Complete Text (Part 31)

vaginalis and testis (periorchitis adhoesiva'), which may cause a partial or even total obliteration of the sac. These are often of syphilitic origin. Purulent inflammation (periorchitis or vaginitis suppurativa') is easily recognized by the purulent character of the contents of the sac. It may be traumatic in its origin, or secondary to some other affection of the testis. 2. The Exterior of the Testis and Epididymis. The testis, in consequence of various processes (inflamma- tory or the growth of tumors), may undergo a hypertrophy, sometimes exceeding the size of a man's fist. Atrophy is constant in old subjects, and also occurs as the result of an arrest of development after puberty, from the compression of hydrocele, and finally from chronic fibrous inflammation, especially that of syphilis. The epididymis is independent of the testis, with reference to changes in size. In many forms of inflammation, especially in those which affect sim- ilarly other portions of the genito-urinary organs (gonor- rhoea, tuberculous inflammation), the epididymis is enlarged. The consistency of the testis, which is very soft, becomes 236 DIAGNOSIS IN PATHOLOGICAL ANATOMY. still softer and more compressible, in the atrophy of old age and in that arising from pressure, provided the tunica albu- ginea is not unusually thickened. In fibrous atrophy the gland is decidedly firmer, also in most inflammatory changes, whereas in many tumors the consistency is perfectly soft (medullary). 3. The Interior of the Testis and Epididymis. In order to examine the jparenchyma a longitudinal incis- ion is to be made, beginning on the side opposite the epidid- ymis and extending through the body of Highmore into the epididymis. The latter, especially its head, may also be ex- amined by a separate incision. The color of the normal parenchyma is, according to the amount of contained blood, gray or grayish-red. When it is pale yellow or yellowish-brown, and the parenchyma is very soft, it is an indication of fatty degeneration of the cells within the tubules of the testis, which appears usually in atrophy, especially in that of old age. A grayish-white color, combined with fibrous hardness, arises from the devel- opment of fibrous tissue. The clear yellow color of cheesy masses is, in the majority of cases, to be attributed to tuber- culosis. Haemorrhages, hoemorrJiagic infarctions (^eniboUc'), and embolic abscesses, occur here also, but much less frequently and more extensively than in other organs. The acute inflammations are rarely met with. As is well known, the epididjauis is the favorite seat of purulent in- flammation (^epididymitis apostematosa'), so frequently gon- orrhoeal, still the testis is not always free. In the latter, cavities of various size are sometimes found, containing greasy yellow masses, composed of fat and glistening Choles- terine crystals (atheroma of the testis), or of such petrifac- tions as result from former abscesses. Cicatricial bands, which often extend to the integument and thus produce a deep depression, may also be due to abscesses which have led to the formation of fistulae and then healed. While the THE TESTIS AND EPIDIDYMIS. 237 fistulas exist they are frequently lined with a layer of granu- lation tissue, which may project upon the surface like a tu- mor. Chronic inflammation is recognized by the fibrous thickening of the interlobular septa, on account of which the intervening glandular tissue is more or less atrophied. Tuberculous and syphilitic affections of the male gener- ative glands, are of the utmost importance. They may be distinguished in a general way from each other by the fact that the former first attacks and has its principal seat in the epididymis, while the latter first attacks and has its princi- pal seat in the testis proper. Among the tuberculous affections, two varieties may be distinguished. In the first the epididymis forms a sausage- like swelling, and has often undergone complete cheesy de- generation, while in the parenchyma of the testis there is no apparent change, or there are very scattered gray, miliary or submiliary, tubercular nodules, which diminish in num- ber from the corpus Highmori towards the periphery, and may be cheesy. In recent cases it may be easily ascer- tained that the process begins in the walls of the epididy- mis and vas deferens, for the latter, and other portions of the genito-urinary organs, usually share in the disease ; the wall is thickened, gray, and translucent, the superficial por- tions are infiltrated to a slight extent with cheesy material, and the inner surface is covered with a layer