catrix naturæ is already overworked caring for a depleted body, let alone to have to smother out a tuberculous ureter. The operation is not finished until a ureterectomy is done on the tuberculous ureter. Of course, we understand that the bladder is somewhat immune on account of its frequent washings with urine, but some are not immune, for we have tubercular cystitis. If this be one of them, tubercular cystitis is inevitable. A like condition is present in the vas deferens in relation to tubercular orchitis. In my opinion the complete operation necessitates both the thorough removal of the testes, with all doubtful tissue and vasa deferentia down to the bladder.

After seeing Zuckerkendl, last winter, do his most excellent work in this kind of pathology, I was more than ever impressed of the thoroughness necessary in this kind of infection, in order to insure its complete eradication.

The writer uses the following technique when both glands are invaded: Incision over inguinal canal down to cord; cord opened; vas deferens isolated; complete removal of all fascial covering. At the region of the internal ring, with the finger covered with gauze and with traction on the proximal end with other hand, the vas is broken away from any surrounding tissue and in that manner followed down as far as the finger will go; at this point it is grasped with the gauze-covered thumb and finger and forcibly extracted (it should break near the ejaculatory duct region); ends of vas cauterized and clamped on account of possible infection. The rest of the cord is ligatured at internal ring; cord with vas loosened from canal through external ring to upper mesial scrotal region. The other side is treated in a like manner. Now a Kocher director is passed through either external ring to scrotum just below the penile junction, external to the raphé, and cut down upon. Through these button-holes the cords and vasa are pulled. After thoroughly disinfecting my hands on account of the infected scrotum handled and discarding the instrument used, the inguinal incisions are closed with fine silver wire sutures shotted; then the dressing is applied. This gives the inguinal incisions a better chance for primary union than if left till after the other field of operation is finished. The reason for tunneling from external ring to mesial scrotal region is

twofold: First, we exclude a clean field from an infected one; second, the superficial external pubic vessels are saved and the benefit of that extra circulation is of worth.

The skin and dartos of the scrotum are now incised, leaving only enough scrotum to fill in the gap that is left. A portion of the mass is now double clamped with forceps (without teeth), the lower clamp being applied just above the deep layer of the superficial fascia (Colles, also Bucks) and the mass excised and clamped as you go till the whole mass is removed. Claudius catgut ligatures, threaded with needles, are now applied by making an over-and-over stich around the forceps, removing the forceps and ligating. A few strands of catgut are left in the dependent portion of the wound for drainage. The breach is now covered with the scrotal flaps, sutured with silver wire and dressed.

The report of two cases will show the immediate benefits resulting from this class of cases operated upon by use of the above technique:

CASE I,

Mr. B. Home in adjoining State; occupation, farmer; age, fifty-three; married thirty-two years. Four years ago, while pulling a plow from under a root, he felt a severe pain in left side; five days afterwards noticed a pronounced hernia; some months afterwards found a similar protrusion on right side (wore double truss). In June last had lancinating pain in the right inguinal region, and pain and enlargement of left testicle. In July right testicle began to pain and enlarge. Left testicle opened June 20, while the right opened towards last of July. Most pain experienced in right inguinal region. Some trouble with bladder for twelve years (due to senility). Prostate found slightly enlarged; micturition four or five times during the night. No pronounced kidney symptoms. No hematinuria. Family history non-tubercular; wife's history negative.

Had intercourse with tuberculous woman prior to his severe pain in the left testicle. No history of Neisserian coccic infection. Tubercular bacilli were found in the pus from sinuses.

This case was operated September 5. A double herniotomy (Halstead) was, of course, done before closing the inguinal incisions.

albumin and a quantity of triple phosphates. No tubercle bacilli found.

Kidney flushings and bladder irrigations produced a normal analysis on the day of operation.

The week following operation the urine contained an enormous quantity of triple phosphates, but no albumin.

From the standpoint of propylaxis, onehalf ounce of 2 per cent. iodoform with olive oil was introduced into the bladder every third day while in hospital. Instructions were given to his physician to

in implement store. Family history negative for tuberculosis. Father died from pneumonia. Mother and two brothers living and healthy. Trouble began about one year ago. (Examined May 21, 1906.) Pain began in left cord, followed by swelling of left testicle which suppurated and was opened after two months' duration. At this time right cord began paining, left testicle swelled, broke down and was opened in six weeks.

Physical examination of lungs showed no pathology. Left kidney somewhat ten

der. Bidder symptoms nil. Testes both enlarged, hard and nodular; sinuses opening into either testicle. Pus examined therefrom and tubercle bacilli found.

