nO°<. J: ^ oo' ^>\^r^^ "^^ '^oTo ^^ .0^ V 'c^ ^ ^ ^ "^. \ V '^ V> s ^^. r^-/-^ "^^ v^' -j^- -0' X ^^'^ ^*^ ;.je^/>^ ''- v»^r V ■/! ■^" .^^' -cP "^^ / ^.^ ■' - "^ ^^ O^ ^. 8 1 T* ^>!- * T \ s- ^~0 z ■'-^ » * ■=> "" 0^ \ "^ #^ >^ V^^ ^ C^^^ ,\V -/' ^, \-c^ ^^• ^^^ ,x^ 'y^ > A C- X * ^ '^ O ^ ^ 0^^ aV •/-, V .^^ %, P, .-i^ \ ^^^ .^^'' A^^ ^Z^'^' x^^'"-^ '^^m: #% 4 -T, -0^ ^ «^' 8 .f '^^mp^^ ^^^ ^ ~ 7 ^ ^' ,A^' '^r^ ^-^' '.^°- >" .v^' O U . •> / ■^ ^ x^ ^^. \ "- x^-^ ,0^^ .s^ ^^ .^^ ^/>. ^^^ v^ .^-^ '''c^. ;^^:^ ^ * -' S ■ K.^ ^. -./> .^x^ A-^^ v> <<;x .v^^'-- A^^ 4^' ->-. " ,0 V ^^x^^ Vl .Oo. L^' .O . r> ^ -=^, ^\X '^ V' a\ o unloaded as to permit an accurate examination, by which it was ascertained that it contained no testicle. Upon mentioning this circumstance to the patient, he said, that he never had one on that side. This declaration was a solution of all diffi- culties, and of all the appearances. When all the effects of the blow were removed, there appeared in the groin a testicle of natural size and figure, which by being much bruised had caused all the mischief.^ It may seem unnecessary to direct the practitioner in all doubtful cases to make a careful examination of the scrotum. Yet it is surprising how apt the absence of the testis is to be overlooked, the defi- ciency not being ascertained until all attempts to reduce the supposed bubonocele have failed, and the patient himself being often unaware of any thing unusual in the state of the parts. The late Mr. Gilbert Burnett has recorded a case in which he honestly acknowledges to having committed this error.t Two cases in which this important point was overlooked have also come to my own know- ledge. Dupuytren has recorded an interesting case of hydro-sarcocele of the left testis coupled with hernia, consequent upon a late descent of the gland. The case was mistaken for simple hernia, and the patient had worn a truss. The diagnosis was ex- tremely difficult. The case was operated on ; and after opening the tunica vaginalis, and letting out * Lib. cit. p, 352, case 1. f Medical and Physical Journal, vol. Ixii. p. 508. IMPERFECT DESCENT OF THE TESTIS. 1 1 7 eight or ten ounces of fluid, he extirpated the en- larged and indurated testis. The patient did well.^ Descent of the Testis into the Perineum. — Mr. Hunter first observed that the testis in changing its situation does not always preserve a proper course towards the scrotum, there being instances of its taking another direction, and descending into the perineum. How this is brought about he re- marks it is difficult to say ; it may possibly be oc- casioned by something unusual in the construction of the scrotum, or more probably, by a peculiarity in that of the perineum itself For it is not easy to imagine how the testicle could make its way to the parts about the perineum, if these were in a perfectly natural state. The first instance of the kind that occurred to him, was the child of a shop- keeper in Oxford Street, but what became of the patient afterwards he did not know. He was con- sulted in a similar case by Mr. Hunt, a surgeon in Oxfordshii^, who gave the following account of the patient : — " The boy is about twelve months old ; his right testicle is situated about an inch below the termination of the scrotum, and half an inch on the right side of the centre of the rapha perinei, where a kind of pouch is formed of the common integuments, without the least rugous or scrotal appearance on its surface. It is perfectly detached from the scrotum ; nor can the testis or spermatic process be at any time felt in any part of the scrotum, though I can readily make the testis pass from its situation * Lecons Orales, t. i. p. 74. edit Bruxelles. 118 ATROPHY OF THE TESTIS. quite up into the groin ; but immediately upon re- moving my hand, the testis falls down into its pouch ; and I can trace the spermatic cord from the body of the testis up to the ring, running about a fourth of an inch on the right side of the scrotum. The scrotum on each side appears perfectly formed, and the left testis is in situ naturali." Mr. Adams has informed me that many years ago a little boy, one of whose testes had thus de- viated from its proper course, was brought to the London Hospital. The testis was lodged in the perineum at the root of the scrotum. The irre- gularity is exceedingly rare, and the above cases are all with which I am acquainted. This peculiar conformation is attended with great inconvenience and risk of injury to the testis, when the subject of it assumes the sitting posture, and rides on horseback. Mr. Hunter advised that the organ should be supported in a situation near the groin, by the application of a bandage that might hinder its descent into the perineum, by which the parts might be in time so consolidated as to retain it by the side of the scrotum. CHAPTER 11. ATROPHY OF THE TESTIS. The testes, like other organs formed for the exer- cise of temporary functions, do not arrive at a perfect state of developement until a certain period ARREST OF DEVELOPEMENT, ETC. 119 of life, after which, their offices being no longer requisite, their activity ceases, and they become gradually and imperceptibly diminished. Thus we find that in early life they are small in propor- tion to the size of the body as compared with their condition at puberty, and that as old age advances, and the generative functions cease to be called into action, they undergo a diminution in size, their vessels grow less, the seminiferous tubes become small and contracted, and partially obliterated. In animals these changes are far more remarkable than in man ; for as the functions of the testes are exerted only at stated periods of the year, as the rutting or copulating season advances, these or- gans rapidly increase in bulk, and in its decline un- dergo a proportionate degree of wasting. In man, it sometimes happens that the testicles do not acquire their proper size at the usual period, their develope- ment being from some cause or other arrested ; and also, after the organs have arrived at their full and perfect growth, that occasionally one or both suffers a premature decay. Under the head, then, of Atrophy of the Testis, I shall consider, 1. Arrest of Developement ; and, 2. Wasting. SECTION I. ARREST OF THE DEVELOPEMENT OF THE TESTIS. If the congenital lesions to which the testis is liable had not been already treated of, the cases of absence of that organ described in the preceding 120 ARREST OF THE DEVELOPEMENT chapter might be correctly referred to the present section, as the deficiency in these cases was no doubt the result of an arrest in the early developement of the organ. But the cases that I am now about to consider are those in which the subsequent evolution which the testes undergo at puberty is delayed beyond the usual period, or never takes place at all. Mr. Wilson relates a curious instance of his having been consulted by a gentleman twenty-six years of age on the propriety of entering the marriage state, whose penis and testicles very little exceeded in size those of a youth of eight years of age. He had never felt the desire for sexual intercourse until he became acquainted with his intended wife ; since that period he had experienced repeated erections, attended with nocturnal emissions. He married, became the father of a family ; and these parts, which at six and twenty years of age were so much smaller than usual, at twenty-eight had increased nearly to the usual size of those of an adult man.* Mr. Wilson mentions this singular case, as it will admit of question whether the parts alluded to became properly formed as to size, and possessed of the power of secretion, in consequence of being, although so late. in life, influenced by the passions excited by attachment to a particular female ; or whether the enlargement and proper action of the parts beginning, occasioned such passion first to exist. He thinks the probability in favour of the former supposition, in which opinion I certainly concur. * Lectures on the Urinary and Genital Organs, p. 424. OF THE TESTIS. 121 Lallemand mentions having seen a man about thirty years of age, extremely fat, and without a beard or hair on the pubes, whose penis and tes- ticles appeared to belong to a child of from seven to eight years : he had never experienced erections or venereal desires.* — A young man was admitted into the physician wards of the London Hospital labouring under disease of the heart and dropsy, of which he died in about a month afterwards. On examination of the body, I found a considerable deposit of ossific matter in the mitral valve of the heart. Having been informed that there was some- thing uncommon in the state of the genital organs, I made a careful examination of the parts. The youth was seventeen years and nine months old ; the body measured five feet ^ve inches in height, and was plump and well formed. There was no appearance of beard or whiskers, or of hair on the pubes. The penis and testes were very small, not larger than they are usually found in boys of three or four years of age. The two testes were about equal in size, and one of them weighed only two scruples and one grain. Both organs were normal in structure, appearing like the glands in early life, when the tubular structure is very indistinctly developed. No spermatozoa could be detected. These were clearly instances of arrest of develop e- ment of the testes. As these organs are chiefly excited to action by an operation of the mind, it is easy to understand that they may sometimes remain * Des Pertes Serainales Involoritaires, t. ii. p. 380. 16 122 ARREST OF THE DEVELOPEMENT undeveloped owing to defective organization of the brain, an absence of sexual desires being invariably remarked in these cases. The cases which I shall hereafter adduce of wasting of the testes after inju- ries of the head, and the frequent absence of the venereal appetite in cretins and idiots, tend to strengthen this opinion. The following is a marked example of defective developement of the sexual organs, accompanied with imperfection of the brain : — An idiot, aged nineteen, subject to epileptic fits, died of typhus fever in the workhouse of the Hackney Union. As the circumstances were curious, Mr. Hovell of Clap- ton, kindly informed me of the case, and allowed me to make an examination of the body. The youth was of short stature, and the form of the body was not indicative of either sex, but the contour was rounded as in the female. There was no ap- pearance of hair about the face or pubes. The abdomen and other parts were covered with a thick layer of fat. The penis and scrotum were remarka- bly small, not larger than they are usually found in a child two or three years of age. Both testes were in the scrotum, but they were of very diminutive size ; the right weighed less than a drachm, and the left not more than twenty-three grains. The cremaster muscle was traced over the cord to the testis on both sides. The right gland had descended a very little way below the abdominal ring. The vessels of the cord were very small. The glan- dular structure and epididymis of both testicles were indistinct, and the vasa deferentia also ex- OF THE TESTIS. 123 tremely small. Nothing remarkable was observed in the structure of the brain. The vesiculse semi- nales were unfortunately not examined. Mr. Hovell also showed me another inmate of the same work- house, a lad aged nineteen, and of weak mind, whose penis and testicles did not exceed in size those of a boy seven or eight years of age, and who had only a few scattered hairs on the pubes. In treating of the imperfect descent of the testis, I have remarked that this gland, when retained in the abdomen or inguinal canal, does not in general acquire its complete state of developement, and that, though frequently capable of secreting, it is com- monly small in size. I have also noticed, in cases of congenital inguinal hernia, that the testis, even in its natural situation, was not of its proper size at the period of puberty ; so that when the infirmity existed on one side only, the testis was not more than half or two thirds the size of the other gland. The arrest of growth in this latter case is attributa- ble to the combined eifects of the pressure of the protruded intestine on the vessels of the cord, and to the obstruction to the circulation caused by the application of trusses and bandages to the groin. SECTION II. WASTING OF THE TESTIS. In investigating the alterations in the nutritive condition of the testis, it is very desirable to hx, if possible, some standard by which they may be 124 WASTING OF THE TESTIS. estimated. The size of the gland is neither uniform nor conveniently appreciated. Its weight, likewise, varies so much in different persons, and in the same individual at different periods, according as it has lately exercised its functions or remained inactive, and as it is full of semen or empty, that it is scarcely possible to determine on any accurate standard of this kind. According to Meckel, the weight of the testis including the epididymis is only four drachms, and according to Sir A. Cooper about an ounce. The former estimate is certainly too low, and the latter too high. I have weighed numerous testicles taken from persons in health, who have been cut off suddenly by accidental violence, and from those who have died of various diseases. In healthy adults, the weight of the gland was found to vary from four drachms to one ounce and one drachm. I have jfixed the mean weight at six drachms. In the most lingering cases of phthisis and in other emaciating diseases, the organ was never found to weigh less than three drachms. I should consider, therefore, the testis of an adult weiojhing less than three drachms as in a state of atrophy. A testis in an advanced state of wasting, not arising from disease of the gland, usually preserves its shape, but feels soft, having lost its elasticity and firmness. Its texture is pale and exhibits few blood-vessels, the tubuli and septa dividing the lobes are indistinct, and the former cannot be so readily drawn out into shreds as before. The epi- didymis does not usually waste so soon nor in the WASTING OF THE TESTIS. 125 same degree as the body of the testis. It some- times, however, loses its characteristic appearance, and I have even found it reduced to a few fibrous threads. The fluid pressed out of the wasted testis and epididymis is entirely destitute of spermatic granules and spermatozoa. In many instances, adipose tissue is deposited behind the tunica va- ginalis, and encroaches on the epididymis and pos- terior part of the testis. Mr. Gulliver has recently discovered fatty matter in the glandular substance of atrophied testes, and I have since had an oppor- tunity of confirming this interesting observation. — A man aged forty-six died in the London Hos- pital of dropsy, consequent on disease of the kidneys. The left testis was found wasted to one fifth its natural size. In addition to the presence of adipose tissue beneath the tunica vaginalis testis, 1 recognised a quantity of yel- low matter irregularly dis- posed amongst the wasted tubuli. This matter, on examination in the micro- scope, proved to be fat glo- bules, and readily dissolved on the application of ether. The wasted testis with the fatty tumour above it is represented of its exact size in the accompanying engraving. The struc- G. 1. Epididymis. 3. Body of testis. 8. Fatty deposit. G 126 WASTING OF THE Testis, tures composing the spermatic cord undergo a cor- responding diminution ; the cremaster muscle dis- appears, the nerves shrink, and the vessels are reduced in size and number. The vas deferens, though small, can generally be injected with mer- cury as far as the commencement of the epididy- mis. A testis atrophied from disease is not only of diminished size and weight, but is altered in shape, being uneven and irregular and sometimes of an elongated form. The surfaces of the tunica vagi- nalis are adherent, and its cavity is partly or en- tirely obliterated. There is no, or very little, trace of the proper glandular structure, the organ being converted into fibrous tissue of a firm texture. It loses its peculiar sensibility to pressure, but is some- times the seat of morbid sensibility. All those causes which produce decay in other parts likewise occasion wasting of the testis. Thus an impeded circulation, pressure, want of exercise, and loss of nervous influence, have been noticed as causes of atrophy of this gland. To these must be added certain causes which specially effect the testis. The following case related by Mr. Wardrop is a good example of atrophy from defective nutrition. A person, both of whose testicles were completely absorbed, nothing being felt in the scrotum but a loose vaginal coat, died of an aneurism of the aorta, formed at the origin of the spermatic arteries, both of which were obliterated.* Mr. Pott mentions an * Note to his edition of Baillie's works, vol. ii. p. 315. WASTIiNG OF THE TESTIS. 127 instance of varicocele, in which the testis became atrophied from the injudicious application of a truss which interfered with the circulation, and occa- sioned great distension of the vessels.* In other cases of varicocele, in which no truss has been applied, the impeded circulation caused by the dilated veins has been sufficient to produce partial wasting of the testis, a circumstance which I have observed in many instances. A ligature on the spermatic artery is sufficient to cause a total decay of the testis,t which induced C. J. Maunoir to pro- pose its application for the removal of certain forms of sarcocele. The influence of pressure in causing partial atrophy of the testis is sometimes remarked in old cases of hydrocele and haematocele, in which the gland has been long subjected to compression from the retained fluid. In long standing cases of irre- ducible scrotal hernia, the gland is often found much wasted, owing, it is said, to the pressure of the intestines ; but I am inclined to attribute the atrophy in these cases to obstruction in the cir- culation through the vessels of the cord, caused both by the hernia and trusses improperly applied, as in many animals, and sometimes, also, in man, the testicles remain throughout life in the abdomen, where they are exposed to greater pressure from the intestines than in a rupture, without, how- ever, undergoing any diminution in size. Wasting of the testes was supposed to have been produced * Lib. cit. p. 471. t T have repeatedly proved this by experiments on dogs. 128 WASTING OF THE TESTIS. by the compression occasioned by contraction of the cicatrix, after recovery from sloughing of the scrotum, in a case which occurred to M. Roux of Paris.=^ It has been said, that the testes waste in those persons who strictly adhere to their monastic vows, but I am not aware that there is sufficient au- thority for this remark. In persons who marry, after many years of abstinence from sexual inter- course, the testes undergo a certain degree of enlargement. These glands naturally remain some- what small when not called upon to exercise their functions ; but whilst they are in a condition for secretion, and can be further developed if excited, this state cannot properly be regarded as morbid atrophy. It is a great error, and one very hurtful to morality, to suppose that sexual connexion in early life is essential for the preservation of these organs. When the excretory duct of the testis is obliterated, so that there is no outlet for the fluid which is secreted, the organ becomes useless, and, it has been said decays. This, however, I have shown in a preceding chapter to be by no means a common result. The following is the most re- markable case I have met with of wasting of the testes, apparently from long^continued inac- tion : — A man fifty-two years of age, and much emaciated, was brought to the hospital in a half- insensible state, and sinking, in the severe winter of February, 1838. There w^as an extensive ulce- * .Tobert, Plaies d'Armes a Feu, p. 232. WASTING OF THE TESTIS. 129 rated sore in the perineum, through which the urine dribbled away, no water passing by the penis. The man could give no account of himself; but his wife stated that he underwent an operation in the perineum, at the hospital, about twelve years ago ; that the water had passed from underneath ever since, and that he had long been out of health. He gradually sank, and died on the third day after his admission. On examination of the body both lungs were found hepatised, but the heart and abdominal viscera were sound. Both kidneys were diseased. The bladder was contracted and empty. The prostate was converted into a multilocular purulent cavity, the urethra covering it being rid- dled with the enlarged prostatic openings. Two ulcerated apertures, each a quarter of an inch in diameter, in the membranous part of the urethra, communicated with the sore in the perineum. The urethra was completely obliterated and impervious near the meatus, and strictured in other parts. Both testes were atrophied, being scarcely larger than hazel nuts, but the tubular structure was still apparent. There was a small hydrocele connected with the right testis. The severe disease of the urinary organs must have incapacitated this man for sexual connexion for a long period of years, and to this circumstance we must chiefly attribute the atrophy of the testes, since the organs were not otherwise diseased. In cases of enlargement of the prostate the ejac- uiatory canals sometimes become completely ob- structed. Under these circumstances, the semen 17 130 WASTIJNG OF THE TESTIS. secreted under excitement having no means of escape encumbers the testes for a time, but after- wards becomes absorbed, and it is said that atrophy of these glands sometimes follows ; but I cannot say that I have observed any instance of wasting of the organs from this cause. As examples of atrophy of the testes, from loss of nervous influence, may be adduced cases of para- plegia, in which these organs have been known to waste. Portar mentions the case of a robust man, aged thirty-five, who was attacked with painter's colic, attended with great debility of the lower ex- tremities. The testes diminished considerably ; and although he afterwards recovered from the paralysis of his limbs, these glands always remained wasted, and the man was incapable of the act of generation.* In the xxth volume of the Medical and Physical Journal there is an account of a case of recovery after fracture, with partial dislocation of the first and second lumbar vertebras, followed by paraplegia, in which three years afterwards the testicles were found entirely obliterated. It has been stated that the testes sometimes waste from injuries, or from compression of the spine at the origin of the spermatic nerves. In a man who had received a blow on the lumbar region, the testes gradually wasted away.t The most common cause of atrophy of the testis is the disturbance in its organization consequent *,Coursd'Anatomie Medicale, t. v. p. 434. {• Baillie's Works by Wardrop, vol. ii. p. 315. WASTING OF THE TESTIS. 131 upon inflammation. As the inflammatory process ceases, the enlarged gland not only becomes re- duced to its original size, but it sometimes slowly, but steadily, diminishes, till at length very little vestige of it remains. Mr. Hunter has related three cases in which the testicle decayed in this way.* I have met with two instances of atrophy arising from this cause, and there are few surgeons of experience who have not witnessed cases of the kind. Wasting of the testicle has been observed to occur after an attack of orchitis in mumps, arising, as it is sup- posed, from the translation of inflammation from the parotid to the testis. Two cases of cynanche parotidea in the adult, in which atrophy took place in the gland chiefly aflected, are related by Dr. R. Hamilton.! I have witnessed one case, in which the patient attributed the loss of the gland to an attack of mumps in his infancy. Wasting is more liable to occur after inflammation of the body of the gland than after consecutive inflammation, in which the epididymis is the part chiefly aflected. One or both testes have been found to waste in persons who have indulged too much in sexual intercourse, or been addicted to onanism. Baron Larrey met with several cases of atrophy from ex- cessive venery, and abuse of strong drinks, amongst the soldiers of the Imperial Guard.J Sir B. Brodie has recorded two cases in which wasting was occa- sioned by over-excitement ; in one from onanism, * Treatise on the Venereal Disease. t Philos. Trans, Edinb. vol. ii. art. ix. p. 59. I Memoires de Chirurg-ie Militaires, vol. ii. p. 66. 132 WASTING OF THE TESTIS, in the other from sexual intercourse.* I have also witnessed an instance of total atrophy of the left testis from excessive masturbation. In this case, and probably in the others just quoted, the wasting was preceded by an attack of inflammation, in- duced by inordinate excitement. It is a common belief that wasting of the testis is liable to be induced by the long-continued use of iodine. I have not met with any instance of it, and I know of no case in which the evidence is such as to render it at all clear that the decay of the gland was really occasioned by this remedy.! Iodine has been employed much more largely and generally since the time that this opinion was promulgated, so that if it exerts the influence on the testis which has been attributed to it, we might reasonably expect that the fact would have been satisfactorily ascertained by recent experience. Such however is not the case ; and I feel convinced that the effect of iodine in producing wasting of the testis, if it ever occurs, happens so rarely, that the liability to it cannot be regarded as any objec- tion to the free and long-continued use of this valuable remedy. Atrophy of the testes has been remarked in elephantiasis of the Greeks, a disease in which tubercles are developed in various parts of the skin. * London Medical and Physical Journal, vol. Ivi. p. 297. 1 1 have heard of the case of a medical gentleman v^ho attributed loss of virile power and a diminution in the size of his testes to the continued use of iodine, but whether justly so I have no means of inquiring. WASTING OF THE TESTIS. 133 Dr. Adams, in an account of the cases of that disease, observed in the Lazaretto, near Funchal, states that all those who were attacked with it before the age of puberty, never acquired the dis- tinguishing marks of that change in the consti- tution, and their testicles diminished in size, and that in those affected later in life the testicles became atrophied, and they lost the power of pro- creation.^ Mr. Peacock also noticed a wasting of the testicles in several cases of elephantiasis in the Leper Hospital of Colombo, in Ceylon.t A similar condition of these glands was remarked in a case of this disease, so rare in this country, narrated by Mr. Lawrence,:]: and also in another case at the London Hospital, which I recorded many years ago.§ Wasting of the testes is liable to occur after in- juries of the head. A few years ago a man who had met with an injury of this description, which had been followed by wasting of the testes, and the developement of tumours on each side of the chest, resembling mammae, presented himself at the dif- ferent hospitals in London. 1 saw him in March, 1828, at the London Hospital, when he had the appearance of a man who had seen hard service. He stated that he was about fifty-nine years of age, a married man, and the father of several children. He had belonged to the legion in the Queen of Spain's service. About two years and a half pre- * On Morbid Poisons, p. 265. t Edinb. Medical and Surgical Journal, vol, liii. p. 139. I Medico-Chirurgical Transactions, vol. vi. p. 214. ^ Vide Medical Gazette, vol. vii. p. 447. 134 WASTING OF THE TESTIS. viously, in an attempt to jump over a trench in a retreat, he fell backwards, and injured the pos- terior part of his head. Whilst on the ground he received a bayonet wound on the left side, and a sabre cut on the forehead of the same side. He recovered from these injuries, and returned to England. Since the accident he had completely lost his virility. He had no desire for sexual con- nexion ; his penis had dwindled in size ; his right testis had gradually wasted, and was no larger than a horse-bean, and the left gland was also a good deal diminished in bulk. The skull at the occiput seemed somewhat flattened. Baron Larrey records the case of a man who was wounded in the back of the neck by a musket-ball, which traversed the extensor muscles of the head, and grazed the in- ferior occipital protuberance. He recovered from the injury, but the testes were reduced to a state of atrophy, and the penis shrunk and remained in- active. He also relates the case of a man of strong constitution and vigorous passions, who received a sabre wound which cut off all the convex project- ing part of the occipital bone, and exposed the dura mater, a portion of which was also removed. The patient lost the senses of sight and hearing on the right side, and experienced at the same time sharp pains in the course of the dorsal spine, and a sense of formication in the testicles, which organs sen- sibly diminished, and in fifteen days were reduced, especially the left, to the size of a bean. He soon afterwards lost all desire for, or remembrance of, WASTING 5F the TESTIS. 135 sexual enjoyment.^ Hennen relates that a Por- tuguese soldier was struck by a shell, which shat- tered the superior part of the occipital bone, and drove in a portion of the left parietal. He re- covered, but completely lost the generative faculty.t Lallemand had for some time under his care at the hospital at Montpellier a man thirty years of age, who, in the expedition to Algiers, had received a large sabre wound at the nape of the neck. His testes were wasted, and venereal desire as well as erections had entirely ceased.J We cannot doubt that in these cases the loss of sexual desire and the wasting of the testes were the direct results of the injury to the brain, and they go far to prove the essential dependence of the functions of these glands upon the cerebral organ. The physiologist cannot fail to notice the rapidity with which the atrophy is stated in some of the cases to have succeeded the injury, and the extent to which it proceeded. The withering of the testicles was, indeed, so remarka- ble, that it can only be attributed to the sudden and complete extinction of the sexual instinct re- sident in the brain, and (if! may so express myself) to the immediate impression on the system of the future uselessness of these organs. In old age and in lingering diseases the decay of the testicles is extremely slow and gradual, and is never carried to the extent observed in cases of injury to the brain. * Memoires de Chirurgie Militaire, p. 262. t Military Surgery, 3d edit. p. 306. \ Pertes Seminales Involontaires, t. ii, p. 41. 136 WASTING OF THE TESTIS. In fact, men have survived the power or desire of performing the sexual act many years without the testes being materially reduced in size. We have seen, too, that in animals the testes have been ren- dered useless by interrupting the vasa deferentia, without any such striking effect being produced on the glands as occurred in these cases of cerebral injury. Wasting of the testis sometimes takes place with- out any apparent cause. A well-grown boy between nine and ten years of age was observed to grow more delicate in his figure for some months. His mother discovered that his testicles had almost disappeared. On examination, it was difficult to find them, and when discovered, they did not seem larger than two full-grown peas. The mother asserted that he was born with them of the usual size, and that they continued to grow for some time afterwards."^ Baron Larrey relates, that in several soldiers of the army in Egypt, at the close of the campaign in 1799, the testicles almost entirely disappeared, for which he assigns no satisfactory cause.t An investigation of the causes of atrophy of the testis is sufficient to show that we have little power by any mode of treatment to promote the develope- ment or arrest the decay of this organ. They are commonly the result of actions beyond the surgeon's reach or control. In certain cases, as in atrophy * Lond. Medical and Physical Journal, vol. xxxvi. p. 174. t Lib. cit. vol. ii. p, 62. INJURIES OF THE TESTIS. 137 from pressure, or an impeded circulation, we may, by judicious measures, assist in retarding the wast- ing process ; but a statement of the circumstances which conduce to this change is sufficient to indi- cate the means required to check its progress. CHAPTER III. INJURIES OF THE TESTIS. Although the testes, owing to their exposed situ- ation, are more liable to injury than any other glandular organ, they are preserved in a remark- able degree from the effects of external violence by their great mobility and capability of eluding pressure, and the nature and strength of their pro- tecting tunics. SECTION I. CONTUSIONS AND INCISED AND PUNCTURED WOUNDS. Contusions. — -The testis is in danger of being bruised in the exercise of riding on horseback, by the organ being struck against the pommel of the saddle, and many of the inflammatory affections of the gland are found to originate in this accident. It is sometimes forcibly compressed between the 18 138 CONTUSIONS, INCISED AND PUNCTURED WOUNDS. thighs, and is occasionally contused by a kick or blow. This injury usually occasions slight extra- vasation of blood within, or in the cellular tissue beneath the tunica vaginalis. The effusion some- times infiltrates the cord, and when the contusion has been particularly severe, it has been found to extend along the cord even to the kidney. A case of contusion of the testis, in which the extravasa- tion reached as high as the diaphragm, is related by Petit.^ The tunica albuginea is so dense and strong, that it is rarely ruptured, and it protects in a great degree the glandular structure from the effects of this injury. The consequences of a contusion of the testis are soon felt, and are often severe -^ the immediate effects of the injury resembling a good deal the symptoms produced by an injury of the viscera of the abdomen, owing to the connexion of its nerves with those of the organs in the abdominal cavity. The patient instantly experiences acute pain, which extends up to the loins, and forces him to bend his body forwards for relief, and he is seized with a sickening sensation, which is often accompanied with syncope, vomiting, and cold perspirations. But these symptoms are transient ; and in many instances, after recovery from the first effects of the injury, no further ill consequences are experienced ; the effused blood is removed and the testis, after remaining tender for a few days, is gradually re- stored to its former healthy state. The only treat- * Traite des Maladies Chirurgicales, t. ii. p. 477. CONTUSIONS, INCISED AND PUNCTURED WOUNDS. 139 m«nt required in these slight cases is rest, support to the organ with a handkerchief or suspensory- bandage, and the application of a cooling lotion. In other instances, the contusion is followed by- severe inflammation, which seriously injures, and sometimes completely destroys, the organ. Fre- quently the injury lays the foundation of chronic disease, which is slowly developed shortly after the accident. These results will be considered in a future chapter of this work. So complete, how- ever, are the disorganizing effects of a severe con- tusion on the gland, that squeezing the testis was one of the modes adopted formerly in the Oriental courts for emasculating the attendants of the ha- rem f and I am informed that a similar plan of castrating bucks is sometimes resorted to by park- keepers in this country, and that, in the agricultural districts, calves and lambs are occasionally treated in the same way. Dupuytren states, too, that in Normandy horses are deprived of their testes by compression.t This, however, is not a very sure way of emasculating, as some of the tubuli are liable to escape injury, and the effects of the sub- sequent inflammation. Punctured and incised wounds of the testis are not in general followed by severe results. The organ has often been injured accidentally in ope- rations with a trocar or lancet, and the wound has afterwards readily healed. These injuries must be * A person rendered an eunuch in this way was termed S-ActoWc t Legons Orales, t. i. 140 SELF-CASTRATION. treated according to the particular circumstances of the cases ; but the fact that they commonly do well should be remembered by the surgeon, that he may not too hastily despair of saving the gland in incised wounds even of a severe character. SECTION 11. SELF-CASTRATION. Persons ignorant of surgery have been known, like the pious Origen, to perform double castration on themselves, and have evinced considerable deter- mination and indifference to pain in accomplishing their purpose. It is natural to suppose that no one would attempt such an act, by which the perpe- trator deprives himself of a faculty whose possession is universally so highly prized, and whose loss so degrades the condition of man, except during a fit of temporary insanity. Yet I am strongly inclined to believe that self-castration is seldom undertaken without some strong motive intimately connected with the sexual functions, arising from a perverted use or guilty indulgence of them, and that some such cause may generally be ascertained by a little cautious inquiry. In some instances the attempt has been made by persons who have been unable to cure themselves of the odious vice of masturbation : such I suspect, was the motive that led to the act in the two following cases which have come under my notice ; in both, double castration was effectually SELF-CASTRATION. 141 completed. — A lad aged sixteen was brought to the London Hospital in June, 1832, exhausted and faint with bleeding going on from two wounds in the front of the scrotum ; they were each about an inch in length, and situated at the sides of the raphe. Upon examination it was found that the scrotum did not contain the testes. The boy subsequently gave the following account of his case. He stated that for about a week he had suffered from low spirits. Early in the morning he suddenly resolved to do himself some injury : his first determination was to cut his throat, but he afterwards resolved to perform the following act of mutilation. Having left his home in the Whitechapel road for some fields in the neighbourhood, he first passed a piece of string tightly around the root of the scrotum ; he then made an incision to the extent of an inch on one side with a common penknife, and having squeezed the testicle through it divided the cord and removed the gland ; he then proceeded to ex- cise the other testicle in the same way. The loss of blood was considerable, and he endeavoured to restrain it by drawing the ligature tighter. He said he was not conscious of any pain in the opera- tion ; and though he could not assign any reason for selecting this mode of mutilation, he admitted that he had read in an encyclopaedia an account of cas- tration. The testes were found in the field where the act was committed. The cord was divided close to the testis on one side, and at about an inch from it on the other. Ligatures were placed upon the spermatic arteries, and in three weeks the wounds 142 SELF-€ASTRATI0N. had completely healed. No symptoms of insanity were evinced whilst the boy remained in the hos- pital : he enjoyed good health and spirits, and he talked and joked concerning his situation, without appearing at all to feel his loss. — A man aged twenty-two was brought to the London Hospital in January, 1836, having cut out both his testicles. He had removed a small piece of the integuments and squeezed the testicles out through the opening, and excised them, having previously tied a piece of string tightly round the spermatic cords to restrain the haemorrhage. These had retracted into the in- guinal canals ; and Mr. Adams, who was called to the case, was compelled to introduce his fingers at the wound and draw down the cords, in order to secure the vessels separately. The man admitted that he had been in the habit of constantly practis- ing masturbation, and it was to rid himself of the perpetual desire to commit what he regarded as a great sin that he determined to remove the testi- cles. The wound healed without any unfavourable symptom . I am indebted to Mr. C. Hawkins for the follow- ing particulars of a case which occurred at St. George's Hospital at the time he officiated as house surgeon. A man about sixty years of age, much reduced in circumstances, and an inmate of a work- house in the neighbourhood of London, where he was employed as a schoolmaster, was about to be dismissed for having had connexion with an idiot girl in the same house, when (as he said), to rid himself of the offending members which had been SELF-CASTRATION, 143 his ruin, he entirely removed with a razor both testicles and a considerable part of the scrotum. A medical man who was called to him immediately after the ablation secured the spermatic arteries, and then sent him to the hospital with his testicles in a paper parcel. Mr. Hawkins secured a small vessel which was still bleeding, and closed the wound in the scrotum with sutures. The part healed without a single bad symptom, and the patient left the hospital quite well in about five weeks, since which he had not been heard of. Mr. Liston relates that a boy in Edinburgh, wishing, as he said, to lead a " holy life," applied to be castrated. Mr. Liston recommended him to wait some time before he had the operation performed, observing that as he was still growing the testicles might be reproduced. After another interview, in which castration was again put off on the plea of his age, he called one evening at Mr. Liston's house, having attempted the operation with a penknife. One of the testicles was completely exposed, and merely hanging by the cord ; the boy, said, " he did not like to cut the string." The wound was dressed, and the boy handed over to the priest to be admonished, but he did not apply again.* Mr. Reid, surgeon, Markinch, states that he was called to a lad, a shoemaker, aged seventeen, who had attempted self-castration with a sharp-pointed knife. The right testicle was found hanging from a clean wound in the scrotum about If inch in * Lancet, vol. i. 1838-9, p. B8. 144 SELF-CASTRATION. length. The tunica vaginalis was cut to the extent of half an inch, and the posterior part of the testicle was slightly lacerated. The testicle was returned into the scrotum, and the wound dressed ; the part was completely healed in about three weeks. He said that his reason for committing the deed was, that for some time past he had had such frequent and copious seminal emissions, that his master had quarrelled with him about soiling his sheets ; so to do away with this cause of disagreement he had committed the rash act. The great bleeding had prevented him from completing the operation.* Dupuytren mentions the case of an old man married to a young and trifling woman, of whose conduct he thought he had good reason to complain, who resolved to destroy himself, and completely ex- tirpated both his testicles. The cure was prompt, but the monomaniac shortly afterwards drowned himself.t It thus appears that these cases of self-mutilation usually do well, and that the state of mind under which the injury is inflicted does not operate pre- judicially to the patient's recovery. * Edinb. Medical and Surgical Journal, July 1837, p. 93. f Lecons Orales, t. ii. HYDKOCELE. 146 CHAPTER IV HYDROCELE. The term hydrocele is usually applied to a chronic swelling produced by a collection of fluid in con- nexion with the testis or spermatic cord. But before I treat of this affection it is necessary to make a few observations on inflammation of the tunica vaginalis, or, as it is sometimes termed, acute hydrocele. The inflammatory changes of the tunica vaginalis resemble those of the other serous membranes. In- vesting, however, an organ not essential to life, this membrane when acutely inflamed very rarely comes under the notice of the pathologist. M. Roux in- jected, in the hospital of La Charite, the hydrocele of a middle-aged man : inflammation was developed, and appeared to be taking its ordinary course till the fourth day, when gangrenous erysipelas attacked the scrotum and surrounding parts, and caused the patient's death on the tenth day after the operation. On examining the tunica vaginalis he found that it contained a large quantity of whitish serum, in the midst of which floated flakes of albumen ; other flakes of the same kind formed a thick coating over the testis, and on the internal surface of the mem- branous pouch. The serous membrane beneath 19 146 HYDROCELE. appeared slightly thickened, and of a deep red colour. The epididymis and the lower part of the cord were swollen, and constituted the more solid part of the tumour produced by the inflammation. The body of the testis was not increased in bulk, and it retained its natural consistence.* In the museum of the College of Sur- geons there is a beautifully in- jected preparation of hydrocele, showing the effects of inflamma- tion after the application of the caustic, which was presented to the college by Sir W. Blizard. It is represented in the annexed wood cut, which exhibits the sac with part of it cut away to show the swollen state of the epididy- mis, and the aperture made by the caustic (1) ; the tunica vagi- nalis is coated with flocculi of lymph. The sac of an inguinal hernia is seen above the hydro- cele. The sound state of the body of the testis, though surrounded by an inflamed serous tunic, whilst the epididymis partakes in the disease, has been accounted for by Gendrin. He says, when the subserous cellular tissue, which always participates * Journal General de Medecine, &c. torn. Iviii. p. 25 ; quoted from Gendrin, Histoire Anatomique des Inflammations, tom. i. p. 143. HYDROCELE. 147 in the inflammation of a serous membrane, pene- trates into the interior of an organ, it becomes a ready means of communicating the inflammatory action ; but when the contiguous organ or subjacent part is of a diflerent structure from that of the cel- lular tissue, the extension of inflammation inwards is checked. Thus, in the case of the inflamed tunica vaginalis, the cellular tissue readily trans- mitted the morbid action to the epididymis, but the tunica albuginea arrested its progress to the body of the testis ; and this explains the fact that after inflammation of the tunica vaginalis excited by injection the body of the gland is rarely found to sufler. On the other hand, the epididymis is seldom attacked with inflammation without the disease being quickly propagated to the tunica vaginalis. In the examination of a testis affected with acute consecutive orchitis supervening upon chronic, I had an opportunity of observing the effects of in- flammation on the tunica vaginalis at a period somewhat later than in the case observed by Roux. The opposite surfaces of the membrane were con- nected throughout by loose cellular adhesions of a light reddish colour, and infiltrated with serum of a faint red hue : small quantities of the serum were isolated in diflerent parts in imperfectly formed cysts. The tunica vaginalis was changed in ap- pearance, being thickly covered with vessels carry- ing red blood, and in two or three places minute branches could be traced penetrating the false membranes. The adhesions were every where so loose as easily to admit of being broken down with 148 HYDROCELE. the finger. On injecting with size coloured with vermilion a testis whose tunica vaginalis had been in a state of inflammation, both portions of the membrane presented a deep uniform scarlet hue. The lymph effused in inflammation becomes organ- ized in the same way as in other serous cavities, and very often forms adhesions between the op- posed serous surfaces. These adhesions after some time are rendered very firm and dense, and in old cases are often converted into a fibro-cartilaginous structure. The chief inconvenience which results from them arises from the greater exposure to injury of the testis, in consequence of its not being able to glide away from pressure so readily as before. In a testis which I had an opportunity of examin- ing some little while after an attack of acute in- flammation, I found the lymph on both surfaces of the tunica vaginalis presenting a honeycomb or lace-like appearance, similar to that often met with on the pericardium. If inflammation of the tunica vaginalis be very violent, it may end in the for- mation of pus ; suppuration, however, is a rare occurrence, except after the introduction of a seton or other foreign body for the cure of hydrocele, or after injections of too irritating a nature used for the same purpose. It was supposed at one time that the cure of hydrocele after injection was always accomplished by the complete adhesion of the two surfaces of the tunica vaginalis ; but more recent observations have proved that in many instances these adhesions are only partial, and that in some HYDROCELE. 149 cases a cure is effected without any adhesion what- ever. In the latter case, it seems that the inflamma- tion produces an alteration in the secernent disposi- tion of the vessels, so that they cease to pour out serum in a preternatural quantity as before the ope- ration. We can thus understand how it happens that the cure of hydrocele by injection is not invaria- bly permanent ; for if the cavity remain either in part or wholly unobliterated, the vessels on the free sur- face of the membrane may again be called into action, in the same manner as before injection was performed. Inflammation of the tunica vaginalis is not only the most frequent disease of the testis, but it is also one of the most common affections to which the body is liable. In the different disorders of the gland this membrane usually becomes in- flamed at some period or other, and adhesions be- tween its opposed surfaces are scarcely less common than those of the pleura. In examining the testes of twenty-four adults, I found adhesions of greater or less extent in one or both glands in nine in- stances. The symptoms produced by active inflam- mation of the tunica vaginalis, and the treatment proper for its removal, are sufficiently comprehend- ed in the observations on acute secondary orchitis, of which disease it is a very frequent complication. The following table exhibits at one view the dif- ferent varieties and complications of hydrocele. 150 HYDROCELE. S .2 c KS bn a D ta w ■Q E <> >% rt (T? O o 'TD c a D_ D 3 H tH H <3) O J3 -C -C G o .13 cS = o rt a o G ^ ffi 1 4 §■ ^ — _ ^ a ^ Cl, O O O 02 K E-i M G H CQ ^ r o 6 ■5 -^ "5 TD* -5 *l i 'I S I '^* ^ *^ ^ *^ r^ ^ g o c o c ?^ o O O O o ±1 3 • ^* s -o ffi ^ s ^ s:- U fcC f>. ^g ^^3- ^U ^^ § ^' o a r-. SIMPLE HYDROCELE. OF THE TESTIS. 151 SECTION L SIMPLE HYDROCELE OF THE TESTIS. The sac of the tunica vaginalis, like other serous cavities,»is liable to dropsical effusion. In its natural state this membrane is filled by a halitus which lubricates its opposed surfaces ; but when from any cause the action of its secernent vessels is increased, or the balance between the secreting and absorbent functions is disturbed, fluid accumu- lates in and distends the tunica vaginalis, giving rise to hydrocele. The fluid effused is usually transparent, and of an amber, pale yellow, citron, or straw colour, and resembles the serum of the blood ; but is occasionally thick, and almost as firm as gelatine. According to Dr. Marcet's analysis,* 1000 grains of this fluid of the specific gravity 1024*3 contained 80 grains of solid matter, of which 71*5 consisted of animal and 8-5 of saline ingredients : hence it appears that this fluid only diflers from the serum of the blood in possessing rather less animal matter. In an analysis of the fluid of hydrocele made by Dr. Bostock,t 100*00 parts of the specific gravity 1024 were found to contain Water 91-25 Albumen - - - - 6-85 Uncoagulable matter - - - M Salts - - - - - -8 10000 * Medico Chirurg. Trans, vol. ii. p. 372. t Ibid. vol. iv. p. 72. 152 SIMPLE HYDROCELE OF THE TESTIS. A quantity of flaky matter or flocculent albumen is sometimes found floating in the fluid ; and it frequently contains, especially in old people, choles- terine in the form of a multitude of minute shining particles. Messrs. Brett and Bird^ found 500 parts of the fluid of a hydrocele, which was of a dark grumous appearance, and contained a number of brilliant crystalline lamellse floating through it, to consist of Water ... - 441-50 Albumen and colouring matter of the blood .... 51-07 Cholesterine . - - - 5*40 Animal matter and salts soluble in alcohol - - - - -90 Animal matter soluble in water - -76 Salts - - » « - -37 500-00 The quantity of cholesterine contained in nine- teen ounces of dark fluid full of these shining par- ticles, which I removed from an old hydrocele, amounted to only nine grains. In the examination of a testis taken from the body of a man of colour, who died at an advanced age from the eflTects of an enlarged prostate, I found the tunica vaginalis and its investing tissues very thick and firm, and the seat of cartilaginous and osseous deposits ; it contained about three drachms of a thick brownish substance, which, when dried, was found to be almost entirely composed of crystals of cholesterine. * Lond. Med. Gazette, vol. xii. p. 764. SIMPLE HYDROCELE OF THE TESTIS. 153 This was no doubt a very old case of hydrocele, in which the more fluid parts having beea absorbed the cholesterine was left behind within the indu- rated sac. The quantity of serum which is sulFered to accu- mulate varies considerably. In this country it seldom exceeds twenty ounces, though it has been known to amount to several pints. The largest quantity which I have met with is forty-eight ounces. Mr. Cline is said to have removed from Gibbon the historian as much as six quarts."^ From a table of 1000 cases of hydrocele which occurred at the native hospital of Calcutta, constructed by Dr. Dujat, it appears that the quantity of serum evacu- ated varied from less than ten to upwards of one hundred ounces. Of 370 cases of double hydrocele, the fluid was more abundant on the right side in 109, and on the left side in 128. Of the 630 cases of single hydrocele, in rather more than a third of the number the quantity of fluid was under ten ounces ; in two sevenths it was from ten to nine- teen ounces ; in nearly a third from twenty to forty- nine ; and in eighteen cases the quantity of serum was from 50 to 120 ounces.t In simple hydrocele the testis is usually found at the posterior part, and rather below the centre of the sac ; its situation, however, is subject to vari- ations. Before the occurrence of hydrocele the tunica vaginalis may have been inflamed, and con- trjicted adhesions, so that the testis may be con- * Sir A. Cooper's Lectures, by Tyrrel, vol. ii. p. 92. t Gazette Medicale de Paris, 1838, p. 562. 20 154 SIMPLE HYDROCELE OF THE TESTIS. nected to the membrane in front ; in which case the serum accumulates on each side of, or above and below, the organ. Sometimes there are several adhesions, producing a sacculated arrangement, and forming what is termed a multilocular hydrocele. Occasionally the cysts thus formed have no com- munication with each other. In two instances 1 have seen a membranous partition in the sac of a hydrocele, separating it into two distinct cavities, formed by a layer of false membrane. There is one kind of sac or pouch often met with in hydro- celes which does not appear to have been described. It is situated on the inner side of the testis ; but the opening into it is always found on the outer side, between the body of the gland and the middle of the epididymis. This sac, which varies very much in size, is formed by the disten- sion of the cul de sac which I have described as existing natu- rally at this part. Two examples of this kind of pouch in the Hun- terian Collection were shown me by Mr. Paget. One of them is represented in the accompa- nying figure. In large hydro- celes the epididymis is usually elongated and displaced ; and instead of a pouch being formed, the central part of the epididymis is drawn to some distance frgm the body of the testis. 1. Aperture of the pouch, between the body of the testis and middle of the epididymis. SIMPLE HYDROCELE OF THE TESTIS. 155 In old hydroceles the sac is often a good deal thickened, the tissues enveloping it being condensed and converted into layers of dense facia, such as are commonly observed investing only hernial sacs. The fibres, also, of the cremaster muscle, having to support an increased weight, frequently become remarkably developed, and extend around the tu- mour. This, however, is not constantly the case ; for in some instances of hydrocele of large size I have found this muscle atrophied. The thickened sac after many years acquires a cartilaginous cha- racter, and it may even become more or less ossi- fied. In cases which have been frequently tapped, the sac is sometimes found closely adherent to the skin of the scrotum at the various points perforated by the trocar. In the collec- tion formed by the late Sir A. Cooper there is a prepara- tion (vide figure) showing a long narrow band of adhe- sion, passing from the ante- rior part of the testis across the dilated sac of the tunica vaginalis to the membrane in front, which is supposed to have resulted from a wound of the testis in the operation of tapping. Scar- pa was the first to notice that in all large hydroceles the spermatic vessels are separated and transposed, so that the artery with the vas deferens occupies one side of the 156 SIMPLE HYDROCELE OF THE TESTIS. I watery tumour, and the veins the other side ; and sometimes both of these vessels, in the manner of a band, pass on both of the sides, or even upon the anterior surface of the vaginal coat at its lower part.^ In hydrocele the glandular structure of the testis is sound, and the organ capable of exercising its functions. The disease is strictly confined to the investing serous tunic. The testis is, however, frequently somewhat altered in shape, being flat- tened by the pressure of the confined fluid ; and in some instances it has been found partially atrophied from the same cause. Hydrocele is a very common disease in persons of all ranks in life, and in most climates, but more particularly in warm countries. It has been re- marked by surgeons in extensive practice in London, that a large number of the patients who apply to them for the relief of this affection have passed several years in the West Indies, or some other warm country. Dr. Farret has noticed the fre- quency of hydrocele in Barbadoes ; and, according to Mr. Martin, it is a very common disease amongst the natives of Lower Bengal.^ This disease occurs at all periods of life ; but commences in early infancy and at middle age, more frequently than at any other period. It is rather a common aflection within a few weeks after * Treatise on Hernia, tr. by Wishart, p. 74. I Medical Records and Researches, p. 182. X Trans, of Med. and Phys. Society of Calcutta, vol. vii. p. 204 SIMPLE HYDROCELE OF THE TESTIS. 157 20 . . . 3 30 . . . 13 40 . . . 11 60 . . . 16 60 . . . 10 70 . . . 6 80 . . . 1* birth. In sixty cases of hydrocele, M. Velpeaa of Paris found, Between the ages of 15 and 20 — 30 — 40 — 50 — 60 — 70 — In a tablet of 1000 cases of hydrocele treated by iodine injection at the Native Hospital of Calcutta, it appears that none of the patients operated on were less than eighteen years of age ; about one twenty-fourth were not more than twenty years old; rather more than a sixteenth were from twenty-one to twenty-five years of age ; a little less than half from twenty-eight to thirty-five ; a little more than a quarter from thirty-six to forty-five ; and an eighteenth were upwards of forty-six years. * La Presse Medicale, Mai, 1837. f Table of 1000 Cases of Hydrocele treated by Iodine Injections at the Native Hospital of Calcutta, from Jan. 1, 1836, to Jan. 5, 1838 ; constructed from the Registers by M. Dujat. Ages. From 18 to 20 years of age 21 to 2.5 - - - - 26 to 35 - - - - 36 to 45 - - - - 46 to 59 - - - - 60 to 70 - - - - Cases of Single Hydrocele. Double. Total. Right. Left. Total. 14 11 25 16 41 51 58 109 64 173 147 147 294 179 473 72 94 167 90 257 17 6 23 20 43 4 8 12 1 13 305 325 630 370 1000 Gazette Medicale de Paris, torn. xvi. 1838, p. 561. 158 SIMPLE HYDROCELE OF THE TESTIS. Hydrocele is generally single, but sometimes occurs on both sides. It is said more frequently to form on the left side than on the right. Of forty- three cases which occurred to M. Velpeau, in thirty the hydrocele was on the left side, and in nine on the right ; in four cases the side was not indicated. Of thirty-six cases observed by M. Gerdy,* in eighteen the disease occurred on the left side, in thirteen on the right, and in five on both sides. During the last few years I have carefully regis- tered the new cases of hydrocele coming under my notice in public and private practice. Of fifty-four cases of simple hydrocele, forty-nine were single, and ^ve double. Of the former, twenty-seven occurred on the right side, and twenty-two on the left. This result, which gives a slight predominance to the right side, does not therefore agree with the observations of Velpeau, Gerdy, and Dujat. In the table constructed by the latter, it will be seen that the disease prevailed rather more on the left side than on the right. Hydrocele in young infants is usually single, and, in my experience, more fre- quent on the right side. I have seen, however, a few cases of double hydrocele at this early period. A child six weeks old was brought to me on ac- count of a hydrocele the size of a hen's egg on the right side, and another little more than half that size on the left ; neither of them had any commu- nication with the cavity of the abdomen. Dropsy of the tunica vaginalis is usually regarded * Archives Generales de Medecine, 111 ser. torn. i. p. 60. SIMPLE HYDROCELE OF THE TESTIS. 159 as purely a local affection, resulting from a dis- turbance of the nicely adjusted balance between the functions of secretion and absorption. The same general causes which tend to produce effusion in the other serous membranes we may conclude likewise operate in occasioning hydrocele. All circumstances which determine blood to the organ in excess, or impede its return to the heart, or which act in any way in disturbing the circulation through the gland, must be regarded as remote causes of the disease ; and, considering the exposed and depending situation of the testicle, the liability of its vessels to obstruction, and the irregular nature of its functions, there can be no difficulty in accounting for the frequency of this affection. I shall hereafter have occasion to mention that hy- drocele is often combined with inguinal hernia ; a disease obviously very favourable to the effusion of serum in the tunica vaginalis, owing to the pres- sure of the rupture on the veins of the spermatic cord, and which is often increased by the use of trusses and bandages. Hydrocele is occasionally developed after a violent strain or great fatigue, or after a slight blow on the gland which was con- sidered at the time to be too trivial to require attention. In many of these cases the effusion appears to originate in a low degree of inflammation of the tunica vaginalis. I have already stated that marks of previous inflammation are occasionally observed in the sacs of hydroceles. On examining the body of a man aged forty-nine who died of apoplexy, I found about two ounces of serum in the 160 SIMPLE HYDROCELE OF THE TESTIS. vaginal sac of both testes, and also several old ad- hesions, and some spots of induration and thicken- ing of the testicular portion of the membrane. I have observed similar appearances in other cases of incipient hydrocele, as well as imperfect mnltilo- cular cavities and septa, and induration, and enlargement of the epididymis, clearly evincing that the part had been the seat of inflammation. In some few instances I have met with hydrocele under circumstances which have led me to suspect that the disease was connected with, or sympathetic of, a chronic affection of the urethra, as stricture and morbid irritation in the canal. Hydrocele occasionally results from the irritation produced by loose accidental bodies in the tunica vaginalis, which are more frequently present than is generally supposed. In disturbed states of the circulation from disease of the heart, the tunica vaginalis is not so frequently the seat of dropsical eflusion as the other serous membranes, with the exception of the arachnoid ; but this is partly owing to the pres- sure exerted around the testis by the accumulation of fluid in the cells of the scrotum, and the relief to the spermatic vessels afforded by the oedema. In cases, however, of general anasarca, I have very frequently found slight effusion into the vaginal sac combined with oedema of the scrotum. When the fluid collected in the tunica vaginalis is attended with disease and enlargement of the testis, the swelling is termed hydrosarcocele. This affection is generally consequent on chronic orchitis, but it is occasioned by other morbid changes. SIMPLE HYDROCELE OF THE TESTIS. 161 malignant as well as innocent. In these cases the disease of the testis is the original complaint and source of the irritation that excites an undue secre- tion from the tunica vaginalis, acting much in the same way as a tumour in the abdomen does in oc- casioning increased secretion from the peritoneum; or as a tumour in the chest, or carcinomatous dis- ease of the lungs, in producing pleuritic effusion. Symptoms. — Simple hydrocele forms a swelling which is elastic and of an oval or pyriform shape, which fluctuates, and has a smooth and even sur- face, and which, commencing at the lower part of the scrotum, increases very gradually and without causing pain. At its back part the tumour feels firm and solid, and strong pressure there occasions the peculiar sensation experienced from compres- sion of the testis. The swelling is movable, but re- mains constant under pressure ; and in all positions of the body, and if not of large size, the spermatic cord can be felt above it. When examined by transmitted light, the tumour is found to be more or less transparent, except at the part where the testis is situated, the opacity there indicating the exact position of the gland. When the hydrocele is of considerable size, the integuments are ren- dered very tense, and the veins ramifying beneath the skin appear prominent and enlarged. The penis is also partly or entirely buried in the swell- ing, the skin which usually invests it being drawn forward into the scrotum, giving to the orifice of the prepuce somewhat the form of the umbilicus. The hydrocele, even when large, is seldom attended 21 162 SIMPLE HYDROCELE OF THE TESTIS. with pain ; though its bulk and weight produce a good deal of inconvenience, and, if not supported, the tumour produces a dragging effect on the sper- matic cord, which causes uneasiness in the loins. Its progress varies in different individuals, the hy- drocele in some instances being several months in attaining a size which in other cases it reaches in as many weeks. But its course is, in general, slow ; and twelve and even eighteen months may elapse before the swelling approaches the abdo- minal ring. Sometimes after arriving at a cer- tain magnitude it ceases to increase ; whilst in other cases its growth, though slow, is uninter- rupted. It rarely happens that a hydrocele attains any considerable magnitude because so much in- convenience is occasioned by the tumour when of large size that the patient obtains relief at an early period ; otherwise it might increase until it reached as low down as the knees, as has really happened in long-neglected cases. Mursinna mentions a case^ in which the tumour measured as much as twenty-seven inches in length and seventeen in width, which is, I believe, the largest hydrocele on record. The symptoms of hydrocele are liable to several modifications. It sometimes happens, especially in children, that the tunica vaginalis remains after birth unobliterated for some distance along the cord \ consequently, when fluid collects within it the swelling assumes a pyramidal and elongated form, and the relative situation of the testis is * Neue Medicinische-Chirurgische. SBTPLE HYDROCELE OF THE TESTIS. 163 lower than in ordinary cases. Owing to a peculiar conformation of the tunica vaginalis, there is occa- sionally a slight contraction in the centre of the hydrocele, giving to the tumour the form of an hour-glass. When, too, the testis is adherent to the front of the sac, the serum accumulating on each side, or above and below, causes the swelling to assume an irregular shape. Fluctuation is some- times obscure, and in other instances is not distin- guishable at all, in consequence of the tension and thickness of the sac and membranes investing it. If the sac happens to be loose and not fully dis- tended, the*^^ testis may sometimes be felt. This is often the case in children. Mr. Pott remarks, " The transparency of the tumour is the most fallible and uncertain sign belonging to it : it is a circumstance which does not depend upon the quantity, colour, or consist- ence of the fluid constituting the disease, so much as on the uncertain thickness or thinness of the containing bag, and of the common membranes of the scrotum. If they are thin, the fluid limpid, and the accumulation made so quick as not to give the tunica vaginalis time to thicken much, the rays of light may sometimes be seen to pass through the tumour ; but this is accidental, and by no means to be depended upon. Whoever would be acquainted with this disorder must learn to dis- tinguish it by other, and those more certain, marks, or he will be apt to fall into very disgraceful as well as pernicious blunders."^ The value of trans- * Works, 4to. p. 394. 164 SIMPLE HYDROCELE OF THE TESTIS. parency, as a sign of hydrocele, is rather under- rated in these remarks. In ordinary cases the surgeon should certainly be able to detect the dis- ease without its assistance ; and this is the more necessary, as its absence is no proof that the tumour is not a hydrocele. But it would be absurd to reject the aid of a symptom which, when present, constitutes one of the most certain signs of the disease, because of its inconstancy ; and, in the present day, there are few surgeons even of ex- perience who do not avail themselves, in cases of doubt, of this ready and simple mode of examina- tion. But, independently of the advantage to be derived from transparency as a means of diagnosis, we are enabled by this mode of examination to ascertain the exact position of the testis, which is always important before undertaking any operation. In cases of encysted hydrocele, or adhesion of the testis to the sac, the unusual situation of the gland may thus be detected, and risk of injury to it be avoided. The mode of making the examination generally adopted is to darken the room, and place a lighted candle so that the tumour may be inter- posed between the eye and the light. The testis is then readily recognised as an opaque object, and its situation exactly ascertained. In cases in which the parietes of the cyst are unusually thick, or the fluid is very dark-coloured, I have sometimes de- rived considerable assistance from using a wooden tube, about three quarters of an inch in diameter, open at both extremities. One end being placed against the swelling opposite the light, the surgeon, SIMPLE HYDROCELE OF THE TESTIS, 165 on looking through the other, can observe the transparency with great advantage. If a more convenient tube be not at hand, a roll of writing paper will answer the purpose. The growth of a hydrocele is occasionally attended with a good deal of local uneasiness, which has been ascribed to pressure on a nerve, or to the presence of acci- dental cartilages in the cyst. I have generally found, when pain exists, that the dropsical collection has originated in and been kept up by some disease of the testis. A hydrocele sometimes varies in size, being larger and more tense in the after part of the day than when the patient first rises in the morning. I have not exactly observed this change ; but it has been so often mentioned to me by per- sons affected with hydrocele, that I entertain no doubt of the fact ; and since the extent of surface afforded by the dilated tunica vaginalis is large, and the condition of the parts during day and night very different, such variations in size consequent upon alterations in the functions of secretion and absorption do not appear at all unlikely to occur. I have been informed of a case in which the change was so remarkable that the scrotum, which was full and tense when the patient retired to rest, became contracted and corrugated by the time he rose in the morning. Diagnosis. — A hydrocele is usually distinguished without difficulty. The surgeon may conclude that a scrotal swelling is a hydrocele, if the tumour be tense, transparent, and fluctuating ; if it has a smooth and uniform surface ; and if the testis can- 166 SIMPLE HYDROCELE OF THE TESTIS. not be felt, and its position can only be ascertained by the greater solidity of the swelling, and the uneasiness experienced on pressure at one par- ticular part, which is generally behind ; and if the spermatic cord can be distinctly felt of its natural size, and in a healthy state. The affections most likely to be confounded with hydrocele are scrotal hernia and malignant disease of the testis. A hydrocele differs from a scrotal hernia in the fol- lowing circumstances : — The swelling commences at the lower part of the scrotum ; whereas in hernia it begins at the ring, and gradually descends. The spermatic cord can be clearly felt above the tumour ; but in hernia it can only be traced indistinctly along the back part of the swelling, and some- times cannot be distinguished at all. The testis cannot be felt ; but in hernia, unless congenital, the gland can be readily perceived at the bottom of the swelling : and, further, there is no impulse communicated on coughing, and the tumour is not subject to variations in size, as in rupture. The diagnosis is made with less facility when the hydro- cele extends upwards along the cord nearly to or even into the ring, as in this case the cord cannot be felt ; and the shape of the tumour nearly re- sembles that of a scrotal hernia, and there may even be a slight impulse transmitted to it on coughing ; but attention to the other distinguishing marks which have been pointed out will always be sufficient to enable the surgeon to make an accu- rate diagnosis. To distinguish simple hydrocele from malignant SIMPLE HYDROCELE OF THE TESTIS. 167 disease of the testis is not difficult, unless the parietes of the sac containing fluid be much thick- ened. But when the cyst is so thick and dense as not to admit the passage of rays of light, a careful examination is necessary to enable the surgeon to form a correct opinion. Like hydrocele, the dis- eased testis may present a tumour of an oval form, which has commenced at the lower part of the scrotum, and has formed gradually and without causing pain. It may also fluctuate indistinctly, and remain of uniform size under pressure, and in all positions ; and the spermatic cord may be felt above it in its natural state. In lightly balancing, however, the tumour in the hand, the diseased testis feels heavier than a hydrocele ; and its ex- ternal surface is seldom so even and uniform as, nor does it often assume the pyramidal form of, a hydrocele. On pressing the part occupied by the testis, if the tumour be a hydrocele the usual pain is experienced ; whereas if it be a malignant swell- ing of a large size, the disorganization is attended with loss of the natural sensibility of the gland. If the slightest transparency can be detected on inspecting the swelling through a tube in the man- ner explained (and I have not met with many cases of hydrocele in which transparency could not be perceived when the tumour was examined in this way), all doubt becomes removed. But in an ob- scure case the surgeon might introduce a grooved needle or trocar into the swelling, when, if the case be hydrocele, the escape of fluid would at once manifest the nature of the disease. I once met 168 SIMPLE HYDROCELE OF THE TESTIS. with an indolent tumour of small size in the scro- tum of an old man, which was so irregular and uneven, felt so solid, and weighed so heavy, that it was impossible to determine exactly whether the swelling was occasioned by a morbid enlargement of the gland, a hoematocele, or a hydrocele with the sac unusually thickened and indurated. The age of the patient was such as to put an operation out of the question. He subsequently died of dis- ease of the chest ; and, on examination, I found the tumour to consist of a hydrocele, the sac of which wascartilaojinous and much thickened, and the con- tents a soft oleaginous kind of substance, consisting chiefly of cholesterine. The nature of such a swell- ing could only have been clearly ascertained by a puncture. The difficulty of the diagnosis, in cases of cartilaginous thickening of the tunica vaginalis, has been attested by Dupuytren. In a case of en- largement and induration of the left testicle, at- tended with lancinating pains in the groin and loins, and much emaciation, symptoms expressive of schirrous disease, and unaccompanied with any sign indicative of hydrocele, or scrofulous or vene- real disease, this distinguished surgeon, to avoid all chance of error, made an exploratory puncture. The result showed the prudence of this precaution ; for, instead of schirrus, the case was found to be a hydrocele, with cartilaginous thickening of the tunica vaginalis.* Treatment. — Though hydrocele is a disease free * Lecons Orales, torn. i. p. 49, edit. Brux. SIMPLE HYDROCELE OF THE TESTIS. 169 from danger, it causes serious inconvenience and discomfort. When of large size, its weight is such that it has a dragging effect on the spermatic cord, and produces considerable uneasiness. This may indeed be obviated in a great measure by support- ing the tumour in a suspender ; and, as a general rule, the patient should always be directed to wear one. There are, however, other sources of annoy- ance. The tumour is constantly exposed to slight blows, and impedes the activity of the patient's movements. In warm weather troublesome exco- riations are often caused by the friction of the hydro- cele against the inner part of the thigh. The penis being partly buried in the swelling, micturition and the genital functions are more or less interfered with ; and as the tumour cannot be fully concealed by the dress, even motives of delicacy strongly incline the patient to desire its removal ; so that persons labouring under this complaint generally apply sooner or later to the surgeon for relief. A hydrocele may disappear without any treat- ment whatever. In infants this is a constant oc- currence, but in adults is extremely rare. Mr. Pott has recorded two instances of the spontaneous disappearance of a confirmed hydrocele in the adult. One is the case of a gentleman forty-five years of age, in which the dropsical collection dispersed during six weeks' confinement for a severe fit of gout. The other is the case of a middle-aged man, who whilst intoxicated fell down and struck his scrotum against a piece of scaffolding, which caused considerable ecchymosis. This disappeared in about 22 170 SIMPLE HYDROCELE OF THE TESTIS. a fortnight, when it was observed that the hydro- cele was much less in size than it was before the accident. In about three weeks more the whole of it had subsided, and it did not afterwards return."* Sir B. Brodie also mentions that he has met with two examples of the spontaneous cure of hydrocele. In one of them the removal of the disease appeared to have resulted from inflammation set up in the sact A hydrocele has also been known to disap- pear permanently after an attack of orchitis, conse- quent upon the extension of inflammation from the urethra. But these cases are exceptions to the general rule, and are not to be taken into account in determining upon the treatment to be adopted. Infants affected with hydrocele are frequently brought to the surgeon within the first or second month after birth, the tumour naturally enough exciting uneasiness in the mind of the mother. In these cases, all that is necessary in the way of treat- ment is a stimulating application, and support to the scrotum with a bandage. A lotion, composed of an ounce of the hydrochlorate of ammonia, four ounces of distilled vinegar, and six ounces of water, will generally cause the removal of the fluid. In many instances I have found it quickly disappear by occasionally painting the scrotum v/ith the tinc- ture of iodine. If the hydrocele does not disperse under this treatment in the course of two or three weeks, the tumour may be pricked with a cataract * Lib. cit. p. 413 and 414. f Lond. Med. Gazette, vol. xiii. p. 90. SIMPLE HYDROCELE OF THE TESTIS. 171 needle, which will allow the greater part of the fluid to drain away. This is the only operation that I ever found necessary in treating hydrocele in in- fants ; and even acupuncture, which is a mild pro- ceeding, and devoid of danger, is seldom required. The cure of hydrocele has been attempted in the adult with external remedies. For this purpose highly stimulating lotions and liniments, frictions with iodine, tartar emetic, and mercurial ointments, and the repeated application of blisters to the scro- tum, have been employed. Dupuytren states that he has succeeded in removing hydrocele by blisters f whereas Sir A. Cooper remarks that he has tried repeated blistering without producing a cure.t I have applied blisters and the linimentum hydrargyri in several instances, and have also been unsuccess- ful.J In the two following cases I succeeded in re- moving hydrocele by external treatment. — A man aged forty-five, and in good health, came under my care at the London Hospital in 1838, on account of a chronic hydrocele on the right side which had appeared gradually without any obvious cause. It was first observed about three months before ; but as it had attained an inconvenient size, and was getting somewhat painful, he was induced to apply for relief The tumour being very tense, I at once * Lecons Orales, torn. iv. p. 239, edit. Brux. t Lib. cit. p. 178. I Blistering the scrotum is not always free from risk. M. Gerdy relates a case in which gangrene of the scrotum occurred after the application of a blister for the removal of hydrocele in a man sixty years of age. Archives Generales de Medecin, 111 ser. torn. i. p. 70. 1 72 SIMPLE HYDROCELE OF THE TESTIS. introduced a trocar, and drew off twelve ounces of serum. The testis was then felt healthy in size and structure. I saw the man again in three days, at which time the swelling had increased to nearly half its former size, and was tender on pressure. Being desirous of attempting the cure of this com- plaint on antiphlogistic principles, and considering a case seen at so early a period favourable for the experiment, 1 directed four or five leeches to be applied to the scrotum twice weekly, the parts to be supported and kept cool with an evaporating lotion, and the bowels to be gently acted on with saline purgatives. This plan of treatment was pur- sued steadily for three weeks, during which period the swelling gradually decreased, and when all but entirely removed the man discontinued his visits. ■ — A corpulent gentleman, fifty-one years of age, called to consult me on account of a hydrocele of the right testis, which he had observed for about six months. The fluid within the sac did not ap- pear to amount to more than three ounces, and it produced no inconvenience. I painted the scrotum with a strong solution of iodine, and directed the use of a suspender. This application was made twice, and in three weeks all the fluid had become absorbed. In a few weeks afterwards the fluid again began to collect, and the hydrocele was sub sequently cured by injection. I have employed local treatment in other cases of older standing, but without success. External applications have, indeed, so seldom proved of any avail, that after the age of puberty chronic hydro- ■J SIMPLE HYDROCELE OF THE TESTIS. 173 cele is considered incurable by such remedies ; and the time lost in the experiment, and the pain and annoyance they produce, are serious objections to any trial of them. The distended tunica vaginalis is liable to be ruptured by accidental violence, the fluid escaping into the surrounding cellular tissue, and producing oedema of the scrotum, instead of the defined tumour which previously existed. The oedema usually extends to the penis, and sometimes reaches the lower part of the abdomen, occasioning a dif- fused swelling, which might prove alarming to the inexperienced surgeon. The fluid, however, is not of an irritating quality, and is so rapidly absorbed that the accident is seldom attended with incon- venience. In these cases the hydrocele is removed for a time, and in many instances permanently ; but in general the fluid collects again. In a French periodical a case is mentioned by M. Serres of a Spaniard about forty years of age aflected with hydrocele, who was in the habit, when the tumour got sufficiently large to be troublesome, of mount- ing a horse, or taking some other violent exercise, until the swelling gave way. He stated that he had done this more than thirty times.'