so as to render the middle and fore part tense and prominent; into
this a trocar and canula are plunged, piercing the coverings in a
perpendicular direction, and then inclining the canula upwards, the
stilet having been partially withdrawn, so as to avoid wounding the
testicle. The venous branches apparent on the surface must be of course
avoided. When fairly passed within the cavity, the trocar is withdrawn
entirely, and the fluid escapes through the canula—gentle pressure
being employed towards the conclusion. The wound usually heals in a
few hours. Various means of radical cure have been proposed—incision,
seton, caustic, and the injection of stimulating fluids. Incision and
the seton are now abandoned, and do not require notice. The application
of caustic perhaps may prove efficient in children when tapping has
failed, and in youths; an aperture is thus made, through which the
fluid escapes, and at the same time considerable excitement is induced,
which may prevent reproduction. I at one period made trial of it in
several instances, and generally with success; but am now inclined to
avoid it, having more than once experienced much difficulty in keeping
within moderate bounds the inflammatory action which succeeded its
application. Injection is now generally practised; and if carefully
performed, it is unattended with risk, and is almost invariably
successful. Various fluids may be employed—cold water, wine, wine
and water, spirits, a solution of the sulphate of zinc, &c. I have
generally used pure port wine; and have scarcely ever seen its effects
either excessive or deficient. I can remember very few cases in which
the disease returned after this injection. Having ascertained that the
testicle is sound, or but slightly enlarged—for injection of the tunica
vaginalis is incompatible with diseased testicle—the fluid is drawn
off by means of a round trocar. The canula is left in the wound, and
to it is adapted the nozzle of a brass stop-cock attached to a small
elastic bottle. By means of these instruments the wine is injected in
sufficient quantity to distend the tunic moderately, taking care that
the extremity of the canula is completely within the cavity, otherwise
the cellular tissue will be injected, and violent inflammation ensue,
terminating in unhealthy suppuration and sloughing. By turning the
cock, the wine is retained until the patient begins to feel pain
shooting upwards to the loins, when it is to be evacuated. He may not
feel any uneasiness, however, and then it will be necessary to draw
off the fluid and inject a fresh quantity. If this, too, fails, a more
stimulating fluid must be used, a solution of sulphate of zinc, spirits
and water, or pure ardent spirits. It is supposed that this treatment
is effectual by inducing adhesive inflammation, and obliteration
of the cavity by adhesion of the tunica vaginalis to the tunica
albuginea; but this does not by any means frequently happen. There
may in some cases be a little lymph deposited, but not in sufficient
quantity to cause adhesion. The excitement following injection seems
to change the action in the parts without altering their structure or
relation—to reëstablish the healthy balance between the exhalants and
absorbents. Its first effect is to produce increase of swelling from
fresh effusion into the cavity of the tunica vaginalis, accompanied
with redness of the integument and considerable pain—sometimes with
slight fever. This fluid, however, is quickly absorbed—usually in from
four to six days—the swelling subsides, as also the pain, and the
patient remains free of the disease. Whilst this salutary action is
in progress, the recumbent posture must be strictly enjoined, along
with low diet and suspension of the organ; and sometimes, though
rarely, it may be necessary to have recourse to more active means to
moderate inflammation. Should the excitement appear insufficient after
a day or two, the surfaces may be rubbed against each other with the
fingers, and gently squeezed, or the patient may be directed to walk
about occasionally through his room until pain is felt. If the disease
return, as need scarcely be dreaded, injection is to be repeated,
either again with wine, or with a more potent fluid.[55]
The term _Cirsocele_ is applied to varix of the spermatic veins. The
affection seldom extends to the inguinal aperture, and is usually
situated on the left side.[56] The tumour is somewhat pyriform,
the larger extremity resting on the testicle, and by its peculiar
appearance and feel its structure is at once apparent; the veins are
seen through the integument. Pressure from below upwards, during the
recumbent posture, diminishes the swelling; pressure above augments
it, particularly if the patient change his posture, and exert the
abdominal muscles. Sometimes a dull pain in the back is complained
of, relieved by suspension of the scrotum, and often wasting of the
testicle slowly advances. In some cases the swelling attains a large
size, elongating the scrotum, and proving a source of very great
uneasiness to the patient—so great that some have requested and urged
castration.[57] Commonly it is sufficient to wear a bag truss, and
avoid all causes of irritation to the parts; thus increase of swelling
is prevented, and the inconvenience rendered trifling. If pain,
with redness of the integument, and additional enlargement, should
supervene, rest and the recumbent posture must be enjoined for a time,
combined perhaps with low diet and local depletion. But in cases of
large inconvenient tumour, accompanied with atrophy of the testicle,
rather than accede to the wishes of the patient and perform castration,
the treatment recommended many centuries ago may be put in practice—the
application of a heated wire to the veins. The upper part of the tumour
is grasped and made prominent, the veins are separated as much as
possible from the other parts composing the chord, and a small-pointed
cautery, a glover’s needle, for example, is inserted at several points.
