Chapter XII

, on Gonorrhea, were described the usual specific forms of urethritis, with their complications and results. To this chapter the reader is referred for all data regarding gonorrhea as it involves this passage-way, with its complications. Such lesions as _ulcers_ may persist for some time, while the papillomatous outgrowths, polypi, etc., connected with gonorrhea and gleet, which are not discoverable from without, are now easily examined and estimated with the endoscope. Specific ulcers of the syphilitic type, and virulent ulcers even of the chancroidal type, also occur, usually within the first inch of the urethra, causing more or less discharge, with local soreness, and leading, unless promptly recognized, to cicatricial stricture formation.

STRICTURES OF THE URETHRA.

Strictures of the urethra may be of _traumatic_ origin, as when produced by external accident, with or without laceration, or by the introduction of foreign bodies, or the minor injuries inflicted during their extraction. _Deep traumatic stricture_ is the result of serious injuries to the perineum. The common type of urethral stricture is the consequence of one or more attacks of _gonorrhea_, which, not having been promptly cured, has merged into so-called _gleet_, and this into these inevitable consequences, with more or less infiltration of the peri-urethral tissues, and subsequent encroachment upon the caliber of the urethra, either by irregular new tissue formations or well-marked annular constriction. In addition to the above conditions there is also known a _spasmodic_ stricture, due to involuntary contraction of the muscular fibers encircling the urethra, and of the deeper perineal muscles which concern it. Otis held that such urethral spasm is a frequent accompaniment of a contracted meatus, and taught that the best method to deal with it is by first enlarging the meatus, as may be easily done with a simple bistoury, under local cocaine anesthesia (_meatotomy_), and the subsequent passage of instruments of proper size.

To persistent and well-marked contraction of the urethra is given the term _organic stricture_, and such a stricture is generally the consequence of injury or disease, whereas purely spasmodic stricture, mentioned above, is a not infrequent occurrence in perfectly chaste individuals.

_Organic stricture may be single or multiple_, of large or small _caliber_, or even _impassable_ and impermeable--that is, from before backward--so that even while urine may leak through, drop by drop, from behind it seems impossible to introduce an instrument from the front. In aggravated cases three or four inches of the urethral canal may be involved in lesions of this kind, which constitute a formidable condition for satisfactory treatment. The ordinary non-traumatic organic strictures are all in front of the prostate and more common near the meatus. The size of a stricture is determined either by the _urethrometer_ devised by Otis, or, more simply, by determining the diameter of the bulbous bougie which may be made to easily slip through it, the latter being the common method. These instruments are indicated by numbers, which refer to the millimeters in circumference of the bulb; thus No. 27 implies that the bulb has a circumference of 27 Mm. The bulbous instrument is far better for examination than the sound, since it indicates the exact depth as well as the length of the strictured passage, and gives a better idea of its density or resilience. (See Figs. 671 and 672.)

The _indications of stricture_ are difficulty in micturition, even to the degree of impossibility, persistence of gleety discharge, and slowness or impossibility of ejaculation, while sometimes cicatricial tissue can be felt from the outside.

The strictured urethral canal should be restored to normal dimensions at the earliest practicable moment. This may be effected through gradual dilatation with a conical steel sound, passed at intervals of two or three days, or rapidly, by the improved instrument of Otis known as the _dilating urethrotome_, which, being passed through the stricture, has its blades expanded by a mechanism at the handle, while the stricture when it is stretched is divided by the working of a concealed blade. The Otis instrument is illustrated in Fig. 673.

A meatus too small to admit a suitable instrument should be incised to the necessary degree.

Gradual dilatation may be employed in the milder cases, and has been combined with a method of electrolysis, in which I have little faith. No matter which method be adopted, the patient should be impressed with the force of the old adage, “Once a stricture always a stricture,” and should be warned that the occasional passage of an instrument is necessary for a long period, and that while he may be taught the procedure he should not neglect it. This is true alike of every method of treatment.

[Illustration: FIG. 671

Bulbous sound.]

_Divulsion_ was a method employed during the past generation of rupturing a stricture by forcible separation of the blades of a divided instrument, tearing it instead of neatly cutting it, thus inflicting a maximum instead of a minimum of local damage. Every divulsion thus led to a subsequent stricture formation. The procedure has been abandoned. Now by the employment of the Otis instrument, or one of its substitutes, the stricture is first found, then penetrated with the instrument, and divided to an extent easily regulated, thus permitting exact work, which is preferable to the older methods of drawing a large blade along the urethral tract.

[Illustration: FIG. 672

Otis’ urethrometer.]

