Part 48

The treatment of enlarged prostate is palliative—attention to the general health, the occasional administration of anodyne suppositories or enemata, prevention of accumulation in the lower bowels, either by gentle laxatives or the throwing up of bland fluid, and the avoiding as far as possible all sources to excitement, of mind as well as body. The radical cure, it has been said, is extirpation of the gland, but the cool proposal of such an operation would indicate either ignorance, or dereliction of principle, or mental obliquity, or all combined.

In retention from effusion of blood into the cavity of the bladder, a long catheter will sometimes evacuate the urine, and after some time also the blood; for the latter, though at first coagulated, ultimately becomes dissolved in the urine, and passes off along with it, even through a catheter of no very large calibre. Should this fail, and the symptoms continue urgent, an exhausting syringe should be employed, well adapted to the extremity of the catheter. After the urine has been thus evacuated, should a suspicion remain of coagula being still in the bladder, tepid water may be injected with the view of promoting the breaking down of the clots, and then the exhaustion may be repeated.

Incontinence of Urine, as already observed, is a common result of distention of the bladder and of stricture. But it also occurs as a primary affection, particularly in young people, from irritability of the posterior part of the urethra not suffering the urine to accumulate within the bladder as in ordinary circumstances. It is sometimes removed by the application of a blister to the perineum, and by the patient attending to empty the bladder at intervals during the night. Attention to the state of the bowels is necessary in such cases. The clearing them of worms or sordes, and the exhibition of tonics is sometimes also useful. Children, and even mothers, sometimes have recourse to a more effectual method, the application of a tight ligature round the penis. But of the folly and danger of such practice, the following may serve as an example. A. R., when 8 years old, passed a brass curtain-ring over his penis to prevent incontinence of urine during the night, and thereby escape chastisement, to which he had been frequently subjected. Great swelling soon took place round the ring, and he was unable to remove the jugum. He experienced much pain and difficulty in voiding his urine; the integuments under the ring gradually ulcerated, the ring appeared to sink into the substance of the penis, and the swelling subsided. The integuments met and adhered, the foreign body was concealed, and all uneasiness soon ceased. The penis performed well all that was required of it; the urine passed easily, and after a while he became the father of a fine family. When between fifty and sixty years of age, he applied to me. For some years previously difficulty in making water had been coming on, and frequent desire to pass it in the night-time rendered him very uncomfortable. He was under the necessity of having a vessel constantly in bed, and was generally disturbed every half hour. The penis had become very unserviceable, and he was now anxious to have the ring removed. A broad hard substance was felt surrounding the penis, close to the symphysis; an incision was made into the urethra at that part, and a calculus easily extracted. The uneasy symptoms quickly disappeared, and the patient recovered with a small fistula at the incised part, which could have been removed without difficulty, had not all treatment been obstinately resisted. The calculus resembled a prune in size, of a crescentic form, with one of the apices detached, and was apparently composed of uric acid, coated with the ammoniaco-magnesian phosphate. On making a section of it, about two-thirds of the brass curtain-ring, partially decomposed, were found firmly impacted in the centre. It would appear that a portion of the ring had speedily made its way into the urethra, had been acted upon and washed away by the urine; while the remainder, coming more gradually in contact with that fluid, had become incrusted with deposit, and formed the nucleus of the calculus. It is strange that the penis should have been efficient,—that the erectile tissue should have remained pervious—after having been cut completely through near the symphysis.

