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 RC898.M95 Tuberculosis oi the 
 
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P^: 
 
 
 Tuberculosis of the Testicle 
 
 THaitb Special Consideration of 
 fits Conservative {Treatment. 
 
 (^> »t »» 
 
 JOHN B. MURPHY, M.D. 
 Chicago 
 
loir 
 
 558 
 
 TUBERCULOSIS OF THE TESTICLE. 
 
 WITH SPECIAL CONSIDERATION OF ITS CONSERVATIVE 
 TREATMENT. 
 
 JOHN B. MURPHY, M.D. 
 
 CHICAGO. 
 
 Before entering into our subject, let us briefly review 
 the anatomy and physiology of the testicle, that we may 
 better understand the pathologic changes and processes 
 of repair which take place when it is the seat of tuber- 
 cular infection. 
 
 The testes are suspended in the scrotum by the two 
 spermatic cords, the left being slightly lower than the 
 right. Each is oval in form, compressed laterally, and 
 occupies an oblique position in the scrotum, the upper 
 extremity being directed forward and outward, and the 
 lower downward and a little inward. The surface of 
 the gland, excepting its posterior border, is free, smooth 
 and covered by the visceral layer of the tunica vagi- 
 inalis. Lying along the posterior border is a narrow 
 flattened body, the epididymis, which consists of three 
 parts, namely, first, the upper enlarged extremity, 
 globus major; second, the pointed lower extremity, 
 globus minor, and, third, the intermediate portion, or 
 body of the epididymis. The globus major is intimately 
 connected with the upper end of the testicle proper by 
 means of its efferent ducts, while the globus minor is 
 attached to its lower end by cellular tissue and a reflec- 
 tion of the tunica vaginalis. This membrane, the tunica 
 vaginalis, as it leaves the testicle proper at its posterior 
 border, is reflected on to the epididymis, covering its 
 outer surface and upper and lower extremities and com- 
 pletely investing the body, excepting along its posterior 
 border, from which it is again reflected on to the inner 
 
2 
 
 surface of the scrotum. It will thus be seen that a sort 
 of mesentery is formed by the membrane between the tes- 
 ticle proper and the epididymis. Attached to the upper 
 end of the testicle or epididymis are one or more small 
 pedunculated bodies, the most constant of which is 
 called the "hydatid of Morgagni." 
 
 Besides the tunica vaginalis, which is the most exter- 
 nal, the Lestis is invested by two tunics, the tunica albu- 
 a and the tunica vasculosa. The tunica albuginea is 
 beneath the serous coat and surrounds the glandular 
 structure of the testis. It is thick and. dense, and com- 
 id of white fibrous tissue. At the posterior border 
 of the gland it is reflected into the interior, forming an 
 incomplete vertical septum, the mediastinum testis, or 
 corpus Highmorianum, from the edge and lateral sur- 
 faces of which numerous fibrous trabecular pass, to be 
 attached to the inner surface of the tunica albuginea. 
 These trabecular divide the interior of the gland into a 
 number of cone-shaped spaces, the bases of the cones 
 being at the periphery and the apices at the mediastinum. 
 The tunica vasculosa consists of a plexus of blood-vessels, 
 which line the inner surface of the tunica albuginea and 
 the fibrous trabecular. 
 
 The glandular structure of the testis (Fig. A) con- 
 sists of numerous cone-shaped lobules (lobuli testis), 
 each contained in one of the spaces described above and 
 composed of one or more convoluted tubules, 2*4 feet in 
 length and 1/150 inch in diameter, the convolutions be- 
 ing held together by an intertubular connective tissue. 
 , The connective tissue presents large interstitial spaces 
 lined with endothelium, the rootlets of the lymphatic 
 vessels, and masses of large cells — the interstitial cells — 
 accompanying the finer blood-vessels. 
 
 Each seminiferous tubule consists of: 1, a hyaline 
 membrana propria ; 2, several layers of epithelial cells — 
 the seminal cells — which are usually arranged as fol- 
 lows: a, an outer (deeper) layer of polyhedral cells, the 
 spermatogoma ; h, an intermediate layer, the cells of 
 which are in active proliferation, the spermatogenie 
 cells ; c, an inner layer, the spermatoblasts. The latter 
 are granular, indistinctly outlined, and show no signs 
 of proliferation. 
 
 At the apices of the lobules the tubes become straight, 
 join together to form larger tubes (vasa recta), and en- 
 
3 
 
 ter channels in the mediastinum (rete testis). At the 
 upper end of the mediastinum the channels of the rete 
 unite to form from 13 to 20 larger tubes (vasa efferen- 
 tia), which perforate the tunica albuginea and enter the 
 epididymis. At first straight, they become convoluted 
 and form a series of cone-shaped masses (coni vascu- 
 losis which together form the globus major. Opposite 
 the bases of the cones the efferent vessels open at narrow 
 intervals into a single duct, which constitutes, by its 
 complex convolutions, the body and globus minor of the 
 epididymis. This tube, the convolutions of which are 
 held together by fine areolar tissue, is about 20 feet in 
 length, and is continuous at the globus minor with the 
 vas deferens. 
 
 The vasa recta and channels of the rete are lined by 
 a single layer of flattened epithelial cells. The vasa ef-- 
 ferentia and tube of the epididymis are lined by colum- 
 nar ciliated epithelium, and their walls contain circu- 
 larly arranged muscular fibers. 
 
 The vas deferens is a continuation of the tube of the 
 epididymis. (See Fig. 1.) Commencing at the lower 
 part of the globus minor, it ascends along the posterior 
 border of the testis and inner side of the epididymis, 
 and along the back part of the cord to the internal ring. 
 From the ring it curves around the epigastric artery and 
 descends into the pelvis at the side of the bladder to its 
 base. In this situation it lies between the bladder and 
 rectum and along the inner border of the seminal vesicle 
 of the same side. Here it becomes enlarged to form the 
 ampulla, then narrows and unites with the duct of the 
 vesicula seminalis to form the ejaculatory duct. It is 
 about 2 feet in length, the walls are thick and the lumen 
 small, measuring 1/25 of an inch. The vas consists of 
 three coats: 1, an external or cellular coat; 2, a mus- 
 cular coat; and, 3, an internal or mucous coat, arranged 
 in longitudinal folds and covered by columnar epi- 
 thelium. 
 
 The blood-supply of the testis is principally from the 
 spermatic artery, which arises from the abdominal aorta, 
 and accompanies the other structures composing the 
 cord through the canal. As it approaches the testicle 
 it divides, some small branches continuing onward to 
 supply the epididymis, while the larger ones perforate 
 the tunica albuginea and enter the mediastinum to 
 supply the glandular portion through the vessels of the 
 
tunica \ asm Id- a. The vessel does not always divide so 
 high as is pictured in the text-books. This is shown in 
 Fig. :.', where the artery was injected with mercury and 
 then skiagraphed. The bifurcation takes place close to 
 i lif testicle, a fact to be borne in mind when operating. 
 
 The spermatic veins commence in the testis and epi- 
 didymis, pass out at the posterior border and ascend in 
 the cord as the pampiniform plexus. (See skiagraph 
 Fig. No. 3.) Finally, two or three larger veins are 
 formed from the plexus, pass into the abdomen with the 
 artery and unite to form the spermatic vein. This, on 
 the left side, empties into the renal vein, and on the 
 right side into the ascending vena cava. 
 
 The lymphatics of the testicle (see Fig. 4) commence 
 as minute vessels around the seminal tubules. These 
 coalesce and most of them pass through the septa into 
 the mediastinum. Others pass outward to join the 
 plexus beneath the tunica albuginea, which plexus also 
 communicates with a more superficial one beneath the 
 tunica vaginalis. Tn the mediastinum the deep and 
 superficial sets unite to form from four to six trunks, 
 which pass upward in the cord into the abdomen. On 
 the left side these vessels enter the glands near the 
 aorta and left renal vein, while on the right they empty 
 into the lumbar glands just above the bifurcation of 
 the aorta. Afferent vessels from the glands of both sides 
 empty into the reeeptaculum chyli. 
 
 The nerves are derived from the sympathetic system, 
 branches from the aortic, renal and hypogastric plexuses, 
 forming the spermatic plexus, which descends upon the 
 spermatic artery and artery of the vas deferens. They 
 are not provided with ganglia and have not been traced 
 into the tubules. The terminal filaments ramify on the 
 surface of the tubules and are distributed to the blood- 
 vessels. 
 
 Physiology. — The functions of the testicle are two in 
 number: 1, the production of spermatozoa; 2, the for- 
 mation of an internal secretion, which is necessary to 
 normal metabolism. 
 
 The spermatozoa are formed in the seminiferous tu- 
 bules by a series of changes which take place in the 
 spermatoblasts, or cells of the internal layer. These 
 changes are as follows: The cell first assumes a pear- 
 shape, the pointed end containing the nucleus, being 
 directed toward the basement membrane. This por- 
 
tion forms the head of the spermatozoon. By a drawing 
 out or elongation of the broad part of the cell the middle 
 piece and tail are formed. 
 
 After puberty the semen is probably being constantly 
 secreted, although most of the time in small quantities. 
 As the spermatozoa are formed they are forced along 
 the tubules by the pressure of accumulated secretion, 
 3,4 H 
 
 Fig. A. — Showing testicle partly macerated in KOH solution, 
 which has loosened the connective tissue framework. (After 
 Toldt.) 1. Tubuli seminiferi contorti. 2. Body of epididymis. 3. 
 Coni vasculosi. 4. Vasa efferentia. 5. Tunica albuginea at hylum 
 6. Lobuli testis. 7. Tubuli seminiferi. 
 
 aided by the ciliary movements of the cells lining the 
 vasa recta, vasa efferentia and tube of the epididymis. 
 In the two latter its expulsion is also aided by contrac- 
 tion of the muscular fibers in their walls. From the vas 
 deferens the semen passes into the ejaeulatory duct 
 
(i 
 
 and seminal vesicle, in which latter, unless discharged 
 immediately by emission, some of it is retained. It is 
 probable, however, that the principal function of the 
 vesiculae seininales is seeretory and that the ducts of 
 the testes, rather than they, act as reservoirs for the 
 semen. 
 
 The second and more important function of the testi- 
 cles is the formation of an internal secretion. While 
 the active principle of this secretion has never been 
 isolated, nor the secretion itself been definitely proved 
 to exist, experimental and pathologic evidence leaves 
 little doubt as to its presence under normal conditions. 
 Its importance to the normal development of the body 
 is shown in cases of cryptorchismus, or where both testi- 
 cles have been destroyed or removed before the age of 
 puberty. These cases invariably show a lack of the 
 sexual characteristics which are normally developed at 
 this time. Its influence is also shown, though to a lesser 
 degree, in cases where both organs have been removed 
 after puberty in early and middle adult life. In many 
 of these, sexual desire is entirely lost, the prostate and 
 other parts of the remaining genital apparatus atrophy, 
 and in a few there is a loss of the sexual characteristics 
 which were formerly possessed. The experiments of 
 Zath, reported in 1896, are interesting in this connec- 
 tion. Under daily injections of testicular extract the 
 working power of a man's neuro-muscular system was 
 increased 5 per cent., and during rest his powers of re- 
 cuperation weTe greatly increased. 
 
 It can thus be seen that the preservation of this 
 normal secretion is worthy of careful consideration, and 
 the purpose of this paper is to emphasize its impor- 
 tance. In addition to the physiologic effects on the gen- 
 eral metabolism produced by the removal of the testes., 
 in many cases grave mental states, such as melancholia, 
 are induced. Finally, there is the practical side, that 
 many patients will not consent to the removal of both 
 testes for tubercular disease until the bladder and pros- 
 tate have become involved, or until they realize that 
 death will result if the diseased organs are retained. 
 while they will readily consent to the removal of both 
 epididvmi, upon the physician's statement that the tes- 
 ticles proper will be preserved. 
 
 FJiolnqn. A n n ■■ — Tuberculosis of tho focfiHo mav 
 occur at anv nco, lmt it i<s muHi morn pommori during 
 
early adult life, between the ages of 20 and 35 years, 
 when the activity of the sexual gland is at its height. 
 In Koenig's cases the different decades were affected 
 as follows : Under 4 years, 3 ; between 20 and 30 years, 
 24; between 30 and 40 years, 8; between 40 and 50 
 year's, 4; between 50 and GO years, 4; between 60 and 
 80 years, 2. Of the latter, one was 67, and one 72 
 years of age. 
 
 The age statistics quoted by Senn from the various 
 authorities are as follows: Sallerton in 47 cases ob- 
 served the period of greatest liability to be between 
 20 and 30 years. Kocher from 50 cases also between 
 20 and 30 years, while Simonds, from an analysis of 
 
 Fig. 1. — Skiagraph showing Vas and Tube of the epididymis In- 
 jected with mercury, a, Vas. ft. Tube of epididymis. 
 
 69 cases, found the greatest number between the ages 
 of 40 and 50 years, with 20 to 30, and 30 to 40 years 
 coming next in frequency. 
 
 Jullien reported 16 cases of tubercular testicle in 
 infants, 6 of which were under 1 year of age, and Dr. 
 Dreschfeld a case where the disease was present at birth. 
 In one of Koenig's cases the disease was noted a few 
 days after birth. 
 
 As regards the other extreme of life, Gibson has re- 
 ported a case in a man aged 81 years. In the cases here 
 reported the average age was about 33 years. 
 
 Hereditary Influence. — This may be shown in two 
 ways : 1, where the disease is present at birth or develops 
 
very soon after; J. as an inherited condition of lowered 
 vitality, in which there is a tendency to the development 
 of tuberculosis, due, probably, to a lessened resistance 
 of the tissues. 
 
 In perhaps the majority of the cases no tubercular 
 family history can be obtained, this absence of hered- 
 itary influence being especially marked in cases which 
 develop in adult life. In 10 cases of testicular tuber- 
 culosis in children, reported by Jullien and Lanne- 
 longue, 4 presented a distinct family historv. In 5 
 of Koenig's cases, in which the disease was distinctly 
 localized in the testis, and in which he believed it to 
 have originated from pre-existing tubercular deposit, 
 there was a family history in 3. 
 
 In 16 cases reported by Jullien, 6 were in patients less 
 than one year of age. An inherited tendency is prob- 
 ably present where the disease develops so soon after 
 birth. 
 