^ When a patient with hydrocele applies to a sur- geon, it is usual to resort at once to operative treatment, which is of two kinds — palliative and radical. * Lancette Francaise. 174 SIMPLE HYDROCELE OF THE TESTIS. Palliative Treatment of Hydrocele by Operation. The palliative operation is exceedingly simple, of easy performance, and, if proper care be taken, free from danger ; but the relief it affords is only temporary. It consists in puncturing the tumour so as to allow of the escape of the fluid contained in the tunica vaginalis : the operation may be per- formed with a lancet or a trocar. The best place for making the puncture is about the centre of the anterior part of the tumour ; but the surgeon should first ascertain the situation of the testis, for when the position of the gland is altered by adhesions or other causes, it may be necessary to puncture the tumour at the side, or even behind. It is better, however, to avoid the posterior part if possible, as in this situation there is some risk of wounding the spermatic artery. Simple as the case may appear, the surgeon should omit none of the customary pre- cautions, for more mishaps have occurred in the treatment of hydrocele than in any other operation in surgery. The lancet was formerly used for this operation, but is not now employed ; for the whole of the fluid cannot well be evacuated through the opening thus made, without much squeezing and handling of the parts ; and there is also risk of the division of some small vessels, which by pouring blood into the tunica vaginalis may change the case to one of haematocele. The operation is therefore generally performed with a trocar, the canula of which is about two inches long and a line in diameter. In selecting an in- SIMPLE HYDROCELE OF THE TESTIS. 175 strument the surgeon should see that the canula fits properly, and that its shoulder does not project too much ; or else, after the point of the trocar has penetrated the cyst, the canula may hitch outside it, and instead of entering the cavity push the tunica vaginalis before it. In such a case, if the accident be not perceived in time,, the testis or the back part of the cyst is very liable to be wounded. The trocar before being used should be thrust through a piece of wash-leather held tense, and unless it penetrates readily, the instrument is unfit for use. This advice may seem unimportant ; but it should be recollected that, in addition to the risk of converting the case into a haematocele, any bungling in an operation of so simple a nature as the tapping of a hydrocele may induce the patient to suspect a general want of skill. I generally prefer performing this operation with the patient standing before me ; but if he be timid, or liable to faint, he may be seated in a chair, or placed in the recumbent position. The surgeon, grasping the tumour behind with his left hand so as to put the integuments upon the stretch, and taking care not to wound any of the enlarged veins beneath the skin, should insert the trocar, previously well oiled, perpendicularly into the tumour with a brisk motion of the right hand ; and as soon as the sac is perforated, which is ascertained by the im- mediate cessation of all resistance, the instrument should be inclined upwards, in order to avoid injury to the testis, and the trocar withdrawn, whilst the 176 SIMPLE HYDROCELE OF THE TESTIS. canula is simultaneously thrust forwards by the action of the thumb and forefinger : gentle pressure is then to be maintained until all the fluid is re- moved. By manipulating in this way all risk of the tunica vaginalis slipping off the tube, or of the testis and back of the sac being injured, is pre- vented. After the whole of the fluid has escaped the canula is to be withdrawn, and the edges of the wound slightly nipped together ; after which the only application necessary is a piece of adhesive plaister to cover the wound : the scrotum is to be suspended in a bag truss. The patient should be enjoined not to walk about much for the next twenty-four hours, and to abstain from active exer- cise for a day or two ; a precaution which is more especially necessary in individuals of an irritable or unhealthy constitution, or in advanced life. If this advice be neglected, acute inflammation of the tunica vaginalis is liable to succeed the operation. Some years ago I tapped the hydrocele of a healthy man fifty years of age, who, notwithstanding the caution I had given him, walked several miles the same afternoon ; the consequence was severe in- flammation of the sac, followed by sloughing of the scrotum. After much suffering he recovered at the expiration of eight weeks, with the disease per- manently cured. At a later period of life, if proper precautions be not taken, the palliative operation can scarcely be viewed as free from danger. Sir A. Cooper mentions two cases of persons in ad- vanced age, who having taken a long walk after SIMPLE HYDROCELE OF THE TESTIS. 177 the operation, had inflammation and sloughing of the scrotum, which terminated fatally."^ The wound made by the trocar heals by the first intention. Friction of the scrotum against the dress sometimes causes slight inflammation, and even ulceration afterwards, so as to require the attention of the surgeon ; but this is seldom the case, and when it occurs is easily remedied by the ordinary means. Occasionally there is slight ex- travasation in the cellular tissue from a wound of some small vessel external to the sac, but very rarely to any extent so as to interfere with the healing of the wound. The operation is always admissible whenever the amount of fluid is suflicient to admit of the intro- duction of the trocar without risk of injury to the testis. It should be repeated as soon after the fluid has collected again as the tumour from its size or weight becomes troublesome. This varies greatly. I have had patients who for many years have been satisfied with the relief afforded by an annual operation ; and in one case the fluid did not collect in a sufficient quantity to need removal for four years, when I drew off no more than sixteen ounces. In other instances patients have returned to have the fluid evacuated again at the expiration of two or three months, and even of a much shorter period. Indeed, I have known the hydrocele to regain its former size in the course of two or three days. Many persons suffer pain and uneasiness from only * Lib. cit. p. 181. 23 178 SIMPLE HYDROCELE OF THE TESTIS. a small quantity of fluid, whilst others experience but little inconvenience until the hydrocele has attained a large size. In most cases the patient's feelings will be the best guide in indicating the necessity for a repetition of the operation. Many persons affected with hydrocele, which after being tapped appears very slowly, and without causing uneasiness, are so satisfied with the tem- porary benefit afforded by this slight and almost painless operation, that they desire no further relief than is derivable from its repeated perform- ance ; and as hydrocele is not a disease which if suffered to remain is commonly followed by im- portant consequences, such persons may be safely left .to consult their own inclinations. Some pa- tients are too timid to submit to any other kind of treatment, and others are unwilling to undergo for the permanent relief of so slight an inconvenience even the short confinement which might be required. Persons out of health, of an irritable constitution, or in advanced life, upon whom the radical opera- tion cannot be performed without risk, must like- wise be content with palliative treatment. The tunica vaginalis may be emptied by a punc- ture made with a needle ; when the fluid, instead of escaping externally, as in the former operation, gradually infiltrates the cellular tissue surrounding the sac, whence it is afterwards removed by absorp- tion. In this operation, which is termed acu- puncture, anarsarca of the scrotum is substituted for a common hydrocele. It was first suggested by Dr. Cumin of Glasgow, who at the conclusion of SIMPLE HYDROCELE OF THE TESTIS. 179 some observations on the treatment of ganglion by a similar procedure published in 1825, remarks, that it has occurred to him that a cure of hydrocele might be accomplished by opening a communi- cation by means of the cataract needle, between the cavity of the tunica vaginalis and the cellular tissue of the scrotum.* He did not, however, submit this idea to the test of experiment. Several surgeons have subsequently claimed the merit of originating this operation as a palliative cure for hydrocele. Mr. Lewis, surgeon, of London, is entitled to the credit of having first recommended acupuncture to his professional brethren on the grounds of practical experience of its efficacy .;t though no doubt can be entertained that the plan had been previously resorted to by other surgeons, who had regarded it as either too simple or too unimportant to deserve a formal notice, or who perhaps did not sufficiently appreciate its value.J Mr. Lewis's practice is to puncture the tumour with a fine needle until a drop of fluid oozes out on withdrawing it, and in a few days the hydrocele will entirely disappear. The absence of danger, the slow re-accumulation of fluid, and the simpli- city of the operation, are the advantages which he considers to be obtained by this mode over the operation of removing the fluid at once. In performing acupuncture I employ the common "^ Edinb. Medical and Surgical Journal, vol. xxiv. p. 97. t Lancet, vol. ii. 1835-36, p. 206. I Vide note from Mr. Keate on the Treatment of Hydrocele, Medical Gazette, vol. xix. p. 789. !80 SIMPLE HYDROCELE OF THE TESTIS. cataract needle, which I usually introduce in two or three different places, rotating the instrument between the finger and thumb to render the open- ings in the sac sufficiently patent. A little serum generally oozes out from the puncture in the skin in drops, or issues in a stream for a few seconds, and then ceases. In the course of a few hours the scrotal swelling becomes a good deal changed, and instead of a tense, smooth, and defined tumour, presents an oedematous tumefaction, with a soft, doughy, and inelastic feel. In large hydroceles the oedema extends to the integuments of the penis. The swelling thus produced takes from three days to a week gradually to disappear, the scrotum in favourable cases being left in its natural condition, without any excess of fluid either in its loose cel- lular tissue or in the sac of the tunica vaginalis. The operation may be repeated again and again as the fluid returns, on each occasion before the tumour has acquired the same size as on the pre- ceding one, by which means the sac may some- times be gradually reduced to its natural size. Though the advocates of this operation have not claimed for it the merit of constantly affording radical relief, it has been observed that the re-accu- mulation follows less quickly than after the fluid has been evacuated at once by the trocar, and in many instances does not take place at all. This certainly accords with my own experience of this operation ; for, in six cases in which it was per- formed, the relief proved so far permanent that there was no return of the hydrocele after a period SIMPLE HYDROCELE OF THE TESTIS. 181 of many months, when I lost sight of my patients. Similar success has attended this practice in the hands of several of my professional friends with whom I have conversed respecting it.^ The cure of the disease in these cases, as well as the slow re-accumulation in others, I conclude are owing to the support and compression afforded to the vaginal sac by the infiltration of the surrounding cellular tissue : they are not likely to arise from any inflam- matory change in the containing membrane. Acupuncture must be regarded, upon the whole, as a useful addition to our remedial measures for the treatment of hydrocele. It does not supersede the use of the trocar ; for the latter is scarcely more painful or less simple, and in careful hands is equally safe and free from hazard, whilst the im- mediate and certain relief which the trocar affords will always give it an advantage. Acupuncture, too, is ill adapted for cases of thickened sac ; and the chance of permanent benefit which it offers is too slight to add much to its value as a means of treatment. In very timid persons, in those of im- paired constitutions, and in children, and in some other forms of hydrocele not yet described, acupunc- ture may be resorted to with benefit, and even pre- ferred to the trocar. I am informed by Mr. Luke, that in the case of a gentleman who was about to proceed to a place in South America, where there would be no surgeon nearer his residence than 400 * Two cases cured by acupuncture have been published by my friend Mr. Wahie in tlie Medical Gazette, vol. xxix, p. 949. 182 SIMPLE HYDROCELE OF THE TESTIS. or 500 miles, he instructed his patient to perform this simple and harmless operation on himself. Radical Treatment of Hydrocele by Operation. The permanent and radical cure of hydrocele maybe effected by any of the following operations: — Incision of the sac ; excision or removal of the tunica vaginalis; caustic applied to the integu- ments ; a tent introduced into the tunica vaginalis ; a seton passed through the sac ; and injection of the sac with a stimulating fluid ; — all which plans appear to have been known to ancient practitioners."^ Incision. — The treatment by incision is the most ancient of all the methods which "have been em- ployed for the cure of hydrocele. In performing it the surgeon cuts gradually down to the cyst with a scalpel, and, making an opening into the upper part, introduces a director or the finger, and with a bistoury lays open the cyst as far as the bottom of the sac, so as completely to expose the testis. The wound is then dressed ; inflammation soon arises, and the tunica vaginalis becomes obliterated by adhesion ; or else suppuration ensues, and the * Those interested in the history of the methods of cure for hydro- cele may consult the writuigs of Sabatier (Medecine Operatoire), and the Treatise on Hydrocele by Sir James Earle. There are few diseases of the same importance which have been so much written on as this affection."" Besides being largely treated of in most works on surgery, hydrocele and the particular modes of curing it has formed the subject of distinct treatises by the following British writers : — Douglas, Else, Pott, Howard, B. Bell, Keate, Earle, Hoibrook, and Dease. Some of these works have run through several editions. SIMPLE HYDROCELE OF THE TESTIS. 183 part heals by granulation. After the incision was completed, it was often the custom to stuff the tunica vaginalis with lint, or to apply some other coarse and irritating substance. This operation was consequently always succeeded by acute in- flammation of the sac, the constitutional effects of which frequently proved exceedingly severe. Many of the older surgeons, as Wiseman, Cheselden, Heister, and Sharp, have noticed the painful and even dangerous consequences which sometimes re- sulted ; and it is observed by Pott, that this "method can never be said to be totally and absolutely void of some danger."^ Mr. B. Bell of Edinburgh is the most recent authority in this country who has advocated this method of treating hydrocele, which he slightly improved upon by devising a less irri- tating mode of dressing.f My brother, Mr. H. Curling of Ramsgate, informs me that when in Paris he witnessed several cases of hydrocele cured by incision by Jobert ; but the treatment proved very severe, and confined the patients to bed for a long time. I have myself seen three cases of this disease attended with considera- ble thickening of the sac, which, after injections had failed, were successfully treated by incision ; and certainly the consequences were less severe than the representations of Sharp and Pott would lead us to expect : but in these cases the tunica vaginalis was evidently less disposed to inflamma- tion than usual. Incision is an operation rarely * Lib. cit. p. 441. f Treatise on Hydrocele. 184 SIMPLE HYDROCELE OF THE TESTIS. resorted to in the present day ; and I quite concur in the general opinion, that the disease can be suc- cessfully treated by milder and safer means. When, however, a hydrocele is found to depend on the pre- sence of loose cartilages in the sac, a small incision for their removal is the only treatment that can be of service. The wound should afterwards be closed, and the admission of air as much as possible pre- vented. Excision consists in cutting down upon the tunica vaginalis and excising the greater part of it with a pair of scissors, the spermatic vessels and testis being left untouched. The wound, which is filled with lint and dressed, subsequently suppurates and heals by granulation. This operation is also one of considerable antiquity; but it long remained in disuse, until it was revived in England in the year 1755 by Mr. Douglas, who advised the removal of an oval portion of the scrotum, together with the cyst."^ About the same period Bertrandi and several surgeons of eminence in France adopted the operation. The consequences of excision were not less severe or dangerous than those of incision ; it was sometimes followed by gangrene of the scro- tum, and generally by much constitutional irritation and tedious suppuration. This operation is now nearly exploded. I have only once seen it practised, and that was in the case of a young man, in which the tunica vaginalis was remarkably thickened, after the operation of injection had failed. The symp- * Treatise on Hydrocele, p. 136. SIMPLE HYDROCELE OF THE TESTIS. 185 tomatic fever which followed was mild, and the operation successful, the wound having healed com- pletely in three weeks. Mr. Kinder Wood, a provincial surgeon, has practised a modification of the operation of exci- sion,^ which is deserving of notice. He opened the tumour with a broad-shouldered lancet in the customary situation, the lancet in consequence of its figure making a larger incision into the external covering than into the tunica vaginalis. After the evacuation of the water through the opening, a small portion of the tunica vaginalis which pre- sented at the internal opening was slightly hooked with a small dissecting hook, and a portion so brought forward through the incision was cut off with a pair of fine scissors. The puncture was then closed, and supported with adhesive plaister. In three cases in which this operation was performed the wound afterwards healed by the first intention. In two of them there was no return of the hydro- cele when the part was examined several years after the operation ; and in the third he remarks, " A suf- ficient time has elapsed to decide upon its certainty." In these three cases the cure was completed with- out an abolition of the cavity. They were instances of a perfect cure of the disease, and not of one effected by the obliteration of a natural membranous sac. In a fourth case in which this operation was tried, it was succeeded by severe inflammation of * Observations on the Cure of Hydrocele without procuring- an Obliteration of the Sac : Medico-Chirurgical Trans, vol. ix. p. 38. 24 186 SIMPLE HYDROCELE OF THE TESTIS. the testis ; the patient, however was an unfavourable subject. It is not recommended in cases in which the sac is much thickened and indurated. This operation, being neither severe nor dan- gerous, must be viewed quite in a different light from the old method of excision. Mr. Wood's re- port, although his experience at the time it was published was very limited, is upon the whole fa- vourable ; but the advantages which he claims for this mode are not such as appear to me to entitle it to any preference over injection. Dr. Titley states that he tried it on six patients in the West Indies ; and although in some of them a very considerable portion of the tunica vaginalis was removed, yet it proved in every case unsuccessful.* We must con- clude, therefore, that the mild form of inflammation which Mr. Wood considers fit to supersede the mor- bid state of the vessels, the cause of the effusion, cannot be insured by his plan with that degree of security and certainty which alone would recom- mend its adoption in practice. Caustic. — In this method of treating hydrocele a caustic is applied to the scrotum, so as to destroy the integuments, and cause a slough extending to the tunica vaginalis. When the slough separates, the cavity of the tunica vaginalis becomes exposed, and the fluid within it escapes. This is followed by inflammation of the membrane, which after- wards contracts and closes by adhesion or granu- lation. The effects of the caustic are represented * Treatise on the Diseases of the Genitals of the Male, p. 340. SIMPLE HYDROCELE OF THE TESTIS. 187 in the woodcut at page 146. In the preparation there is a small aperture in the tunica vaginalis about a quarter of an inch in diameter, produced by a slough, and the inflamed membrane is coated with delicate flocculi of lymph. The caustic, although a mode of treatment introduced at a later date than incision and excision, was practised by surgeons at a very early period. It has been particularly de- scribed and advocated by Mr. Else ; and Mr. Cline, a cautious man, and one of the best practical surgeons of his day, also appears to have formed a very favourable opinion of this remedy, which he considered the mildest mode of all others.^ The caustic is in some respects a better method of treatment than those previously in vogue, the inflammation which it excites being less active and dangerous ; but for many reasons it is an objec- tionable remedy. It occasions a needless destruc- tion of parts, and is liable to produce a tedious and unhealthy sore : its action cannot be regulated with such exactness as to insure an opening through the tunica vaginalis ; so that a fresh application of the caustic, or the introduction of a lancet or trocar, was often necessary to complete the process : its operation is slow, and the consequences are unne- cessarily severe and painful. The treatment by caustic has therefore been long superseded in this country by milder means. * Lectures on Surgery, from Notes by Dr. Wilkinson, Medical Gazette, vol. xxiii. p. 279. It must be observed that Mr. Cline's favourable opinion of the caustic was expressed previous to the ap- pearance of Sir J. Earle's work on the radical cure by injection. 188 SIMPLE HYDROCELE OF THE TESTIS. Tent. — This method consists in keeping a wound made in the tunica vaginalis by a small incision, patent by introducing a tent of linen, lint, or sponge, or some more solid substance, as a canula, or piece of elastic gum catheter, so as to induce inflammation. In some instances, when the tent was not of an irritating nature and was soon removed, the inflammation excited terminated in the eifusion of lymph and the adhesion of the sides of the membrane. In other cases the result was less favourable, the inflammation ending in suppu- ration, and the obliteration of the cyst by granu- lation. The introduction of a tent into the tunica vaginalis is a very certain and effective mode of curing hydrocele, and at one period it was very commonly resorted to by practitioners. One of the most recent authorities by whom it is recommended is the late Baron Larrey, the distinguished French military surgeon. His plan was, after drawing off the fluid by means of a trocar, to pass a piece of gum elastic catheter through the canula into the interior of the tunica vaginalis, and to leave it there until sufficient inflammation to procure adhesion was excited. He speaks of this proceeding as being as mild as it is certain.^ Such has not proved to be the case in other hands ; and this, as well as the other forms of the tent, are in the present day rarely resorted to for the cure of hydrocele. Seton. — The use of the seton is a mode of treat- ment the invention of which is ascribed to the * Memoires de Chirurgie Militaire, torn. iii. p 407. SIMPLE HYDROCELE OF THE TESTIS. 189 Arabians. It appears to have remained in disuse for many years before the time of Mr. Pott. This excellent surgeon having experienced the severe eifects of the methods of treatment already de- scribed, was induced to make trial of the seton, which he employed in numerous instances with success. His aim in the operation was to produce a cohesion without destroying the tunic, or causing it to slough. His improved mode of performing the operation has been particularly described by Sir James Earle,"^ who states that in less than twenty-four hours after the introduction of a seton consisting of coarse sewing silk, the scrotum and testicle began to inflame, and put on the appearance of a hernia humoralis, which was treated in the same manner as is usual in that complaint. When the swelling was diminished, and the parts were regaining their natural state, which happened about the tenth or twelfth day, the seton was gradually removed, a few only of the threads being withdrawn at a time. The setori is a better mode of treating hydrocele than the other plans which I have described ; but though a remedy less severe than these, it is not free from the same objection, of being very liable to produce more inflammation than is requisite for the cure of the complaint. It is still, however, em- ployed, and is found a very useful remedy in certain forms of the disease. Thus in cases of children af- fected with hydrocele, which does not disperse under * Treatise on the Hydrocele, p. 70. 190 SIMPLE HYDROCELE OF THE TESTIS. the application of stimulating lotions, it is a common practice to pass an ordinary curved needle armed with a silk ligature through the skin and sac in front of the swelling, leaving a space of about an inch or an inch and a half between the ends of the ligature, which may be tied together to prevent its escaping. This soon excites inflammation in the sac, and causes the effusion of lymph ; and in three or four days or a week the silk thread is removed, and the hydrocele is subsequently cured by adhesion. I have also adopted this plan with success in encysted hydrocele of the cord, and in ordinary hydrocele of small size in the adult, and once in a larger one after the operation of injection had failed. Mr. Green of St. Thomas's Hospital has recently ad- vocated the plan by seton, in preference to that by injection.'^ His mode of performing the operation is nearly the same as that employed by Mr. Pott ; but there is this important difference, that the seton is retained a much shorter period, the average time being twenty-four hours, though it will vary in dif- ferent instances. In three of the eight cases treated on this plan which are reported, the reintroduction of the seton was necessary. In one case the cel- lular tissue of the scrotum suppurated, and in ano- ther an abscess formed in the vaginal membrane ; both required to be punctured. In two instances the seton was obliged to be removed in a few hours, on account of the excessive pain which it produced. * On the Treatment of Hydrocele by Setons, St. Thomas's Hospital Reports, No. 1, p. 59. SIMPLE HYDROCELE OF THE TESTIS. 191 In the only three cases in which the seton operated mildly as well as successfully, one was cured in twenty-seven days, another in twenty-nine, and a third in about a fortnight. Mr. Green's account of these cases will, I think, induce few to prefer the seton to the treatment by injection in ordinary cases of simple hydrocele. Injection is a plan of treatment alluded to by Celsus, who advised the use of a solution of nitre. Lembert, in his (Euvres Chirurgicales (1667), re- commended the injection of sublimate dissolved in lime-water, and he has recorded several cases in which it was attended with success. The practice of injection, however, appears to have been for some time entirely laid aside, until it was revived about the middle of the last century by Mr. G. Munro of Scotland, who at first employed spirits of wine, but subsequently, in consequence of the pain which it excited, substituted wine.* This plan was soon afterwards adopted by several other surgeons in Edinburgh. Mr. S. Shiarp of London, about the same time, also made trial of an injection of spirits of wine in a case of hydrocele, which was cured after very severe inflammation and the formation of two abscesses. Douglas, Le Dran, and Pott, in their works, disapproved of injections, which towards the end of the last century fell again into disrepute, owing, it seems, to the too irritating nature of the fluids employed. Sir James Earle,t surgeon of * Munro on the Dropsy, 3d edit. p. 222. t The first edition of his Treatise on the Radical Cure of Hydrocele by Injection appeared in 1791. 192 SIMPLE HYDROCELE OF THE TESTIS. St. Bartholomew's Hospital, is entitled to the credit of having introduced injections into general prac- tice by showing the advantages of a milder mode of proceeding ; and those who compare the effects of this operation, practised in the manner he re- commended, with the severe results of all those methods of treating hydrocele previously resorted to, will readily acknowledge the high value of this improvement. The apparatus requisite for the operation of in- jection is a trocar and canula, and an elastic caout- chouc bottle or brass syringe, capable of containing about four ounces of fluid, fitted with a movable brass tube furnished with a stop-cock. I generally perform the operation on the patient standing ; but it may be done equally well in the recumbent posi- tion, which is preferred by many surgeons. The hydrocele is to be punctured at the same place and in the same manner as in the palliative operation, but the canula is to be pushed in up to the hilt ; and after the serum is whglly evacuated, the tube of the elastic bottle is to be applied to the canula, and the stimulating liquid injected gradually until the tunica vaginalis is slightly distended. Before throwing in the fluid, the surgeon should endeavour to nip up the skin and tunica vaginalis around the canula with the thumb and forefinger. The quan- tity of liquid necessary to be injected is always much less than the amount of serum previously removed. The object of the operation is to apply a stimulating fluid to the entire surface of the sac ; and this may be accomplished with a small quantity. SIMPLE HYDROCELE OF THE TESTIS. 193 as an ounce or an ounce and a half, by handling the scrotum, and in this way putting the fluid in motion after it is injected, so as to bring it in contact with every part of the serous membrane. When the tunica vaginalis is fully distended, part of the fluid is liable to be forced out, or to escape by the side of the canula into the scrotum, where it may cause inflammation and gangrene. If the fluid should not pass easily, the surgeon must immediately stop in- jecting ; for most probably the canula has slipped out of the sac, so that by persisting the surrounding cellular tissue would become infiltrated. Whilst the canula remains in its proper place there can be no impediment to the free passage of the fluid. After the injection has remained in for a few minutes, the stop-cock tube is to be withdrawn, and the fluid pressed out through the canula ; which being re- moved, the aperture in the scrotum may be closed with a piece of adhesive plaister. Different surgeons employ diflererit kinds of stimulating fluids for injection. Sir James Earle gave the preference to dilute Port wine, which is still commonly used in this country, in the propor- tion of one third, or one half, water. Solutions of alum, or of the sulphate of zinc (sj — sxvi), are also ' frequently employed. Other fluids have been used, as cold and warm water, and dilute spirits of wine ; and it is stated that the cure of hydrocele has even been effected by the injection of air and of chlorine gas.* The fluid which I generally employ is lime- * British and Foreign Medical Review, vol. xi. p. 267. 25 194 SIMPLE HYDROCELE OF THE TESTIS. water. Though a mild injection, it usually excites sufficient irritation to cure the disease ; and I have rarely had occasion to resort to fluids of a more stimulating nature. Injections, composed of the tincture of iodine diluted with water, have lately been employed by several English and Continental practitioners, who have reported most favourably of their success. The peculiar advantages which iodine injections have been represented to possess will shortly be considered. The fluid injected into the tunica vaginalis should be allowed to remain there from four to six minutes in the adult, and about two or three minutes in younger persons. In general the patient soon feels sick and faint, and experiences uneasiness in the course of the cord. The pain is sometimes so severe that the removal of the injection becomes necessary at the termination of a minute or two ; in other instances it may be retained for ten minutes, or even a longer period. The amount of inflam- mation which may be excited cannot always be estimated by the degree of pain caused by the injec- tion. There is great diflerence in the susceptibility of persons to stimuli ; and although inflammation is more readily excited in some than in others, its amount and intensity do not equally depend on the irritability of the individual. When, therefore, the suftering produced by the injection is considerable, the surgeon must not be too hasty in removing the fluid ; or he may find to his disappointment that, after the pain has subsided, sufficient action has not taken place for the cure of the complaint. Unless SIMPLE HYDROCELE OF THE TESTIS. 195 the pain be very acute, the fluid should not be withdrawn before the usual time. The success of the operation depends a good deal on the after-treatment. If too much inflam- mation be apprehended, means must be taken to moderate it ; on the other hand, as a certain degree of inflammatory action is essential to the cure, if no pain or other symptoms arise the sur- geon must endeavour to excite it. Sir A. Cooper has laid down the following rules for the pa- tient ; — " If you be in much pain, lie down ; if you suffer but little, take exercise ; — if you be in much pain, eat very little, and drink only diluents ; if you suffer but little, take your dinner, and two or three glasses of wine. Come to me to-morrow."* He observes, " If on the morrow there be redness in the scrotum, considerable tenderness, and some swelling, the suspensory bandage is to be worn, the exercise to be moderated, and the diet is to be light ; but if there be little appearance of inflam- mation, it is right to grasp the scrotum in one hand, and gently tap it a few times with the other, to produce slight pain. Exercise and a generous diet are to be recommended until redness of the scrotum, swefling, and pain in the part be produced ; for the inflammatory swelling from the injection should be nearly as great as the enlargement which had been previously produced by the disease." My own ex- perience does not incline me to rely much on the prudence of the patient in regulating the measures * Lib. cit, p. 187. 196 SIMPLE HYDROCELE OF THE TESTIS. to be pursued after the operation. If, as generally happens, symptoms of inflammation arise in the course of a few hours, I usually recommend the use of a suspender to keep the testis supported, and direct the patient to remain in the recumbent posi- tion until the acute symptoms begin to subside. If these precautions be neglected, there is risk of more inflammation being excited than is necessary. Should no symptoms of inflammatory action be evinced in the course of eight or twelve hours, the patient should be encouraged to move about ; and the testis may be handled, so as to occasion slight friction between the surfaces of the tunica vaginalis, in order to induce the requisite vascular excitement. If the swelling should become considerable, and the pain and constitutional disturbance be great, the activity of the inflammation must be moderated by leeches, saline purgatives, or tartar emetic, as in the treatment of acute orchitis. It sometimes happens that the inflammation goes on to suppur- ation, and occasions an abscess in the tunica vagi- nalis. I have never witnessed this ; but when it occurs an incision must be made through the inte- guments and sac, in order to paimit the free escape of the pus. Granulation will then ensue, and the cavity of the tunica vaginalis will becomie com- pletely and permanently ob iterated. Sir B, Brodie remarks, that he has never known suppuration to occur after the operation by injection, except in West Indians, and in them only in three out of a great number of cases. In these cases the injected fluid was not made stronger than usual, but was SIMPLE HYDROCELE OF THE TESTIS. 197 even retained a shorter time — in one case only a single minute — and yet the inflammation was ex- cessive ; there was violent pain, and great consti- tutional disturbance.'^ It may be well to bear this observation in mind, so that in operating on per- sons from warm climates the injections may be of a mild character. I never inject a recent hydrocele, or one, how- ever small, the first time of tapping, as it occasion- ally happens that the fluid ceases to collect after its evacuation. When the fluid amounts to more than ten or twelve ounces the hydrocele is unfit for in- jection, because the extent of the serous surface in large hydroceles is liable to render the eflects of this treatment more severe than is desirable. In these cases it is better to draw oiF the fluid, and then wait until a smaller quantity is formed, when the operation may be undertaken with less risk. The surgeon should also be careful to ascertain that the dropsical eflusion is not dependent on existing disease of the testis. A man was admitted into the London Hospital with a double hydrocele on pur- pose to undergo the operation for the radical cure. He had been suffering for some time previously from disease of the larynx, which increased soon after his admission, and caused suflbcation and death. On examination of the testes, deposits of concrete pus were found in the substance of both the glands. In this case, had his state of health permitted of an operation, after removal of the fluid * liOndon Medical Gazette, vol. xiii. p. 93, 198 SIMPLE HYDROCELE OF THE TESTIS. the diseased condition of the testes would probably have been detected, and injection, which could only have operated injuriously, would have been aban- doned. The fluid effused around the diseased tes- tis by producing pressure sometimes causes pain, and it may then be evacuated with benefit ; but I need scarcely add that to attempt the permanent removal of the hydrocele whilst the original dis- ease remains unsubdued, would be both fruitless and hurtful. The disease producing the enlarge- ment of the gland must be treated without refe- rence to the effusion, and it will commonly be found that as the affection of the testis subsides the hydrocele likewise disappears. Thus in several cases of hydrosarcocele consequent on an attack of orchitis, in which after drawing off the fluid the testis has been found tender as well as enlarged, I have succeeded by the exhibition of small doses of mercury, and by strapping, or by applying mercu- rial or iodine ointment to the part, in subduing the chronic inflammation of the gland and effecting the cure of the hydrocele. In some instances, however, in which inflammation of the testis or epididymis is the primary disease, the hydrocele and disposition to an increased secretion remain long after all morbid action has ceased. The case must then be regarded in the same light, and treated in the same way, as ordinary hydrocele ; but the surgeon will do right to recollect that where inflammation has once been excited, its return is usually induced more readily and by slighter stimulating causes than be- fore. An enlarged and indurated testis or epididy- SIMPLE HYDROCELE OF THE TESTIS, 199 mis does not, then, constitute an absolute objection to the operation for the radical cure of hydrocele ; but the proceeding would not be advisable unless the original disease had been long in abeyance. In favourable cases the operation of injection is followed by only slight pain, tenderness, and swell- ing, and by scarcely any constitutional disturbance ; and when performed with care it is devoid of danger. The chief risk arises from the stimulating fluid being injected into the cellular membrane around the tunica vaginalis instead of into the sac, owing to the canula slipping out of the opening. This accident is commonly succeeded by diffuse inflam- mation of the cellular substance of the scrotum, which is very liable to produce suppuration and gangrene, and in persons advanced in life or of a debilitated constitution it has caused the loss of life. An unfortunate case of this kind must be treated upon the same principles as a case of ex- travasation of urine. Free incisions should be made into the scrotum at a depending part, in order to allow of the escape of the irritating fluid, and fo- mentations and cataplasms afterwards applied. If gangrene ensue, the patient's powers will probably require to be supported by wine, brandy, and bark or ammonia. This accident never ought to happen, for it may always be avoided by proper care and caution : even when it does occur, it is not invari- ably succeeded by serious consequences, and two cases have come to my knowledge in which dilute Port wine was injected into the scrotum without any ill effects resulting. Another accident liable 200 SIMPLE HYDROCELE OF THE TESTIS. to attend this operation is an attack of tetanus. I am informed by my friend Mr. Edwin Quekett of Wellclose Square, that a patient upon whom he had performed the operation was afterwards seized with locked jaw, which proved fatal. It is stated that in a native of the South of Spain, whose hy- drocele had been injected by Sir A. Cooper, teta- nus supervened : the patient fortunately recovered.* Mr. Travers mentions that similar consequences have attended this operation in the West Indies.t An attack of tetanus is, however, so rare an occur- rence, many thousands having undergone injection without an attack, that so remote a liability cannot be regarded as constituting the slightest objection to the performance of the operation. In six or seven days after the operation the pain and swelling generally begin to subside, and in about three weeks the cure is usually accomplished, all the effused fluids having been removed. But sometimes, especially if the inflammation has been unusually severe, this process takes place more slowly, the cure not being completed for two or three months. I have already observed that though injection sometimes eflects a cure by producing complete adhesion of the surfaces of the tunica vaginalis, it more commonly happens that the adhesions are only partial, and that the effusion is often checked merely by an alteration in the secernent disposition of the vessels. When adhe- * Prov. Med. and Surg. Journal. t Inquiry into Constitutional Irritation, part ii. p. 293. SIMPLE HYDROCELE OF THE TESTIS. 201 sion is complete the cure is permanent, and the patient free from all liability to a relapse ; but if the hydrocele is removed without perfect oblitera- tion of the cavity, the relief may be only temporary, and the same causes which originally gave rise to the hydrocele might, at a future period, occasion a return of it. Instances are known in which a hy- drocele, after having been removed by injection, has reappeared at the end of ten, and even twenty years. In cases in which the operation fails, the injection may be repeated with a more stimulating fluid. We sometimes find the tunica vaginalis in- disposed to contract adhesions, or to undergo any change in its actions, since highly stimulating in- jections repeatedly fail to prevent the return of the dropsy. In such cases the surgeon is compelled to resort to some of the other operations for the radical cure which are of greater severity than injections ; as the seton, or incision. In double hydrocele injection should not be per- formed on both sides at the same time ; for not only may the effects of a double operation prove very severe, the degree of inflammation and suffering produced being always uncertain ; but the injec- tion of one has been known to succeed in curing both, by the extension of the inflammatory action from one sac to the other, their external sur- faces being nearly in contact. A man fifty years of age entered Dupuytren's clinical ward at the Hotel Dieu with double hydrocele. That on the right side was large and of old standing ; the other was small and recent. Dupuytren punctured and 26 202 SIMPLE HYDROCELE OF THE TESTIS. injected the first with wine, which caused the usual reaction, and the disease was cured on both sides. He had observed the same phenomenon several times.^ I am inclined to think these patients were fortunate, and that few surgeons have met with similar success from a single operation. The second hydrocele may be injected as soon as the effects of the first operation have subsided, and its result has been ascertained. Iodine Injections. — These were first tried by Mr. Martin, a surgeon in India.t He used the tincture in the proportion of sij — 3vj of water ; injected only a small quantity ; and instead of afterwards with- drawing the fluid, allowed it to remain in the sac to be removed by absorption. In a recent report of cases of hydrocele thus treated at the Native Hos- pital of Calcutta,:]: it is stated that from the 9th of March, 1832, to 31st of December, 1839, 2393 cases were under treatment. Of these 1265 were Hindus, 1076 " Mahomedans, 52 " Christians. 2393 And it appears that the failures were rather under one per cent. ; a result which must be regarded as remarkably successful. The success and safety of iodine injections must be in a great measure attri- buted to only a small quantity of fluid having been * Lancette Francaise, Fevrier, 1837. t Transactions of the Medical Society of Calcutta, vol. vii. X Lancet, April 30, 1842. SIMPLE HYDROCELE OF THE TESTIS. 203 thrown into the sac, so that risk of cellular effusion was avoided, and to the retention of the fluid in- suring the excitement of sufficient inflammation to cure the disease. Iodine injections have since been tried in Europe, by Velpeau, Ricord, and others, at Paris ; byOppenheim at Hamburgh; and by several surgeons in this country. The success which at- tended the practice of the former, as appears from their reports,^ has not been greater than that com- monly obtained in England with other injections in the hands of judicious practitioners. Mr. Walne has published an account of the results of his prac- tice with iodine injections in this country ,t and has narrated four cases, selected from many others, in which they were successful. He reports very fa- vourably of the plan, which, he states, produces a mild degree of inflammation, but slight suffering, and an expeditious cure. He allowed, however, the injection afterwards to escape from the sac instead of retaining it, as practised by Mr. Martin. Mr. Bransby Cooper also states that he has employed iodine injections in hydrocele with marked success. He injected two drachms of the fluid of the same strength as that used by Mr. Martin, and also left it in the sac.J I have found injections of lime- water answer so well that I have had no induce- ment to make trial of new remedies, and cannot therefore speak from personal experience of the * Vide Dublin Journal of Medical Science, vol. xiv. p. 219. La Presse Medicale, Mai, 1837. t Medical Gazette, vol. xxix. p. 949. \ Prov. Med. and Surg-, .lournal. 204 SIMPLE HYDROCELE OF THE TESTIS. efficacy of iodine. But I much question whether this injection possesses such superior advantages as have been represented by many who have employed it. I do not believe that it exerts any peculiar or specific influence on the serous sac ; like other injections it can only act as a stimulant exciting to inflammation,"^ and like them it is liable occasion- ally to fail, owing to difierences in the susceptibility of individuals. Indeed, several of my medical friends, including Mr. Busk, surgeon of the Dread- nought Hospital, who have tried iodine injections, have assured me that though usually successful, they did not answer better than port wine, and that in many cases their effects were equally severe. The evidence, however, in favour of this injection in hydrocele is so strong, that we cannot hesitate to admit that it is a valuable and efficacious mode of treatment, and perhaps as successful as any other injection which has been resorted to for the cure of the disease. YVe must too, in justice, allow that it is a remedy which has been skilfully and judiciously employed, and that the strength of the injection, as first used by Mr. Martin in India, is well adapted to excite the exact amount of in- flammation required. In employing this injection, Mr. Walne recom- mends that those parts of the instruments which are metallic should be protected against the action * In a case of hydrocele successfully treated with iodine injection, M. Velpeau had an opportunity some time afterwards of examining the parts ; he found cellular adhesions established through the whole of the tunica vaginalis. Archives Generales de Medecine, Janvier, 1837. SIMPLE HYDROCELE OF THE TESTIS. 205 of the iodine by being carefully oiled beforehand, and freed from what may remain upon them by being dipped into a solution of potassa immediately after being used. If some care of this kind be not bestowed, they will quickly be corroded and in- jured, the affinity of iodine for metallic substances being very strong, and its effect destructive. [Electro-puncture has been recently proposed for the cure of hydrocele. It is performed by intro- ducing two acupuncture needles into the sac and connecting one to the positive and the other to the negative pole of a Daniel's constant battery. The action may be kept up from ten minutes to an hour. Dr. Ruschenberger of the U. S. Navy suc- ceeded in curing a case after both seton and* in- jection with iodine had failed, by a single intro- duction of the needles kept excited for half an hour. Dr. Washington of New York has at this time a case under treatment which promises to be entirely successful. — Am. Ed.] A careful examination into the merits of the various modes of effecting the radical cure of hy- drocele fully establishes the superiority of the treatment by injection. The great error formerly committed by surgeons in endeavouring to excite a high degree of inflammation arose from a mis- taken view of the object to be attained ; for not perceiving that the exudant secretion could be arrested by altering the action of the vessels of the part, they thought it necessary to obtain the ob- 206 SIMPLE HYDROCELE OF THE TESTIS. literation of the natural cavity, which, moreover, they endeavoured to effect by producing suppu- rative inflammation of the membrane, instead of by the milder process of adhesion. In recent days, surgeons have sought to improve the treatment of hydrocele by reducing the amount of inflammation to the lowest possible standard, and have nearly fallen into the opposite error of suggesting plans too mild to be eflicacious and sure. Injection has now been largely tried in this and other countries ; and experience warrants us in asserting that though it is not an infallible remedy, of all the plans hitherto practised it combines the greatest number of advantages. The pain attending it is slight ; its efiects are mild, and at the same time tolerably sure ; if properly performed, it is free from danger ; and it frequently succeeds without altering the natural condition of the parts. I know it is a question whether the cure by adhesion, though less perfect than that in which the disposition merely of the vessels is changed, is not upon the whole preferable. In the latter there is a possi- bility, if not a probability, of a relapse at some future period, many of the causes conducing to hydrocele still remaining ; whilst the inconvenience produced by an impediment to the free movements of the testis, in cases cured by adhesion, is regarded as too trivial to be any disadvantage. But, in the absence of data* showing the degree to which the * These data cannot be readily obtained, since, to be satisfactory, the result of the operation must be noted to the close of the patient's life. I have lately tapped a hydrocele which had been removed by CONGENITAL HYDROCELE. 207 disease is liable to return after the cure without adhesion, I feel perfectly satisfied with such a re- sult, and much prefer leaving a patient exposed to the doubtful chance of a relapse, than subjecting him to severer treatment in order to make sure of exciting sufficient inflammation to secure adhesion and obliteration of the sac. Injections, however, are not capable of effecting a cure in every case, nor are they adapted for every constitution. The judicious surgeon, therefore, whilst resorting to them as his ordinary remedy, will be prepared to avail himself, in particular and difficult cases, of other means more certain in their effects, such as the seton and incision. SECTION IL CONGENITAL HYDROCELE. In simple hydrocele the original communication between the cavities of the peritoneum and of the tunica vaginalis remains permanently obliterated ; but it sometimes happens that fluid accumulates around the testis in cases in which the obliteration has not been completed, constituting a variety of this disease termed congenital hydrocele. The open- ing of communication between the two cavities is usually small in size, not larger than sufficient injection by Sir A. Cooper twenty-five years before, and had not re- turned till within the last six months. Sir B. Brodie mentions two cases of the return of the disease after injection ; one after the lapse of seventeen years, and the other after a period of twenty years. Medi- cal Gazette, vol. xiii. p. 93. 208 CONGENITAL HYDROCELE. to admit a crow's or goose's quill. In these cases it is difficult to determine whether the fluid is se- creted in the abdomen or in the tunica vaginalis ; since, if poured out by the peritoneum, it must naturally tend to accumulate in the more depend- ing cavity. But as the fluid usually becomes absorbed after the communication between the abdomen and tunica vaginalis has been obliterated by the pressure of a truss, it seems probable that the fluid is originally formed in the abdomen. There is rather a rare variety of congenital hydro- cele, in which the testicle is retained in the ab- domen or inguinal canal, whilst the peritoneum, prolonged for a short distance into the scrotum, forms the cyst containing the fluid, which is covered only by the integuments and superficial fascia. A hydrocele presenting the same characters as the congenital sometimes follows a late descent of the testicle, unaccompanied with a hernial descent. This is also a case of rare occurrence ; but I once met with an instance in a lad eighteen years of age. Symptoms.- — A congenital hydrocele usually ap- pears soon after birth, forming a smooth, transpa- rent, fluctuating swelling, which is prolonged into the inguinal canal, and receives an impulse when the child coughs or struggles. By gentle pressure the fluid may be gradually forced up into the abdo- minal cavity, and as the tumour disappears the testis becomes perceptible in the scrotum. The same symptoms are produced by this complaint in the adult ; it has also been noticed that the hydro- cele is larger at night than when the patient first CONGENITAL HYDROCELE. 209 rises in the morning. M. J. Cloquet observed, in two cases of congenital hydrocele in adults, that the hand experienced a tremulous and peculiar rustling sensation in pressing the fluid into the abdomen. "^ Diagnosis.— Congenital hydrocele is easily dis- tinguished from ordinary hydrocele by the absence of a defined boundary to the tumour at its upper part ; by the impulse received on coughing ; and by pressure, causing the disappearance of the swelling, and rendering the testis perceptible. A congenital hydrocele might be mistaken for a re- ducible intestinal hernia, which also disappears on pressure, and dilates and receives an impulse on coughing ; but the nature of the disease is indicated by the fluctuation and transparency of the swelling, and by the absence of the gurgling sound accom- panying the return of the intestine. Treatment, — In the treatment of congenital hydrocele the primary object is to occasion an obliteration of the neck of the sac, so as to cut off the communication with the abdom.en. For this purpose the patient must constantly wear a truss made to press firmly on the inguinal canal. After adhesion has taken place the fluid usually disap- pears : its removal may be encouraged by the application of a stimulating lotion, or may be effected by acupuncture. This plan is usually suc- cessful when adopted in early life; but if after * Recherches siir ies Causes et TAnatomie des Hernies Abdomi- nales, p. 95. 27 210 CONGENITAL HYDROCELE. many months' trial it is found to fail, the truss should still be worn, not only to prevent the pas- sage of fluid from the abdomen into the sac, but also to impede a hernial descent, and to afford a further chance of obtaining obliteration of the opening. This form of hydrocele very rarely re- quires injections for its cure, and the operation should never be performed unless the surgeon is fully satisfied that a communication no longer exists between the sac and abdomen. If the sac is injected before closure of its neck, peritonitis is very liable to ensue, and to endanger the life of the patient. Desault, Dupuytren, and other sur- geons, after puncturing the sac and evacuating the fluid, have injected a stimulating liquid, firm pressure being made upon the ring, and continued for some time after the operation ; and the practice has in some instances been attended with success. But in other cases peritonitis has been excited, and death has followed. It would not be difficult, by a little cautious management, to avoid injecting fluid into the peritoneal cavity ; but as the object of the operation is to excite inflammation in the sac of the hydrocele, the great risk is of the ex- tension of the inflammation along the continuous serous surface to the peritoneum generally, the prevention of which cannot be secured by the pressure afterwards maintained at the ring. This proceeding, therefore, is not sanctioned by the surgeons of the present day; for no one is justi- fied in undertaking an operation exposed to such danger for the permanent removal of an incon- ENCYSTED HYDROCELE OF THE TESTIS. 211 venience which can be partially remedied by other means free from risk. A strong motive for per- severing in the attempt to cure congenital hydro- cele in early life by means of pressure, is the risk of inflammation to v^hich the testis is afterwards liable, extending to the sac, and thence to the peritoneum in the abdominal cavity, — an inconve- nience similar to that remarked in the case of the undescended testis. Cloquet examined the body of a man aged fifty affected with congenital hernia, whose thoracic and abdominal viscera were perfectly sound ; but the abdominal cavity contained six pints of yellow serum mixed with flocculent al- bumen, which appeared to have originated in dis- ease of the testis, and the extension of inflammation from the tunica vaginalis to the peritoneum.* SECTION III. ENCYSTED HYDROCELE OF THE TESTIS. In encysted hydrocele of the testis, the fluid is contained in an adventitious cyst or cysts distinct from the sac of the tunica vaginalis. The cyst is composed of a thin delicate serous membrane ; it maybe developed in three situations: 1, beneath that part of the tunica vaginalis investing the epi- didymis ; 2, between the tunica vaginalis testis and tunica albuginea, which are thus separated from each other ; 3, between the layers of the outer or * Lib. Cit. p. 144. I 212 ENCYSTED HYDROCELE OF THE TESTIS. loose portion of the tunica vaginalis. The first is by far the most common situation, the two latter being very rare. These cysts are analogous to the aqueous encysted tumours vi^hich are developed in the kidney and other parts, the fluid being of a similar nature, and differing from that of simple hydrocele in being perfectly limpid and colourless, and containing no or only a slight trace of albumen, so that it does not coagulate on the application of heat or by the action of acids. 1. Small serous cysts not larger than a pea, and even smaller, frequently exist immediately beneath the tunica vaginalis covering the head of the epi- didymis, in which they produce a slight depression. In several instances I have found as many as five or six perfectly distinct cysts connected with this part. Sometimes one or two small cysts of this kind are so embedded in the substance of the epididymis, that they cannot be recognised with- out dissection. Though these minute cysts generally con- tain a limpid serum, I have found them filled with fluid of a milky hue, and I have even observed matter like pus H. Cysts developed in the epididymis : a a. Small cysts slightly elevating the tunica vaginalis. h h. Small pedunculated cysts. c. Small process or fold of the serous membrane attached at the junc- tion of the epididymis to the body of the testis, described at page 36. ENCYSTED HYDROCELE OF THE TESTIS. 213 tinged with blood. These accidental cysts, develop- ed in the upper part of the epididymis, sometimes project the tunica vaginalis before them until they become so far separated from the part where they were originally formed, as to be attached only by a narrow peduncle formed by the contracted tunica vaginalis. Such is the mode of developement of those small pendulous pedunculated cysts contain- ing an aqueous fluid often found hanging from the head of the epididymis, which were erroneously supposed by Morgagni to be hydatids. I have on many occasions observed them in the different stages of their production {vide figure). Thus I have seen a pedunculated cyst attached at one part, whilst close to it there was a serous cyst precisely similar embedded in the substance of the epididy- mis. In other instances I have found the cyst very prominent, but still connected by a broad attach- ment of the tunica vaginalis reflected over it, the membrane not having as yet contracted to form the narrow neck. In all these cases the prolongation of the tunica vaginalis investing the cyst could always be demonstrated by a little cautious dis- section, and between this membrane and the cyst some minute red blood-vessels were generally seen ramifying. These pedunculated cysts never acquire a large size ; I have seldom found them to exceed that of a currant. From the exposed situation of the testis, they are liable to be ruptured, the ves- tiges of them consisting of fimbriated folds of mem- brane ; but this is not a common occurrence. I 214 ENCYSTED HYDROCELE OF THE TESTIS. have seen the delicate peduncle by which the cyst was attached as long as three quarters of an inch. So common are small serous cysts connected with the epididymis in the various states and stages I have described, that no one can examine many testes without finding them. Now when one or more of these cysts, instead of becoming pedun- culated, enlarge so as to form an evident tumour in the scrotum, they constitute a form of hydrocele called, from its original seat, an encysted hydro- cele of the epididymis, I have observed this de- scription of hydrocele in all its various modifica- tions, from the enlargement simply of a single cyst to the complication occasioned by the varied dila- tation of several of them. In this form of hydrocele the epididymis becomes flat- tened, and is displaced to one side, whilst the testis is found either in front of the cyst or cysts, or at the bottom of them. It is sometimes at the side, but very rarely indeed at the posterior part of the swelling. In the ad- joining wood-cut of a specimen which I dissected for the Hospi- tal museum, the cyst is above the testis, which is so displaced by it that its anterior edge is directed downwards. The tumour is generally of smaller size than a simple hydrocele, the fluid seldom exceeding three or four ounces in ENCYSTED HYDROCELE OF THE TESTIS. 215 quantity. In a case, however, which I saw with Mr. Crowdy of Brixton, as much as twenty ounces were removed from a single cyst. When the hydrocele is composed of seve- ral cysts, they are seldom of large size, but form a cluster more or less complicated and irregular, according to their number. The sacculated ar- rangement produced by the de- velopement of several cysts may be seen in the annexed figure, taken from a preparation dis- sected by myself: the anterior parietes of the cysts are cut away to exhibit their interior. The cysts are liable to inflammation, which causes a considerable alteration in the qua- lity and appearance of the fluid contained in them. The fluid may become albuminous, and assume the straw or amber colour of ordinary hydrocele ; and the cyst may contain lymph, form adhesions, or be lined with a false membrane, the fluid being thick and turbid. The cysts sometimes also become filled with blood, constituting a variety of haematocele. 2. When a hydrocele forms between the tunica albuginea and the inner layerof the tunica vaginalis, the cyst is generally single and of small size. As it grov/s, it separates the two membranes, which are naturally very closely adherent to each other. This is a very rare form of hydrocele. I have only met with one specimen, which was discovered accidentally 216 ENCYSTED HIDROCELE OF THE TESTIS. after death ; it is represented in the annexed wood- cut. The cyst contained about two drachms of fluid, and is situated along the front of the testis ; it is a little thickened. One section of it is preserved in the museum at the London Hospital ; the other I have presented to the College of Surgeons. Sir B. Brodie has described a very similar case. A man who died in St. George's Hospital was discovered after death to have had encysted hydrocele of one testicle. The cyst was composed of a thin membrane, containing a co- lourless fluid, and was of about the size of a walnut ; it was attached to the anterior part of the testicle, below the epididymis. The inner layer of the tunica vaginalis was reflected over one side of the cyst, while the cyst on the other side rested on the fibrous membrane of the tunica albuginea, by which it was in consequence separated from the glandular struc- ture of the testicle."^ In the museum of St. Thomas's Hospital there is a specimen of a small cyst de- veloped in the epididymis, which in its subsequent growth had extended on the testis, separating the tunica vaginalis from the tunica albuginea. 3. In examining a healthy testis I once found six * Lond. Med. and Phys. Journal, vol. Ivi. p. 522. ENCYSTED HYDROCELE OF THE TESTIS. 217 or seven small serous cysts, about the size of currants, studding the surface of the loose portion of the tunica vaginalis. Two of them were situated in a part of the membrane extending up the cord. They projected internally, and contained a transparent fluid. I have since seen a similar kind of cyst, the size of a large pea, in the same portion of the tunica vaginalis. Ac- cidental serous cysts have also been observed in the sac of a simple hydrocele, and a preparation of this kind is contained in the museum of the College of Surgeons. If a cyst thus situated were to increase to any size, it would constitute a swelling which might be appropriately termed an encysted hydro- cele of the tunica vaginalis. Symptoms, — An encysted hydrocele of the testis or epididymis commences imperceptibly, and in- creases very gradually, and in general without pro- ducing pain. After it has attained a certain size, as that of a grape or walnut, its growth is often arrested, and it remains stationary for many years, causing neither pain nor inconvenience. In this state the swelling is perceptible through the scro- tum, the testis appearing of an irregular or lobular form, or as if it were double. On careful examina- tion the cyst may be detected projecting either at the upper part, on one side, or behind the testis, forming a tense fluctuating tumour, connected with the gland, and moving with it. In other cases the cyst continues to increase until it forms a tense elastic swelling, twice, thrice, or even four times the size of the testis, but which seldom becomes so large as a simple hydrocele. In tumours of some 28 218 ENCYSTED HYDROCELE OF THE TESTIS. size the situation of the testis may be ascertained, as in simple hydrocele, on examination of the swell- ing by means of transmitted light ; by the more solid feel of the cyst at one particular part, and the peculiar pain experienced there on pressure. This form of hydrocele, when large, occasions inconve- nience proportionate to its bulk. A swelling be- comes apparent through the patient's dress ; it is exposed to injury, and feels weighty and uncomfort- able. I have observed in two cases of hydrocele of the epididymis that more pain was experienced than is usual in other forms of hydrocele, the un- easiness extending up to the loins, and not being relieved by support or the recumbent position, which I ascribe to the tension produced by the^^dis- tension of the tunica vaginalis reflected over the testis, and the more direct pressure thereby made on the gland. In these cases the pain was imme- diately relieved on puncturing the cysts. Diagnosis. — An encysted hydrocele of the testis is distinguishable from simple hydrocele by the dif- ferent position of the gland, which is generally found in front or at one side of the tumour ; by the smaller size of the swelling ; and by the limpid and colourless character of the fluid evacuated. When the hydrocele consists of two or more cysts, fluctu- ation and transparency are also less distinct than in simple hydrocele. As the position of the testis is liable to variation in ordinary hydrocele, the nature of the case cannot always be determined with accuracy until the cyst has been punctured. Treatment, — -An encysted hydrocele of the testis ENCYSTED HYDROCELE OF THE TESTIS. 219 should not be interfered with when of small size and unattended with pain or inconvenience* When painful or troublesome from its large size, the tumour may be removed temporarily by acupunc- ture or the trocar, applied either at the back or side of the hydrocele, in order to avoid risk of wounding the testis, the exact situation of which should first be ascertained. The fluid, however, generally again collects, and it becomes necessary to resort to some method of affording permanent relief The radical treatment by injection is not found to succeed so well in this variety of the dis- ease as in ordinary hydrocele. It frequently fails in exciting a sufficient degree of inflammation, and cannot well be employed in those cases in which several cysts are developed. I prefer myself the seton used in the mode recommended at page 190, which I have found to be both safe and eflectual : it is a plan equally well adapted for the treatment of an encysted hydrocele composed of two or more cysts, as to one consisting simply of a single cyst. The inflammation and constitutional effects are usually, however, more severe after an operation upon several cysts than when there is only one. Mr. Laing, one of the surgeons of the hospital at Aberdeen, has published an account of two re- markable cases of what he terms " cystic or hyda- toid disease of the testis ;" but which I entertain no doubt were cases of encysted hydrocele of the epi- didymis.* — ^A man, aged twenty-nine, was admitted * London Medical Gazette, vol. xxvii. pp. 456, 457. 220 ENCYSTED HYDROCELE OF THE TESTIS. with a large swelling of the left side of the scrotum, which was pyriforra, somewhat elastic, had an in- distinct fluctuation, but by no means the feel of hydrocele. It began several years before without any known cause at the lower part of the scrotum. The opposite testis was considerably enlarged and hard ; and there was a cicatrix at the lower part of the scrotum, the result of suppuration two years before. An incision was cautiously made through the integuments of the scrotum and tunica vagina- lis, when a bluish semi-transparent membrane pre- sented itself Into this a small trocar was cautiously pushed, but only about half an ounce of transpa- rent serum escaped. On withdrawing the instru- ment another similar membrane appeared, which was drawn outwards with dissecting forceps, and punctured, and found to contain only two or three drachms of serum. In this manner many similar cysts were successively drawn forward and opened, to the number of upwards of thirty, as the quantity of serum amounted to sixteen ounces. The wound was then closed with adhesive plaister. The opera- > tion was followed by fever, erysipelas of the face, f I delirium, and inflammation of the scrotum ; but the part healed, and the patient was dismissed cured at the end of five weeks. The patient was seen four- teen months afterwards, when the testis operated on was found quite sound, and not larger than natural. — A man aged thirty-five w^as admitted with a large tense elastic swelling of the left side of the scrotum, neither affected by coughing nor change of position, but extending up the cord as ENCYSTED HYDROCELE OF THE TESTIS. 221 far as the abdominal aperture. It gave him little uneasiness, unless what arose from its bulk. On the whole the symptoms closely resembled those of hydrocele ; but the tumour was not transparent, and the fluctuation was less distinct. It commenced about twelve months ago, without any known cause, and extended gradually upwards. An incision was cautiously made through the integuments and the tunica vaginalis, when a hydatid of considerable size presented itself This was punctured, and was immediately followed by another, which was also punctured, exactly as described in the preceding case ; and thus ten or twelve ounces of serum were evacuated. When the scrotum was reduced nearly to the natural size, the edges of the wound were brought together with adhesive plaisters. The operation was followed by severe inflammation and sloughing of the scrotum, and the wound was not healed until two months afterwards. The testis was reduced nearly to its natural size. It is clear that these were not cases of cystic disease of the body of the testis, from the circum- stance of the cysts having been exposed without division of the tunica albuginea, and the gland itself being unaflected, and remaining sound after the operation. Those pathologists who have often examined the testis after death, and observed how frequently small serous cysts, varying in size and number, are connected with the epididymis, even where nothing of the kind has been detected or suspected during life, will readily concur in the opinion that such was originally the nature of the 222 ENCYSTED HYDROCELE OF THE TESTIS. disease in these cases. It is rarely, however, that so thick a cluster of them increases to so large a size. The cases indeed are interesting in several points of view ; and the severe effects which followed the operation of puncturing them with a trocar in both instances will induce practitioners to be cautious in thus meddling with similar tumours, unless they should become very painful, or enlarge to such an extent as to occasion serious incon- venience. In October last, a man aged fifty-six, in a bad state of health, and suffering from a chronic bronchial affection, was referred to me by Dr. Aldis, Physician of the London Dispensary, on account of a swelling of the left testis. On exa- mination I found the testis situated at the lower part of the scrotum ; and immediately above the gland, and connected with it, two distinct fluctuating cysts, each somewhat larger than the testis, which together produced a considerable lobular swelling. The cysts proved to be distinct, fluctuation not being communicable from one to the other. The patient stated that the swellings had been forming between seven and eight years, but had only latterly given him pain. I easily recognised the affection to be encysted hydrocele of the epididymis. Two punctures were made with a cataract needle in each of the cysts. A few drops of pellucid serum escaped, and next day I found the two swellings above the testis entirely removed ; the man also expressed himself much relieved. There was, however, a third cyst, the size of a filbert, with which I did not think it necessary to interfere. DIFFUSED HYDROCELE. 223 The cysts again filled with fluid, and as they be- came tense the pain returned. As the patient's health did not admit of the performance of any operation for his permanent relief, I again punc- tured the cysts, and with the same result as before ; and he has since continued to apply to me about every hve or six weeks to have the operation re- peated. SECTION IV. DIFFUSED HYDROCELE OF THE SPERMATIC CORD. Mr. Pott has given an admirable account of this affection, under the denomination of hydrocele of the cells of the tunica communis.^ It has likewise been particularly described by Scarpa.t The dis- ease is of the nature of simple oedema, a watery fluid being diffused throughout the cellular tissue connecting the vessels of the spermatic cord, and enclosed in a cellular sheath, which is invested by the musculo-aponeurotic structure of the cremaster muscle. On dissection the sheath is found dis- tended, and when the complaint has lasted for some time, more or less thickened. The cellular tissue beneath is infiltrated with a limpid albuminous serum of a white or yellowish colour, which flows * Vide his Treatise on Hydrocele. t Memoria sull' Idrocele de Cordone Spermatico. Bertrandi, an Italian surgeon, in a memoir published by the French Academy of Surgery in 1778, has given an accurate description of this affection which, however, he did not sufficiently distinguish from the encysted hydrocele of the cord. He dissected on the dead body a diffused hydrocele which contained twenty ounces of fluid. 224 DIFFUSED HYDROCELE OF out in the course of the dissection. It is owing to the confinement of the fluid by this investing sheath that the swelling assumes an uniform sur- face and definite shape. The cells infiltrated with serum, which in their natural state are scarcely visible by the unassisted eye, are converted into large vesicles, some of which are big enough to admit the end of the finger. These cells appear larger and more delicate towards the base of the swelling, where they sometimes disappear alto- gether ; so that there is only one considerable cavity, the fluid having a tendency to collect to- wards the lowest and most depending part, and to form a fluctuating tumour there. The base of the swelling corresponds to the point at which the spermatic vessels join the testicle, and at this part a dense septum cuts off all communi- cation with the tunica vaginalis. In some in- stances the efliasion extends along the cord into the abdomen, as in a remarkable case re- lated by Mr. Pott, which will be presently de- scribed. In the annex- ed figure of this af- fection, taken from Scarpa, the sheath of THE SPERMATIC CORD. 225 the cremaster is laid open, exposing the pyramidal swelling enclosed in its firm cellular envelope. The testis and tunica vaginalis are seen below it. In general anasarca the cellular membrane of the spermatic cord is frequently distended with serum, as well as the scrotum ; but oedema of the cord alone is certainly a very rare affection. Sir A. Cooper makes no allusion to it in his work on the diseases of the testis ; and Mr. Pott, to whom we are in- debted for so good and accurate a description of this species of hydrocele, probably met with a greater number of cases of it than have occurred in the practice of any surgeon since his day. Causes obstructing the return of blood from the testis, as induration and enlargement of the glands in the course of the cord, would conduce to its production. I have observed a slight oedema of the cord in two or three instances after acute or- chitis, but it always disappeared as the inflamma- tion subsided. The affection is said to have been induced by the pressure of a truss applied for the cure of an inguinal hernia. Symptoms. — Mr. Pott thus describes the ap- pearance and symptoms of this affection. He says, " In general, while it is of moderate size, the state of it is as follows. The scrotal bag is free from all appearance of disease ; except that when the skin is not corrugated it seems rather fuller, and hangs rather lower on that side than on the other, and if suspended lightly in the palm of the hand feels heavier: the testicle with its epididymis is to be felt perfectly distinct below this fulness, neither 29 226 DIFFUSED HYDROCELE OF enlarged, nor in any manner altered from its na- tural state : the spermatic process is considerably larger than it ought to be, and feels like a varix, or like an omental hernia, according to the diffe- rent size of the tumour ; it has a pyramidal kind of form, broader at the bottom than at the top : by gentle and continued pressure it seems gradually to recede or go up, but drops down again immediately upon removing the pressure, and that as freely in a supine as in an erect posture : it is attended with a very small degree of pain or uneasiness, which uneasiness is not felt in the scrotum, where the tumefaction is, but in the loins. If the extravasa- tion be confined to what is called the spermatic process, the opening in the tendon of the abdominal muscle is not at all dilated, and the process passing through it may be very distinctly felt ; but if the cellular membrane which invests the spermatic vessels within the abdomen be affected, the ten- dinous aperture is enlarged, and the increased size of the distended membrane passing through it produces to the touch a sensation not very unlike that of an omental rupture.""^ At its commence- ment the tumour is of a cylindrical form ; but at a later period, and as it increases in size, it becomes pyramidal, especially when the patient is in the erect posture. By altering his position to the recumbent, the form of the tumour is slightly changed : it becomes more oblong, and nearly of equal dimensions from the ring to the testis. How- * Lib. cit. p. 370, THE SPERMATIC CORD. 227 ever much the swelling may increase, it has been remarked that the 'penis never appears so much retracted as in simple hydrocele of equal size. Diagnosis. — An omental hernia, or an encysted hydrocele of the cord, might be mistaken for a dif- fused hydrocele of the spermatic cord. In regard to the former, Scarpa observes, that "the diffused hydrocele of the cord, when it enters into the ring, resembles an omental hernia so closely that it is very difficult to distinguish the two complaints. Both have a cylindrical form, and extend into the ring. They are similar in consistence and degree of sensibility, as well as in the difficulty expe- rienced in returning them. Pott represents that the omentum, when returned, remains in the ab- domen until the patient assumes the erect position, or makes some e^oxi ; while the swelling in diffused hydrocele comes back immediately. I have found, however, that the omentum comes down quickly in some omental herniae, and that the swelling, when pushed up, does not reappear immediately in some cases of diffused hydrocele. I have observed that the swelling is firmer and more irregular on the surface in the epiplocele than in the watery effusion ; and that the latter is larger below than above, while these proportions are reversed in the rupture."^ Mr. Lawrence remarks, that " The distinction of the two cases must rest on the following points : — the impulse on coughing in the rupture ; the com- * Sull Ernie, Mem, 1, \ xxxii. ; quoted from Lawrence on Hernia, 5th edit, p. 251. 228 DIFFUSED HYDROCELE OF plete removal of the swelling, and the sense of the omentum passing up into the abdomen ; its visi- ble and tangible escape from the cavity when the rupture is brought down again by coughing, and the free natural condition of the cord and ring when the swelling has been replaced. The fluctu- ation of the watery tumour at its lower part ; the absence of impulse in coughing ; its imperfect re- moval under pressure, so that the cord can never be felt in a natural state ; and sometimes a visible enlargement of the inguinal canal and its neigh- bourhood when the fluid is pressed upwards.'"