Hydrocele and varicocele: Operative and injection treatment

HYDROCELE

AND VARICOCELE: OPERATIVE INJECTION TREATMENT LLOYD B.

GREENE,

AND

M.D.

Urologist, Burlington County HospitaI; Associate UroIogist. Pennsylvania and Bryn Mawr Hospitals PHILADELPHIA

T

HE tunica vaginahs testis is derived entirely from the peritoneum through the descent of the testicIe. The viscera1 layer invests the testicle and epididymis compIeteIy, except at their point of attachment, to each other and posteriorIy where the vesseIs and nerves enter the organs. This layer is continuous with the parieta1 Iayer, which, when the funicular process is obIiterated forms a cIosed sac with its proxima1 Iimit just proxima1 to the head of the epididymis. The coverings of the testicIes are independent and compIeteIy separate. The term hydroceIe impIies a coIIection of serous fluid within the cavity of the tunica vaginaIis testis greater than the smaI1 quantity necessary to moisten its surface and considered to be normaI. Any irritation affecting the tunic, primariIy, or secondariIy, from testicle or epididymis, gives rise to an effusion into its cavity; absorption is Iimited and results in a hydroceIe. A faiIure of the funicular process to become compIeteIy obliterated aIIows a variety of abnormahties depending on the anatomica variation present. Some writers designate as hydroceIe, coIIections of ffuid in the cana of Nuck, in the femaIe. The foIIowing cIassification, according to Iocation’, (Jacobson) is convenient and is standard in the recent Iiterature. I. HydroceIe of the testis. A. Hydrocele of the tunica vaginalis. (I) Ordinary type, distending the tunic. (2) CongenitaI type, communicating with the peritonea1 cavity. (3) InfantiIe type, tunica vaginalis and a part of the

funicuIar process, distended wrth Auid, no connection with peritonea1 cavity. (4) InguinaI type, hydroceIe accompanies an undescended testicIe. B. Encysted hydroceIe of testis and epididymis. (I) Occurring as encysted hydroceIe of the epididymis, where the two layers of the viscera1 tunica vaginaIis pass from the testis to the epididymis. (2) Occurring between the tunica aIbuginea of the testicIe and the viscera1 Iayer of the tunica vaginaIis. 2. HydroceIe of the spermatic cord. A. Diffuse type, or serous effusion resembling edema of the cord. B. Encysted type, resuIting from unobIiterated portions, of the funicuIar process, or from the organ of GiraIdes. 3. HydroceIe of the sac of a hernia, occurring where there is a serous effusion into the sac, the contents of which have been reduced with subsequent obIiteration of the neck of the sac. 4. Various combinations of these three types of hydrocele. HydroceIe is of rather frequent occurrence, comprising from 2 to 4 per cent of urologica admissions. It is much more common in the tropics; some authorities state as high as IO per cent. It occurs at any age, but is rare in infants. About 50 per cent of the cases occur after the age of forty years. Some writers suggest a causative relationship with the genita1 vascuIar changes incident to decIining sexua1 func-

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tion. The condition is bilatera1 in about 4 per cent of cases. In unilateral cases one side is involved about as often as the other.

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etiological factor in this condition is diffk cult and in more than 50 per cent of the cases (31 I or 502 in Campbell’s series)

FIG. I. Schematic drawing showing (I) normal relationship of the tunica vaginaIis testis, (2) simple hydrocele; the most common type, (3) the somewhat rarer infantile type of hydrocele.

The condition may be acute or chronic. It may be symptomatic or idiopathic. Keyes reminds us that all of the symptomatic cases are not acute but that all of the idiopathic cases are chronic. Infection of the epididymis or testicle and trauma to these structures or the spermatic cord are the principal causes of acute hydrocele. Young states that Francis Hagner encountered 3 I instances of hydrocele while operating on 33 patients with acute gonorrhea1 epididymitis. It quite commonly follows operatiori for hernia or varicocele. It is said to be common during the course of the first year of inadequately treated syphik It may occur during the course of typhoid fever, pneumonia, etc. The acute and symptomatic types normally disappear spontaneously or after tapping, and treatment of the cause; or, they may persist as a chronic hydrocele. Chronic idiopathic hydrocele is the type with which we are chiefly concerned. The

impossible to determine. As a rule the condition is insidious in its deveIopment. Campbell and others believe that chronic inflammatory change in the epididymis is the etiological factor in the majority of cases. Certainly, induration of varying degree is a usual finding on routine examination of the epididymis, of men passed the age of forty years. It is indeed diffkult to find one in whom some palpable change may not be detected and it is certainly most common to find chronic changes at operation on these patients. I am inclined to agree with the theory of epididymal inflammatory reaction, but I have no proof to offer. The condition is said to be common among those whose occupation subjects them to scrotal trauma; cowboys and circus riders are examples. The fluid in uninfected, uncomplicated hydroceIe is cIear and resembles urine. Its specific gravity is 1020 to 1026; it contains from 4 to 6 per cent of aIbumin, some