 Injury. — In many cases there is a history of trau- 
 matism preceding the onset of the disease. The injury 
 in most cases, slight and insignificant, may be forgotten 
 by the patient, who does not connect it with the onset 
 of his trouble. In other cases the relation between the 
 two is so striking and direct that it can not be over- 
 looked. This etiologic factor is beautifully illustrated 
 in Case 10, where the disease developed almost imme- 
 diately after a kick in the testicle. The rule is that 
 the tubercular process does not manifest itself con- 
 spicuously until at least six weeks or more have elapsed 
 from the time the injury was received. 
 
 Previous Inflammatory Processes. — Of all affections 
 of the genito-urinary tract, which predispose the testi- 
 cle and epididymis to a subsequent tubercular infection, 
 gonorrhea is the most important, either a gonorrheal 
 epididymitis or a posterior urethritis. In 52 cases col- 
 lided by Kocher, 14 had suffered from it previously. 
 The tubercular process may follow the gonorrheal im- 
 mediately, while the latter is yet in the acute stage, or 
 at any time after the subsidence of the active symptoms. 
 It must not be forgotten, however, in this connection, 
 that the gonorrheal inflammation may be simply the 
 means of lighting up a latent tubercular focus, which 
 had been lying dormant in the epididymis for years, 
 without, perhaps, the patient being aware of its exist- 
 ence. 
 
The explanation of this phenomenon is simply that 
 of a locus minoris residential left after subsidence of 
 the acute inflammatory process. This area of dimin- 
 ished resistance may perhaps in some cases be a defect 
 in the mucous lining, through which germs may enter 
 from the surface. Tuberculosis of the testicle does not 
 commonly follow the acute infectious diseases, even 
 when these have been complicated by an orchitis. J. B. 
 Shaw reports a case where it was supposed to have fol- 
 lowed an attack of measles. 
 
 Fig. 2. — Skiagraph of Spermatic Artery injected with mercury. 
 a. Spermatic Artery, b. Branch to epididymis, c. Branch to 
 testicle proper. 
 
 Atrium of Infection. — This at the present time is 
 undergoing most rigid scientific investigations. The 
 channels through which infection may take place are, 
 in order of frequency, as follows : 1, respiratory tract ; 
 2, gastrointestinal tract ; 3, genitourinary tract ; 4, skin. 
 
 That the respiratory tract, with arrest of infecting 
 organisms in the mediastinal glands, is the most fre- 
 quent atrium of infection, is shown by the researches 
 of Jens Bugge. This investigator has shown that 75 
 per cent, of all human beings who come to the post- 
 
1(1 
 
 mortem table have had mediastinal glandular tubercu- 
 losis. As is well known, this disease may exist without 
 producing any symptoms, and it will therefore be seen 
 how readily a crypto-tubercular infection in this locality 
 could precede a localized infection of the testicle. It 
 is our belief that the mediastinal glands are the most 
 common sources of supply for tubercle bacilli in the 
 body. 
 
 Carious teeth with ulceration of the gums about them, 
 and defects in the mucous membrane of the nose, mouth, 
 ronsils and middle ear, with subsequent infection of 
 the cervical lymph-glands may, especially in children, 
 be the primary sources of infection. 
 
 That the gastrointestinal tract admits of infection 
 from tuberculous material taken in as food, can not 
 be questioned, but that it is attacked much less common- 
 ly than is generally supposed is proved by the infre- 
 quency of tuberculosis of the mesenteric glands. 
 (Northrup and Boviard.) Dr. W. J. Mayo, of Minne- 
 sota, has found that in the rural districts, where milk 
 is largely used as an article of diet, a localized tuber- 
 culosis of the intestinal mucosa is not very uncommon, 
 but that the mesenteric glands are very rarely involved 
 without a demonstrable lesion in the intestine. In 
 this respect the intestinal tract differs from the respira- 
 tory, where in many cases no physical changes can be 
 demonstrated at the point where the bacilli have gained 
 entrance. 
 
 That infection can take place directly through the 
 urinary outlet, the urethra, or through the genital out- 
 let, the vagina, is generally admitted, and cases have 
 been reported where it was transmitted from a tubercu- 
 lar uterus or vagina to the glans penis, or prepuce. 
 (Jonin, Cornet.) Reclus denies that infection ever 
 takes place in this way. 
 
 That tubercular infection is often admitted into 
 the system through the skin is shown by the number 
 of cases of the local disease among physicians, and in 
 the children of tuberculous parents, these children so 
 often developing lesions about the cheeks, lips and 
 mouth. 
 
 The tubercle bacilli having gained entrance into the 
 system, the next subject for consideration is : How do 
 they find localization in the testis? There are a number 
 of routes by which the infection mav be carried to the 
 
u 
 
 sexual glands: 1, by the blood-stream; 2, along the 
 surface of the mucous membrane of the genito-urinary 
 tract; 3, by the lymphatics. 
 
 1. Transmission by the blood-stream has been, by 
 most authors, considered to be the most important. 
 The bacilli contained in the blood localize in the epi- 
 didymis at some point M'here there exists a focus of 
 diminished resistance, either congenital, or produced 
 
 3. — Spermatic Veins injected with mercury. 
 
 by previous injury or disease. The frequent localiza- 
 tion in the epididymis is accounted for by the fact that 
 the spermatic artery divides opposite that organ, and 
 that the vessels of the epididymis are smaller and more 
 tortuous than those of the vas or testicle proper, the 
 current therefore being slower . (Saltzman.) 
 
 2. In some cases the infection undoubtedly travels 
 along the surface of the mucous membrane. This view 
 is supported by Koenig in his recent paper on the sub- 
 
ject. lie beli i in a very great majority of cases 
 
 the testicular affection is preceded by tubercular dis- 
 higher up in the genito-urinary tract, especially 
 in the vesiculse seminales and prostate. In the 45 
 cases reported by him, these organs were involved 31 
 times. In the majority of cases, however, there were 
 distant foci in the lungs, bones, glands, etc. Kocher 
 holds the .-ante view. Cayla thinks that a descending 
 infection along the mucous membrane is most common, 
 and believes that the infection travels in the same 
 direction as the current of urine, and against that of 
 the semen. His views are based on 100 sections, in 
 which he observed that tubercular disease of the genito- 
 urinary organs was always preceded by tuberculosis 
 higher up. 
 
 GuyoD and Lancereaux have observed that the process 
 often begins in the vesicular seminales. Virchow has 
 always held that the infection was a descending one, 
 beginning in some of the higher genito-urinary organs. 
 Saleron is opposed to this view, as in 51 cases examined 
 by him, organs, other than the testicles and epididymis, 
 were involved in only one case. Senn states that 
 frequently the infection descends from the prostate, 
 seminal vesicles or kidneys. Weigert (cited by Kocher) 
 thinks that the prostate favors localization of all kinds 
 of micro-organisms, and Kcziwicki. in 15 autopsies on 
 cases of genito-urinary tuberculosis, found the prostate 
 involved 11 times. 
 
 M. Verneuil believes that infection often takes place 
 during coitus, and gives anatomical reasons for his 
 views. This seems very doubtful, however, when we 
 consider the frequency of tubercular epididymitis in 
 children. Furthermore, if this were the case, we should 
 more frequently meet with tubercular lesions of the 
 penis and urethra, for there must be ample means 
 for inoculation in the abrasions of the urethral mucosa 
 so commonly found in gonorrhea. 
 
 While we can undoubtedly have a descending infec- 
 tion, it is our observation and that of many other in- 
 vestigators, that the disease is usually an ascending 
 one, the epididymis being affected primarily and the 
 bladder, prostate, etc., secondarily, the process ex- 
 tending upward along the surface of the mucous mem- 
 brane of the excretory duct. 
 
 3. Transmission of the infectious material to the 
 
13 
 
 L*'ig. 4. — lymphatics of testicle. (Heitzmann.) 
 
li 
 
 testicle by the lymph channels, while usually given 
 as one of the routes, must be very rare, as the lymph- 
 curreni is directed away from the organ rather than 
 toward it. Xo cases have been reported which show the 
 infection to have taken place in this way. 
 
 Koenig thinks that in some cases the disease begins 
 as a primary tuberculosis of the testicle, the infection 
 having been carried to the organ some time before 
 and remaining dormant until lighted up by the occur- 
 rence of one of the exciting causes, such as injury, 
 acute inflammatory processes, etc. This view is based 
 on the studies of Jani, who found bacilli in apparently 
 healthy testicles of patients suffering from pulmonary 
 phthisis. Koenig thinks that this may explain some 
 cases where no atrium of infection can be demonstrated. 
 
 Association of Tuberculosis of the Testicle with Tu- 
 bercular Lesions Elsewhere in the Body. — As stated 
 above, in from 73 to 75 per cent, of persons dying from 
 all causes, mediastinal glandular tuberculosis is present, 
 and this in the majority of cases is probably the atrium 
 of infection in the cases of testicular disease. The latter 
 is not usually associated with pulmonary tuberculosis, 
 though Reclus observed that 50 per cent, presented 
 lung findings, and 2.5 per cent, of the pulmonary 
 cases over 15 years of age suffered also from local- 
 ization in the testicle. In his analysis of 500 cases of 
 phthisis, 64 had involvement of the genito-urinary 
 tract, 45 of the genital tract, and in 19 the testicles 
 alone were affected. Simonds. from his post-mortem 
 experience, found the genital organs involved in 2 
 per cent, of all tubercular children. 
 
 Tuberculosis of the lymphatic glands and bones is 
 not often accompanied by disease of the genital organs. 
 
 In children, tuberculosis of the peritoneum sometimes 
 coexists with disease in the testicles. Reclus thinks 
 there is, in these cases, a communication between the 
 cavity of the tunica vaginalis and the peritoneal cavity, 
 the processus vaginalis. 
 
 Tillmans states that tuberculosis of the testicle almost 
 always develops in persons already tuberculous, but 
 this is not borne out by the experience of most surgeons. 
 
 Tn the majority of our cases the disease, so far as 
 could be determined by physical examination and clin- 
 ical history, was primary in the epididymis. 
 
 As a Part of a General Miliary Tuberculosis. — This 
 
is of but little interest to us in the consideration of 
 this subject, because when it is present, it is over- 
 shadowed by the manifestations of the disease in other 
 parts. Koenig states that the testicles are rarely affect- 
 ed in general miliary tuberculosis. When the involve- 
 ment does occur, both testicles and both epididymi are 
 affected simultaneously. Hutinell and Deschamps state 
 that tuberculosis of the testes in children is seldom 
 primary, but usually a part of a general infection. 
 Occurrence of the Disease in Misplaced and Inverted 
 
 Fig. 5. — Showing involvement of testicle proper and epididymis, 
 the former by extension from latter. a. Globus Major. 6. 
 Testicle proper. 
 
 Testicles. — No authentic case of tubercular disease af- 
 fecting an undescended testicle is on record, although 
 several cases supposed to be such have been reported, one 
 by G-. Fischer, in 1864, and another by F. Roberts. 
 The details of the cases in these reports are indefinite, 
 so that it is very doubtful if they were really cases of 
 tuberculosis. No satisfactory explanation of the ap- 
 parent immunity possessed by these misplaced organs 
 has been offered. Tn a case reported by Rushton 
 Parker, of general tuberculosis, the left testicle was 
 
in 
 
 :it. and the left seminal vesicle free from disease, 
 while the right testicle was present and the right vesicle 
 involve d. 
 
 Lnversic-testis was noted by Koenig five times in 
 his casesj ami it is thought by him to he a predisposing 
 cause. Case No. 13 of our series presents this anomaly 
 in tin' testicle first attacked. 
 
 The right testicle is attacked first in the majority of 
 cases. Rintelen (quoted hy Senn) observed in 15 cases 
 that the right organ was affected first in 10, and the 
 left in 5. In 10 of our cases, in which an accurate 
 history of the onset could be obtained, the right was 
 involved first in 8, and the left in 2. Whichever organ 
 is primarily attacked, it is usually only a question of 
 time before the other becomes similarly diseased, this 
 extension being due, in all probability, to transmission 
 of the infectious material along the vas of the affected 
 side to the prostatic urethra and down the opposite 
 vas to the epididymis on the other side. Jul lien states 
 that in children the left testis is commonlv affected first. 
 
 PaiJiologij. — There has been and still is a marked 
 diversity of opinion as to the location of the primary 
 focus in the testis, and its method of extension sub- 
 sequently, and a still greater divergence as to the rela- 
 tion which the testicular disease bears to tuberculosis 
 of other portions of the genito-urinary tract, or of 
 more distant portions of the body. 
 
 The epididymis is, in a very large percentage of the 
 cases, first attacked. Cases have been reported (Reclus) 
 in which the disease began in the testicle proper, but 
 they are so very rare that practically they may be ex- 
 cluded. Gilbert Barling, M.B., reports a case of acute 
 tubercular disease of the bodies of both testicles. In 
 this case castration was performed, and caseous areas 
 and tubercle bacilli were found in the bodies of the 
 testicles, the epididymi not being involved. There was, 
 however, a suspicion of phthisis in the right apex. 
 
