%. L_ f*r the te-tis measures two inches in'length, one inch in breach, and three lines in thickness. Sir A. Cooper makes its long diameter two inches, ns transverse an inch and a half, and its ^^ Qne the testis. 39 the term reflected or testicular, it will be understood that I mean to imply the outer and loose portion. The two portions are connected and continuous with each other. The outer one loosely invests the whole of the testis, except its posterior edge and inferior extremity, parts where it becomes attached to the gland. It is connected with the testis at about five lines from the lower extremity, and the junction of the two portions is marked by a white and rather irre- gular line. The uncovered portion of the testis corresponds to the original attachment of the gubernaculum. On the inner side of the gland the membrane, after investing the lower part of the cord to a greater or less extent, is reflected to the epididymis just below its head, and to the posterior edge of the body of the testis, being there separated from the epididymis by the vas deferens and blood- vessels of the gland. On the outer side the membrane entirely covers and closely invests the epididymis, and forms a cul-de-sac, which isolates its middle from the posterior border of the testis, and in cases of hydrocele is often distended into a good-sized pouch. At the bottom of this sac the tunica vaginalis on the two sides comes into close contact, and sometimes there is a communication at this spot between the two. The smooth and polished surface of the shut sac thus formed by the tunica vaginalis is lubricated by a halitus, which, when condensed, forms a serum, having the ordinary properties of the secretions of the other serous membranes. The office of this membrane is to facilitate the movements of the testis, so as to enable it to elude pressure and escape violence. In some adult subjects the tunica vaginalis, which was originally a process from the serous lining of the abdomen, still retains its connection with that cavity. When the communication is free, the sac is very liable to receive a protrusion of some of the contents of the abdomen, and become the seat of congenital hernia. Some- times the communication continues through a contracted tubular canal, Avhich, though too narrow to admit the transit of any of the viscera, is open to the passage of fluid. In other cases the ob- literation is partial, one or more isolated serous sacs being left along the cord. It more often happens, however, that after the upper aperture of this process has closed, a considerable part of it below remains unobliterated, so that the tunica vaginalis ex- tends for some distance upwards in front of the cord. Frequently, also, although the obliteration is complete, remains of the prolonga- 40 ANATOMICAL INTRODUCTION. tion may still be found in the form of a slender whitish filament, or fibro-cellular process, which is lost in the cellular tissue in the ante- rior part of the cord, but may sometimes be traced as far as the tunica vaginalis. A small body of an irregular shape and variable size, and of a pale red or pinkish hue, is commonly found attached either to the upper extremity of the testis, or at the angle where the tunica vaginalis passes from the body of the gland to the epididymis. It is composed of a duplicature of this membrane, containing some fine cellular tissue and a number of small vessels. I have seen this little body in the testis of the foetus whilst in the abdomen ; and in early life it is often of proportionally larger size, and of a deeper red color than in the adult. It is quite distinct from the pedunculated cysts often found attached to the head of the epididy- mis. This little appendage to the tunica vaginalis seems to corres- pond with, and to be a type of, the remarkable omental process attached to the superior part of the testis in the Rodentia and other animals. That it is an unimportant structure in the adult is shown by its being frequently wanting. Tunica Albuginea or Tunica Propria is a dense, resisting, in- elastic membrane, composed of fibrous tissue analogous to the scle- rotic coat of the eye. It completely invests the body of the testis, but not the epididymis. Its external surface is covered by the tunica vaginalis reflexa, to which it intimately adheres. This tunic is divisible into two layers, which can only be separated by a tedious dissection, but which in certain animals may be detached without difficulty. The branches of the spermatic artery and veins ramify in the substance of the tunica albuginea, in canals bearing in their arrangement some analogy to the sinuses of the dura mater; which membrane the outer layer is supposed to resemble. The smaller vessels are chiefly distributed on the inner layer, which, owing to its vascularity, has been compared to the pia mater investing the brain. At the postero-superior border of the testicle, and a little to its outer side, the tunica albuginea forms an internal projecting body or process, which lodges the blood-vessels, and a portion of the glandular structure of the testicle called the rete testis. This body is named after the anatomist who first described it the Corpus KeZPr ^^ h0W6Ver' b6en Called b? ^ A. Cooper the medtasUnum tesUs, and he describes it as being formed by the THE TESTIS. 41 tunica albuginea, which at that part is divisible into three layers. The first layer turns upon the spermatic cord, and unites with the sheath which covers the vessels. The second layer unites with a similar layer on the opposite side, and forms a thick substance, between the fibres of which interstices are left for bloodvessels and absorbents ; whilst the internal layer, uniting with that on the oppo- site side, as well as with the preceding layer of the tunica albu- ginea, forms the process called mediastinum, which projects into the testis between the tubuli; and it is in this substance that the seminal canals of the rete are placed. The mediastinum is therefore composed of two bodies; the upper placed towards the spermatic cord, the lower towards the centre of the testis ; in the upper are placed bloodvessels; in the lower the canals of the rete. Its length varies from six to eleven lines. II. Glandular or Secreting Structure. The glandular part of the testis is very simple, ancl more easily demonstrated than the glandular structure of most other organs. It consists of numerous seminiferous vessels or tubes, supplied with bloodvessels, lymphatics, and nerves. Its color is a grayish-yellow or brown, more or less tinged with blood, and is paler in infants and old men than in adults. The tubes are collected into numerous lobes or lobules, invested by a fine cellular tissue, which, detached from the interior of the tunica albuginea penetrates the gland, and sends out lateral processes forming septa, which separate and sus- tain the lobules. These septa at their origin partake of the fibrous character of the tunica albuginea, but as they converge towards the superior border of the testis, occupied by the corpus Highmori, they become finer, and are gradually resolved into a delicate cel- lular tissue. The septa are traversed by numerous bloodvessels which minutely divide in them before being distributed on the semi- niferous tubes.1 1 Sir A. Cooper states, that the inverted portion of the tunica albuginea, forming the mediastinum testis, sends forth numerous ligamentous cords, some of which pass to the anterior edge of the testis; whilst others form shorter processes to support and invest the lobes, being met by similar ligamentous cords from the inner surface of the tunica albuginea. I have not been able to make out any such ligamentous processes, passing into the substance of the testis, as are represented in Sir A. Cooper's work (part i, pi. 2, fig. 3), which I have found to be an exaggerated view of the preparation 40 ANATOMICAL INTRODUCTION. Tuhuli Seminiferi.—-These tubes, which form by far the bulk of the glandular structure of the testis, are very numerous, and radi- ate from all parts of the circumference of the organ towards the mediastinum, making numberless convolutions, which progressively diminish as they approach the rete testis. Two or more of the tubuli being collected together, and invested by a common cellular tunic, form a lobe or lobule of a conical form, its apex terminat- ing at the corpus Highmori. The lobes thus formed are not en- tirely distinct, but communicate with neighboring lobes ; the pro- cesses investing them are therefore incomplete, and the lobes cannot be separated from each other without division of some of the semi- niferous tubuli. Krause estimates the number of the lobes as vary- in o- from 404 to 4S4.1 The tubuli are of a white color and uni- form size, but their calibre differs in different subjects, and varies a good deal according to the age of the subject and the state of activity of the testes, being larger in young adults and when dis- tended with semen than in old persons and when the gland is in a state of rest.2 The size of the ducts also often differs in the two from which it was taken. The cords described appear to me to consist chiefly of bloodvessels supported by slight fibrous processes from the tunica albuginea and cel- lular tissue. In a well-injected testis very little tissue of the nature of ligament can be found between the lobes. 1 Miiller, Archiv. fur Anatomie, 1837, p. 22. 2 The following is frqm a Table of Measurements of the Seminal Tubes made by Mr. Gulliver. (Proceedings of the Zoological Society, July 26, 1842.) Age. Size of Tubes in Fractions of an English Inch. State of Testes. 22 42 60 8G 8 18 months. 6 weeks. Stillborn. Stillborn: 1-142 to 1-77 1-133 to 1-86 1-146 to 1-82 1-160 to 1-100 1-422 1-400 to 1-266 1-333 to 1-230 1-307 1-300 to 1-222 Scarcely any fluid in testes. Died of phthisis. Some spermatozoa in epididymis. Died of phthisis. No spermatozoa. Died of phthisis. Died of pneumonia. Fatty matter in testis. No spermatozoa. Died of phthisis. Died of pneumonia. Child puny and emaciated. Died of pneumonia. Body much emaciated. Well-nourished foetus; born at full period. Fostus weighed 6 lbs. The enlargement of the seminal tubes of birds in the spring, and of the mammalia at the rutting season, and in young animals generally as they become capable of re- production, has been noticed by Wagner (Physiology, tr. by Willis, pp. 23 and 27), and further Ulustrated by Mr. Gulliver in the table from which the above observations in man were taken. THE TESTIS. 43 Fig. 2. testes of the same subject. In general the calibre of the tubuli corresponds to the size of the testis. Observers do not exactly agree in their estimates of the diameter of the tubuli. The average diameter of the uninjected canal is estimated by Miiller at 7*s of a line, by Lauth1 at Tgg of an inch. Krause found the tubuli, when filled with semen, to measure about y2 of a line, and in old men and youths -jV Monro reckoned the number of the seminiferous tubes at 300; Lauth made the average number 840, and he esti- mated the mean length of all the ducts united at 1750 feet. He found the individual ducts to vary in length, the mean being 25 in- ches. Krause estimated their entire length at 1015 feet. The mem- brane composing the tu- buli is of a mucous cha- racter, as has been clearly proved by microscopic examination, and it is con- tinuous with the mucous surface of the genito-uri- nary system. There is no appearance of an inter- tubular substance ; the ducts are merely con- nected by a loose network of vessels, and conse- quently readily admit of being separated and un- ravelled. The tubes, when successfully injected with quicksilver, form a beauti- ful anatomical prepara- tion. Sir A. Cooper suc- ceeded in filling the tubes with size injection; but he has not described the mode in which it was effected, and other anato- mists have failed in similar attempts. 1 Mem. de la SoA6\6, d'Hist. Nat. de Strasbourg, t. 1. Glandular structure of the testis, displayed by mercu- rial injection.—After Lauth. a a a. Glandular substance of the testis subdivided into lobes, each lobe being composed of convoluted tubuli closely packed. b. Rete testis. c c. Vasa efferentia. d. Inflected part of the vasa efferentia forming the coin vasculosi. e e. Dilatations of the efferent vessels. /. Body of the epididymis. g. Tail of the epididymis. h. Vasculum aberrans. i. Convoluted part of the vas deferens. k. Straight part of the vas deferens. 44 ANATOMICAL INTRODUCTION. When the tubuli seminiferi are unravelled, they are found to divide, and form numerous anastomoses, which increase in frequency towards the circumference of the testicle (see Fig. 3, a> a1). The tubuli thus form one vast network of communication, so that it is impossible to isolate completely either a duct or a lobule. The credit of making this interesting discovery of the anastomoses of the seminal tubes is due to Lauth. In only one instance did he succeed in finding a duct terminating in a blind pouch, and this he regarded as exceptional. Blind ends have been found, however, more frequently by Krause. The anastomoses of the tubules have been observed in the rat and other animals as well as in man. The convolutions of the seminal tubes diminish in number as they ap- proach the mediastinum, and cease altogether at a distance of from one to two lines, where two or more unite to form a single straight duct, termed vas rectum, which joins the rete testis at a right angle (a2, a2). The vasa recta are very slender, and easily give way when injected : their calibre, which is greater than that of the seminal tubes, is estimated by Lauth at T£g of an inch. Haller reckoned their number at twenty, which is, however, too few. Rete Testis, as its name implies, consists of a plexus of seminal tubes, which occupies the corpus Highmori, or mediastinum testis. The vasa recta, after penetrating the walls of this body, termi- nate in from seven to thirteen vessels, which, running parallel to each other in a wav- ing course, and fre- quently dividing and anastomosing, form the rete testis (b). Lauth found the mean dia- meter of the vessels of the rete in injected According to Prochaska, these vessels Fig. 3. --C\^« after Lauth. Diagram of the testi a a a. Tubuli. a1 a'. Subdivisions and anastomoses of the tubuli a» a». Vasa recta. The other references are the same as in Fi ,2. preparations ^ of an inch. THE TESTIS. 45 are supplied with valves, but such is not the case. Small dilata- tions, however, are often found in different parts of the plexus. III. The Excretory Parts. The epididymis, a continuation of the testis, is a body of a cres- centic form, divided into an anterior and upper extremity, called head, or globus major, which is firmly attached to the testicle; a middle part or body, which is less in size, and separated from the gland by a pouch of the tunica vaginalis; and a tail or globus minor, connected to the testis by cellular tissue. The volume and weight of the epididymis vary in different subjects, but are propor- tionate to the size of the testis. It is longer than the testis, mea- suring about two inches in length and four or five lines in width. Its name (from inl, upon, and didu/wq, testis) indicates its position, which is along the postero-superior border of the gland. The epi- didymis is chiefly made up of seminal canals connected and sup- ported by a firm resisting cellular tissue. The ducts which spring from the upper part of the rete testis to form the epididymis are termed vasa efferentia. They are usually about twelve or fourteen in number, but vary from nine to thirty. The inflections of each of these efferent ducts are so arranged as to form in the head of the epididymis a series of elongated conical figures called coni vas- culosi. These ducts at their commencement run straight for a dis- tance of about one or two lines, when they form convolutions which become more numerous and close as the ducts recede from the testis. Their length varies, the upper ones being the shortest. Lauth found their average length to be seven inches four lines, and cal- culating their number at thirteen, he makes the united length of the vasa efferentia nearly eight feet. He states that the efferent ducts diminish in size from their commencement to their termination in the canal of the epididymis, where they are less than the semi- niferous ducts of the testicle (see Fig. 4). As in the rete, round dilatations of variable size are often met with in these ducts (see Fig. 2, e e). The efferent ducts, after forming the coni vasculosi, successively join a single duct, the canal of the epididymis, at irre- gular distances, the intermediate portions of the duct varying in length from half an inch to six inches. The efferent ducts are more slender than the canal of the epididymis, and frequently give 46 ANATOMICAL INTRODUCTION. way under the pressure of the column of mercury when injected. The body and tail of the epididymis are entirely made up of the convolutions of the single canal in which the vasa efferentia termi- nate, closely connected by cellular tissue. Monro described this Fig. 4. Fig. 5. An efferent vessel and a portion of the head of the epididymis magnified, to show the pro- gressive diminution of the canal of the cone, and the calibre of this vessel, in comparison wiih that of the canal of the epididymis. c. Vas deferens. d. Inflected portion of the duct. e e. Head of the epididymis.—After Lauth. Canal of the epididymis partly unravelled to show the four series of inflections which the duct undergoes in the several divisions of the epididymis. o o. First series of inflections. pp. Second series. qq. Third series. r r. Fourth series.—After Lauth. canal as gradually increasing in size from the head to the tail, and he estimated its calibre about its middle at B'a of an inch. Lauth states that its size is subject to great irregularities in different parts and m different subjects. This anatomist has particularly described the convolutions of this duct, and has shown that they are regularly arranged in four series, which successively increase in size, the first being the smal est, and the fourth the largest. The arrangement tb l/ ,rt™2CTSt°1 bj refereMe t0 Fi§- 5- Monro estimated ts mefl l! T ^ ^^ fee* eWen inches- Lauth found its mean length to be nineteen feet four inches eight lines. The THE TESTIS. 47 parietes of the canal are strong and bear considerable resistance. The canal of the epididymis terminates in the excretory duct of the testis, the vas deferens, and is usually contracted at the part where the two join. It was calculated by Monro that the semen before arriving at the vas deferens traverses a tube forty-two feet in length. Lauth, however, makes the whole distance but little more than twenty-two feet. [The annexed drawing is made from a mercurial injection of the testicle, by J. P. Hopkinson, and given by him to the University of Pennsylvania. It is laid open so that the rete testis is in the centre. It shows well the tubuli seminiferi on each side, the vasa recta, the rete testis, the coni vasculosi, &c. It the canal of the epididy- mis, which is contracted at its insertion, and terminates in a blind and often dilated extremity. Sometimes after being dilated for a certain distance it diminishes, and becoming very minute, is lost in the cellular tissue of the cord. It usually passes up the cord for about two or three inches, but has been found to extend as far up as the brim of the pelvis. The length of this appendage when un- ravelled varies from one to twelve or fourteen inches. The vascu- lum aberrans is not constantly present; indeed Monro found it 48 ANATOMICAL INTRODUCTION. onl lly four times in sixteen, but I believe Avith Lauth that it exists more frequently. Occasionally there is more than one, and as many as three have been found both by Lauth and Sir A. Cooper. Hunter regarded these ducts as supernumerary vasa deferentia of a nature similar to the double ureters.1 Miiller states that their office is evidently the secretion of a fluid which they pour into the epididy- mis.2 I am inclined to think, however, that the duct does not serve any particular office; but is a sort of diverticulum, which, though common, must be viewed as accidental, like the process not unfrequently connected with the intestinal canal. Vas deferens, the excretory duct of the testicle, commences from the tail of the epididymis, and terminates in one of the ejaculatory canals behind the bladder. Arising from the contracted part of the canal of the epididymis at an acute angle, it ascends along the inner side of this body, from which it is separated by cellular tissue and the spermatic arteries and veins. A right or left testis may thus always be distinguished by the circumstance that when the testis is in position, the vas deferens is situated on the inner or mesial side of the organ. In this part of its course, for the distance of about an inch and a half, or more, the vas deferens forms numerous convolutions (see Figs. 2 and 3 i), which gradually cease as the duct mounts above the testis. The inflected part of the vas deferens, when unravelled, was found by Lauth to measure six inches and a half. It afterwards takes a direct course (k) up the spermatic cord to the inguinal canal, passing behind and at a short distance from the spermatic arteries and veins. On entering the abdomen at the internal ring, it quits the spermatic vessels and descends into the pelvis, passing at first by the side of, and after- wards behind and below the bladder on the inner side of the corres- ponding vesicula seminalis, the excretory duct of which it joins at an acute angle to form the ejaculatory canal. The vas deferens is nearly uniform in thickness until it reaches the vesicula seminalis, and is lined by a fine membrane of a mucous character, which is continuous with the urethra. It is round and indurated, and harder than any other excretory duct in the body, by which character it is easily^distinguished, when handled, from the other parts consti- tuting the spermatic cord. Many anatomists have entertained the 1 Works, by Palmer, vol. iv, p. 24. ' 2 Physiology, trans, by Baly, vol. i, p. 456. THE TESTIS. 49 opinion that the parietes of this duct are muscular. It is distinctly so in the bear, bull, and other animals. On careful examination, however, of sections of the human vas deferens in the microscope, I could discover nothing more than simple fibrous tissue. IV. The Vessels and Nerves. Spermatic vessels.—The spermatic arteries, the chief vessels sup- plying the testes, arise in pairs, at a very acute angle, from the fore part of the aorta, immediately below the renal arteries. Their origin is subject to considerable varieties. The two seldom arise at the same level, and the right is often a branch of the right renal artery. Sometimes one or both come off from the superior mesen- teric. Occasionally there are two spermatic arteries on one or both sides, arising in the regular way. All these deviations are more frequently met with on the left than on the right side of the body. Each artery pursues a tortuous course downwards and outwards, passing behind the peritoneum obliquely across the psoas muscle and ureter, to which, as well as to the surrounding cellular tissue, it gives off several branches. The artery then enters the inguinal canal through the internal ring, and emerging at the external, passes down the cord, being surrounded in its course by the sper- matic veins. The further distribution of the artery is thus correctly described by Sir A. Cooper. When the artery reaches from one to three inches from the epididymis, varying in different subjects, it divides into two branches, which descend to the testicle on its inner side, opposite to that on which the epididymis is placed; one passing on the anterior and upper, the other to the posterior and lower part of the testis. From the anterior branch the vessels of the epididymis arise; first, one passes to its caput; secondly, another to its body; and, thirdly, one to its cauda and the first convolutions of the vas deferens, communicating freely with the deferential artery. The spermatic artery, after giving off branches to the epididymis, enters the testis, by penetrating the outer layer of the tunica al- buginea ; and dividing upon its vascular layer, they form an arch by their junction at the lower part of the testis, from which nume- rous vessels pass upwards; and then descending, they supply the lobes of the tubuli seminiferi. Besides this lower arch there is another passing in the direction of the rete, extremely convoluted in its course, and forming an anastomosis between the principal i 50 ANATOMICAL INTRODUCTION. branches. The testis receives a further supply of blood from another vessel, the artery of the vas deferens, or posterior sper- matic artery, which arises from one of the vesical arteries, branches of the internal iliac. This artery divides into two sets of branches, one set descending to the vesicula seminalis, and to the termina- tion of the vas deferens ; the other, ascending upon the vas defe- rens, runs in a serpentine direction upon the coat of that vessel, passing through the whole length of the spermatic cord; and when it reaches the cauda epididymis, it divides into two sets of branches, one advancing to unite with the spermatic artery to supply the testis and epididymis, the other passing backwards to the tunica vagi- nalis and cremaster. The spermatic veins spring in three sets from the testis, one from the rete and tubuli, another from the vascular layer of the tunica albuginea, and a third from the lower extremity of the vas deferens. The veins of the testis pass in three courses into the beginning of the spermatic cord: two of these quit the back of the testis, one at its anterior and upper part, and a second at its centre; and these, after passing from two to three inches, become united into one. The other column accompanies the vas deferens. There is also a large vein just above the testis, which crosses to join the columns. The veins of the epididymis are one from the caput, another from its body ; one from its cauda, and another from its junction with the vas deferens, besides some small branches: they terminate in the veins of the spermatic cord. The veins, after quitting the testis, become extremely tortuous, and frequently di- vide and inosculate in the cord, forming a plexus termed vasa pam- piniformia. These communications cease as the veins approach the ring, which they enter, and ascending along the psoas muscle in company with the spermatic artery, unite to form a single vein, which usually terminates on the right side in the vena cava infe- rior, and on the left in the renal vein ; though this is subject to some variety. The left spermatic veins pass under the sigmoid flexure of the colon. Many anatomists speak of the spermatic veins as being destitute of valves, which they assign as one of the reasons for the occurrence of varicocele. I have several times in- jected these veins with alcohol, and on laying them open, have ob- served valves in the larger vessels, and I have also found injec- tions thrown into the veins arrested by the valves. They are SPERMATIC fluid. 51 seldom seen, however, very near the testis, or in smaller veins, forming the plexus; nor have I observed them within the abdomen. Absorbents.—The absorbent vessels of the testis are very numer- ous, and arise from every part of its internal structure and coats. They unite to form four or five trunks, which ascend along the cord, and traverse the inguinal canal, without communicating with the glands in the groin, but pass upwards in front of the psoas muscle, behind the peritoneum, and terminate in the lumbar glands, on the side of the aorta. Nerves.—The nerves of the testis are derived chiefly from the renal plexus, but partly also from the superior mesenteric and aortic plexuses. These nerves descend in company with the sper- matic artery to the cord, where, being joined by branches from the hypogastric plexus, Avhich pass along the vas deferens, they form together the spermatic plexus, the branches of which are inter- mingled with the vessels of the cord, and ultimately terminate in the substance of the testis. A feAV twigs from the external sper- matic nerve may also be traced to the coverings of the gland. The minute distribution of these nerves forms a very difficult dissection. SPERMATIC FLUID. The sperm or secretion of the testis is a thick tenacious fluid, of a whitish or grayish-white color, and of greater specific gravity than water. It has an alkaline reaction, and is composed of albu- men, phosphatic and hydrochloric salts, and a peculiar animal matter called spermatine. According to the analysis of Vauquelin, human spermatic fluid consists of the following ingredients : Water,..........90 Animal mucus, ......... 6 Free soda,..........1 Phosphate of lime, ........ 3 Peculiar animal principle,....... 