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fibrinogin, sometimes choIesterin, a trace of gIucose, salts, fibrin and occasionaIIy fibrous bodies impregnated with Iime salts.

FIG. 2. Schematic

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careous pIates. OccasionaIIy villous growths are found, and when adhesions are present the sac becomes multilocular.

drawing showing (4) congenita1 hydrocele, sac.

Microscopically the fluid contains a few endotheIia1 ceIIs, Ieucocytes, choIestrin crystaIs and Iecithin bodies. Spermatozoa may be present, probabIy, as the resuIt of rupture of a spermatocele into the sac, red blood ceIIs, in the event of hemorrhage, and bacteria in the infected cases. Carforio reasoned that the Auid was an exudate because of its aIbumin content and high specific gravity. That the condition is seIdomIy found in connection with varicocele adds additional weight to this hypothesis. The character of the ffuid changes with infection and hemorrhage. The quantity of the Auid varies from a few cubic centimeters to several hundred. CampbeIl, quoting Carforio, states that five gahons is the greatest quantity yet reported. The wall of the sac may be thin and ghstening, or, in oIder hydroceles, thick and Ieathery, and the serous surface covered with irregular fibrous, cartilagenous or caI-

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(5) hydroceIe of cord, (6) hydroceIe of hernial

Hydrocele may produce atrophy of the testicIe in time as the result of pressure and possibIy because of the interference with its thermoreguIatory mechanism. Pain varying with the etioIogy and rapidity of onset is often present in acute hydrocele, but is rare in the chronic type. The usua1 compIaint in the chronic variety is a dragging sensation, and relief is often sought because of the inconvenience and unsightliness of the mass. The diagnosis of chronic idiopathic hydrocele is usuahy not diffrcuIt. An accurate history is of very great value. The typical unilatera1 case presents a pyriform mass in the scrotum with the stem upward. The scrota1 waI1 may be tense and shiny or appear normaI depending on the quantity of fItrid present. On palpation there is a tenseness and yet the mass is compressible and resihent. The testicIe and epididymis are usuaIIy situated in a postero-inferior

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position and may or may not be definitely palpable. They may, however, occupy an anterior position. The upper Iimit of the sac

FIG. 3. Schematic

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predominate may transmit Iight and fhrctuate. BioIogicaI tests may heIp. Gumma is suggested by the history, positive Wasser-

drawing showing (7) congenita1 hernia with hydroceIe, (9) hernia and hydrocele of the cord.

may be outIined and the cord isoIated proximaIIy. There is no cough reflex transmitted into the sac. Finally, the sac is transIucent, and when the testicIe cannot be palpated, its shadow may be seen by transihumination. HydroceIe must be differentiated from hernia, tumor of the testicle or epididymis, gumma, hematoceIe, spermatoceIe, cyst, and chyIocele. Transihumination may fai1 if the ffuid is cloudy or bIoody, in thickened sacs and in Negroes. It is sometimes demonstrable in cysts, certain tumors, and in hernia, especiaIIy in children. Hernia shouId offer Iittle diagnostic difIicuIty. Hernia and hydrocele may occur as separate entities whiIe the former is often associated with congenita1 hydroceIe. Tumor and hydroceIe differ in consistency; the former is solid and heavy, the Iatter lighter and resiIient. The history shouId aid in differenting the two conditions. It must be remembered that some teratomata in which cartiIage and mucoid material

