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ANNALS 
SURGERY 
A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 
EDITED BY 
L. S PILCHER. A.M. M.D. J; WILLIAM WHITE. M.D. 
FREDERICK TREVES. F.R.C.S., WILLIAM MACEWEN. M.D, 
TABLE OF CONTENTS. 
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UNIVERSITY OF PENNSYLVANIA PRESS. 
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MARCH, 1887 
TERTIARY SYPHILITIC EPIDIDYMITIS. 
Ev CHARLES G. CUMSTON, M.D., 
OF BOSTON, 
Assistant Professor of Surgical Pathology, Faculty of Medicine, Tufts College. TERTIARY SYPHILITIC EPIDIDYMITIS.1 
CHARLES G. CUIVISTON, M.D., 
OF BOSTON, 
ASSISTANT PROFESSOR OF SURGICAL PATHOLOGY, FACULTY OF MEDICINE, 
TUFTS COLLEGE. 
FOR a long time tuberculosis and gonorrhoea were the only 
diseases that were supposed to attack the epididymis, but 
of late years a certain number of syphilitic manifestations 
have been proven to occur in this organ, but, as the cases of ter- 
tiary syphilitic epididymitis are not of very frequent occurrence, 
the report of the following case, occurring in the writer’s prac- 
tice, as well as a few remarks regarding the differential diagnosis 
of this affection, may not be without some interest. 
Tertiary syphilitic epididymitis appears from two to twenty 
years after the primary accident, and appears to attack preferably 
patients who are in full sexual activity,—that is to say, from 
thirty-five to forty-five years of age. Now, if sclero-gummous 
orchitis occasionally occurs as a tertiary symptom, the hereditary 
tertiary syphilitic epididymitis, on the other hand, appears to be 
exclusively confined to cases of acquired syphilis. 
A certain number of circumstances appear to cause it to 
occur, and since the time of the illustrious Ricord observers have 
recognized the influence of venereal excess on the development 
of genital syphilis. A large number of cases reported in an 
excellent monograph by Delahaye appear in every way to favor 
this assertion. Traumatism, gonorrhoea, and primary inflamma- 
tory conditions produce a locus minoris resistentice in the epi- 
didymis. In the same way carcinoma has been noticed to follow 
a syphilitic sarcocele, in the same manner as we notice that in 
1 Read at the Surgical Section of the Suffolk District Medical Society, January 
6, 1897. 2 
CHARLES G. CUMSTON. 
many of the cases of gonococcus infection or traumatism has 
favored or awakens anew the syphilitic diathesis. 
The case in question was that of a single gentleman, a merchant 
of some thirty-three years of age, actively engaged in a large busi- 
ness. He was a very well educated man, and took extremely good 
care of himself in every respect. He called on me one day, saying 
that for some two weeks past he had noticed a small swelling at the 
bottom of the left testicle, and that it gave him a feeling of weight 
and tension in the organ, although no actual pain was present, either 
spontaneous or when the organ was pressed upon. 
Upon examination the scrotum appeared in every way normal; 
the left testicle, however, appeared decidedly lower than the right. 
By palpation I discovered a small, round, hard tumor, about the size 
of a cherry, situated on the head of the epididymis. This tumor was 
in no way painful when squeezed between the thumb and index- 
finger; it was spherical and presented a few inequalities over its sur- 
face. The scrotum was normal, and no change could be detected in 
the spermatic cord ; prostate normal. The patient was questioned 
closely regarding any antecedent trouble of venereal origin, but the 
only thing that was admitted was a gonorrhoea contracted some six or 
seven years previously, and of which there remained no trace. The 
patient admitted that he was cohabiting with a woman whose husband 
had had one of his testicles removed for tuberculosis some years 
previously. Thinking that I might possibly be in presence of a 
primary genital tuberculosis, contracted from coitus, I ordered a 
suspensory bandage and the application night and morning of bella- 
donna ointment, which was used as a palliative treatment, without 
any hope of curing the disease, and the patient ordered to return in 
a week. 
He did so, and at this time I found the tumefaction slightly 
increased in size. I then told him that, as he had never had syphilis 
according to his own statement, I considered the growth, although 
not characteristic, as one produced by tuberculosis, and advised 
immediate removal of the testicle, which, by the way, I must here 
state, was normal in every way. Its characteristic sensibility was 
present, it was of normal consistency, and, in fact, in every way 
apparently free from any pathological change. 
When told that he must undergo this operation, as well as the 
loss of this organ, the patient said that he did remember that some TERTIARY SYPHILITIC EPIDIDYMITIS. 
