The cord being cut, the testicle is to be turned out more by tearing than by cutting. An oval piece of skin may be removed with it if it is very large, and, if it adheres pretty tightly, care may be required to prevent wounding the urethra or the other testicle during the dissection. After the testicle is removed, the arteries of the cord (the spermatic, deferential, and the cremasteric) may be tied separately with catgut, and all the bleeding points in the scrotum secured. If a single ligature has been used for the whole cord tied high up, the individual vessels need not be ligated. Pain, however (and even tetanus), has been said to be produced by the single ligature from including the nerves of the cord and the vas deferens. The wound should not be united until all the bleeding points have been secured. There are few operations in surgery which are so liable to be complicated by troublesome bleeding after the wound is closed. This is due to the laxity of scrotal tissue. Drainage and antiseptic dressings insure a good result. Healing by first intention along the whole line is not uncommonly attained.

If hernia complicates the disease of the testis, it is better to take advantage of the opportunity, slit up the sac, and operate for radical cure by suturing the pillars of the ring with catgut or silkworm-gut. If the cord should slip into the inguinal canal after being divided, and before its arteries have been secured, and if it can not be hooked down, the tendon of the external oblique must be cut at the external pillar of the ring, and the dissection continued up the canal until the cut end is reached and all its bleeding points secured. Several instances of death are recorded from neglect of this precaution. If hæmorrhage comes on after the wound has been closed, it should be reopened and the bleeding vessels searched for. A few points of suture are necessary, otherwise the edges of the wound will be kept gaping by the contractions of the dartos. Self-castration has often been resorted to by lunatics, or by individuals, usually young men, laboring under some depression brought on by masturbation or other abuse of the organs. The bleeding is always excessive, but, in the cases reported, has usually been successfully arrested, or ceased spontaneously.

DERMOID CYSTS OF THE TESTIS.

The testicle, next to the ovary, is the most favorite site for the development of dermoid cysts. These cysts are cavities lined by integument, furnished with stunted papillæ, sebaceous and hair glands. Their contents are a sebaceous matter mixed with epithelium and rolls of long hair, usually reddish. Besides these there are often found fully-formed teeth, sometimes in great numbers, often imbedded in portions of bone, bones with smaller bones articulated to them, cartilage, muscle, nerve. In a personal case a portion of the inferior

maxillary bone with some molars and a bicuspid were found. The dermoid cyst may be within or outside the testis, as in Velpeau's * case. These are the cysts sometimes known as fetal inclusions. The cysts are probably always congenital. They usually grow very slowly at first, but may reach an inconvenient size in time. Generally they become very large, then suddenly begin to grow rapidly and are removed, or, becoming injured by a blow, they in flame, suppurate, and discharge their contents, remaining fistulous.

The only treatment is removal with the knife. It should be remembered that the cyst sometimes lies outside the testicle, the latter adhering to it. The gland should be dissected off, and spared if possible.

D'Arcy Power* says that only ten cases have been put on record during the past two hundred years. He showed a specimen at the London Pathological Society. He is evidently wrong.

IRRITABLE TESTIS.

This is a name given to a species of neuralgia of the gland. The whole organ, or usually a particular spot, is extraordinarily sensitive to the lightest touch; contact of the clothing alone is sometimes exquisitely painful. In the recumbent posture, with nothing in contact with the testicle, the pain usually disappears. Sometimes the organ is tense and engorged; but it is of full size, and seemingly normal. Again, it may be decidedly flabby, the scrotal tissues being soft and lax. Irritable testis occurs at all times, from early puberty to late middle life. It is met with chiefly in old bachelors and widowers. The patient otherwise may possess robust health, sometimes (especially with flabby testis) he is anæmic, nervous, hypochondriacal, and dyspeptic.

The causes of irritable testis are lack of use, or abuse, of the sexual powers-perhaps most often ungratified sexual desire. Curling says, "In a person of chaste habits, thus affected, I was informed that the morbid sensibility disappeared on marriage." Temporary irritable testis may be produced in a healthy person, at any time, by prolonged sexual excitement ungratified. Masturbators who have suddenly reformed, and recent widowers, and those who have abused their sexual powers by over-use, are all liable to the affection under consideration.

These patients are usually hypochondriacal, look upon their own *"Gaz. Méd. de Paris," February 15, 1840. André, "Mém. de l'Acad. Royale de Méd.," vol. iii. Ollivier (d'Angers), "Mém. sur la Monstrosité par Inclusion," ""Archiv. Gén.," vol. xv. Verneuil, "Archiv. Gén.," June, 1855, who has collated nine cases besides one of his own.

"Lancet," October 23, 1886, p. 775.

condition as a pitiable one, and ascribe it to loss of seminal fluid-perhaps to nocturnal emissions-to neither of which does it stand in any relation of effect. They often demand castration-a demand which should be acceded to on no account. Curling quotes from Romberg an interesting case bearing on this point: A young man acquired irritable testis after becoming engaged to be married. It distressed him so seriously that he demanded extirpation of the organ, and would not yield until at last the operation was reluctantly performed. Eight days afterward the old pain returned in the other testicle. This being all he had left, the patient preferred to keep it. He married, and "very soon recovered completely."

Treatment.-Hygiene, physical, moral, and sexual, is the proper treatment for irritable testis. As local means, a suspensory bandage and the cold douche are adjuncts. Drugs exert no specific power and can not be relied upon. Marriage, with a proper sexual hygiene, is the natural antidote to any irritability of the sexual apparatus.

