So much for vaccination. We will now hurriedly refer to our practice in reference to isolation. The health officer recommended the following, which became a law in this city February 6, 1899: "That any person who shall have the smallpox and refuse, on the demand of the health officer, to be sent or to be taken to the Eruptive Hospital, or to remain at said hospital, after being sent or taken thereto, during his or her illness from said disease or before being discharged therefrom by its superintendent, shall be fined not less than twenty-five dollars, nor more than one hundred dollars, for each offense."

It will be observed that the health officer has absolute authority to compel isolation by having all persons conveyed to the Eruptive Hospital, which is situated at least five miles from the city on a large tract of land which belongs to the city. Since I have had the honor to be health officer of this city, we have had six hundred and sixty-one cases of smallpox, and that you may know how I have exercised my authority in this direction, I report the fact that out of this number all were sent to the Eruptive Hospital, and thus put in complete isolation, with the exception of nine persons, and they were in such physical condition that their lives would have been endangered by removal, and I will say that three did die within forty-eight hours.

When a suspected case of smallpox is reported to the health department by a physician or otherwise, one of the physicians connected with the office, who is experienced in the diagnosis of this disease, visits the suspected case, and if found to be suffering from smallpox, the ambulance is immediately telephoned for, and the patient is removed to the Eruptive Hospital. The physician then vaccinates the immediate neighborhood. The next step is to send an inspector from the health office who knows his business, and all the old bedding and woolen fabrics in the infected house are saturated with coal oil and cremated, the city remunerating the owners of the property thus destroyed.

The infected house is then tightly closed and fumigated with formaldehyde gas. We use the H. K. Mulford regenerator and a forty-percent solution of formalin. Health departments all over the country after having tried all known means of disinfection have almost unanimously concluded that formaldehyde is the most destructive agent to germ life now known, and our own personal experience fully justifies this almost universal opinion. I am enabled to say that in almost every instance, when cremation and formaldehyde disinfection for a period of from four to six hours has been practiced, we have not had a recurrence of smallpox.

While formaldehyde gas is a destroyer of odors, it has scarcely any odor itself, and it does not attack metals, as does sulphur and other substances which are sometimes used for disinfection. In the use of this agent for the destruction of germ life it is necessary to first close the windows, doors, and other openings of the room or rooms to be disinfected as tightly as possible with folds of paper, wet batting, or old cloths. Bed clothes, carpets, and other fabrics should be lightly spread over chairs and bedsteads. The amount of formaldehyde to be used in any given space can be obtained by multiplying together the length, breadth, and height of the room or rooms, and then allow from eight to twelve ounces of forty-per-cent solution of formaldehyde to each one thousand cubic feet of room space to be disinfected.

It will be thus seen that it would require thirty fluidounces of formaldehyde to properly disinfect a room 15 x 20, with a ceiling 10 feet high. This amount of formaldehyde will be evaporated in about forty minutes. The space thus treated should be kept closed from six to twenty-four hours.

There has recently been placed upon the market a para-formaldehyde candle, put up in two sizes, which can be used as are the candles of sulphur dioxide. These candles consist of para-formaldehyde incorporated with a small proportion of paraffine and pressed in cylindrical form.

These candles are supplied in a tin container or burner, to which a limited amount of oxygen has access during operation, so as to support combustion only at the bottom of the candle, and by burning in this manner the heat produced causes the solid para-formaldehyde to revert to the gaseous formaldehyde.

The smaller of these candles contain three hundred and fifty grains each, and when ignited generate sufficient gas for the surface disinfection of a room not exceeding three hundred cubic feet capacity, and by increasing the number of candles, in the proportion of one candle to every additional three hundred cubic feet of air space, any sized room can be disinfected. The larger candles, containing seven hundred grains of paraform, are useful in disinfecting larger spaces, such as halls, churches, and school-houses.

Exhaustive tests have been made by the bureau of bacteriology of the health department of the city of Buffalo, N. Y., as to the destructive efficiency of these candles. These experiments have fully developed the fact that all pathogenic microbes and spores are energetically destroyed, without exception, by their proper use.

It should be remembered that formaldehyde gas disinfection can not be positively relied on so far as glazed surfaces, such as china, marble, metal, etc., is concerned, and that subsequent washing of these surfaces should be practiced with a solution possessing such recognized properties as a five-per-cent solution of formalin, carbolic acid, or some other disinfecting solution possessing solvent and penetrating germicidal powers.

I will say for the information of any one who may wish to try these candles for disinfecting purposes in any character of contagious diseases, he can be put in communication with the State agent by communicating with the health department of this city.

Now, to sum up the suggestions contained in this paper, which is already too lengthy, I will say that vaccination and revaccination promises absolute immunity against variola, one of the most disgusting diseases with which the human family have to contend. Secondly, that perfect isolation completely checks the spread of variola, and thirdly, that disinfection properly performed with formaldehyde gas does, beyond any reasonable doubt, destroy bacterial life. If these three methods as suggested will accomplish what is not only claimed in this paper, but confirmed by the experience of the whole world and admitted by all intelligence, both professional and otherwise, why should smallpox prevail in any community? And are not those in official authority morally responsible for not providing the proper means to prevent sickness and death from such a disgusting and loathsome disease as is smallpox?