This is followed by some pain, and increase of swelling. Inflammation
and obliteration of the veins is produced at the cauterised points, the
swelling gradually diminishes, and ultimately a dense chord is all that
remains. The cure is radical, and I have never seen the effects prove
too severe. Rest and antiphlogistic regimen are of course necessary for
some days after the application; abstraction of blood will seldom be
required. Within the last few years I have been in the habit of passing
two needles under the veins at an interval of about half an inch from
each other, and twisting a thread firmly over them and the superimposed
integuments. Of course the other parts of the chord are held aside by
the finger and thumb, and the needles are withdrawn within a few days;
as soon, in short, as consolidation of the interposed substance has
taken place. This operation is preferable to any other.[58]
_Hæmatocele_ is an effusion of blood, either into the cellular tissue
of the scrotum, or within the tunica vaginalis, or in both. It is
generally the consequence of a bruise or wound. From the loose nature
of cellular tissue, the effusion into it is apt, if proper attention be
not given, to take place to a great, and, to the patient and friends,
alarming extent. This I have witnessed after the operation for hernia,
and after removal of the testicle—bleeding from some small artery
continues, the blood is by the dressings or pressure prevented from
escaping externally, it is consequently extravasated into the cellular
structure, giving rise to tumour, often of a very dark colour; and in
some cases this swelling, occurring after the operation for hernia, has
been mistaken for re-descent of the bowel. The blood must either be
absorbed or discharged. Absorption is the more safe and desirable, but
necessarily tedious, and more or less thickening and enlargement may
remain for a long time. Discharge, whether spontaneous or by incision,
is usually followed by unhealthy suppuration of the infiltrated
and partially broken down cellular tissue, sloughing of it, tardy
separation of the dead parts, and tedious, perhaps exhausting, flow of
matter.
Hæmatocele of the vaginal coat may supervene on hydrocele, in
consequence of external injury; or bloody effusion may take place from
the vessels of the membrane, from sudden abstraction of their customary
support, after evacuation of the serous fluid, and whether injection
has been resorted to or not;—as happens in careless tapping for
ascites. Some of the diagnostic marks of hydrocele are thereby lost;
there is no translucency of the swelling, and fluctuation is either
indistinct, or altogether imperceptible. The appearance of the contents
varies according to the time which has elapsed betwixt their discharge
and the occurrence of the extravasation; if short, coagula float in
a thin bloody fluid; if considerable, the liquid is thick, dark, and
putrid.
[Illustration]
Bloody effusion into the scrotal cellular tissue produces a dark
appearance of the integuments, and the swelling has a doughy feel. At
one or more points, where the cells are broken down and much blood
has collected, fluctuation is perceived more or less distinct. The
treatment consists of rest, the recumbent posture, support of the
swelling on a small cushion, and the employment of fomentation when
the parts are painful. The absorption proceeds slowly; and after some
time, when all painful feelings have ceased, stimulant embrocation may
be used, with the view of expediting it; a solution of the muriate of
ammonia, of the sulphate of alumina, or of other astringent stimulating
salts, may be employed in strength proportioned to the feelings of the
patient and the progress of the case. If the tumour suddenly become
painful, and increase in size, indicating putrefaction of the blood,
and commixture of it with puriform matter, a free incision is to be
made, and poultices applied. When the parts have become quiet, and
suppuration has been established, poulticing is to be discontinued, and
mild and light dressing employed.