100 When first voided, the sperm has a peculiar odor, Avhich has been compared to that of the farina of the Spanish chestnut; but this odor appears to be derived from the secretions of the vesiculse seminales, prostate, and the mucous glands of the urethra, which are always mixed with it Avhen eA'acuated, as pure semen taken from the epididymis or vas deferens has no such smell. On examination in ANATOMICAL INTRODUCTION. Fig. 7. the microscope, with a high power, this fluid is found to contain a multitude of minute bodies closely croAvded together, Avhich in recent semen display very lively moArements. These bodies (A 1, 2, 3, 4), are the sehiinal animalcules, or spermatozoa, as they are more pro- perly termed; for it is yet a question among physiologists, Avhether they are independent parasitic animals, or merely animated parti- cles of the organism in which they exist. A spermatozoon consists of a flattened oval and per- fectly transparent body, terminating in a filiform i tapering tail, which to- gether measure from g^th to ^gth of aline in length. The spermatic fluid also contains a number of mi- Spermatozoa from man, and their development (AVag- ner). A. Spermatozoa from the semen of the vas deferens. 1 lo 4. Show their variety of character. 5. Seminal gra- nules.—B. Contents of the semen of the testis. 1. Large round corpuscle or cell. 2. A cell containing three round- ish granular bodies, from which the spermatozoa are deve- loped. 3. A fasciculus of spermatozoa, as they are seen grouped together in the testis. nute round colorless gra- nular corpuscles (A 5), which vary in quantity, but are usually much less numerous than the spermatozoa. Both these elements of the sperm are suspended in a clear transparent fluid, termed the liquor seminis. Wagner has shown that the spermatozoa are developed Avithin cells, and originate from the spermatic granules, being formed by the dis- persion of the nuclei of these cells.1 The spermatozoa are peculiar to the spermatic fluid and the chief characteristic of this secretion. They are always present in it after the age of puberty, and do not disappear whilst man retains the power of procreation, having been met with in persons of a very advanced age. They live for many hours after ejaculation; blood produces no effect on them, but urine renders their motions feeble and hastens their death. The quantity of spermatic fluid emitted in sexual union varies from one to two or three drachms. •Much curious information respecting the spermatic fluid may be found in Wag- rnd ^ pZ'" ^ ^ T"iS; MQ,ler'S PhySi0^ * b' ^ Baly, JZZl manu, ues fertes beminales Involontaires, t. 2. DISEASES OF THE TESTIS. CHAPTER I. CONGENITAL IMPERFECTIONS AND MALFORMATIONS. SECTION I. Numerical Excesses and Defects. Supernumerary Testicles.—Cases of supernumerary testicles are mentioned in the writings of the old authors, and persons have been described with four or five of them, accompanied with a propor- tionate increase in the venereal appetite. Nearly all these cases are of a fabulous character, the observations during life not having been confirmed by dissection after death. Such must be remarked of the case of xevropxos, or man with five testicles, mentioned by Schaarf,1 and with that of a man with four testicles, alluded to by Blegny.2 Blasius, an old Avriter not unworthy of credit, has given an account of the examination of the body of a man, thirty years of age, and otherAvise well formed, who had two testicles on the right side, of the same size and shape as that on the left, which is illustrated by a small engraved figure representing a distinct artery from the aorta, and vein from the vena cava proceeding to each of the two testicles on the right side.3 This is the only case of supernumerary testicle recorded by the old authors which has any semblance of authenti- city. Neither Morgagni, Haller, nor Meckel met with a single example, and they questioned the existence of such a condition. ' Eph. Nat. Cur. Dec. iii, Ann. v, vi, Obs. 89, p. 175. 2 Zodiaque Francois, Ann. 11. Most of the reputed cases of Triorchides are quoted by Arnaud in his Memoires de Chirurgie, jVle"m. iii, part 1. 3 Ger. Blasius, Obs. -Med. Anat. Obs. 20, p. GO. 54 numerical excesses and defects. Two cases of the kind have recently been recorded, but they AA-ere not verified by examination after death. One is related by Bltime- ner,1 the other by Dr. Macann, a British army surgeon.2 A fatty or fibrous tumor in the scrotum, or an encysted hydrocele of the cord or testicle, especially the latter, might readily be mistaken for an additional testicle. Morgagni mentions that he was once deceived by a portion of omentum. In the pathological collection at St. Thomas's Hospital, is preserved the testicle of the eccentric Dr. Monsey, who appeared during life to be supplied Avith three of these glands. The supposed additional testicle consists of an indurated fibrous tumor, attached apparently to the tunica vaginalis. Several persons have consulted me, supposing that they had a super- numerary testicle in the scrotum, but in every instance I have been able to recognize without difficulty one of the tumors just mentiqned. In addition to the ordinary characters of the particular swelling, the absence of the testicular pain on pressure will materially assist the diagnosis, as is shown in the following case:—A medical friend brought to me a young gentleman supposed to have three testicles. He had been examined some years before by Sir A. Cooper, who, it was stated, was inclined to believe that this was the case. On examination, I found the left testicle of its full size and in proper position. On the right side I felt two bodies; one, the larger of the two, was about half the size of the left testicle. The spermatic cord could be traced to it, and compression produced the usual sick- ening sensation experienced from pressure on the testicle. Below this, but distinct from it, and quite free in the scrotum, was an oval- shaped body, the size of a small walnut, which was tense and elastic, and felt very much like a small testicle ; the two bodies on the right side being about equal in volume to the left testicle. Something hke a vas deferens even could be traced to the lower tumor, but compression of it produced scarcely any uneasiness. On taking the patient into a dark room, and examining the part by transmitted light, I plainly perceived that the supposed third testicle was a cvst containing fluid, an encysted hydrocele of the testicle. Absence of one or both Testicles.-M^j instances of monor- chia^, or persons having only a single testicle, are also mentioned by the old authors; but as the data are very imperfect, and as little 1 Rust's Magazin fur die Gesammte Heilkunde, for 1824 2 Provincial Medical Journal, Nov. 5, 1842, p. 113. numerical excesses and defects. 55 was knoAvn respecting the transition of the testicle at the time these cases Avere recorded, they cannot be regarded as authentic. They were most probably cases in which one of the glands was either retained within the abdomen, or from some cause had been com- pletely atrophied. I knoAV no good reason why a deficiency of one or both testicles should not occasionally occur Avithout any other malformation ; but they are anomalies of which there are very few authentic examples in the annals of medical science. Mr. Page, of Carlisle, recently sent me a right single testicle of remarkable size, which he had removed in 1844, from the scrotum of a lad, aged seventeen, who died on his Avay to the Cumberland Infirmary from injuries received in a steam saAving machine. When prepared for maceration by cutting aAvay the tunica vaginalis, this monster testicle was found by Mr. Page to weigh tAvo ounces, two drachms, and tAvo scruples. After it had been several years in spirit, I found its weight to be nine drachms. The organ was quite healthy in structure, and the epididymis was loaded with secretion.1 Mr. Page states, "the course of the left testicle Avas so minutely examined as to satisfy me that no such organ existed." This is a satisfactory example of monorchis, and that it Avas an original defect appears to be confirmed by the remarkable hypertrophy of the existing gland ; a circumstance I have never observed in any instance of single undeveloped or retained testicle, or wasted gland.2 Professor Paget has published the particulars of a case in which he believes one testicle Avas deficient at birth.3 No account of the man accompanies the details of the dissection, and it is open to question Avhether the deficiency of the gland was not the result of atrophy. Dr. Fisher, of Boston, has recorded a case of absence of both testi- cles. The deficiency was remarked from birth, and the subject of the malformation was regarded as a natural eunuch, and died at the age of forty-five.4 In a most scrupulous dissection of a male subject, recorded by the accurate anatomist, Blandin (Anatomie Topographique, p. 411), 1 The testicle is preserved in the Museum of the College of Surgeons. 2 In one instance of a right testicle retained within the abdomen of a strong man, the left gland was found to weigh seven drachms fifteen grains. The mean weight of a healthy testicle is about six drachms. 3 London Medical Gazette, vol. xxviii, p. 817. 4 American Journal of the Medical Sciences, vol. xxiii, p. 352. 56 DEFICIENCIES AND IMPERFECTIONS he could find no testicle on one side of the abdomen, and no trace of the corresponding cord, vas deferens, and vesicula seminalis; nor Avas there any mark of a wound discoverable in the scrotum. Mr. Thurnam has given an account of the dissection of an infant who died at the age of four months. In addition to an atrophied condition of the right kidney, and a remarkable malformation of the ureters, it Avas found that neither of the testicles had descended. The right lay in the abdominal cavity, just above the inguinal canal. On the left side no testicle would appear to have been formed; the spermatic vessels on this side terminated in a little mass of fat; the vas deferens, however, was present, and was ap- parently as well developed as that of the perfect testicle.1 A case of monstrosity is related by Dr. Friese in Casper's Wochenschrift.3 The child lived only half an hour: in addition to the absence of the external genital organs, there were neither testes, vasa deferentia, nor vesiculae seminales. Cases, however, in which the whole of the genital apparatus is deficient or irregularly formed do not come within the scope of this work. Union of the Testes.—Geoffrey St. Hilaire has recorded the following remarkable, and, I believe, unique case of union of the testicles in the abdomen. It was communicated to him by M. Bre- ton, of Grenoble. An infant was born at Vizille in 1812 : several physicians consulted respecting the child's sex were of different opinions; they decided, however, to inscribe it in the registers as a girl. It died at the age of eighteen months, and was dissected by ^e!°n,JWh° reC°Snized a comPlete hypospadias. The scrotum was bifid and empty; and the two subrenal capsules, as well as the two^ kidneys and the two testicles, were joined together upon the median line The spermatic arteries and veins, vesicula seminales, 2 dHl f7T> eXhibit6d n°thing rem-kable, each half of the double testicle receiving its particular vessels.3 SECTION II. Deficiencies and Imperfections of the Vas Deferens. stated^that tbaget'S 77 °f SUPP°Sed abSenCe °f the testic1*, ^ is stated that the vas deferens terminated nearly opposite the exter- 1 London Medical Gazette, vol. xx, p. 717. 5 Dec. 25, 1S41, quoted in the British and Foreign Mr i r. • p. 527. 3 . "a Jr0rei"n Mt'<1'cal Review for April, 1842. Hist, des Anomal. de lOrgan, t. i, p. 542. of the vas deferens. 57 nal ring in a rounded cul-de-sac ; and in Dr. Fisher's case of defi- ciency of both testicles, that the vasa deferentia, though properly formed and nearly of natural size, terminated in culs-de-sac at the end of the cord. In the Museum of St. Bartholomew's Hospital there is a preparation taken from a man, fifty years of age, who died of strangulated hernia. A piece of intestine was strictured by a band of adhesion connected with the mesentery, and the tes- ticle Avas detained in the upper opening of the ring. On dissection of the parts, the vas deferens was found to terminate near the tes- ticle in a cul-de-sac. The gland was very small, and its structure appeared granular, like the undeveloped testicle of a youth. There was no trace of the epididymis. Mr. Hunter, in dissecting a male subject, found the vasa deferentia not only deficient near the tes- ticles, but terminating beloAV in a single irregularly formed vesicula seminalis, and having no communication with the urethra.1 M. Gosselin, in the dissection of a man about tAventy years of age, found the vas deferens wanting on the right side from the epididy- mis to the upper part of the bladder.2 There are a few other cases on record in Avhich^the vas deferens has been defective at the extre- mity which joins the ejaculatory canal. Thus Tenon, in the dissec- tion of an infant affected with extroversion of the bladder, found that the vasa deferentia terminated separately at the bottom of the pelvis in two Avhite tubercles: the scrotum, testes, and vesiculse seminales were in a natural state.3 But besides these imperfections at its two extremities, this duct has been found Avanting throughout nearly its Avhole extent. Brugnone mentions, that in dissecting the parts of generation in a robust man, from tAventy-six to tAventy- seven years of age, he found the right epididymis almost entirely absent, the only part remaining being the head, which formed nodules filled with semen. The rest of the epididymis and the vas deferens Avere wanting, without any mark of disease. The testicle Avas perfectly sound, and nearly of the same size as the left one. On examining the corresponding vesicula seminalis he found at its 1 Works by Palmer, vol. iv, p. 23. There is a preparation in the Hunterian Mu- seum at Glasgow (G5 S) of two testicles which exactly agree with John Hunter's description, and are doubtless the organs dissected by him. 2 Archives Generates de Medecine, 4e s6rie, t. xiv, p. K'S. 3 M6m. stir quelques Vices des Yoies Urinaires, &c, in Mem. de lAcad. Roy. des Sciences a Paris, 17i *> «* the vessel was scarcely perceptible. These changes on the left side I ShTsl 2 -result of inflrmation induced ^ ^ °P-ti-- of tevas'Iff' * * 7^ ^ * eXcised a "=»11 portion ti *t round aTtl °* ? ^ ***> ^ °n the ^ tied a *Ure ,htly round all the parts composing the cord, except the vas defe- ' Anatomy of the Testis, p. 5l. ^ ^ ^ ^^ ^ ^ ^ ^ OF THE VAS DEFERENS. 61 rens, and divided the included parts below the ligature. The dog was killed on the 25th of June following. The left testicle was of its natural size, and contained spermatozoa. The right testicle was • completely atrophied, a small epididymis attached to the end of the vas deferens being all that remained of the gland.—April 26th, 1842, in a large young dog, whose testicles had not acquired their full size, I exposed the cord, and made a simple division of the vas deferens on the left side. The dog was killed on the 25th of June following. The two testicles were exactly of the same size, but the left Avas loaded Avith fluid containing spermatozoa. The ends of the divided vas deferens were separated and closed.—June 29th, 1842, in a kitten eight weeks old I divided the vas deferens on each side, and separated the cut extremities of the ducts. He grew a remarkably fine cat; and in the following February became restive and noisy, and evinced a disposition to rove from the house. On 'the 24th of the month I excised the testicles. They were plump, and filled with fluid which was found to contain abundance of lively spermatozoa.1 The foregoing cases and experiments show, then, that the testi- cles may be properly developed, though a physical obstacle to the elimination of their secretion is present from birth ; and that so long as the testicles exist entire, though to no purpose, the indi- vidual acquires and preserves all the marks of the male sex ; the secreting alone appearing to be the special organs of generation upon which the sexual characters depend. The engorgement of the seminal ducts with sperm is liable, it is true, to cause inflammation of the testicle, which may end in atrophy, but this is only a secon- dary and indeed a rare effect of the interruption in the excretory duct. SECTION III. Imperfect Transition of the Testicle. It occasionally happens that at birth one or both testicles have not passed into the scrotum, being detained either in the abdomen 1 M. Gosselin has since performed two similar experiments on dogs. One was killed and examined ten months, the other four months after section of the vas defe- rens. In both the testicle was of normal size. (Archives G6ne"rales de Me"decine, Sept. 1853.) 62 imperfect transition near the groin, in the inguinal canal, or in the groin just outside the external ring. In a table of 103 male infants, examined by Wris- berg at the time of birth, it appears that seventy-three had both testicles in the scrotum ; in twenty-one, one or both were in the groin. Of these, five had both, seven the right, and nine the left in the groin; in twelve, four had both, three the right, five the left, only in the abdomen.1 According to this table, the imperfec- tion occurs rather more frequently on the left side than on the right, in the proportion of seven to five. In twenty-five cases ex- amined at different ages, varying from five to sixty,—sixteen of which came under my observation, the remainder being taken from the recorded experience of others,—in thirteen the imperfection was on the right side, and in twelve on the left. Dr. Marshall states, that in the examination of 10,800 recruits, he had found five in whom the right, and six in Avhom the left testicle was not apparent. In tAvo of these cases there Avas inguinal hernia on the side Avhere the testicle had not descended.2 He met with but one instance in which both testicles had not appeared.3" The testicle sometimes remains permanently fixed in the situation in which it is placed at birth ;4 but in some instances the passage, though delayed, is com- pleted at some period previous to puberty, and often within a few weeks after birth. Mr. Hunter was of opinion that this completion most frequently happens between the years of two and ten. Of the twelve cases mentioned by Wrisberg, in which one or both tes- ticles were retained in the abdomen, in one the descent took place the day of birth, in three on the day after, in three others on the third day, in two instances on the fifth day, and in one on the twenty-first day: in the other cases the testicles had not appeared at the. fourth or fifth week after parturition. My own observa- tions lead me to believe, that if the passage does not take place within a twelvemonth after birth, it is rarely fully and perfectly completed afterwards, without being accompanied with rupture. For the causes which operate at this late period tend as much to promote the formation of hernia as the transition of the testicle. 1 Commentatio Soc. Reg. Scient. Goetting. 1778. 2 Hints to Young Medical Officers in the" Army' n 83 3 Ibid. p. 207. y' P' J.^i£"s had not made ,heii ■"*—» «• -•- «•***> - OF THE TESTICLE. 63 In cases where the testicle makes no appearance before puberty, uneasiness is often experienced at that period, OAving to the enlarge- ment of the gland being restrained by the rings and parts com- posing the inguinal canal. At the same time also, it is often protruded outside the external ring by the movements of the abdomen in respiration. Considerable doubt long preArailed respecting the mode and agency by which the passage of the testicle into the scrotum is effected. Several years ago I carefully investigated this subject ;x and as it is impossible to treat satisfactorily of the causes of a failure in the transition without describing the process itself, I must pre- mise a short account of the change, and of the parts concerned in effecting it. Attached to each testicle whilst in the abdomen is a peculiar body, termed by Mr. Hunter the gubernaculum, as it was supposed to serve as a guide to the testicle in its passage. It is a soft, solid, pro- jecting body, of a conical form, Avhich varies somewhat in shape and size at different periods of the transition of the testicle, becoming shorter and thicker as the gland approaches the abdominal ring. It is. situated in front of the psoas muscle, to which it is connected by a reflection of peritoneum. Its upper part is attached to the inferior extremity of the testicle, loAver end of the epididymis, and commencement of the vas deferens. The lower part of this process passes out of the abdomen at the abdominal ring, and dimi- nishing in substance and spreading terminates in three processes, each of which has a distinct attachment. The central part and bulk of the gubernaculum is composed of a soft transparent gelati- nous substance, Avhich, on examination by the microscope, is found to consist of nucleated cells, the primitive connective tissue: this central mass is surrounded by a layer of well-developed muscular fibres, which may be distinguished by the naked eye, and which can be A'ery distinctly recognized in the microscope to be composed of striped elementary fibres. These muscular fibres, Avhich may be traced the whole Avay from the ring to the testicle, are surrounded by a layer of the soft elements of the connective tissue, similar to that composing the central mass ; and, in the same way as the testicle, the Avhole process, except at its posterior part, is invested with peri- 1 Vide Observations on the Structure of the Gubernaculum, and on the Descent of the Testis in the Fa-tus, by the author, in Lond. Medical Gazette, April 10, 1S11, or in the Lancet, of the same date. 61 I ]M PERFECT TRANSITION toneum. On carefully laying open the inguinal canal and gently drawing up the gubernaculum, the muscular fibres may be traced to the three processes, Avhich are attached as folloAvs: the external and broadest is connected to Poupart's ligament in the inguinal canal; the middle forms a lengthened band Avhich escapes at the external abdominal ring, and passes to the bottom of the scrotum, where it joins the dartos; the internal takes the direction inwards, and has a firm attachment to the os pubis and sheath of the rectus muscle. Besides these, a number of muscular fibres are reflected from the internal oblique on the front of the gubernaculum. It thus appears, that the attachments of the muscle of the guberna- culum, and those of the cremaster in the adult, are exactly similar. I have succeeded in tracing out the former before the testicle has moved from its original position, at different stages of the process of transition, and immediately after its completion; and of the identity of the two muscles I entertain no doubt. Between the fifth and sixth month of foetal existence, some- times later, the testicle begins to move from its situation near the kidney towards the ring, which it usually reaches about the seventh month. During the eighth month it generally traverses the inguinal canal, and by the end of the ninth arrives at the bottom of the scrotum, in which situation it is commonly found at birth. The testicle, both during its passage to the ring and through the inguinal canal, carries along with it its original peritoneal coat, adhering by the reflection of this membrane, during the whole of its course to the parts behind in the same manner as whilst situated below the kidney. The testicle therefore does not pass directly and abruptly into a pouch prepared to receive it, but carries the perito- neum with it, continuing to be connected to the parts behind by the reflection of the membrane, between the folds of which the vessels and nerves join the gland. In the passage of the testicle from the abdomen to the bottom of the scrotum, the gubernaculum, including its peri- toneal investment and muscular fibres, undergoes the same change as that which takes place in certain of the rodentia at the access of the season of sexual excitement; the muscle of the testicle is gra- dually everted, until, when the transition is completed, it forms a mus- cular envelope external to the process of peritoneum, which surrounds the gland andfront of the cord. As the testicle approaches the bottom of the scrotum, the gubernaculum diminishes in size, owing to a change OF THE TESTICLE. 65 in the disposition of its areolar elements; the muscular fibres, how- ever, undergo little or no diminution, and are very distinct around the tunica vaginalis in the recently transposed testicle. The mass com- posing the central part of the gubernaculum, which is 'so soft, lax, and yielding, as in every way to facilitate these changes, be- comes gradually diffused, and after the arrival of the testicle in the scrotum, contributes to form the loose connective tissue which after- wards exists so abundantly in this part; the middle attachment of the gubernaculum, which may be traced to the dartos, at the bottom of the scrotum, gradually wastes away and soon becomes indistinct, though slight traces of this pro- cess often remain to the latest period of life. Thus, after death, in dragging the testicle of an adult out of the scrotum by pulling the cord, the lower part of the gland, which is uncovered by serous membrane, is often found connected to the bottom of the scrotum by a band of firm and dense connective tissue, which requires di- vision with the scalpel. This band is the remains of the middle at- tachment of the gubernaculum. In cases in which the testicle has been retained in the groin, I have traced a cord of dense tissue from the gland to the lower part of the scrotum. After the arrival of the testicle in the scrotum, the peritoneum with which it is closely invested, its original envelope, becomes the inner layer of the tunica vaginalis; whilst the pouch around, winch is continuous with it, forms the outer layer, or vaginal sac' Immediately after the ar- rival of the testicle in the scrotum, this bag communicates with the abdomen, and in quadrupeds continues to do so during life; but in the human subject it soon begins to close, and when the foetus is ushered into the world, the abdominal orifice is often shut, and the Avhole canal from the ring to the upper part of the gland is, in general, completely obliterated in the course of the first month after birth. The obliteration is effected by an intimate union of the sur- 5 Diagram of the gubernaculum and testicle previous to its descent. 1, the kidney; 2, the testicle; 3, 3, the peritoneum; 4, vas deferens passing down into the pelvis by the side of the bladder; 5, the bladder; 6, the abdominal ring; 7, 7. Pouparl's ligament; 8, pubic portion of the cremaster; 9, fibresof the cremaster arising from Poupart's ligament; 10, portion of the gubernaculum attached to the bottom of the scrotum. 66 IMPERFECT TRANSITION faces of the serous membrane. It sometimes does not take place at all,1 or is delayed or only partially completed. Congenital hernia, or hydrocele, is the result of a failure in this process; and other forms of hydrocele are occasioned by imperfect obliteration of the canal. Much difference of opinion exists as to the immediate cause of the transition of the testicle. Hunter, Meckel, and others came to the conclusion that the muscular fibres of the cre- master are insufficient to bring the testicle fur- ther than the abdominal ring and to complete the passage. They Avere not, hoAvever, ac- quainted with the attachment of this muscle to the pubis external to the ring, or it would be difficult to understand why Mr. Hunter, after arriving at the conviction that the cre- Diagram of the testicle imme- master passes to the testicle whilst in the ab- ilialely afler its arrival in the , , . a „ scrotum, the cremaster being donien, chiefly trom analogy, was not induced everted- by the same process of reasoning to conclude, 1, the testicle; 2, the shorten- ,-i , -i i_i /» i • ed gubernaculum; 3,3, the pe- that a muscle capable ot changing the posi- ritoneum; 4, portion of the ere- tion of the testicle in animals, would be ade- master arising from Poupart's . ligament; 5, pubic portion of quate to accomplish the same office in the human foetus. The necessity for some active agent to effect this change in the latter would appear to be greater even than in the lower animals, since, in the usual position of the foetus in utero, the passage of the testicle is contrary to gravitation,2 and unaided by the movements of respiration. Now, when we con- sider the attachments and connections of this muscle in the foetus; the perfect development of its fibres, as ascertained by microsco- pical examination ; and the circumstance that there are apparently, no other means, no other motive powers, by which this change can be effected, or in any way promoted, I think there is sufficient reason for concluding that the cremaster executes the same office in the human embryo, as that which it undoubtedly performs in certain brute animals at a particular season. The fibres proceeding from Poupart's ligament, and the obliquus interims, tend to guide the cordIterpn7niCann C°nStant,y rCmainS °Pen in lumped* *e chimpanzee, ac- forms a 1^"°' °Wm> **"* ^ ^ brUte ™™* - which the tunica vaginalis have^avoiH500 I ^ ****** '""" *' "SUal CUSt0m of *°*™ anatomists, »d have avoided describing the change in the portion of the testicle as the descent. OF THE TESTICLE. 