Elements of Surgery

by Robert Liston

[50] [This is undoubtedly the treatment which should always be adopted in the sacculated variety of the disease, as it is not only free from danger, but affords the most speedy and effectual relief. If the blood, upon the presence of which the irritation and swelling mainly depend, be allowed to remain, it finally becomes organised, and so incorporated with the walls of the tumour that it is impossible to dispose of it in any other way than by excising the whole excrescence.—ED.]

[51] [My own experience does certainly not accord, in this instance, with that of the distinguished author. I can recall to mind at least six or eight cases, several of them in delicate females in dilapidated health, in none of which I used less than two ligatures, and in some as many as three or four, without any serious consequences whatever. When the tumours are numerous, it can never be necessary to tie more than three or four at a time, since the inflammation thus induced generally extends to those around and effects their obliteration. It is always preferable, indeed, to repeat the operation, than to run the risk of producing too much irritation.—ED.]

[52] [Much may be accomplished in chronic cases by means of astringent injections, of which the best perhaps is a solution of alum in a decoction of oak-bark, in the proportion of two drachms of the one to a pint of the other. From two to three ounces of this should be thrown up the rectum twice a day; the bowels being at the same time kept in a soluble state by gentle laxatives, and the patient compelled to void his feces in the standing posture. In cases of an inveterate kind, in which the ordinary remedies prove unavailing, the operation of Dupuytren, which consists in cutting away some of the radiating folds of the skin around the anus, generally affords prompt and effectual relief. When the protruded part is large, it may be necessary to excise from four to six of these folds, and to prolong the incisions into the rectum as far as the junction of the skin with the mucous membrane. The object of this operation is to produce a diminution of the orifice of the anus, which it does by the cicatrization and contraction of the little wounds made in the operation.—ED.]

[53] Bushe on the Rectum, p. 220.

[54] [When the pain is considerable the camphorated liniment with morphia, laudanum, or belladonna, will be of great service. It should be rubbed upon the scrotum every four or five hours, avoiding of course injury to the inflamed testicle and epididymis. When the acute symptoms of the disease have subsided, under the treatment recommended in the text, the most efficacious practice is compression of the enlarged organ, by strapping it with the gum and mercurial plaster. Dr. Fricke of Hamburg pursues this plan in the very commencement of the inflammation, however severe, with the effect often of curing his patients in a few days. The plaster should be cut into narrow strips, not more than half an inch in width, and be applied in a circular manner round the testicle, which is to be previously drawn to the bottom of the scrotum. The first piece is to be placed round the insertion of the cord, just above the epididymis, and after the whole organ has been thus enveloped, another series of strips is to be applied from below upwards, to confine the first, and more completely equalise the pressure. Great care is to be taken not to pucker the skin, which should be previously divested of hair. “If the pressure of the plaster occasions pain or irritation, the strips are to be removed till the inflammation and sensibility are diminished. In many instances the patient experiences almost immediate relief from the application.” This remedy, which has been recently claimed by a European writer as new, appears to have been employed, with marked success, in the Pennsylvania Hospital, in the early part of the present century.—ED.]

[55] [The principal objection to this method is, that it is not always successful, and that it requires, in some cases, to be repeated again and again before a sufficient amount of adhesive action is induced to obliterate the vaginal sac. Moreover, by carelessness on the part of the surgeon, the canula may slip out of the vaginal sac, and so allow the fluid to pass into the cellular substance of the scrotum, where, if it be not speedily evacuated by free incisions, it is sure to occasion gangrene. But this is not all. The operation, even when well performed, is sometimes followed by violent inflammation and suppuration; in one instance, indeed, I knew it to be productive of tetanus. The patient, a stout, robust mechanic, about twenty-six years of age, whom I saw twice in consultation, was doing apparently well during the first eight days after the operation; when, owing to exposure to cold, the symptoms of the disease in question manifested themselves, and in less than twenty-four hours the man expired. Upon examination after death, the vaginal tunic was found to be considerably thickened, and its cavity to contain several ounces of sero-sanguinolent fluid, intermixed with a small quantity of unhealthy-looking pus. No adhesions had taken place between the opposite sides of the sac. A case of a similar kind is alluded to by Sir George Ballinggall, in his “Outlines of Military Surgery.”

The operation by injection has, I know, many advocates, both in this country and in Europe; and, when well executed, is generally unattended with risk, if not always successful. The fact, however, that it may be followed by serious mischief, with occasional loss of life, should be sufficient to deter the practitioner from resorting to it, more especially when we reflect that we are in possession of another remedy, not only entirely devoid of danger, but always, so far as my observation extends, most effective. This remedy is the seton, which I have been in the habit of employing, in repeated instances, for some years past, and from which I have never experienced any other than the most happy results. The operation is perfectly simple, the amount of inflammation produced by the presence of the foreign body may be easily regulated, and there is no danger of sloughing of the scrotum, much less of the development of tetanus, or other mischief.

In performing the operation, a large round trocar is introduced at the usual place, and after the fluid has been thoroughly evacuated, the instrument is again conveyed along the canula to the upper and fore part of the scrotum, for the purpose of effecting a counter-opening, which should be from an inch and a half to two inches from the first. The trocar is now withdrawn, when an eyed-probe, armed with a skein of silk or piece of tape, is passed along the tube, upon removing which the operation is completed. The seton need seldom be retained longer than four or five days; during which period, as well as for some time subsequently, the recumbent posture should be enjoined, along with suspension of the scrotum, and the usual antiphlogistic means. When the inflammation, tenderness, and swelling have considerably abated, the reduction of the tumour may be promoted by the daily inunction of equal parts of iodine and camphorated mercurial ointment.—ED.]

[56] [In upwards of one hundred cases examined by Mons. Breschet of Paris, only one occurred on the right side. With this result, the experience of nearly every practitioner must coincide. Cirsocele may take place at any period of life, in the young as well as in the old; but it is most common, by far, within the first ten years after puberty, or during the period of the greatest excitement of the genital system. In twenty-seven cases observed by Mons. Landouzy, in which this subject was particularly noticed, seven occurred between the ages of nine and fifteen; seventeen between fifteen and twenty-five; three between twenty-five and thirty-five.

Cirsocele appears to be occasionally hereditary. Professor Blandin of Paris, in an able article on this disease, in the “Dict. de Medicine et Chirurgie Pratiques,” refers to three brothers with whom he was personally acquainted, who were all exempted from military duty on account of the existence of this malady: the father was similarly affected. An analogous case is mentioned in an inaugural dissertation published a few years ago at Paris.