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21. April 19, 1928, intestinal obstruction due to urn·
bilical hernia.
22. April 26, 1928, heriotomy, right inguinal.
23. May 14, 1928, exploratory laperotomy.
24. May 21, 1928, appendectomY.
25. May 28, 1928, general peritonitis.
26. May 28, 1928, subhepatic abscess.
27. June 11, 1928, herniotomy, inguinal.
28. June 11, 1928, herniotomy, umbilical and in·
guinal recurrence.
29. June 5, 1928, ruptured ,gallbladder.
30. June 16, 1928, ruptured gallbladder.
. Metropolitan Press, Seattle
1 +·-----,-------------~I
TORSION OF THE
SPERMATIC CORD
WITH GANGRENE
MILLARD S. ROSENBLAIT, M. D.
Portland, Oregon
'.~: ,
Reprint from The Medical Sentinel, July, 1929
I· .:--0--------------..0-'-'-0-0-0-0-0-0-0-'-0-0....:,::"
;;('.( '
,,' - -
it took another 1/6 grain to give re-
lief. The patient was operated on at
8:30 A. M., - three hours after first
being seen. Diagnosis: Torsion of sper-
matic cord.
Operative Record: Orchidectom.y with
excision of three inches of spermatic
cord.
A three-inch right inguinal incision
made. Tumor of scrotal sac delivered,
found to be a testicle which had be-
come twisted on its cord, twist extend-
ing all the way to the internal inguinal
ring. The testicle was already partly
gangrenous. Cord was also gangrenous
to the level of the internal ring. The
veins of the cord were very tortuous and
full. Testicle and cord were removed
at the level of the internal ring. Veins,
arteries and cord were ligated sepa-
rately. Repair of the muscle and fascia
were done just as for inguinal hernia.
Dermal sutures for skin.
Pathological Report (by Dr. Manlove)
Gross: The specimen is a much en-
larged spermatic cord and testicle. The
external surfaces are hemorrhagic. The
cord when cut shows diffuse necrotic
process t h r 0 ugh 0 u t with hemor-
rhage into the tissue. The testicle is
brown with a red tinge.. The entire tes-
ticle shows disintegration from strangu-
lation of the blood supply.
Diagnosis: Necrosis of spermatic
cord with associated disintegration of
testicle from strangulation of blood sup-
ply. Torsion of spermatic cord.
Clinical Course: The patient was dis-
charged, well, from the hospital two
weeks after the operation.
The pathological physiology in this
reported case seems to be the one we
have suggested, for there was abnormal
mobility, plus varicocele, plus sudden
straining.
Treatment, unless spontaneous un-
twisting occurs at once, incision should
be made, and if in the early hours, un-
twisting may be sufficient to relieve the
condition.
If gangrene is present or imminent,
orchidectomy is necessary.
This case was of 12 hours duration
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Necrosis of Spermatic Cord and Testicle from Torsion.
ed. There are acute and occasionally Uffreduzzi has found that a normally
recurring cases. attached testis could not undergo tor-
The onset has been associated with sion. He felt that the contraction of
violent exertion, sudden strain, strain- the cremasteric muscle is responsible for
ing at stool, trauma, sudden crossing of the rotation of the cord. Venous con-
the leg, coughing, rapid walking, squeez- gestion, be it at the time of puberty,
ing, reduction of strangulated hernia. . or at other times, due to varicocele, plus
T~ ORSI~ON-OF THE SPERMATIC COR·Di abnormal mobility, plus sudde~ exer-tIon, appears to be the most lOgIcal ex-
WITH GANGRENE plan~tion of ~he pa~hologic~l physiol-ogy Illvolved III causmg torsIOn.
Differential Diagnosis: The chief
points to be differentiated are epidydi-
mitis, orchitis, strangulated hernia.
Case report of patient treated at the
Good Samaritan Hospital: L. B. L.
Chart No. 0, 7806.
History: A white, adult male, mar-
ried, who is 40 years of age. He had
been in good health, except for several
days prior to the onset of the present
illness when he had been very consti-
pated and had complained of vague gen-
eralized abdominal pain. The evening
before the onset of his acute pain the
patient had given himself an enema, and
while straining excessively at stool had
a very sudden, sharp pain in the right
testicle. This pain was excruciating in
character, and was not relieved. The
patient applied very hot compresses and
certain essential oils to relieve the pain,
but only succeeded in burning the skin
of the parts. Although the pain was
unrelieved, the patient did not call for
medical aid until 5 :30 A. M., some nine
hours after the onset of the acute pain.
