Discussion. Dr. J. M. Ray: I do not know that the ocular symptoms will throw any light upon the case. I remember that this young man came to me some time ago to have his eyes examined. He stated that he had been under the care of a prominent oculist in the South, and had been fitted with glasses. When I saw him he had some trouble in the use of his glasses, and also complained of defective sight of one eye. Upon examination I found a spot of atrophy of the choroid, showing the location of a former acute choroidal disease, and there was considerable diminution in acuteness of vision in that eye, with a defect in refraction in the other eye. Under mydriatics I fitted him with glasses, since which time he has been perfectly comfortable so far as his eyes are concerned.
He states that he remembers I said something to him at that time about tubercular disease, after looking into his eyes, but I have forgotten the circumstance; I only remember that I found choroidal disease.
Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic history of our cases. Chronic inflammations tend to take on the part of the diathesis. I did not understand the reporter to say that any test had been made, by withdrawal of some of the fluid or otherwise, to determine the exact nature of the condition. I desire to say, however, that if this were my testicle I would have it removed. I believe that would be the safest plan. An absolutely positive diagnosis would be difficult to make without a microscopical examination for the tubercle bacillus, but I can not help feeling prejudiced in that direction.
Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done with this testicle; it should come out. I, too, think it tubercular, although in all probability the gonorrhea is a factor in the case in stimulating the growth of the testicle. I do not know that a microscopical examination would give us much light upon the subject; in fact I would not wait for that, I would simply remove the testicle at once.
Dr. Wm. Bailey: The question is not by any means settled as to the exact nature of the disease in the case before us, whether the patient, having had repeated attacks of gonorrhea, has not also been so unfortunate as to have syphilis. With a tuberculous history of course a tuberculous condition of the testicle seems plausible; but inasmuch as tuberculous disease of the testicle may remain for a long time possibly without great danger in affecting the patient otherwise, and knowing the changes that take place in the testicle from repeated attacks of gonorrhea, orchitis, etc., I believe if it were mine I would be disposed to keep it for a while, particularly as the other testicle seems to be somewhat atrophied, with this one of pretty good size. I think I would keep the larger one.
Dr. T. S. Bullock: I am inclined very much to agree in the opinion expressed by Dr. Bailey. I have frequently seen, after repeated attacks of gonorrhea, a testicle that had become enlarged, without any pain. The testicle in this case appears to be perfectly smooth, and in view of the fact that tubercular disease of this organ may exist for a long time without affecting the general system, I should certainly keep the testicle until my general health began to show some evidence of declination.
Dr. F. C. Wilson: The question is a very difficult one to decide. There is one feature of the case that has not been sufficiently emphasized, and that is the probable damage to the testicle itself by the repeated attacks of gonorrhea. We know that the use of the testicle, so far as any procreative uses may be concerned, has probably been abrogated by these repeated attacks of gonorrhea, and with this view of the case the question of removal of the testicle by surgical means would be simplified; and it seems to me with the tuberculous history, if the question could be decided even approximately, or even probably, that it is tubercular, then it had better be removed. But it seems to me I would first make every effort to solve the question, even aspirating or removing a small part of the tissue so as to be able to make a microscopical examination, and in that way possibly throw some light on the subject.
Dr. W. O. Roberts: It strikes me that this is tubercular, although it may have been, as Dr. Howard says, excited by gonorrhea. The condition feels to me nodulated and not smooth, and the disease appears to be located chiefly if not entirely in the epididymis, and I think the testicle should be removed. Whether it is tuberculous or not the usefulness of the organ is destroyed, and I think it ought to come out if it is tuberculous, especially because the other testicle will become involved. So far as the cosmetic appearance is concerned, if that is a feature in the case, we could insert a celluloid testicle. I believe if the affected testicle is not removed, granting the diagnosis of tuberculosis to be correct, that the other testicle will surely become involved.
Dr. Turner Anderson: It is seldom that we have obstetric matters presented to this society. I have thought perhaps a case I recently attended might be of some interest. We are aware that the umbilical cord is frequently found encircling the neck of the child. I delivered a child four days ago in which the cord was wrapped around the neck twice, then branched off under the arm, encircling the arm again at its dorsal surface, then across again, branching over the back. You may better understand the condition when I say that the cord came up from its attachment at the umbilicus, encircling the neck twice, branching over and under the axilla, around the arm, thence to its attachment to the placenta. The woman was a primipara. As soon as the head was delivered I detected that the cord was wrapped around the neck. I made an effort to find the part that led to the placenta. The cord was found pulseless, and I was in some doubt as to whether it had been so long encircling the neck as to have produced death of the child. Just as the body of the child was being extruded the cord snapped, tearing off fortunately from its placental attachment. The child was delivered and after a little effort was easily resuscitated. The pressure was so great, the traction upon the cord was so decided, as to leave a white line across the back of the child. There was a white mark around the neck, across the clavicle, around the arm and over the back of the child which did not disappear for some time afterward.
The proper line of practice, I take it, in those cases where the cord is around the neck of the child, is to first determine whether the cord is still pulsating. If pulsating, we are justified in being a little more tardy in our efforts to deliver the shoulders and release the child. If possible we would of course draw down the cord and release it from the neck of the child in this way; but in those cases where we are confronted with the cord wrapped tightly around the neck of the child, especially in the primipara, where the length of time which will be consumed in delivery is uncertain, the line of practice I believe in should be prompt delivery or division of the cord. As a rule when we are confronted with a condition of this kind we can meet it satisfactorily by a little delay and by holding the head of the child well up against the vulva while the shoulders are being extruded. As the releasing pain occurs and the shoulders and body are extruded, you can usually by pressing the head well up prevent undue traction on the placenta and any accident which might follow rapid delivery and undue traction upon the cord. This was a case in which there was spontaneous rupture of the cord; it tore away entirely by the uterine effort. This accident had no influence upon delivery of the placenta; it came away promptly. It was evidently not torn loose from its attachment, and there was no hemorrhage.