Of Gonorrhœa Præputialis vel spuria.—By this term is understood discharge of puriform matter from the lining membrane of the prepuce, and from the surface of the glans, accompanied with an itching and smarting sensation. The affection may arise from mere inattention to cleanliness, the natural secretion being allowed to collect and deteriorate; or from the application of acrid matter, gonorrhœal, or leucorrhœal. It often attends discharge from the urethra, and is usually met with in those who, from the natural tightness of the prepuce, uncover the glans with difficulty, if at all. It may occur without impure connexion; mucous discharge accumulates, becomes acrid from stagnation, and is washed away by profuse secretion of puriform matter; the parts then become quiet, and resume their healthy functions, but are apt from slight causes to be again the seat of discharge. Generally, the surfaces of the prepuce and glans are relaxed and turgid, but there is no breach of continuity; in neglected cases there is superficial patchy ulceration, and sometimes a deep and sloughing sore. The matter is often confined by tightness of the præputial orifice, and mischief thereby occasioned to the glans; a large purulent collection forms, and, if the case is neglected, ulceration takes place, either of the glans or of the prepuce, or of both; the latter becomes thin, and at length gives way; the aperture thus formed extends, and occasionally is of such a size as to admit of protrusion of the glans. Œdematous swelling generally takes place to a great extent in such cases. The glands of the groin sometimes swell, and through inattention may suppurate. The absorbents of the penis may also become turgid and painful. Tenderness of the glands and prepuce often exists, in a greater or less degree, for years; in such circumstances the affection may be termed gleet of the prepuce, and is usually the consequence of irritable urethra.

The treatment consists in cleanliness and rest, applying astringent washes to the parts, and suspending the organ. When swelling of the prepuce or inflammation of the lymphatics is threatened, constant rest must be enjoined. In obstinate cases, disease of the urethra is to be suspected as the cause, and the state of that canal should therefore be ascertained; if derangement of structure or function is detected, then means must be forthwith adopted for its removal, the applications to the prepuce and glans being at the same time not neglected. Mercury can be of no use.

Phymosis and Paraphymosis are often connected with gonorrhœa of the prepuce, or of the urethra. The edge of the prepuce may be rendered tight by inflammation, swelling from effusion, or cicatrisation of sores; the tightness also attends irritability of the urethra, particularly in young subjects; often it is congenital. The affection is termed Phymosis when the prepuce occupies its natural relative situation, but cannot be drawn back so as to uncover the glans. The contraction exists in various degrees; sometimes the orifice is so tight that the flow of urine is obstructed, the præputial cavity becoming swelled and distended every time the patient attempts to make water. In other instances the uninjected glans can be exposed either in part or entirely, though with difficulty. In consequence of the præputial cavity being frequently filled with urine, in cases of great contraction, urinary concretions have even formed or been detained there or in the orifice of the urethra, giving rise to very annoying, and sometimes alarming, symptoms. In consequence of Phymosis, the urethra and bladder may become diseased. It is often attended with profuse puriform discharge, with sores of different kinds, or with warty excrescences on the glans and prepuce; sometimes the whole surface is completely covered with granulated prominences of various sizes, some large, but the majority small, some broadly attached, others suspended by narrow necks; all generally furnish discharge of thin acrid matter. Adhesion may take place between the raw surfaces of the prepuce and glans, provided the parts be not frequently displaced for the purpose of ablution.

Paraphymosis arises from the same state of the orifice of the prepuce as the former affection, only the parts are in different relations to each other. In phymosis the prepuce covers the glans, the tight part is anterior to it; in paraphymosis the prepuce is reflected over the glans, the tight part acts as a ligature round the penis behind the glans, and such swelling speedily arises in consequence of the constriction so as to prevent reduction. The glans and lining membrane of the prepuce swell anteriorly to the stricture, the integuments of the penis swell behind, and the stricture is depressed and concealed between. The cellular tissue there is necessarily very loose, so as to admit of free motion and change of relative position, and consequently the engorgement is often very great. The infiltration is at first serous, and the swelling is easily compressed; but, from continuance of the inflammatory action, lymph is effused, and becomes organised, and the turgescence is more solid and unyielding. When the stricture is very tight, the patient cachectic and irregular in his mode of life, and the case injudiciously or inertly treated, sloughing takes place rapidly, or phagedenic ulceration occurs anterior to the stricture. But in most cases the prepuce is not so tight as to cause complete strangulation, yet obstructs the flow of blood sufficiently to induce swelling of the included parts, breach of surface more or less extensive, and an unhealthy appearance of the ulceration. The ulceration is generally in the neighbourhood of the stricture, at first limited and superficial, but increasing both in depth and extent so long as the cause remains. The stricture is not situated anteriorly to the swelling, as has been sometimes supposed, but near its middle—where the tight orifice of the prepuce grasps the penis, and causes a depression in the swelling. On separating the anterior and posterior tumours, the stricture is readily exposed, though previously effectually concealed.