 Most authors hold that in the majority of cases the 
 globus major is first attacked, the infection spreading 
 from there to the body and globus minor, and finally 
 to the testicle proper. From our own observations, 
 however, we would say that in adult cases the globus 
 minor is most frequently primarily attacked, the body. 
 ifloluis major, and mediastinum testis becoming affected 
 secondarily by continuity of tissue, or by extension 
 
17 
 
 along the surfaces of the seminal ducts. In children 
 the primary nodule has usually been in the globus major. 
 The morbid anatomy of a testicle, the seat of tuber- 
 cular disease, varies greatly, depending on the stage 
 to which the process has advanced, the anatomical 
 
 Fig. 6. — Tuberculosis of Tunica Vaginalis, a. Tubercular areas. 
 b. Epididymis, c. Healthy Tunica Vaginalis. 
 
 distribution of the lesion, and the presence or absence 
 of secondary infection. We will not consider here the 
 testicular affection which is a part of a general miliary 
 
18 
 
 tuberculosis, In the majority of Lhe cases the epi- 
 didymis is alone involved, and presents In the early 
 stages one or more small nodules, situated in the globus 
 minor or major. Later other nodules form in different 
 parts, which enlarge and coalesce, converting the epi- 
 didymis into a hard, irregularly shaped mass, which, 
 at a still Later period, after caseation and softening have 
 taken place, may be soft and fluctuating. Section 
 of the epididymis in the early stage shows the nodules 
 to be composed of a homogeneous material, which has 
 Largely taken the place of normal tissue, the latter 
 being compressed and infiltrated with inflammatory 
 products. The capsule of the epididymis is greatly 
 thickened, and the vas, near its attachment to the globus 
 minor, may be thickened and nodular, due to the infil- 
 tration of the tissues surrounding it, or to an involve- 
 ment of its walls proper. Later the small nodules have 
 fused with one another to form larger ones, the homo- 
 geneous material may be liquefied so as to resemble 
 pus. Fibrous tissue may have been formed around some 
 of the softened areas, and between them islands of 
 normal or altered tubular tissue may be seen. The 
 capsule now presents caseating areas, and the cellular 
 tissues of the scrotum in its neighborhood may be 
 edematous, infiltrated and adherent to it and the skin. 
 When secondary infection has taken place, and fre- 
 quently without it, the pus may have burrowed toward 
 the skin, the abscess cavity ruptured, and a discharging 
 sinus surrounded by thick fibrous walls formed. The 
 fibrous capsule which surrounds the caseous areas may 
 become infiltrated with lime salts, and in this way a 
 thick shell of calcareous material, surrounding it or 
 perhaps the entire epididymis, is formed. This was 
 beautifully illustrated in a case recently reported by 
 Dr. H. G. Wells. In other cases the disease is not 
 limited to the epididymis, but has also involved the 
 testicle proper by continuity of tissue. (See Fig. No. 5) 
 In these the epididymis presents the appearances de- 
 scribed above, and scattered through the testicle proper 
 are numerous small tubercular nodules in all stages of 
 development. These nodules are most abundant at 
 the periphery of the organ, where they are very small, 
 and on section present the homogeneous appearance 
 characteristic of young tubercles. In the mediastinum 
 testis they are apt to be larger and caseous, showing 
 
19 
 
 that this was the part first affected by extension from 
 the epididymis. The distributions of the lesions in 
 the testicle proper indicate that the extension took place 
 along the seminiferous tubules. Later, in the course 
 of the disease, the nodules here, as in the epididymis, 
 coalesce to form larger ones, these caseating, becoming 
 encapsulated, or frequently breaking externally. Cal- 
 careous deposit may take place either in the fibrous 
 capsule or throughout the broken-down nodules. The 
 glandular portion is wholly or in part destroyed. The 
 tunica vaginalis usually presents evidences of chronic 
 
 \ : 
 
 I'ig. T. — a. Cross sections of tube of epididymis, b. Tubercle witb 
 giant cell. c. Old fibrous tissue. Prom Case 11. 
 
 inflammation, thickening and adhesions between the 
 visceral and parietal layers, or, in some cases tubercular 
 lesions. This involvement of the tunica vaginalis by 
 the tubercular process is well illustrated in Fig. 6, 
 which is a photograph of a testicle removed by Dr. 
 Oswald. In this case the entire testicle had to be re- 
 moved on account of the extensive involvement. An 
 effusion into the cavity of the tunica vaginalis is present 
 in most cases, but is usually small in amount. 
 
 Spermatic Cord. — This is affected in a considerable 
 proportion of the cases, but usually not throughout 
 its entire length. The parts most apt to be involved 
 
20 
 
 are either or both of the extremities, the intermediate 
 portion remaining free. In some cases, however, the 
 entire vas is t hit-lamed and nodular (Senn). 
 
 The tubercular deposits in the cord are usually situ- 
 ated in the neighborhood of the vas, the infection 
 having taken place by extension along the surface of 
 its mucous membrane from the infected epididymis. 
 All stages of development of the tubercular lesions are 
 found here as in the epididymis, but in most cases have 
 not advanced to the same stage. The mucous lining 
 of the vas is greatly thickened, the outer layers of the 
 wall being affected to a lesser degree. The connective 
 tissue surrounding it may also present nodules and 
 caseous areas, but much of the thickening is due to 
 edema and inflammatory exudate. 
 
 Vesicular Seminales. — The vesiculze seminales come 
 next to the vas, as regards their frequency of secondary 
 involvement. While usually these organs are involved 
 only after the vas has become more or less extensively 
 diseased, this is not always the case. The process in 
 them may be far advanced without the vas being affected 
 at all, or the latter may present lesions which have evi- 
 dently developed at a later period than those in the 
 vesicles. Later abscess may form and the pus be dis- 
 charged through the bladder or rectum, or externally 
 through the perineum. 
 
 The Prostate. — This organ follows the vesiculae sem- 
 inales in order of frequency of involvement, though 
 some observers (Kocher) state that it is affected much 
 oftener than i? commonly supposed, the disease in it 
 being overlokcd on account of the absence of symptoms 
 and physical signs in the early stages. The process 
 here is the same as in other parts, the deposits going 
 on to caseation and suppuration, and later rupturing 
 into the rectum, urethra or externally. In most cases 
 the prostatic lesions are in an earlier stage of develop- 
 ment than those in the epididymis. The prostate and 
 seminal vesicles may be affected unilaterally, and when 
 this is the case, the side presenting the lesion usually 
 corresponds to that of the diseased epididymis. It is 
 more common, however, for the entire prostate or both 
 vesicles to be affected. 
 
 Microscopic Appearances. — The series of pathologic 
 changes which follow the lodgement of the bacilli in 
 the tissues is the same as in tuberculous lesions else- 
 
•31 
 
 where in the body, modified somewhat by the anatomical 
 structure of the organ. The bacilli, having gained access 
 to the circulation by one of the channels mentioned 
 above, lodge in the walls of the smaller blood-vessels of 
 the epididymis and there produce their characteristic 
 reaction. (Nepveau.) As to the exact situation of the 
 starting-point of the process, there is great difference 
 of opinion, Malassez and Eeclus locating it in the walls 
 of the seminal tubules; Virchow, Tizzoni, and Gaule, 
 in the intertubular connective tissue; while Langhans, 
 Curling, Kocher, and others believe it to be in the 
 
 Jo 
 
 Pig. 8. — Showing young tubercle between coils of tube of epididy- 
 mis, a. Tube of epididymis, b. Tubercle. From Case 11. 
 
 interior of the tubules themselves. Hutinel and Des- 
 champs found the primary focus in the perivascular 
 spaces in the cases examined by them. As in the 
 majority of cases, the infection probably takes place 
 through the blood-current, it seems reasonable to sup- 
 pose that the primary lodgment of the bacilli is in the 
 intertubular connective tisue of the epididymis, and 
 this view is certainly supported by studies of tubercu- 
 losis in other organs. 
 
 The specific irritation set up by the bacilli and their 
 products causes, first, an increased vascularity of the 
 
22 
 
 part, and then proliferation of the fixed-tissue cells, 
 ami emigration of leucocytes from the capillaries. In 
 this \v;iy nodules of the so-called tubercle tissue are 
 produced between the coils of the tube of the epididymis 
 (Pig. 7). widely separating them Erom each other 
 and encroaching upon their lamina. This tubercle 
 tissue consists essentially of : 1, epithelioid cells, derived 
 from the fixed tissue cells, connective tissue and endo- 
 thelium of the blood-vessels and lymph-spaces; 2, the 
 reticulum, in the meshes of which the epithelioid cells 
 lie. This reticulum may be derived from the newly 
 proliferated endothelial cells, or it may be the remains 
 of the tissues which previously existed. Later, in 
 addition to the tubercle tissue, the leucocytes, which 
 at first were present in small numbers, become more 
 numerous, especially at the periphery of the nodule. 
 (Fig. 8.) It is in this so-called round-celled infiltra- 
 tion that we find the plasma cells, sometimes in great 
 numbers and usually arranged in groups. These, ac- 
 cording to different authors, may be derived either 
 from the lymphocytes of the blood, or from the con- 
 nective-tissue cells. Their function at present is doubt- 
 ful, some claiming that they possess phagocytic prop- 
 erties; others that they have no such function, and 
 are destined to become converted into fibrous connective 
 tissue. Scattered through the tissue, usually occurring 
 singly rather than in groups, are found the mast cells 
 of Ehlrich, which are also of doubtful origin and func- 
 tion. The epithelioid cells may be mononuclear or 
 polynuclear, giant cells (Fig. 9), which latter are 
 formed by the proliferation of the nucleus of the cell 
 without division of the cell body, and are usually found 
 in the center of the tubercle, surrounded by the mono- 
 nuclear epithelioid cells. 
 
 When the individual tubercles have attained a certain 
 size, caseous degeneration sets in, due both to the action 
 of the toxin and to the gradual shutting off of the blood- 
 supply, and it is at this point that the process may be 
 arrested by encapsulation, or that secondary infection, 
 with destruction of a part or whole of the organ, may 
 occur. If encapsulation takes place, the connective- 
 n- in- cells which have proliferated at the periphery of 
 the tubercle, or tubercles, gradually contract and become 
 converted into a dense fibrous tissue, in this wav causing 
 
23 
 
 an arrest of the process, the nodules remaining for an 
 indefinite period of time. 
 
 During the progress of the changes described above, 
 the coils of the tube of the epididymis are encroached 
 upon and present a variety of changes. The epithelium 
 may have entirely desquamated at the site of involve- 
 ment, the cells lying loose in the lumen, which may be 
 greatly dilated and contain pus-cells and granular debris, 
 the remains of degenerated cells and spermatozoa. ' In 
 other sections the lumen is filled with caseous material, 
 which has probably come from the tubercles in the 
 walls, rather than from the interior of the tube pri- 
 
 Fig. 9. — Giant cell in center of Tubercle. From Case 11. 
 
 marily. The duct may present in certain parts great 
 dilatation and be filled with purulent material and 
 spermatozoa. In these latter the epithelium may be 
 intact or desquamated in parts. 
 
 Tubercle bacilli can usually be demonstrated in the 
 sections, especially where the process is in the early 
 stages. Later, after caseation has taken place, they 
 may be so few in number as to escape observation, even 
 on careful examination. 
 
 Beclus has described a rare pathologic condition in 
 tuberculosis of the testicle, in which, instead of the 
 changes described above, the epididymis presents a 
 
34 
 
 reticular arrangement, the alveoli of which are tilled 
 with pus. 
 
 Symptoms. — These differ materially, as in tubercu- 
 losis of other organs, vailing with the rapidity of 
 advancement of the process, the presence or absence 
 of mixed infection, and again as the disease is primary 
 or secondary in the testicle. 
 
 The symptoms of onset vary greatly at the different 
 periods of life. In infants and young children the 
 parents' attention is usually first called to the presence 
 of a small nodule in the epididymis, the child having 
 manifested no other symptoms, except perhaps slight 
 tenderness in this region. 
 
 In adults the initial symptoms may be sudden or 
 gradual in their onset, the latter being much the more 
 common of the two. When associated with mixed infec- 
 tion, the onset is stormy, and there are all the mani- 
 festations of an acute epididymitis, resembling the 
 gonorrheal form. (Case 10.) Abscess formation may 
 be rapid, and the pus find its way to the surface in a 
 short time, leaving a sinus that heals slowly. Instead 
 of breaking externally, the burrowing may be in the 
 direction of the testis proper, and a portion or all of 
 this organ be destroyed. Rupture into the cavity of 
 t\e tunica vaginalis must be extremely rare, if it ever 
 occurs. 
 
 When unassociated with mixed infection, the onset 
 is slower, and many of the patients come to the phys- 
 ician for the first time because of the nodule which they 
 have accidentally discovered in the epididymis. They 
 are usually unable to say how long it has been there, 
 but in some instances date its development from a slight 
 injury or a gonorrheal epididymitis. The nodule or nod- 
 ules are at first painless and only slightly tender on com- 
 pression ; but usually after a short time the patient 
 experiences a dull, aching pain in the testicle, brought 
 on or aggravated by exercise. This pain may be referred 
 to the testicle or upward along the spermatic cord, 
 sometimes even extending into the ilio-lumbar region 
 of the same side. It is rarely severe, and may be 
 entirely absent when the patient is at rest. 
 
 A urethral discharge, usually whitish and mucoid in 
 character, has been noted in a considerable proportion of 
 the cases, usually quite early in the course of the dis- 
 ease. Instead of being white, it may be purulent or 
 
25 
 
 even bloody. Various theories have been advanced as 
 to the origin of this discharge, some claiming that it 
 is due to tuberculosis of the prostate, vesiculse seminales, 
 or the prostatic urethra, while others believe it is 
 caused by a catarrhal condition of the posterior urethra 
 and seminal vesicles. The latter is probably the true 
 explanation, as it disappears after castration or epi- 
 didymectomy. Symptoms of vesical irritation are pres- 
 ent in the great majority of cases without mixed infec- 
 tion, and in some they are the first to attract the 
 patient's attention. At first, there may be slightly 
 
 Pig. 10. — Globus Minor and body of epididymis dissected from 
 testicle proper, a. Globus Minor and body. 6. Globus Major, 
 c. Reflected tunica Vaginalis, d. Testicle proper. 
 
 increased frequency of urination, with perhaps a little 
 burning during the act, referred to the base of the 
 bladder. As the case progresses, the irritability be- 
 comes more marked until the patient is unable to 
 retain his urine more than fifteen or twenty minutes 
 at a time, involuntary passage taking place if he attempts 
 to do so. Later, also, tenesmus develops, and may be- 
 come very severe. The fact that vesical symptoms are 
 usually absent in the cases with secondary infection 
 is to be explained, in all probability, by the edema and 
 swelling of the vas, which does not permit the irri- 
 
26 
 
 t a ling material to pass through it to the vesicular 
 seminales. 
 
 Hemorrhage from the urethra may occur early or 
 late, and is usually not profuse. The blood is passed 
 with the urine, and without obvious cause, in this latteT 
 respect differing from the hemorrhage of renal calculus, 
 which is brought on by severe exercise, such as horse- 
 back riding, etc. The source and cause of this hemor- 
 rhage are somewhat uncertain, but we believe it is due, 
 as are the symptoms of vesical irritation, to the irri- 
 tating action of the products of the tubercular process, 
 which are discharged into the prostatic urethra through 
 the vesicuke seminales. This discharge produces a 
 catarrhal condition of the mucous membrane in the 
 posterior urethra and trigone of the bladder, with, in 
 many cases, erosions and superficial ulcerations. That 
 the vesical irritation and hemorrhage are not manifesta- 
 tions of a tubercular process in the bladder and prostate, 
 we are convinced from clinical observation, as in almost 
 all cases in which these symptoms are present, there 
 is an immediate cessation of them after castration or 
 resection of the epididymis, which could not possibly 
 be the case if they were due to tuberculosis of these 
 parts. This rapid subsidence of the symptoms after op- 
 eration is illustrated in the majority of cases here re- 
 ported, but strikingly so in one operated upon 10 years 
 ago. In this case the patient was obliged to urinate 
 every 15 or 20 minutes and was entirely incapacitated 
 for his duties as clergyman. Unilateral castration was 
 performed and vesical symptoms disappeared almost im- 
 mediately. In a letter received several days ago he re- 
 ports that his weight is now 260 pounds ; there has never 
 been a recurrence of the disease or bladder irritability, 
 and since the operation he has worked steadily. 
 
