The patient is placed recumbent. An incision is commenced a little above the inguinal aperture, and carried downwards; on reaching the tumour it is inclined to one side, so that with a similar one on the opposite side an elliptical portion of integument may be included. This is always necessary when the tumour is adherent to its coverings, or when a fungus has been protruded. One straight incision may be sufficient for removal of the tumour; it is sometimes necessary to take away more or less skin, so that a large, loose, and flabby bag may not remain after the extirpation. This preliminary wound penetrates only through the skin and cellular tissue, and should be made rapidly. At its upper part the chord is then to be cut down upon, exposed, and divided; but the division should not be made until the chord has been isolated for some distance, so as to afford a firm hold to an assistant, and not before the assistant has secured it firmly in his fingers, otherwise it may retract within the inguinal canal, rendering the bleeding from the spermatic artery troublesome. The dissection is now to be continued downwards, rapidly, and yet cautiously; the tumour is detached on all sides, and removed along with a sufficient quantity of integument. In dissecting off its posterior surface, care must be taken not to wound the septum of the scrotum. All adherent skin must be taken away, and in the case of fungus, the incision of the integument must be wide of the projecting part. But, at the same time, unnecessarily extensive removal of skin is always to be avoided, otherwise there will sometimes be a difficulty in covering the root of the penis and the remaining testicle. The assistant has, during the extirpation, retained his firm grasp of the chord, so restraining hemorrhage from that quarter; now the branches, generally two, of the spermatic artery are pulled out by the forceps, and a ligature applied to their extremities, inclosure of any of the surrounding parts being studiously avoided. To tie veins, artery, nerves, vas deferens, and cellular tissue, in one mass, would lead to most serious mischief, not to mention the immediate and excruciating pain occasioned. It has been recommended either to pass a temporary ligature round the chord, before its division, to prevent retraction, or to tie the artery before it is cut across. I have never found either practice necessary; the latter retards the operation; the fingers of an assistant are generally as effectual as a ligature, and inflict less injury to the parts, and less pain to the patient. Should the chord slip, there can be but little difficulty in pulling it down again by means of a hook; at the worst, slight extension of the incision upwards may be necessary. The scrotum is to be sponged clean of coagula, and its bleeding vessels secured: they are often numerous. The incision is brought together by several points of suture, and cold cloths applied. In no operation is secondary bleeding more frequent, occurring within an hour or two after reaction has been established, and the patient begun to get warm in bed. The flow is always from the scrotal vessels in the lower part of the wound, and often profuse. The dressing must be partially undone, so as to expose the vessels, and permit of the application of ligature. On this account, it is well not to approximate the lower part of the wound in the first instance, but to fill the cavity with charpie or dry lint, retaining this until risk of hemorrhage has passed over, or better still to have the wound quite open for five or six hours, and then to bring the edges together. The upper part of the incision often heals by the first intention, but this is seldom effected in the lower; suppuration takes place, and the cavity fills up slowly by granulation. Indeed, attempts to procure primary union of the scrotal wound are scarcely to be recommended; they are very seldom effectual; and should bleeding take place, the patient is either put to much pain, by removal of the stitches, and separation of the edges, or the blood is confined, accumulates in the cavity, and is infiltrated into the cellular tissue, producing much tumour, which terminates in extensive and unhealthy suppuration. Such retardation of the cure is avoided by open dressing of the lower part of the wound from the first.
Not unfrequently infiltration of the cellular tissue over the chord takes place within a few days after the operation, extending upwards under the superficial fascia of the abdomen, with discoloration of the integument, diffused doughy swelling, and much irritation of the system. Matter soon collects at one or more points. Early incision will check the advancement of this affection, followed by fomentation, and poultice, and attention to the constitution. Collection of the matter should never be waited for; and when depôts have formed, a free and dependent opening should be made early. Sometimes the patient may perish, exhausted by the profuse discharge and the disturbance of the system, in cases that have been neglected, or in which infiltration is rapid and extensive and the powers of life weak.
Calculus Vesicæ. Morbid action of the kidneys, producing altered secretion of the urine and deposition from it, takes place in consequence of derangement of the digestive organs—often occasioned by the free use of acids, or of acescent diet, such as fruit tarts, or drink containing a great quantity of saccharine matter. Many causes, which have not as yet been well ascertained or understood, seem to influence and predispose to calculous disorders. The prevalence of these affections in particular districts has been attributed to the quality of the water, or to the use of peculiar food or beverages; but such opinions, in all probability, have been adopted neither on very good grounds, nor after due inquiry and consideration. The county of Norfolk, and the eastern part of Scotland from the Frith of Forth northwards, are districts very similarly situated, exposed to cold and piercing winds, and appear to furnish a greater number of cases of stone than the rest of Great Britain, with Ireland to boot. The reason of this, as already stated, has not been satisfactorily explained.
But this disorder, like gout, seems also to adhere to families, to be transmitted from one generation to another. Some children seem almost to come into the world labouring under calculus.[59] The symptoms are noticed very soon after birth, and often patients labouring under stone are presented to the surgeon at the tender age of twelve or eighteen months.
The depositions from the urine are various. The deposit chiefly affecting children is of a dark colour, dense, hard, and crystallised; but one lighter coloured, and more friable, sometimes precedes the formation of this dark concretion. As seen here, the nucleus is surrounded by an oxalate of lime calculus, and then follows layer after layer of urate of ammonia. The dark sand or stone is occasionally, though much more rarely, met with in older individuals; but in them
the red, dark brown, yellow, and white deposits are more common. And in them, too, the diathesis or disposition to the formation of one or other variety evidently alternates, as is well demonstrated by section of urinary concretions. An alternating calculus is here represented.
The red deposit, by much the most common, at least in adults, consists principally of uric acid, soluble by solutions of the alkalies. The brown and yellowish are also composed of uric acid, often in combination with a base, and are likewise soluble in alkaline solutions, or in alkaline carbonates. The white is most commonly the ammoniaco-magnesian phosphate, soluble in acids; rarely, it consists of phosphate of lime, not so white or friable as the preceding, but likewise soluble in acids; or it may be a compound of phosphate of magnesia, ammonia, and phosphate of lime, very white and soft, and imparting a stain to the finger, soluble in acids, but principally
