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towards cerebral congestion. The only external applications used were sinapisms to the epigastrium, and hot air. Pounded ice was given to allay the intense thirst. When dysenteric symptoms supervened, they were treated with acetate of lead, tannin, or kino, or with astringent and sedative suppositories.
The postmortem appearances were singularly uniform. The animal temperature, rising after death, and the spasmodic muscular twitchings so frequently alluded to, were often observed. The encephalon was, as a general thing, intensely congested; and, in a large majority of cases, serous effusions had taken place into the lateral ventricles, and around the spinal cord. There was also an unusual congestion of all the viscera, with thickening and softening of the mucous coat of the stomach and small intestines. This thickening and softening was observed, to a much greater extent, in those cases which were in a dying condition at the time of their admittance, and which had been treated by some of the many popular “hot-drops," consisting of capsicum, peppermint, &c., administered to them either by non-professional friends or by the physician who had been in attendance. In all cases which had been under treatment in the Hospital, the gall-bladder was found distended with bile, and the whole track of the alimentary canal, below the entrance of the duct, bore evidences of the presence of the same material. Those cases which were admitted too late for any treatment, varied exceedingly in this respect. The urinary bladder was found empty, and contracted down in the pelvic cavity, frequently to the size of a walnut. These were the general pathological conditions. There were a few cases which presented other appearances; but, as they were evidently due to complications, they have not been alluded to.
I have here given, as will be seen, a statistical resumé of the epidemic, as it appeared in the summer of 1854. If it is of any value, it is in the favorable comparison it bears in its results with those of former years, and with those of other institutions.
New YORK, February, 1855.
No. 31 SECOND STREET.
Clinical Remarks on the cases in the first surgical division of the Nero
York Hospital, during the months of October and November, 1854. By Thos. M. MARKOE, M. D., Attending Surgeon. Reported by Mr. Geo. E. S. KEATOR.
Syphilitic Inflammation of Testicle. November 14th. I'wo cases of Syphilitic Testicle.—These two men, Gentlemen, are both suffering from a chronic inflammation of the testicles, depending upon syphilis. This disease is one of much interest to surgeons at this time, because it is one which has only of late years been clearly identified as a form of inflammation essentially connected with a previous poisoning of the system by syphilis. Though noticed by most of the writers on syphilis, during the last ten years, yet I think that more is due to M. Ricord than to any other one observer, for his success in clearly tracing the clinical history of the affection, in all its stages and varieties. The distinct and certain diagnosis of this disease will appear to you the more important, when I remind you that, from the chronic, slow, and painless progress of the affection, it was formerly not unfrequently mistaken for cancerous, tuberculous, or other incurable induration of the organ; and under this pathological mistake, extirpation was recommended as the only remedy for what we now regard as a curable disease.
Syphilitic orchitis, then, is a chronic inflammation of the testicle, coming on as a tertiary symptom, characterized by hardness and insensibility; lasting, when not treated, an indefinite time, and finally terminating in atrophy of the organ; when properly treated, yielding to remedies with a great deal of certainty; which depends, as a cause, upon previous syphilis, most frequently, perhaps, upon that form which begins with the true Hunterian chancre. Let us now examine the clinical history a little more in detail, as it is presented by the two patients before
This first man, A. B., tells us that he had a sore on his penis, thirteen months ago, which continued open for about five days. Following the sore, a bubo appeared, which suppurated; and after this again, he had ulcerated sore throat. He has never had any eruption on his skin that could be regarded as syphilitic, and has had no iritis. Five months after the chancre, the testicles began to swell, gradually, slowly, without pain or soreness, and without the usual signs of active inflammation. This went on during about four months, since which, things have remained about stationary. Now, on examination, you perceive that both testicles are affected. They are hard, and you see he bears rough handling without pain; in fact, he says that he has suffered almost no pain
in thern from the commencement. Though enlarged to at least four times their natural size, their original shape is not much changed; and the surface, to the feel, is smooth and uniform. There is also a collection of fluid in the tunica vaginalis, on both sides. You will particularly notice that the cord, and, as far as we can feel, the epididymis, are both free from induration or enlargement. This is one of the most important features of the syphilitic testicle. It is the testicle itself which is primarily, and often alone affected; whereas in the other forms of chronic disease, the epididymis is usually the original and principal seat of the affection. The skin of the scrotum is sound, and free from adhesions, although the disease has been in existence for so many months. His venereal appetite is entirely gone since the testicles began to be diseased.
This second man, Cunningham, has a similar affection of his testicles, and from a similar cause. He had, seven years ago, a chancre, which continued unhealed for six months; was indurated, and has left a scar, which, from its depth and circular shape, was probably caused by a true Hunterian chancre. He had no bubo. He had ulcerations in the throat and an eruption on the skin, which, from these large white scars, was no doubt syphilitic rupia, with ulceration. Almost every year since his primary disease, he has had some of these spots breaking out on his skin, ulcerating and leaving a scar. In other respects, he is free from secondary symptoms. Now, observe carefully the history he gives us of his early symptoms. He says, that the testicles swelled suddenly, with much pain, then subsided, swelled again, and broke, all within a few days. Since that time, he has had but little pain in them, and no soreness, except in those ulcerations which you observe on two points of the scrotum of the right testicle. These ulcers, he says, he has had from the beginning. The organs are hard, painless, without heat, smooth and even on their surface. The cord is perfectly sound, and the epidermis free from disease upon this side; on the other, the cord is free, but the testicle is so large that the epididymis cannot be distinguished. The fluid in the tunica vaginalis is very small in quantity. Venereal appetite not altered, a very unusual exception. We have, therefore, before us two patients with a chronic enlarge
both testicles, affecting the substance of the gland itself, and not the epididymis; smooth and regular in its surface, preserving very much the natural shape of the organ; hard, painless, and insensible to the touch, which has, in each instance, been gradually progressive for months without the usual pain and heat of chronic inflammation; and which, in the first instance, commenced without any previous acute stage. To this latter statement, Cunningham's case presents an apparent exception. In giving his history, I asked you to note particularly that he said that the affection came on suddenly, then subsided, then came on again and broke, all within a few days, and with a good deal of inflammation and pain. Now, this is not the history of any known disease of the testis ; and, to my mind, it is evident that he refers to the commencement of the rupia blotches, the ulcers of which still exist, and which, occurring on the tender skin of the scrotum, might very well have caused so much pain and swelling as to lead him to suppose, and to tell us, that the testicle was at first acutely inflamed. There is sympathetic hydrocele in both cases; the scrotum is not adherent to the testicle, and is entirely sound, except at the ulcerated spots in Cunningham's case. During all the months which these four testicles have been diseased, there has been no tendency to suppuration, or the formation of a fungous protrusion. There is no glandular enlargement in either case; the cord is unaffected ; and last, and not least, they have both of them begun to be favorably affected by the treatment which has been adopted.