In slight cases of phymosis, the orifice may be dilated by frequent fomentation, and perseverance in withdrawing the prepuce as far as possible. When ulceration or secretion of matter has occurred, astringent injections, at first mild, and gradually strengthened, should be frequently thrown into the præputial cavity. Suspension of the penis should be enjoined, along with rest—of the whole body, as well as of the affected organ in particular. When much inflammation exists, antiphlogistic remedies must be put in force, followed by fomentations. In bad cases, the prepuce must be divided in order to expose the seat of morbid secretions, of ulceration, and vegetations. The preferable situation for incision is close by the side of the frænum, much less deformity ensuing than when the prepuce is divided either laterally or in front. The flaps are at first loose and flabby, but shrink as the œdematous swelling subsides. A straight director is introduced within the præputial orifice—the groove pointing downwards—and passed down to the reflection, close to the frænum; a sharp-pointed curved bistoury is slid along the groove till it also reaches the reflection; by raising the handle and pushing it forwards, the integuments are transfixed there, and withdrawal of the knife by a rapid sweep completes the incision. Care must be taken not to pass the director into the urethra instead of into the præputial cavity. It is very seldom that ligature is required to arrest bleeding. Should the cellular tissue of the divided part not have been the seat of solid effusion, the integument and the lining membrane of the prepuce separate, leaving a large raw surface; and to prevent this a small suture should be passed between the membrane and skin on each side of the wound; these may be withdrawn on the second or third day, the cellular tissue having then become consolidated, so as not to admit of retraction. A warm bread poultice, or water dressing, is the best application for the first few days; afterwards healing of the cut surfaces may be promoted by the application of a gently stimulating lotion. Should œdema of the prepuce remain, this may soon be effaced by bandaging. By this operation sufficient space is obtained for uncovering the glans, under any circumstances; and besides, to this part of the organ is still preserved its natural investment, not in the least curtailed either in size or in efficiency—the glans can be uncovered and covered at will; whereas by any other mode of incision the unseemly flaps always fall away, leaving the greater part of the glans constantly uncovered, and placing the patient, if not in a worse, at least in the same predicament, as if he had been subjected to regular circumcision.

There is danger in allowing the state of phymosis to exist long; it has been already observed, that this condition of the parts predisposes to ulceration, vegetations, and morbid secretions; but besides, experience has shown, that very many cases of cancer of the penis are attributable to phymosis, either congenital, or of long duration. In all cases, when the orifice of the prepuce is so tight as not to admit of exposure of the glans, the operation is expedient, the existing state of parts being very inconvenient; but it becomes a matter of absolute necessity, when there are extensive sores on the prepuce or glans, when there is much tumefaction or hardening of the parts, when urinary concretions lodge in the præputial cavity, or in the orifice of the urethra, when vegetations or warts form on the glans, and when the præputial orifice is so contracted as seriously to impede the flow of urine.

In paraphymosis there is a necessity for early interference, in order to save the organ; indeed active and decided measures are as imperiously called for here, as in the case of strangulated hernia: and it ought to be remembered that the organ is one of importance, and that its loss would render most people very miserable. To attempt relaxation by fomentations, and such like, is absolute folly; the stricture cannot yield to such remedies; and, from increase of swelling, strangulation will become more and more complete. Cold, too, is incapable of reducing the swelling; cold, or astringents, cannot possibly diminish the size of the vessels, whilst return of the blood in them is prevented by tight stricture; and so long as the stricture remains, the serous effusion cannot subside, but will increase. Besides, the application of cold may hasten the occurrence of gangrene, inasmuch as it tends to diminish the power of parts which are already in a weakly condition. The parts must be instantly replaced. With the fingers of the right hand, the surgeon grasps the glans, and by firm and continued pressure diminishes its volume, whilst with the left he endeavours, by steady pulling, to reflect the swollen prepuce over the glans, which he is at the same time pushing back, as well as lessening. By uniformity and perseverance in these manipulations, more than by any force, replacement will often be accomplished. He will be able to judge, from the duration of the disease, and from the appearance and feel of the parts, whether simple reduction, that is, without having recourse to the knife, be practicable or not. In some cases, particularly when gangrene is imminent, and when the ulceration is extensive, there is danger of materially injuring the glans, if attempts at reduction are injudiciously persevered in. When he is foiled in reduction, or deems the attempting of it imprudent, the stricture must be divided; and in this simple operation great errors are often committed from ignorance of the nature of the disease, and of the relative situation of the parts. It is necessary to divide only the edge of the prepuce, which, from being reflected, alone composes the stricture. The anterior and posterior swellings are to be separated as far as possible, and in the very bottom of the depression between them the stricture is exposed; a slight incision, a scratch, through this, either with the point of a bistoury, or with a lancet, is sufficient; the tight edge of the prepuce—the only part in fault—is divided, and then, by the process already detailed, reduction can be readily effected. After reduction, a minute notch in the extreme edge of the prepuce is the only deformity visible, except the swelling. But if, from ignorance of the true seat of the stricture, extensive incisions have been made, pretty much at random, the organ may be considerably disfigured—and that unnecessarily. By fomentations, rest, and low diet, the effusion will be dissipated in a very few days. Reduction is difficult when the contraction has continued for some time, and the tissues have become glued together by effused lymph.