When, on tapping a hydrocele, the fluid is found to be bloody,
injection is not to be resorted to, though the other circumstances
of the case should appear favourable. Rest is enjoined; and a radical
cure is not to be attempted till the fluid has collected a second, or
perhaps a third time, and become colourless.
Acute inflammation of the testicle, from sympathy with the urethra, and
sudden suppression of discharge from the anterior part of the canal,
has been already treated of. The inflammation may also be the result
of external violence. When the urethra is diseased, the testicle is
irritable, and its circulation easily excited. After subsidence of the
inflammatory attack, swelling, particularly of the epididymis, or of
the posterior part of the gland, seldom altogether disappears. The new
matter is not entirely absorbed; and thickening and induration remain,
to an extent depending on the violence of the action and the propriety
of the treatment.
Enlargements of the body of the gland are generally attributed to
injury. But often they occur without such cause being assignable;
and may be the result of chronic excited action, kindled in deposit
produced by a previous acute inflammatory attack. Such indolent
swellings attain considerable size. The tumour is of an irregular
surface, and feels hard and unyielding; there is always more or less
effusion of fluid into the cavity of the tunica vaginalis, adding to
the bulk of the swelling. Indeed, the size and consistence of the
tumour can be correctly ascertained only after evacuation of this fluid.
Many of these tumours, as already observed, are of firm consistence;
others are soft and doughy. They occur at the middle period of life, or
before it. Some are resolved easily, and by ordinary attention. Others
enlarge, notwithstanding the most judicious treatment; they gradually
soften, and at length fluctuation becomes apparent. Curdy matter is
evacuated by incision, perhaps mixed with a small quantity of thin
unhealthy matter; and from the wound projects a pale fungous growth
furnishing profuse discharge. The gland has now lost all appearance of
its original structure; a section of it presents a homogeneous surface,
of a greyish colour, and soft consistence, at some places broken down
and mixed with tubercular matter and pus. The fungus is of the same
nature as the rest of the tumour, but softer, and often with puriform
depôts in its base. In this disease there is nothing malignant; it
occurs in people of impaired or originally weak constitution, and is
generally known as the _scrofulous testicle_.
In the more simple swellings, the gland at some points retains its
original texture, but the greater part has no tubulous appearance, and
seems to consist principally of lymphatic deposit, dense, pale, and
equable. Such often accompany and are attributable to a diseased state
of the urethra,—part of the canal being in an irritable and contracted
state; and all efforts to discuss them usually prove fruitless, unless
the urethra have been previously restored to a healthy condition. The
soundness of this canal is therefore to be inquired into in the first
instance, and if stricture, or irritability independent of contraction,
be discovered, the practice must be directed towards it. The urethra
being sound, counter-irritation is to be applied to the testicle;
and the part should be suspended, though not in function altogether;
walking exercise, and the friction which it occasions, must be avoided
as much as possible. A gum and mercurial plaster protects the part,
and induces a moderate irritation of the surface usually sufficient
to dissipate the swelling slowly; if ineffectual, either repeated
blistering, or the insertion of a seton under the integuments, may be
had recourse to—from either or both much benefit is often derived. In
obstinate cases the recumbent posture must be enjoined. In general,
slight enlargement and induration of the epididymis remains.
The scrofulous swelling often does not yield to the means for
discussion, but advances to suppuration. The abscess is to be opened,
and the unhealthy contents discharged; endeavours are then to be made
to effect closure by granulation, and after that counter-irritation
may dissipate the tumour, or at least diminish its size. If protrusion
occur, as generally happens, it may be cut away; and by then keeping
the granulations on a level with the integument, either by pressure or
escharotics, at the same time attending to improvement of the general
health, cicatrisation may be procured, though tedious: or escharotics
may be used from the first, instead of the knife. For example,
sprinkling the fungous surface occasionally with the acetate of lead,
I have found in several instances effectual; repeated sloughing of the
protruded matter takes place; it sinks to the level of the integument,
and ultimately below it, and then the employment of slightly
stimulating dressing induces contraction and closure.