NEURALGIA OF THE TESTICLE.

An extreme degree of the condition just detailed constitutes neuralgia of the testicle, a disease which sometimes attains horrible intensity, and assumes the tic-douloureux type in paroxysms at irregular (occasionally regular) intervals. The pain in some cases is constant, and perhaps quite mild, but increased by walking and standing so as to occasion great discomfort. The character of the pain is acute, darting, stabbing, sometimes dragging, heavy. The cremaster sometimes contracts spasmodically during the paroxysm, forcibly retracting the testicle, and a cold sweat, with nausea and vomiting, is not a rare accompaniment. Between the paroxysms the testicle is often entirely free from pain. Handling the organ is liable to induce a paroxysm. The testis, sometimes swollen and tense, is usually unaltered. There is no febrile action. Neuralgia is usually confined to one testicle, unlike irritability, which is frequently double. Neuralgia must not be confounded with the sympathetic pain in the testis, and its retraction from spasm of the cremaster, accompanying certain morbid states of the bladder, ureter, and kidneys, and so often seen in kidney-colic.

The cause of neuralgia of the testis is sometimes difficult of appreciation. It is often due to the same general influences which lead to the development of neuralgia elsewhere (gout, syphilis, malaria, etc.). It sometimes follows an attack of orchitis. It has been vaguely referred to the spinal cord, deranged digestion, etc. It has been seen to follow injury and to attend a small, deep-seated, purulent collection. B. Brodie * found it in one case always preceded by clay-col

*"Medical Gazette," vol. xiii, p. 621.

ored evacuations and pain in the back of the head. He believed the cause in this case was situated in the liver. In another case, he found a small projection on the epididymis, which, on pressure, gave the sensation of touching an exposed nerve in a tooth. This latter condition I have encountered a number of times. Neuralgia of the testicle not infrequently is due to irritative inflammatory or other disease of the deep urethra, and may be cured by removing its cause-by deep urethral nitrate-of-silver instillations, use of the sound, or other

means.

In neuralgia of the testis no nerve-lesion has been found. Sexual hygiene will be often found at fault. The affection may last for years and (possibly) then disappear spontaneously.

Treatment.-Neuralgia depending on bladder, urethral, or kidney disease, disappears with its cause. In true neuralgia, a strict hygiene is all-important; this involves marriage. Among drugs, arsenic, quinine, and iron bear the best reputation internally; belladonna, opium, and aconite externally. But little reliance can be placed on them, however; sexual and general hygiene outrank all remedies. If the testicle be extirpated, there is always danger of a return of the pain in the cord, or in the other gland. Diday* recently very strongly advocates the continued application of cold in all pure cases of neuralgia, and claims remarkable success with this agent. His method consists in filling two bladders with large pieces of ice. One of these he places upon towels, so arranged as to underlie and support the testis, the patient being supine. The other bag is now placed upon the testis, so that the whole organ is surrounded by ice, or, rather, iced-water. This application is kept up night and day for two to four days, after which (Diday states) the neuralgia does not return. William A. Hammond † claims to have cured this malady by tightly squeezing the entire cord between the blades of an instrument like a lemon-squeezer for five minutes, then letting up the pressure (to allow circulation to be resumed) and reapplying it. I have not tested this method.

t

"Annales de Derm. et de Syph.," 1869, No. 3, p. 182.
"St. Louis Courier of Medicine," May, 1880.

CHAPTER XXVI.

MALADIES INVOLVING THE GENITAL FUNCTION.

Impotence.-True Impotence, its Causes and Treatment.-False Impotence, its Causes and Treatment. Sterility.-Masturbation. -Pollution, Nocturnal and Diurnal.-Spermatorrhoea.-Erotomania.-Satyriasis.-Priapism.-Aspermatism.

IMPOTENCE is a symptom, usually, of some physical morbid condition entailing inability to accomplish the sexual act. Its causes are very numerous. Most of them have been already considered; the others will receive a few words of detail in this chapter. Impotence will only be considered as affecting the male.

Impotence, from whatever cause, is a complaint not unfrequently submitted to the surgeon; not always frankly and openly as such, but often by implication, as though it should be recognized and inquired about, in answer to remote indications which the patient has scantily furnished. Indeed, the surgeon who would meet the daily wants of his fellow-men, in reference to troubles of this sort, must possess an accurate knowledge of the physiology of the sexual function, and of its various derangements, and be ready to anticipate the reticence of patients; otherwise he will fail to sound many of the depths of human nature, where suffering lurks-which suffering is for the most part preventable or relievable.

Impotence signifies that an individual can not beget children because he can not perform the sexual act properly, no matter what the obstacle may be, whether he have spermatozoa or not. The term must be carefully distinguished from sterility, which signifies inability to beget offspring on account of defect in the semen, whether the individual can have sexual intercourse properly or not. The two are undoubtedly often associated in the same individual, but they may be totally distinct, as the following examples will illustrate. Thus there are two methods of making eunuchs in the East: by one the penis is removed as well as the testicles, and such a eunuch is necessarily both impotent and sterile. By the other method the testicles alone are removed; and a eunuch of this description, though sterile (having no spermatozoa), may be still partly potent, and does not bring so high a price as another eunuch who has no penis. It is a well-known fact that both animals and men, from whom the testicles have been removed after puberty, still retain sexual desires, and may have intercourse, with venereal orgasm and ejaculation of prostatic mucus, occasionally during a period of several years. A cryptorchid is rarely at all impotent, but is very apt to be sterile, and so of a patient with