^ An irreducible epiplocele would be even more liable to be mistaken for a diffused hydrocele, as some of these distinguishing marks would be absent. In cases of much difficulty and doubt, the surgeon must be guarded in pronouncing an opinion, and very cautious in adopting any operation. Scarpa, indeed, frankly confesses the imperfection of our art with respect to the diagnosis in these cases.t Diffused hydrocele is distinguished from encysted hydrocele of the cord by the pyramidal and some- what diffused form of the swelling, which extends to the ring ; by the alteration in shape producible by pressure ; and by the absence of fluctuation in its upper part. As the testis is perceptible in diffused hydrocele of the cord, this disease cannot well be mistaken for simple hydrocele. Nor is diffused hydrocele likely to be confounded with varicocele, the cha- * Lib. cit. p. 252. + Treatise on Hernia, tr. by Wishart, p. 99. THE SPERMATIC CORD. 229 racteristic symptoms of the latter being too evident to allow of the intelligent surgeon erring in his diagnosis of these affections. Treatment. — In regard to the treatment of dif- fused hydrocele of the cord, Mr. Pott observes, *' While it is small it is hardly an object of surgery, the pain or inconvenience which it produces being so little that few people would choose to submit to an operation to get rid of it, and it is very seldom radically curable without one : but when it is large, or affects the membrane within the cavity as well as without, it becomes an apparent deformity, is very inconvenient both from its size and weight ; and the only method of cure which it admits is far from being void of hazard ; as must appear to every one who will consider, or who is at all acquainted either with the nature of lymphatic extravasation or absorption, or with the frequent consequences of wounds inflicted on parts merely membranous.'"^ This form of hydrocele admits of temporary if not permanent relief, with perhaps less risk than was supposed by Mr. Pott. For, as the cells commu- nicate freely, it is not necessary to make a large incision for the removal of the fluid, one or two acupunctures in the depending part of the tumour being sufl[icient to enable the fluid to escape into the cellular tissue of the scrotum, from which it will soon be removed by absorption. The danger of free incisions into the distended cellular tissue arises from their being liable to excite diffuse inflamma- "^ Lib. r.it. p. 371. 230 ENCYSTED HYDROCELE OF tion, which is apt to spread along the cord to the cellular tissue of the pelvis, and end in gangrene, especially in persons of impaired constitution. Both Scarpa and Pott have witnessed instances in which the operation of incision has proved fatal. The latter surgeon has related a remarkable case of dif- fused hydrocele, in a man aged thirty-five, of such prodigious size that it hung more than half way down to the patient's knee, and formed a considera- ble tumour in the inguinal region. The diagnosis was extremely difficult. An incision was made into it, and eleven Winchester pints of water were drained off. The fluid collected again ; and Mr. Pott divided the whole scrotum from the bottom upwards, from which operation the patient died.^ SECTION V. ENCYSTED HYDROCELE OF THE SPERMATIC CORD. This term is applied to a tumour caused by the developement of a cyst containing fluid in the loose cellular tissue of the spermatic cord. The cyst is formed of a thin transparent membrane possessing the ordinary characters of a serous membrane ; and its contents consist in general of a limpid aqueous liquid containing little or no albumen, but some- times of a straws-coloured serum, similar to the fluid of simple hydrocele. It is of an oval form ; and its size, though variable, seldom exceeds that of a hen's * Lib. cit. Case X. p. 377. THE SPERMATIC CORD. 231 egg, and is usually smaller. It is loosely attached by cellular tissue to the vessels of the cord, which become separated and displaced by it, but are situated at its posterior part. The cyst is invested by the common integuments, superficial fascia, mus- culo-aponeurotic sheath of the cremaster muscle, and fascia transversalis. It may occur either im- mediately above the scrotum in the middle of the cord, or just below the abdominal ring, and it has been met with within the inguinal canal. Usually there is a single cyst ; but occasionally several are developed, and a chain of them has been formed along the cord. The cyst and its contents are liable to changes consequent upon inflammation. Encysted hydrocele of the cord appears to origi- nate in general in a partial or imperfect obliteration of the prolongation of peritoneum, drawn down at the period of the descent of the testis. At page 35 I have described the different appearances presented by the remains of this prolongation, which, it has been remarked, sometimes consist of a single cyst, or of two or more sacculi moistened by a serous fluid. When this fluid accumulates in any quantity, an encysted hydrocele is the result. Such is the mode of origin of this affection when occurring in infants. I believe that in adults it is frequently, if not generally, produced in the same way. M. J. Cloquet has remarked, that the remains of the peritoneal process, accompanying the descent of the testicle, were met with in male subjects of all ages : and he mentions, as a singular circumstance, that they were nearly as frequently found in the old as 232 ENCYSTED HYDROCELE OF in the young subject.* My own dissections agree with the observations of this accurate anatomist. In the museum at the London Hospital there is a preparation showing the tunica vaginalis continued for about two inches up the cord, and immediately above it an encysted hydrocele which was taken from an adult subject. — In dissecting the body of a man aged eighteen, who died of pneumonia, I found an encysted hydrocele of the cord above the testis in close contact with the tunica vaginalis. Immediately above this cyst, but quite distinct from it, there was a narrow and empty serous sac three inches in length, with a con- tracted neck, and communi- cating with the abdomen. They are figured in the ac- companying engraving, with the hernial sac laid open, and part of the parietes of the encysted hydrocele cut away to expose their interiors. The position of the testis is so changed that its anterior bor- der is directed downwards. — In the examination of the body of a man who died of disease of the heart, I found on the ri^ht side a thickened and empty serous pouch, extend- ing for about an inch and a 'y F^' * Description of the Parts concerned in Inguinal and Femoral Hernia, tr. by ^M'Whinnie, p. 25. THE SPERMATIC CORD. 233 half below the external abdominal ring. Directly below it was an independent cyst, capable of con- taining a walnut, similar in structure to the her- nial sac, but lined by a thin false membrane. The tunica vaginalis, which was healthy in structure, extended up the cord as far as the cyst, from which it was separated by a thick and firm partition. — In opening the body of a sailor who died with ascites, I noticed at the internal ring a small, deli- cate, transparent, pedunculated cyst, not larger than a nut, projecting into the cavity of the ab- domen. The spermatic cord below appearing full, I made an incision into it, and found a large serous cyst exactly resembling the peritoneum in struc- ture, which extended into the inguinal canal, and contained a small quantity of transparent fluid. Observing a small orifice at its upper part, I intro- duced the point of a blow-pipe ; it passed into the centre of the pedunculated cyst, which was thus shown to be a process from the cyst connected with the cord. In Section 6 of this Chapter, I have described and given a representation of an inguinal hernia, combined with an elongated encysted hydro- cele of the cord ; and in Chapter V., Section 2, I have related a case of encysted haematocele of the cord, in which the tunica vaginalis remained un- obliterated as far up as the cyst, whilst a hernial sac is situated immediately above it. These dissec- tions confirm the view that has been taken of the more general mode of origin of encysted hydrocele of the spermatic cord. In two or three instances, however, I have found a small, thin, delicate serous 30 234 ENCYSTED HYDROCELE OF cyst in the loose cellular tissue of the cord, very like the cysts sometimes developed in the cellular tissue of the neck and in other parts, which very probably originated independently, and had no con- nexion with the process of peritoneum consequent on the descent of the testis. Symptoms. — An encysted hydrocele of the sper- matic cord is seldom discovered until it has attained some considerable size, its formation being imper- ceptible, and unattended with pain or inconvenience. It produces a swelling in the spermatic cord, which is of an oval and defined form, and distinct from the testis, which feels even and tense, and has a manifest fluctuation, and may be handled freely without pain, and which is more or less trans- parent, and quite movable upwards and down- wards. The distance of the tumour from the abdominal ring and testis varies in different cases, and is liable also to temporary alterations from the irregular contractions of the cremaster muscle. The vessels forming the spermatic cord can gene- rally be traced to the posterior part of the cyst. This affection is met with most commonly in infants, and I have seen it as early as a fortnight after birth ; but it occurs at all periods of life. Diagnosis. — An encysted hydrocele of the cord is liable to be mistaken for a simple hydrocele, and for a hernia. In both instances the diagnosis may generally be made without difficulty. It is distin- guished from simple hydrocele by the tumour being felt distinct from the testis, and by its being situ- ated higher up in the scrotum, and above the gland. THE SPERMATIC CORD. 235 When the cyst is of large size the diagnosis may be less easy, in consequence of the testis being partly imbedded in the tumour ; but, by a careful examination, the gland may always be distinguished independent of the hydrocele. This affection differs from hernia in the uniform size and defined shape of the tumour, which does not extend upwards to the ring ; in being trans- parent, very movable, and receiving no impulse on coughing ; and in the absence of the gurgling sen- sation, and other symptoms usually attendant on ruptures. When of small size, and situated near the abdominal ring, the tumour may admit of being pushed upwards into the inguinal canal, a circum- stance which renders the diagnosis rather difficult. The facility, however, with which the vessels of the cord can generally be felt when the tumour has descended again, and the parts between the swell- ing and the ring are grasped between the finger and thumb, will enable the surgeon to ascertain the nature of the case. But if, as sometimes happens, the cyst be situated within the inguinal canal, or at the opening of the external abdominal ring, it is extremely difficult to distinguish the swelling from a hernia ; for it disappears under pressure, is very apparent when the patient is in the erect position, and is removed or is less manifest when he is in the recumbent posture. The diagnosis will be facili- tated by observing that although the tumour can- not be made to descend below the external ring, neither can it be thrust completely into the abdo- men like a portion of intestine. The cyst being lodged in the inguinal canal, there must still be a 236 ENCYSTED HYDROCELE OF tumour in the groin behind the tendon of the ex- ternal oblique muscle, which, though somewhat obscure, will yet be perceptible- to the eye and fingers of the adroit surgeon. Treatment, — In children, encysted hydrocele of the cord, like simple hydrocele, often and indeed generally disappears spontaneously, so that surgi- cal interference is seldom required for its removal. It is frequently, however, a source of uneasiness to parents, who are apt to apprehend the existence of a rupture. The surgeon may therefore safely assure them, not only that it is a complaint of slight importance, but that if it does not vanish of its own accord, or by the application of a stimu- lating lotion, an operation comparatively trifling will effectually remove it whenever it attains such a size as to be productive of inconvenience. But it is better not to interfere with an encysted hydro- cele of the cord, either in children or adults, so long as it is of small size and unattended with pain. In the first instance a stimulating lotion may be directed to be constantly applied to the part. Should the tumour not disperse in the course of two or three weeks under this treatment, and con- tinue to be a source of annoyance from its bulk, it may be punctured in two or three places with a cataract needle, and the fluid pressed out into the surrounding cellular tissue. In many instances, especially at an early period of life, this proves a permanent remedy. But if the swelling returns, and it does so generally in the adult, other measures must be resorted to. The radical cure of encysted hydrocele of the THE SPERMATIC CORD, 237 spermatic cord may be effected in various ways. Excision of a portion of the cyst, incision, the seton, the tent, and injection have all been em- ployed for the purpose. The injection of the cyst of an encysted hydrocele is a plan of treat- ment which is not in much favour with practical surgeons. There is more difficulty in perform- ing the operation, and a greater risk of the fluid being forced into the surrounding cellular tissue, than in the injection of the enlarged tunica vagi- nalis, and the operation is not so generally success- ful as in the latter form of hydrocele. Mr. Hey, of Leeds, used with success the following method, which is similar to that proposed by Mr. Douglas for the cure of simple hydrocele : — " The operator must grasp the integuments and spermatic cord in his left hand at the posterior part of the tumour, till he makes it project and draws the skin tight over it. He must then divide the skin and layers of fascia longitudinally, by repeated gentle strokes of the knife, till he arrives at the cyst, which is generally quite transparent. The projection of the cyst increases as the parts which cover it are divided ; and when it is laid bare almost the whole of it is exposed. The cyst is then punctured with a lancet, and all that appeared perfectly transparent before the puncture, must be cut off with the knife or scissors. The posterior part of the cyst must be left untouched. After the extirpation of the trans- parent part of the cyst, the integuments should be brought over the spermatic cord, and united by the interruptured suture, otherwise they are apt to 238 ENCYSTED HYDROCELE OF shrink back, and leave the cord projecting out of the wound."* This is a very certain mode of treat- ing the disease ; but I prefer the seton, the effects of which are less severe than those of incision, whilst the plan is equally effectual. The surgeon may proceed as follows: — Let the scrotum be tightly grasped with the left hand, so as to render the tumour tense and prominent. Then let a large- sized curved needle armed with a double silk liga- ture be introduced at the lower part of the swell- ing, and brought out above at a distance of an inch and a half or two inches from the part where it was introduced, and the ends tied together to prevent the seton escaping. The fluid will afterwards dribble away along the silk, and in a few days after the operation, and perhaps in twenty-four or thirty- six hours, sufficient inflammation will be esta- blished. The threads can then be withdrawn, after which the cyst becomes permanently obliterated by adhesion, no other trace of it remaining but a slight induration at the part, which disappears completely in a short period. This I have found to be an effectualand safe proceeding. In cases of encysted hydrocele very high up, the surgeon must bear in mind the near proximity of the cyst to the peri- toneum, and the consequent risk of the extension of the inflammatory action to this important struc- ture. He must be careful not to excite too active inflammation. It appears that operations on cysts developed in the spermatic cord are liable to excite * Practical Observations on Surgery, p. 559. THE SPERMATIC CORD. 239 diffuse inflammation of the cellular tissue of the part. Mr. Pott has related a case treated by inci- sion which proved fatal on the seventh day, from inflammation extending to the cellular tissue of the pelvis and loins. The subject of the operation was, however, in a bad state of health.* I have lately been informed by my friend Mr. Morton, of University College Hospital, of a case in which such severe inflammation of the cellular tissue suc- ceeded the introduction of a seton, composed of a single thread of silk, through an encysted hydrocele in the spermatic cord of a boy, that suppuration took place in the iliac fossa, and for a time en- dangered the patient's life, though he finally re- covered. SECTION vi. COMPLICATIONS OF HYDROCELE. The following are the principal complications of hydrocele : 1. Simple hydrocele, combined with encysted hydrocele of the testis. 2. Simple hydrocele, combined with encysted hydrocele of the spermatic cord. 3. Simple hydrocele, combined with diffused hydrocele of the spermatic cord. 4. Oscheo-hydrocele, including both simple hy- drocele and encysted hydrocele of the cord, com- bined separately with inguinal hernia. * Lib. cit. Case XIV. p. 390. 240 COMPLICATIONS OF HYDROCELE. 1. The first is not an uncommon complication. In the dissection of these parts I have often found the tunica vaginalis distended with three or four drachms, and even an ounce or two of serum, two or more small distinct aqueous cysts being at the same time connected with the upper part of the epididymis ; and I have twice met with this com- plication on both sides in the same individual. The small adventitious cysts appear to be the original disease, the irritation produced by them being the cause of the increased quantity of fluid in the tunica vaginalis. The tumour formed by the combined cysts is in some cases smooth, and in others irregular, according to their relative size. When the quantity of fluid effused in the tunica vaginalis is only small, this complication may some- times be distinguished during life ; but when the amount is considerable, the distension of the tunica vaginalis completely masks the cysts developed in the testis or epididymis, rendering it impossible for the surgeon to detect the nature of the case. They sometimes attain so large a size as to require the fluid to be removed, and some of the cases of operation on multilocular hydrocele mentioned by writers, I believe to have been instances of this complication. It sometimes happens in a case of this kind, that when the trocar is introduced at the anterior part of the swelling a quantity of pale straw-coloured serum is drawn off* ; but the tumour is only diminished, not removed. If, however, the trocar be afterwards passed into the fluctuating swelling which still remains, exit is given to a COMPLICATIONS OF HYDROCELE. 241 limpid fluid which does not coagulate on the appli- cation of heat. 2. Simple hydrocele, combined with encysted hydrocele of the spermatic cord, is somewhat rare. The swelling produced by the accumulation in the tunica vaginalis is below and rather in front of the tumour in the spermatic cord, and a well-defined furrow in the scrotum generally marks the boun- dary between the two. In the pathological col- lection at the London Hospital, there are two specimens of a collection of fluid in the tunica vagi- nalis associated with an encysted hydrocele of the spermatic cord. In one of them, the tunica vagi- nalis has remained unobliterated for about two inches along the spermatic cord, and the encysted hydrocele is seen immediately above it. In the other preparation, it is apparent that both sacs have been the seat of inflammation, false membranes being contained within them, and the testis being a good deal enlarged. A child six years of age came under my care at the Hospital on account of a large hydrocele on the right side, which extended up- wards nearly as high as the abdominal ring. Three acupunctures were made in the tumour, and in ten days the whole of the fluid had disappeared ; but observing a small swelling still remaining in the direction of the spermatic cord, I made a further examination, and detected an encysted hydrocele of the cord just above the testis, which had previously been concealed by the fluid collected in the vaginal sac. The skin covering it was painted with a strong solution of iodine twice a 81 242 COMPLICATIONS OF HYDROCELE. week ; but not disappearing so quickly as I wished, it was afterwards punctured with a. needle. The acupuncture was repeated two or three times, and in a fortnight the encysted hydrocele of the cord was removed, and I believe did not return. A case of this complication, in an infant not many weeks old, is recorded in the London Medical Gazette.^ 3. Simple hydrocele, associated with diffused hydrocele of the cord, is also a rare complication. The chief marks of the complaint are, the remark- able volume of the neck of the tumour, with a dilated state of the abdominal ring ; the irre- gular form of the swelling ; and the existence of a furrow passing obliquely on the anterior part of the scrotum, corresponding to the superior margin of the dis- tended vaginal coat, and being higher or lower according to the amount of the fluid ac- cumulated within it. Simple hydrocele of the hour-glass form exhibits a double tumour divided by a furrow ; but the swelling is defined above, and has no neck, and fluctuation is communicable from one to the other. Any doubt in regard to diagnosis in a case of this kind may be cleared up by a I. Simple hydrocele combined with diffused hydrocele of the cord. After Scarpa. 1 — 1. Furrow marking' the division between the tumours. * Vol. xxix. p. 757. COxMPLICATIONS OF HYDROCELE. 243 puncture made into the anterior tumour, when, after the water collected in the tunica vaginalis has escaped, the swelling occasioned by the diffused hy- drocele of the cord will still remain undiminished. Encysted hydrocele, combined with simple hy- drocele, is also distinguished from the present complication by the defined form of the tumour above ; and from a simple hydrocele of the hour- glass form, by fluctuation being limited to the separate swellings. 4. Oscheo-hydrocele. — It is remarked by Mr. Lawrence, that " Scrotal hernia is combined not unfrequently with hydrocele, each disease being marked by its peculiar symptoms. A close ex- amination may be necessary, in order to detect the true nature of the case. The hydrocele and the rupture may form two distinct swellings, an upper and a lower one ; or they may meet together, the distinction being marked externally by a constric- tion ; or they may be completely blended into one swelling, without any distinction recognisable ex- ternally. In the latter case, their relative situations might be expected to depend on the order of their occurrence. If the rupture should have taken place after the formation of the hydrocele, we might expect the former to descend in front of the latter. On the contrary, if fluid should be eflused into the tunica vaginalis of a ruptured patient, the swelling would probably rise in front of the rupture. Mr. Stanley met with two instances in which hydrocele was placed directly before scrotal hernia, and the component parts of the spermatic cord were sepa- 244 COMPLICATIONS OF HYDROCELE. rated by the tumour, which seemed to have been forced between them. These specimens, with three others, are preserved in the museum of St. Bartho- lomew's Hospital. In all five the hydrocele is in front of the rupture, and in most of them it ascends nearly to the ring. The same relative position of the two diseases has been observed by others, and may therefore be considered as the ordinary ar- rangement."* A voluminous hydrocele, if unsup- ported, appears to be highly favourable to the oc- currence of hernia and the extension of the sac, by dragging down the peritoneum. M. J. Cloquet dis- sected the body of an old man, the subject of ex- ternal inguinal hernia on the right side. The sac was four inches in length ; its orifice was large and rounded, and its cavity was separated into two parts by a fibrous projecting ring. Below the latter the peritoneum was thick, whitish, and very adhe- rent to the external coverings ; above, it was thin and transparent, as in the abdomen. The descent of the fibrous ring, and consequently the elongation of the sac, appeared to be owing to the weight of a voluminous hydrocele of the tunica vaginalis, which intimately adhered to the lower part of the hernial tumour. A fold of small intestine, two inches and a half long, and unadherent, occupied the upper division of the sac. M. Cloquet has related the particulars of another case of inguinal hernia, complicated with a very large hydrocele, in which he observed, on raising the tumour and gently * Treatise on Ruptures, 5th edit. p. 256. COMPLICATIONS OF HYDROCELE. 245 drawing up the peritoneum of the abdomen, that the hernial sac receded and diminished in extent. The sac contained omentum, which was reducible, and the hernia was situated behind the hydrocele.* If the rupture were occasioned by the weight and traction of the hydrocele, as is evidently presumed by M. Cloquet, this case would tend to invalidate the conclusion of Mr. Lawrence, in respect to the relation of the parts, when the hernia succeeds the formation of the hydrocele. The occurrence of these two diseases is not an uncommon complica- tion ; in most of the cases which I have met with the hydrocele w^as placed below, and free of the rupture, and in a few only in front of it. I have never found the hernial sac cover- ing the forepart of a hydrocele. The ordinary relations of hydro- cele and scrotal hernia may be seen in the accompanying wood- cut. In the figure at page 146 the sac of an inguinal hernia is represented at some little distance above a small hydrocele. Dupuy- tren states it sometimes occurs, when ^ hydrocele is placed in front of a hernia, that a part of the omentum or intestine descends into a cyst, which projects into the hydrocele, and is formed of the hernial sac and serous fold of the tunic of the * Recherches Pathologiques sur les Causes et I'Anatomie des Hernies Abdominales, p. 22. 246 COMPLICATIONS OF HYDROCELE. testis. Oat of six cases of this kind which came under his observation, in two instances he found symptoms of strangulation to depend on constric- tion at the part where the viscera were engaged in the serous pouch of the testis."^ This complication is of the nature of the hernia infantilis, described by Mr. Hey, and called by Sir A. Cooper encysted hernia of the tunica vaginalis. The co-existence of hernia and hydrocele does not in general constitute an objection to the per- formance of the radical operation for the latter. But the surgeon should be particularly cautious not to excite too much inflammation ; and in cases where the contiguity of the two sacs is close and extensive, and in those in which the hernial sac projects into the hydrocele, he should recommend the patient to be content with the palliative treat- ment. The hernia should always, if possible, be reduced before the tunica vaginalis is punctured. Scarpa has described a case of strangulated in- guinal hernia, complicated with encysted hydrocele of the spermatic cord, in which it was necessary to operate. A student about twenty-nine years of age was attacked with symptoms of incarcerated hernia. He had been subject to a rupture on the left side of the scrotum for more than fifteen years, but had not been able to fit a proper bandage. The hernia was tense, and above the moderate size, and the bottom of the tumour was unusually raised, and as it were pushed upwards, by a body situated * Lecons Orales, Brussels edit, t. iv. p. 233. COMPLICATIONS OF HYDROCELE. 247 behind the hernia ; which body was undoubtedly not the testicle, as the gland was felt distinctly by the touch in the bottom of the scrotum, and lower down than the hernia. The symptoms being very urgent, the patient was operated on in Scarpa's presence. The hernial sac was found to contain a very small quantity of water, and a loop of small intestine slightly tinged of a brown colour, and about three or four inches in length. After divi- sion of the neck of the hernial sac and the ring, and also after reduction of the intestine, there still remained externally a soft tumour, elastic, and evidently full of fluid. An incision was made into this tumour, and a considerable quantity of serous fluid discharged. At the bottom there appeared a vesicular gelatinous substance, which was cut away; and it was clearly perceived that the in- testinal scrotal hernia was accompanied posteriorly with an encysted hydrocele of the spermatic cord. In the course of six weeks the patient was completely cured of both these diseases.* This is a very rare complication : I have met with it in only two instances ; in both on the right side. The patients were adults. In one, who died of peritoneal inflammation, with the hernia unreduced, I had an opportunity of making a careful dissection of the parts. The hernial sac was greatly thickened, and coated with lymph, and contained a small fold of intestine surrounded by turbid serum. Directly below it there was a hydrocele of the cord of an * Treatise on Hernia, tr. by Wishart, p. 23L 248 COMPLICATIONS OF HYDROCELE. 1 oblong shape, and more than two inches in length, the parietes of which dif- fered from the hernial sac in being thin and transpa- rent. The testis hung lower than natural, and was so displaced that its antero- inferior edge presented directly downwards (see figure). In the other case the patient was a young man twenty years of age, and the hydrocele and her- nia were both recent, and had formed about the same time. In encysted hydrocele of the spermatic cord the parts are generally in a condition favourable to a hernial de- scent, the cyst being most commonly the result of an indisposition of the peritoneum in the course of the cord to unite, or become obliterated after the arrival of the testis in the scrotum ; and it often happens in these cases that the peritoneal process above the hydro- cele remains patent, and in communication with the cavity of the abdomen. Thus at page 225, I have narrated two cases of encysted hydrocele of the cord, in which on dissection, I found an empty hernial sac above the cyst of the hydrocele. If the hydrocele extended high up, it would prevent HYDROCELE OF THE HERNIAL SAC. 249 the proper adjustment of a truss, and would therefore require to be cured before the application of any instrument. SECTION vn. HYDROCELE OF THE HERNIAL SAC. A hernial sac sometimes becomes the seat of dropsical effusion, the connexion with the abdomen being interrupted by adhesion at the neck, or by a portion of adherent intestine or omentum blocking up the orifice. Thus the continued application of a truss sometimes causes obliteration of the neck of the sac, and the radical cure of the hernia ; but the lower part, remaining patent, is liable to become the seat of an effusion of serum. A man was admitted into the Hospital of La Charite in Paris, under Boyer, with a tumour in the right groin, which was found to be hydrocele of an old hernial sac. The hernia had been cured by the obliteration of the neck of the sac, and the serous pouch had re- mained for a time wrinkled up in the course of the cord, but it afterwards became the seat of dropsical effusion.^ Mr Pott has narrated two interesting cases of a collection of fluid in the sac of a conge- nital hernia.t In one the opening of the sac was closed by adherent 'omentum ; in the other it was blocked up by intestine. The first was the case of * La Lancette Frangaise, Fevrier, 1837. ■\ Lib. cit p, 463, Cases XXXIV. and XXXV. 32 250 HYDROCELE OF THE HERINIAL SAC. a man aet. 25, who had a large scrotal swelling, accompanied with a remarkable fulness of the sper- matic process. He had had a rupture, and worn a truss for many years ; upon taking his truss oif, his rupture always came down immediately, and was very easily returned. After leaving his truss off, and substituting in its place a bandage, which was buckled on very tight, his scrotum gradually became larger, with considerable pain and uneasi- ness. Pott made no doubt that the tumour con- tained a considerable quantity of fluid, but hesitated respecting the disease being a hydrocele. He made a puncture, and let out about a pint of brown serum. This discharge removed the swelling from below ; but made little or no alteration in the upper part of the process. He endeavoured to reduce it ; but found it impracticable, and desisted, advising the man to wear no bandage ; and if it became trouble- some desired that he might see it. In about a year the fluid had collected ao^ain. Mr. Pott then made an incision from the middle of the scrotum quite up to the groin. The true nature of the case was now discovered. He found in the lower part of the bag, which contained the fluid, the testicle \ and in the upper part or neck of the same bag a consider- able portion of omentum, the upper part of which was hardened in texture, and so perfectly adherent to every point of the neck of the sac as to prohibit the return of even a fluid from thence into the belly : but the lower part was in its natural state, loose, soft, and capable of being expanded. All the loose part he cut ofl'; the upper part he left as he HYDROCELE OF THE HERNIAL SAC. 251 found it, filled the wound lightly with lint, and treated the case as for the radical cure of a hydro- cele. In about seven weeks the man got well. The other was the case of a man aged twenty-two, who had long been subject to a rupture which never came lower than his groin. When a child he had worn a truss, but had for some years disused it. For a month or two past his rupture had been constantly down, and he had not been able to re- turn it. For three days symptoms of strangulation had existed. There was a large scrotal swelling, which bore very much the appearance of a hydro- cele ; but the upper part or spermatic process was hard and painful, and seemed to be girt tight by the tendon of the abdominal muscle. Mr. Pott divided the integuments, as in the operation for hernia, and on opening the sac let out about half a pint of clear limpid water, upon the discharge of which the whole tumour of the scrotum subsided, and it was supposed that he had mistaken a hydro- cele for a hernia. But the tumour and hardness about the abdominal ring still remained unaltered, and on passing the finger upwards a small portion of intestine was found engaged in the abdominal ring, and bound extremely tight. The stricture was divided ; but the gut could not be returned, until an adhesion which connected it to the lower border of the opening was discovered and also di- vided. The patient recovered. Pelletan has recorded two cases of hydrocele of the hernial sac (one of them congenital), in which the communication with the abdomen was closed 252 HYDROCELE OF THE HERNIAL SAC. by adherent omentum. Though the diagnosis was satisfactorily established, he very properly pro- ceeded with much caution in the operation, and instead of puncturing the tumour cut carefully down, as in the operation for strangulated hernia. In both cases the hydrocele was cured by the ordinary ope- ration of incision.* A true hydrocele of the hernial sac is certainly a rai*e affection; and since niy con- nexion with the London Hospital I have witnessed only one case of it. The hydrocele was double ; the tumours were very large on each side, quite uncon- nected with the testes, and resulted from the con- stant wearing of a double truss for a period of thirty-five years. Le Dran has recorded a remark- able case of triple hydrocele on the same side, a hydrocele of a hernial sac having been combined with a hydrocele of the cord and with a simple hydrocele, which together formed a tumour the size of a small melon. The hydrocele of the hernial sac was consequent upon the radical cure of a hernia, the obliteration of the neck of the sac having been caused by the pressure of a truss.f Diagnosis. — In hydrocele of the hernial sac, the absence of a defined margin at the upper part of the tumour, together with the swelling at the abdominal ring and the inability of feeling the spermatic cord, being also marks of scrotal hernia, tend to render the diagnosis of this rare form of hydrocele somewhat obscure. But the detection of * Cliiiique Chirurgicale, torn. iii. pp. 22, 108. f Observations on Surgery, tr., Case I^XXV. p. 260. HYDROCELE OF THE HERNIAL SAC. 253 fluid by the transparency and evident fluctuation of the tumour, and a careful attention to the history of the case, are sufficient to enable the practitioner to avoid any serious error. There is generally, also, an absence of any impulse on coughing; though sometimes, in consequence of the swelling extend- ing up into the inguinal canal, an impulse is com- municated to it from the abdomen, which increases the difficulty of the diagnosis. The extension of the swelling to the abdominal ring, and the testis being distinct from the tumour at the bottom of the scrotum, are sufficient to distinguish hydrocele of the hernial sac from simple hydrocele. I conceive that some little difficulty might be experienced in diagnosing a small hydrocele of the hernial sac from an encysted hydrocele of the cord high up. They are both distinct from the testis, and their relative situation and even mode of formation are very similar ; the only essential difference being that the process of peritoneum constituting the former had once contained either intestine or omentum. A hydrocele of the hernial sac occurring somewhat late in life, is usually of some considerable size, and its fluid contents are of an amber or dark colour ; whilst an encysted hydrocele of the cord generally appears before puberty, is rather small in size, and contains fluid which is generally colourless and nearly free from albumen. Attention, therefore, to these dis- tinguishing m^arks, and to the history of the case, would leave but little room for doubt. Treatment, — Cases of hydrocele of the hernial sac arising after the radical cure of a rupture, the 254 HYDROCELE OF THE HERNIAL SAC. neck of the sac being permanently obliterated by adhesion, should be treated on the same principles and in the same manner as simple hydrocele. In the treatment of cases where there is reason to believe that the opening of coQimunication has be- come closed by the adhesion of a portion of omentum or intestine, more care is required, and the surgeon should be content with palliative means. When symptoms of strangulation arise, as in Mr. Pott's second case, the removal of the hydrocele becomes a matter quite of secondary importance. Scarpa well remarks, " Whatever difficulty these compli- cations may oppose to the exact diagnosis of redu- cible intestinal scrotal hernia, they do not occasion any with regard to the operation, whenever the hernia is affected with strangulation ; as the symp- toms accompanying the incarceration of the intes- tine show clearly the nature of the principal disease, and render the operation necessary, by means of which we have at the same time the advantage of laying bare what formed the complication of the hernia, and of curing radically both diseases."^ He has related an example of hydrocele of the hernial sac, complicated with intestinal scrotal hernia, which illustrates the difficulty of the diagnosis in these cases. A man twenty-five years of age, stout and very fat, was affected with incarcerated scrotal hernia of enormous size. The hernia was of eight years' standing. The day before the incarcera- tion, being obliged to make a rapid journey on "^ Treatise on Hernia, tr. by Wishart, p. 230. HYDROCELE OF THE HERNIAL SAC. 255 horseback, his truss broke on the way, and on alighting he found the scrotum of extraordinary size ; he was likewise affected with nausea, acute pain in the groin, and inclination to vomit. The tumour was fully sixteen inches in circumference, and almost entirely concealed the penis ; it was broad at the bottom, narrow at the upper part towards the ring, equal and smooth in almost its whole surface, and elastic. It resembled a large hydrocele, and might have been taken for one, if there had not been evident marks of incarcerated intestine. Scarpa remarks, " I could with difficulty persuade myself that this large tumour was formed for the most part by water collected in the vaginal coat of the testicle, or in the hernial sac, as the patient never had the smallest mark of serous effu- sion in the scrotum, as well as because, from the repeated assertion of the patient, the hernia in the course of eight years had never exceeded the size of a hen's egg, and there was no reason to suppose that so much water had descended from the cavity of the abdomen into the scrotum in a young man in other respects very healthy and strong. I rather suspected, considering the fatness of the patient, that by the exertion of the riding a great mass of omentum had descended, although there still re- mained some doubt how, in so short a time, the hernial sac could have yielded to so great a disten- sion, and because the tumour had rather the appear- ance and elasticity of a large hydrocele than of a large hernia composed of intestine and omentum." There was no doubt as to the impossibility of redu- 256 HYDROCELE OF THE HERNIAL SAC. cing the parts without an operation, as the symp- toms of strangulation increased in violence every minute. On the first cut into the hernial sac, about three pounds of yellowish serum were discharged. It was a common scrotal hernia. At the upper part of the sac there was a loop of small intestine about two inches long, but no omentum. The stricture was divided, and the intestine returned. The patient recovered, the wound having healed in seven weeks. The term hydrocele of the hernial sac should, I think, be restricted to cases of a chronic collection of fluid in the sac of an old hernia, in which the communication with the abdomen has been perma- nently obliterated by adhesion at the neck, either of the sides of the sac, or of a portion of omentum or intestine. The above case was clearly not of this description. It was an instance of strangulated scrotal hernia attended with a remarkable effusion of fluid, which may be denominated a spurious hy- drocele of the hernial sac ; a term that would apply to all cases of a hernial descent coupled with serous effusion, whether the communication with the ab- domen be closed or open, and the fluid reducible into the abdomen. A somewhat similar case of large strangulated scrotal hernia, in which the bulk of the tumour was formed by serous effusion, is recorded by Mr. Shaw of the Middlesex Hospital.^ Nothing is more common than the presence of fluid in the sac of a strangulated hernia, though it rarely * Lond. Med. and Phys. Journal, vol. Ivi. p. 18. HYDROCELE OF THE HERNIAL SAC. 257 exists, as in these cases, in such abundance as to cause any difficulty in the diagnosis. I have met with three cases of. strangulated scrotal hernia, in which several ounces of fluid were contained in the same sac with the protruded viscera, and in which the rupture being congenital no testicle could be distinguished ; but the previous history, fulness at the abdominal ring, and well-marked symptoms of strangulation, were sufficient to indicate the true nature of the complaint. In one of these cases, which was operated on by Mr. Hamilton, the stric- ture was divided external to the sac ; and the fluid which had concealed the intestine, adherent omen- tum, and testis, remained after the operation, but became absorbed as the patient recovered. Had Scarpa, in the case related above, examined the tu- mour by transmitted light, he could scarcely have suspected that the bulk of the swelling consisted of omentum. In those cases of spurious hydrocele of the hernial sac in which the fluid and intestine or omentum are reducible, the complication may be made out by returning the contents of the sac into the abdomen, the patient being in the horizontal posture ; when, by pressing the finger gently on the abdominal ring and allowing the patient to rise, the fluid will slip down into the scrotum, and produce a transparent tumour or hydrocele. On entirely remitting the pressure, the intestine or omentum will be felt descending into its former situation. In the following case, which was shown me by Mr. Adams, the symptoms produced by spurious hydro- cele of the sac of a congenital hernia closely re- 258 HYDROCELE OF THE HERNIAL SAC. sembled those of a congenital hydrocele. — A lad, aged twelve, applied as an out-patient at the London Hospital, on account of a swelling which occupied the left side of the scrotum. It was a transparent tumour, of an oval form, reaching upwards into the abdominal canal, which fluctuated, completely filled the scrotum, and received an impulse on coughing. The left testis was imperceptible. On making gentle pressure the swelling disappeared rather suddenly, and then the testis could be readily distinguished, and was found less than half the size of the gland on the right side. The sac which con- tained the fluid felt a good deal thickened. The boy stated that the swelling had existed since he was two years of age. This appeared to be a case of congenital hydrocele, of which, indeed", it pre- sented all the usual symptoms, except that on pres- sure the swelling disappeared suddenly instead of gradually. The boy was accordingly directed to have a truss to press on the abdominal ring. After it had been worn for three wrecks, the fluid was found to have entirely disappeared from the sac, and none descended on the removal of the truss. When, however, the boy coughed, a small intestinal hernia came down. It then became clear that this had been a case of spurious hydrocele of the hernial sac ; and thus was explained the only symptom un- usual in congenital hydrocele, viz. the sudden dis- appearance of the tumour on pressure, the fluid passing into the abdomen together with the intes- tine, which it had completely masked from observ- ation. HYDROCELE OF THE HERNIAL SAC. 259 M. J. Cloqiiet has detailed the particulars of the dissection of the parts, in a case of congenital in- guinal hernia on the right side, found in the body of a man aged thirty affected with ascites, who had worn a truss. The testicle, which had not descended lower than just outside the abdominal ring, had formed a valve, which admitted the passage of fluid into the sac, but prevented its return into the abdomen.* The testis, in this case, seems to have acted much in the same way as the valvular 'fold of peritoneum which exists at the ring in many quadrupeds. In operating for the removal of fluid in cases in which there is reason to suspect that intestine or omentum is also contained in the hernial sac, the surgeon should proceed in the most cautious manner. Monro, senior, relates the following case.t — " An old man had long laboured under a hernia, which had not been reduced for many years. The tumour became at last of a monstrous size, de- scending nearly to his knee, and having a propor- tional transverse diameter ; he was confined to lie on his back, had violent pain both in the tumour and his loins, and his flesh and strength wasted. In some places a plain fluctuation was perceived, without any of the unequal solid substances felt every where else. Neither the water nor solid sub- stances could be pushed into the belly. The * Recherches sur les Causes et I'Anatomie des Hernies Abdomi- nal es, p. 97. t Medical Essays and Observations, vol. v. p. 314. 260 HYDROCELE IN THE FEMALE. tumour being pressed, so as to make one of those parts where the fluctuation was most evident and the teguments were thinnest as tense and pro- minent as possible, a trocar, as small as a crow- quill, was thrust very slowly through the teguments and cyst. Whenever the bag was pierced the stilet was taken out, and the canula was pressed a little forward, through which six pounds of clear serous water ran out ; then the convolutions of the in- testines and the knotty parts of the omentum were plainly felt, but none of them would reduce." The patient was greatly relieved of his pain, and no further operation was thought proper. Unless the fluid should accumulate in so large a quantity as to cause serious inconvenience to the patient, as in this remarkable case, an operation for its removal would not be proper ; for the surgeon is not war- ranted in opening a serous sac containing intestine on slight grounds. If it became necessary to get rid of the fluid, I should think acupuncture would be the plan best suitable to such a case. If the intestine or omentum were reducible, the applica- tion of a truss would be the treatment required. SECTION vin. HYDROCELE IN THE FEMALE. Tumours analogous to hydrocele occasionally occur in the female, in connexion with the round ligament of the uterus, at its termination in the groin and pudendum. Three varieties of this af- fection may be distinguished. HYDROCELE IN THE FEMALE. 261 1 . Diffused hydrocele of the round ligament, which is simply an oedema of the cellular tissue of the part corresponding to the diffused hydrocele of the spermatic cord. It is an affection of no moment, and needs no particular description. 2. Hydrocele of the Canal of Nuck. — A diverti- culum or pouch of peritoneum may commonly be observed in the foetus, prolonged through the ab- dominal ring w^ith the round ligament of the uterus. This pouch, which was first noticed by Nuck,* and has been named after him, often remains un- obliterated during life. When examined in the adult it usually consists of a serous pouch, about half an inch in length, external to the abdominal ring, which communicates with the cavity of the abdomen by an aperture so contracted as scarcely to be capable of admitting the passage of a probe. This little pouch may become the seat of dropsical effusion, and form a fluctuating cystic tumour, the contents of which are reducible into the abdomen, thus corresponding to the congenital hydrocele in man. The only treatment required for this affec- tion is the application of a truss to obtain the obliteration of the sac, after which the fluid usually disappears. 3. Encysted hydrocele of the round ligament is produced by the obliteration of the neck of the peritoneal pouch, the lower part remaining patent, and being distended with serum. The cyst is situ- "^Adenographia Curiosa. 262 HEMATOCELE OF THE TESTIS. ated in front of the round ligament, either in the inguinal canal or immediately below the abdominal ring ; and it occasions a tense fluctuating tumour, which sometimes acquires the size of a hen's egg. It may be mistaken for a hernia, from which it can be distinguished by applying the same rules as those given for the diagnosis of an encysted hy- drocele of the spermatic cord. It is to be treated also on the same principles as those applicable to that affection. As in hydrocele of the cord high up, the proximity of the peritoneum must be borne in mind by the surgeon, if he has recourse to active means for obliteration of the cyst. CHAPTER V. HEMATOCELE. Hematocele is a term applied to the swelling occasioned by effusion of blood in the sac of the tunica vaginalis, or in the substance of or cyst in the spermatic cord. SECTION L HEMATOCELE OF THE TESTIS. In haematocele of the tunica vaginalis, which is by far the most common seat of sanguineous effu- sion, the extravasation may take place in a healthy state of the parts, or it may succeed or be combined HEMATOCELE OF THE TESTIS. 263 with hydrocele. The first form occurs from the accidental rupture of some blood-vessel into the vaginal sac. It is usually produced by a blow. Thus it is liable to happen to a person on horse- back, from the testicle being struck against the pommel of the saddle ; or may be occasioned by violent efforts made in straining, as in the attempt to raise a heavy weight : sometimes the effusion takes place without any apparent cause. In these cases the testis immediately enlarges, sometimes to more than double its natural size, from the sudden distension of the tunica vaginalis with blood. The second form of hogmatocele, in which the extravasation takes place in combination with hydrocele, is of more frequent occurrence than the first. It may be produced by a blow, or by the wound of some vessel in the operation of tap- ping. The testis, owing to its free mobility, does not often suffer from mechanical violence ; but when hydrocele exists a tumour is formed, which, from its prominence and size, is necessarily more exposed to injury. A blow occasions a rupture into the tunica vaginalis of some of the enlarged vessels ramifying outside the sac, and the blood which is extravasated, mixing with the fluid of the hydrocele, produces a sudden increase in the size of the tumour. The quantity of blood effused under these circumstances varies considerably. It may be merely sufficient to impart a red tinge to the serum. In general, however, it is greater ; and it sometimes exceeds the serum in amount, occasion- ing a rapid enlargement of the swelling to more 264 HEMATOCELE OF THE TESTIS. than double its previous volume. A h^ematocele may be produced in the operation of tapping a hydrocele in two ways. 1. It may be occasioned by the accidental wound of some vessel ramifying over the tunica vaginalis, which, instead of bleeding externally, or into the celkdar tissue of the scrotum, pours its blood into the sac of the hydrocele. This accident sometimes occurs when the operation is performed with a trocar, but it is more liable to happen w^hen the lancet is used. 2. A hasmatocele may be caused by the trocar or lancet penetrating too far, and wounding the testis or spermatic artery. A case in which a hoeraatocele was occasioned by a wound of the artery in this operation is recorded by Scarpa.^ In hoematoceles consequent upon injury, few opportunities are afforded of tracing the source of haemorrhage. When the parts are in a healthy state, the bleeding probably proceeds from the ves- sels ramifying between the tunica albuginea and the tunica vaginalis testis, in consequence of the rupture of the latter delicate membrane. Sir B. Brodie remarks, that a rupture of a vessel producing hcematocele may arise from a diseased condition of the arteries, analogous to that which occurs in the brain under the form of sanguineous apoplexy, in old persons whose arteries are ossified.t In haema- tocele combined with hydrocele, and caused by a blow, the tunica vaginalis is ruptured, and the blood * Treatise on Hernia, tr. by Wishart, p. 76. f London Medical Gazette, voL ix. p, 927. HEMATOCELE OF THE TESTIS. 265 is derived from some vessel distributed on its ex- ternal or adherent surface. In the case of g. man who had long had a hydrocele, and had received a severe blow upon it^ which suddenly increased the swelling, bruised the scrotum, and produced great pain from distension. Sir A. Cooper, on making an incision into it and discharging a large quantity of water and coagulated blood, found a rent in the tunica vaginalis between one and two inches in length covered with coagulum.'^ In general, when the blood effused is of small amount, it becomes dissolved in the fluid of the hydrocele, which is tinged of a red colour. If a larger quantity be extravasated, coagula are formed, and these remain undissolved in the fluid. In hsematoceles which have existed for a long period, the blood becomes changed into a substance resembling coffee grounds, of a brownish-red or chocolate colour, and more or less fluid. The coagula sometimes present a cellu- lar or honeycomb appearance, the cells being filled with a reddish serum. Occasionally the blood is found converted into a solid fibrinous substance, of a yellow or fawn colour, arranged in firm layers, similar to the coagula lining the sac of an aneurism. In many instances the effused blood is felt as a foreign body, and produces inflammation in the tunica vaginalis, which becomes coated with lymph. Under these circumstances, the tumour undergoes a further increase ; and the lymph efilised becoming mixed with the blood and serum, modifies the ap- * Lib. cit. p. 212. 34 266 H.^MATOCELE OF THE TESTIS. pearance of the contents of the cyst, which is ren- dered soft, turbid, and of a light colour. Some- times the inflammation goes on to suppuration, in which case pus is also found in the sac. The in- flammation usually extends from the tunica vagi- nalis to the cellular tissue and fascia external to the sac, which in recent cases are found infiltrated with serum and lymph, and in cases of old standing become greatly thickened, indurated, and com- pacted. In a case of hoematocele occasioned by the wound of a vessel in tapping a hydrocele, in which I was consulted, the inflammation which ensued caused in the course of a fortnight great thickening of the tissues external to the sac, and the form^ation of an abscess in the scrotum on one side of the hcematocele. 1 have found the tunica vaginalis and tissues investing it as much as half an inch in thickness, and very firm and dense. These changes in the sac are produced by a more chronic form of inflammation of the fascia and cellular tissue investing the sac. In these old cases, the internal surface of the tunica vaginalis, instead of presenting its natural smooth and polished surface, is rough, granular, and irregular, and feels as dense and tough as a piece of leather, having lost all the characters of a serous membrane. In hcematocele the testis preserves the same re- lation to the remainder of the tumour as in simple hydrocele, being situated at the posterior part, and rather below the centre. Its position, however, is liable to similar alterations as occur in hydrocele, and they are dependent upon the same causes. I HiEMATOCELE OF THE TESTIS. 267 once witnessed an '' untoward event," which hap- pened in the practice of a surgeon who was un- aware of the testis being out of its usual position. A young man had a hydrocele, which had suc- ceeded to an attack of secondary orchitis, occasion- ing an adhesion of the gland to the front of the sac at its lower part. The case became converted into a haematocele by the wound of a vessel in the ope- ration of tapping. Inflammation ensued, and it became necessary to lay open the sac. The sur- geon, in carrying the incision to the lower part of the tunica vaginalis, divided the vas deferens, and severed the sound testicle nearly in two with his bistoury, the thickening around the sac having pre- vented him from detecting the gland in its unusual situation. In hcematocele the glandular structure of the testis sometimes disappears in the same manner as in old cases of hydrocele, atrophy being occasioned by the long-continued pressure arising from the extravasated blood. On examining the body of an elderly negro who died in St. George's Hospital of disease in the lungs. Sir B. Brodie observed on the right side of the scrotum a large tumour, which was formed by the tunica vaginalis, distended with about twelve ounces of fluid having the appearance of coffee-grounds, with numerous masses of solid substance, manifestly fragments of coagulum, float- ing in it. The tunica vaginalis itself was much thickened. The substance of the testicle, the tunica albuginea, and the tunica vaginalis immediately covering it, were entirely destroyed, so that not a 268 HiEMATOCELE OF THE TESTIS. vestige of these parts could be discovered. The vas deferens adhered to the posterior part of the tumour, and was imperceptibly lost at the part where it usually joins the testicle. Sir B. Brodie likewise met with another case in which the appear- ances on dissection were precisely similar •, but here also he unfortunately lost an opportunity of learn- ing the history of the case during the patient's life- time."^ In the examination of a large haematocele which had existed for njany years, and was removed by operation under the impression that it was a solid enlargement of the testis, 1 found the tunica * Lond. Med. and Phys. Journal, vol. Iviii. p. 299. HEMATOCELE OF THE TESTIS. 269 vaginalis nearly half an inch thick, and full of a soft friable substance of a chocolate colour ; the testis, which was situated at the posterior part of the cavity, was somewhat flattened, and partly imbedded in the thickened cyst ; but the glandular structure was perfectly healthy, and the bulk of the organ scarcely less than natural. The hsematocele, with the sac and testis laid open, is represented in the opposite engraving. The structure of the testis is indeed usually sound in hcematocele, but its nutrition becomes impaired when the disease is of very old standing. Symptoms. — The first form of haematocele ap- pears suddenly after a strain or the receipt of some injury. The testis quickly enlarges to more than double its natural size, and forms a tumour, which is of an oval shape, tender, tense, and fluctuates indistinctly. If the haematocele be occasioned by a blow, this enlargement is accompanied with appear- ances of extravasation in the cellular tissue of the scrotum. Slight pain and tenderness continue for some days, and then subside, leaving the swelling but little altered, except that it feels rather more solid than at first. In the second form, in which a hydrocele becomes converted into a hsematocele, the tumour undergoes a sudden increase in size, and becomes more or less painful. It still preserves its pyriform shape and even, uniform surface ; but it feels very tense, and heavier and more solid than before, and fluctuates very indistinctly. In the course of a few hours, or on the following day, inflammation arises, the part 270 HJE.MATOCELE OF THE TESTIS. 1 feels hot and tender, the scrotum becomes tense and sometimes injected, and further enlargement ensues. These symptoms are attended with general febrile disturbance. Occasionally there is exces- sive pain, and high symptomatic fever ; and the inflammation, if allowed to proceed, goes on to suppuration. In other cases the tumour from the first assumes an indolent character, becomes more firm and solid, and feels heavier than before, but undergoes no alteration in size. It may remain stationary in this condition for many years, pro- ducing no inconvenience beyond that which arises from its bulk and weight. Diagnosis. — A haematocele may be distinguished from a hydrocele by the absence of transparency, the obscure character of the fluctuation, the heavy feel of the tumour w^hen balanced in the hand, and the sudden and accidental mode of its occurrence. In old cases, in which the tunica vaginalis and its envelopes have become much thickened and in- durated, the tumour possesses so firm a character, feels so heavy and solid, that it is very liable to be mistaken for a chronic enlargement of the testis ; and the diagnosis, at all times difficult, in some instances cannot be satisfactorily made out by the nicest manipulation of the most experienced hands. The records of surgery furnish many cases in which castration has been performed from a mistaken diagnosis : I have known three instances of the kind myself In chronic enlargement of the testis, whether from malignant deposit or other disease, the gland loses for the most part its natural sensi- HEMATOCELE OF THE TESTIS. 271 bility ; but in haematocele pressure on the back part, where the testis is usually situated, occasions the peculiar pain always experienced when the organ is compressed. When the least doubt exists, it should in all cases be removed by the introduc- tion of a lancet or trocar before any further ope- ration is undertaken. Swelling of the scrotum from extravasation of blood in its loose cellular tissue may arise somewhat suddenly after a blow ; but the diffused nature of the tumour and its extension to both sides of the scrotum, the concealment more or less of both testes, doughy feel, and red colour of the skin, are characters too clearly expressive of the nature of the case to mislead the practitioner. Treatment, — In the first form of haematocele, if the quantity of blood effused into the tunica vagi- nalis be small, the treatment should be simply antiphlogistic. The patient is to be kept in the recumbent position, with the testis supported ; a cold lotion is to be applied to the part, and the bowels must be gently acted upon. If the tender- ness be considerable, or symptoms of inflammation arise, a few leeches should be applied to the scro- tum, or, if there be much contusion of the part, to the corresponding groin. By such means, inflam- mation may be prevented, and in the course of time the effused blood becomes absorbed. In gene- ral, this takes place very gradually and slowly, and it is often many months before the blood is entirely removed. If the quantity of blood extravasated be large, so as to cause great tension of the tunica vaginalis and severe pain, and endanger the nu- 272 HiEMATOCELE OF THE TESTIS. trition of the testis, it becomes necessary to lay open the sac by a straight incision, and to remove the blood. Means must afterwards be taken to subdue the inflammation which ensues, and the part then heals by granulation. When hagmatocele is combined with hydrocele, the usual practice is at once to make an incision into the tunica vaginalis, and discharge its contents, leaving the cure to be effected afterwards by the process of inflammation. Sir B. Brodie observes, " If on drawing off the contents of the sac I find that the fluid is tinged with blood, I allow the fluid again to collect, and repeat this operation at cer- tain intervals until it is voided perfectly clear. You may then perform the common operation for hy- drocele by injection and with success."^ I have adopted this proceeding in two cases, in which the blood eflfused was small in quantity, and found it obviate the necessity for a severer operation. If much inflammation arise, the tunica vaginalis ought to be laid open without delay, and the source of irritation removed. No advantage is gained by deferring a proceeding which must subsequently be resorted to ; whilst, on the contrary, if the operation be delayed, it is rendered more painful and severe by the parts becoming thickened and enlarged. When, too, the quantity ,of extravasated blood is large, it is hopeless to await its absorption ; it should be removed at once by an incision. The tunica vaginalis may be punctured with a lancet at * Medical Gazette, vol. ix. p. 928. HEMATOCELE OF THE TESTIS. 273 its upper part, a director or the finger introduced, and the whole extent of the membrane then laid open by an incision with a bistoury carried quite to its lower part, in order to prevent any bagging of the discharge afterwards. This must be done with care, so as to avoid wounding the testis. If in a recent case the spermatic artery or a ves- sel of any size has been wounded, and continues to bleed, it can then be easily secured. In the case related by Scarpa, previously alluded to, the wounded spermatic artery was found, after the tunica vaginalis had been laid open, pumping out blood. The removal of the pressure occasioned by the extravasated blood will be favourable to the recurrence of the hosmorrhage. In dressing the wound, the surgeon may leave a piece of lint be- tween the edges to prevent union by the first in- tention ; but it should not be carried to the bottom of the sac, or be placed in contact with the serous membrane. Severe symptoms and a good deal of constitutional irritation frequently follow this ope- ration : they are occasioned by acute inflammation of the exposed sac, which being much enlarged and dilated in this disease affords a considerable extent of surface. In a few hours the skin becomes hot ; the pulse full, frequent, and bounding; the face flushed ; the tongue white and furred, and the part hot and painfuL The patient becomes restless, and sometimes delirious. By antiphlogistic treatment these symptoms may soon be moderated, and in a few days entirely removed. Their severity depends in a great measure upon the age and natural con- 35 274 HiEMATOCELE OF THE TESTIS* stitution of the patient, as well as upon his state of health at the time of the operation. In old persons gangrene has arisen from the incision of a haemato- cele ; and formerly, when it was the practice to stuff the bottom of the wound with lint or other extra- neous substances for the purpose of insuring suffi- cient inflammation, the operation was not altogether free from risk^ especially in persons of an unhealthy constitution. The danger consists in exciting too much inflammatory action, and the object of the after-treatment is to moderate that which is almost certain to follow from the nature of the parts ex- posed in the operation. I have noticed, however, that the inflammation and febrile disturbance are less severe after the incision of old-standing haema- toceles, in which the sac is much consolidated, and its contents are thick and grumous, than in more recent cases of the disease. In these old cases, the tunica vaginalis having pretty well lost the charac- ters of a serous membrane, the inflammatory action which arises in it is less active, granulations soon form, and in general the wound heals readily. Castration is very rarely required for this disease. It has been recommended in preference to incision in cases of consolidated haematocele in old people ; but the former is a much more severe operation than the latter, and would only be necessary in cases of ossific deposit in the sac. H.^MATOCELE OF THE SPERMATIC CORD. 275 SECTION II. HJEMATOCELE OF THE SPERMATIC CORD» This affection, which was first noticed by Mr. Pott, is generally produced by the accidental rup- ture of a spermatic vein during violent and sudden exertion, as in straining to lift a heavy weight, when blood immediately escapes into and infiltrates the loose cellular tissue along the cord, where it accumulates, its further diffusion being prevented by the fascious envelope of this part. Mr. Pott has related three cases, all of which occurred in this way. It may happen to persons in good health, and whose genital organs are free from disease ; but it is a complaint of rare occurrence. In contusions of these parts, blood is often effused amongst the structures of the cord, as well as in the cellular tissue of the scrotum ; but the symp- toms of the two are so combined, that it is impos- sible to make any distinction in practice, and they must be viewed and treated as common cases of ecchymosis. An encysted hydrocele of the spermatic cord may become converted into a haematocele. In the pathological museum of St. Bartholomew's Hospi- tal,^ there is a preparation of encysted haematocele of the spermatic cord. The cyst is empty ; but it is described to have contained blood, and its walls are deeply stained with the colour of partially de- * Series 22d, No, 11, in printed Catalogue. 276 HiEMATOCELE OF THE SPERMATIC CORD. composed blood. Its lining membrane is wrinkled and coarsely granular ; and the tissues around it are thick- ened, brawny, and adherent together. I lately examined a preparation in the Hunte- rian Collection, which I have no doubt is a specimen of old encysted hoematocele of the spermatic cord. (See figure.) There is a good-sized cyst, lined by a membrane, polished and a little wrinkled, filled with a soft tawny-looking gra- nular matter (3), resembling the altered coagulum of blood which I have observed in or- dinary hsematocele after long maceration in spirit. The tissues around the cyst are thickened and indurated, just like those around an old haematocele of the testis. There is a hernial sac^ immediately above it (2), and a hydrocele below, with the sac open for some distance up the cord as far as the cyst of the haematocele, which does not communicate either with the tunica vaginalis or the hernial sac. I am unacquainted with any case in which such a change has been detected during life ; but I should expect that it would be attended with * In the preparation the hernial sac is laid open behind, instead of in front, as represented in the figure, in order to bring it into view. HiEMATOCELE OF THE SPERMATIC CORD. 277 pain and sudden enlargement of the swelling, which would lose its transparency, fluctuate \e&s distinctly, and feel more firm and solid than before. The symptoms produced by a diffused haemato- cele of the spermatic cord are very similar to those of diffused hydrocele ; from which, however, it may be distinguished by its sudden appearance. Mr. Pott relates the following case. — A labouring man who had fallen down with a load on his back, was brought into St. Bartholomew's Hospital for a supposed rupture, a swelling having appeared in the groin and scrotum immediately after the acci- dent. The tumour seemed to occupy the whole spermatic process, which was so enlarged by it that it was impossible to feel the passage of it from the abdomen through the muscle ; but the testicle below it was perfectly distinct. The appearance of a tumour, the suddenness of its formation, the distinct fluctuation of the testicle below, and an accidental circumstance of the man's not having had a stool for two days past, inclined Mr. Freke to believe it to be hernia, and to treat it accord- ingly. After fruitless attempts at reduction, he determined upon an operation. He divided the superficial parts and tendinous opening in the ab- dominal muscle, and made several trials to reduce what he supposed to be the gut without opening the sac, but ineffectually. He was at length obliged to lay open the containing membrane, when a large quantity of blood, partly fluid and partly grumous, burst forth, and the whole tumour sub- sided. The parts were washed, and search made 278 HiEMATOCELE OF THE SPERMAT[C CORD. 1 for the bleeding vessel, but it could not be found. The wound was dressed, and the man got well."* In this case it does not appear that there were any urgent symptoms of hernia demanding an operation. The costive state of the bowels was an accidental circumstance, which might have been shortly re- moved by the exhibition of a purgative. An operation can very rarely be required in any case of diffused hoematocele. If left alone, the blood will in the course of time be removed by absorption. All that appears to be required in the way of treat- ment is to check any tendency that may arise to inflammation. If the tumour, however, should continue to increase, haemorrhage still going on and infiltrating the cellular tissue, it may become necessary to make an incision, in order to secure the bleeding vessel. The only case that I know of, in which the operation was really necessary, is detailed by Mr. Pott. — A young fellow straining at stool felt a sudden pain in his left groin ; and, upon examination, found a swelling extending from thence into the scrotum. He took it for a rupture, and immediately applied to an advertising opera- tor ; who, after unsuccessful attempts to reduce it, applied a truss. After some days, during which the pain and swelling increased, he was seen by Mr. Pott. The tumour was large, and had some- what the feel of an omental hernia ; the abdominal aperture seemed dilated ; the testicle was tolerably distinct below ; pain in the erect posture was con- * Lib. cit. Case XXX. p. 456. HEMATOCELE OF THE SPERMATIC CORD. 279 siderable, but in a supine one very little : he had neither heat, quickness of pulse, hiccough, nor vomiting, and had been thrice at stool that day. Notwithstanding he was bled freely and kept in bed, the pain and tumour increased, and fluctuation became palpable. Thinking that the fluid might possibly be collected in the sac of an omental hernia, Mr. Pott made a puncture with a lancet, and let out some ounces of clear blood. The haemorrhage continuing for three or four days, an incision of some length was made up to the groin, and the cellular membrane of the spermatic process was found loaded with extravasated blood. The wound was dressed with lint pressed out from a styptic ; but an alarming return of the haemorrhage soon after induced Mr. Pott to perform castration.* Modern surgeons will not be inclined to admit that castration was " the only remedy in this case." Had diligent search been made for the vessel, I should think it mioht have been found and secured. An encysted haematocele of the cord would pro- bably require to be treated in the same way as a haematocele of the testis. In slight cases sufficient relief may be afforded by rest and antiphlogistic measures : if the tumour should become painful and inflamed, and show no disposition to disperse, the blood must be liberated by an incision, and the wound be encouraged to heal by granulations from the bottom of the cyst. * I.ib. cit. Case XXXI. p. 458. 280 ORCHITIS. CHAPTER VI. ORCHITIS. InflaMxMation of the testis occurs in two forms, acute and chronic ; and it may commence either in the body or secreting part of the organ, or in the epididymis. Inflammation beginning in the body of the testis may be idiopathic, or may be ex- cited by external violence : the disease is at first confined to the interior of the organ, the epididymis and tunica vaginalis being affected only secondarily, and sometimes entirely escaping. Orchitis is far more frequently a consecutive affection than a pri- mary, the inflammation being transmitted from the urethra by the course of the vas deferens. In this latter form of orchitis, which is familiarly known by the term hernia humoralis, the epididymis is first attacked, and the tunica vaginalis generally participates in the disease, SECTION I. ACUTE ORCHITIS, Few pathologists have examined a testis in a state of acute inflammation, and I am unacquainted with any authentic account of the alterations in structure from inflammation originating in the body of the gland. I have twice been able to inspect ACUTE ORCHITIS. 281 a testis affected with acute secondary orchitis ; and the following description of the pathological appearances is drawn up from these examinations, and from the account of the dissection of two tes- tes affected with gonorrha3al inflammation recorded by M. GaussaiL* The tunica vaginalis is more or less distended with lymph, or albuminous matter infiltrated with reddish serum, which form loose adhesions between the opposed surfaces of the membrane ; these adhesions are so slight as easily to admit of being broken down with the finger. The membrane is injected with a multitude of minute red vessels, which ramify in various direc- tions, and form a compact network. At a later period red vessels may be traced, proceeding from the free surface of the tunica vaginalis to the false membranes forming the adhesions. The volume of the testis appears very little, if at all increased, the great bulk of the tumour being occasioned by the effusion into the serous sac. When cut into, the gland appears somewhat darker than natural, from a congested state of its vessels. The epididy- mis, particularly the lower part, is enlarged to twice, and sometimes thrice its natural size, and feels thick, firm, and indurated. This enlargement is produced by the effusion of a brownish deposit in the cellular tissue between the convolutions of the duct. The coats of the vas deferens are thick- ened, and the vessels ramifying near them injected. * Memoire sur I'Orchite Blennorrhagique, Archives Generales de Medecine, torn, xxvii. p. 210. 36 282 ACUTE ORCHITIS, sometimes along the whole extent of the duct. Al- buminous deposit is found in the cellular tissue around the tortuous part of the vas deferens and tail of the epididymis, which frequently forms the bulk of the swelling observed in these cases. Owing to the epididymis being the part chiefly and most constantly affected in consecutive orchitis, some of the modern French writers have denominated the disease epididymitis. In treating of the acute inflammatory changes in the tunica vaginalis (page 145), I particularly re- marked that the inflammatory action was very liable to extend to the substance of the epididymis, but not to the body of the testis ; and I noticed the pa- thological law enunciated by Gendrin, by which this circumstance was accounted for. We find, too, that inflammation of the epididymis is much more readily propagated to the tunica vaginalis than in- flammation originating in the glandular structure of the testis. When inflammation commences in the body of the gland, the enlargement takes place slowly, and is seldom considerable until the disease has existed for some length of time, which is easily explained by the unyielding texture of the tunica albuginea, and the circumstance of the tunica vagi- nalis remaining unaffected. Suppuration occasion- ally takes place in this form of orchitis, whereas in consecutive inflammation the formation of pus in the substance of the gland is of rather rare occur- rence. I do not mean, however, to imply that the glandular structure of the testis never suffers in consecutive orchitis, for I believe that it does so in ACUTE ORCHITIS. 283 some instances ; but, according to my observations, and I have paid some attention to the subject, it very commonly escapes, the inflammation not ex- tending further than to the epididymis. When inflammation terminates in suppuration, owing to the density, thickness, and low organiza- tion of the tunica albuginea, the matter is so slow in making its way externally, that it generafly bur- rows in various directions, producing numerous sinuses throughout the gland, and disorganizing its delicate structure. The matter sometimes becomes encysted, forming a separate abscess. In these cases, when the matter efiused is small in quantity, after all inflammation has subsided, the more fluid particles are absorbed, and the pus remains for a considerable time in the form of an indolent con- crete mass, which has been mistaken, after death, for tubercular deposit. The pus, when found in this concrete state, appears at first sight very like crude tubercular deposit ; but on further examina- tion, it will be found to be contained in a distinct cyst, from which it may easily be separated, and the structure of the testis will be perceived to be more or less altered from its healthy state ; whereas in tubercular disease the morbid deposit is in im- mediate contact with the tubular structure, which, though atrophied by pressure, is usually in other respects sound. Concrete pus may likewise be mistaken for the firm yellow matter effused in chronic inflammation. It differs from it, however, in being friable and easily broken up, and also in being enclosed in a cyst ; whereas the yellow fibrinous substance is homogeneous and consistent, 284 ACUTE ORCHITIS. and almost inseparably diffused amongst and con- nected with the convoluted tubuli around it. The distinctive characters just de- scribed will be easily recog- nised on comparing the ac- companying representation of concrete pus encysted in the testis from a preparation in the collection of the late Sir A. Cooper, with the figures at pages 315 and 349. I examined two enlarged testes taken from a man who died somewhat unexpectedly from a disease of the larynx. Both glands had formerly been attacked with acute inflammation, and for some months before death they had been the seat of chronic pain. In the left testis, which was the larger of the two, from two to three drachms of thick yellow inspissated pus were contained in a distinct cyst, which occupied the centre of the gland. There was no trace of tubuli seminiferi, but the remainder of the organ was composed of fibrous tissue : the sac of the tunica vaginalis was obliterated by close adhesions. The tunica vagi- nalis of the right testis contained about half an ounce of yellowish serum ; in the centre of the gland there was a small concrete abscess, but the tubular structure was apparent, and very little diseased. Pus existing in this concrete or inspis- sated state often keeps up pain and irritation for ACUTE ORCHITIS. 285 a long period, and renders the testis liable to repeated relapses of inflammation. Suppuration occasionally takes place in the epididymis. In two cases of consecutive orchitis which came under my care, at a late period of the disease an abscess formed in the cellular tissue around the termina- tion of the epididymis and inflected portion of the vas deferens, and burst at the most depending part of the scrotum. In many instances, after acute orchitis has sub- sided the testis is restored to its natural condition ; in other cases, permanent changes of a serious nature are the consequence. I have observed in testes that have been affected with inflammation some time before, that the septa appear to be more distinct, and to enter more largely into the com- position of the gland than is natural ; that the small seminal tubes are less numerous and apparent ; and that a great part of the organ is converted into a dense white fibrous tissue, without the presence of tubuli. Sir B. Brodie gives the following account of the dissection of a testis which had been at- tacked with inflammation from a gonorrhoea twenty years before. It was smaller than the other testicle, and part of it was considerably indurated. On making a section of the gland, he found that about two thirds of the tubuli testis remained in their na- tural condition, while the remainder had become con- verted into a white substance, having the consistence but not the fibrous structure of ligament."