THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD (with particular reference to their applied Anatomy and Pathology) Hunterian Lecture delivered at the Royal College of Surgeons of England on 8th March, 1950 by Milroy Paul, M.S., F.R.C.S. Professor of Surgery, University of Ceylon JOHN HUNTER'S (1786) work on the riddle of the imperfectly descended testicle gave us the story of the reason for the long course of the blood and lymph pathways passing along the spermatic cord. The drive of Hunter's enquiring mind still spurs on those who follow with the desire to enquire into the unknown, and experience the pleasures of unravelling some of the intricate and fascinating patterns in living beings. Acute Endemic Funiculitis-the recognition of a new clinical entity In 1908, Castellani gave the name Endemic Funiculitis to an affection of the spermatic cord occurring in Ceylon. In the previous year, Madden had described an acute inflammation of the spermatic cord, seen in Egypt, under the name " Cellulitis of the Spermatic Cord," and the subsequent writings of Castellani (1909, 1919), and Coutts (1909) from Egypt, made it evident that the same condition was endemic both in Ceylon and Egypt. The Clinical Features of Acute Endemic Funiculitis When first observed, acute endemic funiculitis was a grave condition. In the early days following its recognition, an acute onset was followed by the symptoms of general septicaemia, and, if a surgical operation were not performed in time, the illness would terminate in death. Even when the illness commenced with milder symptoms, it would progress to the acute stage (Coutts, 1909). The spermatic cord thickened to a diameter of one inch or more, extended like a rope from the deep inguinal ring to the testicle. It was tender and indurated, and the overlying skin was often reddened and odematous. The symptoms of severe toxxmia included vomiting, and this symptom, associated with a tender irreducible swelling in the inguinoscrotal region, gave a picture of which Madden (1909) wrote, " it is impossible to be sure whether we have to deal with strangulated hernia or not." Greater familiarity with the condition soon made this differentiation less difficult. Many diseases undergo a slow change in their manifestations over a period of years. The grave condition described by Castellani in 1908 and 1909-the patient with the jaundiced skin, studded with petechial rashes, the vomiting, the prostration, the thin, small, rapid pulse, depicts an illness which has not been seen in Ceylon for some years now. At the present time the patient presents himself an account of a febrile illness of a few days duration; the spermatic cord is thickened and indurated, 128 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD and on treatment with sulphonamides and antibiotics, there is rapid subsidence of the pyrexia, and a more gradual disappearance of the induration in the cord over a period of some weeks. Surgical treatment is now a thing of the past. Although present day methods of treating infections have modified the course of the disease, the condition now encountered is milder, for no patients are seen in the grave states depicted by Castellani and other early writers. The Pathology of-Acute Endemic Funiculitis The price paid to save the patient from death in the early years following the recognition of the condition was orchidectomy, with high division of the cord at the deep inguinal ring. These early operations gave good opportunities for observation of the changes in the tissues affected by acute endemic funiculitis. There are, on the shelves of the University Museum of Pathology in Colombo, several specimens obtained after operations of this kind. The redness and cedema of the overlying tissues, and the gross thickening of the cord, made a striking picture when the lesion was viewed at operation. The cord was infiltrated with a mass of dense tissue of elastic spongy consistence, which showed scattered sup- purative foci throughout its mass. The specimens in the Museum show two types of change in the spermatic cord. In one the appearances are there which have already been described; in others there are, in addition, several distended veins in the cord filled with red and white clot which is breaking down to pus here and there. These specimens date from 1925 to 1940 and the changes are not so acute as those described by Castellani (1919) who wrote " On making a trans- verse section of the cord, yellow creamy pus will exude from the opened veins and from the vas deferens." The testis is quite normal in all the specimens, and the tunica albuginea retains its normal sheen. This was so even in the very acute cases described by Castellani (1908, 1909), Madden (1907) and Coutts (1909) where the body of the testis remained normal and the epididymis showed at most congestion of its outer coats. The pathological picture is that of an acute cellulitis of the cord. In some of the fatal cases, retroperitoneal cellulitis, continuous with the cellulitis of the cord, was demonstrated at post mortem (Madden, 1907). Castellani isolated a diplostreptococcus from the pus in the spermatic cord, and from the blood, and Coutts confirmed these findings. Castellani claimed that the diplostreptococcus was specific for the condition, as it was agglutinated in high titre by the serum of other patients suffering from acute endemic funiculitis of over two days duration. This work has neither been confirmed nor refuted. Is Endemic Funiculitis a Separate Clinical Entity ? Funiculitis is a common manifestation of filariasis. Wise (1909) described cases of acute funiculitis in British Guiana similar to those 129 10 MILROY PAUL
t.4
I 4-
w~
f i
FIG. 1. Acute endemic funiculitis. Thick cord with clots in veins. Testis normal. Small hydroccele.
