incision and tied, when a second ligature is passed in a similar manner two inches higher up. The intervening vessels are excised. The stumps are then approximated by tying a free end of the lower ligature to a


free end of the upper one, when the remaining ends are threaded and made to transfix its corresponding stump, after which the ends are tied and accurate approximation is gained.

The skin and fascia are coated by a continuous gut suture without irrigation and without drainage, and a pledget of borated cotton applied to the wound which is sealed with flexible collodion, a good support applied, and the patient kept in bed for four days, when some freedom of movement may be permitted, and, in a week, the patient may leave the room.

The last method is that of excision of the scrotum, which may be looked upon as supplementary to the above when it is desirable to remove redundant skin. In moderate types of the disease, where hypochondriasis is marked, this plan seems logical.

With a clamp accurately applied, the scrotum may be excised and coaptation by silk suture accurately made. A liberal amount of the scrotum should be excised and firm supportive dressing applied during the week after the operation to insure good union without retraction of the cut surface.

In twelve operations I have used the subcutaneous method once with a good result. The excision method was performed once in an emotional patient with complete relief. In the ten remaining operations, the open method was pursued, and primary union followed in each case. In one, the wound reopened in three weeks, and the sinus refusing to heal was explored and a piece of silk removed with a resulting restoration of integrity in tissues. This was the only compilcation in twelve operations, and the only one in which silk was used as a ligature.

With complete asepsis, therefore, and perfect operative technique, and the use of absorbable material, complications should be nil, and permanent relief certain.

Wounding the Bladder in Vaginal Hysterectomy.-Jacobs, of Paris, reports that after incising the vaginal mucous membrane in the anterior cul-de-sac, he proceeded with the finger to detach the cellular tissue separating the supra-vaginal portion of the cervix from the bladder, when suddenly and without any warning the index disappeared in the bladder. The author sutured the viscus at once and found then that the muscular fibers of the vesical wall existed only in patches. Twice in my own work I have penetrated the bladder in a similar manner, not to mention the two or three cases in which I have accidentally cut into it with scissors. Unless one is exceedingly careful in making the anterior dissection this accident is extremely liable to occur, as the bladder-wall is frequently very fragile. I have for a long time abandoned the use of scissors in this part of the operation for this very reason. And even with the fingers alone the rupture has twice occurred. Both were too high for vaginal closure. One spontaneously recovered, assisted by a little nitrate of silver; the other was closed by supra-pubic suturing. Both might have been avoided by a little more care. -Lanphear,


Diseased Conditions of the Ovum Leading to Watery Discharges from the Uterus.



T has been the experience of almost every obstetrician to be called to the bedside of a patient to find a history of watery discharges from the uterus, pregnant or otherwise. It may have been with a feeling of uncertainy that he attempted to assure his patient of the prognosis, and it may have been his experience to discover after a while, that he has made a mistake fraught with dangers to a trusting patron, or may be, in fact, his over-confidence that it is but a simple affair, may hazard the confidence of patient and friends, by giving a false security leading to a disastrous


With a feeling that we sometimes make the mistake of improperly weighing these seeming small matters, and with a hope of provoking a profitable discovery I have ventured to make a study of this subject.

It would seem that the best understanding might be attained by an inquiry into the pathological conditions of the different tissues that may lead to such discharges, and among these chronic diffuse endometritis first claims our attention. Schroder considers this to consist of chronic diffuse proliferation of the decidua vera and reflexa, and in this he has been fol lowed by the best students who have given the subject a careful examination. Under the stimulus of an increased blood supply during pregnancy this granulating tissue takes on additional and unnatural growth, and the thickened indurated decidua developing upon this rank soil, so to speak, is liable to undergo cystic degeneration.

The mucous membrane becoming still more thickened, many of the large cells are crowded upon and choked off, and in the deeper layers the cavities are increased in number and size until the cysts occupy most of the substance.

Of polypoyd endometritis, which is considered but an advanced degree of the previous condition by some, and by others considered the results of other pathological conditions, such as syphilis and the changes following the acute infectious diseases, we have a considerable number of cases recorded, characterized by great thickness of the mucous membrane, which is studded by prominences of varying size and varying degrees of elevation from smooth nodules scarcely raised above the surface to the pediculated and sessile.

This complication of pregnancy leads usually to early abortion following a history of frequent aqueous and bloody discharges, and may account for that peculiar tendency to throw off the results of conception, so often observed in the syphilitic and those affected by the infectious diseases.