Urinalysis showed some albumin, but no tubercle bacilli. Albumin was present at time of operation (May 29, 1906.)

In operating this case the same technique as described was used, with the exception of a greater portion of scrotum being left. Primary union throughout with exception of drainage opening. Patient up, walking around out of doors in seven days. In three weeks' time, at the patient's earnest request, the introduction of artificial testes was begun. (Gersuny's method of repeated sittings, with paraffine injections, was used.)

After finishing one testicle according to the biological standard of specifications, I was surprised to have the patient request a continuance of the process to still larger proportions. Likely his pre-operative scrutiny of the pathologic members had perverted his idea of the size that the glands should be normally, or else he is a believer in the old adage, "While you're gettin', get a plenty."

Five weeks after operation Mr. A. returned, suffering from a suppurative adenitis of the upper nodes of the femoral lymphatic chains. They were opened, curetted, cauterized and packed with iodoform gauze.

This shows the operative incompleteness in not finding these glands and removing them at the time of operation.

With the out-of-doors treatment, introduction of iodoform oil in the bladder and orchitic substance per aurum, this man has recovered from a despondent, anemic invalid into a cheerful, optimistic individual with weekly reports of gains in flesh and strength. He reports the power of erection and is quite hopeful for future joys in life.

In these cases of double orcho-vasectomy the presumption is held by the laity and most of the profession that their power and function of sexuality is gone.

I fail to see any reason for this loss of power, unless their impotence be a psychic one. The sexual brain is supposed to be near the veru montanum. The nerve supply comes from the hypogastric plexus and internal pudics. The ejaculatory fluid. is supplied from the seminal vesicles (glands), prostate glands and Cowper's

glands. Surely, none of these are injured. Orchicism is gone, it is true, but that can be supplied by organotherapy in the same way that ovarian extract is given to produce ovarianism in oöphorectomyized

women.

To sum up the problem:

1. To be sure of a cure, all that is infected with tuberculosis must be removed. 2. Primary invasion statistics are so variable that the operator should consider his testicular tuberculoses primary unless other foci are found that disprove the supposition.

3. The modes of infection are so many that the surgeon should be on his guard constantly. This is especially true in infection during the act of cohabitation. 4. The desexation "bugbear' " should be entirely removed from the patient's mind, and, instead, encouragement should be given him for a continuation of his copulative power.

5. Injections of paraffine in producing artificial testes are good from a cosmetic standpoint, and good also from the great satisfaction it gives the patient. It is entirely devoid of danger when properly done.

6. Operations, when indicated, should be immediate, followed by prophylactic and hygienic treatment till the maximum improvement is gained.

DISCUSSION ON PAPERS OF DRS. ASMAN AND

BARNETT.

DR. BRANSFORD LEWIS, St. Louis, Mo.: The subject of tuberculous infection is a very important one, whether connected with the urinary or other organs of the body. One of the features discussed is the avenue of infection. That is indeterminate, according to different authors. Some claim that in most cases the infection is ascending, while others claim it is descending. I believe that it is now pretty well established that the disease may be transmitted from one individual to the other through sexual intercourse. I have observed some cases in my own work in which it appeared to me very evident that such a contribution was made from husband to wife, or vice versa. I had a case come under my observation last spring, the patient being a member of our profession, who came to my office with his wife. He would not have come if she had not compelled him to do so, and at the instance of a physician. He had a tubercular infection of the epididymis, the prostate and bladder, with involvement of the kidney. I gave him some fatherly advice. As he was about to leave to carry out the various hygienic measures I had recommended, his wife said: "By the way, doctor, I forgot to ask you about some remedy that I can take for frequent urination which has disturbed

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me quite a little."

The woman was handsome and robust looking. I told her that I was not prepared to give any absent treatment, or, in fact, any treatment without an examination based on the individual case, and that if she would furnish me a specimen of her urine I would make a careful examination of it. She passed some urine in a glass, and in three minutes we had it under the microscope and got tubercle bacilli from the urine. Her husband has since died, and she is the subject of tuberculous cystitis, and apparently, so far as we can learn, she contracted the tuberculosis from the husband.