of the same. As a rule, the tissues are so firm that sections may be made with a sharp razor, and in these the presence of tubercles in the peripheral layers of the walls may easily be seen. The greatest development of the affection is, as a rule, in the head of the epididymis, which in cases of long duration may be converted into a cavity filled with a greasy, cheesy mass. Not unfrequently perforation takes place, a fistulous opening of greater or less width is then found on the scrotum, lead- ing directly into the interior (^fistula testis tuberculosa')., from whicb a caseo-purulent secretion is discharged. In the testis proper the tubercles are situated in the interstitial tissue, which is increased and appears in the form of gray lines, radi- 238 DIAGNOSIS IN PATHOLOGICAL ANATOMY. ating from the corpus Highmori, or as round gray spots. The tubercles may become very numerous in the testis, and by their confluence produce large cheesy masses, so that finally the testis may attain the size of a hen's egg, or even that of a lemon. The affection is unilateral, or bilateral ; in the latter case one side is often more affected than the other. According to Gaule the formations which have always been looked upon as tubercular nodules are the result of an in- flammation of the tissue about the tubules of the testis (^peri- spermatoplioritis), combined with changes within them, just as the peribronchitic pseudo-tubercles are the product of an inflammation of the peribronchial tissue, except that in the latter case each nodule involves but one small bronchus, while in the former a number of tubuli are involved. The second variety is met with especially in boys who are suffering from general tuberculosis. It has its seat from the beginning in the testis proper, and is essentially a dissem- inated miliary tuberculosis, which may however produce large cheesy masses by the confluence of the nodules. The syphilitic affections of the testis vary according as they are manifested by a simple interstitial fibrous inflam- mation (orchitis interstitialis fibrosa), or the formation of gummata (sarcocele syphilitica). The former somewhat resembles in its gross appearances the first form of tuberculous inflammation, since the changes are greatest in the corpus Highmori, and disappear gradually towards the periphery. Firm, fibrous, cicatricial bands are seen, varying in width, at first connected with each other, but becoming more and more separated as they approach the surface; they correspond to the direction of the septula tes- tis, in which the affection essentially runs its course. The fibrous bands give off numerous lateral branches, so that their combined appearance upon the surface of the section may be compared to a stag's horns. The affection is fre- quently only lobular, but it may extend over the whole parenchyma. The parenchyma lying between the fibrous bands naturally undergoes atrophy from compression, so that THE TESTIS AND EPIDIDYMIS. 239 the testis, at least in the later stages, is always diminished in size. When the affection is extreme, total fibrous atro- phy may finally result. Gummata of the testis never occur alone, but always in connection with an interstitial fibrous orchitis. The yellow, dry, tougli, elastic,' fatty masses of the gummata lie imbed- ded in the fibrous product of interstitial inflammation, and consequently have a much more irregular appearance than the first form. The gummata are sometimes in the form of miliary nodules ; again they form large irregular masses, which lead to considerable enlargement of the testis. The fatty masses here, as in other organs, may gradually disappear by absorption, so that only a fibrous cicatricial tissue remains, which sometimes is only to be distinguished from the fibrous tissue of interstitial inflammation by its unusual situation, it being separated from the corpus Highmori by relatively normal tissue. A chronic fibrous periorchitis, and frequently the adhesive form also, are usually combined with the syph- ilitic processes. The testis is a favorite seat for all varieties of tumors. These are sometimes simple ; again (and in this respect the peculiarity of the testis consists), they are mixed, presenting the most peculiar combinations. The teratoid tumors, which have their favorite seat in the ovaries, occur rarely in the testis. The most frequent forms are the mixed tumors of the histioid class, especially myxosarcoma ; also chondrosar- coma, the character of which is sometimes so apparent that the position of the separate parts of which it is composed may be determined with the unaided eye. While the dif- ferent tissues