/ TUBERCULOUS EPIDIDYMITIS A CLINICAL AMD AETIOLOGICAL STUDY by WALTER M. BORTHWICK ProQuest Number: 13850421 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 13850421 Published by ProQuest LLC(2019). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 S C HEM A Page ACKNOWLEDGMENTS CHAPTER 1. Introduction ........................... 1 2. The Normal Genitalia ............. 4 (a) Embryology .......................... 4 •(b) Anatomy ............................. 15 (c) Physiology .......................... 30 3. The Aetiology of Tuberculous Epididymitis. .. 36 (a) General Incidence .......... 36 (b) Age Incidence ................ 42 (c) Extra-Genital Tuberculous Lesions .... 48 (d) Injury .............................. 52 (e) Infection......................... 57 4. The Diagnostic Standards of Tuberculous Epididymitis. 60 5. The Local Lesion ........................... 67 (a) Incidence of Double Affection ........ 67 (b) Classification of Tuberculous Epididymitis ..................... 72 (1) Subacute and Chronic Epididymitis . 81 (2) Acute Epididymitis .......... 99 (c) Tuberculosis of the Testis ........... 108 (d) Tuberculosis of the Vas Deferens..115 CHAPTER Page 5. (Contd.) (e) Scrotal Pistulae in Association with Tuberculous Epididymitis......... 120 (f) Hydrocele and its Relation to Tuberculous Epididymitis......... 127 (g) Involvement of Inguinal Glands in cases of Tuberculous Epididymitis. ••• 129 6. Pelvic Coincidental Lesions. ................. 132 7. Associated Renal Lesions................. 171 8. The Pathogenesis of Tuberculous Epididymitis.............................. • 227 9. The Treatment of Tuberculous Epididymitis •••• 253 A. (a) Conservative Procedures ............. 253 (b) Operative Procedures ............ 260 B. Treatment and Early Results of Present Series ...........•..................... 278 10. The Prognosis and Late Results of Tuberculous Epididymitis............... 320 11. Operations for Genital Tuberculosis. ......... 337 12. Summary and Conclusions........... 348 Bibliography. ............................... 363 ACKNOWLEDGMENTS To Dr. John Watson, Superintendent of Robroyston Hospital and Sanatorium, Glasgow, the writer is grateful for the facilities offered to him in the examination of patients and for the use of the hospital case-reoords without which the investigation could not have been carried out. The initial stimulus to probe the subject of genital tuberculosis in men, he owes to Dr. M. A. Poulis, Deputy Superintendent and Senior Resident Surgeon, Robroyston Hospital, whose interest in the subject equalled that of the writer!s, thereby making the arguments and discussions which followed the more helpful and instructive. For reading and correcting the original copy of the investiga­ tion the writer is again indebted to Dr. Poulis and also for many of the radiological examinations. Although most of the instrumental investigations were carried out by Mr. Arthur Jacobs, Urologist, Glasgow Royal Infirmary, for which the writer places on record his thanks, he is perhaps more grateful to Mr. Jacobs for the tuition in cystoscopy and ureteral catheterisation which was given to him in Robroyston Hospital and in the Glasgow Royal In­ firmary, thereby enabling the writer to carry out many in­ vestigations himself. The co-operation extended by Dr* Stuart Laidlaw, Senior Tuberculosis Officer and the Tuberculosis Officers, Glasgow Corporation Public Health Department, was invaluable to the writer in his attempt to review all the available patients. Recognition is also due to the former patients of Robroyston Hospital who attended for re-examination, some of whom underwent the discomfort of cystoscopy, but the writer would point out that, up to the present time, several patients have benefited to the extent of having had surgical treat­ ment for an unsuspected renal tuberculosis which had extended beyond the renal cortex and medulla* WAITER M. BORTHWICK. Robroyston Hospital, July, 1944* 1 CHAPTER 1 - INTRODUCTION It would be Indeed an ambitious hope to expect that anything wholly new could derive from an article whose genesis is the accumulated reoords of a hospital; but its Justification is to be found in the very volume of the evidence sifted in an attempt to establish firmly what is known or suspected of tuberculous epididymitis. In this thesis a careful survey has been made of the 402 hospital histories whose pages show evidence that tuberculous disease of the epididymis occurred at some time in the course of a patient's illness. Anything or any record which suggested that the epididymal condition could have been other than tuberculous has occasioned the discard ment of such a record; and it is to the great credit of the dispensary tuberculosis officers of Glasgow that these rejected records are exceedingly few in number. Later will be given the criteria by which a lesion is judged to be tuberculous, but it is the writer's belief that each lesion referred to had the origin assigned to all. The period covered by the files goes as far back as 1921 and the most recent records discussed are those of patients who were admitted to Robroyston Sanatorium up to the end of the year 1941. 