^ In these * London Medical Gazette, vol. xiii. p. 219. 286 ACUTE ORCHITIS. cases the fibrinous matter effused in the cellular tissue connecting the tubuli, not having been ab- sorbed after the cessation of inflammatory action, had occasioned partial atrophy of the proper struc- ture of the organ, and been converted into the dense tissue just described. Complete atrophy is one of the most serious results of acute inflammation of the testis. In Chapter II., the disturbance in the organization of the testis consequent upon inflam- mation was noticed as the most common cause of wasting, and several examples of it were adduced. Consecutive orchitis seldom subsides without leav- ing behind distinct traces of its existence, which never disappear during the remainder of the pa- tient's life. The epididymis frequently remains enlarged, presenting an indurated irregular knotty swelling, seated usually at its lower part, which is occasioned by the presence of a dense hard deposit between the convolutions of the duct and around the inflected portion of the vas deferens. On making a section of the epididymis in this state, I have often observed not only a highly thickened con- dition of its duct, but also, in some instances, very considerable dilatation ; so that the point of a fine probe might be introduced into the canal without difficulty, its area being increased four or five times. In old cases the epididymis acquires the density and consistence of cartilage, and some- times even those of bone. These changes are rarely found without the presence of old adhesions, obliterating partially or completely the sac of the tunica vaginalis. The coats of the vas deferens ACUTE ORCHITIS. 287 are also found for some extent thickened and in- durated. The alterations noticed in the body of the testis have been observed, in some instances, co-existing with those in the epididymis ; but in by far the majority of cases, the glandular structure is unimpaired. In only two cases in which the epididymis was thus diseased, have I remarked a decidedly atrophied condition of the organ. The absence of pressure, owing to the un- resisting nature of the membrane investing the epididymis, appears to prevent the obliteration of the duct of which it is composed, and thus accounts for atrophy occurring much more rarely after con- secutive orchitis than after inflammation originating in the body of the gland, where the delicate seminal tubes are enclosed in the firm unyielding tunica albuginea. Acute orchitis may arise from various causes. It may be produced by contusion, as from a kick on the part, or a blow against the pommel of a saddle, the patient being jerked forwards in riding ; or by compression occasioned by crossing one thigh upon the other, or by other accidental injury. It sometimes appears to arise from exposure to the vicissitudes of the weather, in which case the in- flammation is liable to assume somewhat of a rheu- matic character. Great excitement of the sexual organs, without the opportunity of indulging the passions, may also lead to inflammation of the gland ; in many instances the disease is developed without any evident cause. An inflammatory swelling of the testis sometimes 288 ACUTE ORCHITIS. follows an attack of cynanche parotidea, or mumps. It occurs generally about the period of puberty, and when the swelling of the parotid and sub- maxillary glands is on the decline : it is supposed to be owing to a metastasis of the inflammation from the salivary glands to the testis. The inflam- mation is usually slight, and seldom requires any other than mild treatment. It is commonly be- lieved that wasting of the testis is a frequent result of this complaint. Sir A. Cooper states that he has not met with any instance of the kind in his own practice f^ and no case has come under my observation,t nor have I heard of any amongst the diflerent medical friends of whom I have made inquiries. Dr. R. Hamilton, the first writer who gave a particular description of this affection, has, however, related two cases of atrophy of the testis succeeding the orchitis occurring in mumps. One was the case of a gentleman about forty years of age. On the morning of the fourth day of the attack the testicles began to swell. On the fifth day both glands were much tumefied, the right by far the most so. After all disease had ceased, the right testicle, which had been chiefly affected, continued gradually to waste away, till at length a mere empty bag, consisting of the coats only, remained. The second case was that of a young * Lib. cit. p. 77. f A middle-aged married man in the London Hospital on account of lumbar abscess had one of his testes completely wasted, which he attributed to an attack of mumps in his youth ; but whether correctly so I had no means of ascertaining. ACUTE ORCHITIS. 289 man twenty-five years of age, who was attacked by this distemper. Upon the tumid salivary glands subsiding suddenly, the testicles became affected. One of them was much more swelled than the other, and was found, when the swelling was reduced, to be diminished more than one half of its natural size, at which it remained two months afterwards.* I have already observed that inflammation of the testis is far more frequently met with as a conse- cutive affection than as a primary. This gland is directly connected through the medium of the vas deferens with the urinary organs, the lining mem- brane of its numerous minute ducts being con- tinuous with the mucous membrane of the urethra. Any irritation, therefore, affecting that part of the urethra where the vasa deferentia terminate, is liable to be propagated to the testis, and to cause it to inflame. In cases of gonorrhoea, in which the inflammatory action has reached that part of the canal, or of stricture, in which the portion of the urethra behind the obstruction has become dis- eased; when the urethra has been irritated by foreign bodies, as calculi or instruments, or by an enlarged prostate gland, or disease of the vesiculae seminales ; in morbid states of this part, from the excitement of excessive onanism or sexual in- dulgence, and after its division and laceration in the operation of lithotomy, the irritation and in- flammation are frequently transmitted to the testis, * Trans, of Royal Society of Edinburgh, vol. ii. Art. IX. p. 59. 37 290 ACUTE ORCHITIS. and thus give rise to orchitis. Of all the causes here mentioned as more or less liable to lead to in- flammation of the testis, gonorrhoea is by far the most common. Orchitis is indeed so frequent a sequel of gonorrhoea, that it is generally treated of by writers in connexion with this affection, and few pathologists have drawn any distinction be- tween this and the idiopathic and accidental form of the disease. Secondary orchitis differs, however, from the latter, in many important respects. Orchitis may arise at all periods of a gonorrhoeal discharge, during its early and acute stage as well as towards its termination, though it more fre- quently commences when the pain and discharge begin to subside. It is a common observation, that when inflammation of the testis supervenes in gonorrhoBa, the pain in making water and urethral discharge cease altogether, or undergo considerable diminution, but return as the orchitis subsides ; which has led to the opinion that the orchitis is occasioned by a metastasis, or sudden translation of the inflammation from the urethra to the testis. The doctrine of metastasis, to explain the pheno- mena of disease, has been too often adopted on in- sufficient grounds. It is extremely questionable whether any thing of the kind ever takes place in gonorrhoeal orchitis. Assuredly it does not in those, the more numerous cases, in which the inflammatory action may be gradually traced creeping along the vas deferens to the epididymis. The origin of or- chitis is here clearly made out, without the neces- sity of being accounted for by a metastasis. In ACUTE ORCHITIS. 291 these cases, nevertheless, the pain and discharge from the urethra diminish generally, though not constantly, during the early stage of the disease. Several of the French v\rriters have taken consi- derable pains in investigating the connexion sup- posed to exist between the state of the discharge and the inflammatory action in the testis. In sixty-seven of seventy-three cases observed by M. Gaussail, the discharge and other symptoms of gonorrhoea diminished more or less from the first appearance of the disease. In fifty-eight out of eighty-one patients noticed by M. Aubry, there was a considerable diminution of the discharge at the commencement of the attack.* M. D'Espine states that in six out of twenty-nine cases, the dis- charge underwent no modification on the accession of orchitis. In twenty-two cases the discharge was variously modified : it was either increased, dimi- nished, or suppressed ; but more frequently these modifications occurred only before or after the or- chitis, the amendment of which was not in general followed by a return of the discharge to the state in which it existed before the inflammation of the testis. In only three cases did the running, after having been suppressed at the commencement of the affection, re-appear and increase as the acute symptoms of orchitis subsided.t Mr. Hunter states, that he has known cases where the testicle has * Recherches sur I'Epididymite Blennorrhagique, Archives Gene- rales de Medecine, Mai, 1841. f Meraoire Analytique sur I'Orchite Blennorrhagique, Memoires de ]a Societe Medicale d'Observation, torn. i. p. 494. 292 ACUTE ORCHITIS. swelled, and yet the discharge become more violent ; nay, that he has seen some instances where a swell- ing has come on after the discharge had ceased, yet the discharge has returned with violence, and remained as long as the swelling of the testicle.^ The recurrence of the pain and discharge is not essential to the doctrine of metastasis ; on the other hand, the marked amelioration of the gonorrhoeal symptoms cannot be regarded as adequate proof of its occurrence. It is well known that when a part becomes actively inflamed, the symptoms of inflam- mation going on in another part, especially if it be in near proximity, usually diminish, though the two parts are not directly connected or continuous with each other* The effects of blisters and other counter-irritants in relieving inflammation of in- ternal organs aflbrd a familiar illustration of this remark ; and I once had an opportunity of observing, in a case of orchitis occasioned by a blow, that the symptoms of a gonorrhoBa, with which the patient was affected at the time of the injury, subsided, as is often witnessed in ordinary cases of secondary inflammation of the gland. It is clear that Mr, Hunter entertained considerable doubt as to the influence of metastasis in these cases — a doctrine which was generally admitted in his day. Thus he remarks, ''Although an action in the urethra is the remote cause, yet it is still impossible to say whether it be the cessation of that action that is the cause of the swefling of the testicle, or the swelling of the * Treatise on the Venereal Disease, 4to. 55. ACUTE ORCHITIS. 293 testicle the cause of the cessation.'"^ Inflammation frequently attacks the epididymis and testis of per- sons labouring under gonorrhoea, apparently with- out any previous affection of the vas deferens. It is in such cases only that the orchitis can be attri- buted to a metastasis. But when we consider how readily inflammatory action may be propagated from one part to another along a continuous mem- branous surface, as from the mucous membrane of the bladder to the kidney ; how rapidly this trans- mission may take place without the inflammation remaining fixed in any part of the continuous mem- brane a sufficient time to produce any evident signs of disease ; how rarely it happens that the gonor- rhoea! symptoms entirely subside as the orchitis becomes developed ; and how seldom orchitis occurs when the discharge is quickly arrested by specific remedies or injections ; — we cannot readily admit that the affection of the testis commonly owes its origin to the sudden cessation of disease in the urethra, or assent to the doctrine of a metastasis in these cases. In the sympathetic form of gonorrhoea! orchitis just alluded to, in which the testis is attacked, ap- parently without any previous affection of the vas deferens, the inflammation likewise commences ge- nerally in the epididymis. This form of the disease, though less common than the other, is by no means of unfrequent occurrence. Of one hundred and four cases of gonorrhoeal orchitis noted by M. Aubry, * T>ib. cit. ]\ 55. 294 ACUTE ORCHITIS. in thirty-one the disease was sympathetic ; in the remaining seventy-three, the inflammation first at- tacked the vas deferens. It is the opinion of many surgeons, that inflammation of the testis most fre- quently arises in cases in which the discharge has been somewhat suddenly arrested by the adminis- tration of cubebs or copaiba, or the use of injec- tions. More mischief is perhaps ascribed to these remedies than they can justly be said to produce. I have prescribed copaiba and cubebs separately or conjointly in all stages of gonorrhoea, and have not found the patients to whom they were exhibited more liable to be attacked with orchitis than others treated differently. Mr. Broughton mentions that out of fifty cases of gonorrhciea treated with cubebs, swelling of the testicles occurred in only two in- stances ;* a proportion so small that it would be unfair to attribute the occurrence of the orchitis to the use of the remedy. Sir B. Brodie states, he is satisfied that he has seen this disease quite as often where no remedies, such as cubebs and injections, were used, as where they had been had recourse to.t With regard to injections, my own experience leads me to conclude that when employed of a proper strength they are very little liable to excite orchitis. It is only when used improperly, when too strong and injected too freely, so as to aggravate or too suddenly suppress the urethral inflammation, that they tend to produce inflammation in the testis. * Medico-Chirurgical Transactions, vol. xii. p. 100. t Medical Gazette, vol. xiii. p. 218. ACUTE ORCHITIS. 295 According to my observation, orchitis most fre- quently arises in those cases in which the affection of the urethra is allowed to linger for want of a due exhibition of the remedies alluded to, particularly when the prostatic part of the canal is affected. Some pathologists have gone so far as to say that the chances of a swelled testis are increased in direct ratio to the continuance of the disease in the urethra."* Certainly most practitioners will allow that the occurrence of orchitis during the early and acute stage of gonorrhoea is comparatively rare. In chronic gonorrhoea, stricture, and morbid states of the prostatic part of the urethra, the patients are liable, especially at night, to distressing and painful erections, accompanied with abnormal sexual ex- citement and seminal emissions. In these cases the testis often feels heavy and uneasy, and tender on pressure ; and being in this irritable state is disposed to inflammatory action. Accordingly we find that slight circumstances, which would pro- duce no ill effects at other times, then appear sufficient to excite orchitis. Slight blows or pres- sure, much exercise, any excess in stimulating drinks, and neglect of the use of a suspender, are commonly sufficient to induce the disease. We can- not doubt, though it is difficult to account for it, that some persons are naturally more susceptible to attacks of orchitis than others. Thus there are many individuals who never contract a gonorrhoea without its being followed by inflammation of the * British and Foreign Medical Review, Oct. 1840, p. 392. 296 ACUTE ORCHITIS. testis, notwithstanding every precaution taken to prevent the attack ; whilst there are many others, who, though repeatedly affected with gonorrhoea, yet altogether escape an attack of orchitis. ^Ne do not find, too, that those who suffer most severely from gonorrhoea are the most liable to orchitis. The persons most susceptible of the disease are the scrofulous, and those of a weak habit, who, though they suffer less in the first instance, find great dif- ficulty in getting rid of the discharge, and more frequently experience relapses ; whilst the robust, and persons of a naturally good and strong con- stitution, who when they contract gonorrhoea ex- perience its effects in the most acute form, sooner get rid of the disease, and more commonly escape its after-consequences, orchitis and stricture. Secondary orchitis is generally supposed to occur more frequently on the left side than on the right, but recent statistical inquiries show the fallacy of this opinion. Thus, in seventy-three cases of or- chitis observed by M. Gaussail, in forty-five the dis- ease was on the right side, and in twenty-four on the left ; four were double."^ In twenty-nine cases of gonorrhoeal orchitis, M. D'Espine found twelve on the right side, eleven on the left, and six doublet I have only lately registered the cases coming under my notice. Of thirty-six cases of consecutive or- chitis, twenty-one occurred on the right side, and fourteen on the left ; one only was double. My observations, therefore, agree with those of the * Lib. cit. p. 190. t Lib, cit. p. 443. ACUTE ORCHITIS. 297 above writers in indicating the right testis to be the one most frequently attacked. Taking the three series of observations together, we have 138 cases of orchitis ; of these, the right testis was the seat of disease in seventy-eight, the left in forty-nine, and both glands in eleven. Reasons have been assigned for the more frequent occurrence of orchitis on one side than on the other, but they are very unsatis- factory ; and we can no better explain why inflam- mation extends along the vas deferens to the right testis in preference to the left, or why both are sel- dom attacked simultaneously, than we can account for the fact that the right lung is more liable to pneumonia than the left, or satisfactorily explain the comparative rarity of double pneumonia. Symptoms, — A testis attacked with acute inflam- mation in a few hours becomes swollen, hard, and tender, and feels heavy and painful. It increases to twice or thrice its natural size, but without alteration in its oval form. The enlargement is attended with a sense of weight, which is a good deal increased in the erect posture. The pain is of a constant dull aching description, usually very distressing to the patient. It sometimes resembles the uneasiness produced by squeezing the testis, and is accompanied with the same sickening sensa- tion. The pain extends upwards to the loins, where it is often very severe. It not unfrequently takes a reflex course, extending downwards to the hip, upper part of the thigh, and crista of the ilium, in the direction of the branches of the diflerent lumbar nerves. As the disease advances, the swollen testis 38 298 ACUTE ORCHITIS. becomes so tender that the patient can scarcely allow the part to be touched, and cannot bear even the contact of the thigh. The scrotum becomes in- jected, and is found red, hot, smooth, and slightly oedematous. The constitutional symptoms are usually severe. The pulse is rapid and hard, the skin hot, and the tongue white and furred. If blood be taken from the system, it is found cupped and buffed. The patient often, also, suffers from nausea and vomit- ing, and occasionally from pain in the lower part of the abdomen, which have even been mistaken for symptoms of enteritis. After these acute symptoms have existed for a period varying from forty-eight hours to a week or more, they begin to disappear, subsiding more gradually and slowly than they set in. But the duration of the disease is much influ- enced by the activity of the means adopted for its removal, as well as by the constitution of the pa- tient, I have stated that inflammation of the testis, when arising apparently from cold, sometimes as- sumes somewhat of a rheumatic character ; that is to say, the pain is periodic, and increases towards evening; the inflammatory action arises and sub- sides rather suddenly, and occurs in persons liable to other rheumatic affections. Dr. Macleod ob- serves, " I think I have several times seen rheuma- tism of the tunica albuginea testis. Persons sub- ject to rheumatism have complained of acute pain in one testicle coming on suddenly, accompanied by increased heat, and by great tenderness to the ACUTE ORCHITIS. 299 touch, but without tumefaction ; the symptoms shifting from one testis to the other, and at last disappearing as suddenly as they had come on ; just in the manner we see rheumatism change from one joint to another."^ I am not able to confirm the observation of Dr. Macleod in respect to the tunica albuginea being the seat of the aifection, nor have I in any case found the rheumatic charac- ter of the symptoms very decidedly marked. I do not recollect having met in medical works with any notice of acute inflammation attacking the testes of young infants. I have seen, however, a few cases of orchitis at this early period. The symptoms were acute, and the swelling was con- siderable ; but the disease soon subsided, and it was always confined to one testis. A Jew child, only ^ve months old, was brought to me at the London Hospital on account of a swelling in the left groin and scrotum. The mother first observed it the day before on washing the child : he after- wards cried the greater part of the night. The tumour extended 'from the external ring to the bottom of the scrotum, was full six times the size of the right testicle, felt firm and hard, and re- ceived no impulse when the child cried or struggled. The scrotum was distended, and very red and hot. I ordered the application of a leech and cold lotion, and two drachms of castor oil to be given. In two days I found the swelling reduced about one third, and much less tender ; and the infant appeared * On Rheumatism, p. 20. 300 ACUTE ORCHITIS. free from suffering. I directed four grains of the hydrarg. cum cretd to be given every night. Under this treatment the swelling and induration soon subsided, and in a week the gland was nearly re- duced to the size of the right testis, but the cord still remained thickened and hard. Three weeks after the attack first commenced, 1 found the parts perfectly natural. In November, 1842, I was requested to see in consultation a little boy, tvv^o years of age, who, on recovering from an inflammatory attack of the chest and head, was seized with an affection of the testis. It appeared that before his illness, there was a small hydrocele on the right side. A few days previous to my visit the scrotum became red, tender, and oedematous. I found a swelling of the right testis nearly the size of a hen's egg, which fluctuated in front, felt solid at the back part, and was hot and very tender. I considered this to be a case of acute inflammation of the tunica vaginalis and testis. The child was weak, irritable, and emaciated, and had recently taken mercury to some extent. I ordered a leech to the scrotum, the parts to be frequently fomented and well supported, and the child to be kept in the recumbent position. I saw him again at the end of a week. The tunica vaginalis had suppurated, and burst through the scrotum in front, and had discharged a quantity of thick matter. The swelling was much reduced in size ; but the testis as well as the cord was still enlarged and indurated. A small quantity of matter continued to be discharged. I ordered ACUTE ORCHITIS. 301 quinine and a nourishing diet ; and a month after- wards was informed that the opening had closed, and that the boy was restored to health, slight induration only remaining at the back part of the gland. Consecutive orchitis is usually preceded by un- easiness in the course of the vas deferens ; the patient occasionally experiences distress and irri- tation about the bladder, and is troubled with a frequent desire to pass water, which is shortly fol- lowed by a dull aching pain and slight fulness in the groin. On examination of the spermatic cord, it feels full, and sometimes oedematous, and the vas deferens is found to be tender and enlarged. The thickening is sometimes so great, that the duct feels nearly as large as the little finger. The epi- didymis soon afterwards becomes swollen and pain- ful ; the tumefaction commences at the lower part or tail, and increases very rapidly. It forms an irre- gular elongated swelling at the back of the testis, which is sometimes fuller and larger than the gland itself, and extremely tender, whilst the body of the organ in front may often be pressed without causing uneasiness. The epididymis may remain affected for many hours, and even a day or two or longer, before the inflammation extends further ; and if checked in time it may never reach the tunica vaginalis, or body of the gland. In general the tunica vaginalis participates sooner or later ; and then so much tumefaction ensues that the inflamed mass forms an uniform tumour, in which the epididymis can scarcely be distinguished from 302 ACUTE ORCHITIS. the other parts. In the sympathetic form of the disease, the swelling of the epididymis and testis takes place without the symptoms indicative of a previous affection of the vas deferens. There is much variety in the intensity of the symptoms. In some cases there is merely a slight dull pain, with little enlargement of the gland, and scarcely any constitutional disturbance. Sometimes the swelling is from the first very considerable, the volume of the gland becoming three or four times larger than natural, the pain being acute and con- stant, and the symptomatic fever severe. In other cases the swelling, though considerable, is quite indolent, and its progress slow and of long duration. But, in general, the symptoms continue to increase in intensity for several days till about the seventh or eighth, when they begin to disappear, the febrile disturbance and pain entirely subsiding, and shortly afterwards the tumefaction. As the swelling di- minishes, the epididymis becomes distinct, forming an indurated, knotty, and irregular swelling, at the back part of the testis, which often lasts for many months, and in many instances never disappears entirely during the remainder of the patient's life. In fifteen cases observed by M. D'Espine which were cured, the mean duration of the disease was thirty-three days and a half.^ This closely accords with the observations of M. Gaussail, who found the mean duration of seventy-three cases to vary from thirty to thirty-five days ;t but in my expe- * Lib. cit. p. 435. f Lib. cit. p. 211. ACUTE ORCHITIS. 303 rience it much exceeds the period usually occupied by acute orchitis under suitable treatment. The cure of the disease is liable to be interrupted and its duration prolonged by relapses, which are readily induced by any neglect or imprudence. A testis which has been attacked with inflam- mation is afterwards more liable to orchitis than before. The gland, too, sometimes remains more sensitive ; feels uneasy under gentle pressure, or when the patient gets out of health ; and sometimes becomes painful and swollen from slight causes. Diagnosis. — But little difficulty is experienced in distinguishing a testis swollen from inflammation from a strangulated inguinal hernia. In both there may be a scrotal swelling, accompanied with pain and tenderness of the abdomen, frequent vomiting, obstinate constipation, and a good deal of constitu- tional disturbance. The true nature of the case, when these symptoms exist, can always be ascer- tained very readily by the absence of tension in the abdomen ; the limitation of the pain and tenderness to one side ; inability to feel the testis of its natural size below the swelling (supposing the hernia not to be congenital, and if so the history of the case would set all doubts at rest) ; and by the tumour when handled being found harder, more solid, and more painful than a hernial swelling, and, unless there is much swelling of the spermatic cord, being clearly defined at its upper part. When a testis detained in the groin becomes inflamed, the diag- nosis is much more difficult, a tense inguinal swell- ing being coupled with sickness, pain in the abdo- 304 ACUTE ORCHITIS. men, and sometimes constipation. The empty state of the scrotum would always be sufficient to excite suspicion, and an active purge to set all doubts at rest. (See p. 112.) The active character of the symptoms renders acute orchitis unlikely to be mis- taken for the more chronic diseases of the gland. Secondary orchitis differs from inflammation ori- ginating in the body of the testis in being preceded by swelling, and tenderness of the spermatic cord and in the course of the vas deferens ; in the epi- didymis being invariably the part of the organ first affected ; in the more rapid formation and greater size of the swelling ; in the disease being of a more chronic character, and in the pain and constitutional suffering being less severe. It rarely leads to sup- puration, disorganization, or atrophy of the gland, but usually leaves the epididymis enlarged and in- durated. Treatment. — Acute orchitis, from whatever cause it may originate, must be treated with antiphlogistic remedies, the activity of the means being propor- tioned to the intensity of the inflammatory action and the constitution of the patient. In the gonor- rhoeal form of the affection, all means which may have been resorted to in order to arrest the dis- charge must be abandoned. In all cases in which it can be managed without inconvenience, I direct the patient to place himself in the recumbent posi- tion, either to repose on a sofa or rest in bed. The marked relief derived in inflammation of the extre- mities from promoting the return of blood to the heart is so fully appreciated, that it is unnecessary ACUTE ORCHITIS. 305 to insist on the importance of thus obviating the effects of gravitation in orchitis. In very acute cases, this object may be more fully obtained by elevation of the pelvis by means of a pillov^ placed under the nates. The scrotum and its contents must also be well supported by a suspensory band- age. Those usually sold are often badly constructed, and do not fit well, so that it is necessary for the surgeon to see that they answer the purpose in- tended. In case of greasy or coloured applications being employed, the suspender should be lined with oiled silk for the sake of cleanliness, A silk, or, better still, a cambric handkerchief, doubled so as to form a triangle, the middle of the base being applied to the perineum, and the extremities tied behind, the point being carried forwards and at- tached in front to a band around the waist, will effectually sustain the scrotal parts. Patients sup- pose that the recumbent position obviates the ne- cessity for support ; but this is a mistake, much relief being experienced, and the effects of gravita- tion a good deal counteracted, by raising the testis from its position upon or between the thighs. A cold evaporating lotion, composed of lime-water, or the goulard and rectified spirit, in the proportion of one ounce of the latter to seven ounces of the former, or of a lotion consisting of a drachm of the hydrochlorate of ammonia dissolved in five ounces of cold spring water, with the addition of an ounce of rectified spirit, may be applied to the scrotum and frequently renewed. In the early stage of acute orchitis, lotions sometimes afford a good deal of 39 306 ACUTE ORCHITIS. relief; but on the whole they are less useful than warm applications, and can only be employed to advantage whilst the patient remains at rest in bed, as it is necessary to keep the clothes away from the parts in order to favour evaporation. A good-sized dossil of lint, surrounded with oiled silk to keep it moist, will commonly be found the most grateful and soothing application. Poultices, if not light and thin, occasion uneasiness from their weight, and when dry and harsh become disagreeable. The patient must abstain from taking animal food, and the bowels are to be acted on by a smart purge. Two grains of calomel, with five of the compound extract of colocynth, may be given at night, and followed in the morning by a draught composed of the potassio-tartrate of soda and the infusion and tincture of senna. A quarter of a grain of tartar emetic may be exhibited every three or four hours, and the dose, if necessary, increased until nausea is produced. This is one of the most valuable re- medies that can be employed in acute orchitis : and when patients are desirous of avoiding the trouble, mess, and exposure consequent upon the applica- tion of leeches, the exhibition of tartar emetic will generally render local depletion unnecessary, whilst its depressing influence being only temporary, the patient quickly regains his health and strength. I have seen most acute orchites arrested and subdued in thirty hours by keeping up constant nausea by means of this remedy. When there is much pain or constitutional derangement, two or three grains of calomel, combined with eight or ten grains of ACUTE ORCHITIS. 307 Dover's powder, or with small doses of morphia, may be given at bedtime. In consecutive orchitis, in which the tunica vaginalis is so generally af- fected, considerable benefit is derived from mercury, and experience fully confirms what reason would lead us to expect from its remarkable efficacy in inflammation of the other serous membranes. The value, indeed, of mercury in the treatment of this form of orchitis, scarcely appears to be fully appre- ciated by the profession. In acute cases, after the bowels have been freely acted on, and the pulse has been lowered by tartar emetic, I usually prescribe mercury, and continue it until the gums become slightly affected. I am confident that by this treat- ment the duration of this form of the disease is often materially abridged, and, what is of some import- ance, it is succeeded by much less induration and thickening of the epididymis than when the exhibi- tion of mercury has been deferred to a later period. In treating cases of orchitis in private practice, it is generally desirable to avoid bloodletting, es- pecially local ; but in cases of a severe or obstinate character, depletion sometimes becomes necessary. Bleeding from the arm is only required when the inflammation and symptomatic fever are unusually acute. In a robust person, one full depletion at the onset of the attack in many instances consider- ably abridges its duration, and renders local ab- straction of blood afterwards unnecessary. This is a practice which might be resorted to more fre- quently than it usually is, especiafly in treating the working classes, to whom time and the expense of 308 ACUTE ORCHITIS. leeches are objects of consideration. Local deple- tion, however, is more commonly employed than general. From eight to twenty leeches, according to the circumstances of the case, are applied to the scrotum ; and if no relief be afforded in from twelve to sixteen hours, they are repeated. A light poul- tice applied when the leeches are removed promotes the bleeding for some hours afterwards. The hip bath is also of service in encouraging the flow of blood, and also contributes to the relief of pain. After the application of leeches many persons ex- perience no trifling annoyance from an intolerable itching, which disturbs their rest at night, and in- duces them to scratch the scrotum until the leech- bites form troublesome sores. The best application in this state is the dilute citrine ointment ; but the itching may be obviated by applying the leeches to the skin in the course of the spermatic cord towards the groin, the parts being previously shaved. When objections are made to the application of leeches on account of the exposure it occasions in families, a sufficient quantity of blood may some- times be abstracted from the veins of the scrotum. The patient being in the erect position, distension of the veins is to be encouraged by fomenting the scrotum with warm water, or exposing it to the heat of a fire. Three or four veins are then to be punctured with a lancet. When enough blood is withdrawn, the patient must be directed to lie down, and the bleeding will almost immediately cease. I have removed blood in this way in several cases, but have not always found it flow with readiness, ACUTE ORCHITIS. 309 and I have even failed in removing a sufficient amount. The scrotum is not always tense and distended, nor are the veins always apparent and prominent. Many surgeons recommend cupping on the loins : abstraction of blood in this way gene- rally affords relief The cure of acute orchitis has been much faci- litated, of late years, by the application of a mode of treatment which has been found of great service in relieving certain forms of acute inflammation in other parts of the body, viz. compression. The object of compression is to afford support to the weakened vessels ; and in acute inflammation of the integuments, when properly applied for this purpose, and not so firmly as to produce pressure and arrest the circulation, it often proves a very valuable method of treatment. Dr. Fricke of Hamburgh, I believe, first suggested the practice of treating both acute and chronic orchitis by compression, applied to the testis by means of adhesive plaister. In an early report of this practice, he states that out of fifty-one cases of acute orchitis eighteen were treated by the ordinary means, and thirty-three by compression. In the latter cases the average duration of the disease was nine days, whilst in the former it was thirteen. In cases treated more recently, after improvements had been made in the mode of applying the compression, the result was still more favourable.* This practice has since * Zeitschrift fur die Gesammte Medicin, as quoted in the Gazette Medicale de Paris, Annee 1836, p. 182. 310 ACUTE ORCHITIS. been adopted in Paris by Cullerier and Ricord ; and in this country by Mr. Langston Parker, Mr. Acton, my colleague Mr. Hamilton, myself, and others, and, I am informed, by the army surgeons gene- rally. Some care is required in making the applica- tion, which 1 perform as follows. The patient being placed in the recumbent position, with the testis raised, is to remain there three or four minutes, in order to allow the vessels of the gland to become as empty as possible. The parts are to be shaved ; and some emplastrum plumhi must be cut into strips, about three quarters of an inch in width, and eight or nine inches in length. The opposite testis and side of the scrotum being drawn away from the diseased one, so as to render the integuments of the latter quite tense, the first strap is to be placed cir- cularly round the cord, just above the testis, as tightly as the patient can bear it. The second strap is to be placed in an opposite direction, from behind forwards, at the side of the testis near the septum. The third strap is to be applied below the first, so as partly to overlap it ; and the fourth in like manner, inter- nal to the second ; and so on in succession, until the straps meet, and the whole of the testis is covered, and evenly compressed. A few additional straps may af- terwards be applied where most needed to afford support, and keep the others in place ; the parts are afterwards to be supported in a suspensory ACUTE ORCHITIS. 311 bandage. The strapping generally requires to be reapplied in the course of twenty-four hours. When the patient rises after its application he feels completely relieved from the aching pain and sense of weight ; and patients who have remained in bed in consequence of the pain have immediately been able to get up and walk about. Some surgeons recommend the application of compression at the onset of the inflammatory attack ; and if the in- flammation be moderate this may be done with advantage, so that when concealment is desirable the patient may be able to continue his usual avo- cations. But in decidedly acute orchitis it is better to commence with an active purge, the tartar emetic, and, if necessary, depletion, and to enjoin rest ; and then, after twenty-four or forty-eight hours, to resort to compression : for in active in- flammation of the testis compression is not always sufficient without other antiphlogistic means, and if solely depended on, may disappoint expectations. But after the more acute symptoms are relieved compression greatly facilitates the cure, affording relief from pain, causing the rapid subsidence of swelling, and removal of all effused matter. In cases of a chronic character, or to remove the thick- ening and induration of the epididymis and cord so commonly observed after acute consecutive orchitis, the testis may be strapped with the emplastrum ammoniaci cum hydrargyro ; or iodine or mercurial ointment may be first applied to the scrotum, and then the strapping, so as to combine the advantages of these applications and of compression. The S12 ACUTE ORCHITIS. renioval of the chronic enlargement and induration may be further promoted by the exhibition of small doses of mercury. In these cases I sometimes keep up counter-irritation by painting the scrotum on the side of the affected testis with the following solution — lodin. 3J. Potass. loclid. 3ss. *S^. Vin, Red, 5J.; repeating the application every third or fourth day, until the gland is restored to its healthy state. Blisters are sometimes used : but they are too irritating to be applied to the scrotum, and are even liable to cause mortification. In some constitutions, after the more active symptoms of orchitis have subsided the inflam- matory action persists, and continues unchecked even by local depletion, which, if persevered in, weakens the patient without subduing the disease. This is observed in persons of a weak frame, who usually appear pale, and as if they did not habitu- ally enjoy good health, and in whom the orchitis at first is neither very acute, nor accompanied with much constitutional disturbance. In this sub-acute form of the disease the pulse is quick, hard, and jerking ; there is but little or no fever ; but the digestion is usually impaired, and the testis re- mains swollen, tender, and painful. These patients do not bear depletion well. Eight or ten leeches applied day after day make very little impression on the inflammation of the testis ; but they render the patient weak and irritable, and retard his re- covery. If three or four grains of blue pill, com- bined with four or five of the extract of hyoscyamus, or ^VQ grains of the hydrargyrum cum cretd and of ACUTE ORCHITIS. 313 the pulvis ipecacuanha comp., be exhibited night and morning, — if the diet be improved a little by allow- ing light broths and puddings, and the diseased testis be steadily strapped, I have generally found that the inflammatory action soon ceases, and that the swelling of the gland gradually subsides. The advice given by Bromfield and other sur- geons of his day in cases of gonorrhoeal orchitis, to introduce a bougie into the urethra, or to inoculate it afresh in order to bring ba:*k the discharge, was founded on the erroneous idea, that the acute symptoms of orchitis are never dissipated till the return of the discharge from the urethra. These are absurdities which the common sense of modern surgeons has completely banished from practice. Copaiba, cubebs, and remedies of this class, as well as injection, must not, howe er, be employed so long as any active disease is going on in the testis ; and even after all symptoms of inflammation have disappeared, they must be used with caution and in moderation. Though I have rarely found them give rise to orchitis, I have known them, when in- judiciously used, produce a relapse after all inflam- mation had ceased. In 1811, Mr. Ramsden pub- lished some observations,"^ to show that chronic enlargement and induration of the testis, to which he applied the term sclerocele, were dependent on some affection of the urethra, and that they were to be cured by remedies directed to correct the * Practical Observations on the Sclerocele and other Morbid En- largements of the Testicle, &c. 40 314 ACUTE ORCHITIS. diseased condition of tlie canal. His views never made much impression on the profession. He was wrong in regarding the disease in the uretlira as the invariable cause of the affection of the testis, instead of an occasional one ; but he committed a greater error in practice by chiefly applying his remedies to the part supposed to be the original source of irritation, instead of to the actual seat of disease, and in considering the use of the bougie an essential part of the treatment of these cases. Mr Ramsden's observations, however, were useful in directing attention to the frequency of the con- nexion between morbid states of the urethra and testis, which exists more commonly than was sup- posed. In cases of stricture, it often happens after an attack of acute orchitis that the epididymis con- tinues for several weeks, and even months, tender and en'arged, and the cause of annoyance to the patient, owing to a low degree of inflammation still lurking in the part. In several of these cases, after the stricture has been eured by instruments, the af- fection of the testis has subsided, without any other treatment being necessary than simply supporting the organ. I believe, too, that in the majority of cases in which the inflammation of the testis ex- hibits a tendency to return, or in which relapses occur, there is some disease or source of irritation in the urethra. In the treatment, therefore, of consecutive orchitis of an indolent or obstinate cha- racter, it is often prudent to pass a bougie in order to ascertain the state of the urethra. When suppuration occurs, the scrotum must be ACUTE ORCHITIS. 315 fomented and covered with a poultice or the simple water dressing ; and as soon as matter can be de- tected by fluctuation, a lancet is to be introduced and the pus discharged, in order to obviate the sinuses and fistulous passages liable to be occasioned by the confinement of matter v/ithin the tunics. In consecutive inflammation the small isolated collec- tions of serum often formed between the adhesions of the tunica vaginalis, which fluctuate distinctly, and sometimes evince little disposition to disappear, are apt to be mistaken for deposits of pus. When any doubt exists, a grooved needle can be introduced to remove it. The opening made for the escape of matter should not be allowed to close too soon. I have not made any difference in the treatment of primary and of consecutive orchitis, the same general principles being applicable to both forms of the disease. But the pathological distinction which has been observed is not without practical interest, and should not be altogether lost sight of in the treatment of these cases. As inflammation originat- ing in the body of the testis is of a more destructive character, and more injurious to the organ than that commencing in the epididymis, and as the pain and constitutional derangement are greater in the former, as a general rule the treatment of primary orchitis should be more active than that of consecu- tive, and this form of the disease more generally requires local depletion. The prognosis in con- secutive orchitis is more favourable than in pri- mary : on the other hand, after inflammation has ceased, consecutive orchitis is more exposed to re- 316 CHRONIC ORCHITIS. lapses, and the swelling and induration accompany- ing it subside less readily and quickly than in pri- mary orchitis. SECTION II. CHRONIC ORCHITIS. The testis is liable to a form of inflammatory swelling of a distinct and chronic character, which occasionally succeeds acute orchitis, but far more commonly arises spontaneously. The disease is of importance ; for, if unchecked, it tends to disor- ganize and destroy the gland. The chief anatomical character of this form of inflammation is the deposit of a peculiar yellow% homogeneous, inorganic matter in the structure of the testis. This substance when first formed is of soft consistence, but afterwards becomes firm and solid, and so closely adherent and intimately blended with the proper structure of the organ as not to admit of separation without much difficulty. In some instances there is a single deposit of this substance in the centre of the glandular struc- ture, as in the preparation from which the annexed wood-cut was taken. In others several are inter- spersed throughout the testis, portions of sound gland intervening. In a case of chronic enlarge- CHRONIC ORCHITIS. 317 ment of both testes, taken from a patient who died of ramoUissement of the medulls, sipinalis, I found six or seven separate deposits of this yellow matter in the substance of the right testis, and a single one only in the body of the left. The small masses as they enlarge coalesce, or the single one increases until the whole testis presents an uniform yellowish- white appearance. The epididymis is frequently invaded at the same time by a similar kind of mor- bid deposit, which also tends to obliterate its tubu- lar structure. This, however, is not, as some patho- logists suppose, a constant occurrence ; for in the majority of testes thus diseased that I have exa- mined, the epididymis had entirely escaped. The inorganic nature of this deposit is clearly apparent on injecting the testis, by the contrast which it offers to the surrounding structure. I. have never succeeded in tracing vessels into it. But the vessels of the testis generally are enlarged, and appear more numerous than usual. Pathologists have not yet determined in what particular tissue this yellow matter is deposited. Sir A. Cooper states that when a section is made of a testicle thus enlarged, on throwing it into water and agitating it a whitish yellow-fluid proceeds from the seminiferous tubes, which are extremely dilated, and which then appear emptied. But still the same bulk of testicle remains, owing to the cel- lular membrane of the part being loaded with a yellow fibrine or coagulable lymph ; the rete is filled with the same secretion as the tubuli ; the epididy- mis is similarly diseased ; and sometimes the vesiculie 318 CHRONIC ORCHITIS. seminales and vasa deferentia are distended with a similar morbid secretion."^ Sir B. Brodie is of opinion that it is secreted from the inner surface of the tubiili testis. He has given an accountt of the examination of a testicle enlarged, and containing a considerable quantity of this solid yellow unorgan- ized substance, where, on slitting open the canal of the epididymis, and also the vas deferens, he found some of this same yellow substance adhering to their inner surface, having been manifestly secreted by the lining membrane ; and as the epididymis is only the termination of the tubuli testis, he con- cludes that in the latter the yellow substance has the same origin. I have recently had an oppor- tunity of inspecting a testis affected with this dis- ease in what seems to me to be its early stage, from which examination I think I have been able satisfactorily to ascertain the original seat of the yellow deposit. The appearances were peculiar. — A stout-looking brewer's labourer, aged thirty-eight, a married man, was admitted into the hospital, under the care of Mr. Luke, for an affection of the left testis. It appeared that four days previously he had strained himself in lifting some heavy casks. The next day the testis began to swell, and at length became so painful that he was induced to apply to the hospital for relief He stated that he had never suffered from any aifection of the urethra, and always enjoyed good health. There was a considerable swelling of the epididymis, which was * liib. cit. p. 37. t London Medical and Physical Journal, vol. Ivi. p. 309. CHRONIC ORCHITIS. 319 at least four times its natural size, hot, and very tender; but the body of the testis was natural, and could be pressed without giving pain. He was kept in bed, the scrotum was repeatedly leeched, and mercury was given so as to affect the mouth, but without reducing the swelling. The tumefac- tion steadily increased; fluid was effused in the tunica vaginalis ; the veins of the scrotum became prominent ; the pain continued ; and about six weeks after the patient's admission a distinct fluctuating swelling appeared at the upper part of the tumour, which shortly evinced a disposition to point. This was punctured, and about four drachms of matter were evacuated, with some relief from pain, but very little diminution of the swelling. The testis afterw^ards continued for several weeks in a chronic indolent condition, with a fistulous opening dis- charging pus, and showing no disposition to heal. The man experienced no pain, and suffered scarcely at all in his general health ; but at length getting tired of a disease which seemed likely to prevent his returning to his employment for a long period, he readily consented to lose his testis. The opera- tion was performed rather more than three months after the commencement of the disease. The testis was injected, and a section then made of it. The surfaces of the tunica vaginalis were partly adherent, and about three drachms of serum were collected in one part of the sac. The body of the testis was not much enlarged ; it contained, however, an abundant deposit of a firm opaque matter. Near the anterior edge of the testis this 320 CHRONIC ORCHITIS. deposit appeared in the section like round isolated yellowish-gray bodies, separated from each other by portions of the sound structure of the gland ; about the centre of the organ it assumed a beaded arrangement, and towards the mediastinum formed a number of closely set yellow lines or processes, radiating towards the posterior part of the testis, where they were amalgamated into one uniform mass. Further examination perfectly satisfied me that this matter was lymph deposited in the tubuli seminiferi. The isolated and beaded appearances in the section resulted from breaks in the lymph thus deposited; the real seat of the effusion was very evident, from the arrangement described near the mediastinum. With a good lens some of the convoluted tubuli could be distinctly seen, filled with and dilated by the morbid deposit. A por- tion v/as carefully examined in the microscope by Dr. Letheby, who arrived at the same conclusion respecting the seat of this deposit as myself The epididymis was much enlarged ; its head was filled with soft concrete matter, surrounding an irregular cavity with which the fistulous sinus cummuni- cated ; its tail contained a similar substance, with- out any external opening. The various appear- ances described are depicted in the opposite figure, which was drawn from the recent specimen by Mr. Bagg. The morbid appearances noticed in this case, though, I suspect, very little known to British pathologists, have been accurately described and figured by Cruveilhier, in his Anatomic Patho- CHRONIC ORCHITIS. 321 logique * He states, that of all the forms of sarco- cele this is without doubt the most frequent. It is that which appears con- stantly to succeed to vene- real affections incomplete- ly cured, and to chronic inflammation consequent upon contusions ; in fact it is the most general form of sarcocele, developed under the influence of an acci- dental cause ; and he has been led by a great number of facts to regard this alteration as the result of a chronic inflammation of the epididymis. The disease proceeds from the swollen head or extremity of the epididymis towards the tail. The body of the testicle is only affected consecutively. I believe myself that the yellow deposit is the ordinary result of chronic inflammation of the testis, in whatever way pro- duced ; but that the peculiar appearances noticed in the case just related, and which have likewise been described by Cruveilhier, — I mean the small isolated masses in the substance of the gland, and radiated form of the deposit towards the medias- tinum, — are only observed in those cases in which * Liv. V. pi. 1, and liv. ix. pi. 1. K. 1. Fistulous sinus leading to the suppurating- cavity in the head of the epididymis. 2. Concrete abscess in the tail of the epididymis. 41 322 CHRONIC ORCHITIS. the disease originates in the epididymis, and thence spreads to the body of the testis, and in which the part is examined before the organ has be- come extensively diseased. These appearances are not often seen, because it is not often that it becomes necessary to remove a testis in that con- dition, which is indeed a curable one, unless com- plicated with suppuration. Cruveilhier supposes that this matter is effused in the cellular tissue of the testis, and radiates along the fibrous prolonga- tions from the corpus highmori. I feel satisfied, however, from my own observations, that he is mis- taken, and that the interior of the tubuli is the original seat of the deposit. This yellow substance has been called the yellow tubercle of the testis ; but as it differs from tuber- cular deposit, which is also developed in the testis, the term is objectionable, and liable to lead to error. It appears to be coagulable lymph, which becomes more solid in the testis than in most other parts, owing, perhaps, to the condensation consequent on the firm resistance offered to any enlargement of the gland by the unyielding tunica albuginea. That lymph effused in a part so well supplied with ves- sels should long remain unorganized scarcely seems remarkable, when we recollect what little disposi- tion it evinces to undergo this change when depo- sited on mucous membranes, and in the interior of other glands. Lymph may remain for years in the cells of the cellular tissue without becoming organ- ized, as is often observed around a diseased joint ; and the compactness and firmness of this deposit CHRONIC ORCHITIS. 323 within the testis are circumstances unfavourable to the developement of new vessels. This disease is often accompanied with effusion of serum into the tunica vaginalis, seldom amounting, however, to more than three or four ounces. Lymph also is sometimes poured out on this membrane, and the sac becomes partially or totally obliterated by ad- hesions. The peculiar matter effused in this disease under appropriate treatment undergoes complete absorp- tion, the testis being left in a condition to perform its natural functions. It sometimes happens, how- ever, that ulceration ensues in its tunics and integuments, and that a fungous-looking growth gradually protrudes through the opening which is thus formed. This fungous growth, or as it is sometimes termed granular swelling, may without impropriety receive the name o^ hernia testis ; being formed in a manner very analogous to that of a hernia cerebri, in which the substance of the brain is protruded through an ulcerated opening in the dura mater. It appears that the yellow deposit after some time excites ulceration in some part of the tunica albuginea. The tunica vaginalis, and afterwards the skin, become adherent at this spot, and likewise inflame and ulcerate. The resistance afforded by the dense unyielding tunica albuginea being thus removed, the adventitious deposit gra- dually presses out the tubular structure, which forms a projecting tumour constituted of the tubuli testis mixed up with this yellow substance, and also of ordinary granulations which spring up from the seminiferous structure. (See wood-cut, p. 342.) 324 CHRONIC ORCHITIS. It is only in recent years that this hernial pro- trusion of the structure of the testis has attracted particular attention. In 1808, Mr. Lawrence ex- plained the true nature of the affection in a paper illustrated with several cases f and his observations on its causes, syniptoms, and progress have been confirmed by all succeeding writers on the diseases of the testis. Though this hernial growth occurs most frequently in an advanced stage of the chronic form of inflammation, it is developed in other dis- eases of the organ which occasion ulceration of the tunica albuginea, and thus afford an opening for the escape of its contents. It is occasionally the result of an attack of acute inflammation super- vening upon the chronic disease, and terminating in suppuration in the substance of the gland. In a case of this kind, in addition to the glandular swelling there are sinuses, more or less numerous, which burrow in the interior of the organ, and discharge pus mingled with the yellow matter. An attack of orchitis originally acute, going on to suppuration, is also liable to be followed by a fun- gous protrusion of the secreting structure of the gland. In the latter case the growth is not so exuberant, and the seminiferous structure is more distinctly apparent, owing to the absence of the yellow matter ; but there are generally sinuses which furnish a purulent discharge, sometimes mixed with semen. Tubercular matter deposited in the testis may also lead to suppuration, and the formation of a granular swelling. * Edinb. Medical and Surgical Journal, vol. iv. p. 257. CHRONIC ORCHITIS. 325 A testis, after becoming somewhat enlarged from chronic inflammation, often continues indolent and stationary for years, giving rise to very little incon- venience. On examining the organ in this state, the yellow adventitious deposit is found to possess considerable firmness and consistency ; the tunica albuginea is thickened, and in some places as dense and indurated as cartilage ; and the surfaces of the tunica vaginalis are closely connected by old adhe- sions. The glandular structure is partly displaced and atrophied by the pressure of the yellow matter ; and it often happens after some time that both undergo a slow process of wasting, so that an en- larged and indurated gland is progressively reduced, until scarcely any thing remains beyond a mere nodule of the size of a nut at which the spermatic cord terminates, 1 found, on examination of the body of a man who some few years previously had suffered from chronic inflammation of the testes, both glands much indurated, but about the natural size. In both the tubular structure was very defi- cient, its place being supplied by a dense fibrous tissue. At the upper part of the right testis there was a yellowish deposit almost as dense as cartilage, and exhibiting very little trace of vascularity. A testis in this indolent state, when examined in the hand, often feels as hard nearly as a stone ; and formerly the term schirrus was commonly applied to such enlargements. Its employment to designate this morbid state of the testis is scarcely exploded even now ; but the term is objectionable, being liable to convey the erroneous impression that the ^^j^^l 326 CHRONIC ORCHITIS. disease is of the same nature as schirrous mamma, whereas it is of quite a different nature, and rarely if ever assumes a malignant character. In these indurated testes, the epididymis often escapes the morbid alteration affecting the body of the gland ; in other cases, however, the epididymis is also found nodose, irregular, and hard. It will be perceived, from the preceding observa- tions, that the tendency of this chronic disease is gradually to destroy the integrity of the testis. If the inflammation be checked in an early stage, the gland is left unimpaired ; if its course be not arrested until a later period, the secreting structure is partly disorganized and reduced in size ; but if the disease be allowed to continue unchecked by treatment, the organ is totally destroyed, either by ulceration of its tunics and the escape of the glandular struc- ture in the shape of a fungous growth, or by the slower process of wasting and absorption. The causes of chronic inflammation of the testis are various. It often takes place after a slight con- tusion, the first effects of which were so inconsider- able as to be very little regarded by the patient, the testis not beginning to swell nor to give pain till some weeks after the accident. Occasionally it arises a short time after the cessation of an attack of acute orchitis, more particularly when the patient has been guilty of some imprudence. It occurs also after excess in venery and frequent masturbation. Persons suffering from stricture, and other affec- tions of the urinary organs causing irritation in the urethra, are peculiarly liable to it ; and the inflam- CHRONIC ORCHITIS. 327 mation may sometimes be traced creeping along the vas deferens to the epididymis, and thence to the testis, as in consecutive orchitis. It occasionally arises during an attack of gout, and in persons suffering from rheumatism, in which cases it has partaken of the characters of these constitutional maladies. Sir A. Cooper's observations on this subject are very valuable, as the result of large experience. He remarks, " With respect to the causes of this disease, it is wrong to view it merely as a local affection ; for there is in persons prone to this complaint a constitutional tendency to the malady. It often occurs in those who have been scrofulous in their youth. It is frequently the product of a constitution worn and broken by in- temperance. It often follows a long-continued course of mercury ; and it arises in habits in which the vital powers are diminished, and in which we so often find sloughing of the cellular membrane, in the form of chronic carbuncle. Frequent ex- posure to wet, cold, or fatigue, and an excessive indulgence of the passions, also dispose to its pro- duction. The most frequent occasional cause is urethral disease, whether it be irritation only, ex- citing a sympathetic influence, or an organic change in the mucous membrane; and many of those causes which I have mentioned, in speaking of acute in- flammation of the testes, are in different cases, the precursors of this disease ; the chief difference in the nature and production of the two complaints being in the state of the constitution."^ * Lib. cit. p. 39. 328 CHRONIC ORCHITIS. Symptoms. — The symptoms of this disease are uniformly of an indolent character. At the com- mencement of the inflammatory action the testis feels somewhat tender ; and after a short time the patient detects a slight enlargement, and an irre- gular induration in some part of the organ. This induration often commences at the lower part of the epididymis ; but not always, nor so frequently as is supposed by many pathologists. The body of the gland and the epididymis shortly become involved in one common swelling, which feels smooth, firm, inelastic, and of uniform consistence, and is of an oval form, with the sides somewhat flattened. The enlargement advances slowly, but goes on steadily increasing until the organ is at least twice its natural size. The swelling is attended with slight pain of an obtuse character, and a sense of weight in the part and in the loins. The pain on pressure is also dull; and when the disease continues for seven or eight weeks or longer, the organ loses in a great degree its peculiar sensibility. The spermatic cord is not generally indurated ; but it feels full, and its veins are rather swollen. Formerly the term sarcocele was indiscriminately applied to this morbid state of the testis, as well as to other en- largements of the gland of a very different nature. The confusion produced by confounding various affections under one common appellation is a suf- ficient reason for the discontinuance of the use of this term, which is now seldom met with in surgi- cal works. There is often some effusion in the vaginal sac around the enlarged testis, constituting CHRONIC ORCHITIS. 329 the affect ion to which the term hydrosarcocele has been applied. The effusion is seldom considerable ; indeed I have rarely found it exceed eight ounces. It is frequently collected at one spot, its diffusion throughout the sac being prevented by old adhe- sions. It often happens that both testes become affected, inflammation having commenced in one gland shortly after the enlargement of the other, or, hav- ing ceased in one, then appearing in the other. Sometimes fluid is effused only on one side ; in other cases there is double hydrocele, coupled with morbid enlargement of both testes. So little inconvenience is usually experienced from this disease, that the testis often acquires a considerable size before the patient's attention is seriously attracted to it. He finds relief, perhaps, from a suspensory bandage, and continues his usual occupations, exercise, and mode of living, without paying any further attention to it, until fresh in- flammation is excited by a slight blow, or excess in drinking or venery ; when, the symptoms becoming suddenly severe or increased, he is induced to seek for surgical assistance. After the disease has existed for many weeks, or even months, the skin at some part of the scrotum, usually the front, grows thin and prominent, and becomes red and inflamed. In a short time it breaks, and a fungous-looking substance, and some- times a small quantity of pus, are discharged ; and this is soon followed by a hernial protrusion of the substance of the testis, which gradually increases, 42 330 CHRONIC ORCHITIS. until the part presents the characteristic appearance of the granular swelling. This consists of a pro- tuberant mass, presenting an ash or yellowish-white appearance, varied by irregular patches of a pale red hue, and sometimes of black. This projecting growth is surrounded and often closely girt by the skin of the scrotum, the ulcer- ated edges of which are thick- ened and everted. It furnishes a scanty thin sanious discharge, occasionally mixed with the seminal fluid. It is nearly insensible to friction, the ac- tion of caustics, and incisions with the knife. The sperma- tic cord may be distinctly traced to the base of this morbid protrusion of the gland, v^hich often projects so much that scarcely any part of the organ can fairly be said to be contained within the scrotum. The disease in this stage is very indo- lent, and if not interfered with lasts many months without undergoing any perceptible change. As soon as the scrotum has thus given way all pain abates, and the scrotal swelling partly subsides. Very few cases of hernial protrusion of the testis have come under my notice within the last few years. The disease appears to reach this stage less commonly in the present day than was the case formerly. Cases of granular swelling were cer- tainly of more frequent occurrence in 1826, when I first commenced attending the practice of the Lon- don Hospital, than they have been of late years. CHRONIC ORCHITIS, 331 The circumstance must be ascribed to the profession generally having become better informed in the diseases of the testes, and to the success attending their improved treatment of the earlier stages of the affections of this gland. I have spoken at page 276 of the deposition of matter in the substance of the testis and epididymis in cases of acute orchitis, and have mentioned the concrete form of this deposit, and chronic state of the symptoms which occur after all active disease has subsided. Suppuration occasionally takes place in the chronic form of orchitis, which I am now describing, in connexion wath the formation of the yellow deposits of lymph. Both pus and lymph may be effused in the substance of the testis ; or lymph may be deposited in the testis, whilst sup- puration occurs in the epididymis alone, as in the case related at page 342. The formation of pus in these cases is a serious aggravation of the disease, and much lessens our prospect of being able to save the testis. When effused in the body of the gland it disorganizes the delicate structure ; and when ulceration ensues and the matter escapes, leaves behind sinuses communicating with the in- terior of the organ, which evince but little disposi- tion to close. These sinuses discharge a thin pus, mixed in some cases with the seminal fluid, forming consequently a spermatic fistula. We cannot, of course, treat these sinuses as we should similar passages in other parts, by injecting them, or lay- ing them open from the bottom. We can only en- deavour to remove any existing disease by the 332 CHRONIC ORCHITIS. ordinary remedies for chronic inflammation, in the hope that as the health improves they may be in- duced to heal. Their cure may be a good deal promoted by keeping the testis steadily compressed by means of strapping. In some instances these fistulous passages prove so tedious, and so affect the general health, that it becomes desirable to resort to the operation of castration. I have already described a case in which it became necessary to adopt this proceeding, and I once witnessed the removal of a testis from an elderly man on the same account. On examination the epididymis was found encased in the serous m.embrane, much in- durated and thickened ; the tunica vaginalis con- tained a quantity of serum. There were three distinct deposits of inspissated pus in different parts of the epididymis, and at its lower part a suppu- rating cavity, lined by a rough-looking membrane: the cavity opened externally by a fistulous passage leading to the bottom of the scrotum. The body of the testis was quite sound. The patient had suffered from the disease for eight months, and it had resisted the ordinary treatment. In cases, too, of pus effused in the testis without finding any vent, there is often an indolent intractable enlarge- ment of the gland, which continues stationary, does not yield to remedies, and is attended with very little or no pain ; but still causes so much annoyance to the patient, and so disturbs his mind, that he becomes desirous of parting with the organ in order to regain his health and resume his cus- tomary occupations.— In March. 1841, I was re- CHROxMC ORCHITIS. 333 quested to visit the master of a ship, a man aged forty-three, in consequence of a chronic enlargement of the right testis, which had been gradaally forming for many months. The mouth had been made sore by mercury, and various stimulating applications to the part had been used, v^ithout any effect on the disease. He did not suffer much, and was desirous of returning to his ship ; but Mr. Arthur, his medical attendant, considered it unsafe for him to go to sea again with such a disease unrelieved. As the swelling had not subsided under the re- medies which had been judiciously tried and per- severed with, I recommended the removal of the gland, to which the patient readily consented, rather than submit to any long confinement. I accord- ingly performed the operation, from which the patient recovered, so as to be able to join his ship in a month. The testis was enlarged to more than thrice its natural size. The surfaces of the tunica vaginalis were closely adherent. On making a section of the tumour no trace of the natural tex- ture of the gland was apparent, its place being supplied by irregular masses of lymph and soft purulent deposits, separated by septa of ligamentous tissue. In some instances, when pus is pent up in the testis, the organ continues enlarged and tender, and the seat of a dull chronic pain, the matter proving a continual source of irritation. These symptoms may be relieved by rest, local depletion, and mercury ; but the benefit is in general only temporary, the patient continuing to suffer more 334 CHRONIC ORCHITIS. or less, and frequently experiencing relapses. For this state of the organ there is seldom any other remedy than castration. The following case is related by Sir A. Cooper. " A surgeon in the cavalry had an inflammation and chronic enlarge- ment of the testicle, which had been repeatedly relieved by the recumbent position, local depletion, and the use of mercury ; yet when he returned to the exertions necessary to the due performance of his military duties, the symptoms were renewed. Tired by these repeated disappointments, and un- able to pursue his profession satisfactorily, he re- quested me to remove the part, to which I con- sented, and found, upon dissection of the testis, a chronic abscess in the centre, which kept up irri- tation of the part, and repeatedly reproduced the inflammation."* In cases of this nature the pre- sence of pus cannot be ascertained with any degree of accuracy. No surgeon, therefore, would think of resorting to castration till after a persevering trial had been made, with the usual remedies for the reduction of chronic inflammation of the gland. Sir A. Cooper has remarked that the testis, even in very young children, sometimes becomes enlarged and very hard, but without pain or any inconve- nience ; and the disease is accidentally discovered by the parent or servant. In this state of indolent increase it remains for many weeks, months, or years ; and then, under improvement of the genera health, the enlargement subsides, and the gland re- * Lib. cit. p. 44. CHRONIC ORCHITIS. 335 sumes its natural state.^ No case of this descrip- tion had come under my notice till, very recently, Mr. Hamilton kindly showed me an infant ten months old, who was under his care at the London Hospital on account of a chronic enlargement of both testes. These glands were observed to be rather large at birth, but they had since greatly in- creased in size. The right was nearly as large as a plover's egg: the left was somewhat smaller. They were of an oval shape, and quite hard, had a smooth and even surface, and did not appear at all tender when handled. The infant was in pretty good health. The case had been under Mr. Hamil- ton's care three weeks, during which time they had remained stationary. I have no means of ascertain- ing the pathological nature of this chronic enlarge- ment of the testis in young infants; but I question whether Sir A. Cooper is correct in describing the disease as of a tubercular character. The fact that the enlarged gland usually resumes its natural state, and the even character of the swelling, are unfavour- able to this view of the nature of the tumour. Diagnosis. — A chronic inflammatory enlarge- ment of the testis may be mistaken for encephaloid cancer of the organ, and for a haematocele. It differs from the former in the surface of the gland being more uniform and regular, in the tumour being of less size, and in the absence of any con- comitant affection of the cord and lymphatic glands in the groin. In many cases the origin of the * Lib. cit. p. 97. 336 CHRONIC ORCHITIS. disease in the epididymis also serves to indicate the nature of the case. In the early stage, however, of encephaloid cancer, the characters of the tumour are so similar to those of the present disease that the diagnosis is extremely difficult. The tumour produced by chronic orchitis is more solid, and not so elastic as a hcematocele. It very rarely, too, attains so large a size as the latter, v^ithout causing ulceration of the tunica albuginea, and a hernial protrusion of its glandular structure. On inquiry into the history of the case the disease will be found to have come on very gradually, and not to have occurred suddenly after a blow, or to have suc- ceeded a hydrocele, as is the case with a hoema- tocele. The diagnosis is usually very easy ; indeed, I have not witnessed any case of chronic orchitis in which there was any difficulty in distinguishing the disease from a hsematocele. A hydrosarcocele can only be distinguished from a hydrocele by an examination of the part, after the fluid has been evacuated, unless the serous effusion be very small in quantity, or the sac should happen to be loose and not fully distended, in which case the enlarged and indurated gland may be detected through the fluid. Treatment. — Chronic orchitis, if treated early, is usually very amenable to remedies. Depletive mea- sures are seldom necessary. A few leeches may sometimes be applied with benefit after a fresh or sudden accession of inflammation ; but even local depletion is not often required. Mercury is the chief remedy ; and there are few other diseases in CHRONIC ORCHITIS. 337 which its effects are more uniformly beneficial, or in which it is better entitled to be regarded as a specific, than in chronic orchitis before the occur- rence of suppuration. As soon as its influence on the system begins to be manifested, the pain and tenderness cease, the sw^elling diminishes, and the induration gradually disappears. Five grains of blue pill, with a quarter of a grain of opium, may be given twice daily ; and the dose can afterwards be increased or diminished according to its effects. No object is gained by making the mouth very sore ; but it is desirable to affect the gums slightly, and to keep the patient under the influence of the remedy until all swelling has subsided, and the induration is nearly removed, which takes place slowly, and usually occupies three or four weeks. I prefer the blue pill, because the continued action of the remedy in this form produces less irritation in the system than calomel. It must not be under- stood that chronic orchitis cannot be cured without mercury ; but this remedy is so eminently bene- ficial, that where the constitution can bear it its exhibition should always form an important part of the treatment. At first I generally recommend the patient to keep constantly in the recumbent posi- tion, in bed or on a sofa ; but this is not absolutely necessary, and may often be dispensed with during the treatment and when the inflammation is slight. Compression by means of strapping, applied in the manner already explained, tends to promote the absorption of the adventitious deposit, and hasten the resolution of the swelling. The eflicacy of mer- 43 33S CHRONIC ORCHITIS. cury is so great that I have seldom employed com- pression without it, but I have several times com- bined the two apparently with much benefit. In these cases I generally strap with the emplastrum ammoniaci cum hydrargyro. Dr. Fricke of Hamburgh and Mr. Langston Parker^ also speak favourably of the effects of compression in chronic orchitis. The reduction of the swelling and induration may also be promoted by applying to the scrotum the strong mercurial ointment, or by counter-irritation from the application of the Unguentum lodinii C, or the Ceratum Hydrargyri C. In cases in which I have been desirous of not increasing the mercurial influence, I have somxCtimes kept up irritation by painting the scrotum every alternate day with the tincture of iodine. These local applications are particularly applicable to those cases in which the presence of fluid in the tunica vaginalis prevents the advantageous use of compression. It is often necessary to continue the local means and the exhibition of small doses of mercury for several weeks, before the eflects of the disease are entirely removed. But it is not necessary that the patient should be strictly confined all this time. He may pursue his usual occupations in-doors, and even take gentle exercise in the open air. One great advantage of compression is, that it dispenses with confinement to the recumbent position in most of the cases in which it is employed. In cases where I have found it necessary to discontinue the use of * Lancet, vol. ii. 1839-40, p. 640. CHRONIC ORCHITIS. 339 mercury in consequence of its injurious effects on the constitution, the decoction of sarsaparilla, with five or six grains of the iodide of potassium, has been given with much apparent benefit in getting rid of the swelling and induration. In gouty and rheumatic constitutions, colchicum combined with anodynes may often be exhibited with advantage. During the treatment the patient must strictly abstain from the excitement of venery ; and the diet should be light, and malt liquors and stimulating drinks must not be allowed. The successful result of this treatment necessarily much depends upon the period at which the case comes under the surgeon's care. If the disease has not existed longer than five or six weeks, the restoration of the testis is complete ; but if its duration be greater, the structure of the gland often suffers, though the organ may still be saved from complete destruction. When inflammatory action has been allowed to go on for many months, the testis generally becomes so disorganized that all we can hope for is to arrest the progress of a disease which is a source of suffering, keeps up irritation, and tends to impair the general health. As the inflammation of the testis subsides, the fluid effased into the vaginal sac usually becomes absorbed ; so that the hydrocele seldom requires any other treatment than that -employed for the removal of the disease which produces it. Sometimes, how- ever, these means prove insufficient to get rid of the hydrocele, and an operation becomes necessary to make a complete cure. There should be no 340 CHRONIC ORCHITIS. hurry in resorting to active measures for this pur- pose ; for it often occurs as the patient recovers from the effects of the disease and the treatment, and his health becomes fully re-established, that the fluid in the tunica vaginalis is slowly absorbed. When, therefore, after the removal of the disease of the testis, the quantity of fluid is so considerable as to produce a tumour of inconvenient size, the sur- geon should perform acupuncture, or introduce a trocar, and having drawn off the fluid wait the re- sult. If it should collect again he can then have recourse to injection ; a remedy which, under these circumstances, must be employed with some cau- tion, in order to avoid exciting fresh inflammation in the substance of the gland. The following case will serve to illustrate many points in the history and treatment of this affec- tion, — A captain of a ship, a man of swarthy complexion and muscular frame, £et. 27, who had just returned from a voyage to the West Indies, was brought to me October 1st, 1840, by a medical friend, for my opinion respecting the state of his testes. It appeared that the right gland had begun to swell about a twelvemonth previously, and that six months afterwards the left had also increased in size, and they had since continued to enlarge. The inconvenience which he suffered was so slight that no attention had been paid to his com- plaint, which did not appear to affect his health. He was engaged to undertake another voyage in a few days ; but he thought proper to consult his usual medical attendant before joining his ship. CHRONIC ORCHITIS. 