67 gland into the inguinal canal; those attached to the os pubis to draAV it outside the abdominal ring ; and the process extending to the bottom of the scrotum, to direct it to its final destination. As the process approaches completion, the muscular fibres which perform so important a part in it gradually become everted, and acquire the new functions of elevating, supporting, and compressing the gland. Now, Avhen we reflect on the nature of the process just described, it is clear, that there must not only be a perfect adaptation of parts a due relation betAveen the body displaced and the structures which it traverses, but also corresponding power in the agent by which it is accomplished. There are few muscles in the human body whose development in different individuals varies in a greater degree than that of the cremaster. And if such be the case after birth, it is not unreasonable to presume that similar differences exist in the foetus before the gland changes its position, and that a failure in the pro- cess may be the result of deficient power in the musculus testis to accomplish the passage. It is not improbable that this muscle is sometimes paralyzed, and that the faulty transition is owing to a want of a due supply of the nervous energy, which we know is often denied to other muscles during foetal existence, and is the cause of deformities in the feet and other parts, with which infants are often ushered into the Avorld. I think, indeed, Ave may fairly enumerate paralysis and defective development of the cremaster, amongst the presumed causes of the imperfect transition of the testicle. Peri- tonitis occasionally attacks the foetus in utero,1 and produces adhe- sions betAveen the various abdominal Ariscera. It is well known that in congenital hernia the testicle is frequently united to a portion of intestine or omentum, and that the formation of these adhesions pre- vious to the transition of the testicle is sometimes the cause of the displacement, the viscera being drawn, together with the gland, into the scrotum. Many facts seem to show that similar adhesions are, on the other hand, an occasional cause of the temporary and perma- nent retention of the testicle, the cremaster being insufficient to over- come this obstacle to its passage. In the body of an old man, M. J. Cloquet found the left side of the scrotum empty, and the testicle situated at the distance of an inch from the superior opening of the inguinal canal: the head of the epididymis was connected to the 1 Vide Contributions to Intra-uterine Pathology, by Dr. Simpson, Edinb. Med. and Surg. Journal, Nos. oxxxvii, and cxl. 68 IMPERFECT TRANSITION sigmoid flexure of the colon, by a strong white fibrous band.1 Wris- berg, on examining an infant which had only the right testicle in the scrotum, and died a feAv days after birth, found the opposite gland close to the ring and connected to the omentum by means of three slender filaments.2 Dr. Simpson, in the dissection of an anencephalic foetus, found marks of extensive peritonitis and the right testicle imbedded in a quantity of coagulable lymph, which strongly attached it to the peritoneal surface of the iliac fossa.3 Jobert once found in the foetus, the coecum adherent to the testicle, which Avas on the point of passing the ring.4 In the examination of a man, aged sixty, I found the right testicle just external to the abdominal ring; it was small in size, and closely adherent to a por- tion of omentum. A young man was under my care for many months, on account of an imperfect transition of .the testicle on the left side. The gland moved backwards and forwards through the external abdominal ring. By pressure above, it could be forced down sufficiently to admit of being examined. This testicle was much smaller than the right, which was in the scrotum, and I could distinctly make out a portion of intestine "closely adherent, Avhich accompanied the organ in all its movements. It is probable that the smallness of the opening in the external abdominal ring is sometimes a cause of the detention of the testicle, especially in those cases in which the organ is retained within the inguinal canal. This opinion is supported by the fact, that the testicle is oftener found in the groin than in the cavity of the abdomen. M. Delasiauve mentions a case, in Avhich, he states, the organ was retained by the border of the outer column of the ring.5 In cases also of retained testicle, the epididymis is sometimes found partially disengaged from the gland, elongated and extending through the ring into the upper part of the scrotum. I am indebted to Mr. Cock, of St. Thomas's Hospital, for the opportunity of dis- secting the parts in a case of congenital inguinal hernia, where this Avas the case. The lower part of the epididymis and convolutions of the vas deferens were so surrounded with fat and connective tissue as to form a rounded swelling covered with the tunica vaginalis, | Recherches sur les Causes et 1'Anatomie des Hernies Abdominales, p 24 Lib. C1t P. 229. 3 Edinb. Med and gurg ^^ ; Traite des Maladies Chirugicales du Canal Intestinal, t ii r W 3 Revue Me"dicale. Mars, 1840, p. 3G3. ' OF THE TESTICLE. 69 which closely resembled a testicle, for which, indeed, it Avas mis- taken in the operation for hernia. The gland was situated just within the internal ring. Cloquet, Follin,1 and others, have re- corded similar observations of displacement of the epididymis. The cremaster being attached to its tail, it is easy to understand how this part may be dragged away from the testicle, and drawn into the scrotum, in cases where the proper transition of the body of the gland has been prevented by a narrow external ring. Mr. Hunter was inclined to suspect that the fault originates in the testicles themselves. It is difficult to understand how this can be, for as the gland is passive in this process, it can offer no ob- stacle, except it be too large to pass the opening in the abdominal parietes ; whereas, it is admitted that the gland when retained is usually below the natural size. Nor does it appear, that the inter- ruption is owing to any want of proper length in the vas deferens, for in a case of imperfect transition in a boy, whose body I ex- amined, I particularly noticed that this duct was so long as to be doubled on itself, and tortuous, a circumstance which has been remarked in other cases by Mr. Mayo,2 Rosenmerkel,3 and others. It may be concluded then, that the causes of a failure in the passage of the testicle are various ; that this imperfection may result from want of power, or paralysis of the cremaster muscle; from adhe- sions retaining the gland Avithin the abdomen; and from a con- tracted state of the opening of the external abdominal ring. On the condition of the undescended Testicle.—Mr. Hunter states, that Avhen one or both testicles remain through life in the belly, he belieAres that they are exceedingly imperfe*ct, and probably incapable of performing their natural functions ; and that this im- perfection prevents the disposition for descent taking place. That they are more defective even than those which are late in passing to the scrotum, he infers from the circumstance, that in quadrupeds, the testicle that has reached the scrotum is considerably larger than the one which remains in the abdomen.4 Mr. Hunter had seen 1 Archives Ge"ne"rales de M^decine, t. xxvi, 4e se"rie, p. 270. 2 Human Physiology, 3d edit. p. 411. • 3 Ueber die Radicalcur des in der Weiche liegenden Testikels. 4 Professor Goubaux has given some interesting details of the structure of testicles retained in the belly of the horse (Recueil de Med. Veteiinaire Pratique, t. xxiv, p. 131). Besides alterations in the volume and appearance of the testicle, which was as soft as that of the foetus, M. Goubaux remarked that the sperm found in the vesicula 70 IMPERFECT TRANSITION only one case in the human subject where both testicles continued • in the abdomen, but this proved an exception to the above observa- tion, since we are led to conclude that they Avere perfectly formed, as the person had all the powers and passions of a man.1 Professor Owen, in commenting upon these obsenrations, states, " It seems remarkable that with this experience Mr. Hunter should have formed from inconclusive analogy, and promulgated, an opinion tending to occasion so much unhappiness as that which attributes exceeding imperfection and probable incapacity of performing their natural functions to testes which in the human subject are retained within the abdomen. That there is nothing in such a situation which necessarily tends to impair their efficiency is evident, from the number of animals in Avhich they constantly form part of the abdominal viscera; and in those in Avhich the testes naturally pass into a scrotum, their continuance in the abdomen, according to our author's own observation, is accompanied only Avith a difference of size or shape; now Ave may readily suppose that this may influence the quantity, but not necessarily the quality, of the secretion." There are comparatively few accounts on record of the dissection of detained testicles. In a case, in which M. Cloquet found the left testicle situated within the abdomen, the gland was well formed, and of the same size as the right, which had passed into the scrotum. The parts taken from an apprentice of Sir A. Cooper, who unfor- tunately committed suicide in consequence of the infirmity, are preserved in the Museum of Guy's Hospital. I have examined the preparation ; and the testicles, which are both within the abdomen, close to the internal ring, appear to be nearly, if not quite, the natural size, and it is stated that the ducts contained semen. In a lad, aged nineteen, whose left testicle was found, by Dr. Bright, within the abdomen, near the brim of the pelvis, the gland was considerably smaller than natural, but the ducts and secreting structure were quite perfect.2 It would be more satisfactory if we had some account of the condition, as ascertained by microscopical examination, of the secretion found in these retained testicles. These facts, however, do not bear out the vieAvs of Mr. Hunter, for it appears-that the organs were sound in structure, and, we may wmin.li.-of the side where the testicle was in the abdomen, did not contain sper- matozoa. (Quoted by Dr. Follin.) wmrain sper 1 Works by Palmer, vol. iv, p 18 2 tj™^-. , r, , vui. iv, p. io. Hospital Reports, vol. ii, p. 258. OF THE TESTICLE. 71 suppose, Avcre capable of performing their proper functions. Be- sides, Mr. Hunter himself has adduced one instance of a person, who had full sexual powers, • though his testicles remained in the abdomen. Mr. Poland has recorded the case of a man, aged twenty-nine, who was so formed, and had all the signs of virility. He married twice and had two children.1 Mr. Cock, of Guy's Hospital, has communicated to me the case of a man, about thirty years of age, both of whose testicles were retained in the abdomen. He had a sensual expression of countenance and strong sexual pro- pensities ; he had been tAvice married and had children by both Avives ; he held a situation at a public house, where he intrigued with the landlady and debauched the barmaid. A youth Avas under my care many years ago, on account of retained testicle and rupture on both sides, for which I directed the application of a double truss. He has since grown to manhood, and now exhibits the characters of masculine development. Still it must be remarked that in some of the cases noted, the retained testicle was small in size, and in other instances they have also been found defective in structure. [As an interesting illustrative American case, the following, com- municated to me some time since by Dr. Washington L. Atlee, of Philadelphia, is introduced.—W. II. G. March 7th, 1835, I was consulted by Mr. E. S., aged about twenty-five years, a strong, muscular man, and hard-working farmer. He had congenital double scrotal hernias. On making a careful examination, I discovered on the right side, attached to the lower portion of the hernial tumor, a small body, about the size of a large pea, which I considered to be a rudi- mentary testicle, and which, on returning the intestine into the abdominal cavity, invariably returned with it. On the left side no evidence of a testicle existed, and I inferred that it had never descended, but remained imprisoned within the cavity of the abdo- men. Both hernise were readily reducible; the inguinal orifices were large and the canals were obliterated by an approximation of the internal and external abdominal rings, so that they assumed the characteristics of that form of hernia, known as Direct Ingui- nal. The penis was largely developed, the venereal appetite was active, and the erectile and virile powers were good. > Guy's Hospital Reports, Second Series, vol. i, pp. 162, 1C3. IMPERFECT TRANSITION On seizing the small pea-like body with my fingers, I found that I could replace the intestine within the external abdominal ring, and, at the same time, maintain the small body outside of it. I at once determined to treat the case with this object in view. Accord- ingly I applied a double truss, so as to retain, on the right side, the intestine within and the supposed testicle without the cavity of the abdomen. On the left side, the truss was applied without reference to the testicle, it never having descended. The liberated organ soon began to enlarge, and, in the course of a year or tAvo, it assumed the size, shape, and character of a fully developed testicle. Both hernias were perfectly cured, the use of the truss was aban- doned, the patient married, and the last time I heard of him his wife had presented him two healthy children.] In examining the body of a robust man, aged thirty-six, I found the right testicle within the abdomen, about an inch and a half from the internal ring. The organ was very small, and weighed only 110 grains; it was healthy in structure, but resembled the undeve- loped testicle before puberty. There were no spermatozoa in the efferent ducts, nor in the right vesicula seminalis; the left testicle was unusually large, and in its proper place; the left vesicula semi- nalis contained spermatozoa, but was smaller than the right.—J. W., a lad, aged sixteen, died in the London Hospital, in a state of universal anasarca. There was no appearance of beard, and only a few hairs were scattered over the pubes. My attention was par- ticularly directed to the state of the genital organs, by observing that the scrotum, which was greatly distended with serous effusion, was not fully developed on the right side. I found the right tes- ticle within the abdomen, about an inch and a half above the in- ternal ring. It was very small, not larger than that of a child two years of age; and on cutting into it, the gland presented the gra- nular appearance usually remarked at that early period. M. Broca, in the dissection of a subject, about thirty years of age, found the left testicle in the iliac fossa a little above the internal ring. It was small and flattened, resembling a haricot bean. The spermatic artery Avas as fine as a thread.1 Absence of sexual passion has also been noticed. Mr. Wilson mentions the case of a young man, twenty-five years of age, whose testicles never descended. He had 1 Archiv. Gener. de Med. 4e serie, t. xxvi, p. 265. OF THE TESTICLE. 73 some beard, and not an unmanly appearance; but although an im- prudent, and in some things a dissipated person, he had never shown the least desire for women, or disposition for sexual inter- course.1 Analogy would lead us to expect that the defectiAre deve- lopment of the gland Avould be attended with an imperfect guber- naculum ; hence the detention of the gland probably results from the musculus testis being incapable of withdraAving it from the abdomen. We must riot infer that the testicle is defective in con- sequence of its detention in the abdomen, but we have grounds for presuming that an original imperfection is the primary cause of its remaining in that situation. The knoAvledge that such an imper- fection sometimes exists, however rarely, must always induce us to regard the infirmity, when existing on both sides, Avith anxiety, which, whilst the patient is young, we have no means of removing. At the adult period, the external characters of the body distinguish- ing the sex, and the habits, disposition, and desires of the indivi- dual, will enable the surgeon to arrive at a correct conclusion as to the efficiency of the retained organs, and to decide on the propriety of marriage. M. Cloquet gives an account of a testicle found in the left in- guinal canal, of a subject forty years of age. It was flattened, elongated, and in a state of atrophy, and so small that it could not be felt externally. The epididymis was situated an inch below the testicle, with which it communicated by fine Avhite transparent ves- sels, running parallel to each other, and formed by the seminiferous tubes, unravelled and drawn out. The vas deferens came off from the lower part of the epididymis, and entered the inguinal .canal, where it passed by the side of, and internal to, the testicle. The testicle was situated in a hernial sac, which likewise contained omentum.2 Dr. Follin carefully examined a testicle retained in the inguinal canal of an old man. Its form Avas normal, but its thin tunica albuginea contained only a mass of yellow fatty matter and connective tissue. At only one point Avere there any seminal tubes.3 On inspecting the body of a man who died of phthisis and aneu- 1 Lectures on the Urinary and Genital Organs, p. 408. 2 Lib. cit. p. 23, pi. vii, figs. 2 and 3. 3 Arclnv. G6ner. de Med. 4e serie, t. xxvi, p. 2G3. In three instances M. Follin examined the sperm contained in the vesicula seminalis corresponding to the testicle retained in the ring, and found a complete absence of spermatozoa. They were pre- sent in the other side. In a fourth case, the spermatozoa were wanting on both sides. 74 IMPERFECT TRANSITION rism of the aorta, at the age of forty-two, I found the left testicle situated just outside the external ring. It was but little more than half the usual size, and surrounded by a tunica Araginalis, adherent in several places. There was no trace Avhatever of tubuli semini- feri, their place being supplied by a white but rather loose fibrous tissue. The epididymis was reduced to a few fibrous bands, and the vas deferens Avas small in size: on the injection of the duct Avith quicksilver, the metal passed no further than the commence- ment rf the epididymis. The other testicle, which was situated in the scrotum, Avas of less than the average size, but the structure of the gland was normal, and the tubuli, were distinctly seen. In the case of an old man already referred to, and in another case of a middle-aged man, Avho also died of phthisis, in each of which one testicle Avas situated just outside the external abdominal ring, the organ Avas found atrophied. Paletta examined the body of a man aged about fifty, Avho was supposed to be a monorchis. The sper- matic vessels on the left side, as they approached the pelvis, gra- dually disappeared, a white transparent process alone remaining, Avhich extended beyond the ring. The vas deferens, Avhich was hollow near the ring, degenerated into a solid compact filament, which united to the remains of the spermatic vessels, and termi- nated outside the ring in dense cellular tissue near the os pubis, and connected to Fallopius's ligament. This cellular tissue sus- tained a series of threads of a light yellow color, but not contained in any proper membrane, which might be considered as the remains of the testicle, although the seminal vessels and vas deferens could not be. distinctly traced to it.1 As far as may be judged from these dissections, the testicle is more frequently found imperfect and atrophied when arrested in the inguinal canal than when confined within the abdomen. That such should be the case is not surprising. It has been seen that there is nothing in the situation of the testicle in the abdomen cal- culated to impair its efficiency, and that its detention there may be owing to causes independent of its state of development. No un- easiness or inconvenience is experienced, nor are the generative functions interfered with under these circumstances. When, Iioav- ever, the passage of the testicle is interrupted in the inguinal canal, the case is very different. The organ is then liable to be com^ 1 Nova Gubernaculi Testis, &c. p. H2. OF THE TESTICLE. pressed during any violent action of the abdominal muscles, and even in acute flexion of the thigh, as in Avalking up stairs, and on bending the body fonvards whilst in the sitting posture. It is exposed to injury from Woavs which, being fixed, it is unable to elude, and to pressure from the frequent manipulation of the sur- geon, and the ruder handling of bandage-makers, and often through ignorance, from the application of a truss. It occasionally happens that a testicle, after retention in the abdomen, Avithout any uneasi- ness having been experienced, passes into the inguinal canal, and sometimes appears at the external ring, playing backwards and for- wards from one situation to another. When this is the case, the gland is liable to compression from a sudden contraction or spasm of the abdominal muscles, which gives rise to violent pain and suf- fering, and a sickening sensation which lasts for some hours unless relieved by the hot bath, fomentations, and opiates. Richter relates the folloAving case :—"I remember a young man, twenty years of age, who had a small hernia, and no testicle on the left side of the scrotum. The testicle was contained in the abdo- men, and sometimes presented at the ring, causing violent pain and symptoms of strangulation, which rendered it necessary to push the gland back again. This object, however, could seldom be accom- plished until more than twenty-four hours had elapsed, and emol- lient cataplasms had been employed. The symptoms immediately ceased Avhen the return of the testicle Avas effected."1 I shall pre- sently mention two cases in Avhich occasional compression of a tes- ticle in the groin produced so much suffering as to lead the surgeon to excise the gland in order to afford the patient relief. We perceive, then, that Avhen a testicle is retained in the groin, there are various circumstances Avhich tend to interfere with its evolution at puberty, to impede its nutrition and to excite inflam- mation and disease in it, and I have shown from dissections that such results are not unfrequent. A testicle, therefore, situated in the abdomen is in a more satisfactory position, and is much less exposed to injury and disease, than one which has been arrested in the groin. On this account, and as the passage is seldom perfectly accomplished when delayed beyond the age of one year, if the gland has not made its appearance at this period, the well-being of the patient will be best consulted by the employment of some me- 1 Quoted in Lawrence on Hernia, 5th edit. p. 571. 76 IMPERFECT TRANSITION chanical means to prevent the escape of the organ from the abdo- men. A strong reason for adopting this practice is afforded by the great liability to rupture which exists in all cases of the tardy tran- sition of the organ, owing to the persistence of a sac ready pre- pared for the reception of a protrusion, and in many instances to adhesions between the testicle and intestine or omentum. A hernia may occur whilst the testicle is still in the abdomen, or after it has passed the ring, and the viscera may descend into the scrotum, the gland being detained in the groin. Cases of this kind are embar- rassing, as it is impossible to fulfil the two opposite indications of preventing the protrusion of the viscera, and encouraging the de- scent of the testicle. Many years ago I had under my care a fine child, neither of Avhose testicles had made their appearance out of the abdomen. When I first saw him, he was about a year old, and had an inguinal rupture on both sides, which descended whenever he cried or struggled. In accordance with the usual practice, I objected to the application of any truss. The parents became anxious and impatient at the annoyance arising from the hernia, and consulted a high authority, who gave similar advice to that re- ceived from me. The rupture was consequently left to itself, and the boy restrained from exercise. He was petted, became fretful, and proved a constant cause of uneasiness to the parents. When I last examined him he was eight years of age, and fortunately the rupture on the right side had disappeared spontaneously, and the one on the left protruded very slightly, but there was no appearance of the testicles. Now, if it be granted that a testicle situated in the abdomen is in a better position than one placed in the groin; that it is productive of less inconvenience, and exposed to fewer causes tending to impair its structure; that its subsequent passage, if it ever takes place, is frequently, if not commonly, attended with rup- ture, it must, I imagine, likewise be admitted, that the advice often given in these cases is unsound and injudicious. In recent years I have invariably advised the application of a truss so as to prevent the descent of the testicle as Avell as the escape of intestine, which I am sure has contributed much more to the health and comfort of the patient, than leaving him exposed to the inconveniences and dangers of an unrestrained rupture. In certain cases where the testicle has passed out of the external ring, but without descending fully into the scrotum, complicated OF THE TESTICLE. i i with hernia, a truss with a small pad carefully applied may serve to keep up the rupture, and at the same time prevent the testicle from slipping back into the inguinal canal. When this can be done effectually without risk of the pad pressing on the testicle, it is the practice which should be adopted. But if the testicle is constantly gliding in the way of the pad so as to be exposed to pressure, or if adhesion exists between a portion of intestine and the gland, this treatment is inapplicable, and a truss should be applied to keep the parts if possible Avithin the abdominal cavity.—A middle-aged gen- tleman consulted me on account of a large scrotal rupture on the right side. A great part, which consisted of bowel, could be re- turned Avithout difficulty, but a mass remained irreducible unless in company with the testicle, and this was clearly made out to be a large portion of omentum adherent to the gland. On forcing up all the parts, I found it impossible to apply a truss without making pressure on the testicle, and more than ordinary pressure was needed to prevent the protrusion of so great a mass. So much inconveni- ence and risk attended leaving the rupture unrestrained, that I was compelled to apply a truss without returning the omentum, Avhich was necessarily exposed to pretty strong compression from the truss- pad. The pressure led to his suffering occasionally from a drag- ging pain referred chiefly to the left side, particularly when he was affected with flatulency or distended bowels. The pain was re- lieved by easing the truss and rest in the recumbent posture. This gentleman had a varicocele on the left side, and wore a double moc-main lever truss, by which he was enabled readily to mode- rate the pressure. It must not be inferred from the preceding observations that the arrival of the testicle in the scrotum is a matter of slight moment; for in most cases of imperfect transition, the gland, whether arrested in the abdomen or groin, is small in size, and it cannot be doubted that the natural situation is the one best adapted for the efficient performance of its functions. Besides, the mind is very readily disturbed by any appearance of imperfection in the organs of generation, and the circumstance of the testicles not having descended is very liable to excite suspicion of impotency. I have already alluded to an instance in which the unfortunate subject of this infirmity, a medical student, committed suicide under such an impression; still, after the age of one year, when there is 78 IMPERFECT TRANSITION scarcely a hope of the passage into the scrotum being fully and com- pletely accomplished, and when the patient is exposed to the in- conveniences of a hernia, it is far better to take measures to pre- vent or remedy these serious and certain evils, than to leave him exposed to them in the expectation of an event which experience proves very rarely occurs, and which if incomplete really places the patient in a worse position than he was in before. The pain- ful feelings resulting from the imperfection may be controlled here- after by reason and judicious counsel. The surgeon may confi- dently assure his patient that the detention of the testicles in the abdomen is perfectly compatible with his virility, and in cases Avhere there are no external marks of effeminacy or other grounds for suspecting impotency, and the patient is subject to erections, the imperfection need not be regarded as offering any bar to mar- riage. The detention of the testicle in the groin or abdomen must indeed be regarded under any circumstances as an unfortunate infirmity, but particularly Avhen the gland is attacked Avith disease. One great disadvantage of such an imperfection, which especially attaches to the detention of the testicle in the abdomen, arises from the relation preserved with the peritoneal cavity by which morbid actions originating in the testicle are liable to extend to the parts in the abdomen; and we cannot but view the passage of this gland into the scrotum, and the isolation of its serous investment, as a wise provision, obviating the serious risks to which man would other- wise be liable, owing to the frequency of the diseases of this organ. It will be shown in subsequent chapters that secondary orchitis, or inflammation, commencing in the epididymis, is peculiarly liable to extend to the tunica vaginalis, and that in all diseases of the organ this membrane is very commonly implicated. Noav when the tes- ticle is situated in the abdomen, or in the groin, and surrounded by a prolongation of peritoneum, there is no shut sac, no distinct tunica vaginalis, restricting the limits of inflammation when set up, but the disease is liable to affect the contiguous viscera and to extend throughout the abdominal cavity. Such appears to have happened in the following cases:—A lad, ten years of age, was brought to the London Hospital from a distance in the country, dangerously ill. His mother stated that on returning from school four days before, he was kicked in the right groin by one of his schoolfel- OF THE TESTICLE. 