FIG. 2. Acute endemic funiculitis. Thick cord. Testis normal. Type-diffuse cellulitis of cord. 130 THE BLOOD AND LYMPH PATHWAYS IN THE SPERM ATIC CORD _.~~~~t_ _-:.v4|.F.'9:8.4
,. 1 ,)I s). 17 41181' J jQiculitis. Thi ckA f ld.
FIG. 3. Acute endemic funiculitis. Thick cord.
I 61 7.. , , A . .m i .w I A's .. 4 FIG. 4. Acute endemic funiculitis. Thick cord. Several clots in veins. Testis normal. 131 10-2 MILROY PAUL II f ct t Test normal. FIG. 5. Acute endemic funiculitis. Thrombophlebitis type. Testis normal. FIG. 6. Acute endem c funiculitis. Thick cord. Large clots. Thrombophlebitis type. 132 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD described in Ceylon and Egypt, but with some differences. Dense masses of semipurulent material were found in the epididymis, and there were associated pyocoele. The body of the testis was however normal. In one of these cases, a dead adult Wuchereria Bancrofti, with larvxe and eggs scattered around it, was found in an abscess cavity between the testis and the epididymis. The finding of an adult Wuchereria Bancrofti in the cord is not uncommon (Wolfe and Schofield, 1946). In filarial funiculitis, the worms may be demonstrated in the spermatic veins, and dead worms in these veins could cause thrombophlebitis. Endemic funiculitis has one characteristic difficult to account for on the basis that it is a manifestation of filariasis, and that is its peculiar incidence. Castellani made a significant observation when he wrote: " the condition occasionally takes on a true epidemic character, numerous cases occurring within a short period of time." Modem text books on Tropical Medicine (Manson Bahr (1948), Stitt (1944) and others) describe endemic funiculitis as a manifestation of filariasis, disregarding the riddle of the peculiar incidence of this condition. The Blood Vessels in Acute Endemic Funiculitis The prominent veins filled with clot are a feature of many cords affected by acute endemic funiculitis. Madden (1907) raised the possi- bility that the condition might be a primary thrombophlebitis with secondary cellulitis of the cord, but some cords show only the changes of acute celliilitis. It is more likely that the essential lesion is cellulitis of the cord, and that patients with distended veins in the pampiniform plexus, and those with some stasis in these veins, would react to cellulitis by thrombosis. The thrombosis is so extensive that all the veins of the cord are involved. It is remarkable that the epididymis and testis should appear to be normal in such circumstances. When the patient recovers from the acute attack, the veins become recanalised except in isolated segments, but the period of venous obstruction would have lasted for some weeks, and some degree of testicular damage might well be expected. I have, however, yet to see a case of atrophy of the testis following an attack of acute endemic funiculitis. In assessing testicular damage, the two search- ing tests devised by Hansen (1949) and Engard (1949) could not be used for cases of unilateral testicular disease. There is, however, some interesting evidence in the effects of venous obstruction in the testicle. Using the dog which has a similar blood supply to that of man, Miflet (1887) ligatured the veins going to the testis, and noted that this caused a hkmorrhagic infarction followed by degeneration of the parenchyma of the testis; Griffiths (1896) confirmed these results. Of more direct application are the experiences of Burdick and Higginbotham (1935) who excised the spermatic cord from the deep inguinal ring to its point of entry into the scrotum in 200 instances for the repair of selected cases 133 MILROY PAUL If+--w or a FIG. 7. Acute filarial funiculitis. Thick cord. Pyoccele. Body of testis normal. FIG. 8. Microphotograph x 25. Acute filarial funiculitis. Diffuse cellulitis. - Adult Wuchereriae Bancrofti in lumen of veins. 134 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD FIG. 9. Microphotograph v 210. Acute filarial funiculitis. Diffuse cellulitis. Adult Wuchereriae Bancrofti in lumen of veins. FIG. 10. Microphotograph x< 400. Acute filarial funiculitis. Diffuse cellulitis. Adult Wuchereriae Bancrofti in lumen of veins. 1335 MILROY PAUL of inguinal hernia. The testis remained of normal size in 42 cases. Neuhof and Mencher (1940) employed a similar technique in 25 cases and found that the testis remained of normal size in 11 cases. In one of these cases a testicle, which had suffered division of the spermatic cord 31 months earlier, was ablated as it was.suspected to be the site of an early malignancy. This testis proved to be quite normal and even on a histo- logical examination there were but insignificant changes in the parenchyma. Here the matter rests, and these intriguing questions must await the collection of more evidence. The clot in acute endemic funiculitis affects the veins right up to the deep inguinal ring, and the clot often extends up along the spermatic veins on the posterior abdominal wall. An unusual extension of