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CYSTS OF THE EPIDIDYMIS.
807 Thus the cases of definite pneumonia furnish somewhat less than half of the total (45-6 per cent.). Of the other lung conditions, those showing circulatory disturbances (congestion and oedema) without lung consolidation furnish the great majority, while tuberculosis contributes a fair quota. Table I. shows the Pfeiffer percentage in these groups of cases, and it is apparent that when the acute inflammations are set beside the other lung conditions, the fluctuations in the Pfeiffer percentage are in the" same direction and of the same order. The group of normal " lungs is too small for statistical purposes, but it is conceivable that, had a larger series of normal lungs been available, these would, just as truthfully as the diseased lungs, have reflected the general incidence of B. influenzce as a human parasite. Moreover, Table II. shows that the Pfeiffer percentage, whether in lung or in medium-sized bronchus, shows corresponding monthly variations both in the cases grouped as acutely inflammatory and in the cases without inflammatory lesions (congestion, oedema, and normal lungs) with the incidence in total cases observed month by month. The pneumococcal percentage, high at all times in lungs investigated post mortem, shows little fluctuation
remains uncertain. They are by no means rare, not so common as the small cysts just described. It has been definitely stated (Monod and that they originate between the under surface of the globus major of the epididymis and the upper surface of the testis, and that as the cyst increases in size the epididymis itself becomes flattened out and may be recognised only with difficulty. Other writers have suggested that these cysts take origin in remains of the wolffian duct. Another theory supposes that they are due to partial dilatations of some part of the excretory ducts of the testis, and this is supported by the fact that communication between the cyst and the seminal ducts has often been demonstrated, and also that spermatozoa. are always present in the fluid. They are certainly more common in the region of the globus major, and usually the remains of the body of the epididymis and globus minor can be seen on the wall of the cyst. In some cases, however, the cyst, instead of lying between the globus major and the testis, seems rather to be a cystic degeneration of the greater part of the epididymis itself, the shape of which is preserved though very little of it is left unaltered. A specimen kindly given me by Mr. F. J. F. Barrington shows a throughout the period. change of this kind in the testicle of a bull ; the is not flattened out by a cyst lying between epididymis Conclusion. it and the testis, but is itself the site of development of£ examination of at Bacteriological lungs autopsies a multilocular cyst. In the same way the cysts of over a period of 12 months, during which three distinct the human epididymis are often multilocular, parprevalences of influenzal attack were noted, yielded ticularly when of large size, and usually there is then information which supports the view that the incidencefluctuations of B. influenzce as a lung parasite are some communication between the various loculi so that if one is opened the others are emptied. As independent of the particular pulmonary condition they become larger they always bulge into the tunica. associated with it.
Reference.-Patterson, S. W., Little, E. M., and Williams, F. E.: Medical Research Council Report, No. 36, 1918, p. 88.
CYSTS OF THE EPIDIDYMIS. BY R. FIRST
OGIER WARD, F.R.C.S. ENG.,
M.CH. OXF.,
ASSISTANT, SURGICAL PROFESSORIAL UNIT, ST. BARTHOLOMEW’S HOSPITAL; ASSISTANT SURGEON, ST. PETER’S HOSPITAL FOR STONE, LONDON.
swellings in the scrotum are very common. usually due to the collection of fluid in the tunica vaginalis, but cysts of the epididymis are by no means rare, and these, when well developed, may produce swellings as large as an ordinary hydrocele. A study of 17 cases recently collected in the clinic of the surgical professorial unit at St. Bartholomew’s Hospital and in the out-patient department of St. Peter’s Hospital for Stone, has emphasised the fact that the disease not infrequently affects both epididymes simultaneously, and consideration of the available methods of treatment suggests that excision of the cysts should be more often practised. Monod and Terrillon have classified cysts arising in connexion with the epididymis in two groups : (1) Small cysts which lie above the globus major, and (2) larger cysts, in this country commonly called spermatoceles, which are more closely related to the testicle. The small cysts first mentioned are of little importance. They are not uncommon in old men, and if looked for during post-mortem examinations will usually be found on the convex surface’ of the globus major ; they are commonly sessile and subserous, often only the size of a pin’s head, and rarely larger than a pea. The pathogenesis of these cysts is uncertain. It has been suggested that they arise in vestigeal remains, and that they may result from injury or from inflammation. They give rise to no symptoms and call for no CYSTIC
They
are
treatment.