3 
five years ago he had had a sore on his penis, and a few weeks later 
he had a sore throat and a slight eruption over the thorax and back, 
with loss of hair, all of which symptoms had disappeared and had 
never returned since. He also stated that he had consulted a physician 
at that time, and was given mercury in the form of pills, which he 
took for some three weeks’ time and had never taken any since. 
I carefully examined the patient from head to foot, and found 
all the viscera absolutely normal, and the patient’s condition in every 
respect excellent. Blood examination showed haemoglobin was 98 
per cent., and the blood count showed 4,300,000 red blood-corpuscles 
to the cubic millimetre. The mouth and teeth were in perfect con- 
dition, and so, believing that, on account of the very imperfect specific 
treatment which he had undergone, this was a tertiary manifesta- 
tion of his syphilitic diathesis, and that it was necessary to act imme- 
diately, he was placed on protiodide of mercury, five centigrammes 
thrice daily, and ten centigrammes of iodol thrice daily. The patient 
was seen once a week for four weeks, after which time the tumor 
had become so reduced in size that only a slight induration of the 
epididymis was noticed. 
Since taking the above notes, in February, 1896, the patient has 
again been submitted during the month of September to the same 
mixed treatment, and, although no other manifestation of the disease 
has made its appearance, he has been ordered to return in the spring 
in order to receive more specific treatment. 
Regarding the symptoms of tertiary syphilitic epididymitis, 
it appears that the affection generally begins in a subacute form, 
with pains of variable intensity, either spontaneous or produced 
by pressure. In other cases, as in the one here reported, the 
pain or feeling of weight only occurs after the patient is tired, 
and sometimes the feeling of weight and dragging sensation is 
only present, pain being entirely absent. As in all neoplasms due 
to tertiary syphilis, the growth may occur without any symptoms 
whatever, the patient only noticing it after it has attained a cer- 
tain size, as in one case mentioned, or after the products of the 
tumor have been evacuated through the skin. 
In the beginning the scrotum does not present any trace of 
inflammation, and the soft parts may be pushed over the tume- 
faction with ease. The vaginal membrane is occasionally the 4 
CHARLES G. CUMSTON. 
seat of a liquid collection, and the latter has sometimes been the 
means of preventing a thorough and complete examination of 
the epididymis and testicle. If the testicle is palpated, the organ 
will be found of normal consistency, without any point of indura- 
tion or any change in size, and its characteristic sensibility will 
also be found normal. The spermatic cord is also found healthy, 
although some cases of localized gummata have been reported 
as occurring in this organ, although in the cases of tertiary epi- 
didymitis that have been reported the former do not appear to be 
present during the evolution of the latter affection. 
Let us now consider the syphiloma of the epididymis itself. 
It may invade the caput or a part of the epididymis, but usually 
it is diffused, involving the entire organ, in the form of a tume- 
faction, having a firm and resistant consistency. The tumor is 
irregular, and in some cases palpation will show several indurated 
points in the caput, corpus, and tail of the epididymis, or both 
segments of the organ may be included in a single node. The 
usual size of these nodes of induration vary from that of a small 
nut to an English walnut. When the tumor does not invade the 
entire epididymis, it is sometimes the caput and sometimes the 
tail which is the seat of the disease, but generally—and Delahaye 
insists on this fact—the organ is entirely invaded. An important 
fact to mention is the great distinctness with which the healthy 
testicle may be isolated from the indurated points in the epi- 
didymis, and those adhesions which are found in gonorrhoeal 
epididymo-orchitis are entirely wanting. 
The last proper character of this type of epididymitis, and 
which appears to have a certain clinical value, is that the lesion 
is always unilateral. In nine cases mentioned by Delahaye the 
disease was only found in one epididymis, but Allen mentions 
two cases of bilateral epididymitis occurring eight and ten years 
after the chancre, but the tertiary state of these patients was not 
confirmed by any other syphilitic accident present at the same 
time as the epididymitis. 
When the disease under consideration is acute, the patient 
will immediately seek medical advice, and, if he is found syphi- 
litic, a proper treatment will be applied; but it is not the same TERTIARY SYPHILITIC EPIDIDYMITIS. 
5 
thing when the tumor has been present and has slowly and 
insidiously evoluted. The patient does not notice the affection 
for the simple reason that he suffers in no way from it, and it is 
only after a long time from the commencement that a fistula 
occurs, and the patient will then seek a surgeon. 
