syphilitic disease of both testes occurred thirty years after the primary disease.

Causes. The immediate cause of the morbid action in most instances is probably a blow or slight injury of some kind, or excessive sexual indulgence. Gonorrhoea and epididymitis have apparently no influence in rousing the development of sarcocele of this kind.

Course and Symptoms.-The enlargement of the testis usually makes considerable progress before it attracts attention, but when by chance the disease is detected early, the testicle may be somewhat firmer than the unaffected organ. The scrotum, cord and epididymis at this stage, are perfectly natural. If the surface of the testis be carefully examined, it will be found to be slightly uneven, or even nodulated, and less compressible at one or two points than elsewhere. This change is owing to the induration of isolated parts in the substance of the testis. The masses gradually increase in size and number; when far advanced, they often coalesce. Sometimes the development proceeds so rapidly, that in the course of a few weeks the testicle may gain twice its previous size. The nodular form of the organ is lost by this general enlargement. The surface of the testis is then smooth, and encroaches on, and in very advanced cases almost entirely conceals, the epididymis; otherwise that body can be felt behind the testis in an unaltered condition. In some patients the nodules are more distinct than those just described, and appear to be projections growing on the surface of the tunica albuginea. They vary in size from a pea to a hazel-nut or larger, and form that variety which is most apt to attach itself to the integuments and produce adhesion, ulceration, and fungus testis. Some authors, Duplay and Gosselin for example, maintain that these superficial nodules are gummata springing from the surface of the fibrous tunic and only slightly if at all connected with the internal parts of the testis. Pain is generally altogether absent until the testicle has acquired sufficient weight to excite aching along the cord and in the loins. Sir Astley Cooper states that pain, increased by night, now and then attracts the patient's attention to his testis. The peculiar sensation caused by compressing the healthy organ soon becomes diminished in the syphilitic testis, and often lost altogether; only in the earliest stages of the affection is it greater than in health. The enlarged organ also feels less elastic, or firmer than the healthy one. By the time the testis has gained some enlargement, a small quantity of thin clear fluid often collects in the tunica vaginalis, probably from congestion of the vessels during the progress of the inflammatory changes in the tunica albuginea. This fluid is usually of small

See Reynier: Sarcocèle Gommeux, Archives Gén. de Méd. 1879, Avril, p. 396. 2 Astley Cooper: Loc. cit., p. 103.

amount, and is of no moment. The size of the organ increases slowly, and, according to Ricord, never exceeds twice that of the healthy testis. When the disease has existed for some time in one testicle, the other nearly always enlarges in a similar manner; for this affection attacks both testes more frequently than any other malady of these organs. Goodhart found both testicles affected thirtyeight times in sixty-two necropsies. Zeissl has observed the testes enlarge simultaneously. We also have notes of a case where the disease in the left preceded that in the right testis by a very few weeks, and both increased in size at the same time. The virile power of the patient in double orchitis is greatly lessened, or even destroyed, and the sexual appetite is usually lost during the time this condition continues. The scrotum often remains unaltered throughout the disease. In this respect syphilitic tumours are distinguished from tubercular or malignant growths, which cause adhesion and ulceration of the scrotum. Exceptions to this immunity are not common, but Rollet, De Meric, Curling, and others relate cases where the deposit of syphilitic matter in the testicle was accompanied by circumscribed inflammation of the scrotum, abscess, and fungous granulations of the opening left by the abscess. Curling has thrice seen fungus of both testes at the same time. In Sée's case also there was double fungus.

In our own experience the ulceration of the scrotum may assume two forms. In one, there is no fungous protrusion; in the other, the granulations spring from the interior of the testis, break through the tunica albuginea and integuments, and form the exuberant mass termed benign fungus testis. In the first, the gummy growth probably begins on the outer surface of the tunica albuginea or even in the more superficial investments, and contracts adhesions with the soft tissues overlying it; then, growing onwards into their substance, it ultimately undergoes softening and disintegration. Thus an ulcer is produced in the scrotum, which has the following characters: the floor is yellowish-grey and tolerably even, the scrotum around it, adherent widely to the testis, is thickened, purple red, and at the edges. of the sore, ragged, undermined and melting away. Such sores in time granulate and cicatrise with adhesions. Throughout they have no tendency to form fungous protrusion. Usually only one such ulcer forms, but two or three may occur together. They have no special seat, but are common at the lower part of the scrotum. They soon heal soundly under anti-syphilitic treatment.