clot in a case of this kind had tragic consequences which made it an unforgettable experience. A boy of eight had been admitted to hospital on account of a tender indurated right spermatic cord. He was convalescing in the ward, when he sat up one day, suddenly restless, and in a few minutes he was dead. At the post mortem examination there was thrombo- phlebitis of the cord extending up along the spermatic vein to the inferior vena cava, which was completely occluded by a compact clot. The upper end of this clot in the inferior vena cava had a fractured face. In the heart, entangled between the valves of the right auriculoventri- cular opening, was an embolus 2 inches long, the diameter of the inferior vena cava. The fractured face of the clot in the inferior vena cava, and one of the ends of the cylindrical embolus fitted accurately. Subacute and Chronic Endemic Funiculitis The centre of interest has shifted from acute endemic funiculitis, which no longer causes anxiety, to the cases of subacute and chronic endemic funiculitis, which are so common that one or more of these cases are seen at nearly every session at the Surgical Out-Patients Clinics of the General Hospital, Colombo. The condition was first described by Coutts (1909) who wrote: " A simple non-suppurative thrombosis of the pampiniform plexus is by no means uncommon in Egypt. Cases, intermediate between the simple and the very acute, occur, and this led me to believe that all were due to some common predisposing factor." With regard to this deduction of Coutts, an experience during the last war convinced me that subacute endemic funiculitis is indeed a milder manifestation of acute endemic funiculitis on account of the cases having the same peculiar incidence as the acute cases. At a 1fritish Military Hospital in Colombo, 20 English soldiers, all from the same barracks, near Colombo, were admitted over the same period of time for subacute endemic funiculitis of the type so frequently seen in Ceylon. Stephen Power (1946) had a similar run of cases at a neighbouring Military Hospital in Colombo, and wrote an interesting account of his experiences. 136 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD Subacute endemic funiculitis manifests itself by the formation of clots in isolated segments of the pampiniform plexus of veins. Tenderness in the affected segments of vein, pain or a persistent ache in the cord or in the testicle, draw attention to the condition. There is usually no pyrexia. In the chronic type of endemic funiculitis, indolent nodules of clot in the pampiniform plexus of veins may be detected at a routine examination or may be noticed by the patient. Some cases of subacute endemic funiculitis have had the diffusely indurated cord of acute endemic funiculitis. The receding wave of inflammation leaves behind persistent clots in isolated segments of vein. The differential diagnosis of subacute and chronic endemic funiculitis The nodules produced by isolated clots in the pampiniform plexus of veins need to be examined with care to avoid errors of diagnosis. Clots in the veins in the spermatic cord are liable to be mistaken for tuberculous nodules, more particularly as the vas deferens is thickened in these cases. The nodules are, however, clearly separable from the vas deferens, on palpation, and the clinician working in an endemic area soon learns to recognise these clots. Clotted veins at the posterior border of the testis are more difficult to identify. Von Haberer (1898) made a classical research on the veins of the human testicle, and his descriptions are of particular value for visualising the position of clots at the posterior border of the testis. Von Haberer described two pampiniform plexuses of veins emerging at the posterior border of the testis, which united to form a common pampiniform plexus. The. larger of these two, the posterior pampiniform plexus, consists of wide venous channels emerging from the lower half of the mediastinum testis. The marginal vein of the testis joins this plexus after coursing upwards, medial to the tail and body of the epididymis. Clots forming in these veins would give an indurated area on the posterior border of the testis which would closely simulate an early malignant growth in the body of the testis. The anterior pampiniform plexus is made up of fine leashed vessels from the head of the epididymis, the upper pole of the testis and the upper third of the mediastinum testis. Clots are less likely to form in these fine channelled vessels. An area of induration, abutting on the posterior border of the body of the testis, should determine a search for clots in other veins of the spermatic cord, as this would suggest the correct diagnosis. In case of doubt, and more particularly if there is but one nodule giving an area of induration in the body of the testis, the lesion should be exposed at a surgical operation. The clotted vein could be clearly visualised and an unwarranted orchidectomy would be avoided. Such recognition is particularly important as the effects of clots in the pampiniform plexus are inconsequential. These veins anastomose, divide, subdivide, and anastomose again to form so complex a network that no obstruction could result from thrombosis in an isolated segment 137 MILROY PAUL FIG. 11. The veins of the testis (after Von Haberer). (1) Posterior pampiniform plexus. (2) Anterior pampiniform plexus. (3) Common pampiniform plexus. (4) Marginal vein of testis. FIG. 12. Operation view of exposure of clotted veins in subacute endemic funiculitis. 