Malignant ulcer, with induration of the surrounding parts, and contamination of the lymphatics, occurs occasionally on the glans penis, or on the lining membrane of the prepuce. As before observed, it is most frequently met with in those who have laboured under congenital phymosis; in that state of the organ, its extremity is apt to inflame, swell, and ulcerate, in consequence of accumulation and acrimony of the secretions from the membrane of the prepuce; indolent swellings form in the groin; and in one case, I recollect, these assumed a malignant action, a frightful ulcer formed, and the patient was destroyed, after division of the prepuce, and after the ulceration on it had been long healed, and the part had apparently become quite sound. Early removal of the diseased part, by incision wide of the indurated and altered structure surrounding the ulcer, is the only means of saving the patient, of preventing glandular inguinal tumour, ulceration of it, hemorrhage, hectic, and death. When the prepuce solely is involved, removal of this is sufficient, either entirely or in part, as circumstances may demand. When the glands and coverings, as also the body of the organ, are involved, amputation is to be performed, provided the lymphatics still appear unaffected. In this operation the integuments must be freely removed, otherwise the cut orifice of the urethra will be obstructed by their puckering and contraction during cicatrisation of the wound. With this view, the skin is drawn forwards and stretched by the left hand, and then with one sweep of a long knife a transverse incision is made at once through all the parts composing the organ. Two or three vessels by the side of the septum may require ligatures. The skin retracts considerably, leaving the cut surface free; the wound granulates, contracts, and cicatrises. It is advisable to cut the urethra a little longer than the body of the organ. If diminution in the canal of the urethra be threatened during the cicatrisation, it is to be obviated by the occasional use of a short conical bougie.

Imperfections about the orifice of the urethra are by no means uncommon. Often there is a mere vestige of the orifice of the urethra in the natural situation, the opening being situated half an inch or a whole inch behind, and on the lower part—Hypospadias; in such cases the prepuce is generally short.

Sometimes the urethra is deficient to a great extent, terminating immediately before the scrotum, or even behind it. A child had passed no water thirty hours after its birth. The bladder was distended. The genital organs were imperfect; the urethra was wanting, and the penis was diminutive and abnormal. A small trocar was passed from the vestige of the orifice onwards, in the proper course, guided by the finger in the rectum. The urethra seemed to have terminated at the bulb; the canula reached this, and was retained for twenty-four hours. Afterwards the urine passed readily through the canal, partly natural, but principally artificial, and the power of retaining it became perfect.

In adults the hypospadias is inconvenient; the orifice is often contracted, and the whole parts are irritable; and the ejaculation of the seminal fluid is unsatisfactory to the parties concerned. The deficiency may be repaired in some measure, when there is abundance of skin to spare, but no rules can be laid down for such irregular operations.