+ Curling: Diseases of Testis, 4th edit. 1878, p. 301. See also Zeissl: Vierteljahr. f. Dermat. u. Syph. 1875, p. 137; Marc Sée: Loc. cit.; Reynier: Archives Gén. de Méd. 1879, Avril.

1

The fungous form is far less frequently met with. It begins by nodular expansion of the testis at one part, which slowly increases for some weeks or months; then-usually when the patient has interrupted his treatment, or has received a blow or squeeze of the organ-the swelling rapidly increases, becomes a soft well-defined 'knob,' or 'boss,' which in Zeissl's case attained the size of "a child's fist." The scrotum quickly becomes adherent to the swelling, and absorption of the surface and liquefaction of the interior follow. The gumma breaks at last and leaves a ragged cavity with gelatinous contents. In a few weeks the gelatinous matter is replaced by rapidly growing granulations that soon protrude from the interior and luxuriate as a soft red mass above the level of the scrotum, often overhanging the margins of the orifice, and secreting pus freely. The fungus consists of simple connective tissue, and sometimes contains also the special structures of the testis. If cut off, the mass often grows again rapidly, and needs several operations for its removal. Anti-syphilitic treatment has little influence over the fungus, hence some authors, Lorenzo for example, maintain that the affection is not truly syphilitic, though set in action by the perforation of the tunica albuginea from syphilitic disease. Lorenzo has recorded three cases where the fungus was cured by actual cautery, after mercury and iodide had failed to influence the growth.

Termination. When untreated, the enlargement of the organ in course of time subsides with atrophy and fibrous degeneration of the affected portion, but other gummata form again and again in the organ unless suitable treatment be employed. Sir A. Cooper and Curling relate instances of the enlargement returning many times. The testis sometimes ultimately shrivels to a fibroid mass very much smaller than the original organ. Wilks has recorded such cases. We have also noted the case of a man whose testes enlarged, one after the other, seven years after infection. In course of time both became much shrunken, the right being no bigger than a filbert, and the left about half its original size. This patient had no sexual desire, and never attempted intercourse.

Pathological Anatomy.-Two distinct kinds of change take place: inflammation of the fibrous structures; and the production of gummata. The first commences by congestion and thickening of the tunica albuginea at a few limited points on the surface, from

1 Zeissl: Loc. cit.

2 Giacomo di Lorenzo Sul Fungo benigno del testiculo in rapporto alla Sifilide general. Giorn. Ital. d. Malattie veneree e d. pelle. 1875, p. 260.

3 Astley Cooper: Loc. cit., Case iv., p. 105.

4 Curling Loc. cit.

5 Wilks: Path. Trans., vol. x., p. 210, and vol. xii., p. 216.

Virchow Ueber die constitutionellen Syphilis. 1859. See also Lancereaux, loc. cit., p. 221, and Cornil: Leçons sur la Syph. 1879, p. 433.