Not unfrequently the testicle is attacked by swellings of a more
serious nature—medullary sarcoma is common, as also both fibrous
and soft tumours, with cysts; scirrhus is more rare. These morbid
alterations may take place at once—that is, the swelling may be from
the first malignant—or they may supervene on tumours originally simple
and benign. The tumour increases with the usual rapidity; to describe
minutely the successive stages, would be but repetition of what has
been already stated more than once, in treating of similar diseases
in other organs. The medullary tumour often attains a very large size
before the integuments give way; it may in some cases be mistaken for
hydrocele, unless the history be attended to, and careful manipulation
made: elasticity must not be confounded with fluctuation. After
ulceration has taken place, the formation of a bleeding fungus is not
uncommon: indeed, the testicle is one of the most frequent seats of
fungus hæmatodes. The inguinal glands are in general affected early,
and swell to a large size, ulcerating extensively, bleeding, and
throwing out fungi; not unfrequently the chord feels free and soft,
presenting to all appearance a healthy structure between the inguinal
and scrotal swellings. In the advanced stages of scirrhous testicle,
the chord and its integument are thickened and hard. The progress of
this tumour is slower than that of the medullary, but equally certain.
The cystic sarcomata, when fibrous, may remain long apparently in an
indolent state, and without affection of the lymphatics; but when soft,
the cystic contents are often bloody, the medullary matter soon breaks
down, and then the integuments yield, and the malignant advance is
rapid. It need scarcely be observed, that in such cases nothing but
the knife, used at an early period, when the tumour is yet latent and
the lymphatics uninvolved, can save the patient. Castration must be
performed; and even this is in too many cases insufficient to annul
the malignant disposition of which the parts have become the seat. As
already stated, it must be had recourse to before hard and knotted
swelling in the groin, with thickening and induration of the chord, has
commenced, otherwise it can be of no avail.
The patient is placed recumbent. An incision is commenced a little
above the inguinal aperture, and carried downwards; on reaching the
tumour it is inclined to one side, so that with a similar one on the
opposite side an elliptical portion of integument may be included.
This is always necessary when the tumour is adherent to its coverings,
or when a fungus has been protruded. One straight incision may be
sufficient for removal of the tumour; it is sometimes necessary to take
away more or less skin, so that a large, loose, and flabby bag may
not remain after the extirpation. This preliminary wound penetrates
only through the skin and cellular tissue, and should be made rapidly.
At its upper part the chord is then to be cut down upon, exposed,
and divided; but the division should not be made until the chord has
been isolated for some distance, so as to afford a firm hold to an
assistant, and not before the assistant has secured it firmly in his
fingers, otherwise it may retract within the inguinal canal, rendering
the bleeding from the spermatic artery troublesome. The dissection
is now to be continued downwards, rapidly, and yet cautiously; the
tumour is detached on all sides, and removed along with a sufficient
quantity of integument. In dissecting off its posterior surface, care
must be taken not to wound the septum of the scrotum. All adherent
skin must be taken away, and in the case of fungus, the incision of
the integument must be wide of the projecting part. But, at the same
time, unnecessarily extensive removal of skin is always to be avoided,
otherwise there will sometimes be a difficulty in covering the root
of the penis and the remaining testicle. The assistant has, during
the extirpation, retained his firm grasp of the chord, so restraining
hemorrhage from that quarter; now the branches, generally two, of the
spermatic artery are pulled out by the forceps, and a ligature applied
to their extremities, inclosure of any of the surrounding parts being
studiously avoided. To tie veins, artery, nerves, vas deferens, and
cellular tissue, in one mass, would lead to most serious mischief, not
to mention the immediate and excruciating pain occasioned. It has been
recommended either to pass a temporary ligature round the chord, before
its division, to prevent retraction, or to tie the artery before it is
cut across. I have never found either practice necessary; the latter
retards the operation; the fingers of an assistant are generally as
effectual as a ligature, and inflict less injury to the parts, and
less pain to the patient. Should the chord slip, there can be but
little difficulty in pulling it down again by means of a hook; at the
worst, slight extension of the incision upwards may be necessary. The
scrotum is to be sponged clean of coagula, and its bleeding vessels
secured: they are often numerous. The incision is brought together by
several points of suture, and cold cloths applied. In no operation is
secondary bleeding more frequent, occurring within an hour or two after
reaction has been established, and the patient begun to get warm in
bed. The flow is always from the scrotal vessels in the lower part of
the wound, and often profuse. The dressing must be partially undone, so
as to expose the vessels, and permit of the application of ligature.