which form the mixed tumors are more dis- tinct in other organs, in many chondrosarcomata of the testis both tissues are intimately mixed. The cartilage appears as a worm-like deposit in the sarcomatous mass, easily removed, and evidently situated within preexisting spaces (lymph ves- sels), which are somewhat distended. Myxosarcoma and chondrosarcoma also occur here. What has been already said in regard to distinguishing these tu- 240 DIAGNOSIS IN PATHOLOGICAL ANAT03fY. mors applies to them here. In general, mixed tumors pos- sess a sarcomatous base. Pure, sarcoma and pure carcinoma may often be distinguished from each other by their general gross appearances. (In carcinoma it is possible to scrape off a milky fluid ; a coarse network is often apparent to the naked eye, and from its interspaces the milky fluid exudes. Sarcoma, which has a more even surface, does not permit such a fluid to be pressed out.) In the most malignant growths, the soft encephaloid tumors, the differential diag- nosis can be made only with the aid of the microscope.. Tu- mors of the testis are often remarkable for the abundance of vessels which they contain, and the thinness of their walls, so that hsemorrhagic forms are of frequent occurrence. Other forms than those already mentioned appear exceptionally, for instance, myomata, osteomata, etc. Bony tumors must not be confounded with petrification of the testis, which is occa- sionally found, and has already been mentioned as the result of a purulent inflammation. (^.) THE VULVA. The external female genitals may be examined in the manner already described, either in situ or after they have been removed. The changes in size, due to the enlargement of the labia majora from oedema, and elephantiasis, have already been considered in treating of the skin. The labia . minora, in women who have borne children, are often in- completely covered by the greater labia, and sometimes form long, red pendulous projections, of varying thickness. From one or both sides of the prepuce of the clitoris also, especially where it is continuous with the nymphae, masses resembling pads or polypi, hang down near the orifice of the urethra, in front of the vaginal orifice, and even project from the opening between the nymphae. Occasionally the clitoris itself shows congenital enlargement, which is then frequently associated with other anomalies of formation, constituting what is known as hermaphroditism. Solution of continuity of the parts, especially a rupture of THE VAGINA. 241 the frenulum, extending into the peringeum even, is almost always the result of childbirth. Partly superficial and partly deep lacerations may be found in all possible places; when connected with marked swelling, redness, and even purulent inflammation of the parts, they always suggest the suspicion of an attempt at rape, especially in children, where immissio penis is impossible, owing to the disproportion in size. A traumatic laceration of the tissues, without any rupture of the surface, occurs in the labia majora of puerperal women; these parts may appear much enlarged, owing to the great effusion of blood into their tissues (Jicematoma vulvoe). The consequent inflammation may cause gangrene, which readily extends to the pelvic cellular tissue. Purulent inflammation always runs its course as a virulent catarrh, with marked redness and swelling of the parts. Of the remaining inflammatory processes the diphtheritic, associated with puerperal lacerations, is worthy of mention. It may be easily recognized by the gray infiltration upon the base of the ulcers. These ulcers are frequently of a per- fectly gangrenous character, and may be recognized as such by their unusual grayish-black appearance, and the necrotic condition of their edges and base. If the puerperal lacera- tions are followed by no complication they are immediately converted into purulent ulcers, called puerperal ulcers. The growths upon the external genitals, known as the pointed and broad condylomata, and the chancre, have been sufficiently described, in treating of the skin. Of the true neoplasms, carcinoma and melanoma originate principally from the clitoris. Peculiar atheromatous cysts, containing a butter-like mass, occur in the nymphse, also fibromata (^papilloma'), etc. (Ä.) THE VAGINA. The vagina is to be examined by opening it longitudinally on the left side, and then separating it from the anterior sur- face of the uterus, when it may be laid open and all its parts be conveniently inspected. 16 242 DIAGNOSIS IN PATHOLOGICAL ANAT02IY. In order to preserve the bladder in certain cases, it is well to separate it from the uterus, at least on the left side, before opening the vagina. 