70 MR. BILTON POLLARD ON PERINEAL DISPLACEMENT OF THE TESTICLE.

have been described by Carp 15 in Wesel are of more fpquent occurrence. I, however, do not think this probableWere this the case, then the observations of RumpeP6 anothers of the finding of Koch’s vibrio in the faeces of healthindividuals-a fact sufficiently noteworthy by itself-woulappear in quite a different light. These observations (

Rumpel do not upset Koch’s views, since they were madon individuals who were in relationship with cholera patientor who lived in cholera-infected localities, so that thercould be no doubt about the origin of the vibrios. Fcthe rest, a vibrio resembling the cholera vibrio was oncfound by Metchnikoff 17 in the fseces of a patiensuffering from constipation. Absolute identity was no

asserted, and no exact description published. In thisolated cases described by Finkler and Prior 18 and by Prioalone, of the growth of vibrios in cholera nostras, the cultivations were those of the vibrio proteus, a species quitldifferent from the cholera vibrio. In the isolated cases, itwhich vibrios have been cultivated from the intestinacontents or evacuations of healthy individuals, or fronpatients suffering from other diseases, it appears thaonly a few vibrios were present. In addition all th(observers 19 state that the vibrios were easily distinguishable from the cholera vibrio. In any case, these obser.vations show that great care should be taken irmaking bacteriological examination of suspected cases oj

cholera, and Koch 20 was certainly wrong in ridiculingtheprecaution taken to avoid confusion with the vibrio pro-teus. It is not true that this species has only been foundonce in stinking stools. Finkler and Prior state that theyfound it in ten cases of cholera nostras, and Finkler 21 statesthat in two cases he found it present in pure cultivations.I have found it22 in the decomposed intestinal contents of apatient who had died with symptoms suspicious of cholera,Lustig 23 twice in cases of cholera in addition to Koch’s vibrio,and Knisl21 in the intestinal contents of a person who hadcommitted suicide. That the vibrio proteus is not a veryrare species is shown by the observations made by MaxTeich and E. Wiener in my institution during the autumnof last year. This species was frequently isolated from thewater of the Vienna Danube Canal. We have cultivated itthrough many generations and shall be glad to give cultiva-tions to anyone who requires them.

In spite of these observations the second part of Koch’sproposition is, nevertheless, generally correct-i.e., that

spiral-shaped bacteria simulating the comma bacillus are

not found either microscopically or by cultivation in the intes-tinal evacuations of healthy individuals or of patients sufferingfrom other diseases. In the course of years I have examined

bacteriologically twenty cases of endemic diarrhoea (choleranostras). In many of these cases I have been able to find bymicroscopical examination spiral bacteria in large numbers.They were, however, easily distinguished by their appearancefrom the comma bacillus. They were long, sharply curved,and somewhat slender S forms, staining badly, single or

united into zoogloea masses, and with the ends pointed. Wewere doubtless dealing with the well-known parasites ofthe small intestine described long ago by Escherich. Corre-

sponding to this, I never succeeded in cultivating anykind of vibrio from any case of cholera nostras. Neitherhave I ever been able to cultivate vibrios from- the faeces ofhealthy persons or of individuals suffering from diarrhoea, noteven when vibrios similar to the comma bacillus could bedetected microscopically. In former years I made a largenumber of such examinations. These negative results in casesof cholera nostras have an especial importance, since theyshow that the comma bacilli found in Asiatic cholera are notnormal inhabitants of the intestinal canal, or widely dis-tributed saprophytes, which take the opportunity of multi-plying to an enormous extent, on account of the diseasedcondition of the intestine?.The following are the conclusions I would draw: 1. The

views of Koch are true, that in cholera there are presentvibrios which can be distinguished from all others occurringin the intestinal content*. In additior, the vibrio is of

15 Deutsche Med. Wochenschrift, 1893, No. 2.16 Loc. cit.

17 Annales de l’Institut Pasteur. 1893. No. 7, p. 565.18 Ergänzungshefte zum Centralblatt fur Allg. Gesundheitspflege,

1885, i., fasc. 5, 6.19 B. Fischer (vibrio helcogener), Deutsche Med. Wochenschrift, 1893,

No. 49. Koch, loc. cit., 338. Zorkensdorfer : Prager Med. Wochenschrift,1893, No. 43.