138 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD of vein. Indeed more extensive resections of the pampiniform plexus have been done with impunity for the cure of varicocoele since the intro- duction of this method by Jacobsen in 1887. Spontaneous Thrombosis of the Veins of the Pampiniform Plexus Thrombosis of the veins of the pampiniform plexus is a very rare event outside endemic areas. McGavin (1935) gave an account of three cases seen in London over a period of several years. The cases were all under the care of surgeons of the first rank, but in no case was a diagnosis of thrombosis of a vein envisaged. Orchidectomy was done in all three cases on account of some other diagnosis having been made. The cases are indistinguishable from cases of subacute endemic funiculitis, and a brief abstract of their chief features will illustrate the diagnostic difficulties of this type of case. Case 1.-Was seen on account of pain in the left testicle of five weeks duration. A hard, slightly tender nodular swelling in the globus major of the left epididymis was found on examination. The surgeon in charge of the case was doubtful of a diagnosis of tuberculosis, on account of the short duration of the illness, the diminution in its size since it was first noted, the involvement of the head of the epididymis without a lesion in its tail, and the absence of any induration in the seminal vesicles on a rectal examination. Despite these very pertinent observations, orchidec- tomy was done for tuberculosis of the globus major. Examination of the specimen showed a fibrous mass fused with the globus major which proved, on histological examination, to be a group of veins filled with organised clot. Case 2.-Had noted sudden pain in the left testicle five weeks previously. The epididymis was enlarged and tender, the spermatic cord was thickened, nodular but painless. Orchidectomy was done, the condition being considered to be tuberculosis of the epididymis and vas deferens. Examination of the specimen showed that the nodules were veins filled with organised clot. Case 3.-A hard lump fixed to the body of the testis was noted after the subsidence of an attack ofepididymo-orchitis. The lump was diagnosed as a malignant growth of the testis and orchidectomy was done. The lump proved to be a mass of thrombosed veins. McGavin supposed that these were cases in which spontaneous throm- bosis had occurred in the veins of the pampiniform plexus. Oschner and de Bakey (1939) clearly differentiated thrombophlebitis, in which clotting in a vein was secondary to inflammatory changes in its walls, from phlebothrombosis in which a bland clot extended upwards from a clot in a vein with inflamed walls into a segment of vein with normal walls. Spontaneous thrombosis in a vein with normal walls has been accepted by later workers as a pathological entity. In the cases related by McGavin, there is however a clear history of an acute phase in all three, and the cases might more properly have 139 MILROY PAUL _D.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~0-0 FIG. 13. Large mass of clotted veins excised from cord. Subacute endemic funiculitis. been classified as cases of thrombophiebitis of the veins of the pampiniform plexus. Thrombo-Angiitis Obliterans of the Spermatic Veins A new approach to the pathology of venous thrombosis in the spermatic veins, was made by Leo Buerger (1924) in his report of a case of thrombo-angiitis obliterans of the spermatic veins. A young man had consulted him on account of a subacute enlargement of the testis, epididymis and spermatic cord. Buerger, alive to the possibility of thrombo-angiitis obliterans of vessels, diagnosed tuberculosis 6f the epididymis or thickening of the vessels of the cord, and did an orchi- dectomy with high division of the cord. The specimen showed the veins of the cord and its tributaries about the testis thrombosed. Histological examination showed typical " acute " lesions. in many of the veins. . Buerger (1908) regarded the " acute" lesions as specific and diagnostic of the condition he had named thrombo-angiitis obliterans. The validity 140 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD of this criterion has been criticised not without reason. Perla (1925) pointed out that specific " acute" lesions had never been demonstrated in arteries, which are the most typical site of thrombo-angiitis obliterans. The veins on which Buerger had made his observations of acute lesions were superficial veins affected by " phlebitis migrans " and their only claim to represent the lesions of thrombo-angiitis obliterans was their occurrence in patients who were being observed by Buerger for thrombo- angiitis obliterans of the vessels of the limbs. It must, however, be conceded that it would be impossible to make studies of arteries in the early phases of thrombo-angiitis obliterans. Buerger postulated a continuous sequence of histological changes from the " acute " lesion to the fully organised clot, and he wrote: " In short, the lesions in thrombo-angiitis obliterans are in chronological order- (1) as acute inflammatory lesions with occlusive thrombosis and the formation of miliary giant cell foci, (2) the stage of organisation or healing with disappearance of giant cell foci, the organisation and canalisation of the clot, and the disappearance of the inflammatory products, (3) the development of the fibrotic lesions in the adventitia that binds together the arteries, veins, and nerves." Buerger did, however, succeed in demonstrating miliary giant cell foci in the periphery of intravascular clots in the deep veins of two out of 40 amputated limbs examined by him up to 1920. He also found in the veins affected by " phlebitis migrans" a still earlier stage of miliary foci of polymorphonuclear cells in the periphery of intraluminal red clots. Even if one grants that these histological pictures feature a continuous sequence of changes, their occurrence only in thrombo-angiitis obliterans must be queried. Koyamo (1922) and Krampf (1922) found Buerger's specific lesions in acute thrombosis following infections around blood vessels, and Buerger's own observations of the " acute " lesions in veins affected by " phlebitis migrans " make it difficult to accept his " acute" lesions as specific and diagnostic of thrombo-angiitis obliterans. Apart from the histological appearances there is nothing to differentiate Buerger's case of thrombo-angiitis of the spermatic veins from other cases of thrombophlebitis of the spermatic veins or from the lesions of subacute' endemic funiculitis. There is but one other record of thrombo-angiitis obliterans of the spermatic veins. Tartakoff and Hazard (1938) excised a nodule from a spermatic cord consisting of veins with occluding lesions. Histological examination of these veins showed miliary foci of mononuclear cells and foreign body giant cells in the periphery of the clot. The centre of the clot showed disintegrating fibrin and polymorphonuclear cells. The walls of the veins were infiltrated with polymorphonuclear cells. This is a case with Buerger's specific foci in the clot, but here again the naked eye lesions are the same as those of subacute 141 MILROY PAUL endemic funiculitis and of thrombophlebitis of the veins of the pampiniform plexus. The Internal Spermatic Artery The internal spermatic artery is an important artery. Luschka (1863) wrote: " The internal spermatic artery carries the sole blood supply to the testis." The effects of arterial occlusions of the internal spermatic artery should be dependent on the vascular patterns of the human testis. The subject of the vascular supply to the testis has however been confused by certain errors of observation by anatomists of repute, whose errors have been copied from text book to text book. Harrison and Barclay (1948) made a careful investigation and found that the account of the vascular supply given by Regnerus de Graaf (1677) and Sir Astley Cooper (1830) were in accord with their observations. On the other hand the accounts of Henle (1868), Sappey (1873) and Mihalkovies (1873), which describe a deep artery from the internal spermatic penetrating the mediastinum testis to supply the parenchyma, were found to be inaccurate. The internal spermatic artery passes down to the testis with little or no convolutions and giving off no branches to the spermatic cord and to the epididymis on the way. It then passes to half way down the posterior border of the body of the testis, where it divides into two branches which pass one on each side of the body of the testis, passing beneath the tunica albuginea, to ramify over the medial and lateral surfaces of the body of the testis in a layer immediately subjacent to the tunica albuginea. This layer was described and named the tunica vasculosa by Sir Astley Cooper (1830). The entire arterial supply of the parenchyma of the testis is derived from branches passing from the tunica vasculosa into the body of the testis along its fibrous septa. The mediastinum testis, the back- bone of the testis, gives exit to wide veins draining the interior of the testis, but no arterial branches enter through it. Thrombo-Angiltis Obliterans of the Internal Spermatic Artery There are only two cases on record of infarction of the body of the testicle. Mathe (1940) described a case in which orchidectomy was done on account of an indurated area one centimeter in diameter on the anterior border of the body of the testis, which was diagnosed as a malignant growth. Examination of this specimen showed a wedge shaped infarct of the body of the testis abutting on its anterior border. The tunica albuginea overlying it was normal, and through this layer were seen obliterated arteries running on the surface of the infarct. Section of the body of the testis showed an anemic infarct with a hemorrhagic border. The occluded arteries showed cellular infiltrations of their adventitial coats, and occlusions of their lumina by clot which was partly red and partly organised with evidence of canalisation. Here is a clear account of arterial occlusion with infarction of the testicle over an area which could be predicted from the vascular pattern ofthe testis. 