EPIDIDYMITIS AND ORCHITIS.
Inflammation of the testicle occurring in the course of acute or chronic gonorrhoea is very frequent. Its presence is usually an indi cation of extension of infection to the deep urethra. Exceptions to this rule are met with, but the proposition isr accurate in its general application. Like all inflammations, that of the testis may be acute, subacute, or chronic. The affection may occur at any time during the course of a gonorrhoea, and indeed at times when the pa tient considers himself free from the primary disease. The body of the testis is rarely affected primarily, the condition being in the majority of cases one of inflammation of the epididymis, with per haps more or less secondary involvement of the testis proper.
The mode of infection is of considerable practical importance. Quite frequently the disease comes on within a very short time after the introduction of instruments or after the employment of other mechanical methods of treatment. Under such circumstances the inflammation of the testis is produced in one of two ways, either (1) by direct traumatism and sepsis of the mucous membrane of the deep urethra which eventually involves the ejaculatory ducts; or (2) the instrument acts as a carrier of infectious material into the deep urethra, the germs of the mixed infection and their products being, as it were, rubbed into the mouths of the ejaculatory ducts. The prostatic follicles are usually involved, although they may apparently escape for a time at least. In a general way, the existence of epi didymitis may be accepted as positive evidence of infection of the prostate. h is probable that in some cases infection occurs from the deeper parts into the urethra via the lymphatics, without the inter vention of deep urethral inflammation. As a consequence of sexual indulgence, or without known exciting cause, inflammation of the epididymis very frequently occurs. It is the impression of the author that the sexual orgasm is very often responsible for infection of the deeper parts of the urethra by virtue of the aspirating action of the deep urethral muscles during seminal emission. It appears logical to infer that infectious materials may be drawn from the anterior into the posterior urethra during the venereal act. The rationale of this accident has been considered elsewhere. The old-time view of metas tasis of the urethral inflammation would appear to be no longer tenable. It must be confessed, however, that the clinical features of epididymitis occurring in the course of acute gonorrhoea afford some support to the old-fashioned notions regarding metastatic inflamma tion. The subsidence of the urethral discharge and its reappearance coincidentally with improvement in the testicular inflammation con stitute a very striking feature of this particular complication of gon orrhoea, and one which must have appealed very forcibly to our medi cal forefathers as substantiating the theory of metastasis.
Symptoms.—It is very exceptional that testicular complications occur within the first week of a gonorrhoea,. As a rule, the epididy mis is not involved under ten days or two weeks. Inasmuch as the inflammation gradually progresses toward the deeper parts of the urethra, this fact is readily understood. In some instances the attack is precipitated by sexual or alcoholic indulgence, or over-exertion. Very often, as already stated, the patient presents a history of instru mental interference with the deep urethra. In chronic cases the epididymis may become involved at any time, often indeed when the patient supposes himself perfectly free from urethral discharge. Its occurrence under such circumstances is positive evidence of urethral infection. Stricture of the urethra is especially apt to be complicated from time to time by attacks of epididymitis. It is likely in these chronic cases of urethral disease to assume a subacute or chronic type.
The symptoms vary with the acuteness of the disease. In the acute cases two methods of invasion are observed. (1) Those in which the patient is primarily taken with a severe pain in one or the other groin, referable to the region of the spermatic cord. Great tenderness exists in this region. Symptoms of tissue strangulation, similar to those existing in hernia, may be observed, with slight nau sea and vomiting. The author has in several instances been called in
to operate on strangulated hernia and found inflammation of the spermatic cord, heralding an approaching epididymitis. Whenever this condition exists, the patient may be confidently informed that within twelve to thirty-six hours inflammation of the epididymis will develop. The reason for the severity of the symptoms is a very sim ple one. The spermatic cord is invested by dense fascial tendinous and muscular envelopments, especially in the vicinity of the external ring. It is by no means surprising, therefore, that the sensitive cord should be more or less strangulated when it is affected by acute in flammation. It is the opinion of the author that more or less pelvic peritonitis of that portion of the peritoneum which invests the sper matic cord within the pelvis is a quite constant feature of cases of in flammation of the testicle in which the cord is involved in the manner described. Cases occasionally occur in which acute appendicitis is quite closely simulated. The cases in which the cord is especially involved are usually very slow in recovering. Relapses are more frequent than when the inflammation primarily affects the epididy mis. (2) Cases in which the epididymis is primarily involved and the cord only secondarily and in a minor degree. The patient is likely to feel more or less tenderness and weight with a peculiar drag ging sensation along the spermatic cord for a few days or few hours before the inflammation of the epididymis develops. The testis may be extremely hypermsthetic. The tenderness increases until the in flammation is at its maximum, when the slightest touch produces extreme pain. If the case be examined before marked swelling oc curs, a little swelling and tenderness limited to the epididymis and that portion of the spermatic cord immediately adjacent to the testis will be observed. As the inflammation progresses the scrotum be comes oedematous, reddened, and tender. The urethral discharge diminishes, and in many cases entirely subsides. Milton's conclu sions regarding this particular symptom in epididymitis are some what extraordinary. He makes the assertion that marked subsidence or disappearance of the discharge is not observed in epididymitis. If this be true of Mr. Milton's cases, great allowance must be made for a variation in the phenomena presented by patients in different localities. As far as the observations of most surgeons go, this point is so well established that it is hardly open to argument. When the inflammation is well advanced more or less fluid will be found in the cavity of the tunica vaginalis—acute hydrocele. The acute symptoms persist for from five or six days to a week, and are attended by more or less febrile disturbance. In some cases there appears to be marked disturbance of digestion; the patient loses appetite; the tongue be comes heavily furred, and constipation ensues. When the cord is more or less strangulated, considerable anxiety is manifested. At the end of from five to seven days the inflammation begins to subside ; tenderness diminishes and eventually disappears, but when allowed to take its own course the testicle does not return to even approximately normal size for some weeks. When suitable after-treatment is not instituted, and often in spite of the greatest after-care, permanent induration of the epididymis is likely to result. Whenever such permanent induration exists, occlusion of the lumen of the epididymis may be suspected, and when double epididymitis has occurred and the patient appears to be sterile, the old-time inflammation of the epididymis assumes a rather formidable character. Suppuration very rarely occurs ; when it does do so, it may be due either to tubercular:or to purulent infection. It is worthy of note in this con nection that inflammation of the epididymis is apparently due to the mixed character of the gonorrhoeal infection rather than to the gonococcus per se.
Toxic pseudo-alkaloids have been extracted from gonorrhoeal pus which, inoculated into the epididymis of dogs, have produced charac teristic inflammation.