-
Form and Position of Larger Cysts. which form the subject of this article all belong to the second group of larger cysts. They are of more importance clinically, since they often grow to a large size and may cause great inconvenience. Their pathology has often been discussed, but still
The
cases
TI. er il on) though
vaginalis.
aetiology and Age Incidence. The condition appears to be a form of retention cyst, but the causes are unknown. Previous gonorrhoeal inflammation of the epididymis has often been suggested, and also injury, but it is difficult to prove. either to be responsible, or, indeed, to establish any cause, from an investigation of the patient’s history, for he is usually quite unable to state with accuracy for how long any enlargement has existed. Again, these cysts are probably of much commoner occurrencein later life than is generally suspected, for minor swellings pass quite unnoticed, and since there is neither functional disorder nor any pain, except perhaps an occasional aching, it is only when they are big enough to cause inconvenience that the himself for treatment. patient presents In Cabot’s " Modern Urology " it is stated that the commonest period of life during which this occurs is between 20 and 40 years. The present series, however, shows it to be chiefly a disease of advancing years, the average age being 55, though some swelling iad usually been noticed for one or two years previously. This agrees with the opinion of most vriters. The youngest subject, under the care of Mr. Grey Turner-to whom I am grateful for pernission to publish this case-was aged 41, and had loticed the swelling for about a year. The condition ias been described in patients as young as 25 years. Most of the patients were married, and were fathers of amilies now grown up. In only one patient was there my definite history of injury, which had occurred ive months previously, and he was fairly sure that he swelling was the direct result of it. Two patients iad acquired gonorrhoea many years before, but did iot remember having had epididymitis at the time. n one case there was a history of syphilis 30 years
)reviously.
When examination is made of the frequency with vhich either testicle is affected, it is interesting to ind that in 5 of the 17 cases the cystic enlargement vas on the right side, and in 4 it was on the left, mt that in the remaining 8 both epididymes were ,ffected, one usually being larger than the other. Che common occurrence of cystic degeneration of oth epididymes is not generally realised. The disension was usually not very great, the largest amount f fluid obtained being 13 oz., which was withdrawn
808 !’ by tapping the bigger of bilateral cysts. In other instances about 5 oz. were present. A case has been described in which on one occasion 49 oz. of fluid were withdrawn from the right side and 58 oz. from the left. The fluid, whenever it was examined microscopically, contained spermatozoa, usually in large numbers, living, actively motile, and well formed ; these are commonly numerous enough to give it the characteristic opalescence. An examination of these patients threw no light upon the cause of the condition. The vasa deferentia appeared normal ; the seminal vesicles felt normal when examined per rectum, and no urethral obstruction was found. Posterior urethroscopy in four patients gave no certain evidence of obstruction to the orifices of the common ejaculatory ducts, though in two the region of the verumontanum appeared somewhat cedematous.
SMALL-POX AND "AMAAS" IN SOUTH AFRICA. BY J. A. MITCHELL, M.B., CH.B. GLASG., D.P.H. DURH., SECRETARY FOR PUBLIC HEALTH AND CHIEF HEALTH UNION OF SOUTH AFRICA.