341 On examination I found a hydrocele of moderate size on the right side of the scrotum, and could without difficulty detect the testis behind by the solidity and firmness of the tumour at this part, which were greater than usual. There was a hy- drocele also on the left side, which was of an oblong shape, and extended some way up the cord ; but owing to the looseness of the sac, and the presence of only a small quantity of fluid, I could easily feel the left testis, which was evidently enlarged and indurated. It was rather tender, but not much more so than usual, and the slight inconvenience which the patient experienced appeared to arise from the size and weight of the tumours. I drew off about six ounces of straw-coloured serum from the hydrocele on the right side with a trocar, and then found this testis larger even than the left, and also very hard. In both the induration was in the body of the gland, and not particularly in the epididymis. The spermatic cords appeared to be unaffected. He stated that he had not been subject to any complaint of the urinary organs during the last two years, and he ascribed the origin of the disease of the testicles to excessive venereal indul- gence. The importance of abandoning his inten- tion of shortly going to sea was strongly urged; and it was with some hesitation consented to, being at- tended with serious inconvenience. The following treatment was adopted : — Rest in the recumbent position; three five-grain blue pills in the day; and the application of the Unitnentum liydrargyri to the scrotum,— Oct. 17th. Although the pills 342 CHRONIC ORCHITIS. had been increased to four daily, the mouth was scarcely at all affected by the mercury. The tes- tes were less tender, and a little diminished in size. The hydrocele on the right side returned a few days after the operation. He was now ordered to rub in a drachm of strong mercurial ointment on the inside of the thighs night and morning, and to take two blue pills daily. On the 22d the mouth was rather sore, and the fluid was entirely absorbed from the left side ; and the testis was softer, and partly reduced in size. The right testis and hy- drocele were also diminished. The treatment was continued. — Nov. 3d. The mouth was very sore : the blue pills had been omitted since the 27th ult. Both testes were much diminished in size ; but they felt irregular, and were still heavier and harder than natural. A small quantity of fluid was yet remaining in the tunica vaginalis on the right side. I ordered Decoct. Sarzce. cum Potass. lodid, gr, v. ter die ; pil. hydrarg. gr. ij. o. n. ; and the scrotum to be painted every alternate day with Tinct. lodiniL This treatment was continued for about two weeks. The patient w^as allowed good diet, and to take exercise ; and as his health became re-established all effusion disappeared, and both testes were re- stored to their natural size, a little induration only remaining at the end of ten weeks after I first saw him. Not many years back a hernial protrusion of the testis was regarded as so formidable and incurable a disease, that no other treatment was resorted to but castration. A better acquaintance with the CHRONIC ORCHITIS. 343 pathology of this gland has led to improvements in practice, and now the majority of cases of this af- fection are found to be remediable without recourse to so severe an operation. Indeed, I believe with Mr. Lawrence that, in many instances, if the com- plaint were left entirely to itself the swelling would subside, the fungus shrink, and a complete cure ensue without any professional assistance."^ The chief obstacle to the healing of the wound is the im- pediment offered by the protuberant fungous mass. The first object, therefore, is to reduce this pro- jecting growth to the level of the surrounding skin. Mr. Lawrence recommended its removal with the knife, as the shortest and most effectual mode of treatment. Sir A. Cooper states that he has several times successfully practised the following plan : — " An elliptical incision is made in the skin around the projecting granulations, and then the knife is carried under the whole of the swelling, and close to the tunica albuginea ; by which the part is excised, leaving the epididymis and testicle unin- jured. Then the edges of the skin are approximated over the new surface, and it is healed by adhesion, if possible ; but, if the adhesion be not complete, by pressure with adhesive plaister ; and by approxi- mation of the integuments over the orifice of the tunica albuginea, the granulations are prevented from becoming again prominent."t The protrusion may be remedied and the sore healed without recourse to the knife, and I must confess that the * Lib. cit. p. 258. f Lib. cit. p. IS, 344 CHRONIC ORCHITIS. operation of excising it scarcely seems to be a very scientific mode of proceeding. It has been seen that the projecting fungus partly consists of tubuli seminiferi, and in some instances includes nearly the whole of the glandular part of the testis, so that its removal becomes an operation which in effect is but little less than that of castration. It may, indeed, be doubted whether the secreting struc- ture protruded in this affection can ever be so far restored as to be enabled to perform its proper function ; and in some instances, after the fungus has receded and the part become healed, the testis has been reduced to an atrophied and useless con- dition. Still it is by no means clear that in most of these cases of hernia testis the glandular struc- ture, though more or less injured, is wholly de- stroyed, or incapable of recovery. That the tubuli are capable of secreting whilst projecting from the scrotum has in a few instances been proved by the appearance of semen in the discharge ; and I see no reason why they should not be able to continue their functions after the testis haB resumed its situation, and the sore has closed up. I think the object of the surgeon should be to endeavour to place the diseased organ as nearly as possible in its former healthy condition, and the greater his success the more perfect will be the character of his prac- tice. Upon this principle the extirpation of any part of the gland appears to me to be objectionable, especially as it seldom happens that the healing of the wound cannot be obtained by other treatment as readily as by excision of the fungus. The same CHRONIC ORCHITIS. 345 objection as that made to excision applies to the practice resorted to by some surgeons of tying a ligature tightly round the base of the projecting tumour, in order to produce strangulation and the death of the part ; a plan of treating these cases which is certainly more tedious than the knife. The following is the method which I usually adopt, and I think it will generally be found to succeed in these cases : — The patient is directed to keep in bed ; and if there is any tenderness or pain in the testis, to take four or five grains of blue pill night and morning, until all symptoms of existing inflammatory action are removed. A piece of lint of sufficient size to cover the sore, having been dipped in a strong solution of the nitrate of silver in the proportion of five grains to the drachm, is placed on the part. One or two compresses of lint are applied over this, and tolerably firm com- pression is then made by several strips of adhesive plaister, and the whole is secured by a bandage. This is to be repeated daily ; mjid as the protrusion recedes the scrotum is drawn over it, and the edges of the wound are gradually approximated by narrow strips of plaister. Under this treatment cicatriz- ation takes place, and the testis gradually resumes its place in the scrotum, but remains firmly adher- ent to the new skin. In cases where there is no occasion for the exhibition of mercury^ or after its discontinuance, if the general health be impaired, the sulphate of quinine, iodine, steel medicines, or bark and soda, may be combined with the local remedies. Sir B. Brodie recommends the following 44 346 CHRONIC ORCHITIS. 4 treatment : — Let the patient be kept in bed in the horizontal posture ; give him mercury internally ; sprinkle the surface of the fungus every day with very finely powdered and levigated nitric-oxide of mercury, and over this apply some simple dressing. What with the application of the nitric-oxide of mercury to the part, and what with the mercury administered internally or by inunction, in the course of a short time the surface of the fungus becomes covered with red healthy granulations. As soon as this takes place the application of the nitric-oxide of mercury may be left off, and a weak solution of sulphate of copper in camphor mixture may be used as a dressing. A grain of the former may be dissolved in an ounce of the latter, and a piece of lint dipped in it may be laid on the fungus and changed night and morning, a little simple dressing being applied over the whole merely to keep the parts moist.^ There are many other escharotic applications which will answer the pur- pose of checking the growth of the granulations and causing their disappearance. Equal parts of powdered savine and the sulphate of copper, sprinkled on the parts, will be found to answer very well, acting partly by producing a slough, and partly by promoting absorption. * Medical Gazette, vol. xiii. p. 222. SYPHILITIC ORCHITIS. 347 SECTION in. SYPHILITIC ORCHITIS. In persons affected with secondary syphilis, the testicles are liable to undergo a chronic morbid enlargement, which is known by the term venereal inflammation, it being supposed to be one of the sequelae or constitutional effects of the syphilitic poison. Though this affection of the testis is not an ordinary symptom of secondary syphilis, it is far from being rare : when present it is usually accom- panied with a pustular or scaly eruption of a vene- real character, with periosteal inflammation, and not unfrequently with iritis. The symptoms of this affection closely resemble those of the chronic form of inflammation described in the preceding section; indeed the local symptoms of venereal orchitis only differ from those of chronic inflam- mation of the gland, in the testis becoming occasion- ally more tumid and painful during the evening exacerbation, or in the occurrence in some cases of nocturnal lumbar pains. The enlargement takes place slowly and in the same manner, is accom- panied with the same dull pain and sense of weight, and the disease maintains the same indolent cha- racter throughout its entire course, as in chronic orchitis. It commonly commences in the body of the gland, and rarely terminates in suppuration, or in the production of a hernial fungus. Sir A. Cooper thinks that, in the majority of cases, the disease 348 SYPHILITIC ORCHITIS. attacks both testicles.* The eight examples re- corded in his work do not, however, bear out this remark ; for in only two of them does it appear that both organs were attacked. According to my observation, the disease is more commonly confined to a single gland, though it occasionally affects both ; and this also appears to be the opinion of Ricord.t Sir A. Cooper has had no opportunity of dissecting a testis in this state ; nor have I. Sir B. Brodie mentions one instance in which he ex- amined the venereal testicle, and found the morbid appearances to correspond with those observed in chronic inflammation.^ Syphilitic inflammation of the testis should be treated for the most part on the same principles as ordinary chronic orchitis. The striking efficacy of mercury in this affection has been already explained : in the venereal form of orchitis this remedy is also most generally required for the disease of the testis, as well as for the relief of the other syphilitic symp- toms ; and it will commonly be found necessary to continue its use, so as to keep up its influence on the system for a longer period than in treating simple cases of chronic orchitis. Syphilitic inflam- mation of the testis may, however, be cured without mercury ; and in cases where the constitutional debility has been such as to render its exhibition unsafe and injurious, I have seen the inflammatory enlargement of the gland completely subdued and * Lib. cit. p. 105. f Traite Pratique des Maladies Veneriennes, p. 640, I Medical Gazette, vol. xiii. p. 379. TUBERCULAR DISEASE OF THE TESTIS. 349 the health improved by local depletion, counter- irritation, and rest, combined with the decoction of sarsaparilla and the iodide of potassium, and other remedies adapted for the relief of the constitutional symptoms. Sir B. Brodie has recorded an instruc- tive case, in which the testis enlarged and suppu- rated whilst the constitution was suffering from the effects of syphilis and the continued use of mercury. The patient was ordered to take sarsaparilla ; and in six weeks the testis diminished and the abscess healed."^ It should be borne in mind, therefore, that although in the majority of cases of syphilitic or- chitis mercury is the proper remedy, there are others in which it is productive of no benefit, or actually injurious, the system being unfitted for the use of this remedy, or already suffering from the combined effects of the syphilitic poison and mercurial action. In many instances, when large doses of mercury cannot be safely exhibited, advantage may be ob- tained from giving sarsaparilla with the sixteenth of a grain of the hydrargyri hichloridum, or the sixth of a grain of the hydrargyri iodidum. CHAPTER VII. TUBERCULAR DISEASE OF THE TESTIS. The testis is sometimes the seat of tubercular disease. This deposit is commonly met with in * London Medical and Physical Journal, vol. Ivi. p. 311. 350 TUBERCULAR DISEASE OF THE TESTIS. the crude state, forming a yellow caseous sub- stance, similar to the tubercular matter occurring in the lymphatic glands. It is sometimes developed in a single mass ; at other times several distinct depositions are formed in different parts of the organ ; in both cases at the expense of its glandular structure, which becomes atrophied as the disease advances. The disease also attacks the epididymis, which is, indeed, more frequently affected than the body of the testis. I have examined many testes at- tacked with strumous disease. In a specimen given me by Mr. R. Robinson of Peckham, which was removed from a man who died from the same disease in the lungs (see figure), the whole of the epi- didymis was observed to be occu- pied by tubercular matter, with scarcely any trace of tubuli ; whilst the body of the gland, though small, remained perfectly sound and unaffected. In some cases two, three, px m^ore distinct tubercular deposits were found in the testis and epididymis, separated by portions of healthy gland. This was the case in two testes which I removed from a middle-aged man who died of phthisis. They were injected, and a section of one of them is represented in the adjoining wood-cut. In several TUBERCULAR DISEASE OF THE TESTIS. 351 instances these isolated masses appeared to be con- tained in cysts formed by the processes from the tunica albuginea, which separate and support the lobules. Sometimes the separate deposits seemed to be coalescing and joining together, so as to form one continuous mass ; and I have found a single mass of tubercular matter surrounded by the glan- dular structure expanded into a thin layer. In another specimen the whole testis was occupied by a homogeneous cheesy mass, without any trace re- maining of the original structure of the gland. In some cases in which the disease was thus advanced there was very little increase in the size of the tes- tis ; it only felt heavier and harder than when in the natural state. In others, again, there was either a general uniform enlargement, or an irregular swell- ing at some part, more commonly at the head of the epididymis. Some of these testes, in which the disease w^as not much advanced, when injected made beautiful preparations, the yellow inorganic tuber- cular matter contrasting in a marked degree with the vermilion hue of the intervening sound portions of the organ. On several occasions I found a small quantity of serum in the tunica vaginalis, with par- tial adhesions and depositions of lymph. In a more advanced stage of this disease the characteristic deposit becomes softened down and converted into a yellow pultaceous substance, evidently tubercular matter mixed with pus. The abscess extends to the scrotum ; and after it has burst and the matter has escaped externally, cavities and sinuses are left which may be said to resemble the tubercular cavi- 352 TUBERCULAR DISEASE OF THE TESTIS. ties in the lungs. The course of the affection, however, in the testis, more nearly resembles the changes which ensue in tubercular disease of the absorbent glands. It has not been very clearly made out whether the tubercular matter is originally formed in the cellular tissue connecting the tubuli, or in the tubuli themselves. I have certainly seen this deposit in the vas deferens near the testis, and in the interior of the ducts forming the epididymis ; and Mr. Busk of the Dreadnought Hospital once showed me a preparation of scrofulous disease of the testis, in which the duct of the epididymis could be distinctly seen dilated and filled with this matter. Dr. Cars- well, in his Pathological Anatomy, has also given a representation of a testis from a young man who died of phthisis, containing a multitude of pale yel- low-coloured granular bodies of various sizes, which he says were obviously formed by the accumulation of tuberculous matter in the tubuli seminiferi. The epididymis was as thick as the little finger, and its convoluted ducts were obviously filled with a similar deposit. I believe that tubercular matter is de- posited in both situations, within as well as between the tubuli. It is a question as yet undetermined whether tubercular matter once deposited in the testis is ever got rid of without inflammation, suppuration, and the discharge of the morbid product through an ulcerated opening. We sometimes meet with cases of disease of the testis, the indolent character of which and the marked scrofulous diathesis of TUBERCULAR DISEASE OF THE TESTIS. 353 the patient would favour the presumption that the gland was the seat of tubercular formation ; and yet under appropriate treatment, or even sponta- neously, the induration or enlargement subsides, and all evidence of disease disappears. My friend Mr. R. Robinson had a patient who died of tu- bercular disease in various parts of the body, whose testis during life, after having acquired a considerable magnitude, slowly diminished to its natural size. I am not aware that any dissections have been made bearing upon this point. In some of the above cases the enlargement was pro- bably owing in a great measure to the effusion of fibrine or albuminous serum in the tunica vagi- nalis, consequent upon the inflammation with which this disease is often attended ; which deposits, as the inflammation subsided, became absorbed, the tubercular matter being left but little changed, and the testis itself unaltered in size. Laennec con- sidered the cretaceous matter found in the lungs as an indication of the cure of phthisis ; an opinion which appears to be confirmed by the researches of Dr. Carswell and others. A cretaceous matter is sometimes found in the testis, but more commonly in the epididymis (the most frequent seat of tuber- cular deposit,) which is exactly similar to the dry, putty-looking, chalky matter observed in the lungs and bronchial glands. I think it highly probable that in some of these cases the gland had, at some former period, been the seat of tubercular deposit ; but the circumstances under which this earthy matter has hitherto been found in the testis were 45 354 TUBERCULAR DISEASE OF THE TESTIS. such that I was unable to make any satisfactory inquiries on the subject. A good specimen of this cretaceous matter in the epididymis, from the collection of the late Sir A. Cooper, is represented in the annexed wood-cut. The epi- didymis is enlarged, and con- tains three separate deposits of this matter, whilst the body of the testis is perfectly sound. Tubercular matter, though sometimes formed in the testis in the earlier periods of life, does not usually occur till after the developement of the organ at puberty. We have very little infor- mation respecting the relative frequency of this deposit in the testis, as compared with other organs. In Laennec's table the epididymis is placed in the order of frequency before the body of the testis, which accords with general observation. In the tables of Louis, Lombard, and Papavoine, no men- tion is made of the testis. In many instances only one testis is attacked ; but not unfrequently both glands are affected simultaneously, or one shortly after the other. The occurrence of this disease in the testis must, no doubt, be viewed as one of the manifestations of the peculiar morbid state of constitution commonly known by the term scrofula. It appears, however, that a weak condition of the organ, or an impaired organization consequent upon previous disease, TUBERCULAR DISEASE OF THE TESTIS. 355 tends greatly to favour the developement of tubercle in this part. Thus, in two cases of phthisis in which I met with it, the patients w^ere both affected with obstinate strictures, and had suifered from consecutive orchitis in early life. Symptoms. — The disease commences insidiously, and is indolent in its progress. The patient's atten- tion is usually first attracted by a slight uneasiness in some part of the gland, generally the epididymis, which on examination is found to be somewhat enlarged, prominent, and hardened. Sometimes the whole organ feels slightly enlarged and in- durated, though it more frequently forms a tumour with an unequal and irregular surface. The state of the testis, however, is often masked by small local effusions of fluid in the tunica vaginalis, the surfaces of this membrane being partially adherent. Very little pain is experienced in the part, and there is but slight tenderness on pressure. After the disease has lasted for some time, many months or even a year and more, making little progress, and often remaining stationary, one of the promi- nences begins to increase, so as to be observed externally, and to feel painful and tender ; the skin over it becomes adherent, changes to a livid hue, ulcerates and bursts, giving vent to a soft caseous matter mixed with pus. This is followed by the formation of a fistulous sinus, which discharges a scanty thin serous pus, mixed with particles of tubercular matter, and often with semen, particu- larly after venereal excitement. Similar changes may take place in other parts of the testis, occa- 356 TUBERCULAR DISEASE OF THE TESTIS. sioning two or more sinuses leading to the interior of the gland. These sinuses sometimes communi- cate, and they may continue open and discharging for a great length of time. After the deposit has ail come away, if the original disease be arrested, and no more tubercular matter formed, reparative changes sometimes take place, the discharge ceases, the fistulsg close up, leaving the organ m^ore or less diminished in size or entirely wasted, according to the extent to which it had been disorganized by the tubercular deposit. The bursting of the ab- scess and escape of the tubercular matter are sometimes followed by a hernial protrusion of the testis, as after chronic inflammation of the gland. Strumous disease of the testis is not often seen in the suppurative stage in children, or before the age of puberty, — A little boy aged B.ve years, with fair complexion, bright eyes, and florid cheeks, was brought to me at the hospital in March, 1842, on account of an affection of the left testis. This gland was three or four times the size of the right ; of an oval form, with an uneven surface, so as to feel nodular ; extremely indurated, indeed almost as hard as cartilage ; and was nearly insensible to pressure. 1 ordered small doses of the hydrarg. cum cretu, and the camphorated mercurial ointment to the part. As the swelling remained l3ut little changed at the end of three weeks, I prescribed the decoction of bark, with three grains of the iodide of potassium, to be taken three tim.es a day, and some iodine ointment to be applied to the enlarged testis. In May the skin became adherent to the lower part TUBERCULAR DISEASE OF THE TESTIS. 337 of the testis ; an abscess formed, and about the middle of June burst, and discharged some caseous matter and thin pus, and left a fistulous opening. The health began to fail, which induced me to substitute some steel medicine for the iodide of potassium. The mother became phthisical and too ill to bring the boy, and I saw nothing more of him till the father brought him to see me in the following November ; when I found the fistula closed, the testis a good deal reduced in size, but still hard and nodular, and adherent to the lower part of the scrotum. The boy's health was much improved. Another small abscess subsequently formed and burst as before, since which I have lost sight of the patient. Mr. Lloyd relates the following case. — A child three years and a half old was brought to him with the right testicle affected. The whole scrotum was distended with matter, and appeared like a scrofulous abscess in any other part of the body, and the skin was so thin that you might see the matter through it. A poultice was applied, and in a few days the abscess burst ; and the aper- ture soon enlarged so much that full half of the gland projected through the scrotum, and was converted into a mass of yellow scrofulous matter, which a few days after separated, leaving the re- mainder of the gland enlarged and hardened. This was, however, rapidly diminishing, and seemed likely to entirely waste away."^ This disease is frequently connected with scro- '^ Treatise on Scrofula, p. 93. 358 TUBERCULAR DISEASE OF THE TESTIS. fulous affections of other parts/^ The patient is either phthisical, or subject to strumous swellings of the lymphatic or mesenteric glands ; or affected with disease of the spine, hip, knee, or some other articulation, and manifests the ordinary charac- teristics of a scrofulous constitution ; so that in many cases, certainly in the majority of those which have come under my notice, the affection of the testis was of secondary importance to disease existing in other organs, and to the morbid state of the system generally. The constitution, also, is very slightly affected by, or sympathizes very little with, the morbid changes going on in the testis. Diagnosis. — Tubercular disease of the testis may be mistaken for chronic, inflammatory, and malignant enlargements of the gland. Writers on the diseases of the testis often confound the former of these affections with the tubercular disease, being misled by the indolent nature of the swelling and the yellow appearance of the morbid deposit in chronic orchitis. The strumous disease differs, however, from the chronic inflammatory swelling in being more indolent ; in making even slower progress, and being attended with still less pain and inconve- nience ; in the irregular surface and smaller size of the swelling ; and, when the epididymis is attacked, in the globus major being the part principally affected, instead of the lower part, which is usually first enlarged in chronic inflammation. The di- * When the testes become tubercular, the vesiculse seminales are also very liable to be affected with the sanio disease. TUBERCULAR DISEASE OF THE TESTIS. 359 agnosis, however, is not always easy, as in both cases the character of the swelling is often masked by the effusion of fluid in the tunica vaginalis. The disease may be distinguished from malignant enlargements of the organ by the smaller size, un- even surface, and more indurated nature of the swelling, and by its very chronic progress. In all cases the judgment of the surgeon will be ma- terially assisted by his noting the general characters of the constitution, and whether there is any con- comitant affection of other parts. Treatment, — From what has been remarked in reference to this disease, it will naturally be inferred that the remedies of most consequence are those calculated to correct the morbid state of constitu- tion which predisposes to local scrofulous deposit. The patient should reside in a pure air in the country, and, if possible, by the sea side, for many months. He should take gentle exercise. The diet should be nutritious, consisting of a due pro- portion of animal and vegetable food ; and stimu- lating viands and drinks must be strictly prohibited. Malt liquors, as light pale ale, or a glass or two of wine, may, however, be taken in many cases with advantage. Medicines which tend to improve the appetite and give tone to the digestive organs are to be exhibited. Steel medicines, as the vinum ferri, the citrate or sesquioxide of iron, the decoc- tion of bark with the sesquicarbonate of soda, the sulphate of quinine with sulphuric acid, the infu- sion of gentian or decoction of sarsaparilla with the liquor potassae long continued, are all more or less 360 TUBERCULAR DISEASE OF THE TESTIS. serviceable, and may be occasionally suspended or varied, one being substituted for the other. There is, however, no remedy which exerts a more bene- ficial influence in this affection than iodine, or the iodide of potassium. I usually prescribe for the adult the decoctum sarzcE, with five or six grains of the iodide of potassium, to be taken three times a day for some length of time, directing it to be discontinued for two or three days or a week, and again resorted to. When the patient is in a good air the constitution and local symptoms often mend in a remarkable degree under this treatment. Mer- cury, which is so eminently beneficial in chronic inflammation of the testis, is seldom of service in this disease : indeed, as in strumous affections ge- nerally, its influence is usually prejudicial. Small alterative doses, as four grains of Plummer's pill, taken at night, or the sixteenth of a grain of the bichloride of mercury given in the decoctum sarzae twice 6y thrice in the day, have sometimes been resorted to with advantage ; but my experience generally leads me to think unfavourably of the use of mercury in any form in this affection. When inflammatory symptoms exist they must be combated by the application of leeches, cooling lotions, and rest in the recumbent position. Anti- phlogistic measures are not often necessary. In all cases the gland must be supported. In the indolent stage of the disease the local treatment consists in painting the scrotum with the tincture of iodine every alternate day, or oftener ; or the Ung. lodinii Comp., mixed with an equal proportion of lard, may CARCmOMA OF THE TESTIS. 361 be rubbed on the part. Strapping the testis with the Emplast. Atnmoniaci cum Hydrargyro has, in several instances, appeared to promote the disap- pearance of the swelling and induration. When suppuration ensues the part may be poulticed; and after the abscess has burst the orifices of the sinuses must be kept well open, to allow of the free escape of the morbid deposit. In some cases in which the testis is completely disorganized and useless, and when the sinuses prove very obstinate and trouble- some, castration may be necessary ; but this opera- tion is seldom required, and it should never be per- formed whilst there is any evidence of disease in the lungs, or organic affection elsewhere. CHAPTER VIII. CARCINOMA OF THE TESTIS. The testis, like other glandular organs, is liable to carcinomatous disease. A schirrous testis was for- merly spoken of as a common affection ; but then all chronic enlargements possessing much induration were usually designated schirrus. Surgeons have since learned to discriminate the enlargements con- sequent on inflammation from those produced by malignant disease : the latter are now known to be comparatively rare. Carcinoma is met with in the testis under the four forms of Schirrus, Enccpha- loid, Colloid, and Melanosis. 46 362 SCHIRRUS OF THE TESTIS. SECTION I. SCHIRRUS OF THE TESTIS. n Schirrus never occurs in the testis in the dense form which it commonly assumes in the breast. Sir A. Cooper, however, describes^ a schirrous dis- ease of the testis, in which a hard white mass in lobes or tubercles, and possessing little vascularity, is found in the place of the tubuli seminiferi. This is sometimes interspersed with small portions of cartilage or bone. The epididymis contains a simi- lar firm fibrous mass ; and the spermatic cord is enlarged, and has small white tubercles in it. The glands of the abdomen become converted into a white solid texture, very unlike that of the fungoid disease. The disease appears, from this description, to correspond with that form of schirrus described by Miiller under the name of carcinoma reticulare, the consistency of which ranges between that of ordinary schirrus and encephaloid, and which con- sists fundamentally of a gray globular matter, embedded in meshes formed of fibrous fasciculi, and has a greater tendency to lobular arrangement than simple schirrus. I have not witnessed any case of this disease, which must be exceedingly rare. Symptoms. — Sir A. Cooper describes this kind of cancer as beginning in an enlargement of the body of the testis, accompanied with great weight * Lib. cit. p, 150. SCHIRRUS OF THE TESTIS. 3GS and severe occasional pain ; never becoming soft nor so large as the encephaloid cancer, nor pro- ducing a fungoid or very vascular bleeding surface, but feeling tubercular, irregular, and excessively hard. The pain extends to the loins ; the spermatic cord becomes enlarged, hardened, and tuberculated ; and a smaller tumour than that of the fungoid disease forms in the abdomen. Some water is se- creted into the tunica vaginalis ; the cellular mem- brane of the leg and thigh of the diseased side becomes dropsical, and afterwards the other leg is similarly aifected. Ulceration he had seen occur once : the testis gradually wasted under it ; the glands of the groin became diseased, and the man after some months died. But this state rarely happens ; for generally, without ulceration, the patient's countenance becomes sallow, and he sinks under impaired digestion, pain and tumour in the abdomen, and an irregular state of the bowels, which are frequently accompanied with ascites. Diagnosis. — This form of cancer is characterized by its slow progress and great hardness during the whole continuance of the disease, and also by its weight and irregular and tuberculated feel. It does not become soft like encephaloid cancer, and it occurs less in different parts of the body at the same time, and is slower in proceeding to its fatal termination. Treatment. — There is no other remedy for this disease but castration, which must not be delayed so as to endanger a production of the disease in the spermatic cord, or the growth of a tumour in the 364 ENCEPHALOID CANCER OF THE TESTIS. abdomen. Sir A. Cooper relates the case of a man aged 44, whose testicle was attacked with this form of cancer. The gland was removed in Guy's Hos- pital nine months after its first appearance, and the wound healed ; but the thigh and leg, which were oedematous at the time of the operation, remained swollen, and he died a month after his return home. SECTION 11. ENCEPHALOID CANCER OF THE TESTIS. This is by far the most frequent disease of a ma- lignant character to which the testis is liable. It is called by different writers pulpy testis, medullary sarcoma, soft cancer, fungoid disease, or fungus hcematodes, I have adopted the term encephaloid given to this cancerous growth by Laennec, as it is the one now most generally employed by patho- logists. Encephaloid cancer, when first observed in the testis, is found in one or two masses amongst the tubuli, which gradually become destroyed as the morbid deposit accumulates. In some instances, examined at the commencement of the disease, the glandular structure has been found expanded around a solitary deposit in the centre of the organ. The matter is very rarely infiltrated. The testis at this early period is extremely firm and hard, owing not to the solid nature of the substance effused, but to the excessive distension of the unyielding tunica albuginea by the morbid growth within. The ENCErHALOID CANCER OF THE TESTIS. 365 glandular structure soon entirely disappears, the whole organ being occupied by the new growth in- termixed with, and sustained by, the septa and fibrous processes from the mediastinum and tunica albuginea. At this stage the tunica vaginalis is often distended with serum ; not, however, in any considerable quantity. The effusion is caused by inflammation, excited by the presence of the en- cephaloid matter within the testis: the inflamma- tion sometimes produces adhesion, and partial or complete obliteration of the cavity of the tunica va- ginalis. The tunica albuginea next gives way, and a portion of the morbid growth protrudes, forming a mass projecting from the body of the gland ; this sometimes occurs in more places than one. The epididymis remains for some time unaflected ; but as the disease increases this part likewise becomes implicated and destroyed. In a case I recently ex- amined, the canals at the head of the epididymis (the only part of the gland not destroyed) were distinctly seen filled with a white matter, which on examination in the microscope was found to be car- cinomatous. The scrotum in a short time becomes fully distended by the diseased mass, which pre- sents the well-known appearance of encephaloid cancer :* viz. a homogeneous substance of the con- * I do not think it necessary to give here a detailed account of the characters of encephaloid cancer and its mode of developement, my object being to describe the general appearances and modifications which it presents in the testis. For a more minute description of this morbid deposit, I must refer the reader to works on Morbid Anatomy, but especially to the admirable article on cancer by Professor Walshe, in the Cyclopaedia of Surgery. 366 ENCEPHALOID CANCER OF THE TESTIS. sistence of brain, and easily broken down with the fingers, of an opaque white colour, and variegated with patches of a pinkish hue. It is sometimes mixed with small cysts containing serum and yellow deposits of lymph resembling that effused in chronic orchitis. These small depositions of yellow fibrine, occa- sionally interspersed amongst the carcinomatous matter, I believe to be peculiar to this disease in the testis, as I have not observed cancer it in of other parts. When the scrotum gives way, the morbid growth projects as a bleeding fungus. The enlarged mass then becomes less firm, and its con- sistence varies very much in different parts, the morbid matter being in some a mere pulp, or resem- bling a creamy fluid. It is interspersed with round or irregular patches of dark-looking coagula, and when incised often presents in different places dark minute spots of various sizes, produced by coagu- lation of blood in the vascular network, usually mixed up with the morbid deposit. On macerating these tumours, or on pouring a stream of water on them for some time, a granular substance, the can- cerous matter, is washed away, leaving behind a filamentous shreddy tissue or meshes of a delicate cellular texture, which may often be found con- nected to a denser fibrous substance, the remains of the tunica albuginea. The spermatic cord is often invaded by a similar substance ; and in an ad- vanced stage of the complaint large bodies of the same kind, originating in disease of the lumbar glands, are found on the sides of the vertebrae, ENCEPHALOID CANCER OF THE TESTIS. 367 reaching as high up as the diaphragm. The ab- dominal aorta and ascending vena cava become surrounded by them, and are often displaced or compressed. I have known the circulation through the vena cava completely obstructed by the pres- sure. This vessel has also been found filled with, and obliterated by, encephaloid matter. The kidneys are sometimes encroached upon by the disease. The spine too may be implicated, the bones of the lumbar vertebrae being more or less destroyed by the progress of the morbid growth, which, indeed, spares no parts or textures in its progress. The glands in the groin of the side corresponding to the diseased testis escape contami- nation more frequently than those in the loins ; still they often become affected. It has been said that they do not enlarge until the disease has reached the scrotum. Such, however, is not always the case ; for I have seen them affected before any appearance of disease in this part. Mr. Abernethy describes a case in which the glands in both groins became so enlarged that the skin over them ulcer- ated, without the scrotum being involved.^ As the lumbar glands enlarge, the peritoneum covering them and the various viscera are pushed forwards, and there is often serous effusion in the cavity of the abdomen. In some instances the mesenteric glands are diseased, and carcinomatous tubercles are found dispersed through the liver. Masses of a similar kind are sometimes also found in the * Observations on Tumours, p. 52. 368 ENCEPHALOID CANCER OF THE TESTIS. lungs, the thoracic cavities being occupied by serous effusion. The carcinomatous matter is often de- posited in such abundance as to form a tumour of very considerable size ; indeed, there is no other disease of the testis which occasions solid enlarge- ments of so great a magnitude as encephaloid cancer. M. P. Boyer removed, at the Hopital St. Louis in Paris, a testis converted into an encepha- loid tumour v^^hich weighed more than nine pounds.* The vessels of the cord undergo great enlargement in this disease ; in one case which I examined the spermatic artery was found as large as the radial artery at the wrist. Encephaloid cancer of the testis occurs at all periods of life : no age, indeed, can be said to be exempt from it. Mr. Cline operated for this affec- tion on a boy ^ve years of age ; the disease unfor- tunately returned. Sir W. Blizard extirpated the testis of a child two years and a half old, on account of a carcinomatous tumour of the organ, measuring an inch and a half in its greatest diameter, and one inch in its smallest. The diseased gland is pre- served in the museum of the College of Surgeons. The late Mr. H. Earle published an account of a case in which the disease attacked the testis of a child very little more than a year old. The part was re- moved, but in a few months he died of the same dis- ease in the brain and other parts.t Mr. LangstafF preserved the carcinomatous testis of a child, which began to enlarge when he was only ten months old. * Revue Medicale, Nov. 1839. t Medico-Chirurgical Transactions, p. 59. ENCEPHALOID CANCER OF THE TESTIS. 369 It increased rapidly, and in the course of two months acquired the magnitude and figure of a hen's egg. Castration was performed, but the patient lived only six months afterwards. The lumbar glands, lungs and dura mater were found affected with the same disease."^ The disease, however, more commonly occurs in the middle period of life, or between the ages of twenty and thirty ; but I have met with it at a much more advanced age. A patient lately died in the London Hospital of carcinoma of the testis at the age of sixty. Mr. Byles of Spitalfields sent to my house a pauper aged sixty-four, whose left testis formed a tumour the size of a large orange, which had been coming about six months. The glands in the groin were enlarged and the left leg was cedematous. The disease afterwards made rapid progress. The testis and swellings in the groin increased to a great size : the scrotum ul- cerated, and a bleeding and sloughing fungus pro- truded. The man died about two months after I first saw him. It very rarely happens that both testes become affected ; and in this case the right, though completely enveloped in the morbid deposit, was found after death quite sound. Symptoms. — The disease commences in an en- largement, with considerable induration of the body of the testis, which preserves its oval form and even surface. The enlargement is attended with slight tenderness, a dull pain, and occasionally with a * Catalogue of Preparations, p. 372. 47 370 ENCEPHALOID CANCER OF THE TESTIS. little effusion into the tunica vaginalis. The growth of the morbid deposit varies, and is very unequal. It is sometimes very slow, the disease making but little progress in several months ; at other times it increases rapidly. Its growth is liable to be acce- lerated by a slight blow or exercise. As the gland enlarges it becomes uneven, and feels irregular and tuberculated. It loses, too, its indurated character, and becomes soft, but more so in one part than in another, and acquires an elastic feel. As the disease thus advances the pain increases, but still amounts to little more than a dull sense of weight extending up to the loins. The spermatic cord becomes thick and full, owing to enlargement of the various blood- vessels. The scrotum is at first unaltered ; but as it becomes distended by the increasing size of the tumour, its veins are obstructed, and appear swollen and varicose. By this period the glands in the lumbar region usually become diseased and en- larged, and the lower extremity of the side affected swells from oedema. The surgeon may in a short time distinguish the swellings on the side of the spine by making pressure on the abdomen. The pains in the loins and abdomen soon become con- stant, and the patient's sufferings are altogether much increased. The general health, which was at first but little affected, now exhibits a material al- teration. The patient loses flesh and strength, his countenance assumes a peculiar sallow hue, his tongue is furred, and his appetite and digestion are more or less impaired. As the enlargement goes on the scrotum becomes adherent to the tumour in ENCEPHALOID CANCER OF THE TESTIS. 371 one or more places ; then ulcerates, and allows the protrusion of the morbid mass, which projects as an open bleeding fungus, discharging a thin fluid mixed with blood, and having a disagreeable faint odour. The disease then makes very rapid progress ; the fungus spreads ; sloughs form on its surface ; coagula separate ; bleeding repeatedly occurs ; and the pa- tient at length sinks, dying from the drain on the system, or from the interference of the morbid de- posit in the functions of the important internal organs. The diseased testis sometimes attains a very large size without the appearance of a bleed- ing fungus, as the scrotum admits of great distension before ulceration ensues. Mr. Wardrop remarks, in- deed, that in no case has he even been able to learn that the integuments have given way, and a fungus grown from the diseased testicle ; and Sir B. Brodie likewise states that it has not fallen in his way to observe a tumour in this advanced stage."^ At page 369 I have briefly related the particulars of a case that came under my notice, in which the dis- ease extended so as to produce a bleeding fungus ; but as the testis is usually removed before the disease reaches this point, it is rarely that an op- portunity is afforded to the surgeon of witnessing it. Besides, as the scrotum admits of very considerable distension without ulceration being induced, the patient's life may be destroyed by a similar aifection of the internal organs before the skin gives way. In the case of the old man who lately died in the * Lond. Med. Gazette, vol. xiii. p. 408. 372 ENCEPHALOID CANCER OF THE TESTIS. London Hospital to which 1 have referred, life was destroyed by internal disease before even the tunica albuginea had given way.^ Sir B. Brodie has remarked that in many cases the tumour in the loins gives the patient no pain, and but little inconvenience, while at other times it is attended with the most extraordinary suffering. He sup- poses this to depend on the accidental circum- stance of it sometimes pressing upon nerves, and in other cases lying clear of them. A gentleman with whom he was acquainted many years ago had this disease in the testis, Mr. Cline was con- sulted, and he recommended the amputation of the testis, and performed the operation. A year afterwards the patient became weak in his lower limbs, and at last they became completely paralytic. He died ; and on examining the body after death, there was found a large tumour in the loins, which had affected the vertebrce so as at last to press on the medulla spinalis, thus accounting for the para- plegia.t Cruveilhier has recorded the case of a man aged twenty-seven, whose testis was extirpated on account of alveolar cancer. The disease did not return in the part, but made its appearance in the body of the sixth and seventh cervical vertebrae and the posterior extremities of the two first ribs, and caused death by pressing on the medulla spi- nalis, and producing paralysis of the parts below.J * In this case carcinomatous matter was found deposited in the muscular substance of the heart, and also in the lungs, t Lib. cit. p. 408. } Anatomic Pathologique du Corps Humain, liv. v. p. 1. ENCEPHALOID CANCER OF THE TESTIS. 373 Mr. Pott met with a case of carcinoma affecting a testis detained in the right groin in a man fifty- five years old. There was a large ulcerated sore with high callous edges, which discharged an offen- sive gleet, at times bled profusely, and was ex- tremely painful. After death the lymphatic glands about the vertebrae of the loins, and the liver and right kidney, were found affected with the same disease.* Diagnosis. — Encephaloid cancer of the testis may be confounded with hydrocele, with hasmato- cele, with the cystic disease, and in its early stage with chronic orchitis. It differs from hydrocele in being of an oval shape ; in its sides being somewhat flattened ; in the circumstance that the enlargement takes place uniformly, and not from the bottom, as in hydrocele ; in the uneven surface of the swelling; in the absence of transparency ; and in the greater weight of the tumour when balanced in the hand. Encephaloid cancer, when handled, gives an indis- tinct feeling of fluctuation, which has often proved very deceptive, and puzzled the most experienced surgeons. By a careful examination, however, the difference may generally be detected, as the consist- ence and obscure sense of fluctuation vary in dif- ferent parts, the tumour being softer in one place than in another. A hasmatocele, especially if the sac be much thickened, is more difficult to be dis- tinguished from this disease than a hydrocele, the tumour being heavier and wanting transparency, * Works, 4to. edit. p. 357. 374 ENCEPHALOID CANCER OF THE TESTIS. and fluctuation being very obscure or imperceptible ; circumstances in which I have stated that the en- cephaloid disease differs also from hydrocele. The other distinguishing marks mentioned, together with a patient inquiry into the history of the case, will generally enable the practitioner to distinguish these two affections. In a case of difficulty, all doubt might be set at rest by a puncture with a trocar or lancet. If the swelling should happen to prove carcinomatous, there would be a flow of blood, and perhaps an escape of a small quantity of brain-like matter. But the bleeding would soon cease, and the wound being closed by plaister would probably heal, and no ill consequences result. Encephaloid cancer may very readily be mistaken for the cystic disease, before at least the former arrives at that stage when no prudent surgeon would contemplate an operation. The tumour caused by the malignant disease makes more rapid and more variable progress, and its surface is less even and its consistency less uniform than the cystic sarcoma ; but in other respects the characters of the swelling in these two diseases are so similar, that no certain directions can be given for distin- guishing them. The necessity for making the dis- tinction is perhaps less, since in both cases no other treatment is of service but an operation ; after which an examination of the diseased organ will afford the surgeon the opportunity of pronouncing an opinion as to the security obtained from future disease. Very great difficulty is experienced to distinguish- ing encephaloid disease in its early stage from the ENCEPHALOID CANCER OF THE TESTIS. 375 enlargement produced by chronic inflammation ; and as the success of an operation in cases of this malignant disease depends very much upon the period at which it is performed, it is of no slight importance that the nature of the affection should be detected as early as possible. As there are no external marks that can be relied on for distin- guishing the two diseases, the only course that can be adopted is to exhibit mercury so as to make the gums slightly sore ; when, if the induration and enlargement should happen to depend on chronic inflammation, the gland will gradually begin to soften and diminish, and if the remedy be perse- vered in a little longer will be restored to its natu- ral state. If, on the contrary, no change ensue, or if the testis continue rather to increase in bulk, it may be pretty certainly concluded that the alter- ation in structure is of a malignant character, or that it results from a disease for which there is no remedy but the knife, and we should therefore be justified in recommending an operation. The following example will serve to illustrate some of the difficulties of the diagnosis in these cases, and to point out the kind of careful investi- gation necessary to enable the surgeon to form a correct opinion respecting the nature of the disease. — A healthy-looking man, aged thirty-four, married, and by trade a carpenter, applied for relief on ac- count of a chronic enlargement of his left testis. About nine or ten months previously he first per- ceived an increase in the size and weight of the organ, which occurred without any apparent cause 376 ENCEPHALOID CA^XER OF THE TESTIS. or the receipt of any injury to the part. He con- tinued at his occupation, taking little heed of the swelling, until at length becoming alarmed by its increasing to seven or eight times the size of the other testis, and experiencing considerable incon- venience from its bulk and weight, he was induced to seek surgical assistance. There was a large tumour occupying the left side of the scrotum. It was of an oval form ; its surface was pretty even, except at the upper and front part, which had a slight, smooth, and round projection. The skin covering the swelling was sound, and not adherent ; but the subcutaneous veins were a good deal di- lated. The consistence of the swelling generally was about that of a hoematocele ; but then it was un- equal, being firmer in front than at other parts. On seeking for fluctuation, the obscure sensation pro- duced was more like the resilience of a soft elastic solid than the displacement of a fluid. The small projection above, however, communicated a more evident feeling of fluid. The weight of the tumour was greater than that of a hydrocele, but might be about that of a htematocele or a soft solid growth. The swelling was not transparent, and had little sensibility, firm pressure causing merely a dull pain. The testis completely escaped detection : it could be distinguished neither by its form or con- sistence, nor by the character of the pain usually experienced from compression. The spermatic cord was full and large, but otherwise natural, and it passed to the posterior part of the tumour. The lumbar and iliac glands appeared to be free from ENCEPHALOID CANCER OF THE TESTIS. 377 disease. The important internal organs performed their functions properly, and there was no indi- cation of a morbid state of constitution. Such, then, were the characters of the tumour, and the symptoms by which it was to be ascertained whether the disease was a hydrocele with thickening of the investing tunics, a hasmatocele, cystic sarcoma, or encephaloid cancer. Against the supposition of a hydrocele there was the oval shape, uneven surface, greater weight and irregular consistence of the tumour, the absence of transparency, and the im- possibility of detecting the testis by firm pressure at the part where the gland is usually found in cases of effusion into the tunica vaginalis. Op- posed to the idea of a hsematocele there was not only the irregular surface, varying consistence, and impossibility of detecting the testis by pressure ; but also the mode of growth, the tumour in hsema- tocele being of sudden or rapid formation, more often occurring from some injury, and when formed afterwards remaining little altered for a consider- able period : whereas in this case the swelling arose spontaneously, took nine or ten months to acquire its large size, and still continued to increase. It was concluded, then, that the tumour must be either cystic sarcoma or encephaloid cancer, its mode of formation, shape, size, weight, and general consistence, and the state of the cord being such as might correspond to either of these two diseases. The irregularity in the surface and consistence of the swelling, and the large developement of the subcutaneous vessels, induced me to incline to the 48 378 ENCEPHALOID CANCER OF THE TESTIS. opinion that the growth was of a carcinomatous character ; and such proved to be its nature when the tumour was removed after an exploring punc- ture. There was no trace of the glandular struc- ture of the testis remaining ; but the epididymis was sound, and situated at the upper part of the tumour, surrounded by the tunica vaginalis, which con- tained about six drachms of serum, and formed the indistinctly fluctuating projection observed at this part. Treatment. — There is no disease of a more dan- gerous and fatal tendency than encephaloid cancer. No medicine or local treatment of any kind is able to arrest its progress, and the only alternative left for us to adopt when it attacks the testis is that of amputation of the affected organ. Unfortunately this resource is exceedingly liable to fail, the disease generally reappearing in the lymphatic glands con- nected with the testis, in the wound, or in some internal organ. Numerous cases in which the dis- ease has thus returned have been published by various surgeons ; and so unsuccessful has this operation proved, that the propriety of having re- course to it under any circumstances has been strongly called in question. I scarcely know an instance of castration having been performed for this disease in which the patient has survived for any lengthened period. Sir A. Cooper, whose ex- perience was very great, has recorded ^\e cases, in all of which the disease returned after the operation, but not one attended with a successful result ; and Sir B. Brodie states that he has known but one ENCEPHALOID CANCER OF THE TESTIS. 379 instance in which there was no recurrence of the disease. The patient was a French courier, and had the disease in one testicle, which was ampu- tated. Three or four years after the operation Sir B. Brodie learned that he was going on favourably. The operation may, however, have succeeded in some few cases which have afterwards been lost sight of "^ It has been shown, by the recent microscopical inquiries of Miiller and others, that the intimate texture of carcinoma consists of a mass of nucleated cells, very similar to the primary cells of develope- ment mef with in healthy tissues, and which seem to possess similar independent powers of growth, new cells being formed from the nuclei, which, like the parent cells, have the property of multiplying their kind. There are many reasons for concluding that the origin of carcinoma is local — that the dis- ease is produced by some local irritating cause, and is confined for a time to the part in which it is developed ; but, being once formed, it is very prone to spread to other parts, owing probably to the passage of the cells or cancerous germs into the blood. This liability to the formation of secondary deposits is greater in certain forms of cancer than in others, and also in cancer of certain parts than in that of others. Our present experience of car- cinomatous disease is sufficient to prove, that in some instances a cancerous growth may be removed * Much valuable information might be gained, if surgeons would endeavour to ascertain and register the results of their operations rof this disease. 380 ENCEPHALOID CANCER OF THE TESTIS. before the disease has been communicated to dis- tant parts, patients having survived an operation for years without the appearance of secondary growths, and without experiencing any fresh developement of carcinomatous matter, and having died of another disease ; that carcinomatous matter is sometimes developed in a particular part of the body, and produces death by its irritative effects on the con- stitution, without being conveyed to or contami- nating any other parts, except those immediately connected with its original seat ; and that in other cases, though the removal of the part primarily affected may be too late to eradicate the disease from the constitution, it having ceased to be local, its developement in other parts previously contami- nated may take place so slowly, and make such tardy progress, that the extirpation of the cancer from its original seat, where it was rapidly advancing, tends more or less to prolong the patient's existence. The tendency of carcinoma to spread is particularly rife in the early period of life, when the powers of growth are in active operation, as is evinced by the almost constant failure of operations for cancer of the tes- tis and of the eye in infants. This tendency seems to diminish with age. Thus in advanced life car- cinoma makes slower progress, and, if extirpated, is by no means so apt to reappear as in early life ; so that the prospect of security from a return of the disease after an operation, cceteris paribus, increases with the age of the patient. Of all the forms of car- cinoma, encephaloid cancer is the most prone to form secondary growths, and consequently the most ENCEPHALOID CANCER OF THE TESTIS. 381 difficult to eradicate by operation. Nevertheless, believing the origin of the disease to be local, I think the attempt to remove a malady of so fatal a cha- racter well deserves a trial ; and I am therefore by no means disposed to agree with those practitioners who condemn the extirpation of the testis when affected with encephaloid disease, more especially as castration is not, under ordinary circumstances, an operation dangerous to life. The chance of suc- cess may be a poor one ; but it is better that the patient should have that chance, poor as it is, in- stead of the case being abandoned as hopeless, and the sufferer being left to the consequences of an early and painful death. But to afford a reason- able hope of success, castration should be performed at the earliest period possible, in a suspicious case as soon as the surgeon can make up his mind that the disease, whether carcinomatous or not, is of a nature incurable by ordinary remedies; for there are few diseases in which a prompt decision is more necessary than in this. The operator must of course make a very careful examination of the important internal organs, especially of the lumbar and in- guinal regions and spermatic cord, as an affection of these parts would destroy all hope of benefit from the operation, and render its performance improper. He should also make, just previous to the operation, one or two punctures in the tumour, in order to set at rest any doubt that might exist in regard to the nature of the disease. 382 CARCINOMA OF THE TUNICA VAGINALIS. SECTION III. CARCINOMA OF THE TUNICA VAGINALIS. Carcinomatous disease has, in some few instances, been found to originate from the tunica vaginalis, the glandular part of the testis remaining for some time unaffected. An important peculiarity in these cases is the circumstance that the effusion of fluid into the sac of this membrane, to which the carci- nomatous deposition gives rise, renders it extremely difficult to ascertain the real character of the dis- ease at the early period at which an operation would be desirable. The following case is recorded by Sir Everard Home.* — In December, 1781, a gentleman felt an uneasy sensation in the scrotum. On examining it he perceived the left testicle swelled, with a small degree of hardness to the touch. He immediately applied to a surgeon, who told him that the disease was a hydrocele, and advised him to let it alone till it became large, when it would be necessary to perform an opera- tion, which would effectually cure him. From that time to the beginning of March, 1782, the swelling gradually increased, the pain became acute, and the hardness increased. About this period two other medical gentlemen saw him : they were of opinion that the disease was complicated, and by no means a simple hydrocele ; therefore desired him to do nothing for a fortnight or three weeks, and then * Observations on Cancer, p. 125. CARCINOMA OF THE TUNICA VAGINALIS. 383 they would see him again. In the mean time he was advised to apply to a surgeon noted for curing this complaint, who made two or three punctures for the palliative cure of hydrocele, assuring the patient that the disease was of that nature. On finding a failure of the good effects which had been promised, he again applied to his former surgeon, with the inflammation, pain, and swelling much increased. At this time Mr. Hunter was called in, and it was thought advisable to open into the tumour, to ascertain the real nature of the disease, and then to proceed accordingly. This was done ; and, on examining the substance of the tumour, it appeared to be composed of a thick coat, within which was a grumous and gelatinous substance. From this appearance of the tumour it was thought advisable to remove the whole, which was imme- diately done. Some of the skin, which was diseased and adherent to the fore part of the tumour, was also removed. The tumour was found to consist of a thickened tunica vaginalis, filled with a firm coagulum of blood, which, in some parts, had lost its red particles, the whole appearing like a mottled swelling ; and the testicle entire in the posterior part, only appearing to be squeezed into a smaller size than natural, from the pressure of this sub- stance in the tunica vaginalis. The parts healed up readily, but some months after a swelling on the lower and left side of the abdomen was ob- served. He was sent to sea ; but the swelling increased, and he became weak, hectic, and died. On examining the body there were found large 384 CARCINOMA OF THE TUNICA VAGINALIS. masses of swellings, which were not much firmer than strong coagulated milk with the whey in it. These masses extended up the left side along the back, as high as the diaphragm. The epiploon ap- peared to have a large mass in it, connecting the colon, stomach, and other viscera together. The liver was studded full of small tumours, about the size of a bean, of the same structure ; and the sper- matic cord out of the belly had become thickened in the same way. Sir A. Cooper has described a similar case of carcinoma originating in the tunica vaginalis.* — Mr. T., aged sixty, rather of a bloated unhealthy appearance, fifteen months ago observed a swelling on the left side of the scrotum, which was un- attended with pain, but was accompanied by a formation of water in the tunica vaginalis. He applied to Sir B. Brodie, who directed the mercurial treatment, the application of leeches, and the re- cumbent posture ; but the swelling yielded little to this treatment. About two ounces of fluid were then drawn from the tunica vaginalis by puncture. The operation was repeated, but still the enlarge- ment and hardness remained. Sir A. Cooper was then consulted, and he recommended the same treatment. Afi:er a lapse of several weeks it was agreed that the diseased part should be removed, if, upon puncturing, the quantity of fluid should be found inconsiderable. On passing a lancet into the part in three different places, although fluctua- . * Lib. Cit. p. 207. COLLOID CANCER AND MELANOSIS. 385 tion was apparently distinct, no water was found. The testicle was then removed by Sir B. Brodie, and upon dissection the appearances were as fol- lows : — The testis was perfectly sound The vas deferens could be injected to the beginning of the epididymis only. The epididymis was drawn to a great length by the swelling, and terminated in a membranous cord. The cavity of the tunica vaginalis was occupied by a spongy effusion, which had all the character of incipient fungus. The tunica vaginalis was thickened, and had a large piece of ossific matter in it. The spermatic cord was unaifected. This patient died of erysipelas ; and upon examination, his body was found in other respects free from disease. I have not myself met with any case of this kind. SECTION IV. COLLOID CANCER AND MELANOSIS OF THE TESTIS. The two forms of carcinoma termed colloid or ge- latiniform cancer, and melanosis, scarcely ever attack the testis. The only instance of the former that I know of, is a preparation very characteristic of the disease contained in the museum of Guy's Hospital. The organ is enlarged to four or five times its na- tural size, but preserves its oval form: there is scarcely any trace of the natural structui*e remain- ing. No history is attached to the preparation. Cruveilhier has related the case of a man who 49 386 CYSTIC DISEASE OF THE TESTIS. died at the age of forty-six of melanosis aifecting the hand, lungs, heart, stomach, and other parts.^ The right testis contained a little of the same matter, and the left a deposit the size of a nut. This is also the only case of melanosis of the testis on record with which I am acquainted. CHAPTER IX. CYSTIC SARCOMA OR CYSTIC DISEASE OF THE TESTIS. This is a rare affection, which has been described by Sir A. Cooper under the name of " the hydatid disease of the testicle." But as the cysts are not of the nature of animal hydatids, the term is an im- proper one, and should not be retained. The cysts constituting this disease contain fluid, and are developed in the substance of the testis. , They vary very much, both in number and size, I and in the appearance of their contents. They ' may be only two or three in number, or they may exist in a countless multitude throughout the gland. They vary also in size, from that of a millet seed to the dimensions of a pigeon's egg. At an early period they generally consist of smooth and slightly vascular cysts, closely adherent, and con- taining a transparent light-coloured fluid. The fluid is liable, however, to lose its transparency, * Anatomie Pathologique, liv. x\x. pi. 8 and 4. CYSTIC DISEASE OF THE TESTIS. 587 and sometimes becomes thick, viscid, and albumi- nous, and even tinged with blood. Inflamma- tion occasionally occurs, and coagulable matter is effused into them, and they become more or less thickened. Sometimes small lobulated growths arise from a part of the walls of the cyst, and increase until the cavity is partly or wholly filled and ob- literated by them, in the same manner as in cystic disease of the mamma. The cysts usually increase at the expense of the secreting structure of the testis, which becomes atrophied and displaced from the pressure they produce. When inflammation takes place, fibrine is effused between as well as within the cysts, and becomes organized ; so that eventually no trace is perceived of the natural structure of the testis : the whole character and ap- pearance of the part are completely changed, the organ being partly solid, and partly composed of cysts containing fluid. At an advanced period, particularly when the volume of the testis is much increased, the surfaces of the tunica vaginalis are more or less adherent, and, as well as the tunica albuginea, thickened. In old cases also the tumour is intersected with fibrous bands, and the parietes of the cysts are sometimes transformed into car- tilage or bone. The mode of origin of these cysts has not been satisfactorily made out. Sir A. Cooper was inclined to the opinion that they are formed of enlarged and obstructed seminiferous tubes ; for he remarks, " Although at first sight they appear to be cysts, yet when traced they are not distinct bags, but send 388 CYSTIC DISEASE OF THE TESTIS. out solid processes by which they are connected with other bags."* They seem to me to be ana- logous to the sero-cystic tumours of the breast ; which appear to be formed by a morbid dilatation of the lactiferous tubes. They are evidently quite distinct from the little cysts so commonly developed in the head of the epididymis ; which part, indeed, is rarely affected in this disease. In a testis greatly enlarged by it^ I found the epididymis perfectly healthy. * Lib. eit. p. L. Section of a cystic tumour of the testis, showing a multitude of cysts of various shapes and sizes, with solid matter interposed between them. The natural structure of the gland is wholly destroyed. CYSTIC DISEASE OF THE TESTIS. 389 Some splendid specimens of cystic disease of the testis are preserved in several of the pathological museums in the metropolis. The accompanying wood-cuts, which exhibit the various characters and appearances presented by the disease, are taken from two specimens contained in the museum of the Col- lege of Surgeons. They are reduced in size about one half One of the specimens measures five inches in its longest diameter, and three inches in its smallest. The origin of this disease is sometimes attributed to a blow, but it usually commences without any apparent cause. M. Section of another tumour of the same kind ; the cysts of larger size. 1, 1, 1. Lobular growths from the parietes of the cysts filling and obliterating them. 390 CYSTIC DISEASE OF THE TESTIS. Symptoms. — The swelling to which the cystic disease gives rise takes place imperceptibly, very slowly, and without producing pain. After existing for several months, it occasions a chronic indolent tumour of an oval shape, which seems to fluctuate indistinctly, and is scarcely at all tender or painful. The surface of the tumour is generally smooth and even, but it is sometimes irregular ; and the disease being confined to the body of the gland, the epi- didymis may often be distinguished in its healthy state. But in other cases, especially at an advanced period, the epididymis is lost in the general tume- faction. When the tumour attains a large size it is inconvenient from its bulk, and unless well sup- ported it occasions a dragging sensation and uneasi- ness in the loins. The disease usually commences at the middle period of life ; but I have not myself met with it later than between the ages of forty and fifty. Diagnosis, — Cystic disease of the testis may be mistaken for hydrocele and encephaloid cancer of the testis, and the diagnosis is often very difficult. The tumour is of an oval shape, not pyriform, as in hydrocele ; it feels heavier, and fluctuates less dis- tinctly ; and there is an absence of the pain ex- perienced in compressing the part usually occupied by the testis in hydrocele. The swelling also is not transparent. Notwithstanding these distinctive marks, the surgeon is very liable to err ; and Sir A. Cooper admitted that he had been two or three times mistaken, and had put a lancet into the part expecting to find water issue, and a few drops of CYSTIC DISEASE OF THE TESTIS. 391 blood only have followed * Where there is any doubt the grooved needle should be used. The characters of the tumour occasioned by cystic dis- ease are in general so similar to those produced by encephaloid cancer, that I can give no satisfactory directions for distinguishing them. The surgeon must be guided in his opinion by inquiries into the history of the case, and by noticing the condition of the cord and of the lumbar glands, and the state of the patient's health, which are unaffected in the cystic disease, but are liable to suffer in malignant enlargements of the gland. The tumour produced by the latter affection is also less even and regular, and makes more rapid progress than that occasioned by the cystic disease. Treatment. — No kind of treatment, either local or general, is of any service in this disease, the morbid changes being quite beyond the influence of remedies. The only means that can be adopted is the removal of the diseased gland, which should be performed as soon as the size and weight of the tumour are productive of inconvenience and suffer- ing ; and the disease being confined to the testis, there is no liabiHty afterwards to a return of the affection in other parts, * Lib. cit. p. 84. L 392 FIBROUS TRANSFORMATION OF THE TESTIS. CHAPTER X. FIBROUS TRANSFORMATION OF THE TESTIS. The testis has in some few instances been found transformed into fibrous tissue, its secreting struc- ture having wholly disappeared. It seems that the cellular tissue naturally entering into the com- position of this organ becomes thus changed, and that new fibrous tissue is developed, which, by its pressure, causes atrophy and a total obliteration of the seminiferous ducts. In some instances, the structure into which the testis is converted is a loose fibrous tissue infiltrated with a watery fluid ; more frequently, it is close, dense, and firm, and even car- tilaginous, exactly resembling the fibrous tumour of the uterus. Occasionally it is interspersed with two or three small cells containing a serous fluid. The size of the testis sometimes remains unaltered ; at other times it is increased or slightly diminished. This lesion differs from the fibrous remains of the atrophied testis, since the organ chiefly consists of newly developed or transformed tissue, and not merely of the dehris of old. This disease is not unfi-equently accompanied with adhesions of the tunica vaginalis. The fibrous transformation of the testis is rather a rare pathological change. At page 78 I have described a case of imperfect descent of the testis, in which the gland, though reduced in bulk, had evidently undergone this conversion. In Cruveil- FIBROUS TRANSFORMATION OF THE TESTIS. 393 hier's Anatomie Pathologique,"^ there is an ex- cellent representation of the disease. The testis was removed from a patient at the Hopital Beaujon by M. Marjolin. It was twice the natural size, and very heavy. It offered a good deal of resistance to the knife, and creaked when cut ; and it was entirely composed of a number of grayish-white fibres intersecting each other and arranged in lobules, similar to the fibrous tumour of the uterus. So far as I know, this disease is unattended with pain or any peculiar symptoms besides great indur- ation of the whole organ ; and the change is one over which neither general nor local treatment can exert much control. Sir B. Brodie mentions, that he extirpated a testicle that had undergone this fibrous conversion ; between six and twelve months after the operation the other testicle became hard and enlarged, and apparently affected in a similar way. As an experiment he gave the patient iodine internally, and rubbed the iodine ointment on the testicle also. The hardness became in some degree diminished, and the progress of the disease stopped ; and the patient left the hospital with the greater part of the remaining testicle in a sound state. The disease is not of a malignant character ; and as in general it produces little or no inconvenience, the extirpation of the gland is rarely required. The operation is occasionally undertaken from appre- hension of the disease being scirrhous or malignant. Mr. Travers mentions a case in which the gland was removed, owing to the person affected being impa- * Liv. V. pi. 1. fig. 3. 50 394 FIBROUS TRANSFORMATION OF THE TESTIS. tient for its extirpation on this account.* The gland being quite useless when in this state, there is no particular objection, after other means for the reduction of the induration have failed, to castration to allay the patient's fears, and to remove a con- stant source of uneasiness from his mind ; but it is not a disease which absolutely requires the opera- tion. CHAPTER XL OSSIFIC DEPOSITS IN THE TESTIS. Earthy matter is met with in the testis under two forms : 1. Laminated, and often mixed up with car- tilage ; and, 2, as an inorganic cretaceous deposit. In the first form it is usually deposited between the tunica vaginalis testis and the tunica albuginea, in little bony or cartilaginous patches, in which a jfibrous arrangement may be recognised. I have frequently found one or two irregularly-shaped pro- jecting ossific bodies scarcely larger than a pin's head attached to the tunica vaginalis, covering the upper part of the testis. Ossific matter occurs also on the adherent surface of the tunica vaginalis in old cases of hydrocele, where it has been found so abundant as to form a complete ossific capsule. It has been said that the epididymis alone may be * Medico-Chirurgical Transactions, vol. xvii. p. 327. OSSIFIC DEPOSITS IN THE TESTIS. 395 encased in bone, the testis being free ; but this I have never seen. Earthy matter in this form is not often observed in the substance of the testis. The gland, however, when atrophied and reduced to a mere fibrous tissue, occasionally undergoes both the cartilaginous and osseous transformation. The ac- cidental cysts developed in the testis are likewise liable to similar changes. 109 parts of ossific matter from the tunica vagi- nalis, divested of membrane and dried, were found by Mr. Barry to consist of Phosphate of lime - - - 45 Carbonate of lime (with a trace of magnesia) 17 Animal matter - - - - 38 100* These changes possess more pathological interest than practical importance. The following case, however, is interesting. — A soldier, about seventy years of age, whose left testis was partly converted into bone, and felt extremely firm and indurated, was an out-patient at the London Hospital under Mr. Adams for many weeks. He applied on account of the organ becoming painful and inflamed. After some time it suppurated ; and the pus, on being discharged, had the usual offensive smell of an abscess connected with dead bone. The ossific matter came away by degrees in small pieces, which amounted to nearly one hundred, and the patient ultimately recovered with an atrophied testis. * Sir. A. Cooper on the Diseases of the Testis, p. 245. 396 LOOSE BODIES IN THE TUNICA VAGINALIS. In the second form the earthy matter is deposited in an irregular cretaceous mass containing very little animal matter ; in appearance resembling mortar, and very similar to the earthy substance found in the lungs and bronchial glands. It is generally met with in the globus major of the epi- didymis, and sometimes in the globus minor, but very seldom in the body of the testis. I am inclined to believe that it results from the transformation of tubercular matter deposited in the testis in early life. (See observations at page 349, and the accom- panying figure.) Andral mentions that he once discovered a calculous concretion about the size of a nut betv^een the tunica albuginea and the tunica vaginalis, which latter was elevated over the tumour, the testis and tunica albuginea being unaltered.* CHAPTER XII. LOOSE BODIES IN THE TUNICA VAGINALIS. Loose bodies are occasionally found in the cavity of the tunica vaginalis. They are small in size, and of an oval flattened shape ; and their surface is smooth and polished. Their texture is in most instances elastic and homogeneous, resembling the unattached cartilages found in joints ; and points * Precis d'Anatomie Pathologique, torn. iii. p. 669. LOOSE BODIES IN THE TUNICA VAGINALIS. 397 of ossification are often contained in their in- terior. In some specimens I have observed the cartilaginous matter to be arranged in concentric laminae. The loose body is sometimes entirely composed of bony matter. On examining a thin lamina of one in the microscope, I could distinctly see small oval corpuscules, with a number of lines proceeding from them, very similar to those of bone represented in pi. 1, fig, 13, of Miiller's Physiology by Baly. Richter of Gottingen met with three round bodies in the tunica vaginalis, which were quite hard, and of the size of a very large hazel- nut ; but they rarely attain so large a size as this.