Elements of Surgery

by Robert Liston

Bloody effusion into the scrotal cellular tissue produces a dark appearance of the integuments, and the swelling has a doughy feel. At one or more points, where the cells are broken down and much blood

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

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

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

Enlargements of the body of the gland are generally attributed to injury. But often they occur without such cause being assignable; and may be the result of chronic excited action, kindled in deposit produced by a previous acute inflammatory attack. Such indolent swellings attain considerable size. The tumour is of an irregular surface, and feels hard and unyielding; there is always more or less effusion of fluid into the cavity of the tunica vaginalis, adding to the bulk of the swelling. Indeed, the size and consistence of the tumour can be correctly ascertained only after evacuation of this fluid.

Many of these tumours, as already observed, are of firm consistence; others are soft and doughy. They occur at the middle period of life, or before it. Some are resolved easily, and by ordinary attention. Others enlarge, notwithstanding the most judicious treatment; they gradually soften, and at length fluctuation becomes apparent. Curdy matter is evacuated by incision, perhaps mixed with a small quantity of thin unhealthy matter; and from the wound projects a pale fungous growth furnishing profuse discharge. The gland has now lost all appearance of its original structure; a section of it presents a homogeneous surface, of a greyish colour, and soft consistence, at some places broken down and mixed with tubercular matter and pus. The fungus is of the same nature as the rest of the tumour, but softer, and often with puriform depôts in its base. In this disease there is nothing malignant; it occurs in people of impaired or originally weak constitution, and is generally known as the scrofulous testicle.

In the more simple swellings, the gland at some points retains its original texture, but the greater part has no tubulous appearance, and seems to consist principally of lymphatic deposit, dense, pale, and equable. Such often accompany and are attributable to a diseased state of the urethra,—part of the canal being in an irritable and contracted state; and all efforts to discuss them usually prove fruitless, unless the urethra have been previously restored to a healthy condition. The soundness of this canal is therefore to be inquired into in the first instance, and if stricture, or irritability independent of contraction, be discovered, the practice must be directed towards it. The urethra being sound, counter-irritation is to be applied to the testicle; and the part should be suspended, though not in function altogether; walking exercise, and the friction which it occasions, must be avoided as much as possible. A gum and mercurial plaster protects the part, and induces a moderate irritation of the surface usually sufficient to dissipate the swelling slowly; if ineffectual, either repeated blistering, or the insertion of a seton under the integuments, may be had recourse to—from either or both much benefit is often derived. In obstinate cases the recumbent posture must be enjoined. In general, slight enlargement and induration of the epididymis remains.

The scrofulous swelling often does not yield to the means for discussion, but advances to suppuration. The abscess is to be opened, and the unhealthy contents discharged; endeavours are then to be made to effect closure by granulation, and after that counter-irritation may dissipate the tumour, or at least diminish its size. If protrusion occur, as generally happens, it may be cut away; and by then keeping the granulations on a level with the integument, either by pressure or escharotics, at the same time attending to improvement of the general health, cicatrisation may be procured, though tedious: or escharotics may be used from the first, instead of the knife. For example, sprinkling the fungous surface occasionally with the acetate of lead, I have found in several instances effectual; repeated sloughing of the protruded matter takes place; it sinks to the level of the integument, and ultimately below it, and then the employment of slightly stimulating dressing induces contraction and closure.

Not unfrequently the testicle is attacked by swellings of a more serious nature—medullary sarcoma is common, as also both fibrous and soft tumours, with cysts; scirrhus is more rare. These morbid alterations may take place at once—that is, the swelling may be from the first malignant—or they may supervene on tumours originally simple and benign. The tumour increases with the usual rapidity; to describe minutely the successive stages, would be but repetition of what has been already stated more than once, in treating of similar diseases in other organs. The medullary tumour often attains a very large size before the integuments give way; it may in some cases be mistaken for hydrocele, unless the history be attended to, and careful manipulation made: elasticity must not be confounded with fluctuation. After ulceration has taken place, the formation of a bleeding fungus is not uncommon: indeed, the testicle is one of the most frequent seats of fungus hæmatodes. The inguinal glands are in general affected early, and swell to a large size, ulcerating extensively, bleeding, and throwing out fungi; not unfrequently the chord feels free and soft, presenting to all appearance a healthy structure between the inguinal and scrotal swellings. In the advanced stages of scirrhous testicle, the chord and its integument are thickened and hard. The progress of this tumour is slower than that of the medullary, but equally certain. The cystic sarcomata, when fibrous, may remain long apparently in an indolent state, and without affection of the lymphatics; but when soft, the cystic contents are often bloody, the medullary matter soon breaks down, and then the integuments yield, and the malignant advance is rapid. It need scarcely be observed, that in such cases nothing but the knife, used at an early period, when the tumour is yet latent and the lymphatics uninvolved, can save the patient. Castration must be performed; and even this is in too many cases insufficient to annul the malignant disposition of which the parts have become the seat. As already stated, it must be had recourse to before hard and knotted swelling in the groin, with thickening and induration of the chord, has commenced, otherwise it can be of no avail.