At this time he described the pain by
saying that he felt as though someone
was "kicking him there all the time."
There was a venereal history of gonor-
rhea and chancre some 15 years prev-
ious to this illness. The pain had been
so severe that the patient had vomited
clear fluid three or four times.
Physical Examination: A thin, but
well nourished male, apparently in great
distress, writhing in agony from the
pain. Examination is negative except
for the local condition. The right tes-
ticle is two and one-half times normal
size, extremely tender and very painful.
The spermatic cord is hard as high up
~s it can be felt. The external inguinal
ring is small and there is no bulging
on coughing. No hernia is present. The
skin over the scrotum and lower in-
guinal region is burned from the pa-
tient's applications; 1/4 gr. morphine-
sulphate did not relieve the pain. and
MILLARD S. ROSENBLATT, M. D.,
Portland, Oregon
THE ~rst case of torsion. of t~e sper- Sev~ral have been reported as occurringmatIc cord was descnbed m 1840 .durmg sleep.by D~lassiua(Ve. Wallenstein re- The symptoms associated with the on-
ports 150 cases in the Journal of Urol- set of this condition are sudden and
ogy, for February, 1929, which he has very sharp pain, nausea and vomiting,
summarized from the literature, includ- fever, leukocytosis, plus the local symp~
ing one case of his own. Sixteen addi- toms of swelling and extreme tender-
tional cases have been found in the liter- ness.
ature by us, which are not referred to The recurrent type is described in
by Wallenstein. which the symptoms are more mild and.
In this group of cases it was found there is spontaneous untwisting. Under
that torsion is especially prevalent in etiology, abnormal mobility is considered
undescended testis. Of 150 cases, 60 per a cause. A portion of these cases have
cent were on the right side and 40 per occurred at puberty and it has been sug-
cent on the left side; eight cases of gested that venous congestion at this
intra-abdominal testis have been report- time might be a factor.
\
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,
f author's case at time of operation.
th endometrial new growth at lower
th the incision made at recent opera-
bw growth is shown in inset. Bleeding
~ure of the blebs at the menseS.
'w commenced a dull generalized lower
lssociated with tenderness in the lower
~ve scar, and increasing with' each men-
e months later there appeared gradually
,dular thickening in this region which
~mall quantities of darkish blood-stained
:enstrual period.
ncreased in amount, and at present the
bleeding requires that her sanitary nap-
!'lard in order to absorb the flow from
l as from the vagina. The flow is fre-
Lse but always dark in color. The tender-
the menses is described as excruciating.
ination (second day of menstrual period)
fler distorted midline scar from symphy-
fle condition of the scar is suggestive of
infection. At the lower pole, immediately
;is, there is a wrinkled depressed area,
~red, and about the size of a five cent
repressions are filled with what appears
:\d. A sanitary napkin, the upper end of
area, is quite profusely blood-stained.
)od from this depressed surface, which
,r and deeply indurated, reveals three
blebs in various stages of distention.
The largest was ruptured by a probe in the course of the
examination and its thick chocolate colored contents ex-
truded. A probe can not be inserted without the use of
undue force.
Vaginal examination reveals a small fluctuant tumor
in the region of the right ovary, thought to be an ovarian
cyst, and a fundus of normal size in fair anterior position
and quite fixed, giving the impression of definite adhesion
to the anterior abdominal wall.
Preoperative diagnosis: Endometrioma of abdominal wall,
fundus adherent to anterior abdominal wall. Right cystic
ovary (possibly chocolate cyst). '
Operative report: At operation (eleventh postmenstrual
day) the scar was excised, and the pelvic viscera were
exposed. A firm cord-like adhesion was noted, extending
from the peritoneal aspect of that part of the abdominal
HOMER P. RUSH, M.D.
PORTLAND, ORE.
ADMINISTRATION OF DIGITALIS*
Reprint from Northwest Medicine, Seattle,
Vol. XXVIII, No. 12, Page 56'2, December, 1929.
• Read before the Klickitat and Snohomish County
Medical Society, Everett, Wash., Oct. 17, 1929.
Digitalis has been known to medical science
since it was brought to its attention in 1785 by
William Withering. Although that is approximate-
ly a hundred and forty years ago, we have yet no
drug which can replace it in the treatment of heart
disturbances. The history of digitalis is a most in-
teresting story. Perhaps its most interesting phase
is the correctness of the first observation which,
though discredited during much of the early work,
has finally been proven to be correct.