 Hydrocele, which is present in about one-third of the 
 cases, may have been the first symptom to attract the 
 patient's attention. It is rarely large, when due to 
 tuberculosis in the epididymis, and there is but little 
 difficulty presented in diagnosis. 
 
 At varying intervals from the onset of the trouble 
 softening of the deposit in the epididymis takes place. 
 This, in the acute cases, may be a few weeks, while in 
 the more chronic ones it may not occur for months or 
 even years after the onset. When the abscess is about 
 to rupture, the skin of the scrotum over the fluctuating 
 
ai 
 
 mass becomes adherent to it, bluish in color, and finally 
 perforates by a small opening, through which the 
 characteristic caseous material is discharged. There 
 is usually no pain attending this process and but little 
 tenderness, except where it is associated with mixed in- 
 fection, in which event we have all the manifestations of 
 
 fi 
 
 
 Fig. 11. — Showing epididymis freed from testicle proper, a. Epi- 
 didymis (body). b. Globus Minor. c. Spermatic artery and 
 veins, d. Tunica Vaginalis reflected, e. Testicle proper. 
 
 an acute cellulitis. The sinuses formed by rupture of 
 the abscess cavity may be single or multiple, and situ- 
 ated in different parts of the scrotum. They usually 
 remain open indefinitely, and show no tendency to close 
 spontaneously. The amount of discharge is slight. 
 
28 
 
 Eernia testis is rarely seen at the present time, prob- 
 ably because the cases are operated on at an early stage. 
 It is consequent upon the rupture of a tubercular abscess 
 situated in the testicle proper, and consists simply of 
 tuberculous granulation tissue, which is extruded 
 through the opening, forming a fungus mass of greater 
 or less size. 
 
 Constitutional symptoms are present in the majority 
 of cases, though they differ greatly in degree. Some 
 patients present the typical tubercular appearance, while 
 others appear to be in perfect general health. In most 
 of the cases, after the process has been present for some 
 time, there is loss of weight and strength, with perhaps 
 some evening temperature, rarely exceeding 100 F., 
 and night sweats. 
 
 The sexual desire is usually unaffected, except in the 
 very severe cases, even though, when both epididymi are 
 involved, there may be no seminal discharge during in- 
 tercourse. 
 
 Examination of the patient may reveal the presence 
 of some old tubercular lesions on other parts of the 
 body, such as lupus scars, cicatrices of the neck, or per- 
 haps the evidences of a healed osteomyelitis. In Case 
 No. 10 of our series the diagnosis at first was somewhat 
 doubtful, because of the rapid growth of the testicular 
 tumor, but the presence of a tubercular tendo-synovitis 
 of the hand cleared up all doubt as to its nature. 
 
 Rectal examination, for the purpose of ascertaining 
 the condition of the vesiculse seminales and prostate, 
 should always be made. The seminal vesicles are fre- 
 quently involved, or if only one is affected, it is more 
 likely to be the one on the side of the affected epididy- 
 mis. In the early stages the vesicle is soft, swollen, 
 somewhat painful to pressure, and can be outlined 
 throughout its entire length by the examining finger. 
 Later, nodules develop in it, and it presents a very 
 irregular shape, hard, with, perhaps, fluctuating areas 
 in different parts. When both are affected, they can be 
 plainly felt converging toward the prostatic urethra. 
 
 It is more difficult to determine tubercular disease 
 of the prostate, especially in its early stages, because 
 the process is usually situated deep in the substance of 
 the gland. In the early stage of the prostatic disease 
 the gland may be somewhat swollen and tender to pres- 
 sure, while later, when the process is farther advanced. 
 
29 
 
 it may be nodular, and present fluctuating areas. 
 Either lateral lobe may be affected singly, or if the en- 
 tire gland is involved, it may be more advanced on one 
 side than on the other. The inguinal lymph-glands are 
 rarely involved in tubercular disease of the testicle. 
 
 Uranalysis. — The condition of the urine will depend 
 ■on the stage to which the disease has advanced. Usually 
 when the patient presents himself for treatment small 
 quantities of pus and blood will be found in the cen- 
 trifuged specimen. By staining the pus for tubercle 
 bacilli they can usually be demonstrated, although al- 
 
 Fig. 12. — Showing entire epididymis free from testicle proper and 
 vas isolated. a. Epididymis. b. Vas deferens. c. Spermatic 
 vessels, d. Tunica Vaginalis (reflected), e. Testicle proper. 
 
 most always in very small numbers. It is of great im- 
 portance in searching for the bacilli to use special stain- 
 ing methods, so that the smegma bacillus will not be 
 mistaken for the tubercular germ. Various processes 
 for differentiating these two organisms have been pro- 
 posed, the most reliable being that of Bunge and 
 Trantenroth, which consists of extracting the fat from 
 the bacilli by allowing the preparation to remain for 
 three hours in absolute alcohol, then treating it for 
 fifteen minutes with a 5 per cent, solution of chromic 
 
30 
 
 acid, and washing in several changes ui' water. The 
 
 preparation is then to be stained with carbol-l'iuhsni. 
 destained in dilute sulphuric or pure nitric acid for one 
 to three minutes, and further destained and at the same 
 time counterstained, by immersing in a concentrated 
 
 alcoholic solution of methylene blue for five minutes. 
 By this means the tubercle bacilli retain the stain, while 
 the smegma bacilli become decolorized. Soudan iii, 
 in saturated alcoholic solution, may also be used for 
 differentiating the two. 
 
 Complications. — The routes by which extension of 
 the tubercular process takes place are at present the 
 subject of much dispute, many authors claiming thai 
 the disease exists primarily above and extends downward 
 to the epididymis along the surface of the mucous mem- 
 brane, extension, therefore, in an upward direction not 
 taking place. As stated above, it is our opinion that 
 the primary focus is in the epididymis, and that subse- 
 quently extension takes place along the lumen of the vas 
 to the vesicuke seminales. prostate, and in a few cases 
 to the bladder, ureters and kidne3 r . 
 
 Jacobson .-ays that after the disease localizes itself in 
 the epididymis it may spread by way of the Lymphatics, 
 but this is a very rare exception to the general rule. 
 That it may in rare cases extend by the lymphatics is 
 shown in Sommers' case (quoted by Senn) of a man, 
 aged 36 years, who suffered from tuberculosis of both 
 testicles. The retroperitoneal glands became involved, 
 and later pulmonary tuberculosis developed. In this 
 case the testes were primarily affected, the epididymis 
 remaining free from disease throughout. 
 
 Pott's disease of the spine has frequently been ob- 
 served to follow tuberculosis of the testicle, and this, as 
 well as the cases of general miliary tuberculosis which 
 occasionally develop, must be explained by dissemina- 
 tion of the infectious material through the blood-stream. 
 
 DIFFERENTIAL DIAGNOSIS. 
 
 In acute cases, where the symptoms come on sud- 
 denly and with great intensity, the diagnosis from 
 gonorrheal epididymitis may, at first, be difficult. The 
 principal points to be considered are : 
 
 1. The presence of an active gonorrhea, the discharge 
 of which may have suddenly disappeared just before the 
 onset of swelling in the epididymis. 
 
:;i 
 
 2. Examination of opposite epididymis, vesiculse 
 seminales and prostate shows absence of nodules. 
 
 3. Previous history of patient. In tubercular disease 
 there is frequently a history of recurring mild attacks 
 of epididymitis, or enlarged cervical glands in child- 
 hood, osteomyelitis,, etc. These are more likely to be 
 absent in the gonorrheal cases. 
 
 4. Occasionally it may be impossible to make an 
 immediate diagnosis, and in these we must await fur- 
 ther developments, which will occur after the acute- 
 swelling has subsided. The tuberculin test might be 
 valuable here, and in all cases where a urethral discharge 
 is present a bacteriologic examination should be made. 
 
 Syphilis. — This disease may affect either the testicle 
 proper or the epididymis, or both, in which latter case 
 they are simultaneously involved. 
 
 Syphilis of the Epididymis. 
 
 1. Infrequently localized. 
 
 2. Diffuse or nodular enlarge- 
 ment, ustially the former. 
 
 3. Epididymis not sensitive to 
 
 pressure. 
 
 4. Almost always painless. 
 
 5. No thickening of the sper- 
 
 matic cord. 
 
 6. Vesiculse seminales not in- 
 
 volved. 
 
 7. Usually no vesical symp- 
 . toms. 
 
 8. Rapid disappearance of le- 
 
 sions under KI and mer- 
 cury. 
 
 9. Frequently evidence of 
 
 syphilis elsewhere in the 
 body. 
 
 10. No tubercle bacilli in the 
 urine. 
 
 Tuberculosis of the Epi- 
 didymis. 
 
 1. Frequently localized. 
 
 2. Usually nodular. In most 
 
 cases begins in globus 
 minor, but may commence 
 in globus major. 
 
 3. Almost always some ten- 
 derness on pressure. 
 
 4. Usually slight aching pain 
 
 after exercise. 
 
 5. Spermatic cord frequently 
 thickened and nodular. 
 
 6. Vesiculse seminales may be 
 
 nodular. 
 
 7. Almost always symptoms of 
 
 vesical irritation and fre- 
 quently hemorrhage. 
 
 8. Antisyphilitic remedies have 
 
 no effect. 
 
 9. No such evidences; may be 
 
 signs of old tubercular le- 
 sions in the lungs, glands, 
 etc. 
 
 10. Tubercle bacilli may fre- 
 quently be demonstrated in 
 
32 
 
 Syphilis of Testicle Proper. 
 
 1. Usually begins in the body 
 of the testicle. 
 
 2. Usually diffuse involvement, 
 
 rarely circumscribed. 
 
 3. Sinuses rarely present, and 
 
 if they do exist, usually 
 last but a short time. 
 
 4. Fungating form quite com- 
 
 mon. 
 
 5. Usually definite history of 
 
 primary and secondary 
 manifestations. 
 <3. Yields promptly to anti- 
 syphilitic treatment. 
 
 Tuberculosis of 7'csticlc 
 Proper. 
 
 1. Body of testicle never pri- 
 
 marily affected. Always 
 secondary to epididymitis. 
 
 2. Disease nearly always cir- 
 
 cumscribed, having ex- 
 *. tended from the hilum. 
 
 3. Sinuses more common, and 
 
 they persist indefinitely. 
 
 4. Rare. 
 
 5. No such history. 
 
 6. No effect from antisyph- 
 ilitic treatment. 
 
 Sarcoma and carcinoma are anatomically two dis- 
 tinct and separate diseases of the testicle. Clinically 
 and practically, however, from the standpoint of diag- 
 nosis and treatment, they may be considered as one. 
 
 Malignant Disease of the 
 Testicle. 
 
 1. Usually begins in the body 
 
 of the testicle as a hard, 
 smooth swelling, which 
 later becomes soft. 
 
 2. Growth is very rapid, ex- 
 
 cept in the rare scirrhus 
 form. 
 
 3. May attain a very large 
 
 size. 
 
 4. No inflammatory symptoms 
 
 present during rapid 
 growth. 
 
 ■5. Veins of scrotum enlarged 
 and prominent. Skin thin 
 and dark colored. 
 
 €. Tumor not tender to pres- 
 sure. 
 
 7. Vesical symptoms not 
 marked. 
 
 Tuberculosis of the Testicle. 
 
 1. Tuberculosis always begins 
 
 in the epididymis as a 
 nodular enlargement. 
 
 2. Growth is slow. 
 
 3. Never attains great size. 
 
 4. Usually some inflammatory 
 
 manifestations, which may 
 be violent, if mixed infec- 
 tion takes place. 
 
 5. Veins not enlarged. Skin, 
 
 if affected, is thickened and 
 adherent to the epididymis. 
 
 6. Nodules usually tender. 
 
 7. Vesical symptoms always 
 
 prominent. 
 
33 
 
 8. If fungating, the ulcerated 8. Ulcerating surface has no 
 
 mass bleeds in a character- tendency to bleed profusely, 
 
 istic way. 
 
 9. Cord is much more often en- 9. The cord is nodular and 
 
 larged and swelling is hard, 
 
 smooth and even. 
 
 10. Glands above and below 10. Almost never involved. 
 Poupart's ligament may be 
 
 involved. 
 
 11. May be metastatic tumors 11. Sometimes evidences of old 
 in lungs, abdomen, etc. tubercular lesions else- 
 where, as lupus scars, cica- 
 trices in the neck, etc. 
 
 12. No tubercle bacilli in urine. 12. Bacilli often present. 
 
 Iii fibrous induration of the epididymis, due to some 
 previous acute or subacute inflammation, the epididy- 
 mis, while hard and thickened, is not usually nodular, 
 history of the case is entirely different from that of a 
 tubercular disease. 
 
 Of the benign tumors of the testicle, fibromata, en- 
 chondromata and osteomata are of such rare occurrence 
 that they need not be considered in the differential 
 diagnosis. Enchondroma and osteoma are sometimes 
 secondary developments in sarcoma, adenoma and 
 myxoma. Myomata have been described, but are very 
 rare. 
 
 Adenomata, when they undergo cystic degeneration, 
 may have to be considered in making the diagnosis. 
 
 Hydrocele usually presents no difficulty in diagnosis, 
 but it must be remembered that it is often a part of the 
 tuberculosis of the epididymis and testicle, as is serous 
 pleural effusion of pulmonary tuberculosis. 
 
 Prognosis. — In tuberculosis of the testicle the prog- 
 nosis depends upon: 1, the age of the patient; 2, 
 whether the infection is simple or of a mixed character ; 
 
 3, the location of the primary focus of infection; 
 
 4, whether or not other portions of the genito-urinary 
 tract or more distant parts of the body are involved. 
 
 The prognosis in children in localized disease of the 
 epididymis, or even where it has extended into the 
 testicle proper, with or without mixed infection, is 
 usually favorable. Encapsulation takes place in the 
 majority of cases without pus infection, and a portion 
 of the testis is preserved. Even where secondary infec- 
 tion has taken place and the abscess cavity discharged 
 
34 
 
 ixternally, we ran always hope for the preservation of 
 
 at least a small portion of the glandular struct inc. 
 