LOUISVILLE.

TUBERCULOSIS OF THE TESTICLE AND EPIDIDYMIS.*

BY IRVIN ABELL, M. D.

Assistant to Chairs of Anatomy and Clinical Surgery and Demonstrator of Genito-Urinary Diseases, Louisville Medical College; Visiting Surgeon Louisville City Hospital.

In reviewing the literature upon this subject one is impressed with the diversity of views upon several points connected therewith, expressed by men whose prominence commands respect for their opinions. That the process in the testicle is ever primary is denied by most writers, others regarding it of such rare occurrence as to pass

* Read before the Louisville Pathological Society.

it with a simple mention. That the process in the epididymis is often primary we find asserted by such men as Senn, Councilman, Reclus, Murphy, Saleron, and other investigators, while Virchow, Koenig, and Kocher have always held that the infection is a descending one.

Councilman states his belief that the most common seat of primary urogenital tuberculosis is the epididymis, as follows: "It may be confined to this or the testicle affected by continuity. The epididymis is converted into a more or less firm caseous mass. From this the disease extends along the vas deferens, which becomes enlarged, and, on section, the interior is found to be lined with a whitish caseous tissue. In both the vas deferens and the epididymis the seat of the disease is primarily in the epithelium, and later takes the form of a tubercular inflammation. Seminal vesicles on the same side become affected in most cases, or they may be passed by and the disease appear in the prostate or bladder."

Fuller says: "It is rare for the tubercular deposit in the epididymis to represent a primary focus of disease, as, in a vast majority of cases, the inflammation has extended to the part along the genital tract from the deep urethra or seminal vesicle. In many instances I have watched the process of extension, having detected the tubercular involvement of the deep urethra or seminal vesicle long before the disease had extended itself into the epididymis."

In which belief Guyon and Lancereaux concur.

Among the various influences operating to determine the localization of tubercle bacilli in the epididymis may be mentioned heredity; that is, the local predisposition may be inherited or the disease may be congenital, as in the cases of Giraldes and Dreschfeld (British Medical Journal, 1884), in which the testicle was tubercular at birth.

M. Julien reports sixteen cases in infants, six of which were in patients less than one year old. Injuries, particularly slight and insignificant ones, by lessening local resistance may afford a nidus for deposition of germs. Simmonds experimentally demonstrated this by injecting tubercular sputum into the peritoneal cavities of rabbits and afterward crushing or bruising the testicle, tuberculosis following the subsidence of the orchitis.

Severe injuries are rarely followed by tuberculosis, since, according to Volkmann, the active changes set up in a tissue during its repair following such an injury counteract the propagation of the bacilli.

Antecedent or co-existing disease of testicle, particularly gonorrheal

epididymitis. In fifty-two cases collected by Kocher and sixty by Simmonds, fourteen of Kocher's and eleven of Simmonds' had previously suffered from it.

Senn states that gonorrheal epididymitis at times imparts a malignant character to the tubercular process, and quotes the following case of Birch-Hirschfeld, a soldier with gonorrheal epididymitis, who died in eight days from a diffuse miliary tuberculosis having its apparent point of origin in the gonorrheal epididymis.

Jani has found bacilli in healthy testicles of phthisical patients, and Koenig thinks that in these cases a gonorrheal epididymitis would serve to prepare the ground or culture medium for an already existing infection.

Another cause advanced by Saltzmann for localization is that the branches of the spermatic artery to epididymis are tortuous, consequently slowing blood-current, favoring bacterial growth; in descending infections the epididymis would naturally be involved before the testicle.

The points of entrance of bacilli are conceded by all to be the respiratory, gastro-intestinal, and gastro-urinary tracts, and the skin, the localization in the epididymis then depending on one or more of the aforementioned conditions. The most potent source of tubercle bacilli in the blood is believed to be the mediastinal lymph glands, which have been shown to be tubercular in 75 per cent of cases coming to the post-mortem table.

Another method of infection, the possibility of which can readily be seen, and which is advocated by M. Verneuil, is by coitus. The instances, however, of primary tuberculosis of testicle or epididymis with infection occurring during coitus must be rare, although the disease occurs most frequently at a time when the generative system is at its highest state of physiological activity, and that is between the ages of twenty and thirty years, although no age is exempt.

The macroscopical and microscopical appearances to be found depend upon the stage of the disease in which the examination is made. The tubercular process itself does not differ here from tubercular processes elsewhere, but consists of deposit, caseation, and liquefaction, calcification being rarely observed.

Considerable diversity of opinion seems to exist in regard to the primary starting-point and to the local dissemination. The involvement of the testicle is nearly always secondary to that of the epididy