doses that you will get its physiological result; and it must be watched, of course, by a careful physician in order that it is not carried too far.

I am confident, like many others, that dysentery is frequently accompanied by malaria, and, in fact, I think that malaria is very frequently one of the prime causes of dysentery; and when I am not fully confident that my patient is surrounded by such malarial influences as would determine the disease, I usually give, every other day at least, a fair dose of quinine, to be sure to reach any malarial cause of the disease; it certainly would not do any harm, at any rate. In the chronic form of the difficulty, in my personal practice, I have adhered very closely to the giving of the solution of the per-nitrate of iron with cod-liver oil, and I can say from my own experience that it has worked well.

Dr. BRIGGS.-The treatment last spoken of the injection of starch -is a very good one, and I have often used it. I use ice-water with starch, and, if needed, a little opium. I think we can always use ipecac internally. I think it acts by stimulating the secretions, and so washing out the bowels. Dysentery is probably a disease produced by many causes, and the treatment should depend on the cause if possible. Largely it is due to malarial causes and some error in hygiene; nowa-days I do not think we see much dysentery. I think the better way to use quinine is to use it in the oleate, combined with turpentine. It is generally vitiated secretions that cause dysentery, and that is the reason why ipecac is valuable, by stimulating the secretions and washing out the bowel.

Dr. FAIRBAIRN.-I am very much pleased to have heard from so many members of the Society. It is gratifying to bring forward a subject which excites discussion of the kind we have heard to-night.

I agree with Dr. McCorkle that the medicinal treatment of dysentery cannot always be the same. The cause and complication are not always the same; the measures to combat these must differ therefore.

My aim was to show that the local, pathological condition could be treated most successfully and promptly by topical measuresirrigation. The medicinal measures which had found favor in my hands in this disease were those the action of which was explained by their antiseptic action-e. g., salol, salicylate of sodium, naphthalin, or hydrargyrum bi-chlorid., etc., and others to relieve special symptoms.

BY E. H. WILSON, M.D.,

Visiting Physician and Pathologist to St. Catherine's Hospital.

Read before the Brooklyn Medical Microscopical Society, June 4, 1890.

Tuberculosis of the testicle is not an uncommon lesion, and yet the amount of literature in English on this subject is not great. The older writers found great difficulty in distinguishing between tuberculosis and some forms of chronic diffuse orchitis which presented cheesy areas. It was not until 1882, when Koch demonstrated the causative relation of the bacillus which bears his name, to tuberculosis, that anything like certainty could be arrived at concerning this lesion of the testicle. It was then found that very many of these cheesy areas contained the bacillus, and were undoubtedly tubercular.

The cause (aside from the bacillus) of this affection, varies very much; it may occur in connection with acute general miliary tuberculosis, with chronic miliary tuberculosis in other organs, with tuberculosis elsewhere in the genito-urinary tract, after traumatism or gonorrhoea, and I think we have to acknowledge that there are cases of primary tuberculosis of the testicle, cases at least where the most careful search fails to reveal the presence of tuberculosis elsewhere. Gonorrhoea as a predisposing cause has been studied by Langhans, who found in 52 cases that 14 were preceded by gonorrhoea. BirschHirschfeld found in 60 cases, 11 preceded by gonorrhoea..

Metastatic orchitis with mumps was considered the predisposing cause in one case out of 23 (Rilliet).

In regard to the frequency of tuberculosis of the testicle complicating phthisis pulmonalis, Kocher says (Deutsche Chirurgie) that in 18 per cent. of all cases of pulmonary tuberculosis in males, there were tubercles in the testicles. On the contrary, in two-thirds of the cases of tuberculosis of the testicles where autopsies had been made, the lungs were found free from tubercles; this might be accounted for by the small number of cases when autopsies are made before general infection had occurred.

The gross appearance of these testicles varies as much as does the predisposing cause. They are uniformly enlarged, nodular, and upon being incised may be found to contain cavities containing pus and having sinuses, and often communicating with one another.

The gross appearance upon section will vary with the progress of

the lesion. As a rule two areas will be noticed: a peripheral crescentic area containing tubercles and cheesy masses, and representing the epididymis, and another soft, spongy mass representing the testicle. It is very probable that the tuberculosis begins uniformly in the epididymis and extends to the testicle. At first there will appear a small nodule, situated usually in the caput epididymis; this nodule is hard and gray or grayish-red. Then other nodules appear and these multiply, and finally the whole epididymis and the cells of the canals of the epididymis are degenerated and become cheesy. These nodules. coalesce and degenerate, and form abscesses and fistulæ. That portion of the epididymis which is not converted into abscesses is converted into dense hard connective-tissue or granulation-tissue. The same thing occurs in the vas deferens, and as a result we see thickening, dilatation, sacculation, abscesses, etc. In the testicle the nodules are generally larger, white or yellowish-white, and merge rather imperceptibly into the testicle-tissue. These nodules degenerate at their centre and become dense at their edges.