Imperfection of the urethra anteriorly, on the dorsum, is rare—Epispadias. The following is rather a remarkable instance:—The man was aged 26, robust and healthy. The whole extent of the urethra anterior to the pubes was exposed superiorly, there being a wide fissure through the corpora cavernosa and glans. The penis was retracted considerably, so that the posterior part of the fissure lay beneath the symphysis pubis. The numerous lacunæ of the urethra were beautifully distinct, and the mucous membrane was seen covered by their secretion. When the patient made water, the urine, after emerging from beneath the pubes, divided into numerous small streams, some of which spread over the side of the penis, while others passed along the exposed urethra. The callous margins of the fissure, formed by the corpora cavernosa and glans, were carefully pared, and, a catheter having been introduced, the raw surfaces were retained in apposition by suture. The wound healed perfectly, almost entirely by the first intention; and the organ both looked well and proved efficient. The malformation was congenital, and was considered by the patient as analogous to harelip; but the story related to account for it in consequence of an impression made in his mother’s imagination, was not very plausible.

The disease of the external parts of the male genital organs, commonly called Chimney-sweeper’s Cancer, is one of a formidable and intractable nature, but fortunately not very often met with. The scrotum is the part usually attacked. A wart forms, generally at the lower part, assumes an irritable appearance, and quickly degenerates into open ulceration of a malignant character. The ulcer extends rapidly, consuming the neighbouring integument, and involving the testicle and other subjacent parts in induration and enlargement. The induration extends along the spermatic chord, and the lymphatics participate in the diseased action at an early period. The discharge from the sore is acrid, sanious, and possessed of much fetor; sometimes fungi protrude, but more commonly the surface is excavated and smooth. Not unfrequently the skin surrounding the ulcer is studded, to a considerable extent, with numerous clusters of warts, of an unhealthy and angry aspect. A very aggravated specimen of the disease is here represented. The general health is soon undermined, and the disease advances from bad to worse with the usual certainty and rapidity of malignant action. It seldom occurs till after the age of thirty or forty; and though most frequent in chimney-sweeps, is not peculiar to them. No treatment can be expected to arrest its progress at an advanced stage; the only opportunity of saving the patient is at the commencement of the disease, when the affected part is small, and before the lymphatics have become involved. Local application and internal remedies are not to be trusted to; in the early stage the parts may be excised. An incision is made wide around the wart or ulcer, and the included parts are dissected away to a considerable depth. When the testicle has become affected, the chance of success is much diminished; but still, if the inguinal glands appear sound, and the chord tolerably free, castration is to be performed as the last, though desperate, means of eradicating the disease.

By Hydrocele is meant a tumour caused by accumulation of fluid either in the chord or within the cavity of the tunica vaginalis testis. It has been divided into diffused and encysted. By the former term is understood effusion and accumulation of serum in the cellular tissue, the cells gradually dilating to accommodate the increasing fluid, and ultimately becoming converted into vesicles of large size: the parts around are thickened and condensed. This affection is very rarely a local one, but almost uniformly combined with and forming a part of anasarca arising from constitutional causes. When the swelling proves troublesome, it may be diminished by drawing off the fluid through one or several punctures; in the chronic form of the disease free incision is attended with risk, and is besides unnecessary.

The scrotum is sometimes distended rapidly by effusion of serum often of a putrescent and acrid nature. This affection supervenes upon ulcers or sinuses in the groin, perineum, or neighbourhood of the anus, in patients out of health. It occurs also occasionally as a consequence of injury of the genital organs, or interferes with bad strictures, without any disease of these parts, and without the least cause for the suspicion of urine having escaped into the cellular tissue. This, together with the skin, is destroyed, and the testicles exposed. The only chance of saving the tissues consists in early and free incision of the most dependent part of the swelling, generally the inferior and posterior. Some cases and remarks on this subject will be found in the Medico-Chirurgical Transactions, vol. xxii., p. 288.

Encysted hydrocele of the chord occurs in children more frequently than in adults. The fluid is thin and clear, and contained in a distinct cyst, of a smooth, shining, serous appearance internally; this cyst may be either an unobliterated portion of the congenital spermatic process, or composed of thickened and condensed cellular tissue, strengthened exteriorly by the expansion of the cremaster muscle. The tumour is seldom large, usually of an oval form, and situated nearly midway between the testicle and groin; causing no pain, but proving inconvenient simply from its bulk and situation; fluctuating, and sometimes partially diaphanous; evidently circumscribed, the chord both above and below being natural to both sight and touch; not altered by change of posture or by muscular exertion. Sometimes it encroaches both on the groin and on the testicle, but even then attentive manipulation readily distinguishes it from swellings connected with these parts. Discharge of the fluid by means of a small trocar and canula, not only dissipates the swelling, but often effects a permanent cure, particularly in young persons—the cyst either ceasing to exercise a secretory function, or becoming obliterated. If reaccumulation take place, the treatment is to be conducted on the same principles as in hydrocele of the vaginal coat.