In _tight strictures_ the operator proceeds at first with small _filiform bougies_ made of _whalebone_, with which, sometimes after considerable effort with a bundle of them in the urethra, trying one after another, he may succeed in passing one and causing it to enter the bladder. The others are then withdrawn. It may now be possible to thread over the whalebone a perforated tip made for the urethrotome, and thus to slip the latter down into the depths over the fine bougie as a guide, and then to push it farther, using now more force because it must necessarily follow the urethral canal. When, however, what seems to be judicious manipulation by this method is unsuccessful the metal instrument should be withdrawn, the whalebone bougie remaining _in situ_, and thus serving as a guide for that which is now made necessary, namely, _external urethrotomy_.[72]

[72] Van Hook has recommended the following excellent expedient for the discovery of the urethral canal when apparently lost in the depths of a dense, deep stricture: He gives a dose of potassium iodide two or three hours before the operation. During the latter, and when seeking the proximal end of the urethra, he drops a little acetate of lead solution at the point where the urine is expected to appear. The formation of the bright-yellow lead iodide will mark the actual appearance of the urine and indicate its source.

[Illustration: FIG. 673

Otis’ dilating urethrotome.]

_External urethrotomy_ is essentially a median perineal section, carried down at least to the urethra. It is done preferably with a _guide_, usually a fine bougie. With it the urethral channel may be easily identified; without a guide, in aggravated cases, it is often a difficult matter to identify and dissect out the urethra, and then to find its tortuous passage-way and follow it into the bladder. Patience and a knowledge of the anatomy of the perineum will lead to success. Sometimes extensive dissections are necessary, and the perineal wound needs to be widely retracted in order to better expose the deep tissue. Once the urethra is identified it may be followed in each direction, and the case should not be left until the entire canal has been restored to its normal caliber. In these cases it is best to leave a self-retaining catheter in the perineal wound for at least a day, after which it is sometimes of benefit to introduce a catheter through the meatus, and leave it in the urethra for two or three days. Such a urethra is an infected channel, and must be so cared for that no retention or infection of fresh wounds occurs.

PERINEAL ABSCESS.

Perineal abscess is the not infrequent consequence of a very tight and deep stricture, having its beginnings as a _folliculitis_, with subsequent extension and perforation, with escape of urine, and sometimes with the formation of acute, diffuse phlegmon, which may even extend into the scrotum or to the abdominal wall. Ordinarily it constitutes a circumscribed collection of pus. Such a phlegmon when neglected may be followed by extensive burrowing of pus, or local sloughing, with gangrene, and partial or complete destruction of the external genitals. When such a phlegmon occurs above the triangular ligament there will be swelling about the prostate, with edema of the anterior rectal wall, while the prostate itself may become later involved. Such a collection may terminate as an _ischiorectal abscess_, associated with _perineal fistulas_.

The inevitable results of such conditions have two or three disastrous tendencies, such as burrowing of pus and the formation of urinary fistulas, sometimes at considerable distance from the urinary channels. The same is true in traumatic cases, for in such cases there may be the expression of an old and neglected stricture. To the chronic condition may be added that of tuberculous infection.

=Treatment.=--The _treatment of such abscesses and fistulas_ is based upon the principles of evacuation of pus and restoration of the urinary canal to its proper size. This may be an easy or a difficult task, but it should be accomplished by whatever method will permit it with the least damage to tissues. When urinary infiltration threatens gangrene extensive incisions should be made. When the scrotum is swollen, as it may be to enormous dimensions, free opening should be made into it to permit escape of serum and pus if present. Even the surrounding tissues, including the penis, may be enormously edematous. This swelling will rapidly subside when pressure upon the deep veins has been relieved, _but pus, no matter where present, must be evacuated_.

URINARY FEVER.

Instrumentation of any kind within the urethra may, in some individuals, be followed by what has been called _urethral_ or _urinary fever_, including chill, pyrexia, with sometimes the development of an acute inflammatory affection, either of the urethra or even of the kidney, with not only retention but actual suppression of urine. These manifestations are ordinarily regarded as due to toxemia, but are sometimes difficult to explain, because their violence seems so disproportionate to the amount of intervention. Thus I have known an individual to die, of apparently acute uremia, within four days after the painless passage of a sound for dilatation of an old stricture, the same not being followed by any blood or local disturbance.

These accidents were more prone to occur before the introduction of antiseptic methods in all urethral instrumentation. At present they are much rarer than in former days. Nevertheless the passage of any instrument, even for legitimate examination, as for stone, may be followed by unpleasant consequences. These are preventable to some degree as well as curable, by antiseptic local measures, as well as by the administration of quinine or urotropin, especially the latter, with sitz baths and perhaps general antifebrile measures, while any local disturbance thus set up is to be treated on general principles.

THE TESTICLES, THE CORD, AND THE VESICLES.

The testicle is originally formed by differentiation from the Wolffian bodies, at a level above the pelvis. Its _migration_ from its original location into the pouch where it normally belongs is known as the _descent of the testicle_. When it fails to appear at the external ring it is spoken of as _retained testicle_, and when detained outside the ring above its proper level the condition is referred to as _incomplete descent_, these being purely arbitrary terms. The reasons for incompleteness of the descent are as little understood as those for its completion, and have but little reference to clinical surgery.

