A Case of Strangulation of the Testis Due to Torsion of the Cord
Boston Medical and Surgical Journal
after the curative properties of the ray have been proved to an inquirer is, Will it return? And the answer is : Wc do not know. Cases are on record of several years' standing, with no return. Thus far the percentage of returns is not as great as with the knife for the same period. What the final result will be only after years can tell. This I do know, that all the cases I have treated, with two exceptions, have been cases that have returned, having been cut out previously. One writer states
... One writer states the percentage of recurrences after operation as fifty-two. The prospect is that in thoroughly treated cases by x-ray nothing like this percentage will return. While this is the great item in judging the advantage in method, we should not forget the lack of disfiguring sear, the case of application, not removing the patient from ordinary occupation, fear of the knife, etc. Such facts present an argument too strong to be put aside by even the most radical operating surgeon. Surgeon to the Massachusetts General Hospital. Casus of recognized torsion of the cord causing strangulation of the te*aticle are extremely rare. Dr. Scudderwas able to lind hut, thirty-two cases of this condition in medical literature. The following report presents a well-marked instance of this mishap, and the clinical symptoms were in some respects so peculiar that the case is worthy of record : X, twenty-six years of age, vigorous and well developed, was seen by me in April, 1908. lie had never hail any venereal disease, nor any trouble with his testes, which were normally developed in every way. At 10 a.m., of a Sunday, without previous injury, or other disturbing cause, he had suddenly been seized with a severe paroxysmal pain in the center of the lower abdomen, close above the pulios. He was pallid, nauseated, and was covered with sweat. This pain was serious enough to cause him to go to bed. At 2 p.m. he*, vomited, after which the pain subsided so entirely that he got up at 4 p.m. On the following morning he went down to business as usual, but soon began to suffer pain in the region of the right spermatic cord. This pain increased and extended to the testis, but he continued his occupations that day, not returning home until 7 P.M. On Tuesday the testis was swollen, and presented all the appearance of an ordinary epididymitis, and was so regarded by his physician. The temperature, however, was at no time above 99-4°F. On Thursday there was a decided increase of swelling and the skin over the front of the scrotum became adherent to the deeper parts. The pain became trilling. I saw the patient for the first time that afternoon. The right side of the scrotum was tensely swollen and indistinct fluctuation could be felt. The contour of the testis could not be accurately made out. An antiseptic fomentation was applied, and on the following morning, there being no improvement in the condition, it was decided to operate. On cutting down, the tissues were thick anel cdeniatous. When the tunica vaginalis was opened, a very little blood-stained serum escaped. The testicle was black, mottled with plum color. The cord was tightly twisted, the rotation being from within outward. One complete turn of the testis untwisted it, The mesorchiuni was not long ; in fact, it was so short that it seemed rather surprising that if should have permitted so complete a rotation. The cord was wrapped tightly around it. The testicle was so evidently in a gangrenous condition that itB removal was necessary. The tunica was pushed back far enough to permit access to a healthy part of the cord, which was tied in two parts and divided. The testicle was then removed. A drainage tube was placed in the tunica anel the wound was closed. Convalescence was uninterrupted, the drainage being removed on the third day. According to Dr. ¡Scuelder's investigations, torsion of the cord produces such immediately destructive changes in the testicle that after it has existed for more than one hour, hope of saving the testis must be abandoned. This may be true of the extreme cases of torsion where the circulation is at once and totally shut off. Jf it is so, it is an exception to the rule holding in either parts of the body, for we know that the circulation may be eut off from limbs for ¡i considerably longer time than this without endangering their life. It seems reasonable to suppose that torsion of the cord may sometimes exist in a less serious degree than this, ¡mil it is not improbable that some of the unexplained swellings of the testicle that are recovered from may be instances of a torsion not causing complete strangulation. A sudden attack of pain in the testicle without evident cause and without fever should arouse suspicions of this condition. Especially is this to be suspected when atrophy of the organ follows. It would seem possible in some of these cases to undo the twist if suspected early. Unfortunately the twist is not always in the same direction. Sometimes it is from within outward, and sometimes from without inward. One can only try, therefore, by rotating the testis gently first in one direction and then in the other. If the rotation in one direction is difficult and aggravates the pain, while twisting in the other direction is easy and relieves the pain, we may rightly presume the case to be one of torsion. In the case just reported there were no adhesions, and it seemed as if rotation would have been possible without opening the scrotum had the condition been recognized at the outset. Dr. Van der Pool has reported a case in which the patient had recurrent attacks of this condition, and learned how to rectify the displacement himself.