Hydrocele of the tunica vaginalis is exceedingly common, particularly amongst labouring people, and occurs apparently with equal frequency at all ages. It is a gradual accumulation within the tunica vaginalis of a fluid partaking more or less of the serous character, furnished by the exhalants of that membrane,—but whether from excessive secretion or deficient absorption, it is difficult to determine. It is probable that the accumulation is the result of excited action in the part, for its origin is most frequently attributable to external injury—blows or bruises, followed by rapid swelling, which, after a time, subsides, leaving perhaps some enlargement of the testicle, or of the more superficial tissues, and succeeded by the gradual appearance of the disease in question. Sometimes it is attributed to powerful and habitual muscular exertion, as in blowing wind instruments, lifting heavy weights, &c.; and perhaps the impediment to the venous return, so produced, may be the cause of the effusion. The accumulation, as already stated, is gradual, and consequently the formation of the swelling is proportionally slow. It commences at the lower part of the scrotum, and by degrees ascends, at first globular, afterwards of a pyriform shape; after it has attained a considerable size, the testicle cannot be felt in its usual situation, for it is now placed not at the bottom of the bag but towards its middle and posterior aspect, and if the tumour be tense it can scarcely be felt at all. The raphe is displaced to the opposite side, the usual puckering of the scrotum has disappeared, and the tumour feels light in proportion to its size. On manipulation it is found yielding and elastic, and in all ordinary cases a distinct fluctuation is communicated to the fingers during alternate pressure. And by using the hand as a shade, the rays of light are made to permeate the swelling, rendering it more or less transparent according to the thickness and density of the covering, and the hue of the contained fluid. It is seldom that the distention of the vaginal coat is to such an extent as to reach the groin, consequently the spermatic chord is felt to be free, as also the inguinal aperture; and even when the swelling does reach so high, the upper part is the least tense, permitting displacement of the fluid and distinct perception of the chord. The patient complains of a sense of dragging and weight in the parts, and of uneasiness and inconvenience during exertion, but seldom of pain. When large, the tumour is necessarily covered by borrowed integument, often so as almost entirely to conceal the penis. In many cases the testicle is increased in size and indurated, and sometimes this enlargement forms a considerable part of the swelling. Occasionally the spermatic veins are varicose; and this has been, by some, considered one of the causes of the disease. Hydrocele is occasionally complicated by the presence of hernia, when a careful examination must be instituted in order to understand the exact share each disease has in the production of the swelling. In cases of very slow increase, and in persons of advanced age, the vaginal coat and its investments are not unfrequently much thickened, so as to obscure the sense of fluctuation, and destroy the transparency of the tumour. Sometimes deposit of earthy matter takes place between the layers of the membrane, rendering it hard, rigid, and in a measure osseous; in such cases cholesterine has been found in the contained fluid; sometimes the cavity is intersected by membranous filaments, delicate and reticulated; sometimes complete septa subdivide it into several compartments. The fluid is generally thin, albuminous, and of a straw colour; in some cases paler, and coagulating on cooling, being gelatinous; in others of a dark colour, probably from admixture of blood.

The treatment is either palliative or radical. The former consists in evacuating the fluid from time to time, according as the feelings of the patient demand it; in children this simple tapping is often successful in preventing return of the disease. But here the disease often enough disappears under the use of a stimulating lotion, as a strong solution of the muriate of ammonia.