The surgical anatomy of the testicle may be only briefly considered here. Each is essentially a double organ, consisting of the _testis_ proper, the secreting portion, with its more or less complete double peritoneal covering (originally peritoneum), and the _epididymis_, or conducting portion, variable in size, and corresponding to the parovarium in the ovary in respect that it is subject to cystic degeneration. The pathway made by the testicle as it passes from the abdominal wall should be completely obliterated. When unobliterated it facilitates the occurrence of hernia, while when partially obliterated cystic dilatations of the enclosed portions (_hydroceles of the cord_) occur. The lowermost portion of the accompanying peritoneal pouch is normally left as a closed sac, which constitutes the cavity of the tunica vaginalis testis. In the ordinary standing posture the epididymis occupies toward the testis proper the same relative position that the heel does toward the anterior part of the foot, _i. e._, it lies to its posterior and inner sides. While both portions of the organ may be involved in acute or chronic diseases, each of them may be by itself involved with a minimum of disturbance of the other.

RETAINED TESTICLE, OR CRYPTORCHIDISM.

As above indicated failure in descent varies in degree from complete absence from sight and touch to a presentation of the testicle at a point where it can be both seen and felt but still at too high a level. Ordinarily the condition is symptomless, its only signs being those above rehearsed. Strange to say the condition sometimes passes unrecognized until adult life is reached. Commonly it is early discovered. Pain is felt only when friction or traumatism lead to the same unpleasant sensations which would be produced by pressure upon a normal organ. Thus a testicle retained at the external ring may be irritated by the clothing, and has been many a time mistaken for an incomplete hernia, upon which a truss pad has been applied with inevitably resulting suffering. While accompanying malformations in other parts of the body may be found it does not follow that the individual may not be otherwise perfectly developed.

It is usually held that an incompletely descended testicle is more or less functionless; often it is at least more or less atrophied. Its functional capacity varies. It is usually more or less surrounded by a cavity formed from the peritoneum. While the condition is ordinarily one of minor importance, it has been established by numerous observations that retained testicles are relatively prone to undergo malignant degeneration.[73]

[73] In the pathological museum of the University of Buffalo I deposited specimens illustrating this fact, one testicle forming a tumor as large as the patient’s head, the other as large as a cocoanut. These were both successfully removed from an adult, and without the patient developing any subsequent evidence of malignant infection. It is thus important in every case of intrapelvic tumor in the male to examine the scrotum and be sure that both testicles are in their proper position.

=Treatment.=--The proper early treatment of cryptorchidism has been a matter of dispute, some advising to leave the condition entirely untouched so long as it be not troublesome; others that early intervention should be practised. If the organ be simply displaced and not otherwise diseased, whatever be done may be limited to freeing it from its abnormal surroundings and restoring it as nearly as possible to the position where it belongs. If it be actually diseased it should be removed. What may be accomplished will depend much upon its movability and its blood supply.

Thus Keetley would liberate the testicle, when retained within the inguinal canal, by division of the latter and lengthening of the cord by blunt dissection, with division also of the lateral portions of the gubernaculum near the pillars of the external ring and as far as possible from the testicle. By traction upon this it is then often practicable to bring the testicle down, without undue tension, to the lower part of a new scrotal pouch, which is formed by making for it a nest, as it were, with the finger, with an opening at its lower extremity, through which forceps are thrust, passed upward and made to seize the end of the gubernaculum, or through which a suture may be passed for the same purpose. By means of this device the testicle is now drawn downward into the scrotal pouch, where, being once present, it is held by sutures, both direct and those which close the pouch above it. It is then advisable to close the inguinal canal, as after a hernia operation. In order to prevent upward traction on the scrotum it is necessary to attach its lower end to the skin of the thigh, by a suture which should remain for several days. If this be done on both sides the limbs should be snugly bandaged together and movement of all kinds prevented. Complete separation of the scrotum from the thighs should not be permitted for several weeks, unless unavoidable.

Beck recommends an incision from the external ring three inches downward along the cord, after which he opens the pouch of the testicle, lifts it from its bed, pulls it down, carefully dividing all bands of connective tissue or peritoneum which tend to immobilize it. It is then deposited in a scrotal pocket, in which it is held by a flap dissected from the outer margin of the inguinal ring, and turned downward in such a way that it can be attached to the opposite layer in semilunar shape. Thus a band of aponeurotic tissue is made to surround the testicle “like a necktie,” the organ being retained as in a buttonhole, the length of the flap being determined by the extensibility of the cord. The inguinal canal is then closed as after any other procedure.

_Other abnormalities_ of the testicle include _congenital atrophy_ or _absence_, while in a few cases a _third testicle_ has been found, it lying in contact with one or the other of the naturally separated normal pair.

INJURIES TO THE TESTICLE.