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(8) simple hydrocele

and hernia,

mann reaction, and other findings suggesting this disease. SpermatoceIe may be associated with hydroceIe and perhaps rupture into the sac. It may be single or muItipIe and cannot be diagnosed with certainty in every case; its position in reIationship to the testicIe and to the epididymis might help. The fluid in spermatocele contains IittIe serum aIbumin, and the specific gravity is Iow (1002-1006) which differs considerably from the serumIike fluid of hydroceIe. At any rate it is a matter of smaI1 importance if open operation is performed. Hematocele may occur spontaneously. It is rare and usuaIIy due to trauma. It is remarkabIe that it does not occur more often as a seque1 to tapping. Chylocele, rarely encountered in the temperate zone, is a common comphcation of Maria1 infection. The aspirated f&rid is milky and when ahowed to stand, a Iayer of fat accumuIates on its surface. HydroceIe must be considered in the differentia1 diagnosis of an abdominal mass

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associated with undescended testicle. Congenital and infantile hydroceIe may be associat.ed with hernia and difficult to

FIG. 4, Right idiopathic hydroceIe of thirty years duration. Patient, aged fifty-five years, states that it had never been tapped. Note the complete disappearance of the penis. (Courtesy of Dr. M. B. Dewire.)

differentiate. The cough impulse is present. Transihumination is untrustworthy and tapping shouId not be done if there is doubt. Diffuse hydroceIe of the cord is diffrcuh to diagnose with certainty; if there is a singIe or muItipIe cysts, it is comparativeIy easy. TransiIIumination is the onIy positive sign. The same applies to hydroceIe of a hernia1 sac. A history of previous hernia is heIpfu1. Lipoma of the cord may be confusing. Abdominoscrotal hydroceIe (hydrocele en bissac) is the rarest form of hydrocele. The method of its formation is not entirely

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clear. It seems possibIe that it might be the resuIt of an invagination of a simple hydroceIe ,sac through the inguinal canal to burrow up between the peritoneum and anterior abdominal wall or between the pelvic peritoneum and pelvic wal1. There is an hour-glass constriction where the sac passes through the inguina1 cana1. A fluid wave may be detected in one segment by pressure over the other, and both sacs may be emptied by tapping one of them. In a11 of the reported cases the patient has noted the scrota1 sweIIing first, and apparentIy two to three Iiters of fluid may cohect in the abdominal segment before it creates attention. The treatment of hydroceIe varies with the condition with which we have to dea1. As has been mentioned the treatment of acute and symptomatic hydrocele consists largely in the treatment of the underIying pathoIogy. Tapping may be indicated. The condition either disappears with the causative Iesion, or persists as a chronic hydroceIe. The congenital hydrocele of infants usualfy disappears spontaneously. A smaI1 percentage may persist as such to adult life. The associated hernia occasionahy demands attention. I encountered recently a stranguIated hernia associated with congenita1 hydrocele in a very young infant. The radicaI operative treatment of hydrocele is, in our experience, a most satisfactory procedure. Eversion of the sac is done, in suitabIe cases, with thin-walled sacs. If the sac is Iarge, a portion is excised sufficient to permit approximation of its edges, behind the epididymis without leaving too much redundant tissue. Care must be used to incise the sac from poIe to poIe or there may remain a pocket that wiI1 reMI. PartiaI or compIete excision without eversion is appropriate for thick or unusuahy Iarge sacs. If the epididymis is considerabIy diseased we do not hesitate to remove it; this makes for a much more satisfactory and cIeaner operation. It cannot be stated too often that secondary

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hemorrhage is a troublesome factor and that hemostasis at operation must be absohrte. The high frequency coaguIating current is usefu1 for this purpose. We usuahy drain for twenty-four hours, the scrotum through a counter incision and have never seen troubIesome secondary hemorrhage or infection foIIow its use. Postoperative hemorrhage may be very troublesome and is not infrequently foIIowed by deep secondary infection with loss of the testicle in some instances, (8 times in CampbeII’s series). We prefer inhaIation or spinal anesthesia; 1ocaI anesthesia is not entireIy satisfactory and quite possibIy contributes to the frequent occurrence of secondary infection, in certain reported series of cases. Atrophy of the testicIe is present in many cases before operation. It is difhcuIt to ascertain the effect of operation in this situation. HospitaIization is necessariIy Longer following total excision of the sac than in simple eversion, and the irreguIar tender lump that persists in the scrotum for a Iong time foIIowing the former is disturbing to most patients. Bruns noted recurrence in 2.4 per cent of I 2 I 6 operated cases. The average hospitaIization in CampbeII’s series was 9.4 days. The principIe of injecting scIerosing soIutions into the sac of a hydrocele is a very ancient one. A great many substances, much too numerous to mention in this paper, have been employed. Among these, however, iodine which was introduced in 1832 by Martin seems to have been very wideIy used. One hospita1 reported 2393 cases treated within a seven year period soon after its introduction, with success, in practically ah. This substance caused pain and a disability requiring confinement to bed of from eight days to severa weeks in some cases. There was a considerabIe percentage of abscesses and sloughs. Recurrence, in generaI, was undoubtedIy high. Phenol which was suggested some forty years later was Iess painfu1 than iodine but