* They seldom exceed three in number ; and they occur generally in combination with hydrocele, the loose bodies being the original disease, since in their movements in the cavity of the tunica vagi- nalis they promote a greater secretion of fluid from the serous membrane, in the same way as a loose cartilage in a joint excites an increased syno- vial secretion from the membrane by which it is lined. In some cases the surface of the tunica vaginalis is found thickened and uneven. The manner in which these loose bodies origi- nate does not differ essentially from the mode of developement of loose cartilages in the interior of joints. Deposition takes place between the tunica vaginalis testis and the tunica albuginea ; and the former membrane is gradually protruded, until the cartilaginous or ossific body forms a pendulous * Medical and Chirurgical Observations, tr. 398 SPERMATOCELE. tumour, which, being attached merely by a slender stalk, is accidentally separated in the motions of the testis, and is thus left loose in the cavity of the tunica vaginalis. These bodies have been ob- served in the various stages of their developement. In a loose substance of the size of a small grape of firm consistence, and possessing a bony nucleus, found in a case of hydrocele, Morgagni noticed a short and slender neck by which it had been ad- herent.* But in general there is no trace of the original attachment left on either the loose body or the tunica vaginalis. CHAPTER XIII. SPERMATOCELE. This term implies a tumour formed by a collection of the seminal fluid ; but it has occasionally been applied by writers to swellings produced by vari- cocele and other affections of these parts. I have sometimes noticed in testes, otherwise healthy, small collections of thick caseous matter of a yellow colour (apparently inspissated sperm) blocking up and distending some of the efferent tubes of the epi- didymis, and the round dilatations frequently con- nected with them ; but, with this exception, I know of no affection of the testis to which the term sper- * Cooke's Morgagni, vol. ii. p. 429. FCETAL REMAINS OF THE TESTIS. 399 matocele can be properly applied. It is possible that the semen might collect in and dilate one or more of the seminiferous ducts in the testis, in con- sequence of some obstruction, and thereby consti- tute a swelling of a similar character to the lacteal tumour of the breast ; but amongst the many hun- dred testes I have examined, I have not met with a single instance of the kind.^ CHAPTER XIV. F(ETAL REMAINS IN THE TESTIS. The remains of a foetus have in rare instances been found in the scrotum in connexion with the testis. Several examples of the kind have been collected by Ollivier (D'Angers).t In all these cases it was evident that the scrotal inclusion had succeeded to an inclusion originally abdominal ; that is to say, that the organic debris were first situated in the abdomen along with the testis, having accompanied the gland in its progression out of that cavity. In two of the cases in which the particular testis was indicated, the right was the one affected. M. Velpeau has recently communi- * I have found the semen thus collected in the lower part of the epididymis of the dog, some months after excising a portion of the vas deferens. \ Memoire sur la Monstruosite par Inclusion ; Arcliives Generales de Medecine, torn. xv. p. 540. 400 ENTOZOA IN THE TESTIS. cated to the Academy of Sciences an account of the case of a man, twenty-seven years of age, whose right testis he removed by operation for a con- genital enlargement, which was found to be occa- sioned by the presence of nearly all the anatomical elements of a foetus.* Dr. Andre removed by ligature a tumour con- taining hair and several teeth from the right testis of a boy seven years of age. The boy was well formed at birth ; but at the end of a year his parents observed that the right testis was larger than the left. In six months afterwards the child was operated on for hydrocele : a little serum escaped, but the testis remained larger in size than natural. When he was nearly seven years of age the gland became swollen and painful : a sore formed in the scrotum ; and a fleshy growth pro- truded, which was found to contain several long hairs and teeth.t CHAPTER XV. ENTOZOA IN THE TESTIS. The Entozoa very rarely indeed infest the testis ; in the examination of a large number of testes I have not met with a single example. Sir A. Cooper * Gazette Medicale de Paris, Fev. 15, 1840. I Memoires de FAcademie Royale de Medecine, torn. iii. p. 480. IRRITABLE TESTIS. 401 mentions an instance of an independent cyst, pro- bably an acephalocyst, which was found accidentally on dissection in a sac connected with the epididy- mis."* Dr. Baillie once met with Rjilaria medinen- sis, or Guinea- worm, in a firm cyst adherent to the testicle. CHAPTER XVI. NERVOUS AFFECTIONS OF THE TESTIS. We may distinguish two kinds of nervous affections of the testis. One which, in my experience, is the more common of the two, consists in an exaltation of the natural sensibility of the part ; and it is to this complaint that the term " irritable testis" used by writers more properly applies. The other is a true neuralgic affection of the spermatic nerves. SECTION I. IRRITABLE TESTIS. A patient suffering from an irritable testis cannot in many cases bear the least pressure on the gland, not even the contact of his dress : he shrinks when the part is handled in the most gentle manner ; and the motions of the testis often occasion so much uneasiness that he is prevented from taking exer- * Lib. cit. p. 90. 51 402 IRRITABLE TESTIS. cise, and is compelled to remain constantly at rest in the recumbent position. The morbid sensibility is not always confined to the testis, but sometimes extends up the cord to the loins, so that the passage of faeces through the colon and its distension by flatus are liable to cause uneasiness. The pain is in some degree increased when the patient is in the erect position and the testis without support. It is frequently referred to one particular spot on the gland, which possesses more exquisite sensibility than the surrounding parts. In some instances both testes are affected, one perhaps more than the other ; in other cases the morbid sensibility is con- fined to one side, generally the left. There is no perceptible alteration in the parts, except occasion- ally a degree of fulness, more particularly in the spermatic cord ; slight varicose dilatation of the veins, and a relaxed state of the scrotum. The complaint is usually tedious, and lasts many months. The persons subject to it are those of a weak and irritable habit, who are dyspeptic or hypochon- driacal, and unequal to much bodily or mental exer- tion. In this affection all enjoyment of life and its pleasures disappears ; the sufferers concentrate their thoughts upon their maladies ; they fancy they shall never get cured ; and whilst some become uneasy as to the effect of the complaint in impairing the integrity of the gland, and rendering them impo- tent, others as urgently desire castration as the sole means of relief from their distress. Morbid sensibility of the testes is in general intimately connected with the state of the genital IRRITABLE TESTIS. 403 functions, and is frequently dependent on abuses of them. In several instances I have known it to be consequent on onanism, and on involuntary seminal emissions ; and I have found it disappear when the seminal discharges ceased. It sometimes occurs after cessation from free indulgence in sexual inter- course ; and it occasionally affects persons exposed to sexual excitement, but who have not been able to indulge their passions. In such cases the glands are very much in the same condition as the tender and swollen mammas at the commencement of lactation or of weaning. In a person of chaste habits thus affected, I was informed that the morbid sensibility disappeared on marriage. The testes, like the mammae, often also become affected with morbid sensibility about the period of puberty. The com- plaint sometimes succeeds an attack of orchitis. Though troublesome, it generally disappears either spontaneously or under treatment after a longer or shorter duration. Treatment,— \b. the treatment of morbid sensi- bility of the testis the first object is to endeavour, if possible, to get rid of the cause of the affection. In many cases, however, this cannot be ascertained, or is only suspected. Attention must be paid to the state of the general health and of the digestive organs. Steel medicines and quinine may often be given with benefit. In many cases much service is derived from change of air and scene, so as to amuse the mind, and prevent the sufferer from brooding over his complaints. It often happens that when the mind is occupied, and the patient I 404 IRRITABLE TESTIS. obliged to exert himself, he is free from suffering. As in many other nervous affections, the complaint becomes worse and aggravated by too much atten- tion being paid to it. Advantage is often derived from cold bathing, and sponging the scrotum with iced water. I have sometimes succeeded in pro- curing relief with the douche bath, by causing a stream of cold fresh-drawn spring water to be directed on the scrotum so as to produce a power- ful effect. The eye-douche bath, or a kettle, will answer the purpose very well, and the application should be made at least once daily. Enclosing the scrotum in a belladonna plaister, and supporting the parts, also sornetimes afford relief The testis may at the same time be preserved from the effects of friction and contact of the dress, when the patient moves about, by lining a full-sized suspender with a layer of soft wadding or wool. But the surgeon's success in the treatment of these cases mainly de- pends on his being able to ascertain the true cause of the complaint. — A young man set. 22, a sack and tarpauling maker, applied to me for relief on account of distressing pains in the testicles. He stated that he was a single man, and had suffered from these pains for about two months. He was of a weak frame of body, thin and pale ; and had a languid, melancholy countenance, and was subject to headache. His voice was feeble, and he trembled as he^entered the room. The penis and testes were small in size ; the latter were extremely tender when handled, so that he could scarcely suffer me to touch them. He stated that he had no discharge IRRITABLE TESTIS. 405 from the urethra, and had never been affected with syphilitic disease. I directed the testes to be sup- ported and kept cool, and as much as possible pro- tected from friction, and ordered the shower bath and steel medicines. Suspecting, from his general appearance and the character of his countenance, that he was addicted to onanism, I twice questioned him upon the subject, but without eliciting that he was habituated to this vice. But after he had at- tended for some time, and the above remedies, as well as arsenic, quinine, purging, blisters to the loins, &c. had been tried without any decided improvement, I made further inquiries, and ascertained that he had been for years subject to involuntary seminal emissions, which occurred without erections both in the daytime and at night, and often on evacuating the bowels. I introduced into the urethra a full- sized bougie, and found that it produced great pain on reaching the prostatic part of the canal. I then applied the nitrate of silver to this part of the urethra by means of Lallemand's instrument (see page 444.) The application was transient, but the patient instantly fainted from the sharp pain which it produced. The effects of the lunar caustic subsided in about a week. No emissions occurred afterwards. The pains in the loins and morbid sensibility of the testicles soon completely subsided ; he lost his headache, and in a few weeks became much improved in health, when he was discharged cured. I have treated, with a similar application of the nitrate of silver to the prostatic part of the urethra, and with the same success, two other cases. n 406 NEURALGIA OF THE TESTIS. in which the morbid sensibility of the testis was less severe, but dependent on the same cause as in the one just related. Castration should never be performed for this affection ; for the complaint generally ceases sooner or later, and can almost always be relieved by judicious treatment. Romberg relates,^ that he had a patient under his care who was attacked with this disease at the time he was engaged to be married. In spite of all the serious objections of a distinguished surgeon whom he had called into consultation, in spite of his own earnest representa- tion, the patient insisted upon having castration per- formed ; and the operation was accordingly done, that no greater mischief might ensue. Eight days afterwards the old pain had taken up its seat in the other testis ; but this its owner preferred keep- ing, the marriage being at hand, and he very soon recovered completely. The testis which had been removed, with the exception of a few dilated ves- sels, did not differ in the slightest degree from the normal state. SECTION II. NEURALGIA OF THE TESTIS. In the nervous affection just described there is merely morbid sensibility ; pain seldom being ex- perienced whilst the patient remains at rest, and the gland ^nd spermatic cord are supported, and entirely * Lehob der Nervenkran^kheiteii, S. 142. NEURALGIA OF THE TESTIS. 407 free from pressure or rough contact with the dress. The nerves of the testis are liable, however, to a more painful affection, possessing the characters of tic douloureux or true neuralgia, in which the pain is sudden, severe, and remittent, and occurs in pa- roxysms of variable duration, generally at irregular, but occasionally at regular intervals. The pain is sometimesof an acute dartingor lancinating descrip- tion, at other times of a dragging or pricking nature ; and it is commonly attended with forcible retrac- tion of the testis to the groin by spasmodic action of the cremaster muscle, and occasionally with nausea and vomiting. Dr. Graves mentions a case in which the patient, when attacked with a pa- roxysm, would throw himself on the floor and roll about in the greatest agony, covered with a cold perspiration.^ During the intervals of the pa- roxysms the testis may sometimes be freely handled without causing pain ; but frequently the neuralgia is combined with morbid sensibility, and a paroxysm is readily induced by the slightest pressure. In two cases, in which the neuralgic symptoms were slight, and appeared to depend on some affection of the kidney, the patient complained of a remitting pain or soreness at the crest of the ilium, near the an- terior superior spinous process, though there was no tenderness on pressure. In most cases of neuralgia testis, there is no disease or alteration in the gland ; but when the pains have been long-continued and iutense, the * Dublin Journal of Medical Science, vol. xiv. p. 371. 408 NEURALGIA OF THE TESTIS. testis occasionally becomes swollen and tender, and affected even with a slight degree of inflammation. This painful affection is unaccompanied with fever ; but the digestive organs are usually out of order, and the health deranged from the acute suffering and disturbance of the patient's rest. The neuralgia is almost always confined to the spermatic nerves of one side, whilst in morbid sensibility both sides are as frequently implicated. Neuralgia of the testis occurs at all ages, and is a complaint which appears to arise from various causes. We have examples of it in the uneasiness in the testis and spasm of the cremaster muscle occurring in diseases of the kidney, and in the severe neuralgic pains usually experienced during - the passage of a calculus along the ureter to the bladder. In treating of varicocele, I have stated that a dilated state of the spermatic veins is oc- casionally accompanied with neuralgic pains in the testis ; and as the latter occur subsequently to the appearance of the former, and subside on its re- moval, and often when the patient is in the recum- bent position, we may conclude that the morbid condition of the veins is in some way the cause of the neuralgia. But the pathological cause of neu- ralgia of the testis is seldom so obvious as in the above instances. The testis has been accurately examined, and the nerves of the cord have been carefully dissected out, but nothing to account for this distressing complaint has been discovered."* * A perfectly healthy testicle, extu-pated by Sir W. Blizard on account of this disease, is preserved in the museum of the College of Surgeons. NEURALGIA OF THE TESTIS. 409 Its primary seat has been referred to the spinal cord ; in some instances it has appeared to depend on derangement of the digestive organs,"^ and in others it was evidently connected with a disposition to gout. In several cases, also, it has succeeded an attack of orchitis, continuing to distress the patient after all inflammation has subsided, and recurring or increasing whenever he gets out of health ; but in the majority of instances it is very difficult and even impossible, to make out either the cause or origin of the neuralgic pains. Treatment. — In cases of neuralgia testis de- pendent on renal disease, the passage of a calculus along the ureter, or varicocele, the treatment must chiefly be directed to the relief of the complaints to which the nervous affection owes its origin. The pains may, however, be mitigated by opiates, warm baths, and fomentations of hops or poppy heads. When the disease is connected with derangement of the digestive organs, or a tendency to gout, mea- sures must be taken for their correction. In all cases particular attention should be paid to the condition of the urine. Cases of neuralgia testis, in which neither the cause or seat of disease can be discovered, must necessarily be treated empirically. Those of an intermittent character are sometimes benefited by quinine in large doses, as five grains three times a day, or the liquor arsenicalis. In Dr. Graves' acute case of neuralgia previously alluded to, the * Vide an interesting case related by Sir B. Brodie, London Medi- cal Gazette, vol. xiii. p. 620. 52 410 NEURALGIA OF THE TESTIS. complaint yielded to large doses of the sesquioxide of iron freshly prepared, and frequent inunction of the testicle and cord with belladonna ointment. The oil of turpentine sometimes proves very effica- cious in these cases, when not dependent on renal disease. It may be given in the form of linctus, prepared as follows : — Take the yolk of one egg ; oil of turpentine 3iij ; syrup of orange peel and of tola, of each 3ij ; and of laudanum 3J. Three table spoonfuls to be taken daily. Other remedies of reputed efficacy in neuralgia have been tried in this affection, but have all dis- appointed expectations much oftener than they have cured. The various preparations of opium, hyoscyamus, conium, and aconitum, often affi^rd, however, temporary, if not permanent relief; and they greatly contribute to mitigate the patient's sufferings, when incapable of removing the disease. The scrotum may be blistered, and the surface dressed with an ointment containing the acetate or muriate of morphia, in the proportion of five grains to the ounce. The application of a belladonna plaister often gives relief An ointment containing one grain of aconitina to a drachm of lard, smeared over the scrotum in the direction of the cord twice a day, will sometimes arrest the pains for many hours. The tincture of aconite^ properly prepared, and applied to the scrotum with a piece of sponge, produces a numbing sensation, and is efficacious * Unless care be taken that these expensive preparations are genuine, the practitioner will often be disappointed in their effects. NEURALGIA OF THE TESTIS. 41 I in relieving both the morbid sensibility of the testis and neuralgic pains. I have sometimes known benefit derived from the extract of hyoscyamus, in doses of ^ve grains, combined with half a grain of the acetate of morphia, taken twice a day. Local bloodletting seldom proves of more than temporary service, and is sometimes hurtful by les- sening the patient's powers. I have no confidence in counter-irritation, or the veratria and iodide of mer- cury ointments, which too often cause additional suffering without the compensation of mitigating the nervous disease. No benefit is derived from the action of mercury, except when given in small doses to improve the state of the secretions. In the treatment of these obstinate and protracted cases, the practitioner often labours under a disad- vantage, owing to the patient not obtaining the speedy relief he expected, losing confidence in his attendant, and seeking other advice ; so that he goes from surgeon to surgeon, without affording any one the opportunity of steadily persevering in the management of the case. In cases in which remedies of every kind and in all shapes have been repeatedly tried, and have as frequently failed in affording more than temporary relief, the patient's life is sometimes rendered so truly miserable that his patience is exhausted, and he becomes anxious to undergo some operation, and even that of castration, to get rid of a disease of so obstinate and harassing a character. Opera- tions, however, for the cure of neuralgia are in genera] very precarious and unsatisfactory, and the 412 NEURALGIA OF THE TESTIS. more extended our experience the less encourage- ment we find to repeat them. When the disease has a constitutional origin, or its true seat is at a distance from the part where its painful effects are manifested, and beyond the reach of the knife, it would be unreasonable to expect any beneficial result from the division of the nerves, or the re- moval of the part to which the pains are referred ; and we find that in several of the cases in which the operation has been resorted to no benefit has resulted from it. Dr. Macculloch mentions a case of neuralgia testis, in which, after a long period of suffering, the gland was extirpated in the usual manner, but the disease returned in the cord* Mr. Russell has given a brief account of three casesof this affection which occurred in Edinburgh. In one, in the per- son of a medical practitioner, castration was per- formed on account of the intolerable suffering, and with perfect relief The patient recovered his health, strength, and spirits, which had been im- paired by the severity and continuance of his com- plaints. A practitioner, encouraged by the success of this operation, adopted a similar practice in a like case, which, however, was not followed by an equally favourable result ; as the patient experienced in the first instance but imperfect relief, while the com- plaint gradually returned, increasing in severity, till at last it attained its original violence. The next case that occurred was treated upon other * Essay on the Marsh Fever and Neuralgia, p. 77. NEURALGIA OF THE TESTIS. 413 principles. The practitioner advised the patient to submit to his sufferings with patience, in the hope that time would at last accomplish a cure. The patient followed this advice, and was relieved from his misery in the course of eighteen months.^ Sir A. Coopor has resorted to castration in three cases of neuralgia testis, in all of which the result appears to have been satisfactory, the patients having re- covered, and afterwards continued free from any return of their distressing complaint. — Case 1. Mr. G., in October, 1815, contracted a gonorrhoea, and in consequence had inflammation of the right testicle, for which he applied fomentations, and took aperient medicines. The testicle continued swollen and painful until June, 1816, when the employment of plaisters removed all inconvenience. A slight degree of pain returned at intervals until June; 1817, when he was again relieved by plaisters, and thought himself sufficiently well to join his regiment. The exercise which his duty obliged him to take soon occasioned so much pain, that during the winter of 1817 and spring of 1818 he scarcely had a moment's respite. In May he re- turned to England, and bathed in the sea till Sep- tember, at which time the pain was nearly removed ; but he was unable to walk or ride. He subse- quently became unable to walk ten yards without experiencing considerable pain. The only thing which appeared to relieve him was violent motion in a rough carriage. On account of the continued * Observations on Diseases of the Testicle, p. 186, et scq. 414 NEURALGIA OF THE TESTIS. pain, confinement, consequent depression of spirits, and loss of health, he determined on having the testicle extirpated. It was removed on the 1st of March, 1819. The wound healed slowly, and one or two small abscesses formed in the scrotum ; but he ultimately did extremely well, having no return of pain in the spermatic cord. — Case 2. Captain P. had an irritable state of the left testis, which com- menced in March, 1818. The veins of the sper- matic cord felt distended ; the part was exquisitely tender to the touch ; and exercise produced a degree of suffering which was intolerable, if the part was not supported. He could not rest on the side, or bear the slightest pressure on the testis. He had increased pain in coition ; and after it the part felt full and loaded. He was somewhat, but only for a time, relieved by the hot bath or foment- ations. He tried blistering at five different times ; applied two hundred leeches on separate occasions to the affected part ; employed various lotions, opium, and belladonna, with every medicine which seemed likely to be useful in lessening the irrita- bility, but all without effect. Sir A. Cooper re- moved the testicle for him in 1823. He quickly recovered from the operation, and felt very grateful for his restoration to comfort and society. — Case 3. This subject was a gentleman who came from America for advice, having tried every variety of medicine and local treatment without advantage. At his request Sir A. Cooper removed the part ; and he has since heard that the patient remains quite well. He said for several years past his left J^EURALGIA OF THE TESTIS. 415 testicle had been larger than his right ; at times considerably so, especially when he had taken cold. In August last, after exposure to unusual fatigue, he had pain for the first time in the left thigh and groin, also in the testicle, which was much en- larged. In September a surgeon made an incision into it, and let out a large quantity of water. In a few days after the part again became painful : he applied poultices and fomentations. The pain con- tinued ; in about six weeks the operation was repeated, but very little water was drawn off. He took mercury until his mouth became sore, and lay in a horizontal position. A blister was sub- sequently applied to the scrotum. These remedies gradually reduced the testicle, but the pain con- tinued ; sometimes a sharp shooting pain in the groin, but generally a heavy, dull constant pain. He then applied leeches which produced debility ; since which he used a lotion of lead and opium. The pain was constant, and he could not stand ten minutes without increasing it considerably. There was great sensibility in the part, and the slightest touch was painful. He was subject to headache and other dyspeptic symptoms, and a long residence in warm climates had injured his constitution.* The details of these three interesting cases should be carefully examined, in order that the practice of so eminent a surgeon may not be made to coun- tenance the indiscriminate performance of an operation the general results of which are less * Lib. Cit. p. 69, et. seq. 416 NEURALGIA OF THE TESTIS. satisfactory than might be inferred from these ex- amples. Their success may, I think, be accounted for. In all of them it is clear that the neuralgia had a local oriorin. In the second case it was com- bined with varicocele ; a complication which, it will be shown,* is of occasional occurrence, and admits of perfect relief by castration, the cause of the disease, viz. a morbid condition of the veins, being thereby removed, together with the testis. In the two other cases, it appears that the neu- ralgia was originally induced by an attack of orchitis ; and though it afterwards proved irreme- diable by antiphlogistic means, and persisted after all inflammation had subsided, the nerves affected were evidently those immediately connected with the testis, which having been removed, the painful sym.ptoms all ceased. In such cases, then, in which the neuralgia has a local origin, is confined to one side, and is clearly dependent on some change in the state of the nerves of the testis or cord, cas- tration might be performed when the symptoms are sufficiently severe, and the patient is willing to undergo it with a fair prospect of permanent relief. But in cases in which it is impossible to determine exactly the seat or the cause of the disease, the surgeon incurs no slight risk of failure ; and if he ventures to undertake the removal of so important an organ as the testis at the earnest entreaty of the sufferer, it would be his duty, as it would be his policy, fully to apprise his patient of the un- certainty of the result. * Vide Part III. Chap. 1. SYMPATHETIC DISORDERS OF THE TESTIS. 417 CHAPTER XVII. SYMPATHETIC AND FUNCTIONAL DISORDERS OF THE TESTIS. Imperfect as is our knowledge of the sympathetic and functional disorders of the secreting glands, no organs present greater difficulties in this respect than the testes. Their functions are so involved in those of other parts, are influenced by such peculiar causes, and are so dependent on and mo- dified by particular events and circumstances, that the investigation of them, when disordered, neces- sarily becomes of a complex and difficult character. The product, too, of these glands is one the quali- ties of which it is almost impossible to appreciate, and which during life is never affi^rded in a pure and unmixed state ; and further, taking into ac- count the repugnance felt to such inquiries it is scarcely surprising that the subject has been but imperfectly investigated, and rarely treated of by the pathologist and practitioner. Indeed, the little information we possess respecting it is chiefly to be found under the head of Impotency in works on Medical Jurisprudence, in v/hich it is cursorily considered, principally in relation to points of medico-legal interest, and scarcely at all in reference to practice. The functions of the testicles may, like those of 53 418 SYMPATHETIC APsD FUNCTIONAL many other secreting organs, become suspended, | and be incapable of excitement ; or they may be exerted to excess, and be so abused as to be called into action by the slightest exciting causes. I shall in the first place, consider the former of these dis- orders, which will include the subject of impotency, so far as it depends on an imperfection in the action and condition of the testes. In speaking of the functions of the testes (page 67) I pointed out how much these glands are under the influence of the brain, and noticed the striking effects of impressions on the mind in arresting their secretions ; and in Chapter II. Section 2, several cases have been mentioned in which the testicles had completely wasted after injuries to the head and brain, and also cases of idiots, whose generative organs were imperfectly formed, who had expe- rienced no desire for sexual pleasures. I will now adduce some additional facts in relation to this subject. — Hildanus mentions the case of a man ac- cused of impotency by his wife, who sued for a divorce. Nothing external was defective ; but the man stated that eight years previously he had re- ceived a blow on his head by a stick. From that period " confitebatur penem erigi non posse."^ — Mr. B., aged forty-one, a passenger on the railway between Boston and Providence, apprehending an accident, thrust his head out of window at the mo- ment that the train came in collision with another running in an opposite direction with fearful vio- * Opera Observationum et Curationum Medico-Chirurgicarum, p. 574. DISORDERS OF THE TESTIS. 419 lence. Most of the passengers were thrown out, and seriously injured. Mr. B.'s head and neck struck against the edge of the window-frame with great force ; and he himself was thrown to th€ ground, where he remained for some time in a state of insensibility. He, however, regained his senses, and was conveyed home in a carriage. The surgeon on visiting him found him suffering great pain in the occipital region and upper part of the neck ; but ther€ was no indication of fracture of the skull or spine. On the second day after the accident he complained of a numbness in his right arm, and experienced difficulty in passing his urine. In the course of two weeks he was able to leave his bed, and walk in the street ; but his vision was defective. Between the fourth and fifth week after his injury he made the discovery that he had lost the desire and physical power for sexual intercourse, and that no amorous sentiment, or the approach of a female, could excite it. Under appropriate treatment the bladder gradually recovered its power, and his vision became perfect ; but the numbness of the right arm continued, and the generative functions remained impaired. His mental powers, particu- larly his memory of events, were also for a time seriously affected.^ Dr. Smyth, in some excellent observations on the subject of impotency, states that he has seen complete impotence (absence of erection) of three months' duration, accompanied by general emaciation and impairment of health, * Case related by Dr. Fisher. American JouTiial of the Medical Sciences, Feb. 1839, p. 357. 420 SYMPATHETIC AND FUNCTIONAL excessive irritability of both mind and body, and considerable shrinking of the penis and testicles, occur in a strong young man of twenty-five from injury of the back part of the head. This gentle- man being engaged in a quarrel, received a blow on the face which stunned him ; and having fallen backwards, first struck the ground with the tuber- osity of the occipital bone, and sustained in conse- quence a concussion of the brain, manifested by insensibility and total unconsciousness of eight or ten hours. Being a diligent student of medicine, he continued his professional pursuits the following day, and without interruption for six weeks, during which time he took no further notice of the occur- rence. The general emaciation and failure of the sexual function were first perceived in little more than a week after the injury.^ Dr. Gall mentions that at Vienna he was consulted by two officers who had become impotent in consequence of blows from fire-arms which had grazed the napes of their necks-t When impotency depends on an injury of the head, the prospect of relief is in general far from promising. The event itself is one of the last to be detected, and is rarely perceived till all remedial treatment for the injury has ceased, and the patient is in progress of recovery. In some instances it is first announced by the visible wasting of the testes. When otherwise, however, the surgeon must not despair of the patient regaining his sexual powers * The Lancet, August 28, 1841, p. 784. t On the Functions of the Cerebellum, tr. by Combe, p. 46. DISORDERS OF THE TESTIS. 421 as the other effects of the injury disappear. Thus one of the officers mentioned by Gall recovered by degrees the generative faculty, married, and became the father of several children. Purgation, followed by a slight alterative course of blue pill, effected a complete and speedy cure in Dr. Smyth's patient, after change of air and other hygienic measures had been tried in vain : as the gums became tender the patient began to recover flesh, and to experience a return of the procreative power. In the case of the patient injured on the railroad, the function was only partially restored. The treatment required in these cases would chiefly be such as would be adapted to remove the other symptoms of cerebral mischief If aphrodisiac medicines are used, they must be given with great caution. Electro-galvan- ism, applied from the occiput along the spine, might also prove of service. The reader will recollect the singular case of arrest of the developement of the testis related at page 120, in which the organs acquired their normal size and assumed their functions at an unusually late period of life, as the dormant pas- sions were aroused by a particular attachment. No doubt some men are less susceptible to the in- fluence of the female sex than usual ; and in such persons, until a suitable impression is made, and the instinct is excited, the sexual organs may re- main long inactive, and in abeyance. There are well recorded instances of men, and of persons too of great intellectual attainments, who, though to all appearance perfectly formed, have not only 422 SYMPATHETIC AND FUNCTIONAL passed a life of absolute chastity, but have never even evinced the slightest disposition for sexual enjoy- ment. In the figurative language of Sir A. Cooper, " To such persons a Venus might display her charms, and on such her son might exhaust his quiver, in vain. No genial spring is here, no blooming summer, or fruitful autumn ; but all is winter — a dreary, desolate, and barren winter — in which the springs of life are frozen up, and the animal propensities destroyed." It is difficult to account for such cold indifference ; but we may suppose that, in some instances, that particular part of the brain which is the seat of the procreative function has been but little or imperfectly deve- loped. The several facts stated in this work fully justify the inference that the functions of the testes may remain unexercised, and that impotence may ensue from a cerebral defect, or from the absence of the usual stimulus derived from the sensorium ; and though more often occurring in idiots, I per- ceive no reason why such a fault should not exist in a brain otherwise in a high state of perfection. This constitutional and congenital form of impo- tency is sometimes, but not always, accompanied with arrest in the developement of the sexual organs, and an effeminate appearance and frame of body. Impotency of a temporary nature may be the effect of violent emotions of the mind, as mental affliction, anxiety, and rage ; indeed any impulse sufficiently intense to absorb the attention to the exclusion of the sexual passion will extinguish desire, and arrest the secretion of the testes. When, however, the DISORDERS OF THE TESTIS. 423 emotion subsides, and the mind becomes tranquil- lized, the generative instinct may again be incited to action. Disgust, also, is sometimes a cause of sexual incapacity. Thus men, at other times competent to the act, have remained impotent in the company of certain women, owing to a natural aversion, or the uninviting person of their com- panion. For such cases of relative irnpotency the remedy is obvious. Not an unfrequent cause of a failure in the ex- ercise of the reproductive powers is want of self- confidence, — excessive apprehension of inability to perform well the duty of the sex. When persons are so timid and diffident as to entertain these groundless fears, it may be long before success attends their efforts, every failure adding to the evil by diminishing the reliance upon their powers. Mr. Hunter has treated this kind of impotency depending on the mind with his accustomed sa- gacity, and has related the following case. — He was consulted by a gentleman who had lost his powers in this way. The patient was subject to erections, accompanied with desire ; but from doubt, or fear, or the want of success, was unable to copulate with a particular female. Mr. Hunter told him that he might be cured if he could per- fectly rely on his own power of self-denial. He was then recommended to go to bed to this woman; but first to promise himself that he would not have any connexion with her for six nights, let his in- clinations and powers be what they would, which he engaged to do. This resolution produced such 424 SYMPATHETIC AND FUNCTIONAL a total alteration in the state of his mind, that the power soon took place ; for instead of going to bed with the fear of inability, he went with fears that he should be possessed with too much desire, too much power, so as to become uneasy to him, which really happened ; for he would have been happy to have shortened the time : and when he had once broken the spell, the mind and powers went on together, his mind never returning to its former state.^ Modes of varying this advice in the case of persons | recently married, who may be affected with this form of impotency, will readily occur to the prac- titioner. Thus some mild tonic may be prescribed, and the patient be directed to abstain from inter- course while under treatment, and the surgeon may rest satisfied that not many days will pass over before nature asserts her empire. These cases must on no account be lightly treated. The situ- ation of the patient is often one of great distress of mind, and much relief may be afforded by the surgeon calmly reasoning with him on the subject of his complaint. He may be told that his case is not uncommon ; the true cause of failure may be pointed out ; and he may be confidently assured of the groundless character of his fears, and of the influence of his doubts and apprehensions in pre- venting him from fulfilling his desires. Kind and confidential advice of this nature, by encouraging the patient, will do more in effecting a cure than any sort of medical treatment or stimulating me- dicines. * Treatise on the Venereal Disease, 4to. p. 203. DISORDERS OF THE TESTIS. 425 Diseases which destroy the substance or pro- duce wasting of the testis necessarily prevent its secreting. The functions, however, of this gland are not very readily impaired by disease ; and so long as a small part remains entire, the organ may be fitted to perform its office sufficiently for the end destined by nature. When the testis is to a great extent disorganized by the effusion of tuber- cular matter or lymph, and forms an open fungoid sore, secretion may still go on under excitement, as is evinced by the stiffened state of the dressings, and a microscopic examination of the discharge. This fact shows the importance of the surgeon striving to save the testis when mutilated either by accident or disease. In double hydrocele we know that the functions of the testes may still be performed. In inflammatory affections of the epi- didymis and vas deferens, it is very rarely that the matter effused amongst the convolutions of the duct obstructs the tube through which the semen has to pass, which is in a great degree owing to the absence of a fibrous envelope, and the yielding nature of the serous membrane by which it is in- vested ; whereas after inflammation of the body of the testis, wasting and disorganization are not un- common. In cases of congenital deficiency of the vas deferens, — in others in which this canal or the ducts of the epididymis are obstructed by tubercu- lar matter formed in their interior, or by deposits or tumours of any other kind, however sound may be the substance of the testis, the course of its secretion must necessarily be arrested, and the 54 426 SYMPATHETIC AND FUNCTIONAL organ thereby rendered useless. Severe varicocele tends gradually to impair the nutrition and di- minish the secreting powers of the testis. On the influence of detention of these organs in the abdo- men and in the groin external to the cavity on the sexual functions, I have fully expressed my opinion in Chap. I. Sect. 3, Certain affections, as carci- noma and the cystic disease, generally extend until the glandular structure is wholly destroyed. It is seldom, however, that both sides are affected, or that both testes are disorganized by disease ; and the remaining one, if sound and well developed, is fully sufficient for the purpose of reproduction. The same holds good when one testis has been removed by operation ; but when both are extir- pated or destroyed the patient becomes absolutely and permanently impotent. The question has been raised, and was at one time much discussed in Germany, whether a person castrated after ar- riving at the age of puberty may not retain the power of procreating for a certain period after- wards. The following case bearing on the point is recorded by Sir A. Cooper. — A man had one of his testes removed in 1799. In June, 1801, the other testis was removed by Sir A. Cooper in Guy's Hospital on account of a chronic abscess. He had been married prior to the loss of one testis. Four days after the second operation it was found that he had had during the night an emission, which appeared upon his linen. After he had recovered and quitted the hospital Sir A. Cooper repeatedly visited him for many years. For nearly the first DISORDERS OF THE TESTIS. 427 twelve months he stated that he had emissions in coitu, or that he had the sensations of emission. That then he had erections and coitus at distant intervals, but without the sensations of emission. After two years he had erections very rarely and very imperfectly, and they generally immediately ceased under an attempt at coitus. Ten years after the operation he said he had during the past year been once connected. In 1829 he visited Sir A. Cooper, because he was a severe sufferer from piles. He then stated that for years he had seldom any erection, and then that it was imperfect; that he had no emissions from the first year of the operation ; that he had for many years only a few times attempted coitus, but unsuccessfully ; that he had once or twice dreams of desire, and a sen- sation of emission^ but without the slightest ap- pearance of it. The penis was shrivelled and wasted. He shaved once a week, and sometimes twice. His voice, naturally rather feeble, remained as at the time of the operation."^ Mr. Wilson per- formed the operation of double castration on a married man for carcinomatous disease of the tes- ticles. The wounds cicatrized in little more than a month, and he survived the operation two years. He assured Mr. Wilson that after the removal of the testicles he had occasional erections, not unac- companied with desire, and which, when as a mar- ried man he indulged, were attended with the usual paroxysm and emission of some fluid.t * Lib. cit. p. 53. t Lectures on the Urinary and Genital Organs, p. 133. 428 SYMPATHETIC AND FUNCTIONAL In determining the question alluded to, we must not confound the power to copulate with that of procreation. It has been seen that the loss of the testes so affects the brain as completely to extin- guish the sexual instinct ; but this is an effect which, as is clearly shown by Sir A. Cooper's case, is not immediate, but takes place gradually ; hence we must admit that the castrated individual may experience desire, have erections, accomplish the coitus, and emit fluid for several weeks after re- covery from the operation. But the fluid which is essential for the propagation of the species is the secretion of the testes, none of which can of course be elaborated after the removal of the two glands. The question then resolves itself into this — how long may the seminal fluid already formed remain in the excretory ducts and vesiculae seminales in a condition to impregnate the female ? Much, of course, must depend on the state of the testis or testes at the period of the operation. If the gland last removed were thoroughly disorganized, taking into account the period previous to the operation since which the organ could have been in a condition to secrete, and the time occupied in the healing of the wound, which, together, cannot be estimated at less than eight or nine weeks, we may decide that in such a case the castrated patient would be unable to reproduce ; since in the nu- merous examinations which I have made of the fluid taken from the vesiculoe seminales and vasa deferentia of hospital patients who have died of various diseases, I have never found spermatozoa DISORDERS OF THE TESTIS. 429 in them at a later period than seven weeks after their admission, or after they had possessed the opportunity of having sexual intercourse. In a case, however, in which the testes were sound and capable of secretion at the time of castration, it must be concluded that a sufficiency of the sper- matic fluid may remain in the excretory ducts and vesiculae for two or three weeks after recovery from the operation in the usual period, so as to allow of the possibility of impregnation, improbable as such an occurrence must undoubtedly be re- garded. An attack of apoplexy often permanently extin- guishes all desire as well as capacity for sexual enjoyment. Diseases and injuries of the spinal cord, producing paraplegia, have little effect on the testes, but destroy the power to copulate. In the chapter on Atrophy (page 118), I have given two instances of wasting of the testicles succeeding an injury to the spine ; but such is a rare result of this accident. In general, desire remains, the seat of the instinct being unaiTected ; and I suspect that in the cases alluded to, in which wasting took place, the injury affected other parts besides the spinal cord. M. Brachet has recorded the following curious case : — A soldier after several years' service experienced, in 1814 and 1815, rheu- matic pains, particularly in the lumbar region. In 1816 he had a fall from his horse. By degrees the lower extremities and inferior part of the abdomen became completely paralysed. For eight years the paralysis remained stationary. Whilst 430 SYMPATHETIC AND FUNCTIONAL in this state he had two children. The spermatic fluid was secreted, erection took place, and ejacu- lation followed ; but " sans secousse et sans sensa- tion voluptueuse."* We must suppose that in this case, although the sensibility of the penis was de- stroyed, the connexion between the brain and testes was still maintained by the sympathetic system, which communicated the necessary influence ; and that their functions were, accordingly, as little dis- turbed by the affection of the medulla spinalis as are those of the important organs of the abdo- men in the same disease.t But, notwithstanding the success of this old soldier, there are few in a state of paraplegia who would not find themselves * Recherches Experimentales sur le Systeme Nerveux, 2d edit, p. 280. f M. Brachet performed the following experiments. — Having made sure that a cat a year old had covered several times a female cat with which he was shut up during the day, M. B. divided his spinal marrow between the third and fourth lumbar vertebres. All behind was para- lysed, the rectum and bladder equally so. He kept the animal three days ; when on examining the genital organs, he found them healthy, and the vesiculse seminales full of semen. This experiment was re- peated three times with the same result. The next is given in the words of the experimenter : " Sur un chat de dix mois, je fis la section de la moelle spinale dans la region lombaire. Comme la paralysie du train derriere mettait cet animal dans I'impossibilite d'executer les mancEuvres du coit, j'y fis suppleer par une sorte de masturbation. II fallut plus de terns, mais elle finit par determiner une ejaculation. Vingt-quatre heures apres, je fis repeter la meme manoeuvre ; et une nouvelle ejaculation eutlieu; je la fis encore repeter le lendemain avec le meme resultat." (Lib. cit. pp. 289-291.) These experiments, though interesting, as showing that the functions of the testes may be carried on in paraplegia without sensation or any influence derived from the brain through the spinal cord, do not, as Brachet supposed, prove that the secretion of sperm is altogether independent of the in- fluence of the spinal system. DISORDERS OF THE TESTIS. 431 physically incapacitated. The nux-vomica which would be adapted to relieve the paralytic symptoms would likewise tend to restore the sexual powers. My colleague, Dr. Pereira, states that nux-vomica has been used as a remedy against impotence by Trousseau, who found it successful both in males and females. In some cases, however, its good effects were observed only while the patients were taking the medicine. A young man, twenty-five years of age, of an athletic constitution, who had been married for eighteen months without having any other than almost fraternal communications with his wife, acquired his virility under the use of nux-vomica, though he again lost it soon after leaving off its employment.* We might expect benefit too in these paralytic cases from electro- galvanism, so applied as to stimulate the nerves from the loins to the testes. Some error has prevailed respecting the effects of chronic diseases in impairing the functions of the testis. Thus consumptive individuals are sup- posed to be more than ordinarily addicted to sexual pleasure ; and it has been stated that they have retained the power and propensity to gratify it up to the very day of death. Louis made careful inquiries in reference to this point, and found in every instance that the tendency to sexual inter- course declined with the increase of general weak- ness and other symptoms, almost exactly as is the case with individuals labouring under any other * Elements of Materia Medica, 2cl edit. vol. ii. p. 1305. 432 SYMPATHETIC AND FUNCTIONAL affection * The accuracy of this statement is con- firmed by my own observations and inquiries. I examined the testes of four persons who had died of pulmonary consumption, and found that they were all below the average weight and size of those of healthy adults. In the testes taken from the bodies of twelve phthisical patients examined in the London Hospital, no spermatozoa could be detected in the fluid obtained from the substance of the gland and epididymis. In several of these cases, the contents of the vesiculae seminales were likewise examined, and found destitute of sperma- tozoa.t Rayer has also remarked that the vesiculae of phthisical patients afford few or none of these bodies.^ A fit of dyspepsia is an occasional cause of temporary loss of virile power. A gentleman, after a separation of many weeks from his wife, on his return was much alarmed by finding himself incapacitated. On inquiry, it appeared that he had dined imprudently, and had suffered from indi- gestion and heartburn during the night. Virility is more permanently affected by organic disease of the abdominal viscera ; but there are few com- plaints which have greater influence in impairing the generative functions than those of the kidneys. It has been noticed in men subject to deposits of * Pathological Researches on Phthisis, tr. by Cowan, p. 224. f Dr. Davy examined microscopically the fluid taken from the divided substance of the testis of twelve persons who died of phthisis, but in no instance discovered spermatozoa ; but he found them in several instances either in the vesicula3 seminales or vasa deferentia; Edinb. Medical and Surgical Journal, July, 1838, p. 1. I Archives Genera] es de Medecine, Aout, 1842, p. 487. DISORDERS OF THE TESTIS. 433 the oxalate of lime, that the sexual power is gene- rally deficient, and often absent."^ A middle-aged man, who had led rather a dissipated life, and was subject to pains in the loins and deposits of the phosphates, assured me that when suffering from these attacks he lost all desire for connexion, and was quite unable to indulge in it. Other instances of defective power in persons subject to lumbar pains and urinary deposits have come under my observation. In diabetes, and Bright's disease of the kidney, the reproductive organs are much de- bilitated, and often quite inactive. Again, diuretics, or remedies that excite the secretions of the kid- neys, as the nitrate of potash, digitalis, &c., are found to act as anaphrodisiacs. The testes of persons who die of chronic lingering diseases are almost invariably soft and inelastic. When incised, their internal structure seems to contain but few blood-vessels, is pale, apparently shrunk and dry, and the little fluid that can be squeezed from it is destitute of spermatozoa. Abuse of the sexual organs is a frequent cause of impotency, and of impotency the most difficult to treat and remove ; as moral equally with medical treatment is required, the mind being frequently more at fault than the body, and the surgeon find- ing it as necessary to urge the duty and importance of abstinence and self-control as to prescribe for the patient's health. Persons who indulge to excess sometimes become suddenly impotent, and a con- * Dr. Bird. Medical dazette, vol. xxx. p. 750. 55 454 SYMPATHETIC AND FUNCTIONAL siderable period of rest may elapse before the organs are capable of resuming their functions. Such oc- currences are not unfrequent shortly after mar- riage. Addiction to sexual pleasure in early life often entails a permanent loss of power in middle age, at a period when most men still retain it in full vigour. This is often experienced in the des- potic countries of the East. M. Volney * in his Travels through Asia Minor, mentions that the people of rank in that country, who can afford the expense of a harem, often complain of impotency at the early age of thirty. Mr. Russell of Edin- burgh, in some excellent observations on this sub- ject, remarks that matters are not so bad in this country, though it is a well-known fact that young men of fashion, who indulge their amorous propen- sities at an early age, lose the power of procreating sooner than the more continent, and are familiarly distinguished by the quaint appellation of " God's geldings."t Too great indulgence of the sexual appetite is productive, however, of other effects besides premature impotency : as every practical surgeon is aware, it tends to derange the digestive functions, and to weaken the physical and mental powers. Sexual excesses are likewise a fertile source of the diseases of the testis: persons affected with chronic inflammation and other disorders of the gland frequently, and I believe with justice, refer their complaints to an unrestricted indulgence * Voyage en Syrie et en Egypte, torn. ii. p. 444. f Observations on the Testicles, p. 35. DISORDERS OF THE TE&TIS, 435 of their passions. I suspect, too, that these ex- cesses, if long continued, are very apt to lay the foundation of disease in the kidneys. A gentleman, who when young had been much addicted to the society of women, now invariably suffers from pains in the loins, and alkaline urine, after inter- course with the sex. One of the most common results of inordinate excitement of the genital organs is an excessive secretion of the spermatic fluid, evinced by in- voluntary seminal emissions. For obvious reasons I shall not enter minutely into the history of these cases, but must refer the reader to the work of Professor Lallemand of Montpellier,'^ in which the subject is fully treated of, and numerous cases are detailed. The complaint comes on very gradually. It commences by a precipitate emission of semen either in coition or during lascivious dreams. There exists a state of morbid irritability of the organs. The emissions consequently are prema- ture, and without force, and the erections slight and incomplete, and soon subside. As the affection increases the emissions become more frequent and more readily excited, and are induced merely by * Des Pertes Seminales Involontaires. Mr. Philipps has lately published some cases of this distressing affection in the 31st volume of the Medical Gazette. As this sheet is passing through the press I have received the British and Foreign Medical Review for April, 1843, which contains an instructive article on " involuntary spermatic dis- charges," that cannot fail to be read by the profession with much interest. I fully concur in the strictures of the writer on the exag- gerated views and bad taste exhibited by Lallemand, especially in the concluding volume of his work. 436 SYMPATHETIC AND FUNCTIONAL erotic ideas or the least contact or titillation, and take place without erection and without pleasure. In this weak and susceptible condition of the organs pollutions are liable to occur both day and night, constituting a state of passive spermatorrhoea, which often lasts for many months, gradually undermining the health. The patient becomes thin, pale, and feeble ; has impaired vision, and a sickly languid look ; suffers pains in the head and back ; is hypo- chondriacal and apathetic, and totally unfitted for active bodily or mental occupation. He often expe- riences uneasy sensations in the testicles, which are soft, and hang low. The scrotum is pendulous and lax, and the spermatic veins are commonly large and varicose. His symptoms are aggravated after each emission, which is usually followed by a pain- ful sense of fatigue, and malaise, that last many hours. This obstinate and distressing complaint may be produced either by excessive indulgence in sexual intercourse, or by long-continued and frequent self- abuse, those who give way to these vicious habits being little av/are of the evils they engender. They occasionally acquire a complete m.astery over the reason and will. In some cases not even the strongest self-control can repress the disposition to abuse ; and persons fully aware of the evil results, and actually dreading the consequences, are unable to restrain their fatal desires. In these cases there is a peculiar morbid condition of the nervous system. Indeed, the debilitating and ener- vating effects of this affection are far greater than DISORDERS OF THE TESTIS. 437 would be occasioned merely by a drain of the amount of the fluid emitted, which is to be ascribed to the nervous exhaustion especially attending the reproductive function. The patient's mind is con- stantly absorbed with his sufferings ; he jfinds great difficulty in abstracting his attention from them, and occupying himself with other matters, and eagerly peruses any thing relating to his com- plaint ; a circumstance well known to the empirical authors, who are constantly advertising their works on the subject. The condition of these persons is melancholy enough. Aware of the abhorrence with which their practices are regarded, they hesitate to consult the regular practitioner, and fly for relief to ignorant but artful quacks, by whom their pe- cuniary resources are drained, for which they only meet in return with bitter disappointment. Such is the heavy penalty often paid by man for gross indulgence in sensuality — a degraded nature and a ruined constitution embittering the best days of his existence, and sometimes leading to insanity or suicide. The matter emitted in these cases is thin, and more liquid than healthy semen ; but that it is really spermatic is proved by the spermatozoa which it is found to contain. Lallemand, who carefully examined the fluid voided in all stages of the complaint, found the zoosperms less abundant, and less developed and lively, in proportion to tlie severity of the disease, until at length in very advanced cases they almost entirely disappeared."^ * Lib. cit. torn. ii. p. 407. 438 SYMPATHETIC AND FUNCTIONAL The discharge is largely diluted with the secretions of the vesicalce seminales and prostate ; and in bad cases of the complaint the fluid emitted consists almost entirely of the latter, mixed with purulent matter. Occasionally the spermatic fluid, and even the prostatic secretion, pass into the bladder and mix with the urine, with which they are voided. Directions have been given for distinguishing the semen under these circumstances, but they are not to be depended on ; and the only sure mode of ascertaining the existence of semen in the urine is a microscopic examination of the fluid, in order to detect the spermatozoa. Although this complaint is usually considered and treated as a functional derangement, there are few cases in which the parts remain even in the early stage in a perfectly sound state. It will be found that the patient usually experiences a fre- quent desire to void his urine ; that the evacuation is attended with scalding ; that he frequently feels pain and heat in the prostatic part of the urethra ; and that if a bougie or catheter be introduced as far as this portion of the canal in the most gentle manner, it causes a sharp pain, and sometimes vio- lent spasmodic contractions, the instrument being at the same time grasped in the canal. The pros- tatic and membranous parts of the urethra are indeed in a state of morbid irritation ; and I believe that the increased secretion of the testes, the hasty ejaculations, and inordinate desire for sexual in- dulgence or self-abuse very greatly depend on this diseased condition of the mucous membrane. Nor DISORDERS OF THE TESTIS. 439 is it surprising, considering how much this part of the urethra is concerned in the functions of gene- ration, that a permanent state of disease should be produced by the frequent excitement of unnatural excess. Involuntary spermatic discharges have in some instances been induced by gonorrhoea af- fecting the prostatic part of the urethra. Their origin has also been ascribed to certain affections of the prepuce and of the rectum and skin ; but I have not met with any case of involuntary emissions occurring from these causes independently of local irritation in the urethra. Very few opportunities are afforded of making an anatomical examination of the parts affected, especially in the early stage of the complaint. Lallemand examined them in two very severe and complicated cases of the dis- ease, in which the patients laboured under symp- toms of cerebral congestion before death.* I also carefully dissected them in an aggravated case, in which the patient was comatose for several hours previous to dissolution. In all three the morbid ap- pearances were of the same character. The mucous membrane at the prostatic part of the urethra was swollen and injected. The prostate was nearly de- stroyed, and converted into a multilocular abscess, or a number of alveolae or cells, communicating with each other ; and the diseased mucous membrane covering it was riddled with holes, formed by a con- siderable enlargement of the original orifices of the gland, through which pus or altered secretion freely * Lib. cit. t. i. p. 13, et seq. 440 SYMPATHETIC AND FUNCTIONAL escaped on pressing the prostate. As Lallemand aptly remarks, the membrane at this part covers the multilocalar cavity of the prostate, much in the same way as the cribriform plate of the ethmoid bone covers the nasal fossa in the dried skull. One or both vesiculae seminales were infiltrated with pus, and their walls thickened by inflammation. The orifices of the ejaculatory canals were enlarged and abraded. When the prostate is much afifected, pain is occasioned by pressing on it through the rectum, and there is usually a discharge from the urethra when the patient is at stool. In inveterate cases of the disease, the mucous membrane of the bladder becomes inflamed, and secretes a ropy mucus. The urine is ammoniacal, and the disease extends along the ureters to the kidneys. The irritation attending the morbid condition of the mucous membrane of the prostatic part of the urethra, tends in a very material degree to excite both the excessive seminal discharge and the secre- tions of the prostate, and to produce that morbid craving for indulgence and abuse which persons who have brought themselves to this state find so difficult to repress and resist. It is well known that any irritation at the orifice of an excretory duct usually acts as a stimulus to the secretions of the gland. Thus hurtful matter in the duodenum produces a flow of bile ; and a foreign body in the conjunctiva, as an inverted eyelash, a discharge of tears. So it is with the testis when irritation exists at the orifices of their excretory ducts. The disorder at this part, moreover, appears to react on DISORDERS OF THE TESTIS. 441 the brain, and to become in part the cause of the patient's mind being constantly occupied with sub- jects of sexual excitement, and of his indifference and apathy in respect to other matters.* So that the local disease induced by abuse powerfully aids in perpetuating the mischief, and, judging from the experience which I have had in these cases, is the object to which our treatment should be first direct- ed. Certainly in confirmed cases, until the nK)rbid condition of the mucous membrane of the urethra is corrected, we can scarcely hope to relieve the seminal emissions, or to recruit the patient's health and strength ; and when it is removed there is far less difficulty in inducing him to abandon his injurious habits, and in im.proving his general con- dition by other treatment. In some persons there appears to be a predisposition to this complaint, which is indicated by feeble sexual powers, and irritability of the bladder and incontinency of urine in early life. * This is a truth, I fear, not sufficiently impressed on the minds of medical men. One would be loth to offer any apolog-y for the vicious habits and indulgences to which, it is well known, old men are occa- sionally addicted, — a melancholy example of the kind in the higher ranks in life having lately been brought under public notice. I cannot but think, however, that in many instances these cases are not unde- servmg of professional sympathy, and that the erotic longings which sometimes continue to distress the aged long after the period at which in the course of nature they should have ceased depend as much on physical infirmity as mental depravity, the former inciting and pro- ducing the morbid desires. If these propensities were regarded and treated as symptoms of disease (and that they frequently occur in connexion with affections of the urinary passages is well known to practical surgeons), I believe they would oflen subside, and the dis- tressing results to which they lead would be altogether avoided. m 442 SYMPATHETIC AND FUNCTIONAL It is necessary to remark, that in persons whose constitutions are suffering from frequent seminal emissions, it is not always easy to ascertain the real cause of impaired health. Either from not suspect- ing it, or unwillingness to confess, patients are apt to refer their complaints to any thing but the true cause. They complain of indigestion, palpitations, pains in the head, &c., but neglect to mention the emissions ; so that much tact and cautious inquiry are often necessary in order to discover the nature of the malady with which they are afflicted. In most cases of this disease the local application of the nitrate of silver is by far the most effectual means of restoring the prostatic part of the urethra to a sound state. It allays the morbid sensibility and corrects the altered condition of the membrane and orifices of the ejaculatory canals, and thus ar- rests the excessive secretions of the testicles and prostate. The nitrate of silver, when applied to the diseased part of the urethra, appears to act on the seminal vesicles and follicles of the prostate gland, very much in the same way as a stimulating appli- cation to the conjunctiva of the eye relieves amor- bid condition of the membrane of the nasal sac or duct by being absorbed at the puncta lachrymalia. The dissolved caustic entering at the enlarged ori' fices at the sides of the veru montanum thu& reaches the interior of these glands. The beneficial effects of the nitrate of silver in this affection appear to have been known to Sir E. Home, who, in his work on Strictures,^ has recorded two cases of seminal '^' Vol, ii. p. 427. DISORDERS OF THE TESTIS. 44c5 emissions consequent upon onanism, which were much relieved by the application of the armed bougie. His mode, however, of using this remedy w^as very defective ; and the plan of treatment does not seem to have been followed by other surgeons in these particular cases. It is to Lallemand that we are indebted both for showing the great value of the caustic treatment of this complaint, and for devising an improved instrument for making the application. In January, 1839, some observations were published by me in the Medical Gazette* on the employment of the nitrate of silver in certain kinds of stricture, and in the affection termed " irri- table urethra," in which I gave a description of Lallemand's instrument, and pointed out its supe- riority over other modes of applying the caustic. Shortly afterwards a gentleman partly educated to the profession, who contemplated proceeding to Montpellier to place himself under the care of Lal- lemand for the cure of involuntary seminal emissions attended with the most distressing symptoms, hav- ing seen the paper alluded to, called to ask me to undertake the treatment of his case on Lallemand's plan. I did so ; and the success which followed the use of the lunar caustic in this instance induced me to employ the same remedy in other cases which came under my care, both in public and private practice ; and a considerable share of experience now induces me to speak w^ith confidence of its beneficial effects. * Vol. xxiii. p. 596. 444 SYMPATHETIC AND FUNCTIONAL %> Tig. 2. Lallemand's instrument con- sists of a slightly-curved platina canule or tube, rather smaller than a middle-sized catheter {Fig. 1. A), through which plays a caustic holder, having at its further extremity a narrow groove, eleven lines in length (B), for the purpose of receiving the caustic. After filling the groove with the nitrate of silver i| by fusing it over a spirit lamp, the caustic becomes so securely fixed that there is no danger of its escaping. At the other end there is a sliding screw or stop (C), by which means the appli- cation of the caustic may be limited to any extent less than the length of the groove which contains it. In employing this instrument I proceed as follows : — Having regulated the caustic holder so as to admit of nearly the whole of the groove being uncovered, and having closed the instrument so as to conceal the caustic {Fig, 2), I introduce it well oiled as far as the pros- tatic part of the urethra, its arrival there being easily ascer- tained by the pain experienced by the patient, and 11 DISORDERS OF THE TESTIS. 445 by my being able, after the instrument is depressed and has passed the triangular ligament, to carry it freely onwards.^ I then thrust forwards the caustic holder, and after passing it once or twice backwards and forwards instantly close the apparatus, and then withdraw it. An one time I used to employ a straight instrument, which may generally be intro- duced without difficulty ; but one slightly curved is rather more convenient. When applied in the transient manner I have just described, the caustic occasions a sharp smarting sensation, which sometimes causes the patient to faint ; but it sub- sides in from ten minutes to half an hour. On making water afterwards the patient experiences scalding, and usually passes a little blood and purulent discharge, which continue for twenty- four or thirty-six hours, and then gradually cease. If much pain or retention of urine should re- sult from the application, it may be relieved by leeches to the perineum, the hip-bath, and opiate suppositories or injections. I have never found the caustic produce so much haemorrhage and such severe symptoms as are described by Lallemand occasionally to arise from it, which I attribute to the more gentle manner in which the application is made. In general, the emissions cease entirely after one * At first T used to pass a wax bougie down to the prostatic por- tion of the canal, in order to ascertain its distance from the meatus, that I might be exact in cauterising the particular part affected, but after a little practice in the use of the instrument I found this unne- cessary. 446 SYMPATHETIC AND FUNCTIONAL or two applications of the caustic, though it is sometimes necessary to make three or four before they are completely arrested. Opium or henbane may at the same time be given at night to procure rest and allay irritation, and the cold douche may be daily applied to the pelvis and genitals. The determination of blood to the prostate and neigh- bouring parts may be restrained by an enema of cold spring water, administered by the patient be- fore rising in the morning, which also tends to relieve constipation. ' I have found that the Pulv, Cubebis, in small doses of from gr. xv. to gr. xxx. combined with the tincture of henbane, taken twice a day, by its influence on the urethra materially aids the cure of this affection. Indeed in very slight cases this remedy, and the occasional intro- duction of a catheter or bougie, are sufficient to correct the morbid condition and sensibility of the mucous membrane without the caustic. As the local affection subsides, we must have recourse to other remedies to improve the general health. Thus steel medicines, quinine, cold bathing, a nu- tritious but not stimulating diet, due regulation of the bowels, change of scene and exercise in an open pure air, and cheerful occupation, prove very bene- ficial in these cases. I have previously had occasion to notice the salutary influence of active bodily exercise in subduing the ardour of the sexual pas- sion. The same means, in moderation, are also effi- cacious in allaying the morbid excitement of which I am now treating. It need scarcely be added, that no method of treatment is likely to be successful or DISORDERS OF THE TESTIS. 447 permanent, without the most rigid and persevering abstinence in respect to the exciting causes of the complaint. All subjects capable of exciting erotic ideas should therefore be strictly avoided ; and it must be recollected that a relapse is readily induced by the least imprudence or excess. Persons suffer- ing from involuntary seminal emissions are often recommended to marry. This advice is not only unsound, but actually injurious ; and if followed, which I believe rarely happens, would be a cause of much misery. Persons thus affected are by no means in a condition to enter the marriage state ; they are in fact impotent ; and nothing is more calculated to aggravate their complaints and impede recovery, than the excitements of the sex and fruit- less attempts at sexual indulgence. The indications afforded in these cases are, to arrest the debilitating discharges ; to obtain a period of rest during which the parts may recover their tone, the health may be reinstated, and the constitution fully invigorated. When this is effected, but not till then, marriage is desirable, as it takes away the temptation to solitary vice, and is favourable to regularity and moderation in the performance of the reproductive functions, and thus obviates the tendency to a relapse. Persons troubled with seminal emissions which no effort of the will can prevent their provoking, or which persist in spite of medical treatment, have in some instances been anxious for the removal of the testes, to get rid of a complaint so completely destructive to their health and happiness : and in- dividuals have even been known to perform the 448 SYMPATHETIC AND FUNCTIONAL operation of castration on themselves in conse- quence."^ A short time since I received from a patient thus affected two letters urgently request- ing me to remove his right testicle, his left having been extirpated by a surgeon some time previously. This man refused to submit to any other treatment for his complaints, being impressed with the idea that this operation was the only remedy that could relieve him. He was a patient of my friend Mr. Avery, surgeon of the Charing Cross Hospital, who, as well as myself, was teased with repeated solicita- tions to castrate him.t This operation can scarcely be, in any case of involuntary seminal emissions, justifiable. Unless important organic changes have taken place in the genito-urinary organs, the affec- tion is certainly remediable by judicious treatment steadily pursued ; whilst the operation of castra- tion, even if effectual in relieving the symptoms, would leave the patient in a state of mutilation which might afterwards prove a source of the most bitter regret. I have been informed by a professional friend of a case in which double castration was performed, at the urgent request of the patient, on account of most distressing self-pollutions, that had a very lamentable result. The patient, a gentleman in the upper ranks of life, committed suicide ; and the surgeon, who had been rash enough to emas- culate him, was threatened by the patient's friends * Several cases of self-castration are related in Chap. III. Sect. 2. 1 1 have recently been informed that a surgeon had been induced to perform the operation, and that the patient was well pleased with the result. S DISORDERS OF THE TESTIS. 449 with an action at law for performing so unwarrant- able an operation. Solitary abuse is sometimes practised in infancy ; and in two cases which have come to my knowledge it occurred at the early age of between three and four years. The sexual organs were not prema- turely developed, but in one of them the child had passed a small calculus. The vice has been ascribed to the irritation produced by worms in the rectum ; but 1 fear it is more often induced by the foolish habits of children and their associates. Though little fluid is emitted, the practice is very injurious to the constitution by its effects on the nervous system, and prevents the developement of the sexual powers. As in the adult, it produces a morbid sensibility and condition of the urethra, which is also to be treated on the same principles. I have little to add to the observations already made respecting the treatment of the different forms of impotency. In several instances, whilst explaining the cause of the power being lost, I have suggested the remedies necessary for its re- establishment. Certain medicines, reputed to pos- sess the property of restoring the sexual functions, have been classed as aphrodisiacs; and some of them are said to be used, especially in the East, by the sensualist, to excite the organs when ex- hausted by satiety and excess. Some of them act on and stimulate the urinary apparatus, and thereby give a temporary power to the function of erection, but they produce little or no effect on the special sexual organs. They act much in the same way as 57 450 SYMPATHETIC AND FUNCTIONAL haemorrhoids, affections of the prostate, and calculi in the kidney or bladder, the irritation of which often determines blood to the penis, and causes morbid erections. Such appears to be the nature of the influence produced by the cantharides, the most common of this class of medicines, and the chief ingredient of quack remedies for impotency, There are, however, few cases of defective sexual ■ power in which the use of cantharides would be I proper. In many it would certainly be injurious, producing an unnatural excitement when repose is i most desired ; so that even if it enabled the patient to have connexion, its ultimate effects would rather ,. tend to render the impotency more permanently f' hopeless. Almost the only description of case in which I should be induced to recommend this remedy is an atonic state of the organs consequent ' on long disuse, in which, though the desires are strong,^ the erections are feeble, and take place with difficulty. In such case rnxx. of the Tinct. Can- tharidis, with the same quantity of the Tinct. Ferri Sesquichloridi, may be given twice or thrice a day. Bayle states that Leroy and Bouttatz experimented on themselves with phosphorus, and found that it produced strong excitement on the genital organs. The same was observed in animals to whom Leroy gave this remedy.* Phosphorus seems to act much in the same way as cantharides, irritating and stimulating the urinary organs, and determin- ing the blood to these parts, and no doubt its effects * Bibliotheque de Therapeutique, torn, ii, p. 124. DISORDERS OF THE TESTIS. 451 would be equally injurious in many cases of im- potency. In the class of atonic cases alluded to above, we might hope for some benefit from the ergot of rye, which in man appears to act as a stimulus to the generative organs, as well as to the neighbouring parts; but further experience is re- quired of the effects of this remedy in cases of impotency. The aphrodisiac most wanted is one capable of stiaiulating the sexual organs, and ex- citing the secretion of the testes by its influence on the sensorium, or on that particular part which is the seat of the reproductive function. I know no remedy which possesses this power, except, perhaps, the Indian hemp, or Gunjah (^Cannabis Indica), It is well known that the use of this drug is in- dulged in by the inhabitants of certain countries, on account of the pleasurable excitement to which it gives rise. According to Dr. O'Shaughnessy of Calcutta,^ its effects, when given in small doses^ is to cause an increase in the fulness and frequency of the pulse, a glow on the surface of the body, re- markable increase of appetite, unequivocal aphro- disia, and great mental activity and cheerfulness ; and no headache, delirium, sickness, or other un- pleasant symptom followed its use. The dos^ re- ported to be capable of causing these effects is a quarter of a grain of the resinous extract, or half a drachm of the tincture, once or twice repeated, * On the Preparations of Indian Hemp, &c. Transactions of tlie Medical Society at Calcutta, 1839; and Provincial Medical Join-nal, Jan. 1843. 