Injuries to the testicle are of common occurrence, on account of their exposed position, yet less common than would otherwise occur were it not for their extreme movability. Aside from the lacerated, incised, or punctured wounds which may be inflicted the testicle suffers most often from _contusions_, always with resulting swelling, and sometimes with considerable effusion, of which a large amount may be accommodated in a distended tunica vaginalis.

HEMATOMA OF THE TESTICLE.

Hematomas of the testicle are also thus frequently produced. When of a limited degree of severity spontaneous absorption of blood may be expected, and should be favored by physiological rest, _i. e._, confinement in bed, with elevation of the scrotum and the application of water dressings. Large extravasations of blood, when fresh, may be withdrawn by the trocar, but when clotted will require incision and evacuation of clots, which should always be practised, as it leads to great saving of time. Extravasation is usually followed by induration, and more or less permanent enlargement, which will be slow to disappear; absorption may be encouraged by the use of a weak mercurial ointment.

TUBERCULOSIS OF THE TESTICLE.

Tuberculosis of the testicle simulates very closely that occurring in the lungs, in that one may see a disseminated miliary process, with subsequent coalescence and formation of caseous nodules, subsequently breaking down into abscess cavities, while at the same time the surrounding membranes, _i. e._, the tunica vaginalis, are involved, and effusion (hydrocele) occurs just as in the pleural cavity. In other words every appearance of pulmonary consumption may be imitated within the small extent of the testicles and the epididymis. Of these two parts the latter suffers much more frequently. Here are caused irregular nodules, which may later unite, giving to the entire epididymis a much enlarged, irregular shape, with induration, frequently extending upward along the cord, and always tending so to extend unless the disease be early seen and recognized. Too often adhesions to the skin occur, with ulceration and formation of fistulas, and perhaps more or less extensive ulcers, while in many instances the entire length of the vas becomes infected, and frequently even the prostate and corresponding vesicle become involved. By this time there will be more or less involvement of the inguinal lymphatics, and the patient may be already showing evidences of general tuberculous infection, at least those of some serious constitutional impression made by the local disease. One has to differentiate as between tuberculosis, syphilis, and cancer, which may be difficult in the early stages; but when the disease has extended beyond the epididymis itself it is rarely difficult to recognize, unless entirely masked by distention of the tunica vaginalis with fluid.

=Treatment.=--The treatment for tuberculosis of the testicle is _extirpation_, _i. e._, _castration_, which includes the removal not only of the diseased organ, but of all the tissues, including the skin, to which it may be abnormally adherent, and of the spermatic cord, which, if necessary, should be followed into the pelvis by a long incision extending up along the inguinal canal. To remove a tuberculous testis and leave a tuberculous cord is to accomplish very little, while the latter, being an extraperitoneal tissue, may be followed with relative safety, even to the depths of the pelvis. Local applications in these cases give little relief. This teaching is at variance with that of some writers, but is justified by experience.

SYPHILIS OF THE TESTICLE.

Syphilis occurs in secondary and tertiary manifestations, usually first in the testis, sometimes in the epididymis, but always in the testicle before the cord. It produces nodules which may be mistaken for those of tuberculous trouble, but which often attain much larger size. They are usually painless. Nevertheless a syphilitic testicle is sometimes tender, and constantly so, to a degree causing no little annoyance. The occurrence of nodules in the epididymis, in connection with other evidences of syphilis, is regarded by some as pathognomonic. In this location the condition yields readily to properly directed treatment.

CYSTS OF THE TESTICLE.

Cysts are frequently found along the course of the epididymis. Some of them are expansions of the natural tubes of the paradidymis, while others are distinctly new. _Dermoids_ are occasionally met, and either of these may attain considerable size. Cyst of the epididymis proper is to be distinguished from encysted hydrocele of the cord. All of these purely cystic conditions are essentially innocent, and need similar treatment. They may be evacuated and injected with an irritant like pure carbolic acid, which is sometimes an effective way, or they are better treated by _open incision_ with extirpation of the cyst, which is, in the end, far the more satisfactory course to pursue.

EPIDIDYMITIS AND ORCHITIS.

Each of the separate portions of the testis may have its own nearly self-limited inflammations and infections, or both may participate in a common lesion. The most frequent cause of an acute _epididymitis_ is gonorrhea, the infection travelling from the urethra along the vas, and causing acute and well-marked swelling of the epididymis, which becomes tender and painful in proportion to the amount of exudate. It may come on early or late, during the course of the urethritis. The condition is known to the laity as “swelled testicle.” It has been frequently called orchitis, which is an error, since however much the testis may later

## participate the primary trouble is in the epididymis. It may be easily

distinguished by palpation, the enlarged and hardened epididymis, often very tender, being prominent behind the testis proper. The condition may, however, be masked by the acute effusion likely to occur in the tunica vaginalis, constituting a mild degree of acute hydrocele. This may be expected in nearly all severe cases, and serves to increase the size of the entire mass. A testicle thus affected may assume much more than normal dimensions, and, becoming thereby much heavier, drag upon the cord, which is its normal support. More or less fever and malaise accompany the condition, part of which may be due to the toxemia of gonorrheal infection. Usually but one side is involved. Both are rarely affected simultaneously, but one may follow the other.

