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ment, and all operative interference should be delayed until such blood-dyscrasiæ have been removed.

HEMATOCELE OF THE CORD.

Pott has described a diffused hæmatocele of the cord coming on during straining at lifting or at stool, and confined within the tunica vaginalis communis. This form is exceedingly rare. It may occur, also, in connection with general ecchymosis of the scrotum from injury, and calls for the same treatment. The blood will be reabsorbed in time. It has been confounded with hernia, and operated on as such. If the tumor continue to enlarge in spite of position, rest, and cooling applications, a free incision should be made, the clots turned out, the wound washed, and the bleeding vessel sought for and secured.

When an encysted hydrocele of the cord, by accident or dyscrasial disease, becomes a hæmatocele, the same changes take place in the walls of the sac and surrounding tissue as have been described in hæmatocele of the tunica vaginalis. The treatment is also the same, care being always taken to treat the dyscrasial causative condition.

FREE BODIES IN THE TUNICA VAGINALIS.

Occasionally little excrescences spring up from the surface of the testicle within the cavity of the tunica vaginalis. They may grow anywhere within the tunica vaginalis, but are more common on the epididymis or around the so-called hydatid of Morgagni. These excrescences have an inherent tendency to grow large at the summit by a deposition of concentric layers of very dense connective tissue, and thus become pediculated. New excrescences may form upon an old one, constituting a sort of dendritic vegetation. There is a tendency to a central deposit of calcareous salts early in the formation of these little pedunculated balls, which causes an arrest in their growth. After this the pedicle becomes more and more thin, and finally breaks and disappears in some motion given to the testicle. In this way are the free bodies formed. They are found of all sizes, from the head of a pin to a large hazel-nut. They are not encountered in connection with very large hydroceles, although some fluid in the tunica vaginalis usually accompanies them. They may often be felt from the outside, and be liberated at once by an incision if they cause pain or inconvenience; which, however, they seldom do. Occasionally after tapping a hydrocele great pain has been complained of, which has been found to be connected with the existence. of a loose body in the sac. In structure these bodies consist of concentric layers of very dense fibrous tissue, cartilaginous to the feel, surrounding a central nucleus of calcareous matter. An attentive inspection of the surface of the testicle will often show prominences or depressions corresponding to the points where the free bodies had been attached by their pedicles.

CHAPTER XXIII.

DISEASES OF THE TESTICLE.

Hydrocele, acute, chronic.-Diagnostic Table of Chronic Hydrocele with Incarcerated Hernia. -Palliative Treatment.-Radical Treatment.-Congenital Hydrocele.-Diagnostic Table of Congenital Hydrocele and Hernial Tumor.-True and Spurious Hydrocele of Hernial Sac.-Encysted Hydrocele of Testis.-Spermatocele.-Spermatic Congestion.-Origin of Spermatocele.—Hydrocele of Cord, diffuse, encysted.

HYDROCELE, or dropsy of the testicle, consists in an accumulation of serous fluid within the cavity of the tunica vaginalis (simple hydrocele), or within a cyst connected with the testicle (encysted hydrocele). This fluid is usually highly albuminous and of a pale-yellow color, but it may vary through shades of red, brown, green, and black, by the admixture of more or less blood, or blood-pigment, and in old cases. the fluid may contain fatty matter and plates of cholesterine, granular bodies, pus, epithelium, and occasionally spermatozoa (spermatic hydrocele). The fluid differs, both in its nature and mode of production, from that of general anasarca. be full and the tunica vaginalis empty. contains a substance similar to fibrin. these circumstances, it will generally deposit in one or several layers. Buchanan, of Glasgow, found that if blood were mingled with the fluid it coagulated, when by contact of air alone it would not do

so.

In anasarca the scrotum may The liquid of hydrocele often On exposure to the air under

Alexander Schmidt produced the same coagulation by adding blood-globules or hæmato-crystallin. The fluid sometimes contains salts and albuminates in a proportion analogous to that of lymph— which never obtains in the fluids of simple dropsies (Virchow). Chylocele is the name given to the hydrocele in certain cases. Vidal de Cassis first described this affection, calling it galactocele. † Busey calls it chylous hydrocele, and Claudius Mastin, chylocele. William Mastin cites the cases of Vidal, Ruthnum, Ferguson, and C. H. Mastin, and adds his own, a fifth case, in which, and in C. H. Mastin's case, incision effected a cure. In both, a projecting point, believed to be the offending lymph-vessels, which leaked, was ligated and cut away. Tyson, of Philadelphia, examined the fluid in both instances, and found it to resemble chyle; alkaline, 1015-1018, albuminous, full of molecules and small granular cells. Ether dissolved the fat, which afterward on evaporation offered a cream-like mass. In one of the cases there were a few spermatozoa.

* W. H Mastin, "Ann. of Anat. and Surg.," May, 1882, p. 223.

t "Traité de Pathologie et de Méd. operatoire," 5th edition, vol. v, 1861, p. 180.

Another form is that of multilocular hydrocele, christened lymph angioma by Steinthal,* and consists of a main sac, at the bottom of which are many small ones, the largest as big as a cherry, containing clear, white fluid. Steinthal thinks the cysts are developed out of dilated lymph-vessels. They are lined with endothelium.

Cause of Hydrocele.-In the aged, anæmic, weak, and badly nourished, there may be a chronic dropsy of the tunica vaginalis, the cause of which is simply general hydræmia; there are usually other serous effusions existing at the same time. This condition is a general one, and no special attention need be paid to the hydrocele, except the wearing of a suspensory bandage, until the general health is restored, after which it would be proper to undertake a radical cure, if the hydrocele did not spontaneously subside. In exceptional cases, when the collection of fluid becomes excessive, palliative puncture may be resorted to. A slight amount of hydrocele exists, as a rule, in conjunction with all diseases of the testicle, especially of the inflammatory sort (orchitis, epididymitis), and not infrequently with syphilitic and tubercular disease of the organ. But in these cases again the hydrocele is only a symptom, and a radical cure should not be attempted. When the disease of the testicle subsides, the hydrocele will get well.