 This tendency in children to encapsulation and limi- 
 tation of the process is the same as that observed in 
 tuberculosis of other organs in them, with the exceptions 
 of tubercular meningitis and, to a lesser degree, oste- 
 omyelitis. 
 
 In adult cases many complications are apt to develop, 
 and it is on these that the prognosis will in large part 
 •depend. The most important are : 1, abscess formation 
 with resulting sinuses of the scrotum; 2, involvement of 
 the seminal vesicles and prostate; 3, tuberculosis of the 
 bladder (rare). In addition to these we may have foci 
 develop in any other part of the body, and even general 
 miliary tuberculosis has been known to follow a primary 
 lesion in the epididymis. Whether the affection of the 
 seminal vesicles or prostate precedes or follows the 
 testicular disease or not. the clinical fact remains the 
 same, the removal of the testicle or epididymis causes, 
 in a large percentage of the cases, a complete subsidence 
 •of the vesical and prostatic symptoms, and a healing 
 •of the tubercular process in these parts. From the 
 symptoms presented by some of the patients who have 
 come under our care, it seemed certain that the tubercu- 
 losis had extended to the mucosa of the bladder, but 
 on removal of the diseased testicle or epididymis they 
 •entirely subsided. While the prognosis is favora- 
 ble in prostatic and seminal vesicle involvement, it is 
 distinctly unfavorable when the disease has extended to 
 the bladder. In these cases it very frequently further 
 ■extends to the ureters and kidneys, and the patient 
 soon succumbs to renal or general miliary tuberculosis. 
 
 If the epididymis, which is primarily affected, be re- 
 moved early, it is probable that the other testicle will 
 not become involved. Should it, however, become im- 
 plicated, the urinary and vesical symptoms will recur 
 and bacilli will again be found m the urine. 
 
 As regards life, Jacobson says: "It is to be looked 
 upon as, if left to itself, an ultimately fatal disorder." 
 This, we believe, is an exaggeration, and is by no means 
 invariably the case, as in some the process becomes en- 
 capsulated and remains so throughout life. Even where 
 both testicles are involved and discharging sinuses pres- 
 ent, the general health may remain good indefinitely, as 
 in a case reported by E. Albert of ten years' standing. 
 
35 
 
 Tubercle bacilli can, in some cases, be demonstrated 
 in the semen, and in this way infection may be trans- 
 mitted to the female. It is interesting to observe that 
 Jackh found tubercle bacilli in the semen from healthy 
 testicles in cases of pulmonary tuberculosis. 
 
 Treatment. — This may be divided into 1, palliative; 
 2, radical. 
 
 Under palliative treatment we recognize, a, rest; b, 
 support to tEe diseased organ; c, constitutional treat- 
 ment; d, the various injection methods, with iodoform, 
 chlorid of zinc. etc. ; e. the method recently advocated 
 by Mauclaire, which consists in excising a section of the 
 spermatic cord between two ligatures. 
 
 Radical treatment may be, a, orchiectomy ; b, epididy- 
 mectomy, either partial or complete, with excision of a 
 part or whole of the vas deferens; c, incision and 
 drainage, with or without curettage or cauterization 
 with the thermocautery, chlorid of zinc solution, etc. 
 
 The disease in children, as before stated, has a ten- 
 dency to rapid encapsulation, circumscribing the process 
 to a local caseous nodule in the globus major or minor 
 or, in some cases, even extending into the mediastinum 
 testis, but occasionally there is complete destruction of 
 the epididymis and glandular portion of the testicle 
 proper, nothing remaining after a time but an abscess 
 cavity. In children, too, there is a much greater likeli- 
 hood of mixed infection than in adults, and it is this 
 which usually causes the rapid destruction mentioned 
 above. Felizet years ago made the statement that in 
 acute genital tuberculosis of children castration is the 
 only operation to be considered, and this statement has 
 never been contradicted. (Longuet.) If suppuration, \ 
 with destruction of the testicle, has already taken place 
 when first seen by the surgeon, incision and drainage 
 may be the only operation necessary. Early incision and 
 drainage, without curettage, is urgently indicated 
 in children where secondary infection is present to pre- 
 vent the destruction of the glandular portion, which 
 may take place without it. The rule is, in infants and . » 
 children, that no radical operation is indicated, and the \ 
 treatment of these patients should be the same as for 
 tuberculosis of the lymphatic glands, namely, syrup of 
 the iodid of iron, cod-liver oil and calcium lactophos- 
 phate. Epididymectomy is practically never called for. 
 
 The course of the disease is so varied in adults, from 
 
36 
 
 an acute inflammatory process to a chronic indolent, 
 almost painless one. thai the palliative treatment of each 
 case will depend on the peculiarities presented. Rest 
 and support are of the greatest importance, as is also 
 the constitutional treatment, which is indicated in all 
 cases of tuberculosis, wherever situated. This consists 
 of an abundance of fresh air and sunshine, moderate 
 exercise, plenty of fats in the food and cod-liver oil. 
 Changes of climate and scene, on which so many authors 
 have laid stress, are probably of no great importance. 
 
 If there is no mixed infection and no fistula? present, 
 iodoform and zinc injections are absolutely contrain- 
 dicated, and really have no place in the treatment of this 
 disease. They are uncertain, and while, in a few cases. 
 they seem to have been followed by good results, the 
 procedure is not rational. 
 
 The method of treatment advocated by Mauclaire in 
 his recent, paper has not as yet been tested in a suf- 
 ficient number of cases to say whether or not it will 
 have a place in the treatment of tuberculosis of the 
 epididymis and testicle. It is certainly not radical, and 
 does not seem to be rational if, as he says, the testicle 
 will be nourished by blood-vessels from the tunica 
 vaginalis, after ligation of the spermatic cord. He, how- 
 ever, has noted disappearance of the nodules in several 
 of his cases, and in almost all of them a subsidence of 
 the vesical symptoms, and healing of the lesions in the 
 vesiculas seminales and prostate. 
 
 Orchiectomy was in vogue for many years prior to 
 1895, and is still advocated by many able men, as 
 Koenig, Kocher, Terrilon, Richet and Senn, though 
 most of them are opposed to double castration except 
 in very exceptional instances. It would be the opera- 
 tion of election, because of its ease of performance and 
 the rapid healing of the parts which usually follows, 
 were it not for the unnecessary mutilation, the influence 
 on general metabolism, the mental effect, and for the 
 fact that patients will not consent to it until the 
 1 1 incase is very far advanced. As the glandular por- 
 tion of the testis is practically never primarily in- 
 volved, and very rarely seriously secondarily affected, 
 there is no good surgical basis for its removal. The 
 claim, which has always been made by the advocates of 
 castration, that the operation is more radical than epi- 
 didymectomy, is not proved by the results of opera- 
 
37 
 
 tions, and it is for the purpose of controverting this 
 idea that this paper has been prepared and these cases 
 cited. In 38 cases reported by Badenheuer in which 
 castration was performed for tuberculosis of the testicle 
 there was recurrence of the disease in the other organ 28 
 times. Bazy. Eoutier and Mauclaire have noted the 
 same recurrence in the other testicle in many cases. 
 These statistics form the strongest argument against 
 castration that can possibly be brought forward, be- 
 cause, as the disease so frequently develops on the 
 other side, a double castration will be inevitable, if it 
 be true, as these authors claim, that it is the only radical 
 operation. 
 
 Another great objection to the performance of cas- 
 tration is the profound mental effect which is induced 
 in many patients, not only where both organs have been 
 removed, but sometimes by the removal of one. Pujol, 
 in 2 cases of unilateral castration, observed melan- 
 cholia following the operation, and Fualds, in 3 similar 
 cases, noted the development later of grave mental symp- 
 toms. These mental changes may in part be due to 
 psychical impression, or they may be ascribed to absence 
 of the internal secretion of the testicle, but whatever 
 their cause, the fact remains that they develop in a cer- 
 tain and rather large percentage of the cases. The sec- 
 ondary secretion and its importance to normal metab- 
 olism were considered in the physiology. Tillaux, in 
 1896, says : "I believe that the testicular substance has 
 an important influence on the general health. The 
 secretion is resorbed in part by the system and con- 
 tributes to the vigor of the organism." Audebal also 
 condemns castration for the same reason. 
 
 We do not consider that a surgeon is justified in re- 
 moving a testicle for tuberculosis where the epididymis, 
 or only a part of the testicle proper, is involved. Even 
 when the seminal vesicles are diseased, it does not sup- 
 ply an additional indication for castration, nor is the 
 effect on the vesical symptoms more rapid or more pro- 
 nounced and permanent when castration is performed 
 than when the epididymis alone is ablated. After 
 orchiectomy, in many cases, there is a gradual and often 
 ultimately complete subsidence of the sexual desire, 
 which is not the case after epididjmiectomy. 
 
 Curettage and Drainage. — This is of no more effect in 
 the treatment of tuberculosis of the testicle and epididy- 
 
38 
 
 V^ mis than it is in the knee-joint or other tissue. It is 
 followed by prolonged suppuration, further extension of 
 the disease and final destruction of the organ. It has 
 many disadvantages, and no advantages over the more 
 radical epididymectomy. Where the testicle is much 
 swollen and infiltrated, so that it is impossible to de- 
 termine the exact condition of affairs, it is justifiable 
 to incise and drain the infiltrated tissues, and later, after 
 the acute infection has subsided and the exact extent of 
 the disease ascertained, do an epididymectomy. Lon- 
 guet advocates, in cases where the tubercular foci are 
 softened and liquefied, incision into the abscess cavi- 
 ties, curettage of their walls and cauterization with the 
 thermocautery or chlorid of zinc. His results in some 
 cases were excellent. After curettage the wound may 
 be packed with iodoform gauze and allowed to granulate, 
 or it may be closed with sutures. 
 
 Excision of foci in the testical proper was advocated 
 by Deville in 1852, and about the same time by Syme 
 and Malgaigne (quoted by Longuet). Reclus has per- 
 formed the same operation with perfect success. S. 
 Duplay, in 1897, recommended dissecting out tubercular 
 foci in the testicle and closing the defect left by sutur- 
 ing with catgut. 
 
 Epididymectomy. — L. Longuet, in his recent excel- 
 lent paper, treated very extensively the subject of con- 
 servative operations for tuberculosis of the testicle, both 
 from the historical and technical points of view. The 
 first epididymectomy on record was performed by Jar- 
 javay in 1850, upon a patient 20 years of age, with 
 tuberculosis of the right epididymis. He resected the 
 epididymis Aug. 7, 1850, and swabbed the wound out with 
 tincture of iodin. As mentioned before, Syme and Mal- 
 gaigne, for some time previous to Jarjavay's operation,, 
 had been teaching that in fungus and carcinomatous 
 testicular affections not involving the whole organ the' 
 diseased portion only should be removed, and Deville, 
 in 1852, saved a testicle which was prolapsed through 
 an ulcerating scrotum by resecting the diseased foci. 
 In these earlier operations, however, it was not the- 
 I epididymis that was removed, but rather portions of the 
 testicle proper in which the disease had become localized. 
 
 Typical total epididymectomy was probably first per- 
 formed by Bardenheuer in 1880, and in 1887 he reported 
 12 successful cases. Tuffier in 1883, Villeneuve in 1889,. 
 
39 
 
 Duplay in 1890, Humbert in 1891 and Lejars in 1893,. 
 reported cases and advocated the conservative operations. 
 Dr. Herman Mynter, of New York, in 1893, reported 2 
 cases in which he had performed epididymectomy one 
 and two years previously. Both patients had remained 
 perfectly well up to the time of the report, and there 
 was no prospect of recurrence in either. Guyon. 1892, 
 condemned castration where the epididymis only was 
 involved. Longuet, during the period from 1895 to 
 1898, had performed 30 typical and atypical epididy- 
 mectomies with most excellent results. Humbert, in 
 1897, published the reports of 15 resections, with good 
 results in the majority of cases. Reclus has done a 
 number of successful resections, but thinks the operation 
 indicated only when the disease is distinctly localized 
 in the epididymis. 
 
 Indications for the Operation. — Epididymectomy 
 should be the operation of election in every case of tuber- 
 culosis of the epididymis, single or double, except under 
 the following conditions : 
 
 1. Where there are extensive tubercular lesions else- 
 where, which will shortly terminate the patient's life. 
 
 2. Where the disease has extended to and destroyed 
 the greater part or all of the testis proper. Here cas- 
 tration should be done. 
 
 3. Where the scrotum is riddled with discharging 
 sinuses. The indication is usually here also for castra- 
 tion. In every other ease a resection, typical or atypical, 
 should be done for the following reasons : 
 
 1. Because it is radical and removes all the diseased 
 tissue. 
 
 2. It does not remove the healthy glandular portion 
 of the testicle, the internal secretion being thus pre- 
 served. 
 
 3. Patients will consent to an early removal of the 
 epididymis, thereby avoiding the disastrous results of 
 further infection of the genito-urinary tract. 
 
 4. It has the same beneficial effect on the vesical 
 symptoms as has orchiectomy. 
 
 5. Sexual desire and potency, even to emissions, are 
 retained ; power of procreation, however, is lost. 
 
 6. It has no ill effects on the general metabolism, nor 
 does the patient suffer from the mental distress and mel- 
 ancholia mentioned above. 
 
•10 
 
 7. It is easy of performance and entirely devoid of 
 danger. 
 
 8. The period of convalescence is short, and the good 
 results are permanent. 
 
 The principal objections which have been brought 
 against the operation are: 
 
 1. That it is not radical, as the rete testis is involved 
 in every case, even where it appears normal macroscopi- 
 cally. (Koenig, Fink, Diirr.) 
 
 2. That atrophy of the testicle follows the operation. 
 
 3. That, as the patient will be sterile after either epi- 
 •didymectomy or orchiectomy, it is unwise to risk the 
 possibility of leaving in infected tissue. 
 
 With regard to the first objection, e. g., that the opera- 
 tion is not radical, we have only to say that while theo- 
 retically this may be true, practically it is not. Where 
 the rete testis is seriously involved, to such an extent 
 that it will give rise to trouble later, it will always be 
 possible to determine it macroscopically at the time of 
 the operation, and excise the affected portion with the 
 epididymis. If this is done, recurrence need not be 
 feared, but even supposing it does take place in a small 
 proportion of the cases, a localized focus in the rete can 
 be excised at a subsequent operation and no harm result 
 from the delay, for the reason that as the vas is absent, 
 extension upward can not take place. As a precaution- 
 ary measure, in order to avoid leaving infected tissue, 
 some operators — Lejars, Koenig, Poncet, Delbet and 
 Andre — have recommended an exploratory incision into 
 the testicle, the subsequent operation, castration or epi- 
 didymectomy, to be determined by the condition of af- 
 fairs in the rete. In the cases which have come under 
 our care, this has never been necessary, it always being 
 possible to detect deposits in the rete at the time of re- 
 moval of the epididymis. 
 