For therapeutic application digitalis has been
prepared in many different ways. The strength and
assay of these preparations varied greatly, and as
a result dosage was difficult. It was not until 1918
that standardization of digitalis became uniform.
Since this time, however, the U. S. P. tinctures or
the powdered leaf can be depended upon for assay.
It is no longer necessary to use special prepara-
tions which are much more expensive to the car-
diac patient.
The actions of digitalis upon the animal organ-
ism are many. These are all less or secondary to
its effects upon the heart. This action, which is
usually that of increasing the strength yet slowing
the beat, is due to a combination of effects. Both
vagal stimulation and direct action upon cardiac
musculature play their roles in producing this heart
• From the Department of Gynecology, University of
Oregon Medical School.
• Read before the Fifty-fifth Annual MeetiRf, of Ore-
f~r9.State Medical Society, La Grande, are., ay '16-18,
•• Reference to several more cases has been noted.
They are not included in Table I and bibliography due
to failure to obtain original references. •
lormed "bilateral salpingectomy, left oophorectomy, resec-
tion of fundus of uterus to just below where tubes come
off, removal of cone shaped piece from endomertium."
Three drains were inserted to the cuI de sac.
The patient was discharged twenty-four days after opera-
tion with serous drainage from the incision. Menstruation
occurred at the usual intervals and showed no notable ab-
normality until the sixth month following operation, at
which time the serous discharge from the incision hadI
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Brit. Med. Jour.,
Legneu: Presse med., 1896, 289.
Lenhossek: Anatomischer Anzeiger, 1845.
Lexer: Arch. f. klin. Chir., 1894, xlviii,
410 Medical-Dental Bldg.
(43) Keyes, E. L. Collings, C. W., and Camp-
bell, M. F., J. Urol., vi, 519.
(44) Landau: Muenchen Med. Wchnschr.,
1905, No. 16.
(45) LaPointe: A. La torsion du cord sperma.
tique et l'infarct hemorragie du test, Paris: Ma-
loine, 1904.
(46) Lauentein: Samml. klin. Vortr., 1894, No.
92.
(47) Le Conte: Internat. Clin., iv, 17th series,
1907.
(48)
(49)
(50)
201.
(51) Low: Brit. Med. Jour., 1906, May 26.
(52) Lowden: Brit. Med. Jour., 1905, April 29,
932; Scotch Med. and Surg. Jour., ix, 229.
(53) Lugones: Rev. assoc. med., argent., 1916,'
xxv, 369.
(54) Manson: Bull. med., 1902, 563.
(55) McConnell: Dublin Jour. M. Soc., 1912,
cxxxiii, 337.
(56) Meyer, von: Deutsche.. med. Wchnschr.,
1891, 800.
(57) Moschkowitz: Ann. Surg., 1910, vii, 821.
(58) Moschkowitz: Ann. Surg., June, 1912.
(59) Murray: Brit. Med. Jour., 1912, ii, 7.
(60) Nash: Brit. Med. Jour., 1893, 742.
(61) Nicolandi: Arch. f. klin. Chir., 1885, xxxi,
182.
(62) O'Connor: Surg., Gynecol. and Obstet.,
1919, xxix, 580.
(63) Odiorne and Simmons: Ann. Surg., 1904,
962.
(64) Ormond: Ann. Surg., !<'ebruary, 1927.
(64) Page:: Lancet., 1892, ii, 257.
(66) Pearlman: Jour. Urol., 1927, xvii, 637.
(67) Quadflieg: Deutsche med. Wchnschr.,
1907, xxxiii, 2138.
(68) Reboul: Rev. de chir., 1901, xxvi, 97.
(69) Reizz: O. Gyogyaszat, Budapest, 1904,
No. 44, 726.
(70) Rigby and Howard: Lancet, 1907, i, 1416.
(71) Robertson: ' Med. J. Australia, 1915, i, 213.
(72) Sanders: Med. Miror, St. Louis, 1896, vii,
113.
(73) Scheen: Lancet, 1896, i, 990.
(74) Schiller: Wien, klin. Wchnschr., 1908,
No. 18.
(75) Scudder: Ann. Surg., xxxiv, 234.
(76) Snyder: J. Kansas M. Soc., 1916, xvi,
195.
(77) Spencer: Tr. Lond. Path. Soc., 1892, xliii,
51.
(78) Stanton and Shaw: Albany M. Ann., 1904,
August.
(79) Stiles: Tr. Med. Chir. Soc., Edinburgh,
1906, Feb. 1.
