My experience leads me to believe that high resection of the vas and castration will give the patient the best chance for a permament cure. I fail to see any reason for curetting out these foci, as recommended by some authorities, or partial castration, or excision of the globus major, globus minor, or epididymis. I do not believe that leaving the normal-sized testicles, without the vas, will be of any great. benefit, therefore I see no place for this operation. If you are going to do anything, castrate and remove the cord high up; otherwise I would temporize. If a man had general tuberculosis involving the lungs, if numerous foci were discovered throughout the body, so there would be no chance of improvement by removing the testicle, I would let the man alone. However, if there seemed to be any chance or promise of benefit from the operation, I would advise early removal of the testicle and excision of the vas high up.

Dr. Carl Weidner: In closing the discussion I would like for Dr. Abell to answer the following questions: What proportion of cases give a history of previous gonorrhea; second, what is the relation of this condition to age, that is, what is the most common age at which this condition occurs; does it occur during active sexual life?

Dr. Irvin Abell: The question of etiology was purposely omitted. from the paper. In those cases of descending infection, the process begins higher up in the genital tract and extends along the vas deferens. It is claimed by some observers that tuberculosis never extends in a direction opposite the stream, whether it be blood, lymph, or secretion stream. In cases of primary tuberculosis of the testicle the most reasonable explanation is that infection occurs through the blood current, the source of the bacilli being the lymphatic glands of the mediastinum, which have been shown to be tuberculous in seventy-five per cent of cases. The reason why tuberculous infection, being carried through the blood current, becomes localized in the epididymis remains unsettled. There is a history of gonorrheal epididymitis in a good percentage of cases. In the series of one hundred and twelve cases collected by Kocher and Simmonds there were twenty-five with a previous history of gonorrheal epididymitis. Birch-Hirschfeld reports that a German soldier who had a gonorrheal epididymitis developed tubercular infection of the epididymis, and died in eight days from acute miliary dissemination throughout the body.

It is claimed, also, that slight trauma plays quite an important part in tuberculosis in this situation, provided the injury is not very

extensive. It has been shown by Simmonds that by injection of tubercle bacilli into the peritoneal cavity of rabbits, then slightly bruising the testes, leads to tubercular infection of the testicles. Where the injury has been severe, it is claimed by Volkmann that the reparative process is so active as to overcome the tubercle bacilli. to why the tubercle bacilli should lodge in the epididymis and not in the testicle, the explanation has been offered that the branch of the spermatic artery which goes to the epididymis is more tortuous and offers a certain amount of hindrance to the blood current and also to the bacilli, thus favoring their localization at this point.

The age at which these affections most frequently occur is during the period from fifteen to thirty years, that is, during the most active period of sexual life. This is one reason why some operators suggest resection of the vas instead of castration. Many men have stated that they would rather be dead than have a double castration done upon them at that time of life. Reports from the Heidelburg clinic, I believe, are exceptional; they show twenty-one cases of bilateral castration, in only one of which was there any marked psychical effects following the operation; five showed some decrease in sexual power; all the rest showed no decrease in sexual vigor or desire, event after observation extending over a period of twenty years. I have one case of double castration, without high resection of the cord, done three years ago, with the same experience. Perfect relief followed the operation; the wound healed, all lesions disappeared, and he still retains his sexual desire and power. That there is an internal secretion of the testicle seems abundantly proven by a number of observers, who show that this gland does not atrophy after ligation of its duct, which atrophy we know occurs with all purely excretory glands after ligation of their duct. The testicle retains its size and still has the power to produce spermatozoa. Another evidence is shown by the effect of castration before full development is reached. To a young man, particularly at the age at which these affections occur, between fifteen and thirty years, castration is a serious procedure to contemplate, and this is an important point in favor of a conservative operation. Results are still more favorable from conservative methods than from castration. I do not see why we should remove the entire testicle when only a portion of the epididymis is involved. If we can preserve the testicle, and still cure the patient of his trouble by resecting a portion of it, I think we should certainly give him the benefit of the more conservative operation.

Cancer of the Esophagus. Dr. J. M. Krim: This is a post-mortem specimen of cancer of the esophagus. The patient was a man who had just returned from a pleasure trip to Germany, and came under my observation about three months ago. He apparently had no indication of his condition when he left here for Europe seven months ago.