 The symptoms of vesical irritation subside, after re- 
 section of the epididymis, just as promptly and com- 
 pletely as after castration, and the healing of secondary 
 deposits in the prostate and seminal vesicles takes, place 
 just as rapidly. Even where the tubercular process in 
 these latter situations is far advanced, arrest, by cicatri- 
 zation and encapsulation, is the rule after epididymec- 
 tomy. For this reason it is never necessary to remove 
 these organs. 
 
 The second objection, that atrophy of the testicle fol- 
 
41 
 
 lows removal of the epididymis, is not founded on fact,. 
 for numerous observations and experiments have shown 
 conclusively that when the operation is correctly per- 
 formed and the spermatic vessels not interfered with, 
 atrophy does not take place. (T. Dimetresco.) The 
 testes not only retain their normal size, but also their 
 natural firmness and sensitiveness. (Longuet.) Mau- 
 claire. in one case upon which unilateral epididymec- 
 tomy had been performed observed that the testis on the 
 side of operation retained its normal size, while the op- 
 posite one became hypertrophied. In Cases 4 and 5 of 
 our series the testicle presented some atrophy, which 
 must be accounted for by a slight injury to the vessels 
 at the time of operation; a considerable portion of the 
 organ, however, remains in each case. 
 
 The third objection is hardly worth considering, as 
 the importance of the internal secretion is not recog- 
 nized by those who make it. After epididymectomy the 
 patient is sterile, but not impotent, while after castra- 
 tion he is both. Reynier objects to the conservative 
 operations because he thinks that permanent sinuses 
 are often left. This is certainly not true if the opera- 
 tion is properly done. The sinuses which are occasion- 
 ally formed quickly close. 
 
 The operation of epididymectomy is extremely simple 
 and easy of performance, if the operator will first take 
 the trouble to experiment on the cadaver. It amounts 
 simply to an anatomical dissection, very little cutting 
 being necessary, except in dividing* the vasa efferentia 
 where they enter the globus major. 
 
 The steps of the operation illustrated by Figs. 11, 1& 
 and 13 are as follows: 
 
 1. Incision into the sac of the tunica vaginalis, just 
 external and parallel to the epididymis. 
 
 2. Dissection of epididymis from testis proper, com- 
 mencing below at globus minor and passing upward to 
 mediastinum testis. From here one must proceed 
 slowly and carefully so as not to injure the spermatic 
 artery and veins, closely hugging the epididymis and 
 separating it from the testis proper and spermatic ves- 
 sels. Blunt dissection should be used when possible, 
 cutting only when necessary. If a focus is discovered 
 in the mediastinum it is to be excised in a wedge-shaped 
 piece and the defect closed with catgut sutures. 
 
 3. When the globus major is free, the vas is to be iso- 
 
42 
 
 lated from the other structures of the cord upward, as 
 far as the internal ring, where it is to be clasped on both 
 sides of its circumference with hemostatic forceps, di- 
 vided and the lumen of the proximal end cauterized with 
 95 per cent, carbolic acid in the end of a needle. The 
 needle is to be worked upward in the lumen for one- 
 half inch and the mucous membrane thoroughly cau- 
 terized. 
 
 1. When cauterization is complete the vas is ligated 
 with chromicized catgut, one-quarter of an inch from its 
 end, so as to prevent infectious material from passing 
 backward through it into the tissues. This step is con- 
 sidered of great importance as previous to the use of the 
 ligature it was not uncommon to have induration and 
 occasionally suppuration develop near the stump of the 
 vas. The tunica albuginea is to be sutured with catgut, 
 if it has been opened. 
 
 5. The testicle is now replaced in the scrotal sac, and 
 the external wound closed either with a buried subcu- 
 taneous suture of catgut, or interrupted sutures of silk- 
 worm gut, leaving a small iodoform gauze drain in the 
 lower angle for forty-eight hours. 
 
 6. After forty-eight hours the gauze drain is removed 
 and provisional sutures,, put in at the time of the opera- 
 tion, are tied. 
 
 REPORT OF CASES. 
 
 Case 1. — Mr. E. J. B., aged 22 years. Occupation, factory- 
 man. Unmarried. Admitted to Alexian Brothers Hospital, 
 Sept. 9, 1894. 
 
 Present Illness. — Six months ago patient first noticed some 
 "chafing of skin" on the left side of scrotum, and a varicocele 
 on the same side, which had been present for several months, 
 became larger and somewhat painful. Shortly afterward a 
 small papule developed on the irritated skin and this was 
 opened by patient. Cheesy material was discharged, and a 
 small sinus, which would not close, was formed. There was 
 at no time any marked swelling of testicle and patient suf- 
 fered but little pain. Has had no urinary symptoms of any 
 kind. Has lost considerably in weight (10 pounds). No 
 coui^h. 
 
 Previous History. — Chorea several times in childhood. Be- 
 fore onset of present trouble patient worked in a shop where 
 much heavy lifting was a part of his daily labor. No history 
 of venereal infection. No direct injury to testicles. 
 
 Family History. — No tuberculosis in any members. 
 
 Examination of Patient. — Medium stature. Nourishment 
 
43 
 
 fair. Heart, lungs and abdomen negative. (Jenilalia.—lj ft 
 epididymis thickened, hard, nodular and slightly tender to 
 compression. Testicle proper, normal. A small sinus leading 
 down into nodular epididymis is present in left side of scrotum. 
 Right testicle and epididymis normal. 
 
 Operation.— Sept. 10, 1894. Operator, Dr. J. B. Murphy, 
 assisted by Dr. E. H. Lee. Incision into left tunica vaginalis 
 and dissection of epididymis from testicle proper, leaving the 
 spermatic vessels undisturbed. Vas severed from other struc- 
 tures of cord, ligated and amputated at internal ring. Testi- 
 cle proper replaced in sac of tunica vaginalis and skin wound 
 •closed with silkworm gut suture, leaving small gauze drain in 
 lower angle. The night after operation some secondary hemor- 
 rhage took place and house surgeon applied a ligature to the 
 bleeding vessel. After this the wound healed without further 
 trouble, except at the upper angle, where a small sinus persisted. 
 Sinus remained open for two years, when ligature was dis- 
 charged and it closed. General health improved much after 
 operation and he regained the flesh which he had lost. For 
 ultimate results see notes under Case 5. 
 
 Case 2. — Mr. M. Z., aged 22 years; occupation, watch- 
 maker; unmarried. Admitted to Mercy Hospital December 
 14, 1895. 
 
 Present Illness: For four years previous to last April, when 
 the organ was removed, patient had had repeated attacks of 
 pain and swelling in the right testicle. Eight weeks ago the 
 left testicle began to swell and a permanent nodular enlarge- 
 ment developed. This has been accompanied by considerable 
 dull, aching pain, and some tenderness in the mass. Urina- 
 tion has been frequent and painful. Family history negative 
 as regards tuberculosis. 
 
 Examination of Patient: Right testicle absent. In the left 
 side of the scrotum is a firm nodular mass situated pos- 
 teriorly, and having in front of it the testicle proper, which is 
 apparently normal. 
 
 Operation, Dec. 16, 1895; Operator, Dr. J. B. Murphy, as- 
 sisted by Dr. E. H. Lee. Incision into left tunica vaginalis; 
 dissection of nodular epididymis from the testicle proper; liga- 
 tion and amputation of the vas high up, and cauterization of 
 its lumen with 95 per cent, carbolic acid. Testicle replaced in 
 the scrotum and the wound closed with silkworm gut sutures, 
 a gauze drain being left in the lower angle. Cavity of the 
 tunica vaginalis on the right side opened and a hollow oval 
 ball of silver, the size and shape of a normal testicle, intro- 
 duced and the wound closed. Convalescence was uneventful, 
 and patient was discharged cured Dec. 25, 1895. In a letter 
 received from him May 8, 1900, the following particulars as 
 to his present state of health are given: His general health is 
 excellent. He has gained ten pounds since the operation, now 
 
•14 
 
 weighing ISO. He has no vesical irritation, and has passed no 
 blood or pus in the urine. There has been no return of the 
 disease since the operation, though patient states that occa- 
 sionally he has some slight pain in the testicle, which may be 
 attributed to the silver ball in the right side. There has been 
 no atrophy of the left testicle proper. He has had no cough. 
 fever or sweats. He has been married for several months and 
 states that the sexual desire is normal, there being some dis- 
 charge during intercourse. No nocturnal emissions since 
 operation. 
 
 (ask :!. — M. S. K. V., aged 30 years; married; occupation, 
 electroplater. Admitted to Cook County Hospital, service of 
 Dr. F. "S. Hartman, Dec. 1G, 1895. 
 
 Present Illness: About nine years ago right testicle was 
 swollen for several weeks. Swelling gradually subsided, leav- 
 ing a small, hard, painful nodule in the lower and posterior 
 portion of organ, which has persisted until the present time. 
 Frequent urination has been complained of iately, and he has 
 had to void his urine every fifteen or twenty minutes with- 
 out, however, having any pain during its passage. During the 
 past two or three weeks he has had numerous hemorrhages from 
 urethra. 
 
 Previous History. Patient claims he was never sick before, 
 and positively denies any venereal infection. Family history 
 entirely negative as regards tuberculosis. 
 
 Examination of Patient: Well-nourished man; heart, lungs 
 and abdomen negative. Right testicle is enlarged, and a firm 
 nodular mass can be felt involving the lower and posterior por- 
 tion of the organ. In the left testicle there is a hard nodule 
 occupying the upper and posterior portion. 
 
 JJranalysis : Dark color, neutral reaction. Specific gravity 
 1018. Albumin; no sugar. Microscopic examination, red 
 blood-cells and pus in moderate amount. 
 
 Operation, Dec. 17, 1895. Operator, Dr. J. B. Murphy, as- 
 sisted by Drs. Besley and Champlin. Incision over nodular 
 mass in upper and posterior part of left testicle; diseased 
 tissue well exposed, caught with forceps, and dissected from 
 body of the testicle, the latter being apparently normal. Iodo- 
 form gauze drain inserted and the wound closed with silk- 
 worm gut sutures. Exactly similar operation performed on 
 right side. Convalescence was uneventful and patient was 
 discharged cured Dec. 31. 1895. 
 
 Examination of patient June 27. 1896, showed that there 
 had been no return of the testicular disease, and the blood 
 had disappeared from the urine. He had gained fourteen 
 pounds since the operation, and sexual desire was same as be- 
 fore. About one year after operation, patient suddenly de- 
 veloped urinary suppression, which continued for twenty-four 
 hours. Several days later he had a similar attack lasting 
 
45 
 
 sixty hours. At this time the left kidney became enlarged and 
 soon afterward, the right. He died of the renal complication, 
 probably tuberculosis of both kidneys, early in February, 1897. 
 There was no recurrence of the trouble in the testicles, and the 
 lungs were unail'ected throughout. Tubercle bacilli were found 
 in the urine toward the close of the disease. While the ulti- 
 mate result in this case was bad, the success of the operation, 
 as regards the disease in the testicles and the relief of bladder 
 symptoms, was demonstrated, as there was no sign of local re- 
 currence, and no return of urethral hemorrhages up to the time 
 of his death. 
 
 Case 4. — Mr. A. D. B., aged 38 years; occupation, driver. 
 Admitted to Alexian Brothers' Hospital May 6, 1896. Pres- 
 ent illness dates from three and a half or four years ago, at 
 which time patient had what he calls "eczema of the scrotum." 
 About two years ago urination began to be more frequent than 
 normal, and he suffered from some burning pain at the base of 
 the bladder toward the end of micturition. A short time after 
 this he passed some blood and pus from the urethra. One 
 year ago a perineal cystotomy was performed, and at ths 
 same time some operation on the testicles, the nature of which 
 is unknown to the patient. After operation the urinary 
 fistula remained open for three or four months, when it closed 
 completely. Since closure of fistula he has been unable to hold 
 his urine more than one and one-half hours, involuntary pas- 
 sage taking place after this time. He says that at the time 
 of operation right testicle was discharging pus, but that soon 
 after it the sinus closed. For the past one and one-half years 
 left testicle has been gradually increasing in size, and has been 
 the seat of considerable pain. At the present time he is 
 obliged to urinate every hour at least. He often has pain at 
 the base of the b! adder and along the urethra. Several weeks 
 ago a small ulcer developed on the glans penis, followed after 
 about two weeks by a similar one on the prepuce. These are 
 still present. The general health is good. Bowels constipated. 
 Patient says he was never sick before. Family history nega- 
 tive as regards tuberculosis. 
 
 Examination of Patient: Both epididymi nodular and hard. 
 Testicles proper show no signs of involvement. The inguinal 
 glands on both sides very slightly enlarged. The prepuce 
 presents on its inner surface a large shallow ulceration, which 
 extends a short distance over the glans penis. Temperature 
 on admission ranged from normal to 100.3 F. 
 
 Uranalysis on Admission: Straw-colored, cloudy, acid reac- 
 tion, specifc gravity 1018, albumin present in considerable 
 quantities, no sugar. Microscopic examination showed pus 
 cells, red blood-cells, a few granular and epithelial casts. 
 
 Operation, May 8, 1896. Patient circumcised for removal 
 of preputial ulcer. Operation May 15, 1896. Operator, Dr. 
 
4t> 
 
 J. B. Murphy, assisted by Dr. Oswald. Incision into cavitj 
 of right tunica vaginalis, testicle and epididymis well exposed,. 
 and the latter dissected from the former, beginning below and 
 passing upward. Vas was amputated high up and lumen cau- 
 terized. Testicle proper replaced in sac, and external wound, 
 closed by means of silkworm sutures, leaving a small gauze 
 drain in lower angle. Similar operation performed on the 
 left side. Examination of epididymi showed both to contain, 
 typical caseous nodules. Patient was discharged from hos- 
 pital June 4, 189G, the incision on the left side having closed, 
 by primary union. On the right side there was a small sinus- 
 at the lower angle of the wound, which was discharging a 
 slight amount of purulent material. Uranalysis June 1 showed 
 the same findings as on admission, except that the urine was 
 clearer and contained less blood and pus. On the day of dis- 
 charge from hospital a few pleuritic friction sounds were heard: 
 in the right side of the chest. 
 