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otherwise was open to the same objections, and in addition there were some cases of pheno1 poisoning reported. This method of treatment was largely discarded with the perfection of operative procedures, but since the introduction of sclerosing solutions in the treatment of varicose veins, a new interest has been awakened in the injection treatment of hydrocele. KiIlburne and Murray pubIished a paper in 1932 which I think wiI1 come to be regarded as a cIassic. They state that the idea1 soIution must possess the foIIowing properties : It must be painIess. It must not cause disabihty. 3. It must be efficient in destroying a11 hydroceIes with recurrence. 4. It must not be dangerousIy toxic. 5. It shouId be bactericida1. 6. It must not subject the patient to the danger of hemorrhage into the sac foIIowing the injection. I.

2.

After much experimenta investigation, it was found that quinine hydrochloride 13.33 per cent and urethane 6.66 per cent meet very nearIy the outIined requirements for the idea1 solution. It is subject to the objection that whiIe it wil1 bring about a cure of hydroceIe, it is not as efficient as a solution of quinine dihydrochIoride 13 per cent. However, this soIution causes some pain. AccordingIy, they use the first soIution for the first injection, and for subsequent injections empIoyed the second solution, and state that these subsequent injections are painIess. One gathers the impression from the Iiterature that these scIerosing solutions produce an obIiteration of the sac by the production of fibrous tissue. This opinion, however, is not supported by open operation and actua1 investigation. Ewe11 and his co-workers operated upon one of their patients one month after the last of three injections with quinine hydrochloride and urethane; their findings were that, There was a smaI1 amount of dark amber fIuid and severa Iong, Ioose strands of attached and organized fibrin. GrossIy the testicle and epididymis appeared normaI. Microscopic sec-

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tion of the tunic waII showed the endotheIium to be intact, the bIood vesseIs appeared norma though the subserous Iayer of the tissue was distinctIy thickened and infiItrated with organizing fibrous tissue. From this one case they suspect that the resulting fibrosis of the tunic waI1 folIowing injection so interferes with the blood and Iymph supply of the endothelium, that in some way it alters the process of fluid formation or reabsorption. The injection is done with a Luer type syringe and a needle of rather smalI cahber, I 7 to 20 gauge. The skin is tunnehed before penetrating the tunic. After the sac has been compIeteIy emptied the fluid is examined microscopicahy for pus and blood, and careful paIpation of the scrota1 contents is done for detection of pathoIogicaI changes in the testicle and epididymis. Two to 4 C.C. of the quinine and urethane somtions are injected, the needIe withdrawn and by manipulation an effort is made to distribute the solutions throughout the sac. A snug bandage or suspensory is applied and the patient allowed to go his way. FIuid nearly aIways reaccumuIates within one week after the first injection. The procedure is repeated at that time using quinine dihydrochloride, 3 to IO C.C.ShouId fluid again form, an interva1 of three weeks is ahowed before repeating subsequent injections. The fluid aspirated after the first injection is hazy and contains fibrin. Some cases require onIy one injection, but the average case requires two to three, and occasionally an even greater number is necessary. ShouId epididymo-orchitis deveIop, as it occasionahy does, during the course of the treatment, it must be ahowed to subside before continuing. Injection treatment may be employed with safety and with assurance of good result in simple chronic sterile hydroceIe. It is not indicated in the congenita1 variety or where there is serious pathology present in the testicIe or epididymis. It is not suitable where haste is a necessity. Sacs of 1200 C.C. capacity have been treated successfully by injection. The procedure is

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simpIe and may be readily carried out as an offrce procedure. Few require sedatives or confinement to bed. There have been, as yet, no large series of cases reported. There are, however, many smaI1 series and the rest&s compare favorabIy with the reports of the operated cases. An assistant is desirabIe and aImost a necessity in tapping and injecting a hydrocele. I find very frequently that it is impossibIe to drain the sac completeIy even with assistance. This fact is beheved to be responsibIe for some of the faihrres when injection is done. I do not beheve that injection treatment should be substituted for radical operation under usual circumstances. In a certain number of patients tapping alone seems to be the desirable form of treatment for one reason or another. It does not affect a cure. We have a number of patients whom we have tapped, at intervaIs of from three to nine months, over a period of ten years, and there has never been a comphcation fohowing this procedure. VARICOCELE

