offered for the arrest of the pulmonary disease. In cases suitable for surgical interference it is, of course, apparent that the successful issue depends upon the time of operation. In early cases with the tuberculous process limited to the epididymis the total ablation of the testicle is seldom necessary. Under such circumstances excision of the epididymis, with preservation of the testicle, is the operation of choice. If the vas be found undiseased, the end may be transplanted directly into the body of the testis. In this event, even with total removal of the opposite testis, there is afforded a possible preservation of sexual and procreative ability. If, however, the vas is found to have been invaded with tuberculous deposit, it should be resected and tied as high up as possible, leaving the testis by itself in the tunical sac. This presupposes, of course, that the body of the testis presents no macroscopic appearance of tuberculous disease. The practice of total extirpation of the epididymis and testis by reason of a known involvement of the former and a presumptive invasion of the latter is subject to severe condemnation. A sweeping ablation of the testis and epididymis is far less preferable to the careful dissection of the epididymis as a preliminary procedure, even though the extirpation of the testis is later demanded. The preceding operation is admittedly more tedious, and the period of anesthesia considerably longer, but the interests of the patient are in many instances better conserved. This method of procedure is particularly applicable to cases of early involvement of the epididymis, and relates with special emphasis to instances of bilateral disease. It often happens that while the indications may point imperatively toward the total extirpation of the epididymis and testis upon one side, the conditions admit of at least the preservation of the testis upon the other. Under no circumstances should double castration be performed irrespective of the degree or extent of the pulmonary disease. I have noted several instances of greatly impaired mentality as a result of this operation. Upon the other hand, I have observed a notable illustration of the excellent results possible of attainment from the sacrifice of the tuberculous mass upon one side and the retention of the other testis, despite the removal of the epididymis and vas. unfortunate results of epididymectomy are quite insignificant in comparison with the deplorable consequences of complete castration. The removal of the epididymis in no way lessens the influence of the internal testicular secretion upon the general health, and at the same time does not detract from the moral effect incident to the preservation of the testis. Examples of the disastrous consequences of delay in surgical interference are numerous. I will cite briefly one or two illustrative

cases.

Case 1-A married man, aged thirty-two, who had been for six years the subject of pulmonary tuberculosis, consulted me early in 1907. Although the arrest of the tuberculous process in the lungs was not complete, there was exhibited, nevertheless, but little remaining pulmonary involvement. The general condition was excellent, nutrition was well maintained, and there was entire absence of cough, expectoration, or temperature elevation. Five weeks previously a small nodule had been felt in the epididymis, which rapidly increased in size. This was attended by some pain, although the recumbent position was maintained. The condition grew progressively worse until a hard, irregular, nodular mass was formed, nearly the size of

the fist, with beginning involvement of the epididymis of the opposite side. There was, however, no evidence of local softening. The patient coming under my observation at this time and objecting to surgical operation, was placed upon injections of bacilli emulsion. In addition, efforts were directed toward superalimentation. A Too of a milligram of the emulsion was immediately administered, and repeated every two weeks until three injections had been given, each dose being followed by a perceptible local reaction. During the month that elapsed an appreciable improvement was noted in the general health, and a diminution in the size of the large tuberculous organ. The patient gained seven pounds in weight, local pain and tenderness entirely disappeared, without evidence of increasing involvement of the opposite side. There shortly developed, however, an abrupt change for the worse. Caseation and softening rapidly took place upon the side first involved, together with an acute hard enlargement of the epididymis upon the other. The opinion of a surgeon was rendered unequivocally as to the imperative necessity of double castration. This I strenuously opposed, and insisted upon an attempt to preserve, if possible, the body of the testis upon the side recently affected. This operation was performed by Dr. F. L. Dixon. The tissues of the left side were totally removed because of the advanced and wide-spread character of the tuberculous infection. Upon the right side the epididymis was found studded with tiny tuberculous masses, which were beginning to undergo caseation. The body of the testis was apparently uninvolved, as well as the vas. After excision of the epididymis the vas was transplanted into the body of the testis. Subsequent to the operation it was deemed expedient to administer the tuberculin in order to aid, if possible, in the preservation of the remaining testicle. This has been given weekly during the past six months, and the patient has made a perfect recovery, sexual desire and potency being in no way diminished.