20 Loc. cit. 21 Loc. cit.22 Wiener Med. Wochenschrift, 1887, Nos. 7 and 8.

23 Loc. cit. 24 Fortschritte tier Medicin, 1886, No. 4, p 144.

- etiological significance, although many observations render. it necessary to make wider investigations in order to furtherd prove the truth of Koch’s propositions. 2. It is possible thaty the vibrios found in the different epidemics of cholera belongd to several closely related species. Anyhow the cholera vibrio.If occurs in several sub-species morphologically different. 3. Ite is difficult to distinguish the different species of vibrio, ands especially the cholera vibrio, from one another. 4. Some of thee hitherto accepted distinguishing characteristics of the cholera.r vibrio are of no practical value, others have only the significa.e tion of characteristics of groups of vibrio species, and are.

t therefore not sufficient in difficult cases to distinguish the,t species. Such characteristics are the following : gelatine stab.e cultivations, agar cultivations, potato cultivations, broth cnl.r tivations, the behaviour towards milk, the reaction to litmns.- broth, the nitroso-indol reaction, and the intra-peritoneal3 inoculation of guinea-pigs. 5. In the examination of sns-i pected cases of cholera these difficulties are of not much1 importance, since the vibrios found in the evacuations of other-i cases are easily distinguished from the cholera vibrio, and in, the majority of cases of cholera the vibrios found are quite.; characteristic. 6. On the contrary, we must look with. suspicion on the discovery of cholera vibrios in other material

than the:intestinal evacuations in connexion with cases ofI cholera. In the same way we must be suspicious of the! identification of vibrios found in water with the comma.! bacillus, and occurring without any known connexion with

Indian cholera. Especially must we be careful since these-I observations have generally been based upon the criteria

above mentioned and discussed. 7. The microscopical appear-ances of quite young colonies of Koch’s vibrio in 10 per cent..gelatine appear to be almost absolutely characteristic. Atany rate I have not met with similar appearances in anyother kind of vibrio species. The observations, however, mustbe made under certain definite conditions in order to be-reliable.

A CASE OF PERINEAL DISPLACEMENT OFTHE TESTICLE.

BY BILTON POLLARD, B.S. LOND., F.R.C.S.ENG.,ASSISTANT SURGEON TO UNIVERSITY COLLEGE HOSPITAL, AND SURGEON

TO THE NORTH-EASTERN HOSPITAL FOR CHILDREN.

ECTOPIA PERINEALIS, which is the commonest form of

displacement of the testicle, comprises two varieties-thescroto-femoral, in which the testicle occupies the groove.between the scrotum and the thigh ; and the true perineal,in which the testicle is located behind the scrotum, about aminch and a half in front of the anus and close to the mediae

raph6. The case reported below was an instance of the first.mentioned variety. It is not recorded as a mere instance ofectopia testis, for, though uncommon, the varities of displace-ment of the testicle are sufficiently well known ; it is reportedin order to illustrate a little device which proved useful inrectifying the malformation, and because it is possible to-record the state of the parts seven years and a half after the’operation.An infant aged one month was admitted to the North-Eastern

Hospital for Children in October, 1886. The left testicle occu-pied its proper position in the scrotum, but the right one lay it:-the posterior part of the groove between the scrotum and thethigh, where it formed a distinct projection, as shown in theoaccompanying engraving (Fig. 1), which has been executedfrom a photograph. The right side of the scrotum wa&

flattened, and appeared to be badly developed. Defectivedevelopment of one side of the scrotum has been advancedas an explanation of the malposition. It is more probablethat it is a result rather than the cause of the malposition"and in this case the smallness of the scrotum was moreapparent than real. The testicle was not very movable. Itsspermatic cord could be traced upwards to the externalabdominal ring. An incision was made from just below thering to the lower end of the testicle. The testicle andspermatic cord, with their coverings, were then raised fromtheir bed, as in the operation of castration, and turnedupwards as far as the external abdominal ring. An in-cision was next made into the lower part of the scrotum,and a new bed was prepared for the testicle there..The scars of these incisions are shown in the engraving(Fig. 2), which has been executed from a photograph whicbwas taken seven and a half years after the operation. A

71DR. W. M. DUNLOP ON SMALL-POX IN A CASUAL WARD.

sinus forceps was then thrust from this wound through the’cellular tissue of the upper part of the scrotum to the upperpart of the first incision near the external abdominal ring,- and its Mades were separated so as to dilate a track for theartificial descent of the testicle. Through this track thetestide was pushed down to its fresh bed at the bottom ofthe scrotum. Both wounds were then closed with sutures.They healed by first intention, and the infant was dischargedon the tenth day after the operation. The testicle had notendency to return to its former position, and indeed thiswas not possible, for the two wounds only communicated bya narrow track, which connected the upper ends of each andalong which the testicle had only been forced under consider-able pressure. The boy was seen again seven and a halfyears after the operation, and the photograph from which the

accompanying engraving (Fig. 2) was made was taken then.The testicle occupies its natural position in the scrotum. Itis as large as its fellow, and when the inner side of the thighis stroked in the way the cremaster reflex is excited thetesticle is retracted as thoroughly and as briskly as the leftone is under similar circumstances. This, of course, showsthat the cremaster muscle had been transplanted along withthe testicle and that its development has not been impaired.The operation in this case was performed when the child was<only one month old and both wounds healed by first intention.Most authorities recommend that transplantation of thetesticle should not be attempted until the child is two yearsold, owing to the difficulty of keeping the wounds aseptic atan earlier age. This is not an insuperable difficulty, and so,seeing that misplaced testicles are likely to develop badly, itis wiser to perform the operation during the first few months