79 lows. He suffered great pain at the time, and on the following day became very ill. Having continued to get worse, he was brought to the hospital. The boy was evidently dangerously ill from acute peritonitis. He was almost in a state of collapse; his countenance was anxious ; his pulse quick, small, and feeble; his abdomen hot, tumid, and extremely tender; and his bowels constipated, but they had been opened since the accident. There was a considerable diffused swelling in the right groin, and the right side of the scrotum was empty. He died in twelve hours after his admission. On examination of the body, marks of ex- tensive peritonitis were found throughout the whole of the abdo- minal cavity, the viscera being coated with lymph, and a turbid serum abundantly effused. In the right iliac fossa, just beneath the peritoneum, were seen two small abscesses of recent forma- tion. An atrophied testicle was discovered close to the external ring, amongst a mass of connective tissue, infiltrated with pus and lymph. There were indistinct traces of a tunica vaginalis continu- ous Avith the peritoneum. I apprehend that, in this case, the blow occasioned inflammation in the testicle and surrounding parts, which, extending to the peritoneum, caused the lad's death. I Avas sum- moned one evening to the hospital to see a supposed case of stran- gulated hernia. On my arrival I found the patient, a stout laborer, aged thirty-three, and a married man, with a considerable swell- ing in the right groin, which Avas of an oval form, receiAred a slight impulse on coughing, and was more solid and tender than is usually the case with a rupture. The house pupils had made unsuccessful attempts to reduce the swelling, which gave the man much pain. He stated that he was subject to a swelling in the groin, Avhich occa- sionally came down in the daytime and disappeared at night, but he had never worn a truss. It descended the evening before, and caused considerable pain; and although it went away during the night, the abdomen had continued painful during the day. Whilst straining himself at work in the evening it again made its appear- ance ; and as it occasioned considerable pain, he came to the hos- pital for relief. The abdomen was tender on pressure, and he com- plained of pain in it chiefly in the vicinity of the umbilicus. He did not feel sick, and his bowels had been open twice during the day. The pulse was full and hard. There was no testicle on the rio-ht side of the scrotum, but the left was in its natural situation, and of proper size. I concluded that the tumor consisted of a re- 80 IMPERFECT TRANSITION tained testicle which had been accidentally protruded at the external abdominal ring, and become inflamed from pressure, and -that the inflammation had extended to the peritoneum, the latter membrane being, however, only slightly affected. I could not quite satisfy myself whether a portion of intestine had accompanied the testicle, though this appeared very probable. I ordered the man to be bled, fourteen leeches to be applied over the SAvelling, and a brisk ca- thartic to be given him. He continued in suffering during the early part of the night, but having dropped asleep, he found on awak- ing that the swelling had disappeared. The bowels were relieved in the course of the morning, but the groin and abdomen continued tender for two or three days. There was still a tendency to repro- trusion of the testicle and intestine when the man coughed. A truss therefore was applied as soon as the pressure of it could be borne, Avhich was six days after his admission, Avhen he was dis- charged. I have noticed the pain and inflammation liable to arise from the compression to which a testicle is subject when seated in the groin, especially after the development of puberty. The suffering has proved so great in some instances that the patient has been glad to seek relief from an operation. Rosenmerkel relates the case of a man, aged twenty-six, one of whose testicles first made its ap- pearance in the groin at the age of sixteen; it disappeared, and did not trouble him when at rest, but he suffered so much pain from it on taking exercise that he was obliged to forego all active exer- tion. He was admitted into the hospital at Munich on account of a chronic affection of the throat, and on his recovery Professor Koch proposed to him to undergo an operation for the relief of the testicle, to which he readily assented. The skin over the testicle having been pinched up into a transverse fold, an inci- sion was made from the gland in the groin to the bottom of the scrotum. The parts beneath were next carefully divided upon a director, until a slight fluctuation was detected; a small opening was made in the tunica vaginalis, and about an ounce of serum discharged. The testicle was found of considerable size but soft. On drawing the gland from its position in the inguinal canal, the cord was found convoluted and varicose. The testicle was then placed in a cavity in the scrotum prepared to receive it, and se- cured there by a suture attached to the septum, to prevent the OF THE TESTICLE. 81 gland being drawn up by the action of the cremaster muscle. The wound Avas aftenvards closed with sutures. The testicle showed a dis- position to return to its former position, and the cure proved tedious.1 It does not appear that the operation quite answered, nor was this at all likely to be the case. In retention of the testicle, though the vas deferens is commonly tortuous and capable of elongation, the vessels and nerves of the spermatic cord scarcely admit of a like extension. Besides, in these cases the scrotum is undeveloped, so that there is really no tegumental pouch proper to receive the gland. The operation is not one I should be disposed to practise. Mr. Hamilton, of Dublin, has related an interesting case, in which the distressing symptoms produced by retention of the testicle led him to excise the gland.2—Mr. W., aged forty-five, had a retained testicle in the right groin. About seven weeks since, Avhilst lifting a heavy weight, he felt something in the swelling crack, attended with acute pain. This Avas folloAved by active inflammation of the gland, Avhich appeared to arise from the testicle having been sub- jected to severe compression under the tendon of the external oblique muscle. The inflammation subsided under antiphlogistic treatment, but a fortnight had scarcely elapsed when the testicle became again inflamed, and in the short interval of seven weeks he had altogether four attacks of orchitis from the organ being suddenly gripped. Under these distressing circumstances, the removal of the testicle was proposed, and readily consented to by the patient. The gland Avas lodged in a sac Avhich did not communicate with the peri- toneum. Recovery took place in three weeks. The testicle was small in size, and its body was healthy in structure. The commence- ment of the vas deferens and vasa efferentia were blocked up with yelloAV deposit. It appears that Sir Philip Crampton, who was con- sulted in this case, suggested the operation of cutting down to the external abdominal ring, slitting it up, and that portion of the ten- dinous expansion of the external oblique muscle which forms the anterior wall of the inguinal canal, and which covered the testicle. This proceeding was objected to by Mr. Hamilton, on the ground that it might only prove palliative, for when the wround had healed and cicatrization taken place, the hard cicatrix might be as bad as before. To this I may add the further objection, that weakening the walls of the abdomen in the groin would strongly predispose to 1 Lib. cit. 2 Dublin Quarterly Journal of 3Iedical Science, May, 1852. 6 82 IMPERFECT TRANSITION rupture.—In January, 1853, Mr. Solly kindly afforded me the opportunity of seeing a case at St. Thomas's Hospital, of detained testicle, for Avhich he considered an operation necessary. The patient was a lad, aged nineteen, and looked pale and anxious. His left testicle was situated just outside the outer ring, and there Avas a rupture in the inguinal canal, but whether in a sac distinct from the testicle or not, could not be clearly made out. He could not bear any kind of truss either to retain the testicle outside the ring, or within the abdomen, or to restrain the rupture ; and he suffered so severely at times from compression of the gland in the inguinal canal that he was unable to earn-a livelihood. The removal of the testicle was consequently proposed, and though the patient was informed that the operation could not be done without a certain amount of risk, he readily assented to its performance. The tes- ticle was rather small, but quite healthy in structure ; its sac com- municated with the abdomen. Peritonitis ensued. This yielded to treatment, but the patient's recovery proved tedious. Dia:/nosis in Cases of Imperfect Transition of the Testicle.—A testicle retained in the groin at the external abdominal ring, or immediately below it, is liable to be mistaken for a bubonocele. It often occurs that it can be pushed back partially, or completely, into the inguinal canal, but that it soon reappears when the pres- sure is removed. There is then a swelling in the groin, admitting, like a hernia, of replacement, which might at first lead to the sus- picion of rupture. The size, form, and solidity of the tumor, how- ever, which receives no impulse on coughing, the peculiar sensation produced by pressure, and the absence of the testicle from the scro- tum, are sufficient to establish the true nature of the case, and to prevent it from being mistaken for either an intestinal or omental rupture. More difficulty is experienced in making the diagnosis, when an imperfect descent of the testicle is combined, as it often is, with a congenital rupture ; and the case may be further complicated by the tunica vaginalis containing fluid, which can be passed up into the abdomen, but which returns when the pressure is removed But even in these cases, the empty state of the scrotum, and the peculiar pain excited by pressure on the gland, are usually sufficient to prevent the surgeon from committing any serious error When a testicle detained in the groin becomes inflamed, the sickness and pain in the abdomen consequent upon the orchitis, tend very much OF THE TESTICLE. 83 to complicate the diagnosis, which is liable to be rendered still more perplexing by the effusion of blood or serum in£o the scrotum, con- cealing the absence of the testicle, so that no slight skill and judg- ment are required to solve the difficulties of the case, as will appear from the following example:—Mr. Pott was sent for in a great hurry to perform the operation for bubonocele on a young man, who Avas suffering most acute pain in the groin and back. It appeared that, the day before, he struck his groin against a piece of timber, Avhich gave him such exquisite pain that he fainted away, and his groin became immediately swollen to a ATery considerable degree. An apothecary bled him and poulticed the tumor, but he passed the night without sleep, and in great agony. The next morning he stated that he had long had a rupture on that sideAvhich had never perfectly returned. He Avas again bled, and some pains Avere taken to return the rupture. As the attempts produced great increase of pain, they were desisted from, and tAvo glysters and a purge were given, but without effect. The pain Avas exquisite, the patient very sick, and the groin and scrotum were much SAVollen and very hard. The general appearance and figure of the tumor did not appear like that of a bubonocele. Instead of pointing obliquely from the ilium toAvards the pubes, it lay as it Avere across the groin ; the scrotum Avas full and large, but much harder than Mr. Pott had ever found a piece of intestine. The discoloration Avas not at all like the effect of mortification, but had all the appearance of ecchymosis. The man had not had a fair stool for three days; he had been very sick, and had vomited; his belly Avas tight, hard, and painful, and his pulse much too quick ; very little information was to be gained from examination of the tumor, for the pain was so exquisite that he could not bear the slightest touch. On inquiring further concern- ing the rupture, it was ascertained that he had worn a truss the first four years of his infancy, but that it never kept the gut totally or perfectly up : and that, as he grew bigger and ran about, he was obliged to leave it off on account of the pain it gave him ; that since, little or no alteration in the tumor had been obserAred, and that it had never given him any trouble or uneasiness, if he did not handle it, or kept the waistband of his breeches and his watch from pressing it. All this being far from satisfactory, Mr. Pott determined before attempting any operation, to try the effects of a brisk cathartic, which produced a plentiful discharge, and relieved all apprehensions 84 IMPERFECT TRANSITION of stricture. Under fomentations and poultices, &c, the tumor sub- sided, and in about^evcn or eight days the scrotum was so unloaded as to permit an accurate examination, by which it Avas ascertained that it contained no testicle. Upon mentioning this circumstance to the patient, he said that he never had one on that side. This declaration was a solution of all difficulties, and of all the appear- ances. When all the effects of the blow were removed, there ap- peared in the groin a testicle of natural size and figure, which by being much bruised had caused all the mischief.1 Delasiauve relates a case in Avhich a testicle retained at the groin, and inflamed, Avas mistaken for a strangulated hernia, and actually operated on. When the nature of the case Avas ascertained, the 'gland was extirpated.2 Dupuytren has also recorded an interesting case of hydro-sarcocele of the left testicle coupled with hernia, consequent upon a late descent of the gland. The case was mistaken for simple hernia, and the patient had worn a truss. The diagnosis was extremely difficult. The case was operated on ; and after opening the tunica vaginalis, and letting out eight or ten ounces of fluid, he extirpated the enlarged and indurated testicle. The patient did well.3 It may seem unnecessary to direct the practitioner in all doubtful cases to make a careful examination of the scrotum. Yet it is surprising how apt the absence of the testicle is to be overlooked, the defi- ciency not being ascertained until all attempts to reduce the sup- posed bubonocele have failed, and the patient himself being often unaware of anything unusual in the state of the parts. Several cases in Avhich this important point was overlooked have come to my knowledge. A testicle retained in the groin when inflamed, is liable to be mistaken for a bubo, the prominent oval swelling communicating a deceptive feeling of fluctuation and being attended with pain; the skin over it occasionally exhibiting even a slight red blush, and the tumor being seated in a region Avhere bubo constantly occurs and suppurates. It is related that Ricord, of Paris, was once very nearly deceived by a case of the kind, and even called for a knife to open the supposed abscess, but a re-examination of the tumor having led to the discovery of the absence of the testicle on that 1 Lib. cit. p. 352, case 1. 2 Revue Medicale, Mars, 1840. 3 Lecons Orales, t i, also Dupuytren's Surgical Works, Trans. Sydenham Society 1853-4, p. 347. OF THE TESTICLE. 8.5 side of the scrotum, he made further investigation, and detected the true nature of the case.1 * Passage of the Testicle into the Perineum.—"Sir. Hunter first observed that the testicle, in changing its situation, does not always preserve a proper course towards the scrotum, there being instances of its taking another direction and passing into the perineum. How this is brought about, he remarks, it is difficult to say: it may pos- sibly be occasioned by something unusual in the construction of the scrotum, or more probably, by a peculiarity in that of the perineum itself. For it is not easy to imagine hoAV the testicle could make its way to the parts about the perineum, if these were in a perfectly natural state. He met with tAvo instances of this imperfection. A surgeon gave the folloAving account of one of the cases : " The boy is about tAvelve months old; his right testicle is situated about an inch below the termination of the scrotum, and half an inch on the right side of the centre of the rapha perinei, where a kind of pouch is formed of the common integuments, without the least rugous or scrotal appearance on its surface. It is perfectly detached from the scrotum; nor can the testicle or spermatic process be at any time felt in any part of the scrotum, though I can readily make the testicle pass from its situation quite up into .the groin; but im- mediately upon removing my hand, the testicle falls down into its pouch; and I can trace the spermatic cord from the body of the testicle up to the ring, running about a fourth of an inch on the right side of the scrotum. The scrotum on each side appears per- fectly formed, and the left testicle is in situ natural i.'' Many years ago, a little boy, one of Avhose testicles had thus deviated from its proper course, was brought to the London Hos- pital. The gland Avas lodged in the perineum at the root of the scrotum. M. Ricord met with this singular anomaly in two in- stances. M. Yidal (de Cassis) observed it in two brothers: their father Avas exempt from it. The testicle abnormally placed was smaller than the other.2 Mr. Ledwich recently met with this abnormity in dissecting a subject, aged thirty-five. The scrotum Avas deficient on the right side, and the right testicle was found lying in the perineum anterior and internal to the ascending ramus and forepart of the right tuber ischii, an inch in front of the anus. 1 Provincial Medical Journal, July, 1843. 2 Traite de Pathologie externe, t. v, p. 432, 2eme edit 86 IMPERFECT TRANSITION OF THE TESTICLE. The organ was extremely mobile, and could Avith facility be forced upwards and forAvards into the scrotum, but readily relapsed into its former position. It was small and soft, but its ducts contained spermatozoa.1 This dissection throws no light on the cause of the deviation of the gland from its usual course. The irregularity is exceedingly rare, and the above cases are all with which I am ac- quainted. This peculiar conformation is attended with great inconvenience and risk of injury to the testicle, when the subject of it assumes the sitting posture, and rides on horseback. Mr. Hunter advised that the organ should be supported in a situation near the groin, by the application of a bandage that might hinder its descent into the perineum, by which the parts might be in time so consolidated as to retain it by the side of the scrotum. In one of the cases Avhich occurred to M. Ricord, the patient was affected with gonorrhoea, and the gland becoming inflamed, produced a perineal tumor, which was exquisitely painful, fluctuating, and about the size of a pigeon's egg ; the skin adhered to it. It was at first taken for an abscess, and Ricord was about to open it, when examination of the scrotum led him to the discovery that one testicle was absent.2 Passage of the Testicle through the Crural Ring.—M. Yidal relates the case of a man, one of whose testicles, instead of passing out of the abdomen at the inguinal canal, made its exit at the crural ring. The organ was mounted upon the abdomen like a crural hernia. A portion of intestine traversed the inguinal canal, form- ing a rupture on that side.3 I know of only one other instance of this anomaly, which is reported by Eckardt. In this case, the tes- ticle passed out at first through the inguinal canal, but having been returned by the patient into the abdomen, it subsequently escaped at the femoral ring.4 The following deviation was met with in the body of a healthy man in the dissecting room of the London Hospital: The right testicle was small and not developed, and was lodged in the upper and inner part of the thigh, about three inches below Poupart's ligament. It was found behind the saphena vein, just in the open- 1 Dublin Quart. Joum. of Medical Science, Feb. 1855, p. 76. 2 Provincial Medical Journal, 1843, p. 264. 3 Ibid. 1843, p. 431. 4 Loder's Journal fur die Chirurg. ii, Bd. 1, SuT. s. ] 87. INVERSION OF THE TESTICLE. 87 ing of the fascia lata, the cord, Avhich was long, encircling the vein. The right half of the scrotum was deficient. SECTION IV. Inversion of the Testicle. It sometimes happens that the position of the testicle in the scrotum is reversed, so. that the free surface presents posteriorly, and the epididymis is attached to the anterior part of the gland, instead of to the posterior. The first case that I met with was that of a man Avho had a swelling of the right testicle, which puzzled his medical attendant. On examination I found this to be the epididy- mis thickened from chronic inflammation. I was able clearly to trace the vas deferens proceeding to it along the front of the scro- tum. The body of the testicle Avas unaffected, and its posterior edge was quite smooth and regular. The disposition of the left testicle Avas normal. On visiting Paris, in 1849, I was shown by M. Ricord a case of epididymitis on the left side, in which the gland Avas thus inverted. He informed me that he had often met Avith this arrangement. I have since had several patients under my care, one of Avhose testicles was thus inverted. Three were lads in the London Hospital affected with epididymitis. Another was a gentleman Avho consulted me for chronic orchitis confined to the body of the testicle. The epididymis being unaffected, the inver- sion Avas less perceptible than in the preceding cases. I have also observed this malposition in the dissection of a left congenital inguinal hernia Avhich had been operated on Avith a fatal result. M. Maissonneuve, in a thesis published in Paris, in 1835, I believe, first called attention to this irregularity, which, he states, he had met with many times upon the dead body and upon the liA'ing; and he mentions, what I remarked myself in all the cases in which I have noticed the inversion, that it Avas confined to one side. It is of considerable importance that surgeons should bear in mind the liability of the testicle to this irregular disposition, or they may make serious mistakes in their diagnosis and treatment of the dis- eases of the gland. In hydrocele occurring to a testicle so disposed, the testicle being seated in front of the sac would be particularly exposed to injury in tapping unless its position were preA'iously 88 ARREST OF THE detected; and in treating of hematocele I shall have ( notice instances in which the malposition has led to imp sequences. CHAPTER II. ATROPHY OF THE TESTICLE. The testicles, like other organs formed for the exercise of tempo- rary functions, do not arrive at a perfect state of development until a certain period of life, after which their activity ceases, and they become gradually and imperceptibly diminished. Thus we find that in early life they are small in proportion to the size of the body as compared with their condition at puberty, and that as old age advances and the generative functions cease to be called into action, they undergo a diminution in size, their vessels grow less, the semi- niferous tubes become small and contracted, and partially oblite- rated, their place being supplied by fatty matter.1 In the loAver animals these changes are far more remarkable than in man, for as the functions of the testicle are exerted only at stated periods of the year, as the rutting or copulating season advances these organs rapidly increase in bulk, and in its decline undergo a proportionate degree of Avasting. In man, it sometimes happens that the testicles do not acquire their proper size at the usual period, their develop- ment being from some cause or other arrested; and also, after the organs have arrived at their full and perfect groAvth, that occasion- ally one or both suffer a premature decay. Under the head, then, of Atrophy of the Testicle I shall consider: 1. Arrest of Develop- ment ; and 2. Wasting. SECTION I. Arrest of the Development of the Testicle. If the congenital lesions to which the testicle is liable had not been previously treated of, the cases of absence of the organ already 1 In the testicles of old men the tubules are commonly found loaded with a dark granular substance, the result of fatty degeneration. development of the testicle. 89 described might be correctly referred to the present head, as the de- ficiency in these cases Avas no doubt the result of an arrest in the early development of the organ. But the cases that I am now about to con- sider are those in which the subsequent evolution which the testicles undergo at puberty is delayed beyond the usual period, or never takes place at all. Mr. Wilson relates a curious instance of his having been consulted by a gentleman, twenty-six years of age, on the propriety of entering the marriage state, whose penis and testicles A'ery little exceeded in size those of a boy of eight years of age. He had never felt the desire for sexual intercourse until he became acquainted with his intended Avife; since that period he had experienced repeated erections, attended Avith nocturnal emissions. He married, became the father of a family ; and these parts, Avhich at six-and-twenty years of age were so much smaller than usual, at twenty-eight had increased nearly to the usual size of those of an adult man.1 Mr. Wilson mentions this singular case, as it will admit of question whether the parts alluded to became properly formed as to size, and possessed of the poAver of secretion, in consequence of being, although so late in life, influenced by the passions excited by at- tachment to a particular female ; or whether the enlargement%and proper action of the parts beginning, occasioned such passion first to exist. He thinks the probability in favor of the former supposi- tion, in which opinion I certainly concur. Lallemand mentions hav- ing seen a man about thirty years of age, extremely fat, and with- out a beard or hair on the pubes, Avhose penis and testicles appeared to belong to a child of from seven to eight years: he had never experienced erections or venereal desires.3 A young man died in the London Hospital of disease of the heart. He was seventeen years and nine months old : the body measured five feet five inches in height, and Avas plump and well formed. There was no appear- ance of beard, or whiskers, or of hair on the pubes. The penis and testicles were very small, not larger than they are usually found in boys of three or four years of age. The testicles were about equal in size, and one of them weighed only two scruples and one grain. Both organs Avere normal in structure, appearing like the glands in early life, when the tubular structure is very indistinctly 1 Lectures on the Urinary and Genital Organs, p. 424. 2 Des Pertes Seminales Involontaires. t. ii, p. 3S0. 