Having thus noted the history of the syphilitic affection of the testicle, let us contrast it with the history and symptoms of the simple chronic forms of the disease, not dependent on syphilis, and from which it is most important to distinguish it. These cases, then, of simple chronic orchitis, very commonly begin as the consequence of an acute attack, subsiding into a chronic course. They always affect the epididymis first, and the testicle secondarily; their progress is attended with the usual amount of pain, soreness, and weight of chronic inflammation; as the organ increases in size, it does so irregularly, so as to present a knobbed and distorted shape. The hardness is not of the stony character which we find in the syphilitic affection, nor is the organ free from tenderness when handled. One testicle is usually affected, rarely both; and, very early in the case, the scrotum becomes adherent to some of the knobbed prominences on the testicle, and either an abscess forms, or more commonly a fungus shoots up through an opening in the skin. Hydrocele is rather rare; glandular enlargement is said to be not unfrequent; and, finally, the effect of treatment is slow, unsatisfactory, and often disappoints us altogether.
In order to contrast the two affections more fully, I will write, upon the black board, the main symptoms in each, so that the data for a differential diagnosis may be compared at a glance. Thus, theSyphilitic form.
Non-Syphilitic form. 1. Begins in testicle.
1. Begins in epididymis. 2. Smooth and regular.
2. Irregular and knobbed. 3. Hard and painless.
3. Less hard and more painful. 4. Scrotum unaffected.
4. Scrotum early adherent. 5. Both testicles involved,
6. Usually one only. 6. Hydrocele very common.
6. Hydrocele rare. 7. No suppuration or fungus.
7. Abscess or fungus common. 8. No glandular affection.
8. Glands of groin enlarged. 9. Venereal appetite gone.
9. Not ascertained. 10. Treatment successful.
10. Treatment unsatisfactory. To complete the differential history of these two diseases, we may say that the syphilitic testicle tends finally, if not early cured, to produce atrophy of the organ; while in the chronic simple orchitis, the tendency is to the disorganization of the testicle by abscesses, sinuses, or its entire protrusion in the shape of the fungous testis. Lastly, the pathological anatomy of the syphisitic disease is found to be, according to Ricord, an effusion and partial organization to fibrine on the fibrous surfaces and compartments of the organ; while, according to Curling, there is always found in the simple chronic orchitis, an abundance of the yellow, gelatinous, unorganized material, both within and without the seminiferous tubes, which he considers as the peculiar pathological element of the disease, and which is undoubtedly fibrine in an aplastic or unorganizable condition.
Nov. 24. I present you to-day with another case of diseased testicles, which contrasts well with those which we studied at our previous meeting. This man has, you observe, both testicles moderately enlarged; and he tells us that the disease came on four months ago, with an acute attack of inflammation occurring first in one, and fourteen days afterward in the other. This inflammation, and the pain accompanying it, gradually subsided, leaving the organs in the condition you now see. They are but slightly indurated, and the principal part of their bulk is due to enlargement of the epididymis and cord. They are not painful, not very sensitive to the touch ; the scrotum is sound; hydrocele, if any, very slight; and so far from showing any tendency towards suppuration, the affection has actually been improving for some time; and the man did not come into the hospital on account of the disease of his testicles, but for a chancre which you see on his penis. Now, without inquiring into his syphilitic antecedents, we may pronounce that this is not a syphilitic disorder. Its commencing in the epididymis, and as an acute affection, the testis proper being only secondarily and in a slight degree affected, does not at all correspond with the course of syphilitic orchitis; the further history and present condition of the disease is entirely different from that which we have already studied in the two cases previously presented. To make our diagnosis sure, however, let us examine his previous history. He says, that the chancre which he now has, was contracted some weeks after the testicles began to be affected, and that he never before had a chancre or any suspicious disease. He had, however, a gonorrhea during the whole year preceding; and it was during the existence of this chronic gonorrhæa that the testicles became affected. This is, you know, an exceedingly common circumstance in long-continued or ill-managed gonorrhæa, and places the case under the head of chronic gonorrheal epididymitis, of which it may be regarded as a classical example.
Treatment. The principle on which your treatment is to be founded, is different in the three different diseases considered. In the syphilitic form, the treatment which is best suited to eradicate the syphilitic virus from the system, will soonest cure the case. M. Ricord speaks highly of the iodid. potassii, which he seems to consider as competent to the cure of the largest proportion, if not all the cases. We have been somewhat disappointed in the expectations we had formed from this remedy; several of our cases having been faithfully treated with it in large doses, during many weeks, and, in one case last winter, during several months, without any sensible effect upon the disease, which afterwards yielded readily to mercurials. For my part, I now never waste time on any other