When I saw him three months ago he complained that he could not swallow solid food without considerable difficulty. After several examinations I detected what I took to be a stricture of the esophagus, and found that I could not pass a No. 30 bougie. The solid food that he endeavored to swallow was shortly afterward vomited; for quite a while he was able to swallow liquid food, but finally that would be regurgitated. I think it was about four weeks ago when I made the last attempt to introduce an esophageal bougie and failed, but I did succeed in getting a large soft bougie through to the stomach. The man's breath had a fetid odor, and he vomited and coughed up some exceedingly fetid material, which probably came from the lower part of the right lung. As will be observed by examination of the specimen, the lower third of the right lung, which was also taken away, was gangrenous and almost black. The esophagus was densely adherent to the surrounding structures, and evidently the cancer ulcerated through into the bronchial tubes, which may account for the gangrenous condition of the right lung.

Operation for Umbilical Hernia. Dr. W. H. Wathen: This specimen is an umbilical hernia operated upon a week ago yesterday by Dr. Griffiths and myself. The lady, aged forty-two years, was a patient of Dr. Griffiths. You will see the omentum protruding from the sac, to which it is firmly adherent. You will also observe a very much thickened aponeurotic structure around the neck of the sac at all points.

The interesting part of this case is that the woman is enormously fat, weighing about two hundred and seventy-five pounds, only about five feet four inches tall, with fat across the abdomen below the hernia probably six inches in depth, with an enormous roll hanging down. These fat cases have been considered by many surgeons as usually inoperable in that the immediate mortality is greater than in thin people, and the permanent results very poor. The methods usually employed have been to take out the hernia and dissect up the muscles and unite them

laterally with some of the fascia. This operation was not performed after that fashion. The hernia was cut out by making an incision crosswise below and above the hernia about six inches in length, then dissecting down to the sac and scraping the fat off the aponeurotic structures down to the base and then for one and a half inches below, above, and laterally. The sac was then removed and the peritoneum dissected from the aponeurosis for one inch or more above and below, and sutured with No. 2 catgut. Then the aponeurosis above was brought down over the aponeurosis below and united transversely first by four silver wire sutures inserted one and a half inches above the lower margin of the upper border of the aponeurosis and about a quarter to half an inch below the upper border of the lower part of the aponeurosis, then the upper layer that was now lying down near the fat abdomen was sutured by a running catgut. We then had the opening closed by a suture of the peritoneum, and by overlapping of one and a half inches of the aponeurosis, making double thickness. The tissues above in this case were very easily united by interrupted silkworm gut, so that we had buried only catgut in the peritoneum, that in the aponeurosis and the four silver wires.

The woman has had no elevation of temperature and no increase in the rapidity of her pulse, and she is in practically a normal condition. Some of the sutures were removed yesterday, and there is no tendency toward suppuration.

This is the second case of the kind that I have operated upon within the last few weeks; the first one, a lady aged fifty-two years, also having a ventral hernia with great adhesions of the intestines and omentum. In both cases I removed the larger part of the omentum, and sutured after the fashion described. The first case had no trouble following the operation, and has returned home.

This operation has been performed not very often but quite a number of times during the last few years by Mayo, of Rochester, Wis., and by a few others, and it is to my mind the rational method of operating in these cases, because we find that the only strength we get in union of the abdominal wall lies in the fascia. I have no faith whatever in any permanent union from the muscles unless the muscle is wrapped in fascia and held there. If you suture the ends of the muscles it gives no strength; if you suture the sides of the muscles it gives no strength; then again, in these fat women, after you have dissected out an umbilical hernia the muscles have gotten so far apart that you

have to dissect far out into the tissues to get to them, and when you get to the muscles you will often find they have undergone fatty degeneration; so I see no necessity of attempting to find the muscles in any of these cases; save the fascia in front of the muscle and lap it over in any direction that it unites most easily. You may lap it transversely, vertically, or obliquely, and you may suture the wound over this in any direction you please. I think it is a good idea, if possible, to make the incision in such manner that after you suture the fascia and aponeurotic structures you may bring these tissues together without any more buried sutures, for we know buried catgut, or any other absorbable suture, is liable to cause suppuration in the fatty tissue that we have here.

What will be the ultimate result in these two cases I do not know; in fact, the time has not been long enough following this method of operating for any one to say positively, but it certainly seems to me to be the most rational procedure, and the operation is practically devoid of danger and easily performed, and ought to be more successful than any other.

Dr. George W. Griffiths: I had the case reported by Dr. Wathen under observation for probably a year. She had tried every way in the world-by umbilical trusses, abdominal supporters, etc.—to retain the hernia without any effect, except perhaps to increase her discomfort. It was one of the most unfavorable cases that can be imagined for operation. She was pot-bellied, exceptionally fat, but a very cheerful and brave little woman. Operative intervention offered her the only hope of recovery. Nothing could be found in the way of a device. which would retain the hernia in position. I suggested operation to her months ago.

PHILIP F. BARBOUR, M. D., Secretary.