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<xg+8 , \l\ttF4 i' 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.