On this account, it is well not to approximate the lower part of the
wound in the first instance, but to fill the cavity with charpie or
dry lint, retaining this until risk of hemorrhage has passed over, or
better still to have the wound quite open for five or six hours, and
then to bring the edges together. The upper part of the incision often
heals by the first intention, but this is seldom effected in the lower;
suppuration takes place, and the cavity fills up slowly by granulation.
Indeed, attempts to procure primary union of the scrotal wound are
scarcely to be recommended; they are very seldom effectual; and should
bleeding take place, the patient is either put to much pain, by removal
of the stitches, and separation of the edges, or the blood is confined,
accumulates in the cavity, and is infiltrated into the cellular tissue,
producing much tumour, which terminates in extensive and unhealthy
suppuration. Such retardation of the cure is avoided by open dressing
of the lower part of the wound from the first.
Not unfrequently infiltration of the cellular tissue over the chord
takes place within a few days after the operation, extending upwards
under the superficial fascia of the abdomen, with discoloration of
the integument, diffused doughy swelling, and much irritation of the
system. Matter soon collects at one or more points. Early incision
will check the advancement of this affection, followed by fomentation,
and poultice, and attention to the constitution. Collection of the
matter should never be waited for; and when depôts have formed, a free
and dependent opening should be made early. Sometimes the patient may
perish, exhausted by the profuse discharge and the disturbance of the
system, in cases that have been neglected, or in which infiltration is
rapid and extensive and the powers of life weak.
_Calculus Vesicæ._ Morbid action of the kidneys, producing altered
secretion of the urine and deposition from it, takes place in
consequence of derangement of the digestive organs—often occasioned by
the free use of acids, or of acescent diet, such as fruit tarts, or
drink containing a great quantity of saccharine matter. Many causes,
which have not as yet been well ascertained or understood, seem to
influence and predispose to calculous disorders. The prevalence of
these affections in particular districts has been attributed to the
quality of the water, or to the use of peculiar food or beverages;
but such opinions, in all probability, have been adopted neither on
very good grounds, nor after due inquiry and consideration. The county
of Norfolk, and the eastern part of Scotland from the Frith of Forth
northwards, are districts very similarly situated, exposed to cold and
piercing winds, and appear to furnish a greater number of cases of
stone than the rest of Great Britain, with Ireland to boot. The reason
of this, as already stated, has not been satisfactorily explained.
But this disorder, like gout, seems also to adhere to families, to be
transmitted from one generation to another. Some children seem almost
to come into the world labouring under calculus.[59] The symptoms are
noticed very soon after birth, and often patients labouring under stone
are presented to the surgeon at the tender age of twelve or eighteen
months.
[Illustration]
The depositions from the urine are various. The deposit chiefly
affecting children is of a dark colour, dense, hard, and crystallised;
but one lighter coloured, and more friable, sometimes precedes the
formation of this dark concretion. As seen here, the nucleus is
surrounded by an oxalate of lime calculus, and then follows layer after
layer of urate of ammonia. The dark sand or stone is occasionally,
though much more rarely, met with in older individuals; but in them
the red, dark brown, yellow, and white deposits are more common. And
in them, too, the diathesis or disposition to the formation of one or
other variety evidently alternates, as is well demonstrated by section
of urinary concretions. An alternating calculus is here represented.
[Illustration]
[Illustration]
[Illustration]