 Examination of patient July 11, 1900: General health ex- 
 cellent; patient now weighs 150 pounds, which is more than 
 he ever weighed before. Has no cough ; appetite good ; no 
 symptoms referable to the genital organs, except some itching 
 of the scrotum. Vesical irritation, which was such a marked! 
 symptom before the operation, disappeared almost entirely 
 within a month or six weeks after it was performed, and has- 
 never returned in anything like the same degree. Occasionally 
 he is obliged to urinate more frequently than normal, and. 
 usually has to get up two or three times during the night. 
 Has no pain during urination and never passes blood. Sexual 
 desire is the same as before onset of trouble, and the sensation' 
 attending intercourse is also the same, though he has no dis- 
 charge of seminal fluid. It was neglected in the history to 
 mention that for about one and a half years before the first 
 operation there had been no seminal discharge during coitus. 
 
 Examination of the heart, lungs and abdomen negative. 
 Genitalia: The right testicle proper is of normal size and; 
 consistency, and there is absolutely no sign of recurrence of 
 the disease. The left testicle is very much atrophied, not 
 being larger than the end of the middle finger. It is hard, but 
 not at all tender, and there is no evidence of any recurrence 
 of the tubercular trouble. Rectal examination shows the- 
 prostate and seminal vesicles to be free from disease. 
 
 Uranalysis July 11, 1900. Clear, yellow, acid reaction, no> 
 albumin, no sugar. Microscope showed no pus, blood or casts.. 
 
 Case 5. — (See Case 1). Mr. E. J. B., aged 24 years. Oc- 
 cupation, factoryman. Unmarried. Admitted to Alexias 
 Brothers' Hospital Aug. 17, 1896. 
 
 Present Illness. — Left epididymis was removed for tuber- 
 cular disease Sept. 10, 1894. Small sinus persisted in wound 
 after operation and closed only a short time ago. Health has- 
 
4-7 
 
 been good until about one month ago, when the right testicle 
 suddenly became enlarged, tender and painful. He has lost 
 some flesh, but has had no cough, fever or sweats. No urinary 
 symptoms have been present, either during this or the previous 
 attack. Previous and family histories given under Case 1. 
 
 Examination. — Man of medium stature. Nourishment fair. 
 Heart, lungs and abdomen, negative. 
 
 Genitalia. — Cicatrix of former operation present on left side 
 of scrotum. No recurrence of disease here, and testicle is of 
 normal size and consistency. Right side of scrotum swollen. 
 Right epididymis enlarged, hard, nodular, and very tender. 
 Testicle proper not involved, so far as examination shows. 
 
 Operation. — Aug. 18, 1896. Operator, Dr. J. B. Murphy. 
 Assistant, Dr. E. H. Lee. Epididymectomy performed — ex- 
 actly similar to that done on left side. Drain removed after 
 36 hours. Wound healed by primary union and patient was 
 discharged from hospital cured Sept. 1, 1896. 
 
 Examination of patient, April 7, 1900. Has gained thirty 
 pounds since operation. Feels perfectly well. Has no cough r 
 fever or sweats. No urinary symptoms. Sexual desire and 
 sensation are the same as before onset of trouble, and patient 
 says that seminal discharge is of the sime quantity. Pa- 
 tient always supports testicles in a suspensory. If suspen- 
 sory is not used, left testicle swells and becomes tender. Nc- 
 pain or tenderness when supported. 
 
 Examination: Both testicles present in scrotum and of nor- 
 mal consistency. No nodules present in either. Above left 
 testis is a small firm band about three-quarters of an inch in 
 length, not nodular, but slightly tender to compression. No 
 hydrocele. Patient says the testicles are somewhat smaller 
 than before operation, and they apparently are slightly atro- 
 phied. Rectal examination shows in each seminal vesicle a 
 small, very hard and painless nodule. The tubercular process 
 has here been arrested and encapsulated. Discharge during 
 intercourse, clear, looks like mucus; no spermatozoa. 
 
 Case 6. — Mr. G. L., aged 37 years; occupation, carpenter. 
 Admitted to Alexian Brothers' Hospital Sept. 21, 1897. 
 
 Present Illness: About one year ago patient began to cough 
 and lose flesh. Since then he has coughed continuously, ex- 
 pectoration being at times quite profuse, and occasionally 
 bloody. Loss of flesh has been marked. For some time past 
 he has had afternoon fever, night sweats, loss of appetite and 
 diarrhea. Three years ago he developed an empyema, which 
 was opened and drained by Dr. Murphy. The empyema sinus 
 is still discharging pus. Four months ago patient noticed a 
 small nodule in the right testicle at its posterior and lower 
 portion. This has gradually increased in *\zc. but lias caused 
 no pain or other symptoms referable to it. Complains of 
 increased frequency of urination. 
 
IS 
 
 Previous History: No points of interest except those given 
 above. 
 
 Examination of patient shows physical si<;ns of the con- 
 ditions recorded in the history. The nodule in the globus 
 minor i^ about the size of a hickory-nut. The testicle proper 
 is apparently not involved. 
 
 Operation Sept. 23, 1*!»7. Operator, Dr. J. B. Murphy, 
 assisted by Dr. Moran. Incision through the scrotal coverings 
 down to the epididymis. Epididymis picked up with forceps 
 ami dissected from testicle proper, beginning below and pass- 
 ing upward, the spermatic vessels being left intact. Cord 
 ligated high up and its lumen cauterized with 95 per cent. 
 carbolic acid. Externa] wound closed after first replacing tes- 
 ticle in scrotum. Small gauze drain left in lower angle of 
 wound for twenty-four hours. Convalescence after operation 
 was uneventful, and patient was discharged from the hospital 
 cured,. SO far as his testicular trouble was concerned, Nov. 
 15, 1897. 
 
 This patient later developed a tuberculosis of the spine, and 
 died from a genera] miliary infection some months after the 
 operation. No recurrence of symptoms referable to the genito- 
 urinary (treans. 
 
 Case 7. — Mr. W. C. ; nativity, Ireland. Age, 38 years; 
 married; occupation, laborer. Admitted to Cook County 
 Hospital Oct. 6, 1S97. 
 
 Present Illness: About seven months ago patient first no- 
 ticed swelling in the left side of the scrotum, which swelling 
 had appeared quite suddenly and attained a somewhat larger 
 size than at present in the course of a few days. Its appear- 
 ance was accompanied by sharp, shooting pains. The swelling 
 remained stationary for five or six weeks, when it partially 
 subsided. The pains decreased with the reduction in size of 
 the testicle. About five weeks before admission to hospital a 
 .similar swelling developed in the right side of the scrotum, 
 this running a course resembling the above. He now com- 
 plains of some pain in the right testicle. 
 
 Previous History: Denies syphilis and gonorrhea. Has 
 two children, oldest 18 and youngest 2 years of age. Family 
 history entirely negative as regards tuberculosis. 
 
 Examination: General nourishment good. Scrotum pre- 
 
 iits on the right side an ovoid mass, about 3 by 6 cm. in size, 
 situated posterior to the body of the testicle, which is appar- 
 ently uninvolved. This ovoid mass is composed of several hard 
 nodules. The spermatic cord is negative. On the left side 
 the epididymis answers to the same description as on the 
 right, but here the tunica vaginalis is distended with fluid. 
 Rectal examination shows the prostate and vesiculse seminales 
 to be normal. Left spermatic cord normal. 
 
49 
 
 Operation Oct. 29, 1897. Operator, Dr. J. 15. Murphy, 
 assisted by Drs. Simpson and Morf. Incision into scrotal sac 
 on each side down to the tunica vaginalis. Hydrocele on right 
 side evacuated. Epididymis on both sides now removed by 
 dissecting each from its testicle proper, carefully avoiding the 
 spermatic arteries and veins. Testes replaced in scrotum, 
 hemorrhage controlled and external wound closed -with silk- 
 worm gut sutures; gauze drainage in each lower angle. Pa- 
 tient was discharged cured Nov. 12, 1897. 
 
 Unfortunately we have been unable to locate the patient 
 since his discharge from the hospital, so can not report as 
 to final outcome of the operation. 
 
 Case 8. — Mr. W. L. M., aged 35 years; occupation, clerk. 
 Admitted to Mercy Hospital, July 18, 1898. 
 
 Present illness began about one month ago with sudden 
 painful swelling of the right testicle, the pain being quite 
 severe and aggravated by patient being on his feet. He has 
 had almost constant headache since the onset. Appetite is 
 good ; has no night sweats or fever. Since onset of trouble 
 he has lost considerably in weight; bowels are constipated. 
 Patient complains of frequent urination, it being necessary 
 for him to get up several times every night to void urine. 
 
 Previous History: At the age of 13 years he had enlarged 
 cervical glands, which disappeared under treatment. He has 
 also had "scarlet fever" and "cystitis." No specific history. 
 
 Family History: One aunt died of miliary tuberculosis. 
 
 Examination of patient negative, except as regards sexual 
 glands. On posterior surface of the right testicle there is a 
 hard nodular mass, slightly tender to pressure. The testicle 
 proper is apparently normal. A small amount of fluid is pres- 
 ent in the cavity of the tunica vaginalis; cord not involved. 
 
 Uranalysis on Admission: Quantity in twenty-four, hours, 
 1200 c.c. : specific gravity, 1011; reaction, acid; color, yel- 
 low, cloudy. No albumin, no sugar. Microscopic examination, 
 small amount of pus, no casts. 
 
 Operation, June 20, 1898. Operator, Dr. J. B. Murphy, 
 assisted by Drs. Bick and Daly. Incision on right side of 
 scrotum down to epididymis and into sac of tunica vaginalis. 
 This incision was extended upward to the external inguinal 
 ring. The nodular epididymis was dissected from the testicle 
 proper, beginning below and passing upward, leaving the tes- 
 ticle and spermatic A'essels intact. The vas was ligated and 
 amputated high up, and the lumen of the stump cauterized 
 with a red-hot needle. A few catgut sutures were introduced 
 into the tunica albuginea to check oozing, and the testicle 
 proper then replaced in the scrotum. The fascia was sutured 
 over the cord with buried catgut and the skin wound closed 
 by means of a subcutaneous suture of fine catgut. Collodion 
 dressing. 
 
50 
 
 The patient made a perfect recovery and was discharged 
 . aired Aug. 6, L898. Urinalysis on the day of discharge from 
 
 hospital showed the following: Slightly cloudy; reaction, 
 acid; specific gravity, 1012; no albumin; no sugar. Micro- 
 scopic examination, very small amount of pus. 
 
 (For ultimate result see under Case No. 9.) 
 
 Case 9.— Mr. W. L. M., aged 35 years. (See Case No. 8.) 
 Admitted to Mercy Hospital Sept. 30, 1898. 
 
 Present Illness: Last July, about two months ago, patient 
 underwent an operation for the removal of the right epididy- 
 mis. Shortly after operation left testicle became swollen, 
 slightly tender and painful, and this condition has persisted, 
 gradually becoming more severe, until the present time. He 
 still complains of frequent urination. 
 
 Examination shows nodular swelling of the left epididymis, 
 adherent to the surrounding structures, very hard and slightly 
 tender to compression. There is no sign of recurrence of 
 trouble on the right side. Chest and abdomen negative. 
 
 CJranalysis, Oct. 1, 1898, yellow, slightty cloudy, reaction 
 acid, specific gravity 1015, no albumin, no sugar. Micro- 
 scopic examination, small quantity of pus; no casts. 
 
 Operation Oct. 1, 1898. Operator, Dr. J. B. Murphy, as- 
 sisted by Drs. Rogers, Baccus and Daly. Incision one and a 
 half inches long parallel to raphe, near the bottom of the 
 scrotum; small amount of fluid escaped. Testicle drawn out 
 and epididymis dissected off, leaving the vessels passing to 
 the testicle proper intact; vas ligated, amputated and lumen 
 cauterized. Testicle returned to scrotum and skin wound 
 closed by means of a buried suture of silkworm gut. Small 
 iodoform gauze drain left in lower angle of wound. Unevent- 
 ful convalescence after operation. Patient discharged as 
 cured Oct. 15, 1898. 
 
 Uranalysis, Oct. 3, 1898, quantity in twenty-four hours, 
 1250 c.c, pale yellow, slightly turbid, reaction neutral; specific 
 gravity, 1012; no albumin, no sugar. 
 
 Microscopic examination: Numbers of epithelial cells and a 
 very few pus cells. 
 
 Examination of patient Nov. 9, 1899. General health ex- 
 cellent. No recurrence of tubercular trouble in either testicle, 
 both being apparently normal. No atrophy has taken place. 
 Patient now has no vesical irritation. 
 
 Examination March 25, 1900. Patient feels perfectly well; 
 has gained fifteen pounds since last operation, now weighing 
 145. The sexual desire is the same as before the onset of the 
 disease, and the sensation attending intercourse is unchanged. 
 The seminal emission is less than normal, and patient now has 
 no nocturnal emissions. The vesical irritation has entirely dis- 
 appeared. 
 
51 
 
 Case 10. — Mr. S. R. A., aged 47 years; married. Admitted 
 to Mercy Hospital Sept. 30, 1898. 
 
 Present Illness: Several months ago patient first noticed a 
 small nodule, slightly painful and tender to pressure, on 
 palmar aspect of right index finger. This steadily enlarged 
 and some swelling developed along the entire length of the 
 finger, extending into the palm. Several weeks after swelling 
 was first noticed patient received a slight traumatism to the 
 left testicle. Almost immediately afterward testicle became 
 swollen and the epididymis gradually developed the hard 
 nodular condition which is now present. Testicle is only 
 slightly painful and tender under compression. Patient com- 
 plains of some increased frequency in urination, and the 
 urine is cloudy. He has no cough and the general health is 
 good. No tuberculosis in family. 
 
 Examination of the Patient: Large stature; well nourished; 
 heart, lungs and abdomen are negative. Index finger of right 
 hand swollen along its entire palmar aspect, the swelling 
 •extending into the palm. It is only slightly tender to pressure, 
 the skin over it is not reddened, and along the course of the 
 tendon several small nodules can be felt. Function is much 
 impaired. Left epididymis is thickened, hard, nodular and 
 adherent to the surrounding tissues. The spermatic cord is 
 apparently not involved. 
 
 Uranalysis, Oct. 1, 1898. Quantity in twenty-four hours, 
 1200 c.c. ; reaction acid, specific gravity, 1014; color, yellow; 
 cloudy, trace of albumin, no sugar. A few granular casts and 
 pus cells were found under the microscope. 
 