1. General Ajjpearances. Changes in position, not of the vagina as a whole, but of certain parts, are sometimes primary, and at other times dependent upon a change in the position of the uterus. In the first class are included the protrusion of the anterior wall of the vagina (^cystocele vaginalis), or of the lower part of the posterior wall, caused by the rectum (rectocele vaginalis'), and of the upper from the sinking of the small intestine into Douglases fossa (^enterocele vaginalis). To the latter class belong the eversion of the vagina from prolapsus uteri, and the displacements due to tumors of the uterus. When the vaginal mucous membrane projects from the vulva, its epi- thelium becomes so changed as to resemble the epidermis ; the cells collect in thick layers Qpachyder^nia), and cause a whitish, at times almost milk-white appearance of the surface. Variations in the size and shape of the vagina are some- times congenital and sometimes acquired. Besides the in- stances above referred to, enlargement is apt to follow numerous confinements, or long continued catarrh; in such cases the surface usually becomes smoother, owing to a dimi- nution in the size or a disappearance of the folds. Narrow- ing is of more importance, sometimes affecting the whole vagina (in congenital hypoplasia of the genitals, and in her- maphroditism), or certain portions of it. The latter deform- ity is either congenital (atresia) or acquired (by the contrac- tion of cicatrices) . The narrowing from scars is seldom total, and can be recognized by the cicatricial changes in the con- tracted portion and in its neighborhood. Small projections in the middle of the anterior or posterior wall are also con- genital, and indicate the manner of the formation of the va- gina by the coalescence of the two Miiller's ducts. A greater degree of this arrest of development is reached when a mem- branous septum divides the vagina into two portions ; this is THE VAGINA. 243 limited either to the upper portion or extends to the entrance. It may occur with or without a double uterine cavity. The color of the vaginal mucous membrane is generally a light or dark reddish-gray ; decomposition causes it to assume rapidly a dirty gray hue, especially when a gangrenous or diphtheritic process is present in the vagina or in the uterus. The white color in pachydermia has already been referred to. A uniform gray color combined with fibrous induration is found when leucorrhoea has existed for a long time ; a slaty color arises from hsemorrhagic inflammation. 2. Special Morbid Conditions. Non-puerperal inflammation of the vaginal mucous mem- brane is often met with. A purulent or gangrenous inflam- mation with a very offensive discolored secretion, is less common than the chronic form, which is to be recognized by the gray, smooth, and indurated mucous membrane (kolp- tis chronica fibrosa'). The vagina, like the external geni- tals, often suffers much in childbirth, especially when it is necessary to aid labor by instruments (^puerperal affections'). When the pelvis is narrow, or the head abnormally large, and the forceps are applied, the blades very commonly pro- duce lacerations, which sometimes heal readily and cicatrize, and at other times become infective ulcers. This subject will be again referred to directly. Cicatrices situated on the lateral walls of the vagina and running longitudinally, justify the diagnosis of a difficult labor. Lacerations and cicatrices occur in a like way at the vault of the vagina, and extend outwards from the os uteri, being frequently connected with similar ones in the uterus ; they are also found at the entrance of the vagina, where they are con- ,nected with others on the external genitals. If the force used was very gi-eat, and especially such as to cause extensive crushing, a simple ulcer does not result, but the tissues necrose, and an offensive, greenish-black loss of substance with a ragged base results on both sides. In par- ticularly bad cases the whole thickness of the vaginal walls 244 DIAGNOSIS IN PATHOLOGICAL ANATOMY. may be involved, so that perforation results, and an exten- sive gangrenous phlegmon of the pelvic cellular tissue fol- lows, which may extend to the abdominal walls. In other cases the trouble is situated either on the anterior or the posterior wall, and its location is to be explained by the pe- culiarities of the bony pelvis (spinous pelvis), or by irreg- ularities in the birth (strong pressure of the head against the symphysis). Although these lesions usually heal without further trouble when the necrosis