Some cases reported have demonstrated that these indura- 
tions in the epididymis evolute as all tertiary growths, either 
towards sclerosis or towards gummous degeneration. In one 
case the patient had had his tumor for six months, and palpation 
gave a feeling of a softened gumma. The duration of the dis- 
ease may consequently be quite long, and the mixed treatment 
followed for a few months will finally reduce the tumor to the 
size of a small indurated nodule. 
The persistence of a sclerosis nodule after disappearance of 
the syphiloma is, however, a cure, the second manner in which 
a tertiary epididymitis may end. In other cases an induration 
may undergo the degenerative evolution of a gumma. The 
tumor loses its firm consistency and becomes the seat of a 
pseudo-fluctuation and breaks down. Soon adhesions are 
formed with the neighboring tissues, the scrotum becomes violet 
in color and ulcerated, and a fistula appears at the lower part or 
the back part of the scrotum, from the orifice of which a liquid 
flows out, which in aspect very much resembles a solution of 
gum. 
To sum up, we may say that the beginning is generally 
subacute. The induration is irregular, and often the entire epi- 
didymis is invaded, although without adhesions to the testicle. 
There is a tendency to sclerosis or to the formation of gummata. 
These are the symptoms that I think we may attribute to ter- 
tiary syphilitic epididymitis. 
Regarding the pathology of tertiary epididymitis, not much 
can be said, because so far no case of this disease has been ex- 
amined microscopically. However, it is probable that in an 
advanced condition it would present the same characters as found 
in a gumma. 
According to Allen, a nodule probably represents small 
gumma disseminated throughout the organ, which gives to the 6 
CHARLES G. CUMS TON. 
examining hand the sensation of an irregular body. It may also 
take on the form of an infiltration or gummatous hyperplasia of 
a diffused type, and these form large masses, which may be true 
tumors, and which will finally undergo a sclerous change, and 
the organ will then be found hard and fibrous. 
Regarding the differential diagnosis, tertiary epididymitis 
will certainly present much difficulty, and it is certainly important, 
on account of the prognosis and for the treatment, to arrive at a 
definite conclusion regarding the nature of the affection. 
In the first place, secondary epididymitis is in some ways 
similar to the tertiary form ; the tumor is distinctly isolated from 
the testicle, the pains are subacute on pressure, and its consist- 
ency is firm, and the tumor is lumpy. There are some signs 
which will permit certainly of a differential diagnosis, because 
in secondary epididymitis the lesion is limited to the caput of the 
organ, and out of eighty-six cases collected by Cuilleret, the 
tumefaction, including the entire organ, was not met with in any 
case, while in the tertiary type Delahaye found the lesions were 
diffused in five out of nine cases. 
On the other hand, when we are dealing with a secondary 
epididymitis, both organs are often the seat of the trouble. 
Dron found the affection on both sides in seven cases out of 
fourteen ; Balme five times out of twenty-two cases ; Telemat, 
three times out of eight, and Cuilleret, six times out of twelve. 
In one of the forms of the disease, the commencement is often 
insidious, while the other is accompanied by acute and painful 
symptoms. The tertiary syphiloma does not have the indura- 
tion similar to a pea or pill, and as if set into the caput of the 
epididymis, which is characteristic in the secondary variety. On 
the contrary, the indurated nodes are often multiple, much larger 
than in the secondary form and the entire epididymis or, at least, 
the two neighboring segments of the organ are involved. 
In the therapeutical point of view, there seems also to be a 
difference between these two types, and, according to Dron, the 
secondary resists for a long time specific treatment, and espe- 
cially iodide of potassium, especially when the latter is given 
alone; and Mauriac is also of this opinion. It is not less true TERTIARY SYPHILITIC EPIDIDYMITIS. 
7 
that the diagnosis is sometimes very delicate, especially when we 
find ourselves in presence of one of the transitional forms—that 
is to say, between the secondary and tertiary period,—occurring 
several years after infection ; but in this case the existence or the 
absence of other tertiary manifestations will settle the question as 
to the diagnosis. 