The swelling is grasped from behind by the left hand, and compressed so as to render the middle and fore part tense and prominent; into this a trocar and canula are plunged, piercing the coverings in a perpendicular direction, and then inclining the canula upwards, the stilet having been partially withdrawn, so as to avoid wounding the testicle. The venous branches apparent on the surface must be of course avoided. When fairly passed within the cavity, the trocar is withdrawn entirely, and the fluid escapes through the canula—gentle pressure being employed towards the conclusion. The wound usually heals in a few hours. Various means of radical cure have been proposed—incision, seton, caustic, and the injection of stimulating fluids. Incision and the seton are now abandoned, and do not require notice. The application of caustic perhaps may prove efficient in children when tapping has failed, and in youths; an aperture is thus made, through which the fluid escapes, and at the same time considerable excitement is induced, which may prevent reproduction. I at one period made trial of it in several instances, and generally with success; but am now inclined to avoid it, having more than once experienced much difficulty in keeping within moderate bounds the inflammatory action which succeeded its application. Injection is now generally practised; and if carefully performed, it is unattended with risk, and is almost invariably successful. Various fluids may be employed—cold water, wine, wine and water, spirits, a solution of the sulphate of zinc, &c. I have generally used pure port wine; and have scarcely ever seen its effects either excessive or deficient. I can remember very few cases in which the disease returned after this injection. Having ascertained that the testicle is sound, or but slightly enlarged—for injection of the tunica vaginalis is incompatible with diseased testicle—the fluid is drawn off by means of a round trocar. The canula is left in the wound, and to it is adapted the nozzle of a brass stop-cock attached to a small elastic bottle. By means of these instruments the wine is injected in sufficient quantity to distend the tunic moderately, taking care that the extremity of the canula is completely within the cavity, otherwise the cellular tissue will be injected, and violent inflammation ensue, terminating in unhealthy suppuration and sloughing. By turning the cock, the wine is retained until the patient begins to feel pain shooting upwards to the loins, when it is to be evacuated. He may not feel any uneasiness, however, and then it will be necessary to draw off the fluid and inject a fresh quantity. If this, too, fails, a more stimulating fluid must be used, a solution of sulphate of zinc, spirits and water, or pure ardent spirits. It is supposed that this treatment is effectual by inducing adhesive inflammation, and obliteration of the cavity by adhesion of the tunica vaginalis to the tunica albuginea; but this does not by any means frequently happen. There may in some cases be a little lymph deposited, but not in sufficient quantity to cause adhesion. The excitement following injection seems to change the action in the parts without altering their structure or relation—to reëstablish the healthy balance between the exhalants and absorbents. Its first effect is to produce increase of swelling from fresh effusion into the cavity of the tunica vaginalis, accompanied with redness of the integument and considerable pain—sometimes with slight fever. This fluid, however, is quickly absorbed—usually in from four to six days—the swelling subsides, as also the pain, and the patient remains free of the disease. Whilst this salutary action is in progress, the recumbent posture must be strictly enjoined, along with low diet and suspension of the organ; and sometimes, though rarely, it may be necessary to have recourse to more active means to moderate inflammation. Should the excitement appear insufficient after a day or two, the surfaces may be rubbed against each other with the fingers, and gently squeezed, or the patient may be directed to walk about occasionally through his room until pain is felt. If the disease return, as need scarcely be dreaded, injection is to be repeated, either again with wine, or with a more potent fluid.

The term Cirsocele is applied to varix of the spermatic veins. The affection seldom extends to the inguinal aperture, and is usually situated on the left side. The tumour is somewhat pyriform, the larger extremity resting on the testicle, and by its peculiar appearance and feel its structure is at once apparent; the veins are seen through the integument. Pressure from below upwards, during the recumbent posture, diminishes the swelling; pressure above augments it, particularly if the patient change his posture, and exert the abdominal muscles. Sometimes a dull pain in the back is complained of, relieved by suspension of the scrotum, and often wasting of the testicle slowly advances. In some cases the swelling attains a large size, elongating the scrotum, and proving a source of very great uneasiness to the patient—so great that some have requested and urged castration. Commonly it is sufficient to wear a bag truss, and avoid all causes of irritation to the parts; thus increase of swelling is prevented, and the inconvenience rendered trifling. If pain, with redness of the integument, and additional enlargement, should supervene, rest and the recumbent posture must be enjoined for a time, combined perhaps with low diet and local depletion. But in cases of large inconvenient tumour, accompanied with atrophy of the testicle, rather than accede to the wishes of the patient and perform castration, the treatment recommended many centuries ago may be put in practice—the application of a heated wire to the veins. The upper part of the tumour is grasped and made prominent, the veins are separated as much as possible from the other parts composing the chord, and a small-pointed cautery, a glover’s needle, for example, is inserted at several points. This is followed by some pain, and increase of swelling. Inflammation and obliteration of the veins is produced at the cauterised points, the swelling gradually diminishes, and ultimately a dense chord is all that remains. The cure is radical, and I have never seen the effects prove too severe. Rest and antiphlogistic regimen are of course necessary for some days after the application; abstraction of blood will seldom be required. Within the last few years I have been in the habit of passing two needles under the veins at an interval of about half an inch from each other, and twisting a thread firmly over them and the superimposed integuments. Of course the other parts of the chord are held aside by the finger and thumb, and the needles are withdrawn within a few days; as soon, in short, as consolidation of the interposed substance has taken place. This operation is preferable to any other.