90 ARREST OF DEVELOPMENT OF THE TESTICLE. developed. No spermatozoa could be detected. These Avere clearly instances of arrest of development of tly3 testicles. As the testicles are chiefly excited to action by an operation of the mind, it is easy to understand that they may sometimes re- main undeveloped owing to defective organization of the brain, an absence of sexual desires being invariably remarked in these cases. Cases of wasting of the testicles after injuries of the head, and the frequent absence of the Arenereal appetite in cretins and idiots, tend to strengthen this opinion. The folloAving are marked ex- amples of defective development of the sexual organs accompanied Avith imperfection of the brain. An idiot, aged nineteen, subject to epileptic fits, died of typhus fever in the Hackney Union. The youth was of short stature, and the form of the body was not in- dicative of either sex, but the contour was rounded as in the female. There was no appearance of hair about the face or pubes. The abdomen and other parts were covered with a thick layer of fat. The penis and scrotum were remarkably small; not larger than they are usually found in a child two or three years of age. Both tes- ticles were in the scrotum, but they were of very diminutive size ; the right weighed less than a drachm, and the left not more than twenty-three grains. The right gland had descended a very little way below the abdominal ring. The glandular structure and epi- didymis of both testicles were indistinct, and the vasa deferentia also extremely small. Nothing remarkable was observed in the structure of the brain. Mr. Hovell, the surgeon of the union, also showed me another inmate of the same workhouse, a lad aged nine- teen, and of weak mind, whose penis and testicles did not exceed in size those of a boy seven or eight years of age, and who had only a few scattered hairs on the pubes. In the Museum at Fort Pitt, Chatham, are preserved two undeveloped testicles about the size of those of a child six months old, but healthy in structure, which were taken from a lunatic soldier, fifty-eight years of age. He had been in confinement for many years on account of a homi- cide, after a trial for murder, of which he was acquitted on the plea of mental imbecility supposed to be congenital. His person was diminutive, his voice effeminate, and the beard wanting. His penis was small, and there was an appearance of mammse of considerable size. He acknowledged that he had never experienced any incli- nation for sexual intercourse. WASTING OF THE TESTICLE. 91 In treating of the imperfect transition of the testicle, I have remarked that this gland, when retained in the abdomen "or inguinal canal, does not in general acquire its complete state of development, and that, though frequently capable of secreting, it is commonly small in size. I have also noticed, in cases of congenital inguinal hernia, that the testicle, even in its natural situation, was not of its proper size at the period of puberty ; so that Avhen the infirmity existed on one side only, the testicle was not more than half or two-thirds the size of the other gland. The arrest of growth in this latter case may be in some degree attributable to the com- bined effects of the pressure of the protruded intestine on the vessels of the cord, and to the obstruction to the circulation caused by the application of trusses and bandages to the groin. SECTION Hi Wasting of the Testicle. In investigating the alterations in the nutritive condition of the testicle, it is very desirable to fix, if possible, some standard by Avhich they may be estimated. The size of the gland is neither uniform nor conveniently appreciated. Its Aveight, likewise, varies so much in different persons, and in the same individual at different periods, according as it has lately exercised its functions or remained inactive, and as it is full of semen or empty, that it is scarcely possible to determine on any accurate standard of this kind. Ac- cording to Meckel, the Aveight of the testicle, including the epididy- mis, is only four drachms, and according to Sir A. Cooper about an ounce. The former estimate is certainly too Ioav, and the latter too high. I have found the mean of these tAvo estimates, viz., six drachms, to be the ordinary Aveight of the sound testicle of a healthy adult. In the most lingering cases of phthisis and in other ema- ciating diseases the organ was never found to Aveigh less than three drachms. I should consider, therefore, the testicle of an adult weighing less than three drachms as in a state of atrophy. A testicle in an advanced state of wasting, not arising from dis- ease of the gland, usually preserves its shape, but feels soft, having lost its elasticity and firmness. The tunica albuginea is thin. The 9-2 WASTING OF THE TESTICLE. texture of the gland is pale and exhi- 10- bits feAV bloodvessels, the tubuli and septa dividing the lobes are indistinct, and the former cannot be so readily drawn out into shreds as before. The epididymis does not usually waste so soon nor in the same degree as the body of the testicle. It sometimes, hoAvever, loses its characteristic ap- pearance, and I have even found it reduced to a few fibrous threads. The fluid pressed out of the wasted testicle and epididymis is entirely de- stitute of spermatic granules and sper- matozoa. In many instances adi- pose tissue is deposited behind the tunica vaginalis, and encroaches on the epididymis and posterior part of the testicle. Fatty matter is also found in the glandular substance. Fig. 10 represents the left testicle of its exact size taken from a man aged forty-six, Avho died of dropsy consequent on disease of the kidneys. The gland was wasted to one-fifth its natural size. In addition to the presence of adipose tissue beneath the visceral por- tion of the tunica vaginalis, I recognized a quantity of yellow matter irregularly disposed amongst the Avasted tubuli. This matter on examination proved to be fat-globules, and readily dissolved on the application of ether. I have already (p. 73) quoted a case in which one of the testicles detained in the inguinal canal of an old man was composed almost entirely of fat. The structures compos- ing the spermatic cord undergo a corresponding diminution; the cremaster muscle disappears, the nerves shrink, and the vessels are reduced in size and number. The vas deferens, though small, can generally be injected Avith mercury as far as the commencement of the epididymis, and sometimes the metal reaches the vasa efferentia. A testicle, atrophied from disease, is not only of diminished size and weight, but is often altered in shape, being uneven and irregu- lar, and sometimes of an elongated form. The surfaces of the tunica vaginalis are adherent, and its cavity is partly or entirely 1. Epididymis. 2. Body of testicle. 3. Fatty deposit. WASTING OF THE TESTICLE. 93 obliterated. There is no, or very little, trace of the proper glan- dular structure, the organ being converted into fibrous tissue of a firm texture, the tubuli themselves undergoing this transformation. The testicle loses also its peculiar sensibility to pressure, but is some- times the seat of morbid sensibility. The epididymis undergoes similar changes, but usually to a less extent than the body of the gland. All those causes which produce decay in other parts likewise oc- casion Avasting of the testicle. Thus an impeded circulation, pres- sure, want of exercise, and loss of nervous influence, have been noticed as causes of atrophy of this gland. To these must be added certain causes which specially affect the testicle. The following case, related by Mr. Wardrop, is a good example of atrophy from defective nutrition. A person, both of Avhose testicles were com- pletely absorbed, nothing being felt in the scrotum but a loose vaginal coat, died of an aneurism of the aorta, formed at the origin of the spermatic arteries, both of Avhich were obliterated.1 A liga- ture on the spermatic artery is sufficient to cause a total decay of the testicle, Avhich induced the celebrated Harvey2 to propose its application for the removal of a certain form of sarcocele; a sug- gestion, the credit of which has been wrongly given in recent years to C. J. Maunoir, of Geneva. In Araricocele the interruption to the circulation consequent on the dilatation of the spermatic veins im- pairs the nutrition of the testicle, and causes more or less diminu- tion in its size. In these cases the testicle on the side affected, the left, is almost invariably smaller than the right, whereas in a healthy state of the parts, the left is usually the larger of the tAvo glands. The influence of pressure in causing partial atrophy of the testicle, is sometimes remarked in old cases of hydrocele and hematocele, in Avhich the gland has been long subjected to compression from the retained fluid. It has been said that the testicles waste in those persons who strictly adhere to their monastic voavs, but I am not aware that there is sufficient authority for this remark. In persons avIio marry, after many years of abstinence from sexual intercourse, the testicles undergo a certain degree of enlargement. These glands naturally 1 Note to his edition of Baillie*s Works, vol. ii, p. 315. 2 Anatomical Exercitatidhs concerning the Generation of Living Creatures. Lond. 1653, pp. 113, 114. 94 WASTING OF THE TESTICLE. remain somewhat small when not called upon to exorcise their func- tions ; but wliilst they are in a condition for secretion, and can be further developed if excited, this state cannot properly be re- garded as morbid atrophy. It is a great error to suppose that sexual connection in early life is essential for their preservation. When the excretory duct of the testicle is obliterated or obstructed, the semen secreted tinder excitement having no outlet encumbers the gland for a time, but aftqrwards becomes absorbed, and, it is said, that the useless organ decays. This, however, I have shown in a preceding chapter to be by no means a common result. As examples of atrophy of the testicles from impaired nervous influence, may be adduced cases of paraplegia, in which these organs have been known to waste. Portal mentions the case of a robust man, aged thirty-five, avIio was attacked Avith painter's colic, at- tended Avith great debility of the lower extremities. The testicles diminished considerably ; and although he afterwards recovered from the paralysis of his limbs, these glands always remained wasted; and the man Avas incapable of the act of generation.1 In the 20th volume of the "Medical and Physical Journal," there is an account of a case of recovery after fracture, with, partial dislocation of the first and second lumbar vertebrae, followed by paraplegia, in which, three years afterwards, the testicles were found entirely obliterated. I examined the testicles of a man, aged thirty-one, the lower half of Avhose body had been completely paralyzed after an injury of the middle dorsal vertebrae, nearly two years before. They were sound in structure. One weighed upAvards of two drachms; the other a few grains less. No spermatozoa were found. It has been stated that the testicles sometimes waste from injuries, or from compression of the spine at the origin of the spermatic nerves. In a man who had received a blow on the lumbar region, the testicles gradually wasted aAvay.2 The most common cause of atrophy of the testicle is the disturb- ance in its organization consequent upon inflammation. As the inflammatory process ceases, the enlarged gland not only becomes reduced to its original size, but it sometimes slowly but steadily diminishes, till at length very little vestige of it remains. Mr. Hun- ter has related three cases,3 and Sir E. Home, some others, in Avhich 1 Cours d'Anatomie Medicale, t. v, p. 434. 2 Biillie's Works, by AVardrop, vol. ii, p. 315. » Treatise on the Venereal Disease. WASTING OF THE TESTICLE. 95 the testicle decayed in this Avay. I have myself met with several instances of atrophy arising from this cause, and there are few sur- geons of experience Avho have not Avitnessed cases of. the kind. Wasting of the testicle has been observed to occur after an attack of orchitis in mumps, arising, as it is supposed, from the translation of inflammation from the parotid to the testicle. Two cases of cynanche parotidea in the adult, in which atrophy took place in the gland chiefly affected, are related by Dr. R. Hamilton.1 I have wit- nessed one case, in which the patient attributed the loss of the gland to an attack of mumps in his infancy.. Wasting is more liable to occur after inflammation of the body of the gland than after conse- cutive inflammation, in which the epididymis is the part chiefly affected. One or both testicles have been found to Avaste in persons who have indulged too much in sexual intercourse, or been addicted to onanism. Baron Larrey met Avith several cases of atrophy from excessive venery, and abuse of strong drinks, amongst the soldiers of the Imperial Guard.3 Sir B. Broclie has recorded tAvo cases in Avhich wasting was occasioned by over-excitement; in one from onanism, in the other from sexual intercourse.3 I witnessed an in- stance of total atrophy of the left testicle, which Avas ascribed to excessive masturbation. In this case, and probably in some of the others just quoted, the wasting Avas preceded by an attack of inflam- mation, induced by the inordinate excitement. The atrophy, hoAV- ever, cannot always be referred to inflammatory action. There must be some further cause in operation to account for the change, as in the folloAving instance in Avhich both glands suffered:—H. C, a fair-looking, but apparently a strong and healthy young man, con- sulted me in consequence of Avasting of his testicles and subsidence of all sexual feeling. He stated that both his testicles were for- merly of full size. He had been addicted to excessiAre masturbation, and had abandoned the practice only a year previously. He had had connection with women at different times. About four years back he strained himself in lifting a heavy weight; shortly after- wards, the right testicle swelled and became painful, and since this attack the gland has gradually wasted, and, when I saw him, Avas no bigger than a pea. After straining himself again a year ago, 1 Philos. Trans. Edinb. vol. ii, art. ix, p. 59. 2 M^moires de Chirurgie Militaires, vol. ii, p. 66. 3 London Medical and Physical Journal, vol. lvi, p. 2!»7. 9G WASTING OF THE TESTICLE. the left testicle became swollen and inflamed, and afterwards began to Avaste. On examination I found it about the size of a pigeon'.s egg and Aery firm, but free from the irregularities and indurations commonly met Avith after severe orchitis. The vasa deferentia Avere of the proper size and consistency. The young man had the sleek, fat appearance of a eunuch, and had no beard or whiskers. lie was very uncomfortable in mind respecting his state. The last time he attempted connection Avas three months back, but no emission fol- loAved. We can easily understand that A'iolent inflammation may disorganize a testicle and lead to its Avasting, but in this case the orchitis Avas not of an active character, and left behind no changes indicative of its previous existence. The folloAving case, communi- cated to me by my colleague, Mr. Adams, is of a somewhat similar character to the preceding. He was consulted by a gentleman in consequence of wasting of both testicles, which Avere reduced to the size of large beans. The only cause to Avhich he could attribute the wasting, was over-excitement in dalliance Avith a lady Avith whom he was prevented having more intimate relations. His testicles had been painful, but there Avere no marks to indicate that the glands had been the seat of inflammation. The active secretion and over- loaded state of the organs without the natural relief, must have injuriously affected their nutrition. It is a common belief, that wasting of the testicle is liable to be induced by the long-continued use of iodine. I have not met with any instance of it, and there are few cases in which the evidence is such as to render it at all clear that the decay of the gland Avas really occasioned by the remedy. M. Cullerier has published the case of a young man who took from twenty-five to thirty drops of the tincture of iodine for a period of three months, for the cure of an obstinate gonorrhoea. This was followed by a state of impotency and partial wasting of the testicles, which lasted a twelvemonth, and the organs never regained their former size and vigor. M. Cullerier mentions another case of temporary loss of virile power occurring from the use of the iodide of iron.1 I feel convinced, however, that if iodine produces Avasting of the testicle at all, it does so so rarely, that the liability cannot be regarded as any objection to the free and long- continued use of this valuable remedy. Atrophy of the testicle has been remarked in elephantiasis of the 1 Memoires de la Socie'te' de Chirurgie de Paris, t. i. WASTING OF THE TESTICLE. 97 Greeks, a disease in which tubercles are developed in various parts of the skin. Dr. Adams, in an account of the cases of that dis- ease observed in Madeira, states that all those who were attacked with it before the age of puberty, never acquired the distinguish- ing marks of that change in the constitution, and their testicles diminished in size, and that in those affected later in life the tes- ticles became atrophied, and they lost the power of procreation.1 Mr. Peacock also noticed a wasting of the testicles in several cases of elephantiasis in the Leper Hospital of Colombo, in Ceylon.2 A similar condition of these glands Avas remarked in a case of this disease, so rare in this country, narrated by Mr. Lawrence,3 and also in another case at the London Hospital, Avhich I recorded many years ago.4 In a confirmed case, however, of this disease, in a boy, aged thirteen, who Avas under my care in the year 1849, there was no diminution in the size of these glands. Wasting of the testicles is liable to occur after injuries of the head. Some years ago I saAV a man who had met with an injury of this description, which had been followed by wasting of the tes- ticles, and the development of tumors on each side of the chest resembling mammce. He was about fifty-nine years of age, a mar- ried man, and the father of several children. He had belonged to the legion in the Queen of Spain's service. About two years and a half previously, in an attempt to jump over a trench, he fell back- wards and injured the posterior part of his head. Whilst on the ground he receiAred a bayonet wound on the side, and a sabre cut on the forehead. He recoArered from these injuries and returned to England. Since the accident he had completely lost his virility. He had no desire for sexual connection; his penis had dwindled in size; his right testicle had gradually wasted, and was no larger than a horse-bean, and the left gland was also a good deal diminished in bulk. The skull at the occiput seemed somewhat flattened. Baron Larrey records the case of a man who was wounded in the back of the neck by a musket-ball which grazed the inferior occi- pital protuberance. He recovered from the injury, but the testicles were reduced to a state of atrophy, and the penis shrunk and re- 1 On Morbid Poisons, p. 265. 2 Edinb. Medical and Surgical Journal, vol. liii, p. 139. 3 Medico-Chirurgical Transactions, vol. vi, p. 214. 4 Aide Medical Gazette, vol. vii, p. 447. 7 98 WASTING OF THE TESTICLE. mained inactive. He also relates the case of a man of strong con- stitution and vigorous passions who received a sabre Avound Avhich cut off all the convex projecting part of the occipital bone, and ex- posed the dura mater. The patient lost the senses of sight and hearing on the right side, and his testicles sensibly diminished, and in fifteen days were reduced, especially the left, to the size of a bean.1 Lallemand had under his care a man thirty years of age, who, in the expedition to Algiers, had received a sabre wound at the nape of the neck. His testicles were wasted, and venereal desire as well as erections had entirely ceased.2 We cannot doubt that in these cases the loss of sexual desire, and the wasting of the testicles, were the direct results of the injury to the brain, and they go far to prove the essential dependence of the functions of these glands upon the cerebral organ. The physiologist cannot fail to notice the rapidity with Avhich the atrophy is stated in some of the cases to haAre succeeded the injury and the extent to which it pro- ceeded. The Avithering of the testicles, was, indeed, so remark- able, that it can be attributed only to the sudden and complete ex- tinction of the sexual instinct resident in the brain, and (if I may so express myself) to the immediate impression on the system of the future uselessness of these organs. In old age and in linger- ing diseases the decay of the testicles is extremely slow and gra- dual, and is never carried to the extent observed in cases of injury to the brain. In fact, men have survived the power or desire of performing the sexual act many years without the testicles being materially reduced in size. We have seen, too, that in the lower animals the testicles have been rendered useless by interrupting the A'asa deferentia, Avithout any such striking effect being produced on the glands as occurred in these cases of cerebral injury. An investigation of the causes of atrophy of the testicle is suffi- cient to show that in many of these cases the surgeon has little power by any method of treatment to promote the development or arrest the decay of this organ, these changes being the result of actions beyond his reach or control. In certain cases, as in atro- phy from pressure, or from an impeded circulation, and in some instances of decay from injuries of the head, and affections of the brain, we may by judicious measures assist in retarding the wasting 1 Memoires de Chirurgie Militaire, p. 262. 2 Pertes Se'minales Involontaires, t. ii, p. 41. CONTUSIONS AND INCISED WOUNDS. 99 process. A knowledge of the circumstances which conduce to this change Avill indicate the means required to check its progress. The treatment suitable in some of these cases will be considered in the chapter on Functional Disorders of the Gland. CHAPTER III. INJURIES OF THE TESTICLE. Although the testicles, owing to their exposed situation, are more liable to injury than any other glandular organ, they are pre- served in a remarkable degree from the effects of external violence by their great mobility and capability of eluding pressure, and the nature and strength of their protecting tunics. SECTION I. Contusions and Incised and Punctured Wounds. Contusions.—The testicle is in danger of being bruised in the exercise of riding on horseback, by the organ being struck against the pommel of the saddle, and many of the diseases of the gland are found to originate in this accident. It is sometimes forcibly compressed between the thighs, and is occasionally contused by a kick or blow. This injury usually occasions slight extravasation of blood Avithin the sac of the tunica vaginalis, or between this membrane and the tunica albuginea. The effusion sometimes infil- trates the cord, giving rise to diffused haematocele of this part; and Avhen the contusion has been particularly severe, the extravasa- tion has been found to extend along the cord even to the kidney. A case of contusion of the testicle, in which the extravasation reached as high as the diaphragm, is related by Petit.1 The tunica albuginea is so dense and strong that it is rarely ruptured, and it protects in a great degree the glandular structure from the effects of this injury. The consequences of a contusion of the testicle are soon felt, and are often severe; the immediate effects of the injury resem- bling a good deal the symptoms produced by an injury of the vis- 1 Traite des Maladies Chirurgicales, t. ii, p. 479. 100 contusions and incised wounds. cera of the abdomen, OAving to the connection of its nerves with those of the organs in the abdominal cavity.1 The patient instantly experiences acute pain, which extends up to the loins, and forces him to bend his body forwards for relief; and he is seized with a sickening sensation, often accompanied with syncope, vomiting, and cold perspirations. But these symptoms are transient; and in many instances, after recovery from the first effects of the injury, no further ill consequences are experienced; the effused blood is re- moved, and the testicle, after remaining tender for a few days, is gradually restored to its former healthy state. The only treatment required in these slight cases is rest, support to the organ with a handkerchief or suspensory bandage, and the application of a cool- ing lotion. In other instances, the contusion is followed by severe inflammation, Ayhich seriously injures, and sometimes completely destroys, the organ. Frequently the injury lays the foundation of chronic disease, Avhich is slowly developed shortly after the acci- dent. So complete are the disorganizing effects of a severe contu- sion on the gland, that squeezing the testicle was one of the modes adopted formerly in the Oriental courts for emasculating the atten- dants of the harem ;2 and I am informed that a similar plan of castrating bucks is sometimes resorted to by park-keepers in this country, and that in the agricultural districts, calves and lambs are occasionally treated in the same way. Dupuytren states, too, that in Normandy, horses are deprived of their testicles by compres- sion.3 This, however, is not a very sure way of emasculating, as some of the tubuli are liable to escape injury, and the effects of the subsequent inflammation. Punctured and incised wounds of the testicle are not in general followed by severe results. The organ has often been injured acci- dentally in operations with a trocar or lancet, and the wound has afterwards readily healed. Dupuytren relates that in tapping a ' An interesting case showing the sympathy of the vital organs with the testicles is recorded by Dr. Schlesier. A healthy man engaged in a fray in the dark was sud- denly heard to shriek out: he fell in convulsions, and died in five minutes. On exa- mination the only injury found was the rupture of both the spermatic arteries and veins at the internal rings, produced by the scrotum and testicles having been seized and pulled down by one of those with whom the man was fighting. Quoted by Paget m Brit, and For. Med. Rev., Jan. 1844, from Casper's Wochenschrift, Oct. 22 i»4 A person rendered a eunuch in this way was termed 6x*ji*t. J Lecons Orales, t. i. SELF-CASTRATION. 101 hydrocele in which the testicle was in front, after piercing the gland, he injected the sac three times. The inflammation which supervened was moderate, and the patient did well. These injuries must be treated according to the particular circumstances of the cases, and if inflammation arise, it should be treated actively; but the fact that they commonly do Avell should be remembered by the surgeon, that he may not too hastily despair of saving the gland in incised wounds even of a severe character. In these wounds the tubuli semi- niferi sometimes project through the opening in the tunica albuginea, appearing betAveen the lips of the outer wound like a slough or brownish flocculi. The surgeon should bear this in mind, for if he attempted to remove the projecting tubuli instead of repressing them within the scrotum, he would inevitably draw out more of the tubes and destroy part of the gland. SECTION II. SELF-CASTRATION. Persons ignorant of surgery have been knoAvn, like the pious Origen,1 to perform double castration on themselves, and have evinced considerable determination and indifference to pain in ac- complishing their purpose. It is natural to suppose that no one Avould attempt such an act, by Avhich the perpetrator deprives him- self of a faculty whose possession is universally so highly prized, and Avhose loss so degrades the condition of man, except during a fit of temporary insanity. Yet I am strongly inclined to belieA'e that self-castration is seldom undertaken without some strong motive intimately connected Avith the sexual functions, arising from a per- verted use or guilty indulgence of them, and that some such cause may generally be ascertained by a little cautious inquiry. In some instances the attempt has been made by persons who have been unable to cure themselves of the odious vice of masturbation: such, I suspect, was the motive that led to the act in the two following cases Avhich have come under my notice; in both, double castration was effectually completed. A lad, aged sixteen, was brought to the London Hospital in June, 1832, exhausted and faint with bleeding 1 It is clear from the saying of Christ (St. Matthew 19 : 12) that self-castration was practised, from a religious impulse, at a still earlier period than the time of the an- cient Father, Origen. 