142 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD FIG. 14. Microphotograph x 130. Acute enderric funiculitis. Diffuse cellulitis. Vessels of cord unaffected. FIG. 15. Microphotograph x 75. Acute endemic funiculitis. Diffuse cellulitis. Large vein with organising intraluminal clot. 143 MILROY PAUL FIG. 16. Microphotograph x 85. Acute endemic funiculitis. Diffuse cellulitis. Veins with organised intraluminal clot which is well recanalised. FIG. 17. Microphotograph x 145. Acute endemic funiculitis. Diffuse cellulitis. The artery is patent. 144 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD The other case of infarction of the testis is that recorded by Lubarsch (1927) in which operation was undertaken on a provisional diagnosis of torsion of the cord. At operation a pyocele was opened, and creamy material was seen exuding from a rent in the tunica albuginea near the upper pole of the testis. Orchidectomy was done. Section of the body of the testis showed an area of necrosis, wedge-shaped, reaching to the anterior border of the testis, with a haemorrhagic and leucocytic border. A cross section of the cord two centimetres above the testis showed the vessels to be patent at this place. Although Lubarsch postulated a torsion of the cord, which had corrected itself, as the cause of the lesion, the findings are so much the same as those of Mathe's case, that this must also have been due to a thrombotic occlusion of the terminal branches of the internal spermatic artery. There are only two other records of thrombotic occlusions of the spermatic artery. Buerger (1924) described an " old" lesion in the internal spermatic artery, and McGregor and Simson (1929) described a case with thrombotic occlusions of several veins of the pampiniform plexus, and of the internal spermatic artery. In this case orchidectomy was done, on account of the condition having been diagnosed as tuberculosis of the epididymis and the vas deferens. There are palpable nodules in the globus major and minor, and the vas was appreciably thickened. Histological examination of the occluded vessel showed veins occluded with clots which had Buerger's purulent and giant cell foci in the periphery of the clots. The muscle walls of the veins were infiltrated with acute inflammatory cells. The internal spermatic artery was occluded by organ- ised clot and within the clot was a large newly-formed channel. The effects of occlusions of the internal spermatic artery would be difficult to predict. The experiences of Burdick and Higginbotham (1935) and of Neuhof and Mencher (1940) make it evident that there is a reasonable prospect for survival of the testis in cases of occlusion of its vessels. Moreover the effects of canalisation of the clot are relatively greater in the case of small arteries of the diameter of the internal spermatic than would be the case with large arteries in the lower limb. McGregor and Simson (1929) make a comment on their case which is sufficiently interesting to warrant criticism. They wrote "The disease (thrombo-angiitis obliterans) is characterised by relapses, so that the prognosis is always doubtful. The outlook apart from operation must be extremely bad as regards the testis . . . . The prognosis for the organ is therefore bad and gangrene is a conceivable termination." These considerations are surely based on what was known of the clinical course of thrombo-angiitis obliterans in limb vessels. Although relapses do occur in these vessels, and fresh occlusions are demonstrable, they are not responsible for relapses in the clinical condition of the limb. The poorly nourished limb will fail to maintain an adequate circulation whenever external conditions become unfavourable, and clinical relapses are related to such occasions. An arterial occlusion is complete from 145 11 MILROY PAUL its outset, and there is, if anything, some amelioration of the effects of the occlusion by the subsequent development of a collateral circulation and to a lesser extent by the effects of subsequent canalisation of the clot. Very different considerations are applicable in regard to the testicle. A testicle deprived of its blood supply may necrose, it may atrophy, or it may continue to live despite an extensive vascular deprivation. There is no evidence that the lesions of thrombo-angiitis obliterans in the spermatic artery must