OFFICER,
IN view of the reported occurrence of outbreaks of " amaas " or " alastrim" in Great Britain, and the controversy which has arisen as to its precise nature and its relation to small-pox and vaccinia, a brief statement of experience of this disease in South Africa, and opinions based thereon, may be useful. The question is not merely an abstract scientific one; it is of great importance in practical public health administration. Here, in South Africa, the belief amongst some medical men and a large section of the Diagnosis. that the disease is not small-pox, and that it is public The diagnosis of these swellings is not difficult, yet of mild type and comparatively unimpermanently they are often confused with hydroceles of the tunica portant, has repeatedly led to unfortunate results. vaginalis. Both are fluid swellings within the The medical men who hold this view are mostly scrotum ; in both fluctuation is present, but these (though not exclusivelyl) either senior practitioners, cysts of the epididymis form a much softer swelling whose experience goes back to the time when small-pox than the ordinarily tense hydrocele. Again, individual was a very prevalent and very fatal in. this country loculi can often be felt as rounded prominences which or younger medical men whose knowledge give the swelling a surface irregular and different disease, of small-pox is based mainly on the smaller textfrom the smooth outline of a hydrocele. Another books and observation of a few cases. means by which they can usually be distinguished is to The controversy is in reality very old. Sydenham determine the position of the testis ; this will be refers to extensive outbreaks with very low mortality, found to lie in front, and, when the entire epididymis considered by the laity and some medical authorities is affected, to be surrounded above, behind, and to be different from variola, and described essentially below by a cystic swelling. When there are cysts as " " or" glass-pox." Nothhorn-pox," only of the globus major the testis lies in the bottom nagel states that "stone-pox," in the pre-vaccination period light the scrotum, but it is never displaced backwards of cases (of the character of ’ varioloid’) were associated into the position which it occupies when a hydrocele with severe ones at all times and in all epidemics, and, of the tunica vaginalis is present. It may be menthere were also outbreaks, though more rarely further, tioned here that a small hydrocele is sometimes found than at present, in which milder cases were more associated with cystic degeneration of the epididymis ; than the severer ones." Jenner notes an this was found six times in the present series. A prevalent in Gloucestershire with no deaths. Sir epidemic further aid to diagnosis is transillumination, which in his report mentioned later, records Turner, George of often be of use in the the will identifying position seen an outbreak in England with a mortality having testis ; as these swellings often consist of collections of of only 3 per cent. and refers to another, in Sutherland cysts, they are generally more opaque than the in 1884, in which there were 100 consecutive cases ordinary unilocular hydrocele, though not so opaque without In the Sheffield outbreak of 1887-8 a death. as to provide a certain means of distinction between there were 4995 cases in vaccinated persons with 243 the two conditions, as some writers have implied. deaths, a case mortality of 4-7 per cent., and 1028 Tapping will settle the diagnosis, since it will yield a unvaccinated a case mortality cases with 320 cloudy, colourless fluid, usually containing sper- of 31’1 per cent., the rate fordeaths, all cases being 9-45 per matozoa in numbers large enough to give the charac- cent. In in 1901-2, there were 1010 cases, teristic shimmer ; but even if this is not so, they with 233 Glasgow, deaths, a case mortality of 23-0 per cent. can always be found if the fluid is centrifugalised. Early Epidemics in South 4frica. Treatment. Small-pox was first introduced to South Africa in When the patients come for treatment it will a vessel on which cases had occurred on the 1713-by often be found that tapping has already been emfrom India, but which had recovered before voyage ployed. Sometimes this is all that is necessary, and if Table Bay. Clothing from this vessel was it is performed two or three times a year the patient reaching ashore to be washed at the Dutch East India brought may be quite satisfied. But it must be remembered Company’s slave lodge. The disease broke out among that tapping will not cure the condition, as the cysts the slaves, and of 570 attacked 200 died. The disease always refill themselves. Sometimes they do so very spread rapidly to the European and native population, rapidly, and then it is usually preferable to advise and a widespread and very fatal epidemic followed. removal of the swelling, which can be approached The death-rate was especially high among the through any of the ordinary incisions. The cyst of Hottentots, some of whom fled to the mountains and one or both sides, or perhaps the whole epididymis, is far inland, carrying the infection with them. So excised, and this can easily be done without any became the terror of the natives that they killed damage to the testis or its blood-supply. In the great and burned some of these fugitives. It is recorded present series either epididymectomy, or removal of that the entire inhabitants of many kraals died and a cyst on one side, was performed five times, and it is the very names of tribes for a great distance inland important to notice that no loss of sexual desire or of disappeared. power of ejaculation has resulted, nor has atrophy of A widespread and very fatal outbreak occurred in the testis occurred. In one of the two patients in the infection being introduced by vessels from 1755, whom bilateral epididymectomy was performed the It is recorded that in Table Valley alone result was equally satisfactory ; the other has not Ceylon. 963 Europeans and 1109 natives died of it. Theal, been traced. ’
Summary. 1. Cystic degeneration of the epididymis is
"
common ;
2. It is a disease of is uncertain. Both sides are often affected. 4. Excision is indicated when tapping has failed to give relief for more than inconveniently short periods. (continued at fcot of next colurim.)
its
pathology maturity. 3.
