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.[55]
The term Cirsocele is applied to varix of the spermatic veins. The affection seldom extends to the inguinal aperture, and is usually situated on the left side.[56] The tumour is somewhat pyriform, the larger extremity resting on the testicle, and by its peculiar appearance and feel its structure is at once apparent; the veins are seen through the integument. Pressure from below upwards, during the recumbent posture, diminishes the swelling; pressure above augments it, particularly if the patient change his posture, and exert the abdominal muscles. Sometimes a dull pain in the back is complained of, relieved by suspension of the scrotum, and often wasting of the testicle slowly advances. In some cases the swelling attains a large size, elongating the scrotum, and proving a source of very great uneasiness to the patient—so great that some have requested and urged castration.[57] Commonly it is sufficient to wear a bag truss, and avoid all causes of irritation to the parts; thus increase of swelling is prevented, and the inconvenience rendered trifling. If pain, with redness of the integument, and additional enlargement, should supervene, rest and the recumbent posture must be enjoined for a time, combined perhaps with low diet and local depletion. But in cases of large inconvenient tumour, accompanied with atrophy of the testicle, rather than accede to the wishes of the patient and perform castration, the treatment recommended many centuries ago may be put in practice—the application of a heated wire to the veins. The upper part of the tumour is grasped and made prominent, the veins are separated as much as possible from the other parts composing the chord, and a small-pointed cautery, a glover’s needle, for example, is inserted at several points. This is followed by some pain, and increase of swelling. Inflammation and obliteration of the veins is produced at the cauterised points, the swelling gradually diminishes, and ultimately a dense chord is all that remains. The cure is radical, and I have never seen the effects prove too severe. Rest and antiphlogistic regimen are of course necessary for some days after the application; abstraction of blood will seldom be required. Within the last few years I have been in the habit of passing two needles under the veins at an interval of about half an inch from each other, and twisting a thread firmly over them and the superimposed integuments. Of course the other parts of the chord are held aside by the finger and thumb, and the needles are withdrawn within a few days; as soon, in short, as consolidation of the interposed substance has taken place. This operation is preferable to any other.[58]
Hæmatocele is an effusion of blood, either into the cellular tissue of the scrotum, or within the tunica vaginalis, or in both. It is generally the consequence of a bruise or wound. From the loose nature of cellular tissue, the effusion into it is apt, if proper attention be not given, to take place to a great, and, to the patient and friends, alarming extent. This I have witnessed after the operation for hernia, and after removal of the testicle—bleeding from some small artery continues, the blood is by the dressings or pressure prevented from escaping externally, it is consequently extravasated into the cellular structure, giving rise to tumour, often of a very dark colour; and in some cases this swelling, occurring after the operation for hernia, has been mistaken for re-descent of the bowel. The blood must either be absorbed or discharged. Absorption is the more safe and desirable, but necessarily tedious, and more or less thickening and enlargement may remain for a long time. Discharge, whether spontaneous or by incision, is usually followed by unhealthy suppuration of the infiltrated and partially broken down cellular tissue, sloughing of it, tardy separation of the dead parts, and tedious, perhaps exhausting, flow of matter.
Hæmatocele of the vaginal coat may supervene on hydrocele, in consequence of external injury; or bloody effusion may take place from the vessels of the membrane, from sudden abstraction of their customary support, after evacuation of the serous fluid, and whether injection has been resorted to or not;—as happens in careless tapping for ascites. Some of the diagnostic marks of hydrocele are thereby lost; there is no translucency of the swelling, and fluctuation is either indistinct, or altogether imperceptible. The appearance of the contents varies according to the time which has elapsed betwixt their discharge and the occurrence of the extravasation; if short, coagula float in a thin bloody fluid; if considerable, the liquid is thick, dark, and putrid.