escape inflammation. Peritonitis and inflammation of the vesicula seminalis have also followed inflammation of the cord in one or two cases. More or less general febrile disturbance is usual at the outset of epididymitis, but it is rarely serious except in those peculiar cases of agonising pain, then the constitutional condition becomes most serious, and not free from danger.

In the course of four or five days the pain lessens, and the swelling soon afterwards diminishes, first by reabsorption of the fluid effused, and then of the solid enlargement; though this is exceedingly slow to depart. Relapses are very common, especially in persons who are not able to rest completely during the acute stage. Instead of relapsing in the same testis, the inflammation changes sometimes to the other side, which is affected in its turn.

The usual termination is gradual but complete resolution, but some induration of the epididymis always remains a long time. The persistent enlargement of the globus minor has been found by Gosselin and others to render the patient. sterile by blocking up the excretory duct of the testis at that point. In nineteen patients in whom double epididy mitis had taken place, and in whom this thickening remained, he found that, though the patients retained desire and capacity for sexual intercourse, and their semen was unaltered to the naked eye, the microscope showed it to be entirely destitute of the spermatic bodies or spermatozoids. The testicles in these persons were apparently quite healthy, neither swollen nor atrophid. To test his explanation, Gosselin divided the spermatic cord of one side in two dogs. Several months afterwards the dogs were killed, and the isolated testis was found to be healthy; its vasa efferentia were filled with fluid containing spermatozoids in the usual number; hence Gosselin concludes that the great

1 Archives Générales de Médicine, September, 1853, p. 257.

FF

bulk of the seminal fluid is secreted in the vesiculæ and not in the testis, and that this organ furnishes only the impregnating constituent of the semen. His researches show that sterility may be caused by epididymitis, and how important it is to endeavour to disperse the hardening of the epididymis which obstructs the efferent duct. Gosselin was successful, in two cases where the induration had lasted three and nine months respectively, in removing the enlargement of the globus minor. When the epididymis had regained its natural size the spermatic bodies reappeared in the semen, from which they had previously been absent.

Abscess in the cellular tissue enveloping the epididymis sometimes follows the inflammation, but it is never extensive, and soon heals after making its way to the surface.

The seat of the inflammation is primarily the epididymis; from this the congestion extends to the tunica vaginalis and tunica albuginea, though inflammation of the testis itself is exceedingly unusual. The cellular tissue of the cord and scrotum is also generally more or less congested, but the inflammatory action is mainly confined to the areolar tissue enveloping the convoluted excretory duct, that around the globus minor being most affected. It occasionally happens that both epididymes are inflamed one after the other, not simultaneously. This double epididymitis took place 66 times out of 879 cases collected by Rollet and Fournier. There appears to be no difference in the frequency with which the right and left organs are attacked; of 51 cases remarked by myself, in 27 the right, and in 24 the left epididymis was inflamed. Of the 879 cases first alluded to, 405 were on the right side, and 408 on the left.1

The first effect in epididymitis is congestion of the cellular tissue of the vasa efferentia and excretory duct. Plastic

1 Fournier it., p. 211.

matter exudes among the efferent ducts and into their interior, producing solid enlargement at these points, and obstruction. After the inflammation has subsided, these hard indurations remain long in the epididymis before they are reabsorbed, but are of no moment, unless, as already mentioned, both vasa deferentia are blocked up, and no secretion of the testis can reach the vesiculæ seminales, so that sterility is produced. In one case,1 where the postmortem examination was made twenty-six days after the commencement of the attack, and the acuteness of the inflammation had subsided, the testis, vasa efferentia, and globus major of the epididymis were healthy, but the globus minor at the bottom of the epididymis was enlarged, hard, and firm. Section showed it to be yellow and free from vascularity. The duct was much enlarged, but impervious, being filled with a yellow material, which also infiltrated the walls of the convoluted vas deferens. Under the microscope the yellow substance consisted of granular cells, fatty globules, and débris. The cellular tissue of the scrotum and cord is also congested and thickened by infiltration of plastic matter, which sometimes degenerates into small circumscribed abscesses. The tunica vaginalis is congested and roughened on the surface, and serous fluid is effused into the sac, but further changes have not been noted. The vas deferens of the cord and vesicula seminalis connected with the inflamed testis have been found to be congested in a few cases when examined after death.

The diagnosis of epididymitis is usually made with ease. The swelling and pain are of recent origin; they occur at the time of, or soon after urethral discharge; the pain and tenderness extend also to the cord. The epididymis can be felt enlarged independently from the testis; if the latter be

1 Gazette des Hôpitaux, Decembre 21, 1854; also Gosselin's translation of Curling's "Diseases of the Testis."

also enlarged, it is only slightly so. The tenderness on pressure is much greater in the epididymis than in the testis itself. This is the only acute affection of the epididymis, except that rare congestion of the epididymis which is said to occur in early syphilis, and the only enlargement resembling it in shape is scrofulous disease of the testicle, which often begins in the upper part of the epididymis, but has a very different history, being of slow growth, and not acutely painful. Sometimes epididymitis attacks an undescended testis, and causes much perplexity before the true cause of the swelling and pain can be discovered. But the nature of the case may be suspected if the testis is not in the scrotum, and the patient has had a urethral discharge recently.

In treating epididymitis the first thing is to make the patient lie down; for this he should keep his bed; or if not possible for him to do so, the testis must be supported in a suspensory. He should also take some saline draught with sedatives, such as citrate of potash with small doses of opium or henbane. His diet must be mild and unstimulating. These measures, with local remedies, generally suffice to allay the inflammation. If the constitutional disturbance is great, small doses of antimony (one sixth or one fourth of a grain), with a little ether and camphor julep, should be administered every three or four hours, until the pulse is soft and the skin perspiring. In strong vigorous patients venesection to 8 or 10 oz. gives great relief when the constitutional fever is high. The local abstraction of blood by leeches and cupping, or ice applied to the groin, produces much ease. When ice gives no ease, it should be gradually replaced by warm applications. The testis should be wrapped in flannels wrung out of boiling water, and changed every two or three hours. A small cushion (a pin-cushion) placed between the thighs, relieves the pain by supporting the inflamed testis.

Hot hip baths may be taken at night, 104° F., but the patient should stay in only five or ten minutes, and then return to bed. If the tunica vaginalis be very tense, it should be punctured and the fluid allowed to escape, either through a cannula or into the scrotum, whence it is quickly absorbed. If abscess form in the epididymis or testis, it should be freely opened when fluctuation is distinct, and poulticed. After the acuteness of the inflammation is over, the patient may get up, and the thickening which remains be reduced by pressure, and well supported in a suspensory bandage, which should be lined with wadding.

Pressure by strapping is employed by some surgeons from the beginning of the inflammation, and it sometimes checks the enlargement, and greatly alleviates the pain. On the other hand it often fails, and even aggravates the pain. If used at this stage, it should be applied at the very outset, before there is much swelling, or not until acute inflammation is over. When adopted, the testis is enveloped in strips of diachylon plaster. A number of strips are cut about twelve inches long and half an inch wide, and dipped in hot water when ready to be applied. The scrotum and cord being first shaved, the swollen testis is drawn away from its fellow, and the left fore-finger and thumb grasp the cord above it, including as little of the scrotum as possible. One strip is then rolled round the cord below the thumb and finger to isolate the testis from the rest, then another strip is taken and passed tightly along the middle of the testis from the back to the front of the first circular band. In doing so it compresses the testis firmly against the circular strip; another vertical strip is then applied at the side of the first, overlapping about half its width. By a repetition of these vertical strips, the testis is enclosed in a sheath of plaster. They are then all kept in place by a