The acute stage of gonorrheal epididymitis persists for a week or ten days, even under the best of treatment, and is followed by gradual subsidence, characterized by amelioration of symptoms and decrease in size.

=Treatment.=--This improvement is to be induced, first, by rest in bed, with elevation of the scrotum, and the ordinary eliminative treatment suitable for any febrile condition. Local relief may come from the application either of heat or of ice-bags, the latter being preferable, but will be made more effective by the application over the scrotum of a mixture of two parts of olive oil with one part of methyl salicylate, or of guaiacol reduced with equal parts of oil or glycerin. The anointed surface should be covered with some impervious material, and the dressing be changed every few hours. Later, as the acute merges into the chronic condition, absorption may be stimulated by the ordinary mercurial ichthyol ointment.

In some exceedingly acute cases suppuration ensues, the consequences being a collection of pus in the epididymis, which will give the ordinary signs and call for the usual evacuation which every collection of pus demands. Epididymitis, more or less acute, has been known to follow the introduction of the catheter or sound, even in cases so far as known not previously infected. It is difficult to explain, but requires the same treatment as above.

=Orchitis, or Inflammation of the Testis Proper.=--This condition is rare except as an occasional complication of _mumps_, or, much more rarely, of one of the other exanthems. Why after acute parotiditis there should be a tendency to inflammation of the testis or the ovary has never been fully explained. Nevertheless it is sufficiently frequent to be well known to the laity, and is occasionally so pronounced as to lead to actual atrophy, with loss of function of the testis involved. In any true orchitis there will be considerable pain and tenderness, because the testis proper is so tightly confined within its tunica albuginea, _i. e._, a firm, inelastic membrane. By proximity there will also be set up more or less involvement of the tunica vaginalis, with effusion, so that some degree of acute hydrocele may be looked for in every such instance.

=Treatment.=--The treatment of the condition above described consists essentially in rest, with local soothing applications, of which perhaps nothing will be more satisfactory than guaiacol, which, however, should always be used with caution.

TUMORS OF THE TESTICLE.

_Dermoid cysts_ and _tumors_ and _teratomas_, _i. e._, those of mixed type, are frequently met in this region. Their explanation is doubtless afforded by the extreme complexity of the elements which help to make up the part, while in the embryonic condition, and the confusion of tissue elements which may then and there arise. These growths of embryonic origin vary from single cysts to a mass of cystic tumors, which may replace the organ, or constitute neoplasms of large size, while some of the teratomas have features causing them to resemble the mixed growths occasionally found within or about the ovary. In this way is to be explained the occurrence in such masses of hair, teeth, and other epiblastic elements, as well as of cartilage or bone or other mesoblastic elements. Taken together these growths constitute an interesting group for the pathologist to study. For the surgeon, however, they require essentially the same class of treatment, namely, _extirpation_, or, if this be impossible, complete removal of the organ, _i. e._, _castration_. There should be no hesitation in performing this upon any such growth, as no testicle thus affected is likely to be functionable, and the individual suffers no possible deprivation of potency by its removal.

The other benign and simple tumors, especially _fibromas_ and _chondromas_, are occasionally met, and I have described one rare case of large _lipoma_ within the limits of the testicle proper.

=Cancer of the Testicle.=--This includes, usually, sarcoma, developing from the mesoblastic elements, although adenocarcinoma may be met here, but as an extension from some growth occurring first in the skin or in the immediate neighborhood. Deep cancer in this region is difficult to at first distinguish from the induration produced by tuberculosis or syphilis. In doubtful cases the therapeutic test may be tried in order to differentiate it from the latter. From the former it is usually separated by its more consistent and regular (_i. e._, its less nodular) character. In all three cases the lymphatics of the groin may be early involved, or perhaps not until late. As a rule cancer is met in the later years of life, while the other conditions are more frequently seen in the first half. In the more rapid cases there will be considerable pain, with dilatation of the scrotal veins, and evidences of constitutional involvement. Sarcoma may grow rapidly and metastasis is almost invariably to the lungs.

Of tumors in the testicle, as of those in the breast, it may be said that any new-growth which tends to enlarge, become more dense or adherent, to spread, or to be accompanied by lymphatic involvement _should be removed_; no mistake will be made in applying this rule in these cases, especially if by the therapeutic test or otherwise syphilis can be excluded. Malignant disease sometimes travels rapidly up the cord, and the main fear is not so much of local recurrence as of deep involvement within the pelvis. Cases of cancerous growth of the testicle should be not only thoroughly extirpated from the scrotum, but the _inguinal canal should be opened, and the cord followed as far as possible and completely removed_.