Varicocele may be defined as an affection of the veins of the pampiniform pIexus comparabIe to varicose veins occurring in any other part of the body. We recognize a symptomatic and idiopathic type of varicocele. The symptomatic type is rare, occurs usuahy in oIder men, invoIves either side with equal frequency and causes little or no discomfort. This type deveIops promptly and may attain Iarge size. The veins empty sIowIy, if at ah, when the patient is recumbent. Symptomatic varicoceIe is caused by mechanica pressure exerted on the spermatic vein either within the inguinal canal or the abdomina1 cavity. The condition is most often produced by tumors of the kidney but may be caused by any retroperitonea1 mass, by a hernia, a truss or tumor in the inguina1 canaI. Idiopathic varicoceIe is said by some writers to be present in from 15 to 20 per

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cent of al1 young adults, while others state that it is present in some degree in practically ah. It is generaIIy beIieved that the sexua1 inffuence is the most important factor; the anatomica arrangement of the Ieft spermatic vein and perhaps an hcreditary inAuence play some part. The condition deveIops sIowIy and affects the left side in practicalIy a11 of the cases, may occur bilaterahy, but rareIy on the right side aIone. It occurs most frequentIy during the age of greatest sexua1 potentiality (go per cent between fifteen and thirty&e years in CampbeII’s series) and commonIy disappears or causes no inconvenience after marriage, or with advancing years. These common observations are the basis for the belief that the congestion attending ungratified sexual desire and perhaps, in some cases, overinduIgence are responsibIe for the condition in the majority of patients. Theoretically the left sided preponderance has been expIained on the basis of the anatomica variations in the right and Ieft spermatic veins and on the common observation that the left testicIe hangs lower than the right. Some consideration has been given to the influence of heredity as a factor in the cause of varicoceIe. Barney beIieves that it has some connection, other authorities doubt this. VioIent muscuIar effort may produce acute varicocele by damage to the valves in the veins. CampbeII recognized the condition 3 times in his series. It may be extremely painfu1 and mimic acute epididymitis. The pampiniform pIexus is composed of three groups of veins, a posterior cremasteric, a middle deferentia1 and an anterior spermatic group. Any or a11 of these veins may be involved in a varicoceIe, usuaIIy it is the Iarger spermatic group. The condition is characterized by tortuosity and diIatation occurring primarily, Iater endophIebitis, thickening, fatty infrItration, thrombosis and phIeboIith formation in some cases. The bIood supply of the

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testicIe may become so impaired by these changes that atrophy develops (about I per cent, CampbelI; I 1.5 per cent, Barney). There is a great variety of subjective compIaints presented by those affected with varicocele; a dragging sensation with or without pain is common. Many state that the condition is worse in hot weather or on exertion. A fear of impotence is present in many cases together with a variety of subjective symptoms that we usuaIly associate with sexua1 neurasthenia. A Iarge percentage have no symptoms. The diagnosis of idiopathic varicocele is usuaIIy obvious on inspection, the diIated tortuous veins and a reIaxed scrotum with Iow hanging left testicle are characteristic. The veins empty rapidly in the recumbent posture and refiI1 promptIy on standing. OmentaI hernia may possibly be mistaken for varicocele on inspection aIone but is easiIy differentiated by First reducing the mass in the recumbent posture and retaining it within the abdomen with a finger pressed over the externa1 ring whiIe the patient stands. The “bag of worms ” feIt on paIpation is characteristic of varicocele. The condition may be associated with hernia (40 times in CampbeII’s series) or hydrocele, but this shouId offer no difficulty in differentiation. Idiopathic varicoceIe is asymptomatic in the majority of cases and it is a common observation that symptoms disappear, and the varicoceIe as weI1, with marriage or when sexua1 activity begins to decIine. The condition may be divided roughIy into three groups with reference to treatment, (I) the asymptomatic in which no treatment is required; (2) those with scrotal enlargement who compIain of a feeling of weight or a dragging sensation in the scrotum or referred elsewhere. A suspensory should be tried. If this faiIs to bring relief, operation is indicated. (3) Those with sexua1 neuroses, and a smaI1 varicocele with or without symptoms referabIe to it. Operation is not advised in this group. These patients benefit in proportion to the confidence that their medica adviser is