recur. There is nothing to justify the perform- ance of orchidectomy. Moreover is a diagnosis of thrombo-angiitis obliterans of the spermatic arteries beyond doubt? The changes of thrombo-angiitis obliterans in a large artery of the lower limb arrest the swiftly flowing current of blood in such an artery. So remarkable is this phenomenon, it is diagnostic of thrombo-angiitis obliterans. Occlusal thrombosis could however occur in the terminal branches of the internal spermatic artery and even in the trunk of this artery, from infections passing through its walls, or from infection of the blood within it. If suppuration did not occur, the changes would be those of thrombo-angiitis obliterans. THE LYMPHATICS OF THE SPERMATIC CORD The solitary pathway of the lymphatic vessels of the testicle The developing testicle carries its lymph vessel from the posterior abdominal wall down with it into the scrotal sac. The isolation of this lymphatic pathway is very complete. It leads to interesting effects, some of which prove the absence of any collateral anastomoses with other lymphatics. In operating on an elephantoid scrotum, the testicle and spermatic cord on each side are shelled out of two small beds within the gigantic scrotum. The scrotum is made up of elephantoid tissue which extends inwards from the dermis of the skin to fill the scrotal cavity. The small beds housing the testicles are lined by a smooth membrane, and the plane of separation between this membrane and the external spermatic fascial sheath of the testicle and spermatic cord is never transgressed, no matter how large the scrotum becomes. The testicle and spermatic cord always remain unaffected and of normal size and shape. The two lymphatic pathways of the testicle and of the scrotum respectively maintain their separate paths despite their close proximity. Barringer (1940) in autopsies on 37 cases of teratoma of the testis found no matastases in the inguinal glands till the testicular growth had invaded the scrotal integuments. Malignant cells invading lymphatics even by retrograde permeation could not find any communication across the plane separating the lymphatics draining the testicle and that draining the scrotum. Obstructive Dilatation of the Lymphatic Vessels of the Spermatic Cord The lymphatic vessels of the normal spermatic cord are not visible to the naked eye. The surgeon operating on inguinal hernia in Ceylon 146 TIfE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD FIG. 18. Elephantiasis of scrotum. Shows disposition of elephantoid tissue. occasionally exposes a spermatic cord made up of dilated vessels which look like varicose veins, but which contain lymph instead of blood. These dilated vessels are delicately transparent; the colourless fluid within them is clearly to be seen; there is no trace of scarring in the spermatic cord, and the connective tissues uniting the dilated lymph vessels are barely visible. The dilated vessels conceal all other con- stituents of the cord. Here is a picture of gross damming of lymph in the lymphatics of the cord, and yet there is no evidence of cedema of the cord and the testicle maintains its normal appearance. The lesion gives good proof of the truth of the statement that even in the presence of gross obstruction to the outflow of healthy lymphatic vessels there is no accumulation of fluid in tissue spaces. This gross obstructive dilatation of the lymphatic vessels of the spermatic cord is only seen in patients who have been exposed to filarial infections. It is diagnostic of filariasis. The obstruc- tion must be in the lymphatics of the posterior abdominal wall. Funicular Lymphangitis Lymphangitis is common in filariasis. It would be natural to suppose that filarial funiculitis might be the result of lymphangitis. Lymphangitis 147 11-2 MILROY PAUL FIG. 19. Dilated lymphatic vessels of spermatic cord as viewed at an operation for repair of inguinal hernia. in the subcutaneous tissues manifests itself by the development of red indurated streaks which delineate the path of infection up the lymphatics. In acute endemic funiculitis there is diffuse cellulitis of the cord and there is nothing to delineate the lymphatics. Moreover what could be the source of lymphangitis in filarial funiculitis? Low (1944) stated that the epididymis was a favourite site for the adult Wuchereria Bancrofti and that it set up inflammatory changes around it. Manson Bahr (1948) found filariae around the vasa efferentia of the testis, with associated inflammatory changes, and Wise (1909) found a dead adult worm in an abscess cavity between the testis and the epididymis. Such lesions could be the focus of lymphangitis in the cord. In Ceylon, filarial orchitis is not common. This might be due to the differences in the habitat of the filarial worm, such differences between countries being well known. There is, however, another route which could give lymphangitis of the cord in filariasis the retrograde route. Murray (1949) observed that in the subcutaneous tissues retrograde