Cases may arise where amputation of the scrotum may be justifiable for the purpose of temporary relief, in order to avoid discomfort, hemorrhage, or offensive ulceration.

HYDROCELE.

Strictly speaking the term hydrocele means accumulation of watery fluid in any pre-existing cavity. By universal consent, unless some other cavity be specified, the tunica vaginalis is understood. The consequence is a more or less distended sac of serous fluid, which first occupies a position in front, but finally is spread around the lateral portion of the testicle, and may form a tumor the size even of the individual’s head. It is an innocent collection of serum, but the walls of such a sac will be thickened in proportion to its age and size, and may in the course of time undergo such degenerations as the calcareous, for instance, by which it becomes more or less infiltrated or encrusted with calcareous material. Thus I have in my possession a tumor of this kind, nearly the size and almost as hard as an ostrich egg, the old tunic being converted practically into a shell.

_Acute hydrocele_ occurs, as above mentioned, in connection with the acute infections, but is then ordinarily a matter of but a few days or weeks.

Hydrocele, as usually implied by the term, is an exceedingly chronic and almost painless affection, which may follow injury, but which comes often without any known cause. Many theories have been advanced to account for it, but none are generally satisfactory. These cases, however, occur usually after the fortieth year of life, but may be seen in the young. Their greatest unpleasantness is that produced by the weight of the mass as it drags upon the cord and the scrotum.

The tumor is pear-shaped, and abruptly circumscribed at its upper limit, below the external ring (unless there be also involvement of the cord), and gives no impulse when the individual coughs. By these features it is distinguished from hernia, for which it is often inexcusably mistaken. A hernia is a distinct prolongation from above, whereas a hydrocele terminates below the hernial outlet, and by its smaller extremity. The distended sac will fluctuate, and will return clear fluid upon puncture with a hypodermic needle, and is so translucent that light may be transmitted through it when it is interposed between a candle-flame and the surgeon’s eye. (Serious thickening of the sac may interfere with the value of this test.) A congenital form of hydrocele is also known, due to failure of obliteration of the canal of Nuck, and it might be possible in some such cases to get a slight impulse on coughing, as when the sac connects with the abdominal cavity, in which case it should be possible to gently press its contained fluid back into the abdomen above. In most congenital cases there is a tendency to spontaneous cure, at least to obliteration of the canal.

Occasionally both sides are involved, or the sacculation may be multilocular, or accompanied by cystic extensions along the cord.

=Treatment.=--In regard to methods of treatment, but two will be considered here, _aspiration with injection of carbolic acid_, and _extirpation_. The former consists in the insertion of an ordinary (small) trocar, which is thrust in from below upward, care being taken that its point avoid the testicle, which is always found to the posterior and inner side of the sac. Through this trocar the contained fluid should be completely evacuated, so that the sac is practically dry. Into it is now injected with some force from 2 to 6 Cc. of absolutely pure carbolic acid, after which the trocar is instantly withdrawn, pressure made upon the opening, and massage made upon the scrotum and the contained testicle, in order to distribute the acid freely over the serous surface. Its effect is to completely sear the entire surface so that the mouths of all the absorbents are closed. In this way danger of carbolic poisoning is quite avoided, a danger which would be imminent were the acid reduced in strength. But little pain is caused by the procedure. Its immediate effect is to produce exudate, with some recurrence of swelling, which ordinarily rapidly absorbs, while the exudate, coagulating, serves to produce obliteration of the cavity of the sac. This is the carbolic method of Levis, who introduced the acid as a substitute for the iodine formerly employed, upon which it was a great improvement. For cases of moderate age, whose sacs are not too thick, it often proves satisfactory. Having failed, or the case being considered not adapted to it, the other method is that by open incision and extirpation.

This _open method_ consists in making an incision through the skin, down upon and into the sac, which, being thus instantly evacuated, will collapse. It is now possible to make a more or less complete enucleation of the sac wall, stripping it from the external tissues to which it adheres, as it is not necessary to separate it from the testicle itself. It has been found that when the major portion is thus removed the condition is effectually combated. The cavity may be drained with silkworm strands or with a small tube, but only for a short time, if the technique have been correct.

THE SPERMATIC CORD.

The cord participates essentially by its contained _vas deferens and lymphatics_ in the consequences of acute and chronic infections, travelling in either direction, and thus it may be involved in _tuberculous_, _syphilitic_, or _malignant disease_. These expressions, however, are secondary and the conditions have been described above. _Encysted hydrocele of the cord_ implies simple dilatation of an incompletely obliterated canal of Nuck, by which there may be formed along the cord one or more cystic expansions, causing tumors rarely attaining a size greater than a pigeon’s egg, which are innocent collections of fluid, corresponding to the ordinary hydroceles that may occur below. They are ordinarily not difficult of recognition, and are the most common form of neoplasms occurring in this region. They are amenable to the same treatment as that described for hydrocele.