1 The chief exponent of the amaas, a separate and distinct disease" theory, is Dr. W. E. de Korte. See his paper Amaas or Kafir Milk-Pox, THE LANCET, 1904, p. 1273.
(Continued from preceding column.) References.—Monod, Ch., and Terrillon, O.: Maladies du testicule. 1889. Jacobson, W. H.: Diseases of the Male Organs of Generation, 1893. Thomson Walker, J. W.: Genito-Urinary Surgery, 1914. Cabot, H.: Modern Urology, 1918.
remains uncertain. They are by no means rare, not so common as the small cysts just described. It has been definitely stated (Monod and that they originate between the under surface of the globus major of the epididymis and the upper surface of the testis, and that as the cyst increases in size the epididymis itself becomes flattened out and may be recognised only with difficulty. Other writers have suggested that these cysts take origin in remains of the wolffian duct. Another theory supposes that they are due to partial dilatations of some part of the excretory ducts of the testis, and this is supported by the fact that communication between the cyst and the seminal ducts has often been demonstrated, and also that spermatozoa. are always present in the fluid. They are certainly more common in the region of the globus major, and usually the remains of the body of the epididymis and globus minor can be seen on the wall of the cyst. In some cases, however, the cyst, instead of lying between the globus major and the testis, seems rather to be a cystic degeneration of the greater part of the epididymis itself, the shape of which is preserved though very little of it is left unaltered. A specimen kindly given me by Mr. F. J. F. Barrington shows a throughout the period. change of this kind in the testicle of a bull ; the is not flattened out by a cyst lying between epididymis Conclusion. it and the testis, but is itself the site of development of£ examination of at Bacteriological lungs autopsies a multilocular cyst. In the same way the cysts of over a period of 12 months, during which three distinct the human epididymis are often multilocular, parprevalences of influenzal attack were noted, yielded ticularly when of large size, and usually there is then information which supports the view that the incidencefluctuations of B. influenzce as a lung parasite are some communication between the various loculi so that if one is opened the others are emptied. As independent of the particular pulmonary condition they become larger they always bulge into the tunica. associated with it.
Reference.-Patterson, S. W., Little, E. M., and Williams, F. E.: Medical Research Council Report, No. 36, 1918, p. 88.
CYSTS OF THE EPIDIDYMIS. BY R. FIRST
OGIER WARD, F.R.C.S. ENG.,
M.CH. OXF.,
ASSISTANT, SURGICAL PROFESSORIAL UNIT, ST. BARTHOLOMEW’S HOSPITAL; ASSISTANT SURGEON, ST. PETER’S HOSPITAL FOR STONE, LONDON.
swellings in the scrotum are very common. usually due to the collection of fluid in the tunica vaginalis, but cysts of the epididymis are by no means rare, and these, when well developed, may produce swellings as large as an ordinary hydrocele. A study of 17 cases recently collected in the clinic of the surgical professorial unit at St. Bartholomew’s Hospital and in the out-patient department of St. Peter’s Hospital for Stone, has emphasised the fact that the disease not infrequently affects both epididymes simultaneously, and consideration of the available methods of treatment suggests that excision of the cysts should be more often practised. Monod and Terrillon have classified cysts arising in connexion with the epididymis in two groups : (1) Small cysts which lie above the globus major, and (2) larger cysts, in this country commonly called spermatoceles, which are more closely related to the testicle. The small cysts first mentioned are of little importance. They are not uncommon in old men, and if looked for during post-mortem examinations will usually be found on the convex surface’ of the globus major ; they are commonly sessile and subserous, often only the size of a pin’s head, and rarely larger than a pea. The pathogenesis of these cysts is uncertain. It has been suggested that they arise in vestigeal remains, and that they may result from injury or from inflammation. They give rise to no symptoms and call for no CYSTIC
They
are
treatment.