102 SELF-CASTRATION. going on from two wounds in the front of the scrotum; they were each about an inch in length, and situated at the sides of the raphe. Upon examination it Avas found that the scrotum did not contain the testicles. The boy subsequently gave the folloAving account of his case. He stated that for about a Aveek he had suffered from low spirits. Early in the morning he suddenly resolved to do him- self some injury: his first determination was to cut his throat, but he afterwards resolved to perform the following act of mutilation. Having left his home in the Whitechapel Road for some fields in the neighborhood, he first passed a piece of string tightly around the root of the scrotum; he then made an incision to the extent of an inch on one side with a common penknife, and having squeezed the testicle through it, divided the cord and removed the gland; he then proceeded to excise the other testicle in the same Avay. The loss of blood Avas considerable, and he endeavored to restrain it by draw- ing the ligature tighter. He said he was not conscious of any pain in the operation; and though he could not assign any reason for selecting this mode of mutilation, he admitted that he had read in an encyclopaedia an account of castration. The testicles were found in the field where the act was committed. The cord was divided close to the gland on one side, and at about an inch from it on the other. Ligatures were placed upon the spermatic arteries, and in three weeks the wounds had completely healed. No symptoms of insanity were evinced whilst the boy remained in the hospital: he enjoyed good health and spirits, and he talked and joked concerning his situation, without appearing at all to feel his loss. A man, aged twenty-two, was brought to the London Hospital in January, 1836, having cut out both his testicles. He had removed a small piece of the integuments, and squeezed the testicles out through the opening, and excised them, having previously tied a piece of string tightly round the spermatic cords to restrain the hemorrhage. These had retracted into the inguinal canals; and Mr. Adams, who was called to the case, was compelled to introduce his fingers at the wound and draw down the cords, in order to secure the vessels separately. The man admitted that he had been in the habit of constantly practising masturbation, and it was to rid himself of the perpetual desire to commit what he regarded as a great sin that he determined to remove the testicles. The wound healed without any unfavorable symptom. J SELF-CASTRATION. 103 I am indebted to Mr. Charles Hawkins for the following parti- culars of a case which occurred at St. George's Hospital. A man, about sixty years of age, much reduced in circumstances, and an inmate of a workhouse in the neighborhood of London, where he Avas employed as a schoolmaster, was about to be dismissed for having had connection with an idiot girl in the same house, when (as he said), to rid himself of the offending members which had been his ruin, he entirely removed with a razor both testicles and a con- siderable part of the scrotum. A medical man, who was called to him immediately after the ablation, secured the spermatic arteries, and then sent him to the hospital with his testicles in a paper parcel. Mr. Hawkins secured a small vessel which was still bleeding, and closed the wound in the scrotum with sutures. The part healed Avithout a single bad symptom, and the patient left the hospital quite well in about five weeks, since which he had not been heard of. Mr. Liston relates that a boy in Edinburgh, wishing, as he said, to lead a "holy life," applied to be castrated. Mr. Liston recom- mended him to Avait some time before he had the operation per- formed, observing that as he was still growing the testicles might be reproduced. After another interview, in which castration was again put off on the plea of his age, he called one evening at Mr. Liston's house, having attempted the operation with a penknife. One of the testicles was completely exposed, and merely hanging by the cord ; the boy said, " he did not like to cut the string." The wound was dressed, and the boy handed over to the priest to be admonished, but he did not apply again.1 Mr. Reid, surgeon, Markinch, states that he was called to a lad, a shoemaker, aged seventeen, who had attempted self-castration Avith a sharp-pointed knife. The right testicle was found hanging from a clean wound in the scrotum about If inch in length. The tunica vaginalis was cut to the extent of half an inch, and the pos- terior part of the testicle was slightly lacerated. The testicle was returned into the scrotum, and the wound dressed; the part was completely healed in about three weeks. He said that his reason for committing the deed was, that for some time past he had had such frequent and copious seminal emissions, that his master had quarrelled with him about soiling his sheets; so as to do away with 1 Lancet, vol. i, 1S3S-9, p. 3S. 104 SELF-CASTRATION. this cause of disagreement he had committed the rash act. The great bleeding had prevented him from completing the operation.1 Dupuytren mentions the case of an old man married to a young and trifling woman, of whose conduct he thought he had good reason to complain, who resolved to destroy himself, and completely extir- pated both his testicles. The cure was prompt, but the monoma- niac shortly afterwards drowned himself.2 To these curious cases of self-castration may be added a remark- able one recently communicated to the SociCte* Mddico-Pratique de Paris (1'Union MCdicale, t. ix, No. 129) by Dr. Le Lonjon, of Tours. In August, 1854, he was summoned to a man, aged thirty- two, in consequence of an alarming hemorrhage from a wound in the scrotum, which had been completely arrested, however, before his arrival, by another surgeon, by the application of a concentrated solution of the perchloride of iron. It appeared that the patient had been addicted to masturbation at college, and at the age of twenty-four became troubled with persistent and painful erections, followed by ejaculations, which were attended with excessive pain in the genital organs, especially in the left testicle. He tried various remedies without success ; and having in vain urged his physician to remove the testicle, presumed to be diseased, a pro- ceeding which the sufferer believed could alone put an end to his troubles, he conceived and executed, unknown to his family, self- castration, having ascertained from medical works the mode of pro- ceeding and the after-treatment. The wound healed in three months. After a period of remission, the erections, and sufferings which seemed inseparable from them, returned Avith increasing intensity. The remaining testicle became excessively painful, appeared to the patient the true seat of the evil, and he determined to excise it. After a night passed as usual without sleep, he got up, took a pair of scissors, made an incision in the scrotum, dis- sected, layer by layer, the envelopes of the testicle, and at length reached the organ and the cord, which he exposed and isolated. A ligature was placed round the cord, but unfortunately in dividing the latter he also cut the ligature, and a violent hemorrhage ensued. Preserving his sang froid, he placed his finger over the wounded artery, went into the nearest water-closet, and threw away the tes- 1 Edinb. Medical and Surgical Journal, July, 1837, p. 93. 2 Legons Orales, t. ii. HYDROCELE. 105 tide, returned, and summoned assistance, continuing in spite of the compression to lose blood, but not his presence of mind and stoic courage. In about a month the wound had almost entirely healed, and the patient left Tours. It thus appears that these cases of self-mutilation usually do well, and that the state of mind under which the injury is inflicted does not operate prejudicially to the patient's recovery. CHAPTER IV. HYDROCELE. The term hydrocele is applied to a chronic swelling produced by a collection of fluid in connection with the testicle or spermatic cord. The following table exhibits its different forms, varieties, and complications. ' Vaginal Hydrocele - Of the Testicle Of the Sperma- tic Cord ^ Encysted..... Diffused. Encysted. Vaginal H. combined with Encysted H. of the Tes- ticle. Complications of. Of the Hernial Sac . . . . Simple. Congenital. Of the Epididy- mis. Of the Tunica Al- buginea. Vaginal H. combined with Encysted H. of the Cord. Vaginal H. combined with Diffused H. of the Cord. Oscheo-Hydrocele . . • True. Spurious. C Vaginal H. com- bined with In- guinal Hernia. ■ Encysted H. of the Cord combined with Inguinal Hernia. 106 SIMPLE VAGINAL HYDROCELE SECTION I. Simple Vaginal Hydrocele of the Testicle. The sac of the tunica vaginalis, like other serous cavities, is liable to dropsical effusion. But before treating of this affection I must make a few observations on inflammation of the tunica vaginalis, or, as it is sometimes termed, acute hydrocele. The inflammatory changes of the tunica vaginalis resemble those of the other serous membranes. Investing, however, an organ not essential to life, this membrane AYhen acutely inflamed very rarely comes under the notice of the pathologist. In a testicle which I examined shortly after an attack of acute inflammation, I found fibrinous exudation on both surfaces of the tunica vaginalis present- ing a honeycomb or lace-like appearance, similar to that often met with in the peri- cardium. On examining a testicle affected with acute consecutiA'e orchitis supervening upon chronic, the opposed surfaces of the tunica vaginalis were connected throughout by loose fibrinous adhesions of a light red- dish color, and infiltrated with serum of a faint red hue : small quantities of the serum were isolated in different parts in imperfectly formed cysts. The tunica vaginalis was thickly covered with bloodvessels, and in two or three places minute branches could be traced penetrating the false membranes. In inflammation of the tunica vaginalis the epididymis is generally more or less swollen. In the Museum of the College of Surgeons, there is a beautifully injected preparation of hydrocele, showing the effects of inflam- mation after the application of the caustic. It is represented in the annexed wood-cut, which exhibits the sac with part of it cut away to show the swollen state of the epi- didymis, and the aperture made by the caustic (1); the tunica vaginalis is coated with flocculi of lymph. The sac of an inguinal hernia is seen above the hydrocele. The OF THE TESTICLE. 107 sound state of the body of the testicle, though surrounded by an inflamed serous tunic, whilst the epididymis partakes in the disease, has been accounted for by Gendrin.1 He says, Avhen the subserous cellular tissue, Avhich always participates in the inflammation of a serous membrane, penetrates into the interior of an organ, it be- comes a ready means of communicating the inflammatory action ; but Avhen the contiguous organ or subjacent part is of a different structure from that of the cellular tissue, the extension of inflam- mation inwards is checked. Thus, in the case of the inflamed tunica vaginalis, the cellular tissue readily transmitted the morbid action to the epididymis, but the tunica albuginea arrested its pro- gress to the body of the testicle ; and this explains the fact that after inflammation of the tunica vaginalis, excited by injection, the body of the gland is rarely found to suffer. On the other hand, the epididymis is seldom attacked with inflammation without the disease being quickly propagated to the tunica vaginalis.2 The fibrin exuded in inflammation very often forms adhesions between the opposed serous surfaces, and these, after a time, become firm and dense, and in old cases are liable to be converted into a dense and firm fibrous tissue. The chief inconvenience of these ad- hesions arises from the testicle being more exposed to injury, in con- sequence of its not being able to glide away from pressure so readily as before. If inflammation of the tunica vaginalis be very violent, it may go on to the formation of pus. Suppuration, however, is a rare occurrence, unless artificially excited for the cure of hydrocele. Inflammation of the tunica Aaginalis is not only the most frequent 1 Journal General de Medecine, &c, t. lviii, p. 25; quoted from Gendrin, Histoire Anatomique des Inflammations, t. i, p. 143. 2 An able writer in a review of the first edition of this work, in the British and Foreign Medical Review (vol. xvii), in commenting on these views of Gendrin to which I have given my assent, calls attention to the remarks of Sir A. Cooper, who says, " In general I observe that when there are marks of inflammation upon the tunics of the testis—such as, for example, adhesion—the substance of the gland itself is changed, the septa are much more apparent than natural, the seminiferous tubes appear to be less in number, are unquestionably much reduced in size, and may become cords instead of tubes." (Cooper on Diseases of the Testis, p. '23.) My observations are quite at variance with this statement. I have so constantly found marks of inflammation in the tunica vaginalis coexisting with a perfectly sound con- dition of the body of the gland, that in opposition to the high authority of Sir A. Coo- per, I must regard the presence of morbid changes in the testicle in such cases, as the exception rather than the rule. They occur when the tunica vaginalis has partici- pated in inflammatory disease commencing in the substance of the testicle. 108 SIMPLE VAGINAL HYDROCELE disease of the testicle, but it is also one of the most common affec- tions to which the body is liable. In some of the disorders of the gland, especially orchitis, this membrane usually becomes inflamed, and adhesions between its opposed surfaces are scarcely less com- mon than those of the pleura. In examining the testicles of twenty- four adults, I found fibrinous adhesions of greater or less extent in one or both glands in nine instances. In the testicles of fifty-nine old men, Dr. Duplay found adhesions seventeen times, seATen on the right side, six on the left, and in four instances on both sides.1 The symptoms produced by active inflammation of the tunica va- ginalis, and the treatment proper for its removal, are sufficiently comprehended in the observations on acute secondary orchitis, of Avhich disease it is a very frequent complication. Common vaginal hydrocele is essentially a chronic affection. The fluid effused is usually transparent, and of an amber, pale yellow, citron, or straw color, and resembles the serum of the blood, but is occasionally thick and dark colored from the admixture of blood. According to Dr. Marcet's analysis,2 1000 grains of this fluid, of the specific gravity 1024-3, contained 80 grains of solid matter, of which 71-5 consisted of animal, and 8*5 of saline ingredients ; hence it appears that this fluid only differs from the serum of the blood in possessing rather less animal matter. In an analysis of the fluid of hydrocele made by Dr. Bostock,3100-00 parts of the specific gravity 1024 were found to contain Water>..........91-25 Albumen, . . . . , _ g.gg .Uncoagulable matter,.....' \.\ Salts, ...... .q 100-00 A quantity of flaky matter or flocculent albumen is sometimes found floating in the fluid; and it frequently contains, especially in old people, cholesterine in the form of a multitude of minute shining particles. The quantity of cholesterine contained in nineteen ounces of dark fluid full of these shining particles, which I removed from an old hydrocele, amounted to nine grains. In the examina- tion of a testicle from a man of color who died at an advanced age, I found the tunica vaginalis and its investing tissues very thick and 1 Archives Generates de Mddecine, Aout, 1855. 2 Medico-Chirurg. Trans, vol. ii, p. 372. 3 Ibid> vol< j 72_ OF THE TESTICLE. 109 firm, and the seat of cartilaginous and osseous deposits; it con- tained about three drachms of a thick brownish substance, which was almost entirely composed of cholesterine. This was, no doubt, a very old case of hydrocele, in which, the more fluid parts having been absorbed, the cholesterine was left behind Avithin the indu- rated sac. The quantity of serum Avhich accumulates varies considerably. In this country it seldom exceeds twenty ounces, though it has been known to amount to several pints. The largest quantity which I have met with is forty-eight ounces. Mr. Cline is said to have re- moved from Gibbon the historian, as much as six quarts.1 From a table of 1000 cases of hydrocele which occurred at the native hos- pital of Calcutta, constructed by Dr. Dujat, it appears that the quantity of serum evacuated, varied from less than ten to upwards of one hundred ounces. Of 370 cases of double hydrocele, the fluid was more abundant on the right side in 109, and on the left side in 128. Of the 630 cases of single hydrocele, in rather more than a third of the number the quantity of fluid was under ten ounces; in tAvo-sevenths it was from ten to nineteen ounces; in nearly a third from twenty to forty-nine; and in eighteen cases the quantity of serum was from 50 to 120 ounces.2 In simple hydrocele. the testicle is found at the posterior part, and rather below the centre, of the sac. Its situation, hoAvever, is subject to variations. Before the occurrence of hydrocele, the tunica vaginalis may have been inflamed and contracted adhesions, so that the testicle may be connected to the membrane in front; in which case, the serum accumulates on each side of or above and below the organ. The position of the testicle in front may also be owing to an original immersion of the organ, in which th'e free sur- face presenting backwards, the fluid collects in that direction and presses the testicle to the front of the sac. It is stated that adhe- sions occur, producing a sacculated arrangement, and forming what is termed a multilocular hydrocele ; and that occasionally the cysts thus formed have no communication with each other. In two in- stances I have seen a membranous partition in the sac of a hydrocele, separating it into tAvo distinct cavities, formed by a layer of false membrane; but such a separation is extremely rare, and I believe 1 Sir A. Coopers Lectures, by Tyrrel, vol. ii, p. 02. 2 Gazette Mcdicale de Paris. 1S3S, p. 502. 110 SIMPLE VAGINAL HYDROCELE that what is called the multilocular hydrocele, is, in general, either a form of the encysted, or a complication of the vaginal and encysted. There is one kind of sac or pouch often met with in hydroceles, which is not commonly described. It is situated on the inner side of the testicle, but the opening into it is always found on the outer side, between the body of the gland and the middle of the epididymis. This sac, which varies very much in size, is formed by the distension of the cul-de-sac which I have described as existing naturally at this part. Two examples of this kind of pouch are con- tained in the Hunterian Museum. One of them is represented in the accompanying figure. In a case of congenital hernia, the sac of which contained a good deal of false membrane, I once found the opening be- tween the body of the gland and epididymis, leading to a cul-de-sac which extended as far as an inch and a quarter up the cord. In large hydroceles, the epididymis is usually flattened, elongated, and displaced; and instead of a pouch being formed, the central part of the epididymis is drawn to some distance from the body of the testicle. In old hydroceles the sac is often a good deal thickened, the tissues enveloping it being condensed and con- verted into layers of dense fascia, such as are commonly observed investing only hernial sacs. tThe fibres, also, of the cremaster muscle, become remarkably developed. This, hoAvever, is not constantly the case; for in some instances of hydrocele of large size I have found this muscle atrophied. The sac sometimes acquires the indu- ration of cartilage, and after many years becomes apparently ossi- fied. The thickening and induration are chiefly due to the exuda- tion of fibrin on the parietal portion of the tunica vaginalis, and its conversion into a false membrane of dense fibrous tissue or fibro- cartilage, which, in old cases, contains calcareous concretions. These changes have been minutely described by M. Gosselin, Avho notices that the false membrane stops generally at the epididy- 1. Aperture of the pouch be- tween the body of the testicle and middle of the epididymis. OF THE TESTICLE. Ill mis, and is not continued over the testicle.1 In several instances, however, I have traced it passing over the body of the gland, though in a thinner layer than the lining of the sac. In the Hunterian Museum there is a preparation, shoAving a long narrow band of adhesion passing from the anterior part of the testicle across the dilated sac of the tunica vaginalis to the membrane in / >iil front, which is supposed to have resulted from a wound of the testicle in the ope- ration of tapping. In all large hydro- celes the spermatic vessels are separated Mt and displaced. The glandular structure of the testicle is sound, and the organ capable of exercising its functions. The disease is strictly confined to the invest- ing serous tunic. The testicle is, how- ever, frequently somewhat altered in shape, being flattened by the pressure of the confined fluid; and in some instances has been found par- tially atrophied. Hydrocele is a very common disease in persons of all ranks in life, and in most climates, but more particularly in warm countries. Many writers have noticed its frequency both in the East and West Indies. This disease occurs at all periods of life; but commences in early infancy, and at middle age, more frequently than at any other period. It is rather a common affection within a few weeks after birth. In sixty cases of hydrocele, M. Arelpeau, of Paris, found, Between the ages of 15 and 20,......3 " 20 " 30,......13 " " 30 " 40,......11 " 40 " 50,......16 " " 50 " GO,......10 " GO " 70,......6 " " 70 " 80,......I2 In a table of 1000 cases of hydrocele treated by iodine injection at the Native Hospital of Calcutta, it appears that none of the 1 Archives Ge"nerales de Medecine, 4e se"rie, t. xxvii. 2 La Presse Medicale, Mai, lb-37. 112 SIMPLE VAGINAL HYDROCELE patients operated on were less than eighteen years of age; about one twenty-fourth were not more than tAventy years old ; rather more than a sixteenth were from twenty-one to tAventy-five years of age; a little less than half from twenty-eight to thirty-five; a little more than a quarter from thirty-six to forty-five; and an eighteenth were upwards of forty-six years.1 Hydrocele is generally single, but sometimes occurs on both sides. It is commonly said to form more frequently on the left side than on the right. For a few years I registered the new cases of hydrocele coming under my notice in public and private practice. Of one hun- dred and fifteen cases of simple hydrocele, one hundred and nine were single, and six double. Of the former, sixty-five occurred on the right side, and forty-four on the left. This result, which gives a decided predominance to the right side, does not agree with the observations of Yelpeau, Gerdy, and Dujat, who found the disease to be more frequent on the left side. Hydrocele in young infants is usually single, and, in my experience, more common on the right side. I have seen, also, a few cases of double hydrocele at this early period. Dropsy of the tunica vaginalis is usually regarded as purely a local affection, resulting from a disturbance of the nicely-adjusted balance between the functions of secretion and absorption. The same general causes which tend to produce effusion in the other serous membranes, Ave may conclude likewise operate in occasion- ing hydrocele. All circumstances which determine blood to the organ in excess, or impede its return to the heart, or which act in any way in disturbing the circulation through the gland, must be 1 Table of 1000 cases of Hydrocele treated by Iodine Injections at the Native Hos- pital of Calcutta, from Jan. 1, 1836, to Jan. 5,1838; constructed from the Registers by M. Dujat. Ages. Cases of Single Hydrocele. Donble. Total. 41 Right. Left. Total. From 18 to 20 years of age, 14 11 25 16 21 to 25 " " 51 58 109 64 173 26 to 35 " " 147 147 294 179 473 36 to 45 " " 72 94 167 90 257 46 to 59 " « 17 6 23 20 43 60 to 70 " « 4 8 12 630 1 13 305 325 370 1000 Gazette Mfjdicale de Paris, torn, xvi, 1838, p. 561. OF THE TESTICLE. 113 regarded as remote causes of the disease; and, considering the exposed and depending situation of the testicle, the liability of its vessels to 'obstruction, and the irregular nature of its functions, there can be no difficulty in accounting for the frequency of this affection. Hydrocele is occasionally deAreloped after a violent strain or great fatigue, or after a slight blow on the gland Avhich was considered at the time to be too trivial to require attention. In many of these cases the effusion appears to originate in a low degree of inflamma- tion of the tunica vaginalis. I have already stated that marks of previous inflammation are occasionally obscnred in the sacs of hy- droceles. On examining the body of a man, aged forty-nine, who died of apoplexy, I found about two ounces of serum in the vaginal sac of both testicles, and also several old adhesions, and some spots of induration and thickening of the testicular portion of the mem- brane. I have observed similar appearances in other cases of inci- pient hydrocele, as well as imperfect multilocular cavities and septa, and induration, and enlargement of the epididymis, clearly evincing that the part had been the seat of inflammation. In some few in- stances I have met with hydrocele under circumstances which have led me to suspect that the disease was connected with, or sympathetic of, a chronic affection of the urethra, as stricture and morbid irritation in the canal. Hydrocele occasionally results from the irritation pro- duced by loose accidental bodies in the tunica vaginalis, which are more frequently present than is generally supposed. In disturbed states of the circulation from disease of the heart, the tunica A-agi- nalis is not so frequently the seat of dropsical effusion as the other serous membranes, Avith the exception of the arachnoid; but this is partly owing to the pressure exerted around the testicle by the accumulation of fluid in the scrotum, and the relief to the spermatic vessels afforded by the oedema. In cases, however, of general ana- sarca, I have very frequently found slight effusion into the vaginal sac combined with oedema of the scrotum. When the fluid collected in the tunica vaginalis is attended with enlargement of the testicle, the SAvelling is termed a hydro-sarcocele. This affection is generally Consequent on chronic orchitis, but it is occasioned by other morbid changes, malignant as well as innocent. In these cases the disease of the testicle is the original complaint s; 114 SIMPLE VAGINAL HYDROCELE and source of the irritation that excites an undue secretion from the tunica vaginalis. Symptoms.—Simple hydrocele forms a swelling which is elastic and of an oval or pyriform shape, which fluctuates, and has a smooth and even surface, and which, commencing at the lower part of the scrotum, increases very gradually and without causing pain. At its back part the tumor feels firm and solid, and strong pressure there occasions the peculiar sensation experienced from compression of the testicle. The swelling is movable, but remains constant under pressure, and in all positions of the body; and unless of large size, the spermatic cord can be felt above it. When examined by transmitted light, the tumor is found to be more or less transpa- rent, except at the part where the testicle is situated, the opacity there indicating the exact position of the gland. When the hydro- cele is of considerable size, the integuments are tense, and the veins ramifying beneath the skin appear prominent and enlarged. The penis is also partly or entirely buried in the swelling, the skin which usually invests it being drawn forward into the scrotum, giving to the orifice of the prepuce somewhat the form of the um- bilicus. The hydrocele, even when large, is seldom attended with pain; though its bulk and weight produce a good deal of inconve- nience, and, if not supported, the tumor produces a dragging effect on the spermatic cord, which causes uneasiness in the loins. Its progress varies in different individuals, the hydrocele in some in- stances being several months in attaining a size which in other cases it reaches in as many weeks. But its course is, in general, slow; and twelve and even eighteen months may elapse before the swelling approaches the abdominal ring. Sometimes after arriving at a certain magnitude it ceases to increase; whilst in other cases its growth, though slow, is uninterrupted. It rarely happens that a hydrocele attains any considerable magnitude, because so much inconvenience is occasioned by the tumor when of large size that the patient obtains relief at an early period; otherwise it might in- crease until it reached as low down as the knees, as has really hap- pened in long-neglected cases. Mursinna mentions a case1 in Avhich the tumor measured as much as twenty-seven inches in length, and seventeen in width, which is, I believe, the largest hydrocele on record. 1 Neue Medicinische-Chirurgische. OF THE TESTICLE. 