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able to in&I in them. They must be told the facts. A sympathetic attitude, patience and time wil1 affect a cure. With this grouping used as a criterion, we operate upon comparativeIy few varicoceles. The operation may be successfuIIy performed under IocaI anesthesia with slight inconvenience to the patient. Most of our patients choose some inhaIation anesthetic, however. We prefer a combined inguinal and scrota1 incision. The cord is exposed, the anterior group of vesseIs isolated and a section removed from them. DoubIe Iigatures are appIied to both stumps after gentIe crushing. Due care must be exercised in preserving the deferentia1 circulation. We sometimes sew the cut ends of the stumps together with fine catgut but more generaIIy empIoy the method of suspending the testicIe devised by Vincent and described by Keyes in his textbook. We have not found abbreviation of the scrotum necessary, it usuaIIy becomes Iess redundant after operation. We do not employ drainage postoperativeIy. The most serious compIication is hemorrhage. We have not encountered it. Various observers have found that hydroceIe follows operation in 23 to 30 per cent of cases. We have no figures on our cases but do not beIieve that it wiI1 even approximate such figures. Some have advocated eversion of the tunica vaginaIis at the time the varicocele is attacked, but we do not agree that this is necessary or desirable. Atrophy 0ccasionaIIy occurs foIIowing operation. Its cause is not known but one always wonders about the preservation of the testicuIar circulation where it occurs. CampbeII noted atrophy 3 times in 43 foIlowed cases, whiIe DougIas encountered it onIy 4 times in a foIlowed series of I I 6 cases. Infection may occur and is quite IikeIy to if there is secondary hemorrhage. Acute epididymitis occasionaIIy foIIows operation. A firm scrotal bandage is desirable postoperatively and a suspensory should be worn for a period of two weeks. Confine-

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ment to bed is required for five to seven days postoperativeIy. Injection of the anterior group of veins after exposing and doubly Iigating them has been advocated. It is cIaimed that the resuIting fibrous cord makes a good suspension for the testicIe. I have had no experience with the method, but it does not seem to me to be a rationa procedure. SUMMARY

Since the introduction of the newer types of scIerosing soIutions in the injection treatment of hydroceIe, it is now a practica1 procedure with definite advantages over radica1 surgica1 treatment in some instances. The procedure wiI1 affect a cure in a high percentage of cases and causes very sIight inconvenience to the patient. We prefer radica1 surgery in the usua1 case, reserving injection treatment where the circumstances seem to justify its use. We cannot see any advantage in the injection treatment of varicoceIe. A reIativeIy smaI1 proportion of varicoceIes requires operative treatment. In those cases in which operation is indicated, the resuIts are as a ruIe satisfactory. REFERENCES BARETZ,L. H. Med. Times and Long Island Med. Jour., 63: 9-14 (Jan.) 1935. BARNEY, J. D. Pub. Mass. Gen. Hosp., 3: 335, 19x0. CAMPBELL,M. F. Surg. Gynec. and Obst., 45: 192-200, 1927. CAMPBELL,M. F. Surg. Gynec. and Obst., 47: 4, 1928. EISENDRATHand ROLNICK. Text Book of UroIogy. -_ Phila., Lippincott Co. EWELL. SARGENT and MAROUART. Wisconsin Med. Jo&, 34: 451-456, 1935. HENNINGER,H. Ural. and Cutan. Rev.. 38: 1934. HINMAN, FRANK. PrincipIes and Practice of UroIogy. Phila., W. B. Saunders Co., 1935. KEITZER, W. A. Jour. Micb. State Med. Sot., 35: 1689 (March) 1936. KEYES, E. L. Urology. New York, D. AppIeton & CO., 1928. KILBOURNE,N. J. and MURRAY, CHAS. J. Calijornia and West. Med., 37: 1932. LUBOWA, IRWIN. Med. Re&143: 490-491 (June) 1936. NELSON’S SURGERY.New York. Thos. Nelson & Son. FLOM, E. and PITTMAN,J. L. Jkr. Med. Assn. Georgia, 23: 63-66, 1934. RoLNIcK, H. C. S. Clin. N. Am., 15: 757-766, 1935. SOLLEY,F. W. S. Clin. N. Am., 16: 867-870 (June) 1936. TANZER, RADFORDC. Jour. urol., 34: 447-452, 1935.