[Illustration: FIG. 674

Varicocele. (Hartmann.)]

SPERMATOCELE.

Spermatocele implies a cystic tumor in whose contained fluid, no matter what its source, are found spermatozoa, which may be seen alive under the microscope if examined immediately after removal. Spermatoceles are usually found at the lower end of the cord and in close connection with the testicle. Their occurrence is not uncommon, but somewhat difficult to explain, for it implies connection, at least at some time, between the structures of the cord and a more or less displaced seminiferous tubule. Spermatoceles are rarely diagnosticated as such until aspiration or evacuation and examination of their fluid contents, which usually are of a milky appearance. In general they are to be treated like any other cysts, and by the same methods.

VARICOCELE.

This exceedingly prevalent affection is the result of a varicose condition of the pampiniform plexuses and of the spermatic veins. It occurs in perhaps 10 or 12 per cent. of adult males, rarely before puberty, and almost invariably upon the left side, varicocele upon the right side being as rare as 1 in 500 cases. Its confinement to the left side is explained partly by compression of the left spermatic veins beneath an overloaded and distended sigmoid, and by the disadvantage at which the blood current from the left spermatic vein empties into the vena cava, this being on the left side at a right angle, while on the right the angle is oblique. It has occasionally to do with accident or injury, as well as with occupation or habit. It occurs more frequently in those who are long in the saddle and in those who ride the bicycle to excess. (See Fig. 674.)

Varicocele is usually of slow development, and discovered finally by accident or by attention being drawn to these parts through quack advertisements or misleading statements. The effect is to produce an elongated mass of varicose veins, often described as feeling like a “bag of angle worms,” occupying the lower portion of the cord and extending down upon the back of the testicle. In the more advanced cases the condition can be traced almost to the external ring, but is always more marked low down than higher up. Sometimes it is so extreme that the entire group of veins corresponds in bulk to a hen’s egg; ordinarily it is but a fraction of this size. The consequence is increase of weight and production of dragging sensation upon the cord, often referred to the back, and displacement downward of the testicle, with consequent elongation of the scrotum, which may so greatly relax that it appears to be twice its normal length and contains this varicose mass at its lower extremity. Such a condition will naturally produce a certain degree of discomfort and annoyance, but _beyond this it is innocent_, save that it is made to cause much mental anxiety, mainly through ignorance, and has led thousands of victims to quacks, for treatment for conditions dishonestly represented and treated as both distressing and extreme. It is true that a large mass of enlarged veins may in time produce some atrophy of the testicle; it is likewise true, also, that virility or masculine potency may be to a trifling extent limited in this way. It is not true, however, that impotence can be so produced, because the affection is limited to but one organ, so that the impotency of which many men complain is mainly of psychical origin. Such individuals need explanations and advice as much as treatment, although it is difficult to elevate many of them from the condition of sexual hypochondria into which they gradually fall.

[Illustration: FIG. 675

FIG. 676

Resection of scrotum for varicocele. (Hartmann.)]

=Treatment.=--Treatment of varicocele may be _palliative_, _i. e._, it may consist of suspension of the overloaded testicle and somewhat relaxed scrotum within a well-fitting _suspensory bandage_, and this suffices for most mild cases in normally minded individuals. When, however, the condition preys deeply upon the mind or upon the body, or when it is actually and anatomically advanced, then _radical operation_ is legitimate and humane. Of the many operations recommended in time past only two will be described here, for it seems to me that all subcutaneous and blind methods are bad in theory as in practise.

_Excision of the varicose veins_ is easily performed under local cocaine anesthesia. It is done by incision below the external ring, over the course of the cord, the cord itself being exposed for two to three inches. Here the enlarged veins appear usually in a group (the pampiniform plexus), and as such can be isolated and separated from the balance of the cord, it being essential to _carefully exclude the vas_, as injury to or division of this canal would naturally be followed by impotence of that testicle. The veins involved being isolated to an extent of two inches, are ligated above and below, the intervening portion being then exsected, after which it is my custom to utilize the catgut with which this ligation is effected, threading it on each side into a needle, using each as a suture, thus providing two sutures, by which the divided ends are approximated and tied together, the effect being to bring the testicle up and make a more effective suspensory of the cord itself.

=Shortening of the Scrotum.=--To the above procedure, when the scrotum is much elongated and relaxed, may be added its _shortening by a species of amputation_. The entire procedure may be practised as follows: The scrotum being stretched downward is shortened by removing one and a half to three inches from the lower end of the scrotal pouch of skin and the contained connective tissue, including the septum. In this way the tunical sacs and lower ends of the testicle will be immediately exposed. The left testicle can now be drawn down, and the operation, described above, of exsection of a portion of its veins, may then be practised. This being completed the scrotal wound is closed with sutures, with or without catgut drainage. The effect is to not only remove the varicose veins, but to reduce the size of the scrotum, and to make it, as it were, a suspensory of living tissue (Figs. 675 and 676).