-
Form and Position of Larger Cysts. which form the subject of this article all belong to the second group of larger cysts. They are of more importance clinically, since they often grow to a large size and may cause great inconvenience. Their pathology has often been discussed, but still
The
cases
TI. er il on) though
vaginalis.
aetiology and Age Incidence. The condition appears to be a form of retention cyst, but the causes are unknown. Previous gonorrhoeal inflammation of the epididymis has often been suggested, and also injury, but it is difficult to prove. either to be responsible, or, indeed, to establish any cause, from an investigation of the patient’s history, for he is usually quite unable to state with accuracy for how long any enlargement has existed. Again, these cysts are probably of much commoner occurrencein later life than is generally suspected, for minor swellings pass quite unnoticed, and since there is neither functional disorder nor any pain, except perhaps an occasional aching, it is only when they are big enough to cause inconvenience that the himself for treatment. patient presents In Cabot’s " Modern Urology " it is stated that the commonest period of life during which this occurs is between 20 and 40 years. The present series, however, shows it to be chiefly a disease of advancing years, the average age being 55, though some swelling iad usually been noticed for one or two years previously. This agrees with the opinion of most vriters. The youngest subject, under the care of Mr. Grey Turner-to whom I am grateful for pernission to publish this case-was aged 41, and had loticed the swelling for about a year. The condition ias been described in patients as young as 25 years. Most of the patients were married, and were fathers of amilies now grown up. In only one patient was there my definite history of injury, which had occurred ive months previously, and he was fairly sure that he swelling was the direct result of it. Two patients iad acquired gonorrhoea many years before, but did iot remember having had epididymitis at the time. n one case there was a history of syphilis 30 years
)reviously.
When examination is made of the frequency with vhich either testicle is affected, it is interesting to ind that in 5 of the 17 cases the cystic enlargement vas on the right side, and in 4 it was on the left, mt that in the remaining 8 both epididymes were ,ffected, one usually being larger than the other. Che common occurrence of cystic degeneration of oth epididymes is not generally realised. The disension was usually not very great, the largest amount f fluid obtained being 13 oz., which was withdrawn
808 !’ by tapping the bigger of bilateral cysts. In other instances about 5 oz. were present. A case has been described in which on one occasion 49 oz. of fluid were withdrawn from the right side and 58 oz. from the left. The fluid, whenever it was examined microscopically, contained spermatozoa, usually in large numbers, living, actively motile, and well formed ; these are commonly numerous enough to give it the characteristic opalescence. An examination of these patients threw no light upon the cause of the condition. The vasa deferentia appeared normal ; the seminal vesicles felt normal when examined per rectum, and no urethral obstruction was found. Posterior urethroscopy in four patients gave no certain evidence of obstruction to the orifices of the common ejaculatory ducts, though in two the region of the verumontanum appeared somewhat cedematous.
SMALL-POX AND "AMAAS" IN SOUTH AFRICA. BY J. A. MITCHELL, M.B., CH.B. GLASG., D.P.H. DURH., SECRETARY FOR PUBLIC HEALTH AND CHIEF HEALTH UNION OF SOUTH AFRICA.
OFFICER,
IN view of the reported occurrence of outbreaks of " amaas " or " alastrim" in Great Britain, and the controversy which has arisen as to its precise nature and its relation to small-pox and vaccinia, a brief statement of experience of this disease in South Africa, and opinions based thereon, may be useful. The question is not merely an abstract scientific one; it is of great importance in practical public health administration. Here, in South Africa, the belief amongst some medical men and a large section of the Diagnosis. that the disease is not small-pox, and that it is public The diagnosis of these swellings is not difficult, yet of mild type and comparatively unimpermanently they are often confused with hydroceles of the tunica portant, has repeatedly led to unfortunate results. vaginalis. Both are fluid swellings within the The medical men who hold this view are mostly scrotum ; in both fluctuation is present, but these (though not exclusivelyl) either senior practitioners, cysts of the epididymis form a much softer swelling whose experience goes back to the time when small-pox than the ordinarily tense hydrocele. Again, individual was a very prevalent and very fatal in. this country loculi can often be felt as rounded prominences which or younger medical men whose knowledge give the swelling a surface irregular and different disease, of small-pox is based mainly on the smaller textfrom the smooth outline of a hydrocele. Another books and observation of a few cases. means by which they can usually be distinguished is to The controversy