452 CASTRATION. until the remedy produces its exhilarating influence on the system. I have lately made some experiments with the extract of hemp, obtained from Mr. Squire of Ox- ford Street, which is understood to be genuine ; but it certainly produced no marked aphrodisiac effects. I gave a gentleman five grains of it at a dose ; it produced a feeling of intoxication, dilata- tion of the pupils, and dizziness, but did not quicken the pulse : there was a feeling of desire, but no expression of power to indulge. I believe that its effects on the European constitution are in some degree different from those which it exerts on the Asiatic, and that in the former larger doses are required to obtain its influence. On the latter the concurring testimony of different observers leaves no room to doubt its aphrodisiac powers, and its general use by the inhabitants of the East for the purposes of erotic excitement. CHAPTER XVIII. CASTRATION. Castration, or the extirpation of the testis, is well known to be an operation of great antiquity, and was formerly one of the most common in surgery. Even at the present day it is frequently performed by the barbarous people of the East to deprive CASTRATION. 453 their slaves of manhood ; but this cruel and un- christian practice is now rarely resorted to in Europe, except for the removal of disease, being uncommon even in Italy, where it was once fre- quently performed on account of its effects on the vocal organs. The diseases of the testis which may lead to the necessity for castration are the different forms of carcinoma, incurable strumous disease, tedious sinuses and fungoid growths consequent on in- flammation, cystic disease, and varicocele combined with severe neuralgia. The circumstances under which the operation is admissible in these various diseases have already been considered. Castration is an operation simple, easy of per- formance, and nearly free from danger ; but painful, owing to the large number of nerves and great sen- sibility of the parts incised. The surgeon should endeavour, therefore, to perform it with expe- dition. Before he commences the hair must be cleanly shaved off from the pubes and scrotum, or it will interfere with the plaister in the dressing of the wound. The only instruments required are a straight bistoury or large scalpel, a pair of for- ceps, tenaculum, and curved needles armed with ligatures. The patient is to recline upon a table of convenient height, and the operator is to place himself on the right side ; or he may seat himself between the patient's legs. An incision is to be made skin-deep from about half an inch below the external ring, along the front of the tumour to the bottom of the scrotum. The envelopes of the cord 454 CASTRATION. and testis, the layers of thickened fasciee, and the cremaster muscle are then to be freely divided, nearly as high up as the abdominal ring. If this part of the operation be interrupted by bleeding from any of the branches of the external pudic artery, it will be well to secure them with ligatures. As soon as the spermatic cord is detached from the surrounding parts and fully exposed, it is to be grasped between the finger and thumb of an assist- ant to prevent its retraction within the inguinal canal after being divided, and it is then to be cut across by a single stroke of the knife. Some sur- geons are accustomed to secure the cord by passing a tenaculum or needle and ligature through it ; a plan which need only be adopted when it is neces- sary to divide the cord very high up, as in general the fingers of an assistant are sufficient for the purpose, and giv^ less pain and produce less dis- turbance of the parts than the other method. The arteries of the cord can now be secured ; or if the compression employed by the assistant be sufficient to check the haemorrhage, the surgeon may at once proceed to dissect the tumour from out of the scro- tum. This part of the operation may often be much facilitated by traction, so employed as to lacerate and detach the cellalar connexions of the diseased gland. In chronic cases, the cellular tissue of the scrotum is often too condensed and thickened to admit of being thus torn ; and in nearly all in- stances the dense adhesion between the lower part of the testis and the scrotum requires division with the knife. When the tumour is of large size, care CASTRATION. 455 is necessary in detaching the testis from the scro- timi to avoid wounding the urethra and corpus cavernosum, and also the opposite gland, which should be drawn aside by an assistant. Many surgeons recommend that the testis should be detached from the scrotum before the division of the cord ; but, as Sir A. Cooper has remarked,"^ this obviously prolongs the time of the operation, and adds considerably to the sufferings of the pa- tient. On the other hand, when the cord is first divided, the testis is easily drawn forth from the scrotum by means of the cord itself, and the adhe- sions that may exist are cut or broken down with greater facility and rapidity than by any other mode. The bleeding mouth of the spermatic artery is soon found, and is to be secured separately by a silk ligature. The artery of the vas deferens must next be sought for near the duct, and also tied. This vessel is so small that it is not always ap- parent ; but the surgeon should endeavour to se- cure it, as it is sometimes the source of a trouble- some haemorrhage after the conclusion of the ope- ration. The bleeding vessels of the scrotum are next to be tied : if the tumour be large, or the disease of long standing, they are likely to be very numerous. In securing vessels in the loose cellular tissue of the scrotum and other parts much assist- ance may be derived, especially if the assistants be unaccustomed to operations, from the employment * Cyclopsedia of Surgery, art. Castration, vol. i. p. 704 456 CASTRATION. of a clumsy-looking but very useful pair of forceps, with broad blades coming abruptly to a point, to slip the ligature on the vessel. The oozing of blood from many of the smaller vessels may be arrested by torsion, or bathing the parts with cold water. The ligatures attached to the cord being carried to the upper angle of the wound, the divided edges are to be brought together by two or three sutures or more, according to the length of the incision. Strips of plaister are not sufficient, as the natural contractility of the scrotum tends to separate and evert the edges of the wound. The closure of the wound is to be completed with narrow strips of adhesive plaister applied transversely, and the part is to be covered with a dossil of lint : the scrotum must afterwards be supported, and the dressings retained by a T bandage. When the patient re- turns to bed the parts must be kept cool by a cradle placed over the pelvis under the bed-clothes. The upper part of the wound often unites by the first intention ; but the lower usually heals by gra- nulation in from twenty to thirty days. There are a few circumstances of importance to be attended to in this apparently simple operation, and certain modifications are sometimes required. The operator should be careful to carry the first in- cision to the lowest part of the scrotum, as by this means he not only facilitates the detachment of the tumour, but afterwards prevents the bagging of matter in the scrotum, which is very liable to occur, and retard the healing process when this point is neglected. If the gland is of great size, or the skin CASTRATION. 457 adherent to it or diseased, it will be advisable to remove a portion of the scrotum. Instead, there- fore, of a single straight cut, two lunated incisions should be made, so as to include an oval piece of the integuments. By this means, if the skin be adherent, a tedious dissection is avoided ; or, if the tumour be very large, the inconvenience of a bag of useless integument may be obviated : the haemor- rhage, also, will be less ; and the vessels requiring ligatures will not be so numerous. The retraction of the cord after its division is liable to become a source of embarrassment and delay. The retreat of this part is usually ascribed to the action of the cremaster ; but as the greater part of this muscle, together with the organ upon which its action is exerted, is cut off at the division of the cord, I attribute the retraction chiefly to the elasticity of this part, which, after the cord has become relieved of the weight of the enlarged testis by which it was pulled down, enables it to recover its former position. The surgeon should take care to divide the muscular and fascious envelope of the cord be- fore cutting it across ; as, if this be neglected, some difficulty is likely to be experienced in tying the vessels after its division. In cases in which the cord has retracted within the abdominal ring, the surgeon has been obliged to divide the tendon of the external oblique muscle, in order to get at the bleeding vessels. In a case which came under the observation of Sir A. Cooper, the bleeding from the vessels of the retracted cord was so profuse, that the operator was convinced he had wounded the 58 458 CASTRATION. iliac artery, and unfortunately proceeded to place a ligature on that vessel. The patient died the day after the separation of the ligature. The iliac artery, though not wounded, had been tied securely enough ; but the vessels of the cord, the source of the haemorrhage, had been neglected. Mr. Ben- jamin Bell mentions two instances of patients having lost their lives from hcemorrhage, in conse- quence of retraction of the cord before the vessels were properly secured."^ This ought never to happen ; for the bleeding arteries may always be reached by laying open the inguinal canal. But this proceeding increases the dangers of the ope- ration, in consequence of the proximity of the peritoneum. Professor Fergusson mentions a case in which the operator had to pursue the vessels into the canal : inflammation within the abdomen ensued, and carried the patient off within three days.t When the vessels of the cord are not pro- perly secured, and afterwards bleed, the cellular membrane becomes so infiltrated with blood that the surgeon not only experiences great difficulty in finding the bleeding vessel, but the disturbance occasioned by the effusion is liable to induce in- flammation and suppuration ; and abscesses from this cause have been known to extend to the iliac fossa. It was formerly the practice to arrest the bleeding from the cord by tightly tying all the parts composing it in a single ligature. This un- "^ Treatise on the Hydrocele, &c. p. 265. t Practical Siiro-ery. p. 54(1 CASTRATION. 459 scientific proceeding occasioned severe pain and suffering ; produced inflammation ; and in many cases was the cause of tetanus. It is needless in the present day to offer any caution against a prac- tice so rude and unskilful, which has been long abandoned by British surgeons. There is perhaps no operation more frequently succeeded by secondary haemorrhage than castration. In morbid enlargements of the testis, the scrotal vessels as well as the spermatic undergo consider- able increase in size, and pour out blood freely when divided. Mr. Sharp castrated a man whose testicle weighed above three pounds, where some of the vessels were so exceedingly varicose and dilated as nearly to equal the size of the humeral artery.^ I have myself found the spermatic artery of a testis, which was removed in consequence of its being affected with malignant disease, as large certainly as the radial artery at the wrist. From exposure to the cold atmosphere and the corrugation of the skin, or in consequence of the patient becoming faint, the bleeding from many of the vessels of the scrotum often stops in the course of the operation ; but as soon as the patient becomes warm in bed, and the scrotum relaxes and the circulation is restored, the vessels again begin to pour out blood. On this account many surgeons prefer waiting an hour or two after the patient has been put to bed before closing the wound, in order to ensure him from so unpleasant and painful an occurrence as the dis- * Treatise on the Operations of Surgery, p. 52. 460 CASTRATION. turbance of the dressings and re-opening the wound to arrest a secondary hcemorrhage ; and this pre- caution I should always recommend, whenever vessels particularly large and numerous appear to cease bleeding from the effects of syncope or cold. Gentle pressure on the scrotum by a dossil of lint applied over the wound, and retained by strips of plaister or a bandage, and keeping the parts cool by an evaporating lotion, are usually, however, sufficient to prevent a return of haemorrhage. There is cer- tainly less bleeding from the vessels of the scrotum when the cellular connexions of the testis have been lacerated, than after they have been divided by the knife. In one case in which I operated in this way, although the testis was of considerable size, not a single scrotal vessel required ligature, and there was no after-haemorrhage. This practice may be adopted with advantage in other operations ; as in the removal of a diseased gland from the loose cellular tissue of the axilla, and in amputations of the mamma. The surgeon may thus save time and trouble, and procure a readier cure of the wound, fewer ligatures being present to interfere with the healing process. The disease of the testis requiring castration may be complicated with scrotal hernia. In such a case the parts must be returned, if possible, into the cavity of the abdomen, and protrusion prevented during the operation by the fingers of an assistant ; and the surgeon should carefully endeavour to dis- sect away the cord without wounding the hernial sac. In one case of extirpation of the testis, Sir E. CASTRATION. 461 Home relates, " After the operation was com- pleted, and the wound dressed, the patient being seized with a fit of coughing, to the astonishment and dismay of the surgeon, the dressings were forced off by a protrusion of several convolutions of small intestines : from this it was proved that the patient had had a hernia : but the diseased enlargement of the testicle had acted as a truss, and prevented the rupture from coming down."* If the diseased gland be of great size, the practitioner will do well to satisfy himself respecting the exist- ence of hernia before commencing this operation, as it is liable to be overlooked. Dr. Wedemeyer of Hanover removed the left testis of a patient who had also, on the same side, a reducible scrotal rupture of considerable magnitude. The rupture, which was reduced at the time of the operation, did not subsequently protrude. Considerable inflam- mation supervened after the operation ; and it is presumed that the descent of the intestine was pre- vented by adhesions formed during its process in the track through which the rupture had originally passed.t A few instances are on record in which a testis retained in the inguinal canal has become so dis- eased as to lead to the necessity of castration. Mr. Pott mentions a case of diseased testicle in the groin successfully removed by operation at St. * Observations on Cancer, p. 236. f Journal fur Chirurgie, band. ix. stuck 1 ; as quoted in London Med. and Phys. Journal, vol. Ivi. p. 482. 462 CASTRATION. George's Hospital.^ In 1823, Manzoni of Florence extirpated a cancerous testis retained within the abdominal ring. A similar operation was shortly afterwards performed at Pisa for the removal of an enormously enlarged cancerous testis, and the canal was laid open even into the abdomen. The patient recovered from the operation ; the disease, however, returned in the glands of the mesentery, and he died two years afterwards from the relapse.t Pro- fessor Naegele extirpated an enlarged and diseased testis from the left groin of a man twenty years of age. The peritoneum was wounded, and a portion of epiploon protruded. The man survived the ope- ration ; but the disease, which is said to have been carcinomatous, returned a month afterwards at the cicatrix of the wound. :j: There would be no great difficulty in extirpating a testis seated in the inguinal canal. The first incision should be made in the same direction, but a little higher up, as in operating for inguinal hernia ; and the tendon forming the anterior boun- dary of the canal might be divided upon a director introduced at the ring, so as fully to expose the diseased gland. The danger would certainly be greater than after the extirpation of a testis from the scrotum, owing to the liability of wounding the peritoneum, opening a vaginal sac communicating * Lib. cit. 4to. edit. p. 356. Case III. + Fragments d'un Voyage Medicale en Italie, par T. J. E. Petrequin ; Bulletin Medicale, Beige, Juin, 1837. I Quoted from a German Journal in Archiv. Gen. de Medecine, t. xiii. p. 423, 1837. CASTRATION. 463 with the abdomen, or interfering with a testis adherent to a piece of intestine. The surgeon should not, therefore, interfere hastily with a mor- bid gland in this position, especially if the case be one of malignant affection ; since it would be impossible to determine beforehand, with any de- gree of accuracy, to what extent the disease had reached. I have remarked that castration is not, under ordinary circumstances, a dangerous operation. I have witnessed, during the last seventeen years, about a dozen cases of it, and not one of them terminated fatally. In a table of operations per- formed at the Hotel Dieu,"* it appears there were five deaths in twenty-nine cases of castration, being in the ratio of 1 in 4^, which 1 feel satisfied is a much higher rate of mortality than would be afforded by the results of British practice. C. T. Maunoir, in 1820, suggested a new opera- tion for the cure of sarcocele, without recourse to- the extirpation of the testis.t It consists in cutting down upon and tying the spermatic artery, and thus interrupting the supply of blood to the organ. Two cases in which this plan was adopted are detailed. In the first the nerves were tied, as well as the artery, and the operation was followed by abscesses in the course of the cord. From this * Gazette Med. de Paris, Dec. 17, 1842. It should be observed that at the Hotel Dieu the mortality from operations is well known to be very great. f Nouvelle Methode de traiter le Sarcocele sans avoir Recours a 3'Extirpation dn Testicule. 464 CASTRATION. cause the cure proved tedious; but the testis underwent absorption, until scarcely any vestige remained. In the second case the artery only v^^as tied, and the operation v^as followed by wasting of the enlarged gland, and the absorption of the fluid collected in the tunica vaginalis. That the tying of the main artery should cause the reduction of a gland swollen from a chronic inflammation (as was probably the case in the above instances), and receiving so little blood from other sources, is not surprising. There are, however, very few forms of morbid enlargement to which this operation is ap- plicable. In intractable diseases of the gland with an open sore, castration would be preferable ; as cutting ofl* the supply of blood would not assist in healing the v^ounds, and in malignant aflfections such an operation would be quite out of the ques- tion. One great objection to its adoption is the degree of doubt v\^hich often exists, in cases of morbid enlargement requiring operation, respect- ing the true character of the disease. PART III. DISEASES OF THE SPERMATIC CORD. CHAPTER I. VARICOCELE. The term varicocele is sometimes applied to de- signate a varicose enlargement of the veins of the scrotum, whilst the term circocele is used to denote a varicose state of the veins of the cord and testis ; but as the scrotal veins are not subject to any degree of enlargement that merits the name of disease, I shall, as is generally done, apply the term varicocele to a morbid dilatation of the spermatic veins. On dissecting the spermatic veins when varicose, they are found dilated, elongated, and more tortuous than natural, and apparently more numerous, owing to the enlargement of the smaller vessels. In an advanced stage of the disease, their coats are thickened ; so that when divided the vessels remain patent, and thus present the appearance of arteries. The enlarged veins hang down below the testis, and reach upwards into the inguinal canal ; and when very voluminous conceal the gland, encroach on the septum, and extend to the other side of the scrotum. In a good specimen of these dilated 59 466 VARICOCELE. reins which I recently examined, the vessels were arranged in three clusters (see figure). One formed of the larger vessels proceeded from the inferior extremity of the testis ; the second, in which the vessels were less in size, but more numerous and tor- tuous, arose from the upper extremity of the testis ; whilst the third and smallest cluster surrounded and accompanied the vas deferens (1). The dila- tation is not confined to the veins exterior to the gland : even those in the organ itself are found varicose, and en- larged veins may often be dis- tinctly seen ramifying between the tunica vaginalis and tunica albuginea. The veins occa- sionally contain phlebolites, which are lodged in round dilatations of the vessels. The veins of the left testis are more subject to varicocele than those of the right. In upwards of 120 operations performed by Breschet, in only one instance was the varicocele on the right side."* Pott met with this disease on both sides of the body in only one instance, which is recorded in his treatise on Hydrocele.t The disease, however, is far from * Landouzy, Du Varicocele, p. 24. t Case XXXVIII. VARICOCELE. 467 being so rare on the right side as is generally supposed, and often exists on both at the same time, although the varicose state of the right spermatic veins is always much less than that of the left. Landouzy, who has written a work on this affection containing much accurate inform- ation, states that in eight cases out of seventeen he found the veins of the right testis more dilated than natural, though they were much less in size than those of the left. This writer endeavoured to ascertain whether any relation subsists between varicocele and varices in other parts. In fifteen individuals affected with varicocele whom he ex- amined, only one had varicose veins of the lower extremities ; and in twenty persons with varicose veins of the leg, not one had a varicocele, and no connexion could be traced between varicocele and haemorrhoids. I have several times examined the veins of the lower extremities in persons affected with varicocele, but I have only once observed varicocele of the left side in connexion with a varicose state of the veins of the left leg. Of the causes of varicocele, some operate on both sides, others only on one. The most influential of the former is the hydrostatic pressure consequent upon the depending position of these veins, which have to support the weight of a column of blood extend- ing from the testis to the second dorsal vertebra. Many of the Continental writers mention the ab- sence of valves as a circumstance conducing to this disease : but this is an error, for the larger spermatic veins are always furnished with valves, though 468 VARICOCELE. the dilatation which takes place in varicocele pre- vents them performing their office. There are seve- ral anatomical circumstances which, taken together, are sufficient to explain the frequency of varicocele on the left side. On the right side the spermatic vein joins the vena cava, nearly parallel to the axis of that vessel, so that the blood enters in the course of the circulation ; but on the left side the sper- matic vein terminates in the emulgent vein at a right angle, and in a direction perpendicular to the venous current from the kidney, which is less favourable to the return of blood from the testis, since the two currents pursue a different direction. The left testis hangs lower than the right ; conse- quently the veins must be longer, and the pressure produced by the column of blood greater on the left side than on the other. The accumulation of the faeces in the sigmoid flexure of the colon previous to an evacuation tends to produce pressure on the spermatic vein, and impede the return of blood from the left testis, especially in persons whose bowels are habitually constipated. Some persons subject to varicocele suffer from it only when the bowels are in this condition. But even the natural daily accumulation may be sufficient to produce some obstruction to the return of the blood by these veins. To this cause, I imagine, we must chiefly attribute the circumstance that a varicose dilata- || tion of the veins of the ovary in the female is nearly always confined to the left side. I have had many , . opportunities of making this observation ; and Sir 'j A. Cooper remarks that he has never met with a VARICOCELE. 469 varicose state of the veins of the right ovary, which cannot be attributed to any variation in the height of the column of blood, since the two ovaria are on the same level. The occasional causes of varicocele not depending on organization include all those circumstances which tend either to determine the blood in an inordinate degree to the testes, or to impede its return to the heart, and which operate chiefly by weakening the coats of the vessels. In the first class are abuse of venery, masturbation, and at- tacks of orchitis. The second class comprehends tumours developed in the abdomen, enlargement of the lumbar glands, hernial swellings which press on the cord, trusses improperly adjusted, an accu- mulation of fat in the omentum and mesentery, and belts worn round the abdomen. Certain kinds of exercise greatly prolonged, as riding and rowing, and sudden and violent efforts, as in straining, also give rise to varicocele. That the latter powerfully conduces to the production of a dilatation of the spermatic vessels, may certainly be concluded from the circumstance that the stress to which they are subjected during violent exertion is sometimes so great as to occasion rupture of their coats and extravasation of blood, as was pointed out in treat- ing of haematocele of the spermatic cord. Pa- tients, too, often ascribe the origin of the disease to some sudden effort or straining. Want of the proper support afforded to the testes and spermatic vessels by the contractility of the scrotum likewise predisposes to this disease. It is partly on this 470 VARICOCELE. account that varicocele is more common in warm than in cold climates, and in persons of a weakened and relaxed habit than those of a robust and vigorous constitution, and is more troublesome in warm than in cold weather. In the slight degree and chronic state in which we more frequently meet with this disease, the dilatation of the spermatic veins produces no in- jurious effects on the gland ; but when highly or rapidly developed, a varicocele interferes so much with the circulation of the testis as to occasion a diminution in its size. This effect of varicocele upon the nutritive condition of the testis was originally noticed by Celsus.^ Sharp observed, in a case of this disease, a gradual wasting of the body of the testicle, which at length was diminished to the size of a hazel-nut.t A partial atrophy of the gland, co-existing with varicocele, has come under my observation in more than a dozen instances ; indeed, in nearly all cases in which there was a decided dilatation of the spermatic veins on one side only, the testis of that side was the smaller of the two. In one instance I found the gland diminished to half the size of the one on the sound side ; and in a man aged fifty-six who was found drowned, and had a varicocele on the left side, the testis was so reduced that it scarcely exceeded the usual size of the organ in an infant. Some years ago a tall, seafaring man, about forty-five years of age, was under my care at the London Hospital on ac- * Lib. vii. chap. 18. | Critical Inquiry, p, 100, VARICOCELE. 47 1 count of a varicose ulcer on the left leg, who had a large varicocele on the left side, and a testis on the same side so wasted, that it could scarcely be felt even through the tunica vaginalis, which was loosely distended with fluid. In forty-five cases in which Landouzy noted the age at which varicocele was first observed, ten having been taken from authors, and thirty-five having come under his own observation, the age was as follows : From 9 years to 15 - 13 15 25 - 29 25 35 - 3 45 This result very nearly agrees with my own experience in the cases in which I have had an opportunity of ascertaining when the disease first commenced. They show that the period of puberty is the time at which varicocele most commonly occurs. I have only once met v/ith it before that age. The patient was a lad aged thirteen, and the varicocele was on the left side, and was first ob- served a week before, after a fall. The periodic enlargement of the testes had not commenced, but the left gland was smaller than the right. Symptoms. — A varicose distension of the sper- matic veins in general takes place so gradually, and produces so little inconvenience, that it is seldom detected until the affection has made some progress, and is then only discovered accidentally. When some- 472 VAKICOCELE. I what advanced it occasions a sensation of weight in the testis, and a feeling of uneasiness in the course of the spermatic cord, which often extends to the loins, and is aggravated by exercise, as riding or walking. The patient is then apt to carry his hand to the scrotum to relieve the sensation of weight, or to give the part a more favourable and con- venient position in his clothes. On examination the scrotum is found to be long, pendulous, and lax ; and in persons of a thin and delicate skin has a slight livid appearance, the colour of the blood in the veins being indistinctly visible through the integuments. A pyriform swelling is observed in the course of the cord, occasioned by the enlarged veins. This when handled has a soft, doughy, in- elastic feel, and communicates to the fingers a sensation which has been compared to that of a bundle of ropes or earthworms. The dilated veins may be traced upwards into the inguinal canal in advanced cases ; and when very pendulous they sometimes form a double cone, the testis being nearly in the centre, and the varicose veins above and below it. The swelling is diminished by cold and the recumbent position ; and on the other hand is increased by warmth, the erect position, and by straining and coughing. The disease, indeed, is often first discovered by the patient whilst taking a bath, or during an attack of catarrh. The disten- sion of the vessels is also greater towards evening than in the morning. Landouzy has noticed a curious fact in connexion with this disease ; viz. the marked relief experienced by patients during and VARICOCELE. 473 immediately after coition, followed by a severe ex- acerbation of the symptoms the next day.^ This is owing to the support afforded to the vessels of the part by the tone and contraction of the scrotum, and the increased vigour of the circulation during the venereal orgasm ; but as this is only temporary, when relaxation and lassitude ensue the symptoms of varicocele return with greater severity than before. I can confirm the latter observation ; pa- tients having several times complained to me of their symptoms being aggravated for several days after sexual connexion. Varicocele, when slight, often remains stationary for a considerable time, neither increasing nor pro- ducing inconvenience. This is more particularly the case with varicocele in old people, and also on the right side ; so that patients who have discovered the disease on the left side remain for years in ignorance of any thing wrong on the right, which they believe to be sound, though it contains the rudiments of the same affection as exists on the left. In all cases varicocele on the right side is less voluminous, occasions less uneasiness, and leads to consequences less grave than the same affection on the left, and very rarely requires any operation or even treatment for its relief If a patient affected with slight varicocele avoids fatigue and the exciting causes of the disease, and wears a suspensory bandage, its progress is usually arrested ; but if permitted to increase it becomes * Lib. cit. p. 76. 60 474 VARICOCELE. a source of continual suffering. Slight exertion, warmth, or excitement of any kind increases the local uneasiness ; so that the patient is prevented from taking exercise, and is disabled from earning his livelihood by labour. The pain and distress occasioned by this disease vary, however, a good deal, and are not exactly proportionate to the size of the varicocele. In cases of varicocele of large size the pain is sometimes very slight ; whilst in others small in volume it is occasionally very severe. Persons affected with it at an early age, on the whole, suffer more than those who are attacked when advanced in life. The pain in some cases is dull and heavy ; in others it assumes a neuralgic character, darting and shooting, supervening sud- denly, and occurring in irregular exacerbations. The pain is sometimes so excessive and intolerable, that patients have gladly submitted to the operation of castration for their relief, which has been per- formed at the urgent request of the patient by Gooch,* Sir B. Brodie,t Mr, Key,J and others. Severe neuralgic pains are not, however, to be regarded as an essential or common character of this disease; and, as before mentioned, they are not dependent on the degree of vascular dilatation. A combination of a varicose state of veins and neu- ralgia or morbid sensibility is occasionally observed * Practical Treatise on Wcunds and other Chirurgical Subjects, vol. i. p. 244. f London Medical and Physical Journal, vol, Ivi. p. 299. I Sir A. Cooper's Observations on the Testis, p. 224. Vide Case by Mr. Thompson of Stalybridge, Lancef, vol. ii. 1839-40, p. 137. f VARICOCELE. 475 in other parts. Sharp mentions, in his Critical Inquiry, a case where the cephalic and median veins in the bend of the arm were varicose for near two inches, and so extremely painful that the patient could find no relief till he cut them away.^ I have myself noticed in some cases a degree of neuralgia attending varicose veins of the lower extremities ; and a few years back I extirpated from the wrist of a girl eleven years of age a small plexus of vari- cose veins situated at the ulnar side and edge of the lesser vola, near the prominence of the pisiform bone, the skin covering which was so exquisitely tender that she could scarcely bear me to touch the part, and was nearly deprived of the use of the hand. The operation effectually removed the mor- bid sensibility and pain. Though varicocele usually occurs as a chronic affection, it sometimes forms suddenly and ad- vances rapidly, appearing shortly after a severe injury or strain, which had probably occasioned a dilatation of the coats of the veins from which they were unable to recover. There may have been a previous tendency to the complaint ; but patients often ascribe its origin to some sudden effort, since which they had experienced the annoying symp- toms of the disease. In these acute cases, which nearly always occur in early life, the suffering is much greater than in the more chronic cases. Va- ricocele has also been known to occur as an acute affection shortly after an attack of orchitis. Mr. * P. lOL 476 VARICOCELE. Pott has recorded three remarkable cases, in which varicocele made its appearance, not only suddenly and with acute pain, but was attended with very rapid wasting of the testis."^ — 1. A young man after a fatiguing journey was seized in bed with a violent pain in the back, which (to use his own words) shot down into his stone. The pain was so great that he sent for immediate assistance, and was bled, but without relief There was no tumour of the testicle or scrotum. The pain continued without remission all the next day, and he was again bled and purged. On the third day, toward evening, the pain totally left him, and a fulness appeared in the groin tending down towards the testicle. This made him so uneasy that he got into a post-chaise and came home to London. His journey brought on a return of the pain ; but by losing more blood, keeping in bed, and suspending the parts, he be- came easy, and all the tumefaction dispersed except a small fulness of the spermatic cord occasioned by the varicose state of its vessels. But the testicle was so diminished as to be hardly perceptible. — 2. An ostler was thrown from his horse, and struck his groin against the pommel of the saddle. It gave him exquisite pain. He was brought imme- diately to the hospital. When he was examined, there was no apparent swelling of the testicle or spermatic cord. He was largely blooded and purged • his pain continued two days, and when it left him the spermatic vessels became greatly vari- * Lib. cit. p. 46a. Cases XXXVL XXXVIL and XXXVIIL VARICOCELE. 477 cose. He left the hospital free from pain, but his testicle on that side was scarcely discernible. — 3. A gentleman aged twenty-five, after being heated by exercise went to bathe. In the ensuing night he was seized with coldness and shivering, followed by heat, thirst, and a slight sweat. He was bled, purged, and kept in bed. For three days his fever was unremitting ; but on the fourth he became cooler, and was seized with a most acute pain in the loins, for which he was again bled and purged. On the fifth day his back became easy ; but both testicles, though very little swollen, were extremely tender : in a very few hours the spermatic vessels were so distended as to make an apparent tumour. By fomentation, poultice, and rest, all uneasiness was removed in about a fortnight ; but at the end of that time both surgeon and patient were exces- sively astonished at not being able to find the tes- ticles. The patient came to London immediately and consulted Mr. Pott, who found the spermatic vessels full and varicose ; the vasa deferentia too large, and rather too hard, as also the epididymes ; but there was not on either side the least appear- ance of a natural testicle : a flattened, compressed kind of membranous substance, which he supposed was the tunica albuginea, seemed to hang from each epididymis ; but there was not any trace or vestige of the glandular or vascular parts of either testis. The concise history which Mr. Pott has given of these cases seems to afford grounds for sus- pecting that there was some further cause than a 478 VARICOCELE. varicose aiTection of the veins of the testis for the acute symptoms by which they were character- ized. In all three the complaint was preceded by the sudden occurrence of acute pain, without tume- faction of the testis, scrotum, or cord ; and when the pain subsided, which happened in a few days, the swollen vessels then became apparent, and the testes rapidly disappeared. In the two first cases this took place on one side only ; in the third, in which the complaint was preceded by fever, the symptoms were more severe than in the two former, and both testes wasted away entirely in a fortnight. Now such is not the history of varicocele as I have met with it, nor does it correspond with the ac- counts usually given of the disease. Its progress is in general chronic ; and though sometimes acute, I have certainly never known it to become deve^ loped with such rapidity as in these cases. The pain, too, is rather heavy and dull than violent, and does not precede, but seems consequent on, the varicose enlargement ; and instead of the testes decaying rapidly, the atrophy takes place in the most slow and gradual manner, being often imper- ceptible in varicoceles of many years' duration, and rarely going on to the entire destruction of the gland. I scarcely know in what way such a rapid and total wasting of the testis as appears to have taken place in these cases could have been produced, unless from some cause cutting off the chief supply of blood by the spermatic artery. The same cause might likewise obstruct the spermatic veins. In the last case, it is observed that the vasa deferentia VARICOCELE. 479 were too large and rather too hard, as also the epididymes; which would seem to indicate that these parts, if not the testis, had been the seat of inflammation. I think, therefore, there is suffi- cient reason to question the propriety of consider- ing these cases as simple examples of varicocele. Diagnosis. — The symptoms of varicocele slightly resemble those of a scrotal hernia. Like hernia, the tumefaction in varicocele increases when the patient is in the erect position ; subsides spon- taneously, or on pressure, when he is in the recum- bent ; and soon reappears when he again assumes the erect posture. When the dilated condition of the veins extends into the inguinal canal the ring is enlarged, and the swelling increases, and receives a slight impulse in coughing. A varicocele, how- ever, cannot well be mistaken for an intestinal hernia ; but the student may sometimes be unable to distinguish the feel of the tortuous and dilated vessels from that of an omental protrusion. The best mode of making the diagnosis is as follows. The patient having placed himself in the recumbent position, the testis of the side affected is to be raised until the swelling disappears. The surgeon must then press gently with the fingers on the external abdominal ring, and direct the patient to rise. If the case be a varicocele, the swelling soon reappears; but if it be a hernia, the descent of the omentum is prevented by the pressure. As the tumefaction is reproduced, it commences, if a varicocele, from below ; if an omental hernia, from above. In making this examination, care must be taken that 480 VARICOCELE. the pressure be not too great, or the veins will remain empty. A varicocele might possibly be mistaken for a congenital hydrocele, which likewise swells in the erect position and disappears in the recumbent ; the transparency of the tumour in hydrocele is sufficient to set all doubt at rest. Though I have given the above directions, I must observe that I have never met with a case of varicocele in which there was any difficulty in detecting the nature of the case, or distinguishing the disease from other affections of the part. PALLIATIVE TREATMENT OF VARICOCELE. Varicocele is almost an incurable disease ; but as it is an affection which, in the mild form that is more commonly met with, produces little suffering or even inconvenience, the treatment chiefly re- quired is to keep the scrotum and testes well supported with a suspensory bandage, in order to diminish the length of the vessels, and the w^eight of the column of blood circulating in them. As it is desirable that the parts should be kept cool, the suspender should be made of open silk net. A cold evaporating lotion is usually recommended in these cases ; and no doubt benefit might be derived from its constringent effects, if the parts were kept free from the clothes around, so as to permit evapora- tion to take place, but this is seldom convenient. The lotion used should be free from smell. The parts may be freely soused with cold spring water VARICOCELE. 48 1 morning and evening, or the patient may daily use the shower bath. The dress ought to be as light as comfort will admit of, and not tight about the abdomen. Fatiguing exercise, warm baths, much indulgence in venery, — every thing, in fact, which tends to determine the blood to the testes and scrotum must be avoided. The bowels should be properly regulated, and any disposition to costive- ness obviated by gentle aperients, or, what is better, by enemata of warm water thrown well up into the colon every morning, in order to remove the feculent collections from this part of the intestine. By these means, if we cannot correct the dilated con- dition of the veins, we may generally prevent its increasing, and contribute to the comfort and health of the patient. For the purpose of supporting the testis in cases of varicocele, Mr. Wormald of St. Bartholomew's Hospital makes use of the following plan.^ — The lower part of the scrotum, whilst the patient is in the recumbent position and the veins comparatively empty, is drawn through a ring about an inch in diameter, made of soft silver wire of a suitable thickness, padded, and covered with wash-leather. The sides of the instrument are then pressed to- wards each other with sufficient force to prevent the scrotum escaping. Mr. Wormald represents that great relief has been experienced in cases of varicocele from this simple contrivance. I have tried this plan, but have not found that it possesses * Medical Gazette, vol. xxii. p, 194. 61 482 VARICOCELE. any particular advantage over the suspensory truss : it is equally annoying to the patient's feelings, and cannot always be steadily fixed, so as to answer the purpose intended. As the above means are only palliative, and in severe cases do not always afford sufficient relief, and as patients, especially at the age at which va- ricocele usually occurs, do not much like being condemned to wear a bandage for the remainder of their lives, further assistance is often required from the surgeon. RADICAL TREATMENT OF VARICOCELE. In order to afford a permanent and morel complete support to the testis, and to render a suspensory bandage unnecessary, Sir. A. Cooper suggested a very simple operation ; viz. the re- moval of a portion of the relaxed scrotum, leaving the remaining part to form adhesions and to con- stitute a natural suspensory bandage. He states that the operation is safe, effectual, and by no means painful ; and he directs its performance in the following manner. — " The patient being placed in the recumbent posture the relaxed scrotum is drawn between the fingers ; the testis is to be raised to the external ring by an assistant ; and then the portion of the scrotum is removed by the knife or knife-scissors : but I prefer the former. Any artery of the scrotum which bleeds is to be tied ; and a suture is then made to bring; the ed^es of the VARICOCELE. 483 diminished scrotum together. The patient should be kept for a few hours in the recumbent posture, to prevent any tendency to bleeding ; and then a sus- pensory bag is to be applied to press the testis up- wards, and to glue the scrotum to the surface. The only difficulty in the operation of removing the scro- tum by excision is in ascertaining the proper quan- tity to be removed ; but it adds but little to the pain if a second portion be taken away, if the first does not make sufficient pressure on the spermatic cord. It is of no use to remove a small portion of the scrotum, for from doing this I have failed. When the wound has healed the varicocele is lessened, but not always entirely removed ; but the pain and distressing sensations cease, if sufficient of the scrotum be removed."^ Sir A. Cooper recommended this operation only in those cases of varicocele in which the patient suffers great local pain ; in cases in which he is most urgent to have the swelling and deformity of the part removed ; and more espe- cially in those instances in which the function of digestion suffers, and there is a great degree of nervousness and of mental depression. For slighter cases a suspensory bandage must still be recom- mended.t In the paper from which I have quoted, five cases are related in which the painful symptoms of varicocele were fully relieved by this operation : four of them were operated on by Sir Astley him- self, and the fifth by Mr. Key. The son of a medi- cal gentleman of my acquaintance, when sixteen + Guy's Hospital Reports, vol. iii. p, 9. f Ibid. p. 13. 484 VARICOCELE. years of age, had part of his scrotum excised by Sir A. Cooper in May, 1840, in consequence of varicocele. The effects of the operation were mild ; very little confinement was necessary, and the parts healed in little more than a week. In December, 1842, he had continued relieved from all uneasiness ; and the testis was of proper size, though the veins still remained enlarged. In a case operated on by Dr. Watson of New York, the patient was perma- nently relieved of the dragging sensation and pains of which he complained before the operation.* Mr. Bransby Cooper has recordedt another case of severe varicocele, in which the operation was at- tended with a very beneficial result ; but the effects described were extremely severe, — indeed fully as much so as after operations performed on the veins, and not altogether devoid of danger: the cure also proved very tedious. A short time since I exa- mined a man, part of whose scrotum had been excised by Sir A. Cooper on account of varicocele, but who derived so little benefit from the operation that he afterwards subm.itted to castration ; and a medical friend lately informed me that in one of the published cases of success the disease subsequently returned as bad as ever. Mr. Luke made trial of the operation in the following case at the London Hospital. — W. Dudley, an engineer aged twenty-one, was admitted into the London Hospital in May 1841, with a varicocele on the left side. He stated that * New York Med. and Surg. Journal, Oct 1840. f Guy's Hospital Reports, vol. iv. p. 201. VARICOCELE. 485 it came rather suddenly after he had exerted him- self in lifting a plank of wood. The veins were greatly enlarged, and formed a plexus which de- scended below the testis ; the scrotum was lax and pendulous, and the left testis was smaller than the right. The affection was attended with a heavy aching pain in the testis and groin, and uneasiness in the loins, which were so much increased by any exertion that he was obliged to abstain from hard work. The symptoms were only partially relieved by a suspensory bandage and cooling lotion ; and as he was anxious to obtain permanent relief, he was admitted into the hospital for the purpose of having part of the scrotum excised. A considerable por- tion of the integuments was removed with the knife, so as to expose both testes. The edges of the wound were brought together with three liga- tures, and closed with strapping ; but the testes were with difficulty prevented from protruding at the intervals of the sutures, especially the right, the tunica vaginalis of which contained a small quantity of fluid. There was very little bleeding, and only two vessels required ligature. The wound healed up very slowly, and was not entirely closed till six weeks after the operation, during the greater part of which time he was kiept in bed. The testes were then found to be well braced up and supported, and the man was a good deal, but not wholly re- lieved, of the uneasiness in the groin and cord he had previously experienced. He complained for some time afterwards of pain in the loins ; but as he regained his health and strength this left him, 486 VARICOCELE. and he resumed his work. I have not since been able to obtain any further account of the case. This operation has not been generally adopted by operating surgeons, and considerable doubt is entertained of its efficacy. I have taken some pains to ascertain the amount of benefit which it is capable of affording ; and from the inquiries that I have been able to make it appears to me that ex- cision of a portion of the scrotum is calculated to arrest the progress of varicocele, and afford full and permanent relief, only in those cases in which the painful symptoms of the disease admit of being temporarily but completely removed by suspending the parts in the hand, or in a well-adjusted sus- pensory bandage ; when the contraction of the scrotum succeeds in compensating for the previous laxity of the tissues, gives adequate support to the dilated veins, and sufficiently diminishes the pres- sure of the column of blood circulating in them. The objects contemplated in the preceding ope- ration, viz. shortening of the scrotum and per- manent support to the testis, have been attempted to be obtained in another way by Dr. Lehmann, a German surgeon. The mode of operating is very similar to that which he states he has in several cases adopted successfully for the radical cure of hernia. A portion of the relaxed scrotum is pushed up on the fore finger, and invaginated into the part above it, till the finger reaches the abdominal ring. A broad curved needle, with a double thread passed through an eye near its point, is then carried through the bottom of the inverted portion of the VARICOCELE. 487 scrotum, and made to penetrate the integuments immediately over the external ring. The thread is next removed from the eye, and the needle drawn back, and again carried through the scrotum and integuments at the distance of about half an inch from the parts previously penetrated. The threads passed through the two apertures being drawn, the invaginated portion of scrotum is pulled up to the desired height. The threads are then tied in a knot, and the parts are left for eight or nine days, by which time adhesion takes place between the opposed surfaces of the inverted portion of the scrotum and that into which it is pushed. The author relates six cases in which this mode of operating was adopted with success, but in none of them had sufficient time elapsed to enable him to determine that the treatment was permanently beneficial.^ This plan does not appear to possess any advantages over the operation of excision of part of the scrotum ; and I should think it must be liable to even a greater risk of failing in its object than the latter operation. Various attempts have been made to obtain a radical cure of varicocele by causing obliteration of the dilated veins. This has been eifected in four different ways. 1. By division of the vessels ; 2. By ligature ; S. By compression : and 4. By ex- cision. 1. Division of the Vessels, — This operation was first practised by Sir B. Brodie. A man twenty- * Med. Zeitung-, Dec. 2, 1840 ; as quoted in Brit, and For. Med. Rev. No. xxii. April 1841, p. 529. 488 VARICOCELE. one years of age was admitted into St. George's Hospital with a varicocele on the left side, prin- cipally situated at the posterior part of the epi- didymis, which, though not very large, caused a very considerable degree of pain, especially in the evening, when the veins were more distended than in the morning. Finding that the pain was re- ferred almost wholly to the cluster of varicose veins situated at the posterior part of the epididy- mis, he was induced to believe that the sufferings of the patient arose from the pressure of the tumour on some contiguous nerve or nerves, and that if the dilated veins forming it could be obliterated the pain would be relieved. With this impression on his mind, Sir B. Brodie performed the following operation. He divided, with a sharp-pointed bis- toury, the skin and cellular texture at the posterior part of the scrotum, so as to expose the varicose cluster ; and then, by a second incision, he divided the varicose cluster itself, cutting through its centre. When first exposed the cluster was of ^bout the size of a horse-bean, of a purple colour: on being divided it immediately collapsed, and there was a slight venous haemorrhage. Some cold lotion was applied, the wound being allowed to re- main open, in order to favour the escape of blood, and prevent its effusion into the cellular texture of the scrotum. Some inflammation and tumefaction of the scrotum followed the operation ; but there was no fever, nor much uneasiness of any kind- A month after the operation the wound was healed, and the patient was free from pain. A slight I VARICOCELE. 489 degree of hardness remained where the divided cluster of veins was situated. I have not heard that this operation has been adopted in other cases of the disease. 2. Ligature. — Celsus recommended cutting down upon the spermatic veins, and the application of a ligature around them ; an operation which has been frequently performed since his day by many of the older surgeons. This operation is adequate to the cure of the disease ; but is not free from danger, owing to its liability to induce phlebitis. Sir Everard Home cut down upon and tied the spermatic veins for the cure of varicocele in a pa- tient in St. George's Hospital. In this case, accord- ing to Sir B. Brodie, venous inflammation took place, attended with so much constitutional dis- turbance that the patient nearly died.^ It is open also to the further objection of occasioning atrophy of the testis. Delpech, a surgeon of dis- tinction in France, was assassinated by a man whom he had cured of double varicocele a year before by tying the dilated veins. The patient's testes were found after death wasted and soft. To avoid the risks consequent upon the simple application of a ligature, many modern surgeons have had recourse to a plan for the obliteration of the dilated veins which was first tried by M. Davat on the veins of animals.t This plan consists in * Lond. Med. Gaz, vol. xiii. p. 379. I have been informed that several of the patients whose spermatic veins had been tied by Roux in Paris, for the cure of varicocele, died from the operation. t Vide Archives Gcnerales de Medecine, 11 ser. t. xi. p. 1. 1833. 490 VARICOCELE. passing a straight pin or needle through the scrotum, and underneath the varicose vessels, be- tween the latter and the yas deferens, and then twisting a strong silk ligature around the project- ing extremities of the pin in the form of the figure 8, with sufficient tightness to compress and flatten the vessels and arrest the circulation through them. Inflammation is by this means excited in the coats of the vessels ; and the sides of the inner one being retained in contact, the vessels soon become ob- literated by adhesion. The pin after remaining in a few days is removed, and the sores produced by it soon heal up. Velpeau and Jobert"* have practised this operation with success in several cases, and it has also been performed in America,! and in this country by Mr. Liston± and other sur- geons, with favourable results. The pins should not remain in longer than four or ^ve days, or they are liable to occasion ulceration of the veins, and suppuration in the cellular tissue of the scro- tum. In large varicoceles it is necessary to intro- duce a second or third pin at the distance of from half an inch to an inch from each other. M. Ricord of Paris also has recourse to the liga- ture, which he applies in the following ingenious manner : — The vas deferens is separated from the mass of veins ; and the latter being taken up with a jj fold of the scrotum, a flat lance-shaped needle, armed with a double-looped thread, is passed beneath them. * Bulletin Generale de Therapeutique, Aout, 1837. t American Journal of the Medical Sciences, vol. xxiii. p. -SOO. I Practical Surgery^ 3d edit. p. 446. ■ VARICOCELE. 491 When the needle has been passed completely through the skin from one side to the other, the veins are let go, the skin alone being now held up ; and then a second needle, similarly armed, is passed through over the veins, entering at the same hole by which the first needle was thrust out, and pass- ing out at the same hole by which it entered. The bundle of veins is thus fixed between two double threads, of which one passes over the other beneath it. The ends of each double thread on each side are then passed into the loop of the other, and now by drawing these ends in opposite directions the vessels are tied beneath the skin. By this kind of ligature the vessels may either be suddenly constricted, or be tied gradually, in a manner some- thing like that practised by Breschet ; or most con- veniently by a properly adapted serre-nceud, after the fashion of a tourniquet. It is usually from the tenth to the twentieth day that the vessels are divided by this means ; and their division may be easily recognised by the freedom with which the ligatures may be drawn from one side to the other without being, as they were before, retained by the parts which they inclosed. Sometimes a slight oedema of the scrotum supervenes after the opera- tion, and Ricord has twice observed rather a con- siderable serous efiusion in the tunica vaginalis. In one patient also, who a few days afterwards exposed himself to great fatigue, a slight abscess formed in the cellular tissue ; but with these ex- ceptions there has been no important accident. If the patient is strong and plethoric, he is to be bled 492 VARICOCELE. from the arm directly after the operation ; the horizontal position must be maintained till the vessels are cut through, and the bowels must be carefully kept open. Twelve pa- tients had been operated on in this manner at the Venereal Hos- pital, and in all the most com- plete and satisfactory result had been obtained."* Mr. Luke has lately cured a case of varicocele at the London Hospital with the ligature, ap- plied by means of an instrument termed a " fistula tourniquet," with which he has successfully treated several cases of fistula in ano. — Matthew Quin, a tall and muscular Irishman, aged twenty- four, was admitted in August, 1842, on account of varicocele on the left side. The left testis was about half the size of the right, and above it there was a consider- able swelling formed by the varicose spermatic veins. * British and Foreig-n Medical Review, July, 1840, p. 270. (From Bulletin Generale Therapeutique, Mars, 1840.) Several other modi- fications of the operation by ligature have been practised by different French surgeons ; but they are not important. (iV) Mr. Luke's tourniquet for the cure of fistula and varicocele. A. The screw. B. Button upon which the screw turns. C. Movable nut, D. Key for turning the screw in order to tighten the ligature. VARICOCELE. 49o He experienced a dragging pain in the course of the cord, and an uneasy sensation of weight, which were only partially relieved by supporting the parts. He had been a private in the Light Dragoons, and he attributed the origin of his complaint to his testis having been accidentally struck against the saddle in riding about fourteen months before. He had left the regiment invalided in consequence of it about two months. — September 3. Mr. Luke, the patient standing before him, having separated as far as possible the whole of the plexus of varicose veins from the vas deferens, passed a straight sewing needle armed with a ligature of strong dentist's silk through the root of the scrotum between these parts ; and having attached the ends of the ligature to the fistula tourniquet, secured them so as to make gentle pressure on the veins. The man was then sent to bed. Three days afterwards the liga- ture was tightened by turning the screw, and a grain of calomel was directed to be taken at night. As the ligature cut through the included parts and got slack it was again tightened, the turning of the screw being stopped immediately the patient com- plained of pain. He had continued so free from pain during the treatment that at the end of ten days the calomel was omitted, and he was allowed to walk about the ward and take his diet as usual. The ligature came away on the 28th, and on the 30th the wound was healed. A few dilated veins were still felt in the lower part of the scrotum. The man was greatly relieved, though he was not quite free from the sensation of weight without 4 94 VARICOCELE. wearing the suspensory bandage. The testis was not diminished in size. — Oct. 4. He was discharged from the hospital. — Dec. 20. He was still quite well, and had taken a situation as policeman. The testis was about the same size as before the opera- tion, and the tumefaction of the veins removed. 3. Compression, — In the preceding operations the veins are pressed upon by the pin or ligature with which they are immediately in contact, and are thereby liable to become inflamed. To obviate this disadvantage M. Breschet has contrived a pair of forceps, to cause obliteration of the veins, by making firm pressure on them from outside the scrotum. By means of this instrument, the blades of which are well padded, and admit of being closed by screws, the walls of the dilated veins are at once brought into contact ; blood coagulates in the vessels ; and adhesion taking place, the danger to which the other plans are liable is said to be avoided, and by securing the spermatic artery from compression atrophy of the testis is also prevented. In thirteen cases in which this operation was performed there was only one relapse, which was owing to a vein not being included in the forceps.^ A writer who witnessed the treatment of several of Breschet's cases, and has reported favourably of the operation, has nevertheless represented the inflammation and swelling consequent upon it as being considerable, and the cure as proving tedious.t * Landouzy, lib. cit. f Vide Observations on M. Breschet's Operation for the Radical Cure of Varicocele, by W. H. Walshe ; Medical Gazette, vol. xv. p. 369. VARICOCELE. 495 Under the head of Compression must be men- tioned a mode of relieving varicocele, which, as far as may be judged from the few cases in which it has hitherto been tried, bids fair to become a valu- able acquisition to our means of treating this obsti- nate disease. The history of the plan is as follows. A surgeon suffering from a varix in the leg, having heard the late Sir Charles Bell state, in his lectures at the College of Surgeons, in illustration of the fact of the dilatation of a varicose vein being caused solely by the pressure of the column of blood, that if the distended vein be compressed with the finger the swollen condition of the vessel beneath shortly disappears, was led to apply the principle thus in- dicated to the treatment of his own case, which was attended with a satisfactory result. This gentle- man mentioned the circumstance to Mr. Aston Key, who was accordingly induced to adopt the same principle in the treatment of cases of varicocele ; and in a private communication with which I have been kindly favoured by Mr. Key, he has assured me that he believes the practice resorted to is effective, and applicable to the majority of cases of varicocele. In a patient affected with this disease, if the spermatic cord be pretty firmly compressed between the fingers while the patient is in the recumbent position and the vessels are empty, it will be found, on his assuming the erect posture, that the vessels, instead of swelling as before, still remain empty and contracted."^ Even, too, when the patient is * This may seem incompatible with the account given at page 479, of the mode of distingiiishino; a varicocele from a hernia; hut such is 493 VARICOCELE. standing, and the veins are full, if firm pressure be made on the cord, the vessels below being thus re- lieved of the superincumbent weight of the blood, will gradually become emptied of their contents. It was natural, therefore, to conclude that if the pressure could be steadily continued for a sufficient length of time, it would enable the vessels to recover from the morbid state of dilatation in which they were previously retained by the hydrostatic pressure of the blood. In the case of the varix in the leg, it is clear that the local pressure could have had no effect on the artery by which the vein was supplied, and we may reasonably conclude that the blood in the veins below the point of compression found its way back to the heart by collateral and healthy channels. When the spermatic vessels are com- pressed in the manner just described, the pressure does not appear to be sufficient to obstruct the spermatic artery ; whilst the blood in the vessels below the part compressed no doubt returns by the smaller vessels, a sufficiency of which always exists in these cases in an adequately healthy state for the purposes of the circulation. The object, then, of this method of treatment may be stated to be — the maintenance, whilst the patient is in the upright po- sition, of such a degree of pressure on the spermatic veins as may be sufficient to relieve them from the superincumbent weight of the blood, without at the same time endangering the integrity of the testis by not the case, since for the latter purpose a much less degree of pressure oa the veins is required than to produce the effect described in the text. VARICOCELE. 497 obstructing the spermatic artery, and without caus- ing so much uneasiness as to render the remedy as painful as, or more difficult to be borne, than the dis- ease. This pressure must be continued a sufficient time to enable the coats of the vessels to return to their natural dimensions, and to acquire strength to carry on the circulation. When this is effected the patient is cured. It is obvious, therefore, that the main difficulty of this treatment consists in the ap- plication of continuous local pressure. The only part where this can well be made on the spermatic veins is at the external abdominal ring ; but the force required is such, that unless it be skilfully applied patients are unable to submit to it. Two cases have been mentioned to me in which it was tried, but the instrument caused so much pain and inconvenience that the patients were obliged to dis- continue its use. In the following case of varicocele successfully treated by compression, for which lam indebted to my friend Mr. Daldy, he had recourse to a truss, which appears calculated to meet the exigencies of this mode of treatment better than any other mechanical contrivance with which I am acquainted, — F. U., cet. 21 , who had been the subject of varicocele, attended with a sensation of dragging and weight from the loins, for four years, at length became alarmed by the increase of the varix and the diminution of the left testis, which was reduced to about half the size of the right. At that period, now a twelvemonth ago, Evans's patent truss was applied to the external abdominal ring ; and at the present time, no other means having been used, 63 498 , VARICOCELE. the varix has disappeared, the pain has subsided, and the left testis has resumed its natural size, no appreciable difference now existing between the two. The truss has not yet been discontinued ; as some slightly distended veins, on a careful ex- amination, may still be felt above the testis. Mr. Daldy remarks, '* It appears to me that I gained considerable advantage in the treatment of this case by the use of Evans's patent lever truss, as the patient was enabled to wear it without the slightest inconvenience, and to regulate the pressure at will, so that he never suffered any pain from it." He I was induced to adopt this treatment in the case in ' consequence of a gentleman of his acquaintance, twenty-seven years of age, who was affected with a rapidly-increasing varicocele, having been recom- mended by Mr. Key to have recourse to pressure on the spermatic vein by means of a truss. He wore it for two months, and clearly derived benefit from it ; when he quitted the country for Canada, since which no intelligence has been received of the case. The truss employed in the above case certainly appears to possess many important advantages. Being made without any circular spring, it is not so liable to be displaced as the ordinary trusses. The lever spring enables the patient readily to regu- late the pressure of the pad, to increase or diminish it as may be necessary ; whilst the pad itself, being stuffed with a material^ of remarkable lightness and * This substance, called " moc-main," is the produce of the silk cotton tree, Bombax heptaphyllum, a plant which grows abundantly in the East Indies. I VARICOCELE. 499 elasticity, allows of the application of greater force than could be tolerated under other circumstances. 4. Excision of the Spermatic Veins. — This opera- tion has been practised by Petit and other surgeons. It is performed in the following manner. An as- sistant first separates the vas deferens, which he is to hold firmly and carefully between his thumb and forefinger. An incision from two to three inches in length is then made in the integuments over the cluster of dilated veins. The veins which then protrude are excised with a pair of curved scissors, or divided with a bistoury, first above and then below. If any troublesome haemorrhage after- wards ensue, the bleeding vessels are secured by ligature. A needle and ligature are sometimes passed under the veins at the upper part of the wound, in order to secure them from retraction after their division. The wound is closed by a single suture and adhesive plaister ; it often heals by the first intention. Dr. Warren states that he has been in the practice of doing this operation for a number of years ; that he has found it give great relief; that in no instance has it been necessary to repeat it ; and that it has never been attended with unpleasant consequences, except in a single instance. In that case, bleeding ensued after the operation, from which the scrotum became so enormously distended that it caused inflammation and sloughing of the cellular membrane and testicle ; after which the patient recovered.* * Surgical Observations on Tumours, p. 441, 500 VARICOCELE. This is a more severe operation than the ligature, and it is equally, if not more liable, to be followed by phlebitis and wasting of the testis ; and besides is attended with risk of haemorrhage, and the produc- tion of a considerable and troublesome suppurating wound- In the treatment of cases of varicocele, the sur- geon should bear in mind that as the complaint is not dangerous, seldom produces pain amounting to more than an inconvenience, and usually admits of relief by palliative means, it is not justifiable in ordinary cases to risk the loss of the testis, or to perform severe operations for its removal. For this reason, ligature and excision of the veins, and such operations as are severe or at all liable to induce phlebitis, are never resorted to by judicious and cautious practitioners, except in the few instances in which palliative means fail to afford relief and arrest the decay of the testis, and the pain and annoyance are really so great as to require some- thing to be done to alleviate the patient's sufferings. The indication for the perfect cure of varicocele is not merely to aid and support the dilated and weakened vessels, but so far to relieve them of the superincumbent weight of the blood as to enable them to return to their natural dimensions, and recover their tone so as duly to carry on the circu- lation. The first indication may be fulfilled to a certain extent by the suspensory bandage, and in » some cases permanently by the excision of a portion of the scrotum ; and in mild cases these plans are VARICOCELE. 601 sufficient to give all the relief required, and to prevent the extension of the disease : the latter proceeding may be resorted to whenever the patient is tired of wearing a bandage, and is willing to submit to an operation which, though painful, is not under ordinary circumstances attended with danger. But neither artificial support, nor excision of the scrotum, is capable of fulfilling the second indication — of reducing the size and thickened coats of the dilated veins. The only plan which appears to be fully adapted to effect this object is firm, steady, and continued pressure on the spermatic veins at the ring by means of a well-adjusted truss. At present our experience of this mode of treatment is too limited to admit of any opinion of its efficacy being confidently expressed ; but I look with no slight interest to the result of further trials of a remedy which seems to me to be based on sound views of the pathology of the disease. This plan appears to be particularly applicable to cases of varicocele in young persons, whose reparative powers would be sufficient to restore the veins when relieved of pressure to a healthy state. In acute or severe cases of varicocele, when the distress is considerable, or the symptoms partake of a neuralgic character, and when the methods of treatment just alluded to fail in affiDrding sufficient relief, it may become ne- cessary to have recourse to the ligature for the obliteration of the varicose veins ; and as in these cases life is embittered by the disease, the patient being incapacitated by it from earning a livelihood, and that too at an early age, it would certainly be 50 2 VARICOCELE. justifiable in such cases to incur the slight hazard of phlebitis incidental to the ligature, and to risk even the loss of the testis, which would undoubtedly suffer if the disease continued, in order to obtain the relief and comfort which the operation is cal- culated to afford. The plan adopted in the case reported at page 492, is the one to which I should be inclined to give the preference ; for, with the ingenious tourniquet devised by Mr. Luke, the sur- geon has it readily in his power to tighten or relax the constriction as the circumstances of the case may require ; and no treatment could have been milder than the ligature thus applied in the case related. An important point supposed to be gained by this mode of treatment, is the effect of the gentle pressure first produced in exciting sufficient irri- tation to cause obliteration of the veins before the constriction afterwards made by tightening the ligature cuts the vessels through ; by which means the risk of phlebitis is in a great degree, if not en- tirely obviated, the ligature acting in fact on an impervious cord instead of on a tubular canal. The ligature should be applied as high up as pos- sible ; for the plexus of enlarged veins is small above, and increases in size towards the testis. I should never, however, recommend the application of a ligature to the veins in a person far advanced in life or not in a good state of health ; for the sur- geon cannot, under the best of circumstances, divest his mind of all fear of the occurrence of inflamma- tion of the veins. In some of the cases which have been operated on by ligature the testis has not been found to ADIPOSE TUMOURS OF THE SPERMATIC CORD. 503 suffer. In these instances, no doubt, some of the veins — for it is difficult to include them all — espe- cially the plexus running close to the vas deferens, had escaped the effects of the ligature, and proved sufficient to return the blood from the testis. Such appeared to me to have happened in the case v^hich I have detailed. Hence it becomes a question whether the surgeon should endeavour to include all the spermatic plexus in the ligature, or be satis- fied with tying only a part of the veins ; since, by including the whole, the loss of the testis, which is of importance at the period of life that this disease occurs, is very likely to result.^ It may, however, be objected to the latter plan, that the attempt would only increase the risk of the operation fail- ing, without insuring sufficient means of circulation to preserve the integrity of the testis ; but upon this point further experience is required. CHAPTER II. ADIPOSE TUMOURS OF THE SPERMATIC CORD. I HAVE already treated, under the head of Hydro- cele, of the serous cysts occasionally developed in the course of the spermatic cord. This part may * In the unfortunate case in which Delpech tied the spermatic veins, atrophy of both testes resulted. I have heard of other instances in which the gland has wasted after operations for the obliteration of the veins. It is not improbable that in some of these cases the spermatic arterv was also included in the ligature. 504 ADIPOSE TUMOURS OF THE SPERMATIC CORD. also be the seat of abnormal depositions of fat. They generally occur in persons advanced in life. The adipose matter is formed in the loose cellular tissue, and is often interposed between the parts composing the cord. It occurs at different parts of the spermatic cord, as high up as the inguinal canal, and as low down as the epididymis. In examining the testes of a young man who died of pleurisy in the London Hospital, I found a quantity of fat along the cord and around the epididymis, and some also beneath the tunica vaginalis reflexaon the posterior part of the testis. I have lately met in another case with some small isolated masses of fat, coupled with a small encysted hydrocele of the cord. Mor- gagni in one instance met with a similar deposition extending to the testis.^ He also remarks, " On one occasion when the testis was enlarged, I found a little fat deposited within the innermost substance, which, in other respects, was not much diseased. From this case I inferred that tumours of the testis may occasionally originate from an unnatural gene- ration of fat, and its subsequent increase."t When fat is developed in the cord in considerable abundance, it sometimes forms, in front of the sper- matic vessels, a loose and movable tumour, having the soft doughy feel and lobular character of ordi- nary adipose swellings. These accumulations of fat occasion no inconvenience, and consequently do not require any surgical treatment. They have, however, been mistaken for omental hernia. Pel- letan, by whom they have been noticed, speaks of * Cooke's Morgagni, vol. ii. p. 435. f Ibid. p. 437. ADIPOSE TUMOURS OF THE SPERMATIC CORD. 505 them under the denomination of " hernie grais- seuse"^ I once dissected a lobulated fatty tumour, surrounded by the thickened sheath of the spermatic cord, on the body of a man upwards of eighty years of age, which was very similar in appearance to a por- tion of omentum contained in a her- nial sac. It is represented in the annexed wood-cut. Cloquet has also given an account of the dissection of a fatty tumour, found in the left spermatic cord of an old man, which resembled an irreducible epiplocele.t Mr. Macilwain mentions an instance in which it was thought proper to cut down upon a tumour of this kind in the spermatic cord to ascertain its nature, in consequence of the patient labouring under the symptoms of strangulated hernia. The surgeon, finding the fatty tumour to be so intimately connected with the cord as not to admit of extirpation without injury to it, removed tumour, testicle, and allf — a proceeding which, in such a case, could scarcely have been justifiable. These swellings have the soft inelastic feel, elongated form, and indolent character of an irreducible omental hernia. In a case, there- * Clinique Chirurgicale, t iii. p. 33. t Recherches sur les Causes et I'Anatomie des Hernies Abdomi- nales, p. 26. I Surgical Observations, p. 291, note. 64 506 SPASxM OF THE CREiMASTER MUSCLE. fore, where obstinate constipation and other symp- toms of strangulated hernia exist, if after a careful examination of the tumour, and an attentive con- sideration of the history of the case, any question remain respecting its nature, it would be quite right to remove all doubt by cutting down upon the part. Fatty deposits in the spermatic cord might easily be mistaken for a varicocele ; and some tact and experience are required to distinguish the peculiar swelling caused by the dilated veins from a soft, inelastic, indefined adipose tumour. The latter is constant, whilst varicocele diminishes or disappears in the recumbent position, Ossific tumours have in some rare instances been observed in the spermatic cord. In the London Hospital Museum there is a preparation of a stone, the size of a small walnut, in the cellular tissue at the upper part of the spermatic cord of a man who died of strangulated hernia. CHAPTER III. SPASM OF THE CREMASTER MUSCLE. Spasm of the cremaster muscle is an occasional symptom in different affections of the urinary or- gans. It occurs in diseases of the kidney and in the passage of a calculus down the ureter, and also in affections of the prostatic portion of the urethra. SPASM OF THE CREMASTER MUSCLE. 507 being the result of irritation transmitted froni these parts. In the two first cases, it may be explained by the connexion which exists between the spermatic plexus of nerves and the renal, and in the latter one by the connexion of the same nerves with the hypogastric plexus along the vasa deferentia. The spasm comes on suddenly ; so that the testes are forcibly drawn up and retained, whilst it lasts, at the external abdominal rings, the patient suffering more or less pain. This affection is to be treated with the warm bath, fo- mentations of hops or poppyheads^ opiates, &c., attention being at the same time paid to the source of irritation. In the following case spasm of the cremaster muscle, of a mild character, appeared to be the result of an injury, — A Jew boy, aged eleven, applied to me at the London Hospital, on account of an uneasy state of the testes. They were retracted to the external abdominal rings, producing a deep vi^inkle across the pubes. The scrotum was flaccid and empty. It appeared that a short time before he had received a kick on the pubes, since which the testes had become drawn up. Pressure on the pubes gave pain, and when made at the part where the cremaster is attached the testis immediately descended, but was again elevated as soon as the pressure was remitted."* Conceiving that the spasm was chiefly owing to sligkt inflammation at the seat of injury which * I once observed the same eircumstance in a case of spasmodic retraction of the testes, symptomatic of irritation at the prostatic part of the urethra. 