SOME OBSERVATIONS ON THE SURGICAL TREATMENT OF GONORRHEAL EPIDIDYMITIS
Journal of the American Medical Association
and recording cases in army practice, it has been possible to collect a large number of case records of the various types with their complications. The purpose of this paper is to draw some conclusions from the results obtained by the surgical treatment of gonorrheal epididymitis. Various writers have placed the incidence of gonorrheal epididymitis at from 10 to 25 per cent. It has been 15 per cent. during the past year at the Canadian Special Military Hospital, Etchinghill. Cases of
... Cases of epididymitis show a distinctly longer stay in hospital than many other complicated types of gonorrhea. In addition they are a frequent source of relapse of the urethritis, the cause of sterility on the side affected in a very high percentage of cases, and the reason for a great deal of acute pain and discomfort to the patient. The operation of epididymotomy was commenced as a routine mea¬ sure with a view of short¬ ening the duration of treatment in hospital, of reducing the liability to sterility and of relieving symptoms. I have observed two distinct types of gonorrheal epididymitis ; first, the subacute type, coming on slowly, in which the epididymis never becomes much larger than a man's thumb, with only a slight hydrocele and very little edema or redness of the scrotum. In these cases the pain is not acute, and constitutional symp¬ toms are not marked. It is seldom that these cases develop into the second or acute type, in which the onset may be, (a) slow, resembling the beginning of the subacute type, but gradually progressing in a few days, with intense pain, marked redness and edema of the scrotum, pain in the cord, radiating into the iliac fossa, accompanied by hydrocele, fever and high leukocyte count; (b) rapid, commencing with pain, swelling, edema, fever and hydrocele, progressing to an acute stage within from twenty-four to forty-eight hours. These types are due undoubtedly to the degree of virulence and to the strain of the infecting gonococcus. There may be three channels of infection: (1) direct extension through the urethra, ejaculatory ducts, vesicles and vas ; most observers incline to believe in this method of infection; (2) the lymphatics, which to my mind constitute a more common channel Fig. 1.-Initial incision: A, dartos; , cremaster. of infection than is generally supposed; (3) the blood stream, which is least likely. If we consider the pathology of an acute epididymitis, we find that the epididymis becomes enlarged, tense and painful, and on section it is found congested, showing tubules distended with some fluid exúdate. Frequently this passes on to actual abscess formation. The exudation which causes most of the enlargement is due to the inflammatory process around and between the convolutions of the tubules and duct of the epididy¬ mis. If this process goes on to pus formation, small cavities fill with pus and form small localized intertubular abscesses. The cells of the ducts are infiltrated, a certain amount of epithelium is shed, and the lumen contains a mixture of pus, epithelium and spermatozoa. The inflamed surface of the tunica vaginalis gives off an exúdate which is at first clear, and later may contain pus and fibrin, or even go on to definite pus formation. It is claimed that a great deal of the pain present is due to the tension caused by the hydrocele. My personal experience has been that this is not the case, but that the tension occurring within the fibrous tunica covering the epididymis, caused by the inflamma¬ tion and edema of that body, and which sometimes extend up into the cord, isprimarily responsible for the pain. Hagner1 in his original article quotes Monod and Terillon, who have shown that the en¬ largement of the epididy¬ mis is due to the edema or inflammatory exúdate occurring in the cellular tissue surrounding the tubules rather than to any changes in the tubules themselves. After having dissected off the fibrous tunica from the cord and having made an opening in its upper and anterior border, they were able to fix a cannula into the cellular tissue and to inject through the cannula a weak solution of gentian violet. When the fibrous tunica had been sufficiently filled they saw that the infiltration charac¬ teristic of this special form was reproduced and resem¬ bled an increase in size of the epididymis. Hagner himself has duplicated the above experiment. I have found the globus minor to be the part of the epididymis most frequently involved, the body more rarely, and the globus major least frequently. In one' of my cases I found the entire body of the epididymis destroyed ; a large abscess communicated directly into the testicle, of which a mere shell remained, owing to the great destruction of tissue. It was deemed advis¬ able to remove the testicle. When resolution commences the hydrocele is gradu¬ ally absorbed, the tunica vaginalis is in many cases bound down by dense adhesions, either to the tunica albugínea or to the cremasteric fascia, or to both. Often absorption does not take place and a chronic hydrocele results. Within the epididymis itself the pus 1.