(80) Taylor: Brit. Med. Jour., 1897, Feb. 20.
(81) Thorek: Interest. Med. Jour., xxvi, No.
3, 194.
(82) Thorek: Ann. Surg., lxxxi, 1142.
(83 Uffreduzzi: Arch. f. klin. Chir., 1912, c;
1913, ci, 159.
(84) Van Der Pool: Med. Rec., 1800, 282.
(85) :vanverts: Ann. d. mal, d. org. genito-
urin, xxiii, 401.
(86) Wallenstein, S.: J. Urol., 1929, xxi, 279.
(87) Wendel: Muenchen. med. Wchnschr., 1908,
877.
(88) Whipple and Nash:
1891, June 6, 1226.
(89) Williams: Med. Fotrnightly, St. Louis,
1903, xxiv, 543.
Brit. Med. Jour., 1893, ii, 13.
Tr. M. Soc. Virginia, 1905, 402.
Boston Med. and Surg. Jour., 1903,
TORSION OF INTRO-ABDOMINAL TESTIS
(1) Atherton: Med. Rec., 1901, lx, 816.
(2) Atlee: Lancet, 1911, ii, 761.
(3) Berg: Brit. Med. Jour., 1921, ii, 843.
(4) Berg: Ann. Surg., August, 1904.
(5) Berry: Birmingham M. Rev., 1898, 270.
(6) Bevan: Arch. f. klin. Chir., lxxii, 1035.
(7) Bevan: Jour. Amer. Med. Assoc., 1899,
xxxiii, 773.
(8) Bevan: Jour. Amer. Med. Assoc., 1903,
xli, 718.
(9) Brazil:
(10) Bryan:
(11) Cabot:
cxlviii, 700.
(12) Campbell: Meredith F., Surg. Gyn. and
Obs. 1927 (March), 311.
(13) Chevassu: Arch. gen. de chir., Par., 1908,
ii, 225.
(14) Corner: Clin. Jour., 1909-1904-1905, 202.
(15) Cotte: Lyon med., 1911, cxvi, 758.
(16) Cupler: Surg., Gynecol. and Obstet., 1915,
xxi, 250.
(17) Curling: Diseases of the Testis, 4th ed.,
20.
(18) Davis-Colley:: Brit. Med. Jour., 1892, Apr.
16, 811.
(19) Delassiuave: Rev. Med. Franc. et etrang.,
1840, 363.
(20) De Quervain: Leut. Ztscher, f. chir., xli,
271.
(21) Eccles: Lancet, 1902, i, 569.
(22) Edington: Lancet, 1904, January 25, 1782.
(23) Eitel: Northwest Lancet, 1905, xxv, 418.
(24) Englische and Mayer: Wien. klin. Wchn
schr., 1893, 603.
(25) Farr: Ann. Surg., 1913, lxviii, 8138-852.
(26) Finney: J. Roy, Army Med. Corps., Lond.,
1914, xxii, 201.
(27) Firth: Bristol Med. Jour., 1904, No. 86,
320.
(28) Gerster: Ann. Surg., xxvii, 64.
(29) Going and Keith: Lancet, 1906, 370.
(30) Golding: Med. Rec., 1905, January 21, 98.
(31) Gould, Pearce: Clin. Soc. Tr., xiv. 80.
(32) Griffiths: Jour. Anat. and Physiol., 1896,
xxx, 81.
(33) Guiteras: Med. Rec., 1896, xlix, 11.
(34) Halstead: Surg., Gynecol. and Obstet.,
1907, iv, 129.
(35) Howard: Brit. Med. Jour., 1907, ii, 719.
(36) Howse: Royal College of Surgeon's Mu-
seum Catalogue.
(37) Jeffrey: Brit. Med. Jour., 1902, i, 1339.
(38) Johnson: Ann. Surg., 1893, 282.
(39) Johnson: H. A., Boston Med. and Surg.
Jour., 1927, 1036.
(40) Jordan: Leut. Med. Wchnscher., 1895,
xxi, 525.
(41) Keen: Tr. Roy. Med. and Chir. Sec., 1892,
cclxxv, 25,3.
(42) Kelly: Liverpool Med. and Chir. Jour.,
1912, lxii, 394.
and probably the necrosis and gangrene
existing at operation, had so existed for
several hours.
Summary
(1) A case of Torsion of the Sper-
matic cord is reported.
(2) The important features of such
cases are summarized from the litera-
ture.
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