Case II. I have recently had under my care a man of twenty-nine years whose history of tuberculosis dates back nine years, at which time he exhibited the first evidences of an infection of the epididymis. This was permitted to remain, although extensively diseased, during a period of three years. It was then removed, but not until he had developed tuberculous involvement of the bladder and one kidney. The patient remained under my observation one year, and in addition to well-defined renal tuberculosis, has been compelled to suffer the pain and discomfort incident to advanced infection of the bladder, prostate, and seminal vesicles. His general condition was one of extreme debility, sufficient to preclude the expediency of surgical interference even were this permissible upon the score of the local conditions. There has been no evidence of pulmonary tuberculosis. The masterly delay in surgical intervention during a period of three years in a young man without evidence of pulmonary tuberculosis in this case is directly responsible for most unfortunate results, and is a striking commentary upon the fallacious teaching relative to treating patients with tuberculosis of the epididymis and testis in accordance with the principles appropriate for pulmonary tuberculosis. Conspicuous improvement has been attained in this case by the administration of the bacilli emulsion.

CHAPTER LXXV

TUBERCULOSIS OF THE FALLOPIAN TUBES, UTERUS, AND ADJACENT STRUCTURES

TUBERCULOUS involvement of the Fallopian tubes is exceedingly comThe infection of the tubes is often primary, but may take place as a result of extension from a neighboring tuberculous focus. It is probable, as stated in connection with the general etiology of tuberculosis of the genito-urinary organs, that primary involvement of the tubes occurs almost as frequently as of the epididymis, and perhaps even more often than of the prostate. The origin of the tuberculous process may be traced, in the majority of instances, to an infection conveyed by the circulation. It is uncertain to what extent the lymphatics act as carriers of the bacilli. It is possible that, in rare instances, infection may take place as a result of coitus with a tuberculous invalid. It is more than likely, however, that this manner of bacillary invasion of the female genital tract occurs but exceptionally. Admitting such possibility, however, it still remains highly improbable that a suitable lodging-place for the bacilli is afforded in the vagina, on account of the natural fortifications of this region. Protection is afforded, first, by the tough squamous epithelium, the noneroded surface of the mucous membrane, and the profuseness of the mucous secretions, which are usually highly acid in reaction. Although tubercle bacilli are sometimes found in the vagina, a genuine tuberculous process in this region is relatively infrequent. When this does exist, it occurs almost always in conjunction with, and secondary to, tuberculosis of the Fallopian tubes, the uterus, or of both. It may be accepted as an almost universal fact that tuberculosis of the female genital system, other than the occasional existence of lupus of the external genitalia, has its primary origin in the tubes. From such point of departure secondary deposits may take place. Hare refers to the statistics of eight European pathologists in illustration of the great frequency of tuberculosis of the female genital tract. Tuberculous involvement of the genitals was found at autopsy 208 times out of 8627 cases of tuberculosis in females. According to Cornet, Kiwisch found the proportion of involvement in similar cases to be one in forty, and Cornil in one to fifty or sixty.

Tuberculous disease of these parts may exist at any time of life, though it is more frequent at the period of greatest sexual activity. Many cases. of its occurrence have been reported, however, among young children. Gusserow has cited a case of tuberculous disease in the ovaries and uterus at this time of life, without implication of the tubes. Bender has collected a record of 48 cases of tuberculosis of the vulva, exhibiting ulcerative and hypertrophic lesions. Some of these were undoubtedly influenced in their development by trauma. From the statistical observations thus far reported it may be assumed that the lungs are diseased in at least onehalf of the cases of genital tuberculosis, and some other portion of the urinary system in about the same proportion of cases.

The gross pathologic change in tuberculosis of the Fallopian tubes consists of a thickened, indurated condition of the wall. This is associated with a collection of cheesy pus, somewhat after the manner of

ordinary pyosalpinx. The abscess formation takes place almost always at some point in the tube more or less remote from either extremity. The fimbriated end usually becomes thickened and adherent to the ovary or the peritoneum, producing a permanent occlusion of the lumen. Obliteration of the canal often takes place also at its proximal end, and this suffices in many cases to prevent the escape of infected cheesy detritus into the uterus. The intervening portion of the tube is usually somewhat dilated, and in some cases becomes the seat of miliary nodules. In the event of uterine infection, the tuberculous process commonly begins in the vicinity of the tubal orifices, the cervix seldom being involved. Tuberculosis of the uterus has been regarded in the past as a very rare condition, but is undoubtedly somewhat more frequent than was formerly supposed. The process makes its first appearance in the endometrium, which becomes infiltrated with tubercle deposit. Caseation, softening, and coalescence of these lesions produce an ulcerative endometritis in the discharge of which tubercle bacilli are sometimes found. The disease may extend from the distal end of the tube to the ovary or peritoneum. The former may become studded with. tuberculous nodules or break down into an abscess cavity. Evidences of localized peritonitis sometimes follow the invasion of the serous membrane in the immediate neighborhood of the fimbriated end of the tube.