after birth. It is, of course, different in cases of incom-

pletely descended testicles, for in them it is possible thatfurther descent may be effected by natural means alone.Transplantation of the testicle from the perineum to thescrotum has been attempted several times, but not alwayswith success, and, so far as I am aware, the plan adoptedin this case has not been tried before. Attempts have beenmade to reach the testicle through a single scrotal incisionand to draw it forwards to its proper place. Its tendency toslip back to its original position has necessitated its beingstitched to the scrotum. The plan adopted in this case notonly got over this difficulty but also prevented retraction ofthe testicle towards the external abdominal ring, as is apt tooccur when the scrotal and perineal incisions communicatefreely at their upper extremities. The perfect functionalactivity of the cremaster muscle which was observed seven

and a half years after the operation is an additional featureof interest in thia case.

Harley-street, W.

SMALL-POX IN A CASUAL WARD.BY W. M. DUNLOP, M.B., C.M. GLASG.,

RESIDENT MEDICAL OFFICER, ST. PANCRAS WORKHOUSE INFIRMARY, N.W.

ALTHOUGH my acquaintance with casual ward life is notso realistic as that of a certain versatile and able writer whoonce upon a time sought admission and actually lived andslept as a tramp for one or more days and nights for anultimate literary purpose, still I have seen sufficient of thisnomadic section of civilisation to make it probable that myobservations and experience may not be without general, ifnot, indeed, of medical interest. And it happened in this way.In the early part of last year, when a recrudescence of small-pox occurred, it came to the knowledge of the Local Govern-ment Board that several cases of the disease had appearedin casual wards of the metropolis and elsewhere, and theBoard therefore issued a circular letter to the Poor-lawguardians suggesting the propriety of a systematic dailymedical inspection being made of the wayfarers, with the’primary object of detecting small-pox and dealing with thecases at once. I was appointed to perform this duty at thecasual wards of this parish, the period of inspection extending’over seven months-from Feb. 28th to Sept. 30th, 1893.I made my visits nightly between 7.30 and 8.30 (thehour in which nearly all good casuals come in), andduring these seven months I passed in review 3896 tramps,comprising a motley crew of 3197 men and 630 women,and, I grieve to add, 69 children, mostly girls. Threecases of small-pox occurred at different times, and inevery case the casuals applied for admission either with theeruption on them or just appearing, and requiring only a fewhours’ observation to ensure the diagnosis. They had, infact, been wandering about in this infected state, and had itnot been for the Board’s valuable suggestion they wouldprobably have gone at large once more, circulating as activecentres of infection and thus swelling the figures in that" diffusion of small-pox " to which frequent reference is madein the columns of THE LANCET. All the cases were sent assoon as possible to hospital, the remaining casuals were vacci-nated, and the wards were closed until they hadbeen efficiently fumigated and disinfected. A curious in-cident happened on our first disinfection. After theward door had been sealed up so as to prevent the escape ofthe fumes of the material used, the superintendent’s cat, afine tabby, was nowhere to be found; next morning whenthe door was reopened the animal was found lying just insidein a dazed condition, from which it soon recovered on

being taken out into the fresh air, after having been inthe sulphurous chamber for over sixteen hours. This factmay make the sceptic ask: "If this were all the effectthe fumes had upon the unfortunate cat, how did theinfective germs fare? " Perhaps, however, the incident letsa side-light in on the fable about the cat having ninelives. As has been said, vaccination was performed inall cases where necessary ; a considerable number objected,but, as a rule, the great proportion of them, after per-suasion and a little reasoning, readily assented. A few,however, declared that they would rather die of small-pox,or have their arms cut off at once, or have some other equallyunnecessary thing happen to them. On account of theirwandering habits of life a very large proportion of thesetramps were either not vaccinated at all or very inefficientlyprotected, and thus these inspections had not only the value

; of their original design, but they also afforded frequentopportunities of offering, as I did, the benefits of vaccination

i to these people. It was by no means uncommon, especially! among the casuals of older years, to see their faces and. bodies deeply pitted from confluent small-pox which theyhad had in their younger days ; none of them had any know-ledge of ever having been vaccinated-several did not know

I what it meant-and in none of the cases could I trace any. vaccinal cicatrix.; As regards diseases other than small-pox I found these. casuals remarkably free from all the ordinary ailmentsI which flesh is heir to ; many were, as a matter of course,t footsore; one of the "army men had marked aorticl aneurysm, and I came across a few transient cases ofl erysipelas which soon got well after a few days in our