2 The writer's interest in the subject on the title page dates back to a little time after his Joining the staff of Robroyston Sanatorium in 1936. As an Assistant Resident Medical Officer he had both surgical and medical lesions in his keeping, and on becoming Senior Resident Medical Officer in 1937 his further duties included some degree of super­ vision of his more Junior colleagues and their wards. Throughout this earlier period he was still a novice in the treatment of tuberculosis, but a lasting impression of that period was the marked difference between the treatment of tuberculous epididymitis as practised by his senior col­ leagues, and his own teaching supplemented by post-graduate reading. Argument, discussion and observation of results culminated in his being convinced in some degree of the Justification of the established practice at the hospital, and following a short paper read to the Tuberculosis Society of Scotland by a senior colleague it became obvious to the writer that nothing short of a mass survey of all the cases dealt with in the past could throw further light on the matter; in this conclusion his senior colleagues, both resident and visiting, heartily concurred. In 1940 the writer became Junior Resident Surgeon and his increased responsibilities and further duties resulted in a close liaison between himself and the Visiting Urologist, to whom he is indebted for the instrumental investigation of many 3 of the patients. It has already been suggested that the perusal of case records can but rarely lead to wholly con­ vincing evidence. At best, findings derived from such sources can be but suggestive; and this viewpoint gains added weight when the period of time covered is a long one. In such a period many Resident Medical Officers have been responsible for the records and it is little to be wondered at that there has been great variation in the importance attached to tuberculous epididymitis. On the whole, where the lesion has been the cause of a patient's admission, the description and investigation have been adequate, but where a tuberculous epididymitis occurred as a complication of a more serious condition, the recorded notes have not always proved adequate for the purposes of this investigation. Most interesting, however, is the obviously growing interest in tuberculosis of the epididymis which has taken place throughout the years covered. Whereas in the earlier records scant attention was paid to the wider significance of the lesion, the later records show a growing recognition that tuberculous epididymitis is but an obvious lesion in a widely disseminated though frequently hidden tuberculous infection. To a great extent the writer has focussed his attention on these wider implications. 4 CHAPTER 2 - THE NORMAL GENITALIA (a) EMBRYOLOGY» A* General considerations. B. The genital organs. (1) The indifferent stage (a) The gonads (b) The primitive genital ducts. (2) The stage of differentiation (a) The testes (b) The transformation of the mesonephric tubules and ducts. (c) The transformation of the Mftllerlan ducts (d) The ligaments of the internal gen­ italia . (3) The descent of the testis* C. The development of the scrotum, urethra, and prostate gland. A. General Considerations. In development, there is an intimate association between the urinary and reproductive systems. These two systems originate from mesoderm of the same region and though at first visible as a common urogenital fold, further growth soon brings about a sub-division into nephric and genital 5 ridges. Early In embryonic life, these systems are united through a joint use of the cloaca and later close relation­ ship is maintained, especially in the male, where the urethra is utilised permanently as a.common urinary and genital duct• The history of each system is complicated as, some organs result from the association of