There is one point I wish to raise with a large question mark after it, because I am not yet convinced of the necessity of it-that is, removing the whole ureter when it is found partly infected with a tubercular deposit-a case of urinary tuberculosis. It is generally conceded by operators now that if a kidney and bladder be the subject of tuberculous inflammation, and you remove the kidney, the patient stands an excellent chance of making a permanent recovery, notwithstanding the fact that the bladder is involved with tuberculous cystitis. If that is the case, it demonstrates, notwithstanding the presence of tubercu. lous infection in that part of the urinary apparatus, the removal of the one kidney contributes to the probability of recovery. Now, why not apply the same reasoning to a ureter that may be partly tuberculous, simply removing the kidney in that case? I have carried that out in a young woman about six or seven months ago, who had active tuberculosis of the left kidney, the left ureter and bladder. I removed the kidney, but did not remove the ureter, because of her extreme debility. I did not make a long incision such as is made to effect the removal of the ureter. She has practically recovered. She has gained twenty-five pounds or more in weight since then, and subsequent treatment of the bladder by means of iodoform oil has relieved that woman considerably. She is not well yet. That case is still put down with a question mark. I thought I would report that case, hoping that it and similar cases will be made a matter of further inquiry on the part of the profession.

I think the maneuvers applied by Dr. Barnett are excellent in the cases he has described, and I wish to express my thanks to him for his excellent contribution.

DR. JOHN N. SLUSS, Indianapolis, Ind.: I was much interested in these papers, although I have not had any particular experience along the line of Dr. Barnett's paper. It interested me very much, however.

With regard to the pruritus ani, I want to make a suggestion. I do not know whether Dr. Asman brought it out in his paper or not, and that is, in these obscure cases we should always try to recall the distribution of the internal pudic nerve. Oftentime the pruritus will have its origin in some part which is associated with and influenced by the nerve supply. I have had several cases of protracted pruritus ani which have been rapidly relieved or cured by passing a sound a few times. The trouble had its origin in a stricture. I may say that there are other cases in which, when no exact cause can be found, the trouble may have its origin somewhere along the branches of some of the internal pudic nerves This is a point well worth bearing in mind.

DR. J. HENRY CARSTENS, Detroit, Mich. : Some of these cases are very intractable to treatment, while others can be relieved or cured with the X-ray. I do not know how the X-ray acts, but I know that I have had a number of cases that have been cured by the X-ray.

In reference to the paper of Dr. Barnett, I want to say, with reference to what Dr. Lewis has said, that we take out a suppurating kidney and cure the patient. Why do we cure the patient? Not because we remove all of the tuberculosis, but because we remove the mixed infection the patient was suffering from. We do not always remove the tuberculous condition in the ureter, and yet the bladder gets well. Dr. Barnett removes a testicle with the lymphatic glands that contain tubercle bacilli, which afterwards break down. He operates, curettes, and removes some of the tuberculous process, leaves the rest, and his patient gets well. That being the case, why, in the name of heaven, did he take out the testicle in the first place? If the testicle is not broken down, suppurating, why should it be removed? I believe it is bad practice to remove such a testicle. If we are able to cure tuberculosis of the peritoneum or tuberculosis of the lungs by having patients go out in the fresh air and feeding them properly, we can cure tuberculosis of the testicle or tuberculosis anywhere else, barring, of course, complications in the way of streptococcus and staphylococcus infection.

About two years ago a patient came to me who had one of his testicles removed because it was tubercular. He wanted me to remove the other testicle. He came to me in great trouble. I hesitated to remove the testicle because it was swollen, although there may have been some tubercular deposit there. I gave him directions in the way of hygienic treatment and impressed upon him the importance of living outdoors, etc., and to-day that patient is all right. His testicle was not removed, and he is mighty glad of it.

DR. MCCHORD: If you had a case of tuberculosis of the ovary, would you remove the ovary. DR. CARSTENS: I do not take out tubercular ovaries; I wash out the abdomen. I do not take out a tube or tubes unless there is a mixed infection.

DR. BARNETT: Have you ever seen any cases of tuberculosis in which the infection was not mixed?

DR. CARSTENS: I have seen lots of them.

DR. ASMAN, closing the discussion on his part: The point made by Dr. Sluss in regard to the use of the sound in pruritus ani, where it is due to irritation of the pudic nerve and its branches, is a good one. I recognize it as being one of the causes, and I have seen such cases in which relief has followed the use of the sound quite promptly, and I think it is a valuable means to employ in such cases.

In regard to the use of the X-ray, I have had but little opportunity to obsetve the results of such treatment in this class of cases. My impressions, however, regarding it have been unfavorable. It may be of value, and I should think it worthy of trial when these other simple measures have failed.

DR. BARNETT (closing the discussion): I am sorry Dr. Lewis is not here, because I think I saw the case he referred to of the man and wife, and I was glad to hear him say that he thought