508 SPASM OF THE CREMASTER MUSCLE. had affected the internal attachment of the cre- master, I ordered leeches to the part, fomentations, and mild aperients. No relief followed this treat- ment. The cold douche was then applied, with the effect of causing the muscle immediately to relax. The spasm returned soon afterwards, but not to the same extent as before. The douche was repeated with the same effect, and the boy ceased to attend. He came to me again, some months afterwards, with gonorrhoea and a return of the spasm in the cremaster, which subsided as the disease in the urethra became relieved. PAET IV. DISEASES OF THE SCROTUM, CHAPTER I. INJURIES OF THE SCROTUM. The scrotum is exposed to contusion and lacera- tion from external violence. Contused wounds of the scrotum are chiefly remarkable on account of the large quantity of blood generally effused be- neath the skin. The cellular tissue, like that of the eyelids, is exceedingly loose, so that a slight blow produces rupture of vessels and abundant ecchymosis. The swelling which arises is consider- able : the testes become surrounded with so much blood that they cannot be felt, and the skin in a few days assumes a deep purple hue. These cases generally do well ; but some weeks elapse before the blood is all absorbed, and the swelling and discoloration are completely removed. All that is usually necessary in the way of treatment, pro- vided the testes have escaped injury, is rest, support to the swollen scrotum with a bandage or pillow, and the application of a cold evaporating lotion. A lotion composed of the hydrochlorate of ammonia, or a poultice of oatmeal and vinegar, appears to accele- rate the absorption of the effused blood. When the 510 DISEASES OF THE SCROTUM. contusion is severe and the extravasation consider- able, inflammation sometimes arises, and even termi- nates in suppuration or mortification ; but this is a rare result of such injuries, and only follov^^s in persons of impaired constitution. In a case of the kind, after gangrene or suppuration has taken place, the scrotum should be relieved by free incisions. Under other circumstances this operation is highly objectionable, and must never be resorted to for the relief merely of the extravasation, as incisions are very liable to be followed by sloughing of the cellular tissue and severe constitutional symp- toms. Lacerations of the scrotum, though formidable in appearance, usually terminate favourably. There is not much haemorrhage ; but, ov\r^ing to the con- tractile nature of the integuments, the scrotum presents a large gaping wound. This must be cleansed, the coagula removed, and the edges brought together and retained by sutures and ad- hesive plaister. The wound heals in general very readily. — I was sent for to see a man who, in a state of intoxication, had sustained an injury of the privates by sitting down upon the broken arm of a chair. I found a large triangular lacerated wound on the left side of the scrotum, the edges of which were so far separated that the part appeared as if a great portion of the integuments had been re- moved, the whole of the left testis and part of the spermatic cord being completely exposed and pro- jecting. The edges of the wound were without difficulty immediately closed with sutures : they PRURIGO SCROTI. 611 united by the first intention, and in a week the part had completely united and the patient was cured. The scrotum is not very often injured by burns or scalds, the part being protected by a woollen dress. — A deaf and dumb man, at work at a soap- boiler's, fell into a vat containing caustic potass of the strength of 10 per cent. He was admitted into the London Hospital shortly after the acci- dent. The skin was denuded of cuticle, and su- perficial sloughs were produced on the face and hands ; but his chief sufferings arose from the action of the caustic on the prepuce and scrotum, which were entirely excoriated and a good deal of the skin destroyed. The sloughs separated and the sores healed in about three weeks, the scrotum being slightly contracted. CHAPTER 11. PRURIGO SCROTI. The scrotum is sometimes the seat of an intolerable itching, which produces much distress, tormenting the patient by day and disturbing his rest by night, and thus whilst it lasts rendering his life truly miserable. This complaint is commonly accom- panied with the formation of a number of round flattened papulag of a slight red colour, which are readily recognised on the dull and darker surface 512 PRURIGO SCROTI. of the scrotum. The skin becomes excoriated by the patient scratching himself; which, though pro- ductive of temporary relief, aggravates his suffer- ings afterwards. There is often a disagreeable discharge from the sebaceous follicles ; and after the complaint has existed for some time the skin becomes browner than in its natural state, and somewhat thickened. The irritation comes on in paroxysms: it is increased by exercise, especially in warm weather, and by the heat of the bed at night, and it is liable to extend towards the anus and down the inside of the thighs. This affection attacks adults ; but occurs gene- rally to persons in advanced life, and is supposed to be induced by inattention to cleanliness. It is a very obstinate complaint, often resisting every kind of treatment for months, and even years, though liable to complete remissions and frequent relapses at variable intervals. Treatment. — Very little relief is afforded in this affection by internal remedies. The bowels should be occasionally acted on by saline purgatives. It has appeared to me that benefit has been derived in some cases from 3ss. to 3J. of the sulphate of magnesia dissolved in the infusion of roses, with fi\e or six minims of the dilute sulphuric acid, given three times a day. If the general health should suffer from want of rest at night, as some- times happens, the acetate or muriate of morphia may be taken at bedtime. Alteratives, as five grains of the Pil. Hydrargyri Chloridi Comp., given daily or every other day, will tend to correct the state of the PRURIGO SCROTI. 513 secretions, which are often disordered in this affec- tion. The patient should be enjoined to refrain from scratching the parts ; his dress should be light and loose ; and he ought to avoid exercise in warm weather and a stimulating diet. A warm bath should be taken two or three times a week, as it promotes cleanliness, which is very essential in these cases. The parts ought to be kept cool with a lotion of vinegar and water, or of the bichloride of mercury, in the proportion of two grains to the ounce of water. The yellow wash, and lotions composed of the carbonate of potass in the propor- tion of four drachms to twelve ounces of rose water, have also proved of service. I have found the Unguentum Hydrargyri Nitratis DiL, smeared over the scrotum at night, one of the most efficacious applications for diminishing the itching. Sulphur ointment and sulphureous vapour baths sometimes succeed in affording relief Local cinnabar fumi- gations, applied by means of an apparatus adapted for the purpose, have been strongly recommended by M. Biett in this troublesome and distressing complaint."* * Cazenave et Schedel, Abrege pratique des Maladies de la Peau, edit. 3eme, p. 315. 65 514 VARICOSE VEINS OF THE SCROTUM. CHAPTER III. VARICOSE VEINS OF THE SCROTUM. Some authors have noticed, amongst the diseases incidental to the scrotum, a varicose condition of its veins. The veins, however, of this part are never weakened and dilated to a degree sufficient to require the attention of the surgeon. The re- markable contractility of the dartos contributes to their support, and to diminish the tendency to dilatation. Varix of the spermatic veins com- mences much more commonly in young men than in old ; whereas, in consequence of the lax state of the scrotum in advanced life, the scrotal veins more frequently become varicose at that period. In old men they sometimes present a curious ap- pearance, the scrotum being studded with a number of minute red or black spots, about the size of a pin's head, and sometimes larger, evidently dilata- tions of the small veins, as they disappear for a time under gentle pressure of the finger. I have occasionally observed them when the scrotum has been distended by a hydrocele. In severe cases of varicocele the veins of the scrotum sometimes par- take in the dilatation of the vesselsof the spermatic cord. PNEUMATOCELE. (EDEMA SCROTI. 615 CHAPTER IV. PNEUMATOCELE Is a term employed to designate a distended state of the scrotum from the presence of air in its loose cellular tissue, which is treated of by old writers on surgery as an affection of no uncommon occurrence. Emphysema of the scrotum, however, is only seen in the present day when produced by artificial in- flation ; a trick of feigning disease sometimes prac- tised by soldiers, and by others for the purpose of imposing on the charitable. The scrotum has been inflated to the size of a child's head ; a degree of distension which is borne without any injurious consequences. The nature of the tumour can be readily detected by the crepitation of the part under the finger. CHAPTER V. (EDEMA SCROTL The cellular substance of the scrotum being loose, abundant, and free from fat, and the skin plentiful and very extensible, this part undergoes a more remarkable degree of distension from oedema than any other part of the body ; and, owing to the pen- dent position of the scrotum, oedema of this part is 516 (EDEMA SCROTI. often met with, occurring generally as a symptom of organic disease, in conjunction with serous infil- tration of the extremities or body at large. (Ede- ma of the scrotum, termed by some writers ana- sarcous hydrocele, occasionally occurs, however, as a distinct aifection, or independently of oedema in other parts. On cutting into the scrotum when thus affected, the cellular tissue is found loaded with a white or pale straw-coloured transparent serum, which readily drains off through the opening. The cells are dis- tinctly seen of large size, some of them being ca- pable of admitting the extremity of a goose's quill, or even of the little finger. The testes are wholly surrounded with the serous infiltration : the vagi- nal membrane covering them is found to be loosely attached amidst the cellular tissue. The blood- vessels appear small, indistinct, and few in number. Symptoms. — The oedema commences at the most depending part of the scrotum, to which it is con- fined when the infiltration is slight. When the whole scrotum is involved, the part presents an uniform, indistinctly defined tumour, with a soft and doughy feel, and pits on pressure ; but, owing to the large size of the cells, the fluid traverses the cellular tissue so freely that the parts retain the impression of the finger for but a few moments. As the tumefaction increases the tegumental rugae are obliterated, and the surface of the skin becomes smooth and somewhat tense, and has a pale, glisten- ing, semi-transparent appearance. The testes are so surrounded with the infiltrated serum that they (EDEMA SCROTI. 517 cannot be distinguished. When the oedema is con- siderable, the integuments of the penis generally participate in the distension : the prepuce becomes twisted and distorted, and so enlarged as to conceal the glans penis. The tumefaction often extends also to the groins and lower part of the abdomen. (Edema of the scrotum is occasioned by the vari- ous causes obstructing the circulation and producing dropsical effusion in other parts ; and, owing to the depending position of the scrotum, it is usually one of the parts first distended in general dropsy. It is observed occasionally as a local affection in old men, and in persons debilitated by disease, espe- cially where the scrotum is particularly pendent. It is sometimes seen in children shortly after birth, and is produced by disease of the inguinal glands, and by tumours obstructing the course of the veins and lymphatics. It is occasionally caused by the accidental rupture of a hydrocele of the tunica vaginalis, and in the attempt to cure this disease by acupuncture. Diagnosis. — The symptoms presented by oedema of the scrotum are of so marked a character, that this affection is not readily confounded with any other disease, and when the dropsy is general it is scarcely possible that any error can be committed. Local oedema may, however, be mistaken for a hydrocele, and when of great extent for elephanti- asis of the scrotum. In oedema the tumefaction is soft and diffuse, pits on pressure, occupies both sides of the scrotum, and conceals both testes : in hydrocele it is resisting, defined, and fluctuating. 518 (EDEMA SCROTI. and confined to one side ; except in double hydro- cele, in which case there is no similitude to oedema, as there are always two well-defined and distinct tumours on the two sides of the scrotum. Pott once operated on an oedematous swelling of one side of the scrotum, having mistaken the case for a hydrocele. — A man, aet. 45, showed him a swelling on the left side of the scrotum, which was large, full, tight, and had all the symptoms of a hydro- cele ; viz. fluctuation, freedom of the upper part of the process, and concealment of the testicle. Thinking himself clear in the true nature of the disease, he without scruple pierced it with a small trocar in the lower and anterior part, and let out about two ounces of limpid water, but could not draw off any more. He withdrew the canula, and examined the swelling again, which was but little diminished, though altered in appearance. He could then plainly distinguish the testicle, and became convinced that the disease was (what he had never seen before) an anasarca of the scrotum on one side only, having a certain quantity of water in one cyst or bag, and the rest difiused through the cells in the usual manner: the latter made all the tumefaction, which remained after tapping ; and the former had concealed the testicle.* If this case had been narrated by a surgeon of less judgment and experience than Mr. Pott, we should be inclined to suspect that the tumour had origin- ally been a hydrocele, and that, when tapped, the * Chirurgical Works, 4to. p. 336. (EDEMA SCROTI. * 519 fluid had partially escaped into and infiltrated the cellular tissue around the sac. The limitation of the oedematous swelling to one side of the scrotum was a very unusual occurrence ; for although the cellular tissue is usually somewhat condensed in the course of the septum, there is always a ready and free communication between the two sides. In this case the septum must have been particularly close and dense, and the cause of the dropsical effusion have operated only on one side. The smooth surface of the skin, the softness and laxity of the tumour, its ready retention of the impression of the finger, and its comparatively small size, are the characters by which oedema of the scrotum may easily be distinguished from ele- phantiasis. Treatment. — (Edema of the scrotum being in general only a symptom of disease elsewhere, and not of itself of any serious moment, seldom requires any separate or local treatment. When the tume- faction is very great, and the skin so tense that there is risk of its bursting or mortifying, the part must then be relieved by acupuncture. The cells so freely communicate with each other, that one or two punctures with a darning needle are sufficient to relieve the most bulky swellings. It was usual formerly to relieve the distended scrotum by inci- sions. But this is a dangerous practice ; for inci- sions are very likely to excite diffuse inflammation, which, in the weak state of the part and of the patient's powers, is speedily followed by mortifica- tion. Pott has recorded three cases in which exten- 520 * DIFFUSE INFLAMMATION OF THE SCROTUM. sive mortification followed incisions of the scrotum for this complaint, one of which proved fatal.^ CHAPTER VI. DIFFUSE INFLAMMATION OF THE SCROTUM. Diffuse inflammation of the scrotum, though not particularly noticed by writers on surgery ,t often occurs as a distinct affection ; and, owing to modifi- cations in the texture of the integuments, the cha- racter of the disease diflers in some respects from that of diffuse inflammation in other parts. This affection is well known to practitioners of expe- rience, and is not unfrequently seen in hospital practice. It occurs under two forms. In one it is mild and unattended with danger, and terminates favourably under gentle antiphlogistic treatment. In the other form the complaint is severe and dan- gerous, and prompt and decisive measures are requisite to avert serious consequences. The first form occurs generally to persons at the adult period of life. The skin of the scrotum becomes affected with slight erythema ; assumes a faint rosy hue ; soon becomes shining, tense, and oedematous ; and * Lib. cit. Case VI. p. 365. t Some cases of this affection have been published by Mr. Listen, under the denomination of "Acute Anasarca of the Scrotum," in the twenty-second volume of the Transactions of the Medico-Chirurgical Society. DIFFUSE INFLAMMATION OF THE SCROTUM. 521 quickly loses its rugous character. The light in- flammatory blush extends in a short time to the perineum and integuments of the penis, which also become tumid and oedematous ; and in some in- stances it spreads even to the groins, lower part of the abdomen, and inside of the thighs. Its appear- ance is accompanied with symptoms of slight fever, a hot skin, and furred tongue. This affection usually occurs to persons exhausted by fatigue and want of rest and nutriment. — A lad, twenty years of age, previously in tolerable health, who had walked up to London from a long distance in the country for work, and had fared badly on the road, applied to me on account of this affection, with which he 7/as seized the day after his arrival in the metropolis. — A labouring man who had been ex- posed to the inclemency of the weather, and had undergone a good deal of fatigue on board a barge in the river, was attacked in the same manner. I have seen it in weakly persons arise from slighter circumstances, and sometimes without any obvious cause. It is occasionally produced, especially in old people, by the irritation of the urine dribbling over the parts, and the lodgment of discharges and acrimonious fluids amongst the rugae of the scrotum. The second form of diffuse inflammation of the scrotum com^mences like the former ; but the dis- ease runs rapidly into mortification. The slight rosy hue of the scrotum soon becomes changed to a violet or livid colour, and ash-coloured or tawny spots appear at an early period on the most depend- 66 522 DIFFUSE INFLAMMATION OF THE SCROTUM. ing parts. These quickly extend, and, unless checked by decisive treatment, the whole scrotum soon becomes involved-; so that if the patient sur- vive, and the sloughs separate, the testes are entirely denuded of their integuments. The sloughing is attended with symptoms of a low typhoid charac- ter, a hot skin, feeble pulse, and a brown and dry tongue, under which the patient often sinks. This form of the affection attacks persons of a cachec- tic habit and broken-down constitution, or men enfeebled by age. It is produced by the same causes as the milder form ; but it is also liable to occur after a slight injury, and is often excited by disease of the urinary organs, as stricture, or an abscess in the perineum, independently of urinary extravasation. The following case is recorded by Mr. Liston. — W. R., aged forty, admitted into Royal Infirmary, July 21st, 1834. Received a kick on the perineum from a cow about a fortnight ago. There was much pain at the time ; but the injury was followed by no further inconvenience until about eight days ago, when the pain returned, and was followed by considerable and rapid swell- ing of the scrotum. Upon examination the scrotum was found to be much swelled and extremely tender. At the lower part it was of a dark livid colour ; and, on pressing it, an emphysematous crackling was distinctly felt. There was little swelling in the perineum ; but on the right side, about an inch anterior to the rectum., there was a small opening, irregular in its appearance, through which the dead cellular tissue protruded, and a small quantity of DIFFUSE INFLAMMATION OF THE SCROTUM. 523 what was, at first, believed to be urine, escaped. The pulse was small and rapid ; the tongue dry in the centre and moist round the edges. Bowels reported open ; and states that he passes his urine freely. Immediately after his admission free inci- sions were made into the scrotum, and the opening in the perineum enlarged. In both places the cel- lular tissue was found in a state of gangrene ; and a considerable quantity of thin foetid fluid, mixed with air, escaped from the scrotum. The man was a habitual drunkard and of weak intellect. He gradually sunk and died on the 28th of July, before the sloughs had separated. On dissection, the whole urinary apparatus was found in a perfectly healthy state."* It is a remarkable circumstance, that inflamma- tion of the scrotum rarely terminates in the eflusion of lymph or pus. It seems that the pressure con- sequent upon the abundant effusion of serum is sufficient to arrest the circulation, and occasion mortification before other changes ensue. When suppuration takes place it is generally in the dif- fused form, though the matter has a tendency to collect at the most depending part of the scrotum. I have rarely met with a well-formed abscess in this part unconnected with suppuration in the perineum or with disease of the urethra. Diagnosis. — Diffuse inflammation of the scrotum may be confounded with oedema ; but differs from it in the more active character of the disease, in the f' Lib. cit. p. ,293. 624 DIFFU&E INFLAMMATION OF THE SCROTUM. inflammatory redness of the skin, and the general febrile disturbance which accompanies it. Treatment. — In the milder form of this affec- tion gentle purgatives, antimonials to determine to the skin, and rest in the recumbent position for a few days, with the application of an evaporating lotion to the scrotum, which should be well elevated on a pillow placed between the thighs, are gene- rally all that is required to subdue the inflammatory action, and cause the swelling to subside. When there is much tension, warm fomentations are pre- ferable to cold applications. It is bad practice to apply leeches in these cases, as they are very liable to induce sloughing. If gangrene be apprehended, punctures with a lancet should be made in the scrotum at its most depending part, to allow the serum to escape, and thereby remove the tension. Nothing succeeds so speedily and effectually in averting the sloughing process as early incisions. They must not be merely skin-deep, but the dis- tended cellular tissue beneath should also be divided. They need not, however, be very extensive, as one or two small openings well placed will be sufficient for the relief of the tension. Incisions are very painful, and when large produce a considerable shock to the nervous system ; which the patient, in his weakened state, is not well able to bear. It is also of great moment to avoid the loss of blood : consequently, if bleeding ensue from any of the divided vessels, an active assistant should be at hand to place his fingers upon them, and restrain the haemorrhage by pressure. These vessels pour MORTIFICATION OF THE SCROTUM. 525 out blood profusely when first divided ; but they soon contract, and do not in general require liga- tures. There is often a free oozing from the skin generally, which may be checked by the application of small dossils of dry lint. The parts are to be treated after they have been incised with fomenta- tions, water dressings, or light poultices. In this dangerous form of the disease the powers require to be supported by quinine, ammonia, wine, and brandy, and a nourishing diet. The diffuse inflam- mation v^^hich occurs in connexion with stricture or perineal abscess usually subsides as soon as the obstruction is overcome, the matter discharged, and the exciting cause removed. Where this is ne- glected, the mortification which ensues adds greatly to the danger and urgency of the case. CHAPTER VII. MORTIFICATION OF THE SCROTUM. Mortification of the scrotum is commonly the result either of the worst form of diflfuse inflamma- tion just described, or of urinary extravasation, and it sometimes occurs at the close of exhausting fevers. It would be out of place to treat here of the subject of urinary eflusion. It will be sufficient to remark that the eflect of the irritating fluid dif- fused throughout, and distending the cellular tissue of the sciotum, is soon to excite inflammation and 526 MORTIFICATION OF THE SCROTUM. produce the death of all the parts with which it comes in contact, unless such a result be speedily averted by deep and pretty free incisions, so as completely to relieve the distension and allow the urine to drain off from every part of the scrotum. The scrotum is so situated, protected by and re- ceiving the warmth of the thighs, and at no great distance from the centre of the circulation, and at the same time is so well supplied with blood-vessels, that it is a part by no means exposed to mortifica- tion from deprivation of animal heat. Amongst the numerous cases of frost-bites which have come under my notice, I have only w^itnessed one in which the scrotum had suffered from this cause. The spots were very small, and after the separation of the superficial sloughs the sores soon healed. Sir A. Cooper has recorded the following case. — A patient in Guy's Hospital, who was in the retreat with the Duke of York's army in the Netherlands, and exposed to excessively severe cold, had his scrotum become frostbitten, and sloughed away, exposing the tunica vaginalis and tendon of the cremaster muscle, which were, when he was in the hospital, covered by granulations, but had not a new scrotum formed. The slough had extended to the penis, and divided the vessels of the penis, which was swollen to an enormous size.* Treatment. — Sloughing of the scrotum, from whatever cause it may proceed, is seldom free from danger, being attended in most instances with a * Lib. cit. p. 20. MORTIFICATION OF THE SCROTUM. 527 failure of the powers of life and low febrile symp- toms, which require to be counteracted by stimu- lants. The local treatment, after free incisions have been made, consists in the application of fo- mentations and light poultices, which may be moistened with the Liquor Calcii Chloridi, to correct the offensive foetor. In many cases the extension of gangrene can be arrested and the powers rallied by judicious treatment ; and then the process of separation and detachment of the dead parts soon commences, and, as would be expected from the vascularity of the scrotum, pro- ceeds with activity. Large sloughs come away, leaving behind an extensive, open, and formidable- looking sore, with the testes and spermatic cords completely denuded. Fortunately there is no part of the body in which the reparative efforts of na- ture are more remarkably displayed after extensive mortification than in the scrotum. In cases in which the whole scrotum and even part of the integuments of the penis have sloughed away, gra- nulations have rapidly sprung up from the exterior of the tunica vaginalis and proper investments of the cords ; cicatrization has taken place all around from the edges of the wound ; and partly by liberal demands upon the integuments of the pubes, groins, and perineum, and partly by the production of new skin, the exposed testes and spermatic cords have become invested with a new covering adequate for the protection of these important organs. The new scrotum is not exactly like its predecessor ; it is thin, tense, and without colour, and closelv in- 528 ELEPHANIIASIS SCROTI. vests the testes; and sometimes, when there is much contraction of the cicatrix, these glands are forced upwards into the groins. In these cases the surgeon can do but little to aid and promote the efforts of nature. He has only to apply mild and simple dressings, and to avoid unnecessary med- dling. Officious interference by sutures, plaisters, and bandages for the purpose of approximating the edges of the wound, avails very little in accele- rating the healing process. CHAPTER VIII. ELEPHANTIASIS SCROTI^ Elephantiasis is a disease of the scrotum occasion- ing a remarkable tumour; it is rarely seen in Europe, but is of very common occurrence in many other parts of the globe. As I have never wit- nessed a case of this affection, the following de- scription is taken from an examination of some of the tumours removed by operation, which have been preserved, and from the accounts of elephantiasis given by the best writers on the subject. Elephantiasis consists in a morbid thickening of the tissues of which the scrotum is composed. The epidermis becomes thickened, rough as in icthyosis, and intersected with fissures or chaps. The chorion is immensely consolidated, and often nearly an inch in thickness, and very dense. The chief bulk, how- ELEPHANTIASIS SCROTI. 529 ever, of the tumour is formed by the conversion of the loose cellular tissue of the scrotum into a large mass of fibro-cellular tissue, infiltrated with a thick jelly-like fluid, evidently albumen, as it coagulates on the application of heat, acid, or alcohol, and some- times on cooling, after its removal from the body. The areolae of this tissue vary a good deal in size, but some of them have been found large enough to admit the extremity of the little finger. These cells, when condensed by inflammation, form hard- ened masses in the substance of the tumour, which has a lardaceous appearance when cut, or resembles cartilage ; and they sometimes undergo conversion into bone. The testes are buried in the morbid mass towards its posterior part, but they are usually sound in structure. Occasionally there is a small quantity of serum in the tunica vaginalis. In a case operated on in Calcutta, there was a hydrocele on both sides imbedded in the diseased parts, the largest of which contained between five and six pints of fluid.* The spermatic cords are elongated several inches, owing to the testes being dragged downwards during the growth of the tumour, but they are not otherwise diseased. In a remarkable case operated on in Guy's Hospital, the cremaster muscles were nearly as thick as the finger.t The morbid growth is lowly organized. Its arteries are chiefly derived from the external pudic and perineal vessels ; but these, owing to the magnitude of the tumour, become of great size. The veins are numerous, large, varicose, and very tortuous. * Calcutta Quarterly Journal, No. 3. f Medical Gazette, vol. viii. p. 95. 67 530 ELEPHANTIASIS SCROTI. Elephantiasis chiefly affects the inhabitants of the warmer regions of the earth. It appears to be endemic in many parts of Asia and Africa, and is a very common disease in the East Indies, Syria, and Arabia, and also in Egypt. This disease was for- merly considered peculiar to Barbadoes ; but it now prevails in the other West India Islands, and like- wise on the continent of America. Negroes are very subject to it. It is not, however, confined to the natives of warm climates, though they more frequently suffer from its attacks than European residents. Very few cases of this disease have oc- curred in Europe. Sir W. Blizard presented to the College of Surgeons a good specimen of a scrotum and prepuce affected with this disease in its early stage, which appears to have been removed after death. M. Charles Delacroix, formerly minister for foreign affairs in France, suffered from this affec- tion of the scrotum for fourteen years. The tumour, which weighed thirty-two pounds, was removed by operation, and he afterwards recovered.^ Mr. Liston excised at Edinburgh a large tumour of this kind, which weighed upwards of forty-five pounds, from a young man aged twenty-two. It had commenced when he was only ten years of age, and had gone on increasing gradually from that time.t Delpech operated on a patient aged thirty- five, a native of Perpignan in the south of France, * Delonnes, Operation de Sarcocele. t Edinb. Medical and Surgical Journal, vol. xix. p. 566. This turaour is now deposited in the Museum of the College of Surgeons in London. ELEPHANTIASIS SCROTI. 531 whose scrotum was converted into a large mass weighing sixty French pounds.* Elephantiasis of the scrotum is a morbid affection of the integuments, analogous to the enlargement of the extremities commonly known by the name of Barhadoes leg ; with which, indeed, in those coun- tries where the disease is prevalent, it is liable to be combined. Elephantiasis of the scrotum, how- ever, grows to a greater size and makes more rapid progress than the same disease in the leg, owing to the very loose texture and depending state of the parts. The labia pudendi of females in warm cli- mates are subject to a similar change, though not to the same extent nor so frequently as the scrotum. Elephantiasis has been attributed to inflammation of the lymphatic glands by Dr. Hendy, and of the lymphatic vessels by M. Alard. The inflammation of these parts, which is in general only temporary, is probably the effect rather than the cause of elephantiasis ; and in many cases in which there has been great enlargement the inguinal glands have been found quite free from disease. Dr. Wise, who appears to have seen a good deal of this disease amongst the natives of Bengal, believes that it is produced by an inflammation of the veins, and that it is a complaint analogous to phlegmasia dolcns.t Bouilland also inclines to the opinion that elephan- tiasis is caused by an affection of the venous system. * Chirurg. Clinique de Montpellier, t ii. p. 5. f Transactions of the Medical «,nd Physical Society of Calcutta, vol. vii. p. 156. 532 ELEPHANTIASIS SCROTI. An obstruction of the lymphatics or veins can scarcely, however, be adequate to account for the remarkable hypertrophy or thickening of the cutaneous tissue, which occurs in this disease. We find, in cases of cancer affecting the axillary | glands and obstructing the course of the lymph- atics, that although great distension of the arm is produced by infiltration of the subcutaneous cellular tissue, it is not accompanied by a thickened state of the skin ; nor is this change the ordinary result of venous obstruction or of phlebitis. The dis- ease would appear to be something more than mere inflammation or obstruction, either of the lymphatic or venous system. Dr. Titley, who has published much interesting information on the subject of elephantiasis, states that we are totally unacquainted with the causes which give rise to it. In Barbadoes it was thought to depend on some local peculiarity ; but the disease having now extended throughout the other islands, in which the same local causes do not exist, at once negatives that supposition, and we must confess our ignorance of the circumstances on which it is dependent ; nor is it easy to account for the great frequency of the disease now in many islands in which it was forty or fifty years ago entirely un- known, and in which the climate, soil, customs, &c., were the same formerly as at present. He remarks, peculiarity of food or clothing, or exposure to the vicissitudes of the weather, cannot be considered to give rise to it ; for the children of the gentry, who are not exposed to these causes, are frequently af- ELEPHANTIASIS SCROTI. 533 fected. It is not infectious, though he thinks that children born of parents labouring under the dis- ease are more liable to suffer from it than such as are descended from a more healthy stock."^ Symptoms, — Authors describe elephantiasis as commencing with rigors, followed by fever, pain, and heat in the part affected, and swelling and ten- derness of the neighbouring lymphatic glands, the scrotum remaining swollen after these symptoms subside. Similar attacks of fever and inflammation occur more or less frequently, and at various inter- vals, the tumefaction being increased after each attack. Dr. Titley states that on each accession of fever there takes place an effusion of lymph into the cellular membrane, and that the part affected remains swollen for a longer period after each at- tack. After several returns, the quantity of lymph effused being greater than can be absorbed, the limb or part becomes permanently enlarged. The skin, as the disease advances, becomes rough and rugged. Patients will live for many years, carry- ing about with them an enormous leg or scrotum, and will enjoy excellent health, except during the occasional attacks of fever. When the scrotum is the part affected, after a certain time the tumour increases, independently of the febrile attacks. Where the penis is also affected, these parts enlarge together in an equal ratio ; but if the scrotum only be affected, then the penis, as the scrotum enlarges, becomes drawn in, so as ultimately to disappear, * Dr. Titley on Diseases of the Genitals of the Male, p. 300. 534 ELEPHANTIASIS SCROTI. and become completely imbedded in the tumour ; the prepuce being distended elongates, and opens by a navel-like aperture on some part of the an- terior surface (see figure, page 536), or even at the very end of the tumour.* When the disease is fully established the enlarge- ment increases gradually and constantly for many years, until at length the swelling reaches an enormous magnitude. As this takes place the skin is borrov^ed from the lower part of the abdomen, so that the hair on the pubes becomes thinly scat- tered on the front and upper part of the tumour, which at the same time encroaches on the perineum behind. The tumour, which is of an oval or py- ramidal form, the apex being superior, thus becomes attached to the body by a thick peduncle, which extends from the pubes, occupies the whole of the perineum, and terminates posteriorly at the verge of the anus. The surface of the swelling is some- times equal and smooth ; more generally it is rough, rugous, and tuberculated, and covered in various parts with brownish scales. It is often ulcerated in different places, the sores being covered with scabs, or discharging a sanious matter. The tumour feels firm and solid ; and sometimes, when handled, communicates an indistinct sense of fluctuation. In some instances it pits on pressure, but the den- sity and thickness of the skin usually prevent the part from receiving the impression of the finger. Its growth is unattended with pain ; the part is by * Lib. cit. p. 801, et. seq. ELEPHANTIASIS SCROTI. 535 no means tender, and bears rough handling, and even being pricked and scratched without the pa- tient suffering uneasiness, owing to the skin having lost its natural sensibility. The chief inconvenience which it produces arises from its great bulk and weight ; occasioning deformity, impeding and in many instances entirely putting a stop to the pa- tient's movements, and interfering with micturition and the performance of the genital functions. Elephantiasis is sometimes complicated with scrotal hernia ; and often, as has already been ob- served, with hydrocele. There is scarcely any limit to the size which the tumour may attain. It has been known to acquire such a magnitude as to weigh more than two hundred pounds,* exceeding the weight of the rest of the body. Baron Larrey met with a case in Egypt in which the tumour was estimated to weigh fifty kilograms, or a hundred pounds ; and he also states that he saw, in different parts of the same country, ten or twelve more cases of the kind nearly as large. It has been found to measure more than four feet in circumference, and almost to reach the ground when the patient is in the upright position. In the case operated on by Clot-Bey, the morbid mass, which weighed one hundred and ten pounds, kept the patient's legs far apart, and obliged him to remain constantly on the ground ; it was so bulky that he could even sit upon it. In the accompanying figure of a black man * Case cited from " Ephemerides d'Allemagne," by Larrey, Me- moires de Chirurgie Militaire, t. ii. p. 115, 536 ELEPHANTIASIS SCROTI. affected with elephantiasis, taken from Dr. Titley's work, the tumour descended nearly to the ankles. All surgeons who have had much experience of this disease agree that it is entirely local, and tends but little to impair the general health and shorten the duration of life. The tumour, however, when of great size, is liable to mortify. Dr. Hendy of Barbadoes has related the case of a black man who had a scrotal swelling, which measured six feet in circumference, and twenty-four inches in length. A mortification of the part terminated the mise- rable existence of this poor creature.^ Dr. Hendy * A Vindication of the Facts and Opinions contained in a Treatise on the Glandular Disease of Barbadoes, p. 117. ELEPHANTIASIS SCROTI. 537 states that five other cases had come within his knowledge where the scrotum, being much enlarged, had sloughed, leaving the testicles denuded. [The above plate gives the appearance of a negro suffering from Elephantiasis Scroti, and the same individual two months after its extirpation by Dr. Picton of New Orleans. The operation was performed on the 3d of October, 1837, in the presence 68 538 ELEPHANTIASIS SCROTI. of twenty physicians and surgeons of New Orleans. The disease had existed ten years, and the weight of the tumour was fifty-three pounds. The prepa- ration is in the Anatomical Museum of the Uni- versity of Pennsylvania. — Am. Ed.] Diagnosis. — The symptoms of this disease are so remarkable, that it can scarcely be confounded v^ith any other affection. (Edema of the scrotum is the only disease which bears any resemblance to it. The rough and indurated state of the skin, the firm and solid nature of the tumour, and its large size, are characters quite sufiicient to pre- vent elephantiasis from being mistaken for simple oedema. Treatment. — Elephantiasis, when advanced so as to produce considerable enlargement of the scrotum, is an incurable disease. Various local applications and internal remedies have been tried, but there is no satisfactory account of beneficial effects having resulted. The surgeon rarely meets with this dis- ease at a sufficiently early period to afford a fair hope of his being able, by remedies, either to obtain its removal or even to arrest its progress. At its first commencement it should be treated by mild antiphlogistic remedies, the repeated application of leeches, and protracted counter-irritation ; the scro- tum being well supported, and the patient kept in the recumbent position. Iodine is a remedy which seems to be very applicable to this disease ; but I am not av^^are that it has yet been fairly tried in the early stage. Free scarifications and firm compres- sion long continued have been found of decided ser~ vice in reducing elephantiasis of the leg. Pressure. ELEPHANTIASIS SCROTI. 539 however, cannot be applied with equal effect to the scrotum, owing to the want of some resisting point. When the enlargement of the scrotum has reached such a magnitude as to occasion serious inconve- nience and render the patient's life miserable, there is no other remedy but its removal by the knife ; an operation which has been performed in several in- stances with a favourable result. I have already noticed cases in which considerable tumours of the scrotum have been successfully removed by De- lonnes, Mr. Liston, and Delpech. Tumours even of a much larger size have also been excised, and the patients have afterwards recovered. Dr. Titley successfully removed from a young man, a negro, a tumour weighing seventy pounds, which is repre- sented in the engraving at page 536. Clot-Bey ex- cised one weighing one hundred and ten pounds.* There is nothing in the situation, structure, or re- lations of the tumour offering any objection to its removal. Its situation is external to the important cavities ; its structure is not very highly organized ; integuments are the parts affected ; and the only organs in any way involved are the testes and penis, — parts of importance, but not essential to life. But owing to the great extent of the parts divided, and the size of the vessels supplying a morbid mass of the magnitude which many of these tumours ac- quire, the operation becomes a very formidable and dangerous affair ; and patients have died from haemorrhage during or immediately after its per- * Histoire d'une Tumeur Elephaiitiaquo du Scroluni. 540 ELEPHANTIASIS SCROTI. formance. In Mr. Listen's operation the flow of blood was compared by those present to the dis- charge of water from a shower-bath, it was so in- stantaneous and abundant. Before half the vessels could be tied the patient sunk off the table, without pulse and with relaxed muscles. He was only saved by being freely plied with strong whisky. Mr. Key removed, at Guy's Hospital, from Hoo Loo, a native of China, aged thirty-two, who came over to this country on purpose to undergo the operation, a tumour of the scrotum which w^eighed fifty-six pounds eight ounces ; but the patient died a few minutes after its termination from loss of blood.* A tumour weighing fifty-six pounds was excised by Dr. Goodeve of Calcutta ; but the patient, a man forty-five years of age, lost between thirty and forty ounces of blood, and gradually sank, and died in about six hours after the operation.! Dr. Titley has also recorded a remarkable case in which a mass weighing one hundred and sixty-five pounds, and measuring two feet five inches in length and five feet ten inches in circumference, was removed from a slave at St. Christopher by Mr. Wilks, a sur- geon. The operation occupied nearly eight hours ; a copious venous hemorrhage followed each stroke of the knife, and the man died, apparently from exhaustion, towards its conclusion.:): Before undertaking the removal of a large tumour produced by this disease, it is important to deter- mine whether the penis and testes can be preserved. * Medical Gazette, vol. viii. p. 93. t Calcutta Quarterly Journal, No. 3. I Diseases of the Genitals, p. 317. ELEPHANTIASIS SCROTI. 541 Iq the operation expedition is of the greatest mo- ment ; and the patient's safety might be compro- mised by a tedious dissection in order to preserve those parts. Surgeons have commenced with the intention of leaving them ; but, in consequence of the alarming loss of blood, the attempt has been abandoned in the course of the operation. This was the case in Mr. Liston's operation, and like- wise in Mr. Key's ; the patient's powers, in the latter, having become so depressed, that Sir A. Cooper proposed that no further attempts should be made to save the penis and testes, which were accordingly excised. Clot-Bey and Dr. Titley suc- ceeded in saving the penis, but they were obliged to remove the testes. The elongation of the sper- matic cords, and the difficulty of finding healthy integuments to cover the genital organs, are fur- ther reasons for not making the attempt to preserve them when the elephantiasis is of great magnitude. Delpech succeeded, after a tedious and difficult dis- section, in saving these parts in his operation, which was performed in the following way. — Three flaps, two lateral and one in front, having been marked out on the tumour with ink, the operation was com- menced by the division of the integuments so as to form the flaps. Several vessels then required to be secured. An incision several inches in length was next made on the right side of the tumour; and, at the depth of two inches, a cluster of vessels was discovered proceeding towards the bottom of the scrotum. These, which were branches of the external pudic, were cut and tied near the groin. A similar incision was made on the left side, and 542 ELEPHANTIASIS SCROTI. the corresponding vessels in like manner were divided and secured. Afterwards, on cutting deeper, the operator recognised the spermatic cord much enlarged. This was easily detached with the finger, which served as a guide for an incision through the whole depth of the tumour, in order to expose the testis, which was situated at a distance of a foot from the ring. This organ was enlarged without effusion in the tunica vaginalis, but it was rather firmly fixed at its posterior part to a kind of cavity in which it was lodged. The testis and cord, having been entirely disengaged, were deposited on the abdomen. A similar proceeding was pursued on the right side ; but with less difficulty, the testis not being so adherent. An attempt was next made to reach the penis by transverse incisions through the soft parts situated between the two rings ; but the great density of the tissues rendering this ha- zardous, the finger was introduced into the orifice at the bottom of the tumour through which the urine escaped, and the prepuce was divided upwards, the distance of a foot, as far as the penis. The in- cision was afterwards prolonged to the base of the organ and the symphysis pubis. The penis was carefully dissected out, and the prepuce cut away from around the base of the glans ; and the organ was then deposited, with the testes, on the abdomen. The peduncle of the tumour was detached with great care, in the course of which the different structures of the perineum were all exposed. The tumour having been at length entirely cut away, several arteries required to be secured ; including the artery of the septum scroti, the dorsal arteries ELEPHANTIASIS SCROTI. 543 of the penis, the transverse artery of the perineum, the arteries of the bulb, and several branches of the inferior haemorrhoidal. All these vessels were tied separately, and the ligatures cut short. The testes were placed in the perineum at the sides of the penis ; but the spermatic cords, owing to their great length, being arranged in tortuous folds in order to occupy the limited space allotted to them, were with difficulty retained in their position. The two lateral flaps of integument were brought toge- ther, and their borders united by the interrupted suture, from the anus upwards, for four fifths of their extent. The anterior flap was then rolled round the penis, and united by suture, the anterior border being left free to form the prepuce ; and, in order to prevent the penis from slipping from its new sheath, a little of its cellular tissue was included in the sutures. The sides of this flap were then connected by suture to the remaining fifth of each lateral flap. The parts were afterwards supported and kept in contact by compresses of charpie and a ' double T bandage. The patient recovered, and the wound completely healed in two months. He re- turned to Perpignan, where he led an intemperate life, and died of a large abscess in the liver six months after the operation. The quantity of blood lost in this operation is not stated ; but we may infer that it was consider- able, for immediately afterwards the pulse was im- perceptible, the face pallid, and the limbs were cold. The tumour weighed sixty pounds ; and the time occupied in its removal, which, if we may judge from the minute details of the operation re- 544 ELEPHAJNTIASIS SCROTI. lated by Delpech, was skilfully executed, was fifty- seven minutes, — a long period for the patient to be under the knife ; and the time subsequently taken up by the approximation of the flaps and dressing of the wounds of course greatly added to the dura- tion of the operation. Notwithstanding the re- covery of Delpech's patient, the case seems to me to afford but little encouragement to attempt the preservation of the genital organs in operations for the excision of tumours of so large a size. When no attempt is made to save the genital organs the operation is of a simple nature. The peduncle of the tumour is to be divided near its at- tachment to the body by rapid strokes made with a large bistoury, or a scalpel-shaped amputating knife, including in one sweep the penis and sper- matic cords, which latter should be immediately seized with the fingers by assistants to prevent their retracting. If any part of the integuments be sufiiciently sound to form a flap to cover the large open wound, the surgeon must take advan- tage of it, and modify the operation accordingly. When the intention is to preserve the genital organs, three flaps of appropriate size must be formed ; one in front to cover the penis, and two others, one on each side, to be brought together in order to invest the testes in the manner practised by Delpech. In cases complicated with hernia the sac is usually adherent to the diseased tissues around, and requires to be detached with caution, which tends to delay and increase the difficulties of the operation. Active assistants must be ready with their fingers to close the mouths of the bleed- HYPERTROPHY OF THE SCROTUM. o45 ing vessels. Firm pressure on the cut surface by means of a large sponge, expertly applied so as to follow the surgeon's knife, will be found a good way of arresting the bleeding until the surgeon is ready to secure the vessels. Stimulants and the trans- fusing instruments should be at hand in case of need. It appears that patients who recover from the first effects of the operation generally do well, and that the large wound which is made heals readily. CHAPTER IX. HYPERTROPHY OF THE SCROTUM. The scrotum is liable to a hypertrophied affection of the same nature as the knotty and lobulated growth of the skin occasionally observed on the nose. In this affection the integuments appear as if composed of lobes divided by fissures. In the museum of St. Bartholomew's Hospital there is a preparation of this kind. It belonged to Mr. Aber- nethy ; but no history is attached to it. The hypertrophied scrotum appears to have been re- moved during life ; and I am informed by Mr. Paget that the sebaceous and hair follicles are remarkably developed in it. This disease is liable to be confounded with elephantiasis, but differs from it in the circumstance that the morbid en- 69 546 CANCER SCROTI. largement is entirely confined to the skin, the sub- cutaneous cellular tissue being unaffected. When the disease increases so as to cause inconvenience, it may be excised without difficulty or danger. I witnessed an operation in a case of this kind, which was performed by M. Velpeau at La Charite in Paris. The patient was a young man, whose scrotum w^as hypertrophied to about four times its natural size. He afterwards did well. CHAPTER X. CANCER SCROTI. Cancer scroti, or as it is commonly called chira- ney-sweepefs cancer, is a disease of the skin of a carcinomatous nature, which attacks the scrotum of persons who have been exposed to the contact of soot. It is originally developed in the form of a small pimple, or warty excrescence, termed soot- wart, which often remains on the scrotum for months, or even years, without undergoing any change. Usually there is only a single wart at the lower part of the scrotum ; sometimes there are two or three of different sizes ; and occasionally they are so numerous, and so abundantly and largely developed, as to form a considerable cauliflower ex- crescence. After a time the w^art becomes soft, excoriated, and red, and exudes a thin irritating discharge ; which, becoming dry, forms an incrus- tation over the excrescence. After the scab has CANCER SCROTI. 547 been picked or rubbed off by friction against the dress, ulceration ensues, destroys the wart, and pro- duces a painful chronic sore, possessing the ordinary characters of a carcinomatous ulcer on the skin ; thick, indurated, and everted edges, and an irre- gular excavated base, the surface of which dis- charges a thin sanious fluid. The ulcer, if suffered to proceed, increases widely, in- vading the whole scrotum to the perineum, and laying bare the crura penis. At the same time it penetrates deeply to the tunica vaginalis, which becomes firmly connected to the morbid scrotum, and adherent to the testis. This organ, in time, also becomes in- volved in the disease, and forms the seat of a deep excavated sore. The glands in the groin often enlarge at an early period from irritation ; but at length these as well as the lumbar glands become indurated and diseased. The inguinal glands some- times suppurate, and form intractable ulcers in the groin, similar in character to the sore on the scro- tum. The ulcer spreads towards its circumference widely and superficially, whilst in the centre it burrows deeply, until in many instances it reaches the great vessels of the thigh, destroys their coats, and causes death by haemorrhage. In other cases the glands remain unaffected ; but ulceration con- O. 1. Small groot-warts. 2. Cancerous nicer succeeding- the wart. — From a preparation in the London Hospital Museum. 548 - CANCER SCROTI. tinues to proceed slowly in the direction of the cord, and in time extends to the groin and abdomen, its progress being attended throughout with severe darting pains. The patient's sufferings are pro- tracted for many months, and sometimes for years ; a frightful sore is produced ; he becomes gradually cachectic ; loses appetite and flesh ; his countenance assumes a peculiar leaden or waxy hue and anxious expression ; and he ultimately sinks, worn out by his sufferings and the effects of the disease on his constitution. The small excrescence in which cancer scroti usually originates is soft, vascular, and sensitive, and in many respects similar to the soft warts which occur on the internal membrane of the pre- puce, and on the glans penis. The soot-wart ap- pears, in fact, to consist of a congeries of morbidly enlarged papillae. The museum of the London Hospital contains a remarkable specimen of chim- ney-sweeper's cancer, in which nearly the whole scro- tum is occupied by a cauliflower excrescence, which exhibits these papillae in a very advanced state of developement. It was removed by Mr. Headington from an old man about sixty-four years of age, who afterwards left the hospital cured. Both testes were exposed in the operation. The morbid growth is composed of a number of projecting processes densely grouped together, of variable size, but many very large, with their summits lobulated, expanded, and elevated on narrow peduncles more or less flattened. Mr. Bagg has made an excellent repre- sentation of it in the annexed engraving. The warty processes closely resemble the elevated CANCER SCROTI. 549 growths abundantly developed about the cancerous ulcer, produced by soot on the back of the hand and wrist, preserved in the museum at St. Bartho- lomew's Hospital. The case will be described pre- sently. The soot-wart is sometimes covered with a dense and thick concretion, formed by successive layers of incrustation, the superficial still remaining attached, so as to form a projecting elongated conical process, which is not unlike the spur of the cock, and when very long is occasionally twisted like the horn of a ram. Some curious excrescences of this kind are represented in the clever etchings of Mr. Wadd."^ The figure on the next page, taken from one of them, exhibits the process of its exact size. Upon dissecting a scrotum affected with chimney- sweeper's cancer, the part is found to present very much the same appearances as carcinoma of the lip. The tissue at the base of the ulcer is dense, * Cases of Diseased Prepuce and Scrotum, PI. x. xi. xii. 550 CANCER SCROTI. indurated, and distinctly laminated ; but it is not always easy to make out clearly any trace of hete- rologous deposit. The morbid structure possesses very little vascularity. On recently examining some matter scraped from the base of a soot-v^art shortly after its removal from the body, I distinctly perceived a number of caudate and spindle-shaped nucleated cells. Professor Walshe has likewise re- cognised the microscopical characters of cancer, in a specimen of carcinoma scroti examined imme- diately after excision.^ On examining some diseased glands in the groin, in a case of chimney-sweeper's cancer, I found them enlarged and indurated, and composed of a whitish brown or yellowish white substance, mixed up in some places with a soft curd- * Cyclopaedia of Practical Surgery, vol, i. p. 650. CANCER SCROTI. 551 like matter, or grayish pus, contained in thin white cysts. Carcinoma scroti is, with few exceptions, confined to chimney-sweepers ; and the action of the soot on the skin of the scrotum is no doubt its exciting cause. That such is the case seems to be pretty clear, from the following interesting case, recorded by Sir James Earle. — Allan Spragg, aged forty- nine, came into St. Bartholomew's Hospital on account of a large cancerous sore, which reached from the bend of the wrist to the knuckles, occupy- ing almost the whole of the back of the left hand. He had been under the care of many persons, and various applications and internal remedies had been given. The circumference of the sore rose in large ulcerated tumours, and seemed inclined to spread. In some parts of the middle it appeared in a heal- ing state, in other parts ulcerated ; but he said dif- ferent parts of it had often healed, and broke out again, as we afterwards found it inclined to do. The complaint having very much the appearance of the sooty-wart, or chimney-sweeper's cancer, par- ticular inquiry was made into this person's life and occupation. He said he was a gardener ; that about five years before he was employed in a garden at Low Layton in Essex ; that in the spring of that year he was engaged about two hours every morn- ing to strew soot on the ground round the young and tender plants, to preserve them from the slugs ; that he carried the soot in an old garden-pot, which hung on the left hand by a handle over the top, while he strewed it with the right. About this time he conceived the wart commenced near the 552 CANCER SCROTI. knuckles, and continued not very troublesome all that year. The next spring he was again employed to distribute soot : the wart was then increased and ulcerated, and continued growing worse all that year. The spring following he again used soot in the same manner : the sore then spread, and grew larger, which made work of any kind very difficult to him. For the last two years he had not used soot, but the sore continued to spread rapidly : however he kept on working till he was incapable of using the hand. Various means were used, both internally and externally, to cure the disease, but without any material service ; and at last he sub- mitted to amputation, after which the excruciating pains which he had suffered soon left him, the wound healed kindly, and he got perfectly well."^ From the appearance of the disease in this case on that part of the body where alone the soot was able to lodge, and its occurrence on the scrotum only in persons exposed to its contact, it is reason- able to conclude that this substance is the exciting cause of the disease.t This form of cancer, though occasionally deve- loped on the face, prepuce, glans penis, and other parts of the body of chimney-sweepers, occurs so much more frequently on the scrotum than else- where, that the term " chimney-sweeper's cancer'' is generally understood to imply a cancerous disease of the scrotum. The marked preference for this * Chirurgical Works of Percival Pott, by Sir James Earle, vol. iii. p. 182. f According to Dr. Ure, soot contains some sulphate and carbonate of ammonia, along with bituminous matter ; but it has not, that I am aware of, been very minutely analysed. CANCER SCROTI. 553 part, in cases in which the skin of nearly the whole body is more or less exposed to the same source of irritation, is a circumstance worthy of notice. It is attributed to the scrotum being better adapted to harbour the soot than the integuments of any other region, the skin being loose and rugous, its sebaceous follicles large and numerous, and the part being usually moist and seldom cleansed. It would appear as if a lengthened contact of the soot was essential to excite the disease. In the case of the gardener just related, it was remarked that the right hand, which strewed the soot, was unaf- fected ; but the left, being two hours daily exposed to the vapours or dust arising from the soot as it was continually stirred up, a lodgment of it was probably made on the thin skin at the back of the hand. In the case of a very old man, whose face was wrinkled from age and therefore liable to retain the soot, mentioned by Sir A. Cooper, the sore was seated in the centre of the cheek.* Cancer scroti is known to be a rare complaint, even amongst the class of persons peculiarly liable to it, and many hundreds have followed the occu- pation of chimney-sweeping for years, and even during the whole of their lives, without contracting this disease. We must therefore conceive the ex- istence of individual predisposition as a condition necessary for its developement, and attribute a minor influence to the soot ; which, it would seem, does not generate the disease, but by its long-con- * Lib. cit. p. 227. 70 I 554 CANCER SCROTI. tinued irritative action becomes the exciting cause of its production. Other irritating substances may excite a similar disease. Dr. Paris states that the smelters are occasionally affected with a cancerous disease in the scrotum, similar to that which affects chimney-sweepers.^ Dr. Warren of the United States remarks that he has met with a few in- stances of cancer scroti in persons who were not chimney-sweepers.t The predisposition to cancer scroti appears in some instances to be hereditary. The late Mr. Earle extirpated the testis and diseased integu- ments from a sweep aged 35, a patient in St. Bar^ tholomew's Hospital, whose grandfather, father, and one brother had all perished from the effects of the disease.^ A father and son were once in St. George's Hospital at the same time on account of it.§ Mr. Cusack mentions that he removed a soot-wart from the hand of a female who carried on the business of chimney-sweeping, and that he had previously excised an excrescence of the same nature from the ear of her son.|| Cancer scroti occurs more commonly at the middle period than at any other time of life. In the majority of cases which I have met with, the disease occurred between the ages of thirty and forty, and this accords with the experience of Mr. Earle.^ Those exposed, however, to the action * Pharmacolog-ia, vol. ii. p. 89. t Surgical Observations on Tumours, p. 328. | Lib. cit. p. 304. § Mr. Hawkins' Lectures on Tumours, London Medical Gazette, vol. xxi. p. 842. 11 Dublin Journal of Medical Science, vol. xxi. p. 137. IT Lib. cit. p. 299. CANCER SCROTI. 555 of soot may become affected at a much earlier period. Mr. Wadd has figured a diseased prepuce and soot- wart on the scrotum, from a boy aged fifteen ; and Sir J. Earle witnessed an undoubted case of the disease as early as at eight years of age. It is liable also to attack the scrotum of sweeps far advanced in life. The age at which cancer scroti usually first appears is a point of some interest. It appears that the seeds of this malady are sown in early life, but in general do not germinate until they have remained for some time dormant in the system. What is the per- manent effect on the scrotum produced by soot, which thus renders it in certain individuals so peculiarly susceptible of a cancerous action at some distant period, we cannot explain; but that the soot, though the exciting cause of the disease, may in some instances be a remote one, is shown by several striking facts. It is known that persons who have been sweeps when young, but have abandoned the occupation, have afterwards been attacked with chimney-sweeper's cancer, although they have long been removed from all contact with soot. — A sailor, between forty and fifty years of age, was admitted into the London Hospital with an ulcerated sore on the scrotum, presenting all the characters of genuine chimney-sweeper's cancer. The inguinal glands were indurated and enlarged. He had been brought up as a sweep ; but for the last twenty- two years, during which period he had served at sea, he had not been employed amongst soot in any way whatever. The disease first commenced on the scrotum about three years before. The 556 CANCER SCROTI. diseased part of the scrotum was excised, but the man left the hospital before the wound was com- pletely cicatrized. In a few months ulceration commenced in both groins, and eight months after the operation he was re-admitted into the hospital with extensive ulcers in the inguinal regions, and in very impaired health, with a sallow complexion and much emaciated. About a fortnight after his admission, a considerable haemorrhage took place from the left groin, from the profunda artery (as was ascertained by dissection after death). Bleed- ing recurred at intervals, and in a week he died. In this case, therefore, the injurious influence of soot must have been exerted nineteen years before the appearance of disease, during which long period he was entirely removed from the effects of what is supposed to have been its exciting cause. It has sometimes happened, after the morbid parts have been completely extirpated, and the wound having healed the patient has avoided further contact with soot, that the disease has reappeared, as it were afresh, a second and even a third time ; not, however, in the cicatrix of the wound, but on a different part of the scrotum. These then, and similar facts, unfortunately lead to the conclusion that abandonment of his occupation, though it may render the adult chimney-sweeper less liable to cancer, by no means forms a satisfactory security against its occurrence. Cancer scroti chiefly extends its ravages by affecting the contiguous tissues, and has little dis- position to contaminate the lymphatic glands or distant parts. An instance is on record of an old CANCER SCROTI, 557 chimney-sweeper, who had been subject to this disease for forty years, and had undergone three operations for its removal, yet even then the glands in the groin were unaffected.^ In a case also of a chimney-sweeper who had been repeatedly attacked with this disease during more than twenty years, and had submitted to no less than five operations for its removal, which I have related at page 561, it was only recently that the glands in one groin became affected. The inguinal glands are fre- quently enlarged from irritation, but the swelling generally subsides after removal of the morbid parts. It must not be supposed, however, that these glands constantly escape carcinomatous inva- sion. I have myself witnessed three instances, in which they were enlarged and indurated, and after- wards suppurated and became the seat of a true cancerous ulcer ; and similar cases have occurred in the practice of other surgeons. Chimney-sweeper's cancer is a disease almost peculiar to this country. Dr. Warren, a surgeon of great experience in the United States, remarks that he has never seen it in chimney-sweepers in his country.t RicherandJ and other French writers inform us that it does not occur in France. Pit- coal, from which soot is produced, is very sparingly employed as fuel abroad ; whilst in this country its almost universal use by all classes, and the inhuman custom of employing climbing-boys to cleanse our chimneys, only very recently abolished, are sufficient to account for the occasional occurrence of this pe- * Mr. Hawkins' Lectures on Tumours, lib. cit. t Loc. cit. I Nosog-raphie Chirurgicale, torn. iv. p. 300. 558 CANCER SCROTI. culiar disease. But chimney-sweeper's cancer is by no means a common affection even in Great Britain. Mr. Russell states that it is rare at the Royal In- firmary in Edinburgh, and that he has seen but few cases of it."^ Mr. Syme makes a similar state- ment. Within my own recollection the complaint has become much less common than formerly in the large Hospitals of London, which I believe to be owing to the general use of machinery in the cleansing of chimneys during the last few years. The legislative enactment to prevent the employ- ment of climbing-boys for this purpose, which has lately come into operation, we may fairly expect will in the course of a few years, render the dis- ease even far more rare than it is now. It will not have the effect, as som.e have hoped, of com- pletely removing this description of cancer from the list of human maladies ; for master-sweeps, unless very cleanly in their habits, will still be liable to it ; but as a cause of mortality its influence will be very materially reduced. Diagnosis. — I scarcely know of any disease for which chimney-sweeper's cancer in a state of ulcer- ation could well be mistaken, the malignant cha- racter of the sore having been in all cases that I have witnessed very clearly marked. The warty excrescence which precedes the ulcerative stage bears some resemblance to the syphilitic warts which sometimes form on the scrotum ; but the history of the case, and more especially the occupa- tion of the patient, would always excite suspicion, * Observations on the Testicle, p. 98. CANCER SCROTI. 559 and in most instances be sufficient to indicate the true nature of the disease. Treatment. — Cancer scroti is a disease quite be- yond the control of topical and internal remedies. Time has been lost in attempts to eradicate it by arsenical and various other escharotic applications, but nothing hitherto tried has proved of any avail in arresting its destructive progress. There is, indeed, no remedy but the knife ; and fortunately this is a resource attended w^ith a greater share of success than generally awaits operations on can- cerous disease in other parts. When the scrotum is alone affected, the proceeding is very simple. The morbid parts are to be removed by two ellip- tical incisions, care being taken to cut wide of all disease ; for if any part of the morbid tissue be left behind, the complaint will certainly reappear. If the base of the ulcer be adherent to the tunica vaginalis, so that the morbid parts cannot well be removed without excising a portion of that mem- brane, the surgeon, instead of attempting to save the testis, should at once perform castration. The disease indeed has not much tendency to spread to the testes, and it often makes extensive ravages in the parts around without reaching them ; but in a complaint of so fatal a nature, it is better to err on the safe side by removing more than is absolutely required, than incur any risk of a re- turn of the disease. When the testis even is ulcer- ated, it is now admitted, contrary to the opinion entertained by Mr. Pott, that an operation may be undertaken with a fair prospect of a successful result. 569 CANCER SCROTI. The inguinal glands are so seldom contaminated, till a late period of the disease, and the swelling to which they are liable in this affection is so rarely of a specific character, that, as a practical rale, simple enlargement of them does not con- stitute an obstacle to the excision of the diseased scrotum. If they should be much indurated as well as enlarged, and the seat of lancinating pains, there would be sufficient reason to apprehend that the disease had extended to them ; but unless de- cidedly carcinomatous, I should be inclined to afford the patient the chance of relief from so terrible a malady as cancer by an operation which in itself is neither severe nor hazardous. A case has been published^ in which, after excision of the diseased part of the scrotum, several indurated glands in the groin which were the seat of lancinating pains were carefully dissected out by the eminent surgeon who operated. I do not know what was the ulti- mate result of this case, but I should scarcely an- ticipate success from such a proceeding. If the glands were merely enlarged from irritation, their extirpation would of course be unnecessary ; but when affected with carcinomatous deposit, I should fear that the disease had become too deeply rooted to admit of being wholly and successfully removed by operation. After chimney-sweeper's cancer has to all ap- pearance been effectually extirpated, and the wound has healed and remained so for some length of time, the disease has often been known to reappear ; and, * Lancet, 1840-1, p. 793. CANCER SCROTI. 661 what is remarkable, it does not in general return in or near the cicatrix of the wound, as ordinarily occurs after operations for cancer in other situations, but is often developed in a different part of the scrotum. Now I believe that in these cases the re- appearance of the disease is not in general the result of previous contamination, or of imperfect removal of the morbid tissues, but that the cancer is gene- rated altogether anew. The eifect of the operation would seem to be the eradication of all existing dis- ease, but unfortunately not to destroy the inherent susceptibility to its developeraent in the parts that remain ; which may subsequently, therefore, become a fresh seat of cancerous action, especially if, as often happens, they continue exposed to its exciting cause, the soot. The surgeon should not, then, exactly apply to these cases the principles which regulate his conduct in treating cancer in other parts, in which a repetition of the operation is generally inadmissible, and rarely successful. On the contrary, if cancer appear after extirpation in a fresh part of the scrotum, it must be met as if it were a new disease, and not the return of an old one ; and a second operation may be undertaken on the same grounds, and nearly with the same hope of success, as in the first instance. I have heard, indeed, of two interesting examples in which life had evidently been prolonged by a second and third operation ; and of another instance in which after the performance of a second operation the patient lived for years, and ultimately died of another dis- ease. The following case, which has recently come 71 562 CANCER SCROTI. under my notice, likewise illustrates the above views of this disease. — William More, aged fifty-one, a man of stunted growth, who had been a chimney- sweeper since the age of seven years and still fol- lowed the occupation, applied to me April 27, 1843, on account of a painful swelling in the groin. It appeared that he had been affected with chimney- sweeper's cancer for many years. As long ago as the year 1821, a portion of his scrotum affected with this disease had been excised at St. Bartholo- mew's Hospital ; and he had since undergone two operations of the same kind in that hospital, in consequence of a return of the cancer. Another part of the scrotum was afterwards removed at Guy's Hospital ; and in March last a portion of integument at the under part of the penis was ex- cised by a surgeon in the city, — making in all five operations. The scrotum was much contracted, and marked by several cicatrices. The scar under the penis, which was still sore, was separated from the scrotum by some sound skin. There was a tumour in the groin, which was soft in the centre and fluctuated, but had a very indurated base ; and the man complained of experiencing pricking and shoot- ing pains in it. This swelling in the groin, which was obviously of a carcinomatous character, had only appeared since Christmas last, though he had been subject to the disease in the scrotum for two and twenty years. When the inguinal glands are ulcerated, or the cancerous disease has extended too far to admit of its being effectually extirpated, there is nothing to be done but to endeavour to mitigate the patient's MELANOSIS OF THE SCROTUM. 563 sufferings by opiates and anodyne applications, and to correct the irritating fetid discharge. Henbane and the acetate or muriate of morphia may be given internally, and a lotion containing the chloride of lime and tincture of opium applied to the sore; or it may be covered with a poultice composed of an ounce of the dried leaves of conium, three ounces of bread, twelve ounces of water, and a small quantity of the chloride of lime. CHAPTER XL MELANOSIS OF THE SCROTUM. I HAVE not met with any account of melanosis occurring in the scrotum ; but the following case appeared to be an instance of it. — A cabinet- maker in the Commercial Road, aged thirty-two, and enjoying tolerable health, consulted me in November, 1842, on account of a fungous growth on the scrotum. The tumour was about the size of a small walnut and of a dark colour, had an irregular granular surface, and was attached to the left side of the scrotum by a narrow peduncle or neck. About an inch on one side of this tumour I observed a small dark spot, apparently produced by some black deposit beneath the epidermis raising it a little above the surrounding surface. The patient stated that the fungous growth was first noticed about three months before, when it resem- 564 ADIPOSE TUMOURS OF THE SCROTUM. bled the little speck just described, which had only been observed a fortnight. It had increased rapidly of late, but gave no pain. The shirt was discoloured by a slight discharge and bloody marks. There was no enlargement of the glands in the groins. I excised the tumour and small speck near it. On making a section of the morbid growth, the fungus appeared to spring from the cutis. Its base was hard and evidently fibrous, and of a schirrous character ; but the projecting part was soft and easily broken down. Small irregular spots of melanic pigment were observed on the cut surface, as well as on the exterior of the tumour, and the little speck seemed to consist of a similar matter deposited immediately beneath the epider- mis. The morbid growth is preserved in the Lon- don Hospital museum. The wound healed favour- ably, and as yet there is no appearance of a return of the disease. CHAPTER XII. ADIPOSE TUMOURS OF THE SCROTUM. Collections of fat in the scrotum have been known from the time of Galen by the term " Stea- tocele." Morgagni states that he has sometimes seen fat accumulated in the scrotum to a consider- able extent.* I am indebted to Mr. Kiernan for a * Cook's Morgagni, vol. ii. p. 435. FIBROUS TUxMOURS OF THE SCROTUM. 565 section of a large scrotal tumour entirely composed of adipose tissue in the lobulated form. As the cellular tissue of the scrotum naturally never con- tains fat, the latter, when present in any quantity, must be regarded as an adventitious formation. Such tumours, however, are of exceedingly rare occurrence. CHAPTER XIII. FIBROUS TUMOURS OF THE SCROTUM. - A SMALL fibrous tumour has in some few instances been developed in the cellular tissue of the scrotum. It may acquire the size of the testis, and, being firm and of an oval form, resemble a supernume- rary gland. At page 75, 1 have described a tumour of this kind, which was removed from the scrotum by Professor Fergusson. Dr. Mott, of the United States, excised an enor- mous diseased mass from the scrotum of a man about seventy-three years of age. The scrotum was twelve to fifteen times its ordinary bulk, and was filled with tumours of a stony hardness, from the size of nutmegs to that of a large pea. The tumours had all a very white appearance ; and the integuments over two or three of the largest, hav- ing been ulcerated for upwards of a year, poured forth a fetid discharge. A white substance, re- sembling mortar, was discharged from these open- 566 FIBROUS TUMOURS OF THE SCROTUM. ings. The disease was upwards of twenty years duration, and had been gradually increasing, the tumours multiplying as the scrotum augmented in size. The whole of the disease was removed, and the patient recovered from the operation, and at the end of three years afterwards he was enjoying excellent health.* I suspect this disease was originally a fibrous tumour similar to the small one which I have described as having been removed from the scrotum by operation. The calcareous matter and other changes resemble those occasion- ally observed in large fibrous tumours of the uterus. * Philadelphia Journal, as quoted in the Ix)ndon Medical and Physical Journal, vol. Iviii. p. 516. APPENDIX. After Chapter IV., Section 3, which contains an account of encysted hydrocele of the testis, had passed through the press, I was informed by Mr. Liston that on recently examining some rather milky-looking fluid removed by operation in a case of this affection, he had discovered myriads of sper- matozoa ia it in a lively state, and he has favoured me with a view of some of them which were pre- served. Mr. L. thinks that this interesting fact may indicate the mode of developement of encysted hydrocele ; and if further observation should prove that the cyst originates in a dilatation of one of the tubes of the epididymis, that the mucous character of the sac would explain the difficulty which exists in procuring their obliteration by injection. Ac- cording, then, to this supposition, encysted hydro- cele of the testis very much resembles, in its mode of developement, the swelling formed by a dilatation of the duct of the submaxillary gland termed raniila ; but as this view is opposed to that which I have been led to take of the origin of this affection, I 568 APPENDIX. availed myself of an early opportunity of carefully examining, in several recent testes, the small serous cysts w^hich are so commonly developed in the head of the epidid}/mis ; and in which 1 concluded, after numerous dissections, that this form of hydrocele commonly originates. (See page 214.) I can now state that I have found no reason to question the accuracy of this explanation. In the testis with a single cyst at the head of the epididymis, removed from a man aged twenty-one, who died of fever, abundance of spermatozoa were observed in the contents of the epididymis, but none could be detected in the clear pellucid fluid of the cyst. The cyst was distinctly seen to be unconnected with the seminal ducts; and on examination in the micro- scope its internal surface exhibited the characters of a serous membrane. I am inclined, therefore, to believe that the occurrence of spermatozoa in Mr. Liston's case was accidental, owing probably to the rupture of the seminal canal, which permitted an escape of the spermatic fluid. THE END. 3477 X291 1 '-^^^^ '% %' •v^ ■'^ ^v>~ §^^ O V ,0 c V >0^ ..f^^/ -%.c.^ .^ '^^> ^^^ .4 - .^\v ^^-^-^ .X>' -/', ^"^ % -^~^^ ^0m^^ "^ ,^".0^ ..^^- .^.''"'^ '"^c^. ^^^^^^o^\o '0' ~o . ^1 . v' ^ ^' " ° , ^y^. v^^ ..^^^ .V ?/}9?^'r V 1- %. >' > .-\^ ^^^