is in reality very old. Sydenham determine the position of the testis ; this will be refers to extensive outbreaks with very low mortality, found to lie in front, and, when the entire epididymis considered by the laity and some medical authorities is affected, to be surrounded above, behind, and to be different from variola, and described essentially below by a cystic swelling. When there are cysts as " " or" glass-pox." Nothhorn-pox," only of the globus major the testis lies in the bottom nagel states that "stone-pox," in the pre-vaccination period light the scrotum, but it is never displaced backwards of cases (of the character of ’ varioloid’) were associated into the position which it occupies when a hydrocele with severe ones at all times and in all epidemics, and, of the tunica vaginalis is present. It may be menthere were also outbreaks, though more rarely further, tioned here that a small hydrocele is sometimes found than at present, in which milder cases were more associated with cystic degeneration of the epididymis ; than the severer ones." Jenner notes an this was found six times in the present series. A prevalent in Gloucestershire with no deaths. Sir epidemic further aid to diagnosis is transillumination, which in his report mentioned later, records Turner, George of often be of use in the the will identifying position seen an outbreak in England with a mortality having testis ; as these swellings often consist of collections of of only 3 per cent. and refers to another, in Sutherland cysts, they are generally more opaque than the in 1884, in which there were 100 consecutive cases ordinary unilocular hydrocele, though not so opaque without In the Sheffield outbreak of 1887-8 a death. as to provide a certain means of distinction between there were 4995 cases in vaccinated persons with 243 the two conditions, as some writers have implied. deaths, a case mortality of 4-7 per cent., and 1028 Tapping will settle the diagnosis, since it will yield a unvaccinated a case mortality cases with 320 cloudy, colourless fluid, usually containing sper- of 31’1 per cent., the rate fordeaths, all cases being 9-45 per matozoa in numbers large enough to give the charac- cent. In in 1901-2, there were 1010 cases, teristic shimmer ; but even if this is not so, they with 233 Glasgow, deaths, a case mortality of 23-0 per cent. can always be found if the fluid is centrifugalised. Early Epidemics in South 4frica. Treatment. Small-pox was first introduced to South Africa in When the patients come for treatment it will a vessel on which cases had occurred on the 1713-by often be found that tapping has already been emfrom India, but which had recovered before voyage ployed. Sometimes this is all that is necessary, and if Table Bay. Clothing from this vessel was it is performed two or three times a year the patient reaching ashore to be washed at the Dutch East India brought may be quite satisfied. But it must be remembered Company’s slave lodge. The disease broke out among that tapping will not cure the condition, as the cysts the slaves, and of 570 attacked 200 died. The disease always refill themselves. Sometimes they do so very spread rapidly to the European and native population, rapidly, and then it is usually preferable to advise and a widespread and very fatal epidemic followed. removal of the swelling, which can be approached The death-rate was especially high among the through any of the ordinary incisions. The cyst of Hottentots, some of whom fled to the mountains and one or both sides, or perhaps the whole epididymis, is far inland, carrying the infection with them. So excised, and this can easily be done without any became the terror of the natives that they killed damage to the testis or its blood-supply. In the great and burned some of these fugitives. It is recorded present series either epididymectomy, or removal of that the entire inhabitants of many kraals died and a cyst on one side, was performed five times, and it is the very names of tribes for a great distance inland important to notice that no loss of sexual desire or of disappeared. power of ejaculation has resulted, nor has atrophy of A widespread and very fatal outbreak occurred in the testis occurred. In one of the two patients in the infection being introduced by vessels from 1755, whom bilateral epididymectomy was performed the It is recorded that in Table Valley alone result was equally satisfactory ; the other has not Ceylon. 963 Europeans and 1109 natives died of it. Theal, been traced. ’
Summary. 1. Cystic degeneration of the epididymis is
"
common ;
2. It is a disease of is uncertain. Both sides are often affected. 4. Excision is indicated when tapping has failed to give relief for more than inconveniently short periods. (continued at fcot of next colurim.)
its
pathology maturity. 3.
1 The chief exponent of the amaas, a separate and distinct disease" theory, is Dr. W. E. de Korte. See his paper Amaas or Kafir Milk-Pox, THE LANCET, 1904, p. 1273.
(Continued from preceding column.) References.—Monod, Ch., and Terrillon, O.: Maladies du testicule. 1889. Jacobson, W. H.: Diseases of the Male Organs of Generation, 1893. Thomson Walker, J. W.: Genito-Urinary Surgery, 1914. Cabot, H.: Modern Urology, 1918.