True hydrocele is the result of a secretory irritation of the tunica - vaginalis testis, produced usually by mechanical violence, or in sympathy with some irritation of the testicle, cord, or urethra. The mechanical violence most apt to produce it is such as is slight, irritative, and long continued; rubbing, jolting, crushing. In warm climates it is very frequent, on account of the relaxed condition of the scrotum, which exposes the testicle to injury. In Brazil one man in every ten is said to suffer from hydrocele (Hyrtl). Hydrocele may be left behind after an acute inflammation of the testis, and, in those exceptional cases where the communication of the tunica vaginalis with the peritoneal cavity has not been closed after birth, a hydrocele is known as congenital.

ACUTE HYDROCELE.

This is an acute peripheral orchitis, coming on in connection with acute epididymitis or orchitis, and needs no detailed account. condition is analogous to pleurisy. The effusion is rapid, sero-plastic, or sero-hæmorrhagic. The fluid is absorbed, as a rule, while the inflammation of the testicle is subsiding, and no treatment is of any service before that time, unless, possibly, puncture, if the effusion be very large.

* "Cntrlbltt. f. Chirurgie," October 10, 1885, and Hays's, "International Journal," January, 1886, p. 283.

It is always caused in a mild degree by the stimulating injections, or other treatment used for the cure of chronic hydrocele, and may occur idiopathically without necessary connection with other inflammatory disease of the testicle, but this is exceedingly rare. Rest with cooling lotions, and acupuncture, if necessary, constitute the treatment.

CHRONIC HYDROCELE.

In chronic hydrocele, the effusion takes place slowly, and without pain. The swelling is often only discovered by accident. It commences in the lower part of the testicle in front. It has no tendency to spontaneous subsidence. The accumulation of fluid tends to go on. indefinitely, with occasional periods of quiet, until, in some cases, an enormous size is reached. The amount of fluid may be only a few drachms. It seldom exceeds a pint. Curling met with one case which contained forty-eight ounces. Sixty-four ounces were taken from one (personal) case. Mr. Cline is said to have removed as much as six quarts from the historian Gibbon (Sir Astley Cooper). Out of a thousand cases reported by Dr. Dujat, from the Hospital of Calcutta, in eighteen the quantity drawn off varied from fifty to one hundred and twenty ounces for each case. The mechanical inconvenience of such a tumor in such a position is at once apparent.

When a hydrocele has lasted for a length of time, its walls are liable to a fibrous thickening, which greatly obscures the diagnosis, or they may undergo cartilaginous or, more rarely, calcareous degeneration. If subjected to irritation or repeated injury, which can hardly be avoided, these changes are all the more apt to occur. The contents of hydrocele may be mixed with blood, or even become purulent. Secondary cysts may form in or upon the surface of the testicle, surrounded by the fluid of the hydrocele, but this is rare. Longcontinued pressure of the fluid, especially when the tunic is thickened and covered with lymph, occasionally, but very rarely, leads to atrophy of the testicle. Points of adherence may exist between the two surfaces of the tunica vaginalis, dividing the cavity into compartments.

Symptoms.-Hydrocele is usually pear-shaped, larger below than above; or it may be oval, and, if very large, almost spherical. It can not be reduced by pressure. Fluctuation can usually be made out. The tumor is generally very tense, the scrotum often stretched and shining. The cord, of natural size and feel, can be grasped above the tumor. The weight is slight compared with the size of the mass. The testicle is usually situated behind, a little below the center (Fig. 107), and pressure on this point gives rise to the peculiar sensation experienced when the testicle is squeezed. Occasionally the testicle is found below and in front, more rarely in the center, in front, from plastic adhesion. Its position should always be ascertained before

operating on a hydrocele. Dupuytren mentions several cases where this precaution was overlooked, the testicle was wounded and the diagnosis unconfirmed. If the testicle be punctured, as a rule no serious inflammation results. Pressure on a hydrocele does not produce pain; there is no heat or redness

of the skin, unless the tumor be large enough to keep it constantly on the stretch. There is flatness on percussion, differing from hernia, and there is no subjective symptom except a little dragging sensation in the groin and lower part of the abdomen, running up to the back, caused by the weight of the tumor.

[graphic]

FIG. 107 (Pott).

Diagnosis.-The infallible diagnostic sign is translucency. This is obtained by making the skin tense over the tumor, and viewing a lighted candle, held as near the tumor as possible, through the upper part of the swelling, shading the eye with the hand, or, better still, looking through a cylindrical roll of paper, or a stethoscope. If the room be darkened, translucency may be detected where otherwise the test might fail. Often translucency may be made out by simply making the tumor tense with one hand, shading the eye with the other, and holding the hydrocele between the eye and the window, in the daytime. Translucency is greater in proportion to the slowness of the accumulation, the thinness and whiteness of the walls, and the limpidity of the fluid. If the contents of the tumor are dark-colored, or its walls very dense and thick, there will be no translucency.

In such a case exploratory puncture will decide on the nature of the tumor. A fine exploring trocar should be used with an aspirator. Few diseases are easier of detection than simple, uncomplicated hydrocele; few more difficult where many complications exist. Varicocele may complicate hydrocele.

To recapitulate the symptoms of simple hydrocele are pyriform shape, slow growth, commencing at the bottom of the scrotum, fluctuation, translucency-all with absence of pain.

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