Hæmatocele is an effusion of blood, either into the cellular tissue of the scrotum, or within the tunica vaginalis, or in both. It is generally the consequence of a bruise or wound. From the loose nature of cellular tissue, the effusion into it is apt, if proper attention be not given, to take place to a great, and, to the patient and friends, alarming extent. This I have witnessed after the operation for hernia, and after removal of the testicle—bleeding from some small artery continues, the blood is by the dressings or pressure prevented from escaping externally, it is consequently extravasated into the cellular structure, giving rise to tumour, often of a very dark colour; and in some cases this swelling, occurring after the operation for hernia, has been mistaken for re-descent of the bowel. The blood must either be absorbed or discharged. Absorption is the more safe and desirable, but necessarily tedious, and more or less thickening and enlargement may remain for a long time. Discharge, whether spontaneous or by incision, is usually followed by unhealthy suppuration of the infiltrated and partially broken down cellular tissue, sloughing of it, tardy separation of the dead parts, and tedious, perhaps exhausting, flow of matter.

Hæmatocele of the vaginal coat may supervene on hydrocele, in consequence of external injury; or bloody effusion may take place from the vessels of the membrane, from sudden abstraction of their customary support, after evacuation of the serous fluid, and whether injection has been resorted to or not;—as happens in careless tapping for ascites. Some of the diagnostic marks of hydrocele are thereby lost; there is no translucency of the swelling, and fluctuation is either indistinct, or altogether imperceptible. The appearance of the contents varies according to the time which has elapsed betwixt their discharge and the occurrence of the extravasation; if short, coagula float in a thin bloody fluid; if considerable, the liquid is thick, dark, and putrid.

Bloody effusion into the scrotal cellular tissue produces a dark appearance of the integuments, and the swelling has a doughy feel. At one or more points, where the cells are broken down and much blood has collected, fluctuation is perceived more or less distinct. The treatment consists of rest, the recumbent posture, support of the swelling on a small cushion, and the employment of fomentation when the parts are painful. The absorption proceeds slowly; and after some time, when all painful feelings have ceased, stimulant embrocation may be used, with the view of expediting it; a solution of the muriate of ammonia, of the sulphate of alumina, or of other astringent stimulating salts, may be employed in strength proportioned to the feelings of the patient and the progress of the case. If the tumour suddenly become painful, and increase in size, indicating putrefaction of the blood, and commixture of it with puriform matter, a free incision is to be made, and poultices applied. When the parts have become quiet, and suppuration has been established, poulticing is to be discontinued, and mild and light dressing employed.

When, on tapping a hydrocele, the fluid is found to be bloody, injection is not to be resorted to, though the other circumstances of the case should appear favourable. Rest is enjoined; and a radical cure is not to be attempted till the fluid has collected a second, or perhaps a third time, and become colourless.

Acute inflammation of the testicle, from sympathy with the urethra, and sudden suppression of discharge from the anterior part of the canal, has been already treated of. The inflammation may also be the result of external violence. When the urethra is diseased, the testicle is irritable, and its circulation easily excited. After subsidence of the inflammatory attack, swelling, particularly of the epididymis, or of the posterior part of the gland, seldom altogether disappears. The new matter is not entirely absorbed; and thickening and induration remain, to an extent depending on the violence of the action and the propriety of the treatment.