Tizzoni and Gaule say (Cornil and Ranvier's Pathological Histology) that the affection begins by a new formation of the epithelium of the tubules. Others say (Wilkes and Moxon) that it begins in the intertubular structure.

In tuberculosis testis complicating general miliary tuberculosis, the tubercles are more apt to be found in the intertubular tissue, while on the other hand, in primary tuberculosis of the testicle, the tubercles are more apt to be found in the mucous membrane of the tubules and in the walls of the tubules.

It is, however, with the microscopical appearances of this lesion that we have to do.

We find that there are two elements in the lesion which we will have to consider separately. In the first place there is a diffuse general orchitis which is associated with the tuberculosis, and in the second place there is a typical tubercular inflammation with the production of tubercle tissue.

There are changes in the interstitial tissue, in the seminal tubules, in the vessels, in the cells of the seminal tubules, and a growth of new tissue. In examining some of the sections which I have placed under the microscopes, you will see that the interstitial tissue is loose in texture and composed of a finely reticulated stroma containing round and branching cells. These cells are for the most part diffusely scattered throughout the stroma, but in places they are aggregated together in masses, and in other places are especially abundant around the

blood-vessels. The seminal tubules are distorted; their membrana propria is markedly thickened, and the cells in the membrana propria have undergone proliferative changes. When we come to examine the cells of the seminal tubules we see a marked change; they are degenerated, granular, detached from the wall of the tubule, and lie, a nucleated, granular mass, in the centre of the tubule; in the centre of this mass may often be seen an opening which represents the original lumen of the tubule. The vessels are changed. Some of them are obliterated and some have thickened walls, and these walls are infiltrated with round cells and their adventitia cells are increased in number.

These are the changes of chronic diffuse orchitis associated with tuberculosis, and they are more or less constant factors in the lesion. We see the same thing in tuberculosis of other organs, for instance, the kidney; here also we have chronic diffuse nephritis in addition to the tubercular inflammation.

When we examine the other element in the lesion, the tubercular portion, we see a typical tubercular inflammation with the production of new tissue, composed of a basement substance and of cells. There is a dense round cell infiltration, and these round cells are in places aggregated together in large masses of a more or less circular shape; the centres of these masses have undergone degeneration and the cells have lost their individuality and refuse to stain. Among the cells at the periphery of these masses are many giant cells; large cells with homogeneous centres and peripheral nuclei, which may be situated intra or extra-canalicular.

I have been able to demonstrate, also, the presence of the bacillus tuberculosis in these masses.

In regard to the origin of these cells, it is probable that part of them are transformed leucocytes, part of them formed from the con

nective tissue cells, and part of them from the epithelial cells of the seminal tubules. Langhans says that the invasion of the epithelial cells by the bacilli cause them to undergo karyo-kinesis, and thus to contribute, in the form of epithelioid cells, to the formation of the tubercle.

The stroma of this new tissue is probably derived largely from the giant cells and from the branching cells of the connective tissue; this stroma is usually better developed than in tubercles in other organs. Some of the giant cells have processes which unite with the stroma of the surrounding tissues; we see, also, near the centre of the tubercle a few large stellate cells, with long, slender, rod-like nuclei and a pale cell substance.

In the meshes of the anastomosing processes of the giant cells and the stellate cells the other cells are contained.

Near the centre of the tubercle the stroma is more granular.

The elements of the membrana propria also contribute to the formation both of the stroma and the cellular elements of the tubercle.

In the particular testicle from which these sections were cut, it can be noticed that the giant cells are very abundant; some of these giant cells are imbedded in the stroma without seeming to take any part in its formation, while others are evidently a part of the basementsubstance. It has been observed that, as a rule, where there were large numbers of giant cells, there were small numbers of bacilli, and where there were many bacilli, very few giant cells were observed. It has been observed also that in old cases, where the tubercles had existed for a long time, the bacilli were very seldom found.

1 Deutsche Chirurgie, 1888: "Die Kranheiten der Männlichen Geschlechtorgane."