 Operation Oct. 1, 1898. Operator, Dr. J. B. Murphy, as- 
 sisted by Drs. Rogers and Daly. 
 
 1. Finger. Esmarch on wrist. Incision on palmar surface 
 of finger along its entire length down to tendon; numerous 
 rice bodies escaped. Fungus granulations dissected out, 
 hemorrhage controlled and wound closed with buried silkworm 
 gut suture. Collodion dressing. 
 
 2. Testicle. Incision one and a half inches long near the 
 bottom of the scrotum on the left side, into the cavity of the 
 tunica vaginalis; small amount of hydrocele fluid escaped; 
 testicle drawn out and diseased epididymis dissected from it, 
 the dissection beginning below and proceeding upward. The 
 spermatic artery and veins were left intact; the vas ligated 
 and amputated high up and its lumen cauterized with 95 per 
 cent, carbolic acid. One or two fine catgut sutures were used 
 to draw together the edges of the abraded surface, left by the 
 removal of the globus major. Testicle now returned into the 
 scrotum and the wound closed by means of buried catgut 
 suture, a small gauze drain being left in the lower angle of the 
 wound. 
 
Uninterrupted convalescence followed the operation, and 
 patient was discharged cured Oct. 10, 1898. 
 
 (See Case No. 11 for result.) 
 
 Case 11. — Mr. S. R. A. (see Case No. 10), aged 49 years. 
 Admitted to Mercy Hospital Feb. 13, 1900. 
 
 Present Illness: Since Oct. 1898, when patient underwent 
 operation for the removal of the left epididymis, his health has 
 been good. Five or six months ago some soreness developed 
 in right epididymis, and a small hard nodule became palpable. 
 There has been no pain in the testicle except on pressure. He 
 complains of frequent urination, the act being accompanied 
 by some pain at the base of the bladder. General health at 
 present is good. 
 
 Family history and previous history given under Case 
 No. 10. ' 
 
 Examination of the Patient: Nourishment good; lungs, 
 heart and abdomen negative. Cicatrix on palmar aspect of 
 index finger of right hand present; no recurrence of trouble 
 lure. Left epididymis absent, and the wound left by former 
 epididymectomy now scarcely noticeable. No atrophy of left 
 testicle and no sign of recurrence of tubercular trouble. The 
 right epididymis is hard, nodular and slightly tender to 
 pressure, the process being confined quite closely to the globus 
 major. The vas is apparently uninvolved. The right seminal 
 vesicle is slightly thickened, while the left is apparently 
 normal. 
 
 Uranalysis Feb. 17, 1900. Color, light yellow, slightly 
 cloudy; acid reaction; specific gravity, 1015; urea, 1.5; al- 
 bumin, trace; no sugar. 
 
 Microscopic examination: A few hyaline and granular casts 
 found. Pus cells numerous. Tubercle bacilli found in the 
 centrifuged specimen. 
 
 Operation Feb. 14. 1900. Operator, Dr. J. B. Murphy, assisted 
 by Drs. Lcmke and Fggert. Incision two inches long into 
 cavity of tunica vaginalis over nodular epididymis, just to the 
 right of it. Testicle brought out of wound; tunica vaginalis 
 incised at upper border of testes, and dissected from epididy- 
 mis laterally. Epididymis now dissected from the testicle 
 proper, leaving the nutrient vessels of the latter intact; vas 
 clamped as high as possible, amputated and lumen cauterized 
 with 05 per cent, carbolic acid. Abraded surface left by re- 
 moval of the epididymis now covered by flaps of tunica 
 vaginalis and testicle returned into the scrotum. Small gntizo 
 drain introduced into lower angle and the external wound 
 closed with silkworm gut sutures. The day after the opera- 
 tion irritability of the bladder had almost entirely subsided, 
 and has not since returned. Convalescence was uneventful, 
 and patient left hospital March 3, 1900. 
 
53 
 
 Several later examinations of the urine show a small amount 
 of albumin to persist, with a few hyaline and granular casts. 
 In the centrifuged specimen pus cells are still found, though in 
 smaller numbers than before operation. Tubercle bacilli have 
 also been demonstrated on several occasions since the last 
 operation. 
 
 Examination of patient June 20, 1900: General health ex- 
 cellent; has gained fourteen pounds since the last operation; 
 appetite is good. There are no signs of recurrence of the 
 tubercular trouble in either testicle. Vesical irritability not 
 now present, although occasionally he is obliged to urinate 
 somewhat more frequently than normal. No pain on urination 
 and no blood passed. Rectal examination shows in each semfi- 
 nal vesicle a small', very hard nodule, which is only slightlv 
 tender to pressure. The foci in the seminal vesicles have evi- 
 dently become encapsulated, as there are now no tubercle 
 bacilli present in the urine. We believe that the seminal 
 vesicles were the source of the bacilli which persisted so long 
 after the last operation. 
 
 Case 12. — Mr. P. McC, aged 30 years; married; occupa- 
 tion moulder. Admitted to Alexian Brothers Hospital March 
 11, 1900. 
 
 Present Illness: Patient has a double hydrocele, each side 
 being as large as a goose Qgg- Scrotum has gradually in- 
 creased in size since November, 1899. Patient complains of 
 pain in lumbar region and scrotum ; also of great weakness. 
 
 Previous History: Diseases of childhood; specific urethritis 
 five years ago. Initial lesion of syphilis ten years ago. In- 
 guinal adenitis in 1894. Operation for hernia in 1899. 
 
 Family History: Negative as regards tuberculosis. 
 
 Examination of Patient: Heart and lungs negative; 
 cicatrices of hernial operation in both inguinal regions. 
 
 Genitalia: Scrotum very much enlarged, due to double 
 hydrocele. Testicles situated below and behind the fluid sacs. 
 Both testicles are apparently somewhat enlarged, and epi- 
 didymi enlarged and nodular, especially in the region of the 
 globus major. 
 
 Uranalysis: The urine contains some pus, and the centri- 
 fuged specimen shows tubercle bacilli. 
 
 Operation March 12, 1900. Operator, Dr. J. B. Murphy, 
 assisted by Drs. Lee and Hess. Two incisions, one on each 
 side of the median line of scrotum. Hydroceles exposed, sacs 
 opened and fluid evacuated. Testicles drawn out and inspected ; 
 both epididymi nodular and thickened, the tubercular de- 
 posits extending for a short distance on to the tunica albugi- 
 hea of the testicle proper. Both hydrocele sacs dissected out 
 and removed; both epididymi and adjacent tunica albuginea 
 removed by dissecting from the testicle proper, beginning be- 
 
54 
 
 low and passing upward. Leaving the vessels of the testicle 
 proper intact. Cords isolated, and the vas on each side 
 clamped and ligated high up. Lumina cauterized with 95 per 
 nut. carbolic acid. Cut edges ul tunica albuginea approxi- 
 mated and sutured. A small gauze drain inserted at the 
 lower angle of each scrotal incision and external wounds 
 closed. 
 
 Microscopic examination of epididymi showed large amount 
 of old fibrous connective tissue, with a few scattered tubercles 
 containing giant cells. 
 
 Convalescence uneventful, and patient discharged from the 
 hospital March 15, 1000. 
 
 We have been unable to trace this patient since his dis- 
 charge from the hospital, so can not report on his present con- 
 dition. 
 
 Case 13. — Mr. J. M., aged 37 years; German; married. 
 Admitted to Alexias Brothers' .Hospital. April 1, 1900. 
 
 Present illness dates from two months ago, when patient 
 was taken sick with high fever, pains all over the body and 
 other symptoms of an acute infectious disease. He had no 
 cough or any localizing symptoms at first, but two days after 
 the onset the left testicle suddenly became swollen, and he 
 experienced some pain in the left inguinal region. Testicle 
 continued to enlarge for a number of days, but was not tender, 
 and was the seat of no pain. He did not complain of frequent 
 urination, and never passed blood in the urine. The bowels 
 have been constipated, and he has some pain in the rectum 
 during defecation. 
 
 Previous History: Patient states that twelve years ago he 
 "strained himself," and soon after had some swelling and pain 
 in the right testicle. The symptoms subsided after a few 
 days, but a nodule remained in the upper and posterior por- 
 tion. This nodule enlarged slowly and two years ago a sur- 
 geon incised the swelling and allowed "water" to escape. No 
 tissue was removed at that time, and the nodule is still pres- 
 ent. One year ago patient suffered from very frequent and 
 painful urinations, and on two occasions passed some blood 
 in the urine. At that time he had fever, and during the six 
 months that the trouble persisted lost twenty or twenty-five 
 pounds in weight. He bad no symptoms directly referable 
 to the testicles at that time. After about six months the 
 symptoms disappeared and he was in good health until the 
 onset of the present trouble, two months ago. He denies ab- 
 solutely ever having had any venereal disease. No history of 
 injury. He is married and the father of a number of children. 
 
 Family history presents no points of interest. No tubercu- 
 losis in any of the members so far as can be ascertained. 
 
 Examination of Patient: Medium stature; nourishment 
 poor; temperature, 98.6 F. 
 
55 
 
 Heart and lungs negative. Abdomen, some slight diffuse 
 tenderness. The edge of the liver is palpable three-quarters 
 of an inch below the costal arch. Kidneys are not palpable. 
 There is quite marked tenderness in the right lower quadrant 
 of the abdomen. 
 
 Genitalia: In right epididymis there is a hard, round and 
 slightly tender nodule in the globus major. The vas deferens 
 passes somewhat more anteriorly than normal, and the testicle 
 is rotated so that the epididymis lies to the inner side rather 
 than posteriorly. In the left epididymis there are numerous 
 hard nodules massed together. The cord is thickened and ten- 
 der at its lower portion. 
 
 Rectal Examination: Both seminal vesicles are enlarged, 
 the right soft, the left nodular and tender. Urine, yellow, 
 turbid, reaction acid. Trace of albumin. The microscope re- 
 veals pus cells and a few red cells. No tubercle bacilli found. 
 
 Operation April 12, 1900. Operator, Dr. J. B. Murphy. 
 Incision over the left epididymis and cord, epididymis dissected 
 from testicle proper, leaving the spermatic vessels intact. 
 The cord was dissected from the surrounding tissues up to the 
 internal ring, where it was ligated, amputated, and the lumen 
 cauterized with 95 per cent, carbolic acid. Testicle proper 
 replaced in scrotum, and wound closed with subcutaneous 
 suture, leaving a small gauze drain in the lower angle. Right 
 epididymis not operated upon, as the process had evidently 
 been arrested by encapsulation. Convalescence was uneventful, 
 and the patient discharged about ten days after operation. 
 
 Since discharge from hospital, pain in the left groin has 
 persisted. Left testicle is tender, as is also the stump of the 
 amputated cord. Occasionally he is obliged to pass the urine 
 oftener than normal, but has passed no blood. Complains of 
 some pain in the left ilio-lumbar region, which is aggravated 
 by stooping forward. Defecation is still painful. He states 
 that his weight is the same as before operation. Has no chills, 
 fever or sweats. Has some burning pain in the urethra dur- 
 ing urination. There is a small discharging sinus in the 
 cicatrix on the left side of the scrotum, and the tissues pos- 
 terior to the testicle and at the stump of the cord present 
 some inflammatory infiltration. Both seminal vesicles are in 
 the same condition as they were when patient was admitted to 
 the hospital. Heart, lungs and abdomen negative. 
 
 In a letter written August 25, 1900, patient states that he 
 is at work and feeling better, but still has considerable pain 
 in the left side and back. It was not possible for him to come 
 to the city for examination. 
 
 I desire to express my appreciation of the valuable 
 services rendered by Dr. J. M. jSTeff in the preparation 
 of this paper. 
 
56 
 
 BIBLIOGRAPHY. 
 
 Albert, E. : Gegen die Castration bei Tuberculosa des Neben- 
 hodens. Th. von Gegenvert. Berl. and Wien, 1900, N. F. ii, 17. 
 
 Audebal, A. : De L'epididymectomie dans la tuberculose testlcu- 
 laire. Thesis, Paris, 1S98. 
 
 Barling, Gilbert: Clinical lecture on tubercular disease of the 
 testicle. Birmingham Med. Review, 1S92, xxxi, 152-156. 
 
 Bugge, Jens : Undersogelser om Lungetuberkulosens Ilyppighed 
 og Helbredelighed, 1896. 
 
 Delore : De L'orehidotomie dans la tuberculose du testicule. 
 Gaz. hebd. de M6d., Paris, 1898, 553-556. 
 
 Diuretresco, T. : MSd. Mod., Oct. 2, 1897 (Gould's Year-BookL 
 
 Duplay, S. : Sem. M6d.. Aug. 27, 1897 (Gould's Year-Book ). 
 
 Jacobson : Diseases of the male organs of generation, 1893. 
 
 Jarjavay : Tubercules du testicule. Resection. Phthisie pul- 
 monale aigue. Gazette des Ilopitaux. La Lancette Frangaise, 
 Sept. 28, 1850. 
 
 Koenig : Beitrag zum Studiren der Ilodentuberculose. Deut. 
 Ztsch. f. Chir., Leipz., 1898, xlvii, 502-522. 
 
 Longuet, L. : Traitement chirurgical de la tuberculose gSnltale 
 chez l'liomme. Revue <1 • < 'Mrurgie, Paris, Janvier, 1900. 
 
 Mauclaire : Traitemci.i de la tuberculose epididymo-testiculaire 
 par les ligatures et les sections des 616ments du cordon spermatique. 
 Annales des maladies des organes genito-urinaires, Paris, 1900, 
 xviii, p. 356-413. 
 
 Mynter, Herman : Tuberculosis of the epididymis. Ann. of Sur- 
 gery, Phila., 1893, xvii, 430-438. 
 
 Northrup and Bovaird : Quoted by Blackader in Progressive Medi- 
 cine, March, 1900, p. 269. 
 
 Parker, Preston : Monorchism, tuberculous orchitis and pros- 
 tatitis — fatal general tuberculosis. British Med. Journal, London, 
 1892, i, p. 118. 
 
 Senn, N..: Tuberculosis of the Genito-urinary Organs, 1897. 
 
 Shaw : Tuberculosis of the testicle following an attack of 
 measles. British Med. Journal, 1S9S. i. 1586. 
 
 Reprinted from 
 
 The Journal of the American Medical Association 
 
 November 10, 17, 24, 31 ; December 1 and 8, 1900 
 
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