cent nitric acid, washed and dried, and placed for two minutes in ninetyfive-per-cent alcohol. Tumor in the kidney region is a late symptom, but should be looked for. Pain depends on involvement of pelvis or ureter, though if the kidney parenchyma is involved alone there may be a dragging sensation. As a rule the pain is uninfluenced by motion, but is quieted by the dorsal decubitis. It may be aggravated by meals, or a blow or cold, but chiefly before the monthly period. It may be sharp, simulating stone, possibly from the excretion of purulent lumps or phosphatic concretions, or from renal congestion.-Medical News.

THE BACTERICIDAL PROPErties of UrOTROPIN.-Orlowski finds that the bactericidal powers of urotropin toward the majority of bacteria are distinctly inferior to those of carbolic acid or of corrosive sublimate, and are further diminished in the presence of albumen. It has, however, a very decided influence in restraining the fermentation of urine, much more powerful than that of salol. When administered internally, the acid reaction of the urine is increased, and in cases of cystitis with alkaline urine the reaction may become neutral. Its administration is not attended with any undesirable accompaniments.- Centralbl. f. Chir., Leipzig.

SYMPHYSEOTOMY AS CONTRASTED WITH CESAREAN SECTION.-Charles Jewett believes that, within a limited range of pelvic contraction, symphyseotomy is still a useful operation. It is suited to conditions in which only very little additional space is required. It is a valuable resource in cases in which forceps unexpectedly prove inadequate. Axis-traction forceps with the aid of posture should be tried before resorting to symphyseotomy. Its results would be much improved by restricting it to pelves with a conjugate of not less than 7.5 centimetres in simple flatness or 9 centimetres in general contraction. Under equally favorable conditions its total mortality should be no greater than that of Cesarean section. When the pelvic space permits, it should replace the Cesarean operation in the presence of exhaustion. It may be elected primarily as an alternative of Cesarean section when the operator can be assured that the degree of obstruction is well within its safe limit. Within its proper field symphyseotomy is better than Cesarean section for an operator of little experience in abdominal surgery.-American Jourual of Obstetrics.

REMOVAL OF THE ENTIRE STOMACH FOR CANCER.-Von Bardeleben records the case of a woman, aged fifty-two, in which he performed the above operation in August of last year. In dealing with the cardiac end, the esophagus was pulled down as far as possible, ligatured and cut across; the entire stomach, along with the diseased glands along its curvatures, was removed, and the gullet and duodenum were then closed by means of a double row of sutures. The highest loop of the jejunum was then drawn upward, and was anastomosed by means of sutures to the esophagus at a distance of fourteen inches from the duodeno-jejunal junction. The patient was fed by the mouth on the evening of the operation, and has subsequently gained thirty-seven pounds in weight.-Deutsche med. Wchnschr.

THE

VOL. XXXIII.

“NEC TENUI PENNÂ.”

LOUISVILLE, KY., APRIL 1, 1902.

No 7.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

TREATMENT OF TUBERCULOSIS OF TESTICLE AND EPIDIDYMIS.*

BY IRVIN ABELL, M. D.

Assistant to the Chairs of Anatomy and Clinical Surgery, Demonstrator of Genito-Urinary Surgery, Louisville Medical College; Lecturer on Surgery, City Hospital Training School; Visiting Surgeon to Louisville City Hospital.

Tubercular infection of the male genito-urinary tract constitutes one of the most frequent infections of this part with which we have to deal, probably second only to gonorrhea, and a review of the literature, particularly that pertaining to the testicle and epididymis, reveals such widely discrepant views and such conflicting experiences that I thought the subject might not be an uninteresting one for our consideration this evening.

Turning for a moment to the pathology, a knowledge of which is absolutely essential for the application of correct treatment, we are impressed with the diversity of views upon several points connected therewith, expressed by men whose prominence command respect for their opinion. That the process in the testicle is ever primary is denied by most writers, others regarding it as of such rare occurrence as to pass it with a simple mention. That the process in the epididymis is often primary we find asserted by such men as Senn, Councilman, Reclus, Murphy, Saleron, and other investigators, while Virchow, Köenig, and Kocher have always held that the infection is a descending one.

'Councilman states his belief that the most common seat of primary uro-genital tuberculosis is the epididymis as follows: "It may be confined to this, or the testicle affected by continuity. The epididymis is

* Read before the Louisville Clinical Society, February 25, 1902. For discussion see p. 256.

converted into a more or less firm, caseous mass. From this the disease extends along the vas deferens, which becomes enlarged, and on section the interior is found to be lined with a whitish caseous tissue. In both the vas deferens and the epididymis the seat of the disease is primarily the epithelium, and later takes the form of a tubercular inflammation. Seminal vesicles on the same side become affected in most cases, or they may be passed by and the disease appear in the prostate or bladder."

"Fuller says: "It is rare for the tubercular deposit in the epididymis to represent a primary focus of the disease, as in a vast majority of cases the inflammation has extended to the part along the genital tract from the deep urethra or seminal vesicle. In many instances I have watched the process of extension, having detected the tubercular involvement of the deep urethra or seminal vesicle long before the disease had extended itself into the epididymis." In which belief Guyon and Lancereaux concur.