In gonorrhoeal epididymitis, the beginning is subacute, and 
the division of the lesions characteristic of the tertiary manifesta- 
tion may sometimes be taken for an epididymitis due to the 
gonococcus, but the intensity of the pain, the fever, the ex- 
ternal signs of inflammation, induration of the epididymis, which 
is firmly bound to the testicle, the frequency of inflammation of 
the vaginal membrane, and especially the presence of a discharge 
from the urethra, will assure the diagnosis in the majority of 
cases. But, if we are dealing with one of the acute and sub- 
acute forms described by Angagneur and mentioned by Dela- 
haye, if the discharge is slight or has disappeared for some time, 
the problem is far more delicate. And, nevertheless, in cases of 
latent and chronic gonorrhoea, the induration becomes localized 
in the tail of the epididymis, and careful palpation will show the 
presence of adhesions with the testicle, while in tertiary epidid- 
ymitis the testicle and epididymis are distinctly isolated one 
from the other. And, lastly, the antecedents of the patient and 
the history of a former primary sclerosis, the presence of other 
tertiary symptoms, as well as the result of treatment, will con- 
firm the diagnosis. 
Tubercular epididymitis may have an acute or chronic 
course, and, as in the disease under consideration, the softened 
contents of the foci break down and are evacuated through the 
skin of the scrotum, leaving behind one or several fistulse. 
If we are dealing with a case in which the scrotum is 
healthy, the indurations of a tubercular epididymitis are less 
well marked and less distinct than in tertiary syphilis. These 
bosses are often very large, of unequal consistency, and less 
rounded. Frequently the testicle and the cord are often the 
seat of disease, and the prostate and the seminal vesicles may 
also be involved in a tubercular process before the epididymis is 8 
CHARLES G. CUMS7ON. 
attacked. Rectal examination is consequently decidedly indi- 
cated, in order to make a diagnosis, and often the examination 
of the lungs will reveal symptoms of pulmonary tuberculosis. 
If all these signs are wanting, the only thing that remains 
for us to try is the antisyphilitic treatment; iodide of potassium 
and mercury will never have any action on tuberculosis, while 
the contrary is true for tertiary lesions. 
If we are dealing with a case presenting a fistula, which is 
present at the lower or posterior aspect of the scrotum, with an 
indurated epididymis adherent to the neighboring parts, the diag- 
nostic means before mentioned are still useful in these cases. 
On the other hand, the depression of the external orifice of the 
fistula, the characters of pus containing cheesy matter, and, lastly, 
bacteriological and microscopical examination of the matter dis- 
charged will be sufficient to indicate the tubercular nature of the 
affection. 
Malignant tumors may attack the epididymis as well as 
the vas deferens. These neoplasms are very numerous, such as 
sarcoma, diffused or cystic epithelioma, enchondroma, etc. But 
it is extremely infrequent that a malignant growth begins in the 
epididymis, and in the large majority of cases the testicle is the 
first diseased. 
In cases of cancer of the epididymis, the pains are lancinat- 
ing and spontaneous; the age of the patient, the usually large size 
of the tumor, the rapid growth of the latter and the condition 
of the lymphatic glands, and especially the absence of tertiary 
symptoms present at the same time, as well as the uselessness of 
the iodides, will allow us to eliminate the diagnosis of syphilis. 
Regarding cysts of the epididymis, we know that they are 
often met with on the convex aspect and on the free end of the 
caput of the epididymis, and occasionally near the tail of the 
organ. In the beginning, when the cyst is only the size of a 
bean, its consistency may appear hard, and transparency and 
fluctuation will not as yet appear. Its indolence and localization 
will, however, allow us to make out its nature. Later on, when 
it is larger, it will be no longer hard to the feel, and in many 
cases fluctuation will be made out, but we must always remem- TERTIARY SYPHILITIC EPIDIDYMITIS. 
9 
ber the possible presence of a gumma undergoing softening, and 
specific treatment should be tried. Puncture may, perhaps, be 
recommended, but it is not perfectly legitimate, excepting when 
the treatment and the absence of tertiary symptoms will have 
allowed us to eliminate the possibility of the lesion being of a 
syphilitic nature. These considerations are also applicable to 
spermatocele. 
As to gumma of the scrotum and vaginal membrane we 
will not insist, because an error in the diagnosis in this case is 
not a bad point for the patient, the treatment being the same, 
and, for that matter, the ease with which the tumor slides over 
the underlying tissues in both cases ; the frequency of the vagi- 
nitis in the second will be sufficient for us to make a localiza- 
tion of the new growth. 
The prognosis is excellent in the disease under considera- 
tion, and all trace, with the exception of a slight induration, will 
disappear after a certain time, when proper therapeutic measures 
have been employed and for a sufficiently long time. It is 
useless for the writer to insist upon the treatment of this lesion ; 
it naturally requires a specific one, and, as each one has his own 
methods of prescribing mercury and the iodides, it is unnecessary 
to insist upon any detail here; suffice it to say that the mixed 
treatment is considered as by far the best by the writer, and that 
this should be persisted in for a sufficiently long time.