In regard to catarrhal endometritis of which the German authors, Schroder, Spigleberg and Braun, hold the opinion that chronic inflammation of the decidua may, aside from the cellular proliferation mentioned above, produce an abnormal liquid secretion. But Stoffer, whose opinion is much respected, holds to two sources of these collections, the traumatic and the catarrhal,

Collecting at various points and between the different layers of membranes and between the membranes and the uterine walls and with contents varying in consistency and color from that formed in cystic degenerations and in hydatids, they give rise to discharges varying in amount and simulating the breaking of the waters at full term.

The source of the liquid has been held to be by transudation from the amnion, by secretion from the uterine walls, and by transudation from the contiguous blood-vessels.

Among the diseases to which the placental structure is subject that may lead to those conditions, must be mentioned placentitis. This inflammation leading to a weakened state of all the tissues, including stroma, blood-vessels and the villi, may lead to extravasations in the midst of the tissues aptly called placental apoplexies. In these irregular cavities filled with blood, the solid elements of which, degenerating or being absorbed, leaves behind cavities filled with serum products in the form of slightly colored and sometimes viscid fluid. The fetus not surviving, the changed condition results in the so-called carnified mole which, continuing to sojourn in utero, the contents meanwhile undergoing pigmentary and other changes, we have a cystic mole remaining with cavities filled with a sero-sanguinous fluid from the blood serum.

In the last division, that of the so-called hydatid mole, we have the most interesting cause of these discharges.

They are most apt to occur during the last half of the child-bearing period, and that uterine disease was the determining factor has been the prevailing opinion. Later investigations, however, have tended to disprove this by showing that by far the greater number of cases show no such diseased conditions.

The most important and interesting vital property in these cases is that the vesicles consist of living, growing tissue elements. Fatty degeneration of the epithelial covering and connective tissue stroma exists only to a minor degree, thus supporting the theory of their origin from other than dead masses of tissue where these changes would be made. On the contrary, an unusual proliferating tendency is present, while they receive their nourishment directly from the uterine wall, and while chorion vili and all attachments are nourished from vessels of the allantois, this mode of blood supply cannot exist, because in cases of total destruction of chorion there is no fetal circulation, and even in mola pantralis the vessels to the degenerated parts are obliterated in toto.

The diagnosis and treatment become of interest when we consider the inroads upon the vitality of the uterine tissues, the liability to form adhesions, difficulty of separation and danger of alarming and uncontrolable hemorrhage. In all varieties where the liquid is contained in the cavities.


between different layers of membranes and between the membranes and the maternal structures proper. There is little in the way of symptoms except that the woman, during the last of a seeming normal pregnancy, is surprised by a jet of liquid, usually of considerable amount, followed by oozing, leading her to fear the oncome of labor. Yet in the absence of the usual pains these fears are usually quickly set at rest, and recurring attacks may settle the diagnosis.

The presence of catarrhal metritis at time of conception may be of value as a determining factor. The prognosis in this class of cases is good, neither health nor pregnancy being compromised, and the treatment should be expectant and watchful of uterine contractions.

Of all other varieties the diagnosis is difficult, the symptoms depending on obscure conditions. In many cases there may be such a grouping of symptoms as may lead to an intelligent and safe position. Rapid and exaggerated development of abbomen, not in accord with the period of pregnancy, is of value, but alone may give rise to suspicion of malignant growth or ovarian cyst.

Small and frequent discharges of a peculiar type have weight, especially where there is alteration of bloody and aqueous flows commencing about the second month. To the careless this may lead to diagnosis of cancer of the cervix or vicious placental insertion. Where we have a combination of these during the first months of pregnnancy when the development is easily appreciated and faulty insertion not liable to give trouble we may easily direct our mind to those morbid conditions of the developing membranes that occasionally occur. Couple with these a history of tender uterine walls. and a history of painful contractions of the irritable surface and we have such a grouping of symptoms as are of great diagnostic value.

All conditions the result of extravasations and of degenerations that are extensive, leading to cystic and carnified moles, cause cessation of growth of fetus, and there being no proliferating tendency we have no increase in size, while parturition is delayed and menstruation interfered with until no longer tolerant of the contents of the uterus, rids itself of the mass. the contrary, in those cases where there is no excess of proliferating tissue we have great increase in size and painful contractions from over-distension producing discharges from the breaking down of the walls of the cysts, and sometimes discharge of the vesicles themselves.


Combinations of degenerated tissue with continuing pregnancy makes the diagnosis more difficult and requires more discretion lest we fail to be clear and hazard the life of a fetus which might go to full term.

Upon a proper and careful diagnosis depends the proper application of treatment. In those cases of simple hydrorrhea and where extra racks of water exists as incidents to a pregnancy otherwise normal, no concern need attach save to make certain the diagnosis and to assure the interested that at a proper time all will be well. Once determined that pregnancy continues in the presence of cystic degenerations of the membranes and our position must be tentative with a constant watch and care for impending danger,

« ForrigeFortsæt »