115 The symptoms of hydrocele are liable to several modifications. It sometimes happens, especially in children, that the tunica vagi- nalis remains after birth unobliterated for some distance along the cord ; consequently, when fluid collects, the swelling assumes a pyramidal and elongated form, and the relative situation of the testicle is lower than in ordinary cases. Under these circumstances, there is often a well-marked contraction in the centre of the hydro- cele, giving to the tumor the form of an hour-glass. The contrac- tion is found just above the testicle, corresponding to the point where the obliteration of the prolongation of peritoneum usually takes place. A somewhat similar contraction is sometimes produced by bands of adhesions between the sufaces of the tunica vaginalis. In consequence of the sac and its investing tissues yielding unequally to the pressure of the fluid, the surface of the tumor, instead of being smooth and even, may be more or less irregular and unequal. In inversion of the testicle (vide p. 87) the relation of parts is re- versed, and the gland, instead of being at the back of the sac, is seated directly in front. When the sac is loose and not fully dis- tended, the testicle may be readily felt wherever situated. This is often the case in children. Fluctuation is sometimes obscure, and in other instances is not distinguishable at all, owing to extreme tension or great thickness of the sac. Mr. Pott remarks, " The transparency of the tumor is the most fallible and uncertain sign belonging to it: it is a circumstance which does not depend upon the quantity, color, or consistence of the fluid constituting the disease, so much as on the uncertain thickness or thinness of the containing bag, and of the common membranes of the scrotum. If they are thin, the fluid limpid, and the accumula- tion made so quick as not to give the tunica vaginalis time to thicken much, the rays of light may sometimes be seen to pass through the tumor; but this is accidental, and by no means to be depended upon. WThoever would be acquainted Avith this disorder must learn to distinguish it by other, and those more certain, marks, or he will be apt to fall into very disgraceful as well as pernicious blunders."1 The value of transparency, as a sign of hydrocele, is underrated in these remarks. In ordinary cases the surgeon should certainly be able to detect the disease Avithout its assistance; and this is the more necessary, as its absence is no proof that the tumor is not a 1 Works, 4to. p. 394. 116 SIMPLE VAGINAL HYDROCELE hydrocele. But it would be absurd to reject the aid of a symptom which, when present, constitutes one of the most certain signs of the disease, because of its inconstancy; and, in the present day, there are feAv surgeons even of experience who do not avail them- selves, in cases of doubt, of this ready and simple mode of examina- tion. But, independently of the advantage to be derived from transparency as a means of diagnosis, we are enabled by this mode of examination to ascertain the exact position of the testicle, which is always important before undertaking any operation. In cases of encysted hydrocele, or inversion of the testicle, the unusual situa- tion of the gland may thus be detected, and risk of injury to it be avoided. The mode of making the examination is to darken the room, and place a lighted candle so that the tumor, when thrust forwards by the hand grasping it behind, may be interposed betAveen the eye and the light, whilst the edge of the other hand is at the same time closely applied to the front of the hydrocele in order to intercept the light from the candle. The testicle is then recognized as an opaque object, and its situation exactly ascertained. In cases in Avhich the walls of the sac are unusually thick, or when the fluid is dark in color, I have derived assistance from usuing a common stethoscope. One end being placed against the tumor opposite the light, the surgeon on looking through the bore of the instrument can observe the transparency with great advantage. The growth of a hydrocele is occasionally attended with a good deal of local uneasiness, which has been ascribed to pressure on a nerve, or to the presence of accidental cartilages in the cyst. I have generally found, when pain exists, that the dropsical collection has either originated in, and been kept up by some disease of the testicle, or has formed quickly and produced great tension of the sac, the tunica vaginalis being too forcibly dilated to accommodate itself gradually to the effusion. A hydrocele sometimes varies in size, being larger and more tense in the after part of the day than when the patient first rises in the morning. I have not exactly observed this change; but it has been so often mentioned to me by persons affected with hydrocele, that I entertain no doubt of the fact; and since the extent of surface afforded by the dilated tunica vaginalis is large, and the condition of the parts during day and night very different, such variations in size consequent upon alterations in the functions of secretion and absorption do not appear at all unlikely to occur. OF THE TESTICLE. 117 I have been informed of a case in Avhich the change was so remark- able, that the scrotum, which Avas full and tense Avhen the patient retired to rest, became contracted and corrugated by the time he rose in the morning. Diagnosis.—A hydrocele is usually distinguished without diffi- culty. The surgeon may conclude that a scrotal swelling is a hydrocele, if the tumor be tense, transparent, and fluctuating; if it has a smooth and uniform surface; and if the testicle cannot be felt, and its position can only be ascertained by the greater solidity of the swelling, and the uneasiness experienced on pressure at one particular part, Avhich is generally behind; and if the spermatic cord can be distinctly felt of its natural size, and in a healthy state. The affections most likely to be confounded with hydrocele are scrotal hernia and malignant disease of the testicle. A hydro- cele differs from a scrotal hernia in the folloAving circumstances:— The sAvelling commences at the loAver part of the scrotum ; whereas in hernia it begins at the ring, and gradually descends. The sper- matic cord can be clearly felt above the tumor; but in hernia it can only be traced indistinctly along the back part of the swelling, and sometimes cannot be distinguished at all. The testicle cannot be felt; but in hernia, unless congenital, the gland can be readily perceived at the bottom of the swelling : and, further, there is no impulse communicated on coughing, and the tumor is not subject to variations in size, as in rupture. The diagnosis is made Avith less facility when the hydrocele extends upwards along the cord nearly to or even into the ring, as in this case the cord cannot be felt; and the shape of the tumor nearly resembles that of a scrotal hernia, and there may even be a slight impulse transmitted to it on coughing ; but attention to the other distinguishing marks which have been pointed out will always be sufficient to enable the sur- geon to make an accurate diagnosis. I have never experienced greater difficulty in the diagnosis of this affection, than in a caer. torn, i, p. 70. 1 Lancette Frangaise. 122 SIMPLE VAGINAL HYDROCELE PALLIATIA'E TREATMENT OF HYDROCELE BY OPERATION. The palliative operation is exceedingly simple, of easy perform- ance, and, if proper care be taken, free from danger ; but the relief it affords is only temporary. It consists in puncturing the tumor so as to allow of the escape of the fluid contained in the tunica vagi- nalis : the operation may be performed with a lancet or a trocar. The best place for making the puncture is a little below the centre of the anterior part of the tumor ; but the surgeon should first ascertain the situation of the testicle, for Avhen the position of the gland is altered by adhesions or other causes, it may be necessary to puncture the tumor at the side, or even behind. It is better, however, to avoid the posterior part if possible, as in this situation there is some risk of Avounding the spermatic artery. Simple as the case may appear, the surgeon should omit none of the cus- tomary precautions, for more mishaps have occurred in the puncture of hydroceles than in any other operation in surgery. The lancet was formerly used for this operation, but is not now em- ployed ; for the whole of the fluid cannot Avell be evacuated through the opening thus made, Avithout much squeezing and handling of the parts; and there is also risk of the division of some small vessel, Avhich by pouring blood into the tunica vaginalis may produce a haematocele. The operation is usually performed Avith a trocar, the canula of Avhich is about two inches long and a line in diameter. In selecting an instrument the surgeon should see that the canula fits properly, and that its shoulder does not project too much; or else, after the point of the trocar has penetrated the cyst, the canula may hitch outside it, and instead of entering the cavity push the tunica vaginalis before it. In such a case, if the acci- dent be not perceived in time, the testicle or the back part of the cyst is very liable to be wounded. The trocar before being used should be thrust through a piece of wash-leather held tense, and unless it penetrates readily the instrument is unfit for use. This advice may seem unimportant; but it should be recollected that, in addition to the risk of converting the case into a haemato- cele, any bungling in an operation of so simple a nature as the tapping of a hydrocele may induce the patient to suspect a general want of skill. ^ 8 I generally prefer performing this operation with the patient OF THE TESTICLE. 123 standing before me ; but if he be timid, or liable to faint, he may be seated in a chair, or placed in the recumbent position. The surgeon, grasping the tumor behind Avith his left hand so as to put the integuments upon the stretch, and taking care not to wound any of the enlarged veins beneath the skin, should insert the trocar, previously well oiled, in an oblique direction upwards Avith a brisk motion of the right hand ; and as soon as the sac is perforated, which is ascertained by the immediate cessation of all resistance, the trocar should be withdraAvn, whilst the canula is simultane- ously thrust forAvards by the action of the thumb and fore- finger : gentle pressure is then to be maintained until all the fluid is removed. By manipu- lating in this Avay all risk of the tunica vaginalis slipping off the tube, or of the testicle and back of the sac being injured, is pre- vented. After the whole of the fluid has escaped the canula is withdrawn, and the edges of the wound slightly nipped together ; after Avhich the only application necessary is a piece of adhesive plaster to the Avound. The part should be suspended and the patient should be directed not to walk about much for the next tAventy- four hours, and to abstain from active exercise for a day or two ; a precaution which is more especially necessary in individuals of an irritable or unhealthy constitution, or in advanced life. If this adA-ice be neglected, acute inflammation of the tunica Araginalis is liable to succeed the operation. Some years ago I tapped the hydrocele of a healthy man, fifty years of age, who, notAvithstand- ing the caution I had given him, walked several miles the same afternoon; the consequence Avas se\rere inflammation of the sac, followed by sloughing of the scrotum. After much suffering he recovered at the expiration of eight weeks, with the disease perma- nently cured. At a later period of life, if proper precautions be not taken, the palliative operation can scarcely be viewed as free 124 SIMPLE VAGINAL HYDROCELE from danger. Sir A. Cooper mentions two cases of persons in advanced age, Avho haA'ing taken a long walk after the operation, had inflammation and sloughing of the scrotum, which terminated fatally.1 Mr. Hamilton, of Dublin, also mentioned to me a case of gangrene of the scrotum ending fatally, which occurred in a person of unhealthy constitution from simple tapping. The wound made by the trocar heals by the first intention. Fric- tion of the scrotum against the dress sometimes causes slight in- flammation, and even ulceration afterwards, so as to require the attention of the surgeon ; but this is seldom the case, and when it occurs is easily remedied by the ordinary means. Occasionally there is slight extravasation in the connective tissue of the scrotum from a wound of some small vessel external to the sac, but very rarely to any extent so as to interfere with the healing of the wound. The operation is ahvays admissible whenever the amount of fluid is sufficient to admit of the introduction of the trocar without risk of injury to the testicle. It should be repeated as soon after the fluid has collected again as the tumor from its size or weight be- comes troublesome. This varies greatly. I have had patients who for many years have been satisfied with the relief afforded by an annual operation; and in one case the fluid did not collect in a sufficient quantity to need removal for four years, when I drew off no more than sixteen ounces. In other instances patients have returned to have the fluid evacuated again at the expiration of two or three months, and even of a much shorter period. Indeed, I have knoAvn the hydrocele to regain its former size in the course of two or three days. Many persons complain of uneasiness from only a small quantity of fluid, whilst others experience but little inconvenience until the hydrocele has attained a large size. In most cases the patient's feelings will be the best guide in indicat- ing the necessity for a repetition of the operation. Many persons affected with hydrocele, which after being tapped appears very slowly, and without causing uneasiness, are so satisfied with the temporary benefit afforded by this slight and almost pain- less operation, that they desire no further relief than is derivable from its repeated performance; and rfs hydrocele is not a disease which if suffered to remain is commonly followed by important con- 1 Lib. cit. p. 181. OF THE TESTICLE. 125 sequences, such persons may be safely left to consult their own inclinations. Some patients are too timid to submit to any other kind of treatment, and others are unwilling to undergo for the permanent relief of so slight an inconvenience even the short con- finement Avhich might be required. Persons out of health, of an irritable constitution, or in advanced life, upon whom the radical operation cannot be performed Avithout risk, must likewise be con- tent Avith palliative treatment. The tunica vaginalis may be emptied by a puncture made with a needle; Avhen the fluid, instead of escaping externally, as in the former operation, gradually infiltrates the connective tissue sur- rounding the sac, Avhence it is afterwards removed by absorption. In this operation, which is termed acupuncture, anasarca of the scrotum is substituted for a common hydrocele. It was first sug- gested by Dr. Cumin, of GlasgOAv, who, at the conclusion of some observations on the treatment of ganglion by a similar-procedure published in 1825, remarks, that it has occurred to him that a cure of hydrocele might be accomplished by opening a communi- cation, by means of the cataract needle, between the cavity of the tunica vaginalis and the cellular tissue of the scrotum.1 He did not, hoAvever, submit this idea to the test of experiment. Several surgeons have subsequently claimed the merit of originating this operation as a palliative cure for hydrocele. Mr. Lewis, surgeon, of London, is entitled to the credit of having first recommended acu- puncture to his professional brethren on the grounds of practical ex- perience of its efficacy ;3 though no doubt can be entertained that the plan had been previously resorted to by other surgeons, who had regarded it as either too simple or too unimportant to deserve a formal notice, or who perhaps did not sufficiently appreciate its value.3 Mr. Lewis punctured the tumor Avith a fine needle until a drop of fluid oozed out on withdrawing it, and in a few days the hydrocele entirely disappeared. The absence of danger, the slow reaccumulation of fluid, and the simplicity of the operation, are the advantages which he considers to be obtained by this mode over the operation of removing the fluid at once. In performing acupuncture I employ the common cataract needle, which I usu- 1 Edinb. Medical and Surgical Journal, vol. xxiv, p. 97. 2 Lancet, vol. ii, 1S35-36, p. 206. 3 Vide note from xMr. Keate on the Treatment of Hydrocele, Medical Gazette, vol. xix. p. "!>9. 126 SIMPLE VAGINAL HYDROCELE ally introduce in two or three different places, rotating the in- strument between the finger and thumb to render the openings in the sac sufficiently patent. A little serum generally oozes out from the puncture in the skin in drops, or issues in a stream for a few seconds, and then ceases. In the course of a few hours the scrotal swelling becomes a good deal changed, and instead of a tense, smooth, and defined tumor, presents an eedematous tumefaction, with a soft, doughy, and inelastic feel. In large hydroceles the oedema extends to the integuments of the penis. The swelling thus produced takes from three days to a week gradually to disap- pear, the scrotum in favorable cases being left in its natural con- dition, Avithout any excess of fluid either in its loose connective tissue or in the sac of the tunica vaginalis. The operation may be repeated again and again as the fluid returns, on each occasion before the tumor has acquired the same size as on the preceding one, by Avhich means the sac may sometimes be gradually reduced to its natural size. Though the advocates of this operation have not claimed for it the merit of constantly affording radical relief, it has been observed that the reaccumulation follows less quickly than after the fluid has been evacuated at once by the trocar, and in many instances does not take place at all. This accords to a certain extent with my own experience, for in several cases in which I haAre performed it, there was no return of the hydrocele for a period of many months. Acupuncture cannot, however, be relied on for the permanent cure of hydrocele, but it must be regarded as a useful addition to our remedial means. It does not supersede the use of the trocar; for the latter is scarcely more painful or less simple, and in careful hands is equally safe and free from hazard, whilst the immediate and certain relief Avhich the trocar affords will always give it an advantage. Acupuncture, too, is ill adapted for cases of thickened sac. In very timid persons, in those of impaired constitutions, and in children, and in some other forms of hydrocele not yet described, acupuncture may be resorted to with benefit, and even preferred to the trocar. I am informed by Mr. Luke, that in the case of a gentleman who was about to proceed to a place in South America, where there would be no surgeon nearer his residence than 400 or 500 miles, he instructed his patient to perform this simple and harmless operation on himself. OF THE TESTICLE. 127 RADICAL TREATMENT OF HYDROCELE BY OPERATION. The permanent and radical cure of hydrocele may be effected by any of the folloAving operations:—Incision of the sac; excision or removal of the tunica vaginalis ; caustic applied to the integuments ; a tent introduced into the tunica vaginalis ; a seton passed through the sac; and injection of the sac with a stimulating fluid;—all which plans appear to have been known to ancient practitioners.1 Incision.—The treatment by incision is the most ancient of all these methods. In performing it the surgeon cuts gradually down to the cyst with a scalpel, and, making an opening into the upper part, introduces a director or the finger, and with a bistoury lays open the cyst as far as the bottom of the sac, so as completely to expose the testicle. Inflammation soon arises, and the tunica vagi- nalis becomes obliterated by adhesion ; or else suppuration ensues, and the part heals by granulation. After the incision was com- pleted, it was often the custom to stuff the tunica vaginalis with lint, or to apply some other coarse and irritating substance. This operation was consequently ahvays succeeded by acute inflamma- tion of the sac, the constitutional effects of which frequently proved exceedingly severe. Many of the older surgeons, as Wiseman, Cheselden, Heister, and Sharp, have noticed the painful and even dangerous consequences which sometimes resulted ; and it is ob- served by Pott, that this " method can never be said to be totally and absolutely void of some danger."2 Mr. B. Bell, of Edinburgh, is the most recent authority in this country who has advocated this method of treating hydrocele, which he slightly improved upon by devising a less irritating mode of dressing.3 My brother, Mr. II. Curling, of Ramsgate, when in Paris witnessed several cases of hydrocele cured by incision by Jobert; but the treatment proved very severe, and confined the patients to bed for a long time. I have myself seen three cases of this disease 1 Those interested in the history of the methods of cure for hydrocele may consult the writings of Sabatier (Medecine Op6ratoire), and the Treatise on Hydrocele by Sir James Earle. There are few diseases of the same importance which have been so much written on as this affection. Besides being largely treated of in most works on surgery, hydrocele and the particular modes of curing it has formed the subject of distinct treatises by the following British writers:—Douglas, Else, Pott, Howard, B. Bell, Keate, Earle, Holbrook, and Dease. Some of these works have run through several editions. 2 Lib. cit. p. 441. s Treatise on Hydrocele. 128 SIMPLE VAGINAL HYDROCELE attended with considerable thickening of the sac, Avhich, after in- jections had failed, were successfully treated by incision; and cer- tainly the consequences were less severe than the representations of Sharp and Pott would lead us to expect; but in these cases the tunica vaginalis was evidently less disposed to inflammation than usual. Incision is an operation rarely resorted to in the present day; and I quite concur in the general opinion, that the disease can be successfully treated by milder and safer means. When, however, in consequence of difficulty in the diagnosis, or of sus- picion of hernia or disease of the testicle, an exploratory operation is required ; or when a hydrocele is attended with great thickening of the sac, or is found to depend on the presence of loose cartilages, an incision may then be made with advantage. Excision consists in cutting down upon the tunica vaginalis and excising the greater part of it with a pair of scissors, the spermatic vessels and testicle being left untouched. The wound, which is filled with lint and dressed, subsequently suppurates and heals by granulation. This operation is also one of considerable antiquity; but it long remained in disuse, until it was revived in England in the year 1755 by Mr. Douglas, who advised the removal of an oval portion of the scrotum, together with the cyst.1 About the same period Bertrandi and several surgeons of eminence in France adopted the operation. The consequences of excision were not less severe or dangerous than those of incision ; it was sometimes fol- lowed by gangrene of the scrotum, and generally by much consti- tutional irritation and tedious suppuration. This operation is now nearly exploded. I have only once seen it practised, and that was in the case of a young man, in which the tunica vaginalis was re- markably thickened, after the operation of injection had failed. The symptomatic fever which followed was mild, and the operation successful, the wound having healed completely in three weeks. Mr. Kinder Wood, a provincial surgeon, has practised a modifi- cation of the operation of excision,2 which is deserving of notice. He opened the tumor with a broad-shouldered lancet in the cus- tomary situation, the lancet in consequence of its figure making a larger incision into the external covering than into the tunica vagi- 1 Treatise on Hydrocele, p. 136. Sa^MeZ Cr °**\ v™ °f Hy In dealing with hydroceles composed of two or more distinct cysts, the surgeon should bear in mind that the inflammation excited in one may extend to the others, and be sufficient for their oblitera- tion. This does not always happen, but it is better to wait the 158 ENCYSTED HYDROCELE. result of an operation on one cyst before meddling with the others. This course was adopted in the following case, which came under my care before I treated encysted hydroceles by injection. I. H., aged thirty-one, was admitted into hospital in 1846, on account of a large lobulated tumor of the left testicle, which was found to con- sist of three cysts of different sizes attached to the head of the epi- didymis. The largest cyst contained eight ounces of fluid. The tAvo others were each about the size of a chestnut. One of these was also punctured, and spermatozoa Avere detected in the fluid re- moved from it. The spermatic cord passed in front of the tumor, and to the outer side of one of the smaller cysts. After the cysts which had been tapped had refilled, I passed a seton consisting of six silk threads through the whole length of the large cyst. The inflammation excited was mild, but as the tumor felt solid on the third day after, the seton was removed. The induration and swell- ing subsided slowly. A month after this operation I passed a seton of four threads through the second-sized cyst. The inflammation was so active on the following day, that the seton was removed in the evening to prevent suppuration taking place. The tenderness and swelling gradually diminished, and in a short time it became evident that both the smaller cysts were obliterated, no doubt from the extension of inflammation from the cyst operated on to the adjoining one. The patient was under treatment altogether seven weeks. In the case related at p. 156 the surgeon intended at first to incise the cysts. This operation, which involves the laying open also the tunica vaginalis, is not to be lightly undertaken, as it is liable to be followed by severe inflammation and constitutional dis- turbance. Mr. Laing, surgeon, of Aberdeen, some years ago pub- lished two cases of what he termed " cystic or hydatoid disease of the testis," but which were evidently cases of encysted hydrocele, in which he was led to cut down upon and puncture the cysts. The cases were remarkable from the great number of cysts which pre- sented themselves. The effects of the operation were severe in both instances, and in one the inflammation extended to the scrotum and produced sloughing.1 1 Lond. Medical Gazette, vol. xxvii, p. 456. DIFFUSED HYDROCELE. 159 SECTION IV. Diffused Hydrocele of the Spermatic Cord. Mr. Pott has given an admirable account of this affection, under the denomination of hydrocele of the cells of the_ tunica communis.1 It has likewise been particularly described by Scarpa.2 The disease is of the nature of simple oedema, a watery fluid being diffused throughout the loose tissue connecting the vessels of the spermatic cord, and enclosed in a sheath of condensed tissue, which is invested by the musculo-aponeurotic structure of the cremaster muscle. On dissection the sheath is foUnd distended, and when the complaint has lasted for some time, more or less thickened. The connective tissue beneath is infiltrated with a limpid albuminous serum of a white or yellowish color, which Aoavs out in the course of the dis- section. It is owing to the confinement of the fluid by the invest- ing sheath that the swelling assumes a uniform surface, and defi- nite shape. The cells infiltrated with serum are converted into large vesicles, some of Avhich are big enough to admit the end of the finger. These cells are larger and more delicate towards the base of the swelling, where they sometimes disappear altogether ; so that there is only one considerable cavity, the fluid having a ten- dency to collect towards the lowest and most depending part, and to form a fluctuating tumor there. The base of the swelling cor- responds to the point at which the spermatic vessels join the testi- cle, and at this part a dense septum cuts off all communication with the tunica vaginalis. In some instances the effusion extends along the cord into the abdomen, as in a remarkable case related by Mr. Pott. In the figure of this affection, on page 160, taken from Scarpa, the envelope of the cremaster is laid open, exposing the pyramidal SAvelling enclosed in its sheath of condensed connective tissue. The testicle and tunica vaginalis are seen below it. In general ana- sarca the connective tissue of the spermatic cord, as well as of the 1 \ride his Treatise on Hydrocele. 2 Memoria sull' Idrocele de Cordone Spermatico. Bertrandi, an Italian surgeon, in a memoir published by the French Academy of Surgery in 177S, has given an accu- rate description of this affection, which, however, he did not sufficiently distinguish from the encysted hydrocele of the cord. He dissected on the dead body a diffused hydrocele which contained twenty ounces of fluid. 