which spring adhesions of the tunica vaginalis and effusion of fluid into the serous cavity. This inflammatory action passes inwards through the fibrous tunic to the substance of the testis, so that the fine laminæ of cellular membrane between the tubules, which are naturally very vascular, are converted into a soft cellular tissue crowded with nuclei. This new tissue contracts and indurates, whereupon the tubes alter, their walls thicken, lose their epithelial secreting lining, and shrink into an almost homogeneous mass. It is no longer possible to draw out the tubules, as may be easily done in the healthy testis. These changes, slow in taking place, are usually at first, and for some time, confined to one or two isolated lobules, and they do not generally affect the rete testis, or vasa efferentia. As the morbid action rarely affects more than a few of the lobules at first, and as the disease is commonly arrested by treatment before the secreting structure of the tubules is destroyed, the gland recovers its normal condition to a great extent. The inflammatory induration, if long-continued in the tunica albuginea, renders it thick and gristly, and the free surfaces of the serous coat become adherent. Gummata. These are not so frequent as the changes which have just been described. The gummy form of disease commences by the development of a hard nodule, where the tunica albuginea or one of the lobules of the testis has been previously indurated in the manner already described. The gummy masses, when recently produced, are surrounded by a vascular areola that becomes, when the masses have existed some time, a tough capsule. These areola consist of an irregular network of cellular tissue, enclosing a centre of dense fibrous tissue, in which cells that have undergone fatty degeneration are packed, and resemble those seen in the atheroma of arteries. The gummy masses are not unlike tuberculous nodules in the testis, but they are more fleshy and elastic, and are distinguished by the absence of the miliary grey granulations, that can be often found round real tubercle, and by the fibrous or vascular capsule of the gummy growth. Wilks and Moxon have found tubercle and gumma in the same testis; each with its proper characters.

Diagnosis. When the case is seen at the beginning, the testis is uneven on the surface, but this irregularity may disappear in the general enlargement, and the organ become smooth and regular in shape. Pain is absent, and the sensibility of the gland is diminished. The cord and epididymis commonly remain unattacked, but in rare cases they do get thickened and involved with the disease; but usually the epididymis is only more or less concealed by the enlarged

1A case of Canton's, Path. Trans., vol. xii., p. 163, and Wilks', Guy's Hospital Reports, 1863. 2 Wilks and Moxon: Pathological Anatomy. 1875, p. 534.

3 As in Lancereaux's case, loc. cit., p. 222.

testis. In most cases of syphilitic testis other symptoms are still present; if not, there is generally the history of past eruptions of the skin, sore throat, or other lesions, sufficiently deciding the origin of the disease.

Cases in which the nodular condition is present, may be confounded with tuberculous or cancerous disease, or with simple orchitis; but there are these distinctions. Tuberculous disease commonly begins in the epididymis; in syphilis that part remains almost always free from morbid change. As the tuberculous disease progresses, the nodules and irregular projections adhere to the scrotum and form abscess. The syphilitic testicle, if somewhat irregular at first, generally becomes smooth, and rarely forms connections with the scrotum, or causes abscess. Pain, though absent in the early stages of tubercle, is an accompaniment of its softening and suppuration. The pain in syphilis is always slight, being caused merely by the weight of the organ; thus it is felt less in the testicle than in the groin and back. In tuberculous testis the cord is often thickened, and the lymphatic glands of the groin enlarge when the scrotum is implicated, and the seminal vesicles, if examined per anum, are often found to be affected with similar disease. These changes do not take place in the syphilitic testis. Lastly, tuberculous disease occurs more often in youths than adults, but syphilitic disease is rare before 25 or 30 years of

age.

Malignant disease of the testis is in its early progress more easily confounded with syphilitic testis. At first the testicle, and not the epididymis, is attacked; the surface is uneven, and pain may be absent; but as the disease advances the distinction soon grows clear, the projections of cancer rapidly enlarge, and the testis usually remains uneven, studded with masses firmer than the rest of the organ. The outgrowths in due time adhere to the scrotum, which reddens, ulcerates, and a protruding fungous surface developes. The pain in cancer long before this stage becomes stabbing and shooting in character, and often very great indeed. Cancer never remains stationary; the epididymis and cord soon become enlarged and uneven, and when the scrotum is much involved, the inguinal lymphatic glands are affected also. These changes are wanting in the syphilitic testis, which increases slowly and regularly, rendering the epididymis indistinct; but the cord is hardly ever reached, and the scrotum is in the great majority of cases left in its ordinary condition. Cancer very rarely attacks both testes, and its enlargements do not subside. Syphilis usually attacks both organs, one after the other, and its projections subside spontaneously in time. When both testes are attacked, there is usually other evidence which at once decides the nature of the malady. Cancer is com