THE SEMINAL VESICLES.

The lower ends of the vasa and the seminal vesicles themselves suffer most commonly from the consequences of _tuberculous_ or of _gonorrheal infection_, travelling in either direction, they being easily invaded from the prostatic urethra along the seminal ducts. The consequence is _seminal vesiculitis_, which produces a more or less tender swelling, with discomfort referred to the lower end of the rectum, and discoverable by digital examination above the prostate. When the vesicles are distended or infiltrated they may be felt with the finger in the rectum. In addition there may be on pressure more or less discharge of fluid into the prostatic urethra, while the semen when emitted may be more or less mixed with blood.

It is necessary usually to differentiate between prostatitis or prostatic hypertrophy and vesiculitis.

Chronic involvement of the seminal vesicles may be best treated by a species of massage or “milking,” by which retained contents are coaxed along the ducts and into the urethra. Its local treatment is almost impossible. When the conditions resulting from infection of either type have become chronic and intractable we may take advantage of recent advances and decide upon _removal of the vesicles_ by operation. Fuller suggested that this be done by putting the patient in the knee-chest position or a modified Sims position. While it is not difficult to reach the vesicles through the rectum, the method has its disadvantages and the perineal route is much the better. The operation is then effected, much as is prostatectomy, by perineal opening and blunt dissection between the rectum and the prostate, carried upward until the vesicles themselves are reached, after which they may be curetted or extirpated by a process of enucleation.[74]

[74] In the treatment of infections of the seminal vesicles,

## particularly those of gonorrheal origin, Belfield has advised

irrigation and drainage of the same through the vas deferens. He brings this up against the skin of the scrotum, where it is easily identified, and then, through a one to two-inch incision, made under local anesthesia, exposes the vas, into which the blunted end of a hypodermic-syringe needle may be introduced, by means of which a solution of any desired agent may be injected. This being thrown in the direction of the seminal current passes up through the vas and into the vesicle. He has even recommended in certain cases to attach the vas to the skin by a fine silkworm suture, and in this way to make a minute fistula, which can be used for the purpose as long as may be necessary. He considers the method invaluable in the treatment of chronic gonorrheal vesiculitis or the chronic infections of the seminal canal in the elderly, which are often mistaken for enlarged prostate, as well as in cases of recurrent epididymitis resulting from repeated invasion from behind. Thus he has seen benefit follow, in tuberculosis of the epididymis, from irrigation with carbolic solution. The amount injected into the vesicle should never exceed 2 Cc.

SPERMATORRHEA.

Accurately defined this term refers to the escape of semen under abnormal and involuntary conditions, an occurrence which is of great rarity. Most cases of so-called spermatorrhea are, in effect, but the escape of excessive or superfluous amounts of _prostatic mucus (prostatorrhea)_, the fluid, whether it appear drop by drop or in considerable quantity, being mistaken by the patient for semen. Thus with the extrusion of a hard fecal mass there may be sufficient pressure upon the prostate to express from it 1 Cc. or more of this fluid. True spermatorrhea, on the other hand, rarely occurs except in connection with disease of the vesicles or prostate, and will then be recognized rather by the detection of spermatozoa in the urine than from any phenomenon noticeable by the patient. All statements, therefore, made by patients to the effect that they suffer from involuntary escape of semen should be taken with the greatest allowance, and will usually be found to be misleading.

All of this might lead up to a considerable discussion of matters included within the domain of sexual physiology and hygiene, topics which, however, cannot be afforded space in the present work; all that can be said being that many patients are in need of accurate information who suffer acutely in mind, and sometimes slightly in body, for lack of it, and who are tempted by motives of delicacy to consult quacks and charlatans rather than their family physician.

CASTRATION.

The only operation of importance upon the external genitals not yet described is that of _castration_, _i. e._, removal of the testicle. This is ordinarily a simple procedure, requiring, first, incision of sufficient length. If the disease condition include the slightest infiltration or involvement of the overlying skin a little or the greater portion of it, as required, should be included in an oval incision, in order that it may be totally removed. The testicle and its coverings, being now exposed, are to be loosened from all their surroundings, the organ pulled down, and the cord brought into sight. If there be no reason for following up the spermatic cord it is sufficient to surround it with a ligature (chromic gut), at a convenient height above the testicle, after which the cord is divided below it and the mass removed. In most instances, however, the disease which calls for so much operating will require to be followed up along the cord, and perhaps through the inguinal canal down into the pelvis. This is done by continuing the incision in the proper direction, isolating the cord, ligating bleeding vessels, and finally dividing the cord itself at a point of election decided to be above the disease. Previous generations were hesitant about including the entire cord in a ligature, for fear of tetanus, but we now know that if the technique be carefully carried out there need be no fear on this score. The diseased mass being removed the wound is closed, with or without catgut drainage at one or more points, as may be indicated.

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