The symptoms of tuberculosis of the tube in some cases do not differ from those of ordinary catarrhal salpingitis, but there may be in other instances characteristic evidences of pyosalpinx. The condition is usually bilateral. Upon palpation alone it is difficult to differentiate tuberculosis of the tube from other pathologic conditions producing tumor in this region.

The symptoms of tuberculosis of the uterus are not especially dissimilar to those of non-tuberculous endometritis. There may be temperature elevation and evidence of moderate septic infection, with, usually, tenderness and some enlargement. The character of the involvement is suggested by the recognition of tuberculous disease in other parts of the body, and confirmed by the detection of tubercle bacilli in the uterine discharge. In the event of a negative history of tuberculosis and failure to discover an infection in other regions, the nature of the involvement may be disclosed by the presence of bacilli in the discharge, or by a microscopic examination of the uterine mucosa removed by the curet.

In the absence of active and extensive pulmonary disease, the prognosis depends upon the early recognition of the condition and the adoption of prompt surgical measures. The diagnosis once established. there should be no delay in operative interference among patients whose general condition does not contraindicate surgical aid.

The treatment is purely surgical, and consists of vaginal hysterectomy, with removal of tubes and ovary if infected.

It is important, even in woman, to ascertain conclusively in regard to the condition of the kidneys and urinary tract in cases of genital tuberculosis. Kelly has recently called attention to the rather surprising association between renal tuberculosis and a similar involvement. of the tubes and uterus. The treatment of lesions involving the external genitals is that of free and wide excision, or tentative recourse to tuberculin injection.

SECTION VIII

TUBERCULOSIS OF THE SKIN AND UPPER RESPIRATORY TRACT

CHAPTER LXXVI

TUBERCULOSIS OF THE SKIN

GENUINE tuberculous involvement of the cutaneous tissue is rare among phthisical patients, but nevertheless of exceeding interest. Tuberculous lesions of the skin occur among individuals otherwise healthy, but some of the clinical varieties are found with greater frequency among patients suffering from tubercle deposit in other parts of the body. Illustrative of this, is the well-known relation of the ulcerative form of tuberculosis cutis to infective processes in the nasal cavities and to lesions of the genito-urinary tract. The uniform proximity of certain types of tuberculous skin lesions to the mucous orifices, viz., of the mouth, nose, vagina, and rectum, is presumptive evidence of an infection derived from these respective avenues, despite the absence of demonstrable tuberculous processes in parts tributary to the openings.

Other clinical forms of cutaneous tuberculosis suggest source of infection from without the body, either as a result of contagion or accidental inoculation. This is especially true of the verrucous type of skin infection, the verruca necrogenica, or so-called anatomic wart, the verruca cutis, believed by many to be identical with the preceding, and, lastly, lupus verrucosa.

Still other varieties owe their origin to contiguity of structure, particularly the scrofuloderma, which results by extension from adjacent. tuberculous glands or an underlying infection.

Finally, the local condition may arise from a dissemination of the infection through the circulation, the integument becoming affected as a result of the conveyance of bacilli from some internal focus. It is likely that certain forms of lupus originate in this manner, and particularly the tuberculosis disseminata.

Waiving for the time being any discussion regarding the clinical aspects of these types of cutaneous tuberculosis, attention is directed. to the role of the skin as a channel for tuberculous infection. This is perhaps of greater scientific interest than the local manifestations of the tuberculous condition. It is to be remembered that a localized tuberculosis of the integument affords no evidence in favor of the skin as a port of entry for the initial tuberculous invasion. Local processes, however, may be expected to attend an entrance of the infection through the skin. It has been claimed by some observers that whenever the skin constitutes the avenue of infection, the tuberculous deposit is confined to the integument, and remains a distinctly localized process. This is unsupported by clinical data, although in many instances the advance of the bacilli is arrested by the proximal lymphatic glands. The virulence of the infection following inoculation is usually slight.