The points of entrance of the bacilli are conceded by all to be the skin, respiratory, gastro-intestinal, and genito-urinary tracts, the localization in the epididymis then depending on one or more of several conditions. The most potent source of tubercle bacilli in the blood is believed to be the mediastinal lymph glands, which have been shown. to be tubercular in 75 per cent of cases coming to the post-mortem table. The situation of the primary nodule has been and is the subject of dispute. Reclus and Malassey locate it in the wall of the seminal tubule; Virchow, Gaule, and Steiner in the intercanalicular connective tissue; while Langhans, Curling, and others locate it in the interior of the tubule itself. Reclus was able to remove the nodules when he resected portions of the seminal ducts, thus showing their connection with the ducts. He believes the process to originate in the endothelial envelopes of the tubules, the lumen being secondarily affected.

Murphy, in a recent article, supports the view of Virchow and others by saying: "As in the majority of cases the infection probably takes place through the blood-current, it seems reasonable to suppose that the primary lodgment of the bacilli is in the intertubular connective tissue of the epididymis, and this view is certainly supported by studies of tuberculosis in other organs."

Curling, in his work on diseases of the testes, expresses the opinion that the point of origin is in the interior of the tubule, and continuing says: "Anatomic considerations, indeed, support the opinion that abnor

mal nutrition in the cellular contents of the tubes induces the formation of miliary tubercles in the walls without at all negativing the development of tubercle in the intertubular tissue, as seen by Virchow, or in the adventitia of the blood-vessels, as observed by Nepveau. Indeed, the discrepant views upon the matter may be explained by assuming that different observers have regarded what has been found in particular cases as the result of some general law. With reference to this the suggestion of Klebs is valuable. Admitting that in acute miliary tuberculosis, where the dissemination of the virus is effected by the vascular system, the blood-vessels and their surroundings are the seat of tubercles, he has seen preparations from Langhans where the tubercles were in the interior of the tubules, and Klebs adds that 'it would be very desirable to ascertain whether this was uniformly the case in the so-frequent extension of tuberculosis from the older nodules in the epididymis to the testes.'

But let the starting be at either of the three mentioned places, the tubercular process itself does not differ here from tubercular processes elsewhere, but consists of deposit, caseation, and liquefaction, calcification being rarely observed. The tunica vaginalis usually shows evidence of chronic trouble, is unnaturally vascular, its cavity wholly or partially obliterated, or may contain fluid which may be serous, sero-purulent, or pus, tubercle bacilli having been found in all three varieties. Simon examined twelve tubercular testicles and found evidence of involvement in eight. M. Tuffier found that the liquid of hydroceles present in three cases of tubercular testes injected into the cavities of animals produced fatal tuberculosis, although no tubercle bacilli could be demonstrated in the fluid. The vas deferens is very commonly involved, becoming hard, knotty, and thickened, rendering it more or less irregular with nodules. The lesions are found particularly near the testicle and near the seminal vesicle. The involvement of the testicle is nearly always secondary to that of the epididymis; the epididymis is most frequently attacked in the globus major, although the observations of some few have been that the globus minor is first. affected. Jacobson suggests that those cases in which the globus major is first affected are the primary ones, as the spot of involvement usually corresponds to the entrance of the branch of the spermatic artery, while those in which the tail is attacked first are secondary to other uro-genital lesions, the infection descending from the urethra or seminal vesicles through the vas deferens. Murphy, in the November

Practical Medicine Series, says: "Baumgarten experimented on rabbits to determine the manner in which uro-genital tuberculosis is disseminated. Inoculation of the urethra never produced a tuberculosis of the testicle, but always developed a tuberculous ulcer of the posterior urethra, and often of the fundus of the bladder and the prostate; it never extended along the ureter to the kidney. If, however, the epididymis was inoculated, tuberculosis of the vas and prostate of same side always resulted; it never spread to the opposite side. The results of these experiments are in harmony with the rule pertaining to all cases of experimental tuberculosis: tubercle bacilli never spread in a direction opposite to the current (against the stream), whether it be blood, lymph, or a secretion stream. The explanation of this is found in the fact that tubercle bacilli are non-motile and do not multiply in normal secretions. To infect, these bacilli must enter the channel wall; from here, through ulceration of the channel wall, they again reach the secretion, thus spreading the infection only in the direction of its flow. The infection is also disseminated by the lymph vessels within the wall, but this lymphogenous infection is also carried from the epididymis along the vas to the seminal vesicles and prostate. The results of these experiments agree with the findings in autopsies. The conditions for the spread of the tuberculous process are the same in man as in the rabbit, because the anatomic relations are essentially the same. He confirms the opinion of Von Brun, that tuberculosis of the testicle is the only localization possible in the uro-genital tract; and this view is sustained by the conformity in results obtained by clinical experience, pathologic investigation, and experimental research."

After noting how widely divided the profession appears to be in regard to the pathology and dissemination of the tubercular process here, we are not unprepared for the various radical and conservative measures advocated for its relief; among the advocates of the radical operation (castration) are Kocher, Von Bruns, Simon, and others.

"Young quotes Köenig's report of Kocher's forty five cases as follows: "Kocher does not favor the partial operation, and in this series has performed only three epididymectomies to thirty-seven castrations. Among the forty-five cases there are nine deaths and nine could not be followed. Twenty-seven cases have been carefully examined after periods varying from two to nine years. Of these twenty-seven cases there have been twenty-two cures of both local and distant tuberculosis,