centrifugal spread of lymphangitis 148 THE BLOOD AND LYMPH PATHWAYS IN THE SPERMATIC CORD was diagnostic of filariasis. This could be applicable to the lymphatics of the spermatic cord. There are, however, objections to the theory of lymphatic infection of the cord in filariasis. Lymphangitis complicating filariasis gives chronic cedema and finally elephantiasis. In Ceylon elephantiasis of the lowver limb is common, and elephantiasis of the scrotum is not infrequent. Elephantiasis of the spermatic cord is unknown and even the stage of cedema which precedes the formation of elephantoid tissue is also not seen in the cord. The repeated infections of water-logged tissues by recurrent bouts of lymphangitis, so common in the lower limb and in the scrotum in filariasis, does not occur in the cord. The cord affected by funiculitis is a normal one. Even when the cord has been the seat of a previous attack of funiculitis there is restoration of the normal suppleness of the cord, and the next attack of funiculitis again attacks a normal cord or a cord with isolated clots in its veins. The changes of funiculitis are those of a diffuse cellulitis. Its origin is obscure. The adult filarial worm can be demonstrated sometimes in these cords. Microfilarie can be demonstrated in the lymphatics of the cord in some of the cases. Filarial funiculitis is a definite entity. The peculiar incidence of endemic funiculitis warrants its recognition as a separate condition. Conclusions The lesions of endemic funiculitis and the manifestations of filariasis in the spermatic cord have been made the basis for a review of some of the affections of the blood and lymph vessels of the spermatic cord. The significance of some clinical observations made in this field are discussed. This lecture owes much to the encouragement and help given me by my old teacher, Sir Cecil Wakeley, President of the College. It is also a pleasure to acknowledge the help of Professor Karunaratne and Dr. Attygalle of the Department of Pathology, University of Ceylon, and of Dr. W. D. Ratnavale, now in London, who gave much valuable help and advice. I am very conscious of the honour accorded my country and me by the Council of this College. The privilege of delivering this Hunterian Lecture will be a treasured memory, and I can here just say: Thank you for encouraging me to venture a little into the strange seas of the unknown. REFERENCES BARRINGER, B. S. (1940) Tr. Am. Ass. of Genito Urinary Surgeons 33, 269. BUERGER, LEO Am. J. of M.Sc., Oct. 1908 136, 567. Medical Record, March 13, 1920 431. (1924) The Circulatory Disturbances of the,Extremities. Philadelphia, W. B. Saunders & Co. 149 MILROY PAUL CASTELLANI, A. Lancet, July 4, 1908, 15. B.M.J., Sept. 18, 1909, 780. and CHALMERS, A. (1919) Tropical Medicine, 3rd Ed. Bailli&re, Tindall & Cox. COOPER, Sir Astley (1830) On the Anatomy of the Testis. Observations on the Structures and Diseases of the Testis. Longman, Rees, Orme, Brown and Green. CouTrs, D. K. Lancet, Jan. 23, 1909, 229. DE GRAAF, R. (1677) Opera Omnia, Leyden. ENGBERG, H. Proc. Roy. Soc. Med., 1949 42, 634. HABERER, H. (1898) Arch. fir Anat.. u. Phys. 413. HANSEN, T. S. Proc. Roy. Soc. Med., 1949 42, 634. HARRISON, R. G., and BARCLAY, A. E. Brit. J. Urol., 1948 20, 57. HENLE, J. (1868) Handbuch der systematischen Anatomie des Menschen, 3 Gefaisslehre Braunschweig, Vieweg. HUNTER, J. (1786) Observations on Certain Parts of the Animal Economy. A description of the situation of the testis in the fietus with its descent into the scrotum. JACOBSEN (1887) Quoted by Henry Morris. Injuries and Diseases of the Genital and Urinary Organs. Cassel and Co., 1895. KoyAmo (1922) Acta Scholae Med. Univ. Imp. Kioto 4, 468. KRAMPF (1922) Deut. Zeits. f. Chir. 174, 387. LUBARSCH, S. J. (1927) J. Urol. 18, 421. LUSCHKA, H. (1863) Die Anatomie des Menschen, 2, Pt. 1, 322. Tiubingen, Laupp MADDEN, F. C. (1907) Lancet 1, 505. MANSON-BAHR, P. H. (1948) Manson's Tropical Diseases, 12 Ed. MATHE, C. P. (1940) J. Urol. 44, 768. McGAVIN, D. (1935) Lancet 2, 368. McGREGOR, L., and SIMSON, F. W. (1929) Brit. J. Surg. 16, 539. MIFLET, J. (1879) Arch. f klin. Chir. 24, 399. MIHALKOVIES, V. von (1873) Ber. Sachs. Ges. (Akad.) Wiss. 25, 217. NEUHOF, H., and MENCHER, W. H. (1940) Surgery 8, 672. OSCHNER, A., and DE BAKEY, M. E. (1939) South Surgeon 8, 269. PERLA, D. (1925) Surg. Gynec. Obstet. 41, 21. POWER, S. (1946) Lancet 1, 572. SAPPEY, P. C. (1873) Traite d'Anatomie Descriptive, 2nd Ed. 11, 612. STrrr, (1944) Diagnosis, Prevention and Treatment of Tropical Diseases. Edited by R. P. Strong. TARTAKOFF, J., and HAZARD, J. B. (1938) New Eng. J. Med. 218, 173. WISE, K. S. (1909) J. Trop. Med. 276. WOLFE, H. R. I., and SCHOFIELD, A. L. (1946) Brit. J. Surg. 33, 395-396. HONORARY MEMBERSHIP OF THE BRITISH DENTAL ASSOCIATION At the annual meeting of the British Dental Association, held in the Great Hall of the University of Birmingham, on Tuesday, 11th July, 1950, Sir Cecil Wakeley, was elected an Honorary Member of the Association. 150