160 DIFFUSED HYDROCELE scrotum, is frequently distended with serum ; but oedema of the cord alone is certainly a very rare affection. Sir A. Cooper makes no allusion to it, and Mr. Pott, to' whom we are indebted for so good and accurate a description of this species of hydrocele, probably met with a greater number of cases of it than have occurred in the prac- tice of any surgeon since his day. Causes obstructing the return of blood from the testicle, as indu- ration and enlargement of the glands in the course of the cord, would conduce to its production. I have observed a slight oedema of the cord in tAvo or three in- stances after acute orchitis, but it always disappeared as the in- flammation subsided. The affec- tion is said to have been induced by the pressure of a truss applied for the cure of an inguinal hernia. Symptoms,.—Mr. Pott thus describes the appearance and symp- toms of this affection: " In general, while it is of moderate size, the state of it is as follows.. The scrotal bag is free from all appearance of disease; except that when the skin is not corrugated it seems rather fuller, and hangs rather lower on that side than on the other, and if suspended lightly in the palm of the hand feels heavier; the testicle with its epididymis is to be felt perfectly distinct below this fulness, neither enlarged, nor in any manner altered from its natural state: the spermatic process is considerably larger than it ought to be, and feels like a varix, or like an omental hernia, ac- cording to the different size of the tumor; it has a pyramidal kind of form, broader at the bottom than at the top: by gentle and con- tinued pressure it seems gradually to recede or go up, but drops doAvn again immediately upon removing the pressure, and that as freely in a supine as in an erect posture: it is attended with a very small degree of pain or uneasiness, which uneasiness is not felt in OF THE SPERMATIC CORD. 161 the scrotum, Avhere the tumefaction is, but in the loins. If the ex- travasation be confined to what is called the spermatic process, the opening in the tendon of the abdominal muscle is not at all dilated, and the process passing through it may be very distinctly felt; but if the cellular membrane which invests the spermatic vessels within the abdomen be affected, the tendinous aperture is enlarged, and the increased size of the distended membrane passing through it produces to the touch a sensation not very unlike that of an omental rupture.1 At its commencement the tumor is of a cylindrical form; but at a later period, and as it increases in size, it becomes pyra- midal, especially when the patient is in the erect posture. By altering his position to the recumbent the form of the tumor is slightly changed : it becomes more oblong, and nearly of equal di- mensions from the ring to the testicle. However much the swelling may increase, it has been remarked that the penis never appears so much retracted as in simple hydrocele of equal size. Diagnosis.—An omental hernia, or an encysted hydrocele of the cord, might be mistaken for a diffused hydrocele of the spermatic cord. In regard to the former, Scarpa observes, that "-the diffused hydrocele of the cord, when it enters into the ring, resembles an omental hernia so closely that it is very difficult to distinguish the two complaints. Both have a cylindrical form, and extend into the ring. They are similar in consistence and degree of sensibility, as well as in the difficulty experienced in returning them. Pott repre- sents that the omentum, when returned, remains in the abdomen until the patient assumes the erect position, or makes some effort ; while the swelling in diffused hydrocele comes back immediately. I have found, hoAvever, that the omentum comes down quickly in some omental hernia?, and that the swelling, when pushed up, does not reappear immediately in some cases of diffused hydrocele. I have observed that the swelling is firmer and more irregular on the sur- face in the epiplocele than in the watery effusion; and that the latter is larger below than above, Avhile these proportions are reversed in the rupture."2 Mr. Lawrence remarks, that " The distinction of the tAvo cases must rest on the following points:—the impulse on couching in the rupture ; the complete removal of the swelling, and the sense of the omentum passing up into the abdomen ; its visible 1 Lib. cit. p. 370. 3 Sull Ernie, Mem. 1, § xxxii; quoted from Lawrence on Hernia, 5th edit. p. 251. 11 162 DIFFUSED HYDROCELE and tangible escape from the cavity when the rupture is brought down again by coughing, and the free natural condition of the cord and ring when the swelling has been replaced. The fluctuation of the watery tumor at its lower part; the absence of impulse in cough- ing ; its imperfect removal under pressure, so that the cord can never be felt in a natural state; and sometimes a visible enlarge- ment of the inguinal canal and its neighborhood when the fluid is pressed upwards."1 An irreducible epiplocele would be even more liable to be mistaken for a diffused hydrocele, as some of these dis- tinguishing marks would be absent. In cases of much difficulty and doubt, the surgeon must be guarded in pronouncing an opinion, and very cautious in performing any operation. Scarpa, indeed, frankly confesses the imperfection of our art with respect to the diagnosis in these cases.2 Diffused hydrocele is distinguished from encysted hydrocele of the cord by the pyramidal and somewhat diffused form of the savcII- ing, which extends to the ring; by the alteration in shape produci- ble by pressure ; and by the absence of fluctuation in its upper part. As the testicle is perceptible in diffused hydrocele of the cord, this disease cannot well be mistaken for simple hydrocele. Nor is diffused hydrocele likely to be confounded Avith varicocele, the cha- racteristic symptoms of the latter being too evident to allow of the intelligent surgeon erring in his diagnosis of these affections. Treatment.—In regard to the treatment of diffused hydrocele of the cord, Mr. Pott observes, "While it is small it is hardly an object of surgery, the pain or inconvenience which it produces being so little that few people would choose to submit to an operation to get rid of it, and it is very seldom radically curable without one; but Avhen it is large, or affects the membrane within the cavity as well as without, it becomes an apparent deformity, is very incon- venient both from its size and weight; and the only method of cure which it admits is far from being void of hazard ; as must appear to every one who will consider, or who is at all acquainted either with the nature of lymphatic extravasation or absorption, or with the frequent consequences of wounds inflicted on parts merely mem- branous."3 This form of hydrocele admits of temporary if not per- manent relief, with less risk than was supposed by Mr. Pott. For, as the cells communicate freely, it is not necessary to make a large 1 Lib. cit. p. 252. 2 Treatise on Hernia, tr. by Wishart, p. 99. 3 Lib. cit. p. 371. OF THE SPERMATIC CORD. 163 incision for the removal of the fluid, one or two acupunctures in the depending part of the tumor being sufficient to enable the fluid to escape into the connective tissue of the scrotum, from which it will soon be removed by absorption. The danger of free incisions into the distended connective tissue arises from their being liable to excite diffused inflammation, which is apt to spread along the cord to the pelvis, and end in gangrene, especially in persons of im- paired constitution. Both Scarpa and Pott have witnessed instances in Avhich the operation of incision has proved fatal. The latter surgeon has related a remarkable case of diffused hydrocele, in a man, aged thirty-five, of such prodigious size that it hung more than half-way doAvn to the patient's knee, and formed a considerable tumor in the inguinal region. The diagnosis was extremely difficult. An incision was made into it, and eleven Winchester pints of water were drained off. The fluid collected again; and Mr. Pott divided the Avhole scrotum from the bottom upwards, from which operation the patient died.1 SECTION V. Encysted Hydrocele of the Spermatic Cord. This term is applied to a tumor caused by the development of a cyst containing fluid, in the loose connective tissue of the sper- matic cord. The cyst is formed of a thin transparent membrane, possessing the ordinary characters of a serous membrane, and contains generally a limpid aqueous liquid, having little or no albumen, but sometimes a straw-colored serum similar to the fluid of simple hydrocele. It is of an oval form, and its size, though variable, seldom exceeds that of a hen's egg, and is usually smaller. It is loosely attached to the vessels of the cord, which are situated at its back part, but become separated and displaced by it. The cyst is invested by the common integuments, superficial fascia, mus- culo-aponeurotic sheath of the cremaster muscle, and fascia trans- versalis. It may occur either immediately above the testicle, in the middle of the cord, or just below the abdominal ring, and even within the inguinal canal. Usually there is a single cyst, but occa- sionally several are developed, and a chain of them has been formed along the cord. The cyst and its contents are liable to changes consequent upon inflammation. • Lib. cit. Case X. p. 377. 164 ENCYSTED HYDROCELE Fig. 21. Encysted hydrocele of the cord appears to originate in a partial or imperfect obliteration of the prolongation of peritoneum, formed at the period of the transition of the testicle. Thus, in consequence of the serous membrane remaining unclosed at one or more spots, an isolated sac or sacs are left in the course of the spermatic cord. A cyst of this kind when distended with serum constitutes an encysted hydrocele. Such is obviously the mode of origin of this affection when occurring in infants, and no doubt in adults it generally origi- nates in the same way. M. J. Cloquet has remarked that the re- mains of the peritoneal process accompanying the testicles in their descent were met with in male subjects of all ages, and he mentions as a singular circumstance that they were nearly as frequently found in the old as in the young subjects.1 My own dissections agree with the observations of this accu- rate anatomist. In the London College Hospital there is a preparation showing the tunica vaginalis continued for about two inches up the cord, and, immedi- ately above it, an encysted hydrocele, which was taken from an adult subject. In dissecting the body of a man, aged eighteen, I found an encysted hydrocele of the cord above the testicle in close contact with the tunica vaginalis. Im- mediately above this cyst, but quite dis- tinct from it, there was a narrow and empty serous sac three inches in length, with a contracted neck, and communica- ting with the abdomen. They are figured in the accompanying engraving, with the hernial sac laid open, and part of the parietes of the encysted hydrocele cut away to expose their interiors. The po- sition of the testicle is so changed that its anterior border is directed downwards—In the examination of the body of a man who died of disease of the heart, I found on the right side a thickened and empty serous pouch, extending for about 'Description of the parts concerned in Inguinal and Femoral Hernia, tr. by McWhinme, p. 25. } OF THE SPERMATIC CORD. 165 an inch and a half beloAv the external abdominal ring. Directly below it was an independent cyst, capable of containing a walnut, similar in structure to the hernial sac, but lined by a thin false membrane. The tunica vaginalis, which was healthy in structure, extended up the cord as far as the cyst, from which it was separated by a thick and firm partition.—In opening the body of a sailor who died with ascites, I noticed at the internal ring a small, delicate, transparent, pedunculated cyst, not larger than a nut, projecting into the cavity of the abdomen. In the spermatic cord there was a large serous cyst, which extended into the inguinal canal, and contained a small quantity of transparent fluid. A small orifice at its upper part opened into the pedunculated cyst, which proved to be a pro- cess from the cyst in the cord. In Fig. 24 I have given a repre- sentation of an inguinal hernia, combined with an elongated en- cysted hydrocele of the cord ; and in Fig. 27 a representation of an encysted hematocele of the cord, in which the tunica vaginalis remained unobliterated as far up as the cyst, whilst a hernial sac is situated immediately above it. These dissections confirm the view taken by Sir A. Cooper, and now commonly adopted, of the mode of origin of encysted hydrocele of the spermatic cord in the adult. Symptoms.—An encysted hydrocele of the spermatic cord is seldom discovered until it has attained some considerable size, its forma- tion being imperceptible, and unattended with pain or inconvenience. It produces a swelling in the spermatic cord, which is of an oval and defined form, and distinct from the testicle, which feels even and tense, and has an obscure fluctuation, and may be handled freely without pain, and which is more or less transparent, and quite movable upwards and downwards. The distance of the tumor from the abdominal ring and testicle varies in different cases, and is liable also to temporary alterations from the irregular con- tractions of the cremaster muscle. The vessels forming the sper- matic cord can generally be traced to the posterior part of the cyst. This affection is met with most commonly in infants, and I have seen it as early as a fortnight after birth; but it occurs at all periods of life. Diagnosis.—An encysted hydrocele of the spermatic cord can scarcely be mistaken for a vaginal hydrocele, but sometimes cannot be distinguished without difficulty from an encysted hydrocele of the testicle. Indeed I know that cases which have been described as hvdroceles of the cord, the fluid containing spermatozoa, have been 166 ENCYSTED HYDROCELE in reality encysted hydroceles springing from the epididymis. When the cyst in the cord is situated high up, the distinction is clear; but when it is close to the gland and of large size, so that the tes- ticle is more or less embedded in the tumor, this form of hydrocele is very readily mistaken for an encysted hydrocele of the testicle, nor is the diagnosis always possible. The chief distinctive mark is the circumstance that notwithstanding its apparent close connec- tion with the gland, the cyst may be detached by manipulation, and proved to be formed above and distinct from the testicle or epididymis ; Whereas when an encysted hydrocele of the epididymis is pushed towards the ring, the testicle closely follows or moves with it. An encysted hydrocele of the cord is liable to be mistaken for an inguinal hernia. It differs, however, in the uniform size and defined shape of the tumor, which does not extend upwards to the ring; in being transparent, very movable, and receiving no impulse on coughing; and in the absence of the gurgling sensation, and other symptoms usually attendant on ruptures. When of small size, and situated near the abdominal ring, the tumor may admit of being pushed upwards into the inguinal canal, a circumstance which renders the diagnosis rather difficult. The facility, however, with which the vessels of the cord can generally be felt when the tumor has descended again, and the parts between the swelling and the ring are grasped between the finger and thumb, will enable the surgeon to ascertain the nature of the case. But if, as sometimes happens, the cyst be situated within the inguinal canal, or at the opening of the external abdominal ring, it is extremely difficult to distinguish the swelling from a hernia; for it disappears under pressure, is very apparent when the patient is in the erect position, and is removed or is less manifest when he is in the recumbent pos^ ure The diagnosis will be facilitated by observing that although the tumor cannot be made to descend below the external ring, of ntestan Th ^ TPletdy int° the abdomen like a Potion mn t St at ^^ Lmg l0dgGd " thG in^inal Ca-]> *™ Z obii! T" Z l^ f °ln behind the tendon of th^xter- pe en ible t tb" ' ,\ ^ BOmewhat °bsCUre> *® 7« ^ perceptible to the eye and fingers of the adroit surgeon The fol- culty was experienced in the diagnosis.-A youth, aged fifteen was OF THE SPERMATIC CORD. 167 admitted into hospital on account of a supposed strangulated hernia. When three years of age he had been subject to rupture on the right side, and had worn a truss for two years, when it was discon- tinued, as the hernia seemed cured. On the morning of his admis- sion he was seized Avhilst at work with pain in the right groin, and on feeling the part discovered a small swelling. As the pain was increasing, he returned home, and shortly afterwards vomited. A surgeon Avho was sent for applied the taxis, and failing to reduce what he supposed from the history and examination to be a hernia, sent the lad to the hospital, when he was again examined, and placed in a Avarm bath, after Avhich I was summoned to perform an operation. I found the lad with an anxious countenance, and affected Avith nausea. Just beloAv the abdominal ring there was an extremely tense and tender oval swelling the size of a pullet's egg. It had a contracted neck extending into the inguinal canal, received no impulse on coughing, and the testicle Avas below and distinct from it. On examination by transmitted light the swelling was found to be quite transparent. I at once came to the conclusion that the case was an acute hydrocele of the spermatic cord, and by the application of leeches and ice to the tumor, and the administra- tion of calomel and opium, all the symptoms were relieved. He was discharged in a few days, at which time the fluid had nearly disappeared. Above the SAvelling there was a slight hernial descent, for Avhich a truss Avas ordered. Treatment.—In children encysted hydrocele of the cord, like simple vaginal hydrocele, often and indeed generally disappears spon- taneously, so that surgical interference is seldom required for its re- moval. It is frequently, however, a source of uneasiness to parents, who are apt to apprehend the existence of a rupture. The surgeon may therefore safely assure them, not only that it is a complaint of slight importance, but that if it does not vanish of its own accord, or by simple treatment, an operation comparatively trifling will effectually remove it AAhenever it attains such a size as to be pro- ductive of inconvenience. But it is better not to interfere with an encysted hydrocele of the cord, either in children or adults, so long as it is of small size and unattended with pain. The compound tincture of iodine may be painted over the swell- in «• every second or third day. Should it not disperse under this treatment in the course of two or three weeks, and continue to be 168 COMPLICATIONS OF* HYDROCELE. a source of annoyance from its bulk, acupuncture may be performed. In early life this generally proves a permanent remedy. But if the swelling return, as may be expected in the adult, other measures must be resorted to. The radical cure of encysted hydrocele of the spermatic cord maybe effected in various ways. Excision of a portion of the cyst, incision, the seton, the tent, and injection, have all been employed for the purpose. Incision and the seton are not free from risk, being liable to excite diffuse inflammation of the connective tissue of the part. Mr. Pott has related a case treated by incision which proved fatal on the seventh day, from inflammation extending to the connective tissue of the pelvis and loins. The subject of the operation was, however, in a bad state of health.1 I was informed by the late Mr. Morton of a case in which such severe inflamma- tion of the connective tissue succeeded the introduction of a seton, composed of a single thread of silk, through an encysted hydro- cele in the spermatic cord of a boy, that suppuration took place in the iliac fossa, and for a time endangered the patient's life, though he finally recovered. The injection of the tincture of iodine is quite applicable to this form of hydrocele, and is the treatment which I recommend as both safe and effectual. SECTION VI. Complications of Hydrocele. The following are the principal complications of hydrocele :— 1. Vaginal hydrocele, combined with encysted hydrocele of the testicle. 2. Vaginal hydrocele, combined with encysted hydrocele of the spermatic cord. 3. Vaginal hydrocele, combined with diffused hydrocele of the ■ spermatic cord. 4. Oscheo-hydrocele, including both vaginal hydrocele, and encysted hydrocele of the cord, combined separately with inguinal hernia. 1. Vaginal hydrocele, combined with encysted hydrocele of the testicle, is not an uncommon complication. In dissections I have 1 Lib. cit. Case XIV, p. 390. COMPLICATIONS of hydrocele. 169 often found the tunica vaginalis distended with three or four drachms, and even an ounce or two of serum, tAvo or more small distinct cysts being at the same time connected with the upper part of the epididymis ; and I have twice met with this complication on both sides in the same individual. The small adventitious cysts appear to be the original disease, the irritation produced by them being the cause of the effusion in the tunica vaginalis. The tumor formed by the Combined cysts is in some cases smooth, and in others irregular, according to their relative size. When the quantity of fluid effused in the tunica vaginalis is only small, this complication may sometimes be distinguished; but when the amount is consider- able, the distension of the tunica vaginalis completely masks the cysts developed in the testicle or epididymis, rendering it impossible for the surgeon to detect the nature of the case until after the withdrawal of the fluid from the vaginal sac. The combined hydro- celes sometimes attain so great a size as to require tapping; and some of the cases of operation on multilocular hydrocele mentioned by writers I believe to have been instances of this complication. It sometimes happens in a case of this kind, that when • the trocar is introduced at the anterior part of the swelling a quantity of pale straAV-colored serum is drawn off; but the tumor, though diminished, is not removed. If, however, the trocar be aftenvards passed into the fluctuating swelling which still remains, exit is given to a limpid or opaque white fluid.—A man, aged fifty-four, consulted me on account of a hydrocele. I removed four ounces of yellow serum from the sac of the tunica vaginalis, and then detected a cyst attached to the epididymis. This I tapped with a fine trocar, and drew off two drachms of opaque fluid, which contained spermatozoa. There was no return of either hydrocele at the end of two months. The only after-treatment adopted was suspension and the outward application of the tincture of iodine. It is fair to infer that by the non-return of the encysted hydrocele, the irritation Avhich produced the vaginal hydrocele was removed. The facility of diagnosis and cure in this instance may be contrasted Avith the difficulties encoun- tered in the following case, for which I am indebted to Mr. Hamil- ton, surgeon to the Richmond Hospital, Dublin.—Mr. B., a fair vouni; man, aged twenty, consulted Mr. Hamilton about a hydro- cele of moderate size on the left side. It had existed for two years, and had been acupunctured and repeatedly tapped, and its radical 170 complications of hydrocele. cure had been attempted by iodine injection and also by seton, but without any effect on the hydrocele. The testicle was declared to be diseased, and he had been salivated, but with no diminution of the swelling. Mr. H. drew off about half a pint of clear pale yel- low fluid, and then observed that the testicle was enlarged, very irregular and nodulated, the lower part of the epididymis being pro- longed considerably downwards. The patient being of a strumous constitution and family, two of his brothers having died of phthisis at the age of puberty, the case was regarded as one of scrofulous disease of the testicle with extensive deposit in the epididymis. Castration was advised and performed, and the patient recovered favorably. When I Avas in Dublin, last summer, the tumor was shown me by Mr. Hamilton. The tunica vaginalis was thickened, but free from adhesions. The testicle was healthy, and displaced to one side by a moderate-sized multilocular hydrocele of the epi- didymis. There was also a small distinct cyst between the tunica vaginalis reflexa and tunica albuginea. The above case is one of remarkable interest and practical value. The strumous habit of the patient, the irregular tumor of the epididymis, and the resistance of the hydrocele to active treatment, indicated serious disease of the organ, and led to its being excised. In a similar case, the exami- nation of the tumor by transmitted light in a dark room would pro- bably enable the surgeon to detect the nature of the disease; yet not Avithout difficulty, especially if, as in the case just narrated, the tunica vaginalis were thickened, and the encysted hydrocele multi- locular. The following case occurred to my colleague, Mr. Adams. As in the one just related, the failure of the radical treatment of the vaginal hydrocele appears to have been owing to the complication with encysted hydrocele.—A man, aged twenty-two, was admitted into the London Hospital, in February, 1855, with a hydrocele, which had formed after a contusion of the right testicle. It had already been tapped five or six times. Mr. Adams injected the tunica vaginalis with tincture of iodine without success. Three months afterwards he laid open the thickened sac, and then per- ceived three transparent cysts about the size of hazel-nuts connected with the epididymis. These cysts were also incised. A good deal of inflammation and swelling of the parts followed the operation. This subsided, and the wound closed by granulation in three Aveeks. I complications of hydrocele. 171 2. Vaginal hydrocele, combined with encysted hydrocele of the spermatic cord, is somewhat rare. The swelling produced by the accumulation in the tunica vaginalis is below and rather in front of the tumor in the spermatic cord, and a well-defined furrow in the scrotum generally marks the boundary between the two. In the London Hospital College there are two specimens of a collection of fluid in the tunica vaginalis associated with an encysted hydrocele of the spermatic cord. In one of them, the tunica vaginalis has remained unobliterated for about tAvo inches along the spermatic cord, and the encysted hydrocele is seen immediately above it. In the other preparation, it is apparent that both sacs have been the seat of inflammation, false membranes being contained within them, and the testicle being a good deal enlarged.—A child, six years of age, came under my care at the hospital on account of a large hydrocele on the right side, which extended upwards nearly as high as the abdominal ring. Three acupunctures were made in the tumor, and in ten days the Avhole of the fluid had disappeared; but observing a small SAvelling still remaining in the direction of the spermatic cord, I made a further examination, and detected an encysted hydrocele of the cord just above the testicle, Avhich had previously been concealed by the fluid collected in the vaginal sac. The skin covering it Avas painted with tincture of iodine twice a Aveek; but not disappearing so quickly as I wished, it was after- Avards punctured Avith a needle. The acupuncture Avas repeated two or three times, and in a fortnight the encysted hydrocele of the cord was removed, and I believe did not return. A case of this complication, in an infant not many weeks old, is recorded in the Medical Gazette.1 3. Vaginal hydrocele, associated with diffused hydrocele of the cord, is also a rare complication. The chief marks of the complaint arc, the remarkable volume of the neck of the tumor, with a dilated state of the abdominal ring; the irregular form of the swelling ; and the existence of a furrow passing obliquely on the anterior part of the scrotum, corresponding to the superior margin of the dis- tended vaginal coat, and being higher or lower according to the amount of the fluid accumulated within it. Simple hydrocele of the hour-glass form exhibits a double tumor divided by a furrow; but the swelling is defined above, and has no neck, and fluctuation 1 Vol. xxix, p. 757. 172 COMPLICATIONS OF HYDROCELE. Fig. 22. is communicable from one to the other. Any doubt in regard to diagnosis in a case of this kind may be cleared up by a puncture made into the anterior tumor, when, after the water collected in the tunica vaginalis has escaped, the swelling occasioned by the diffused hydrocele of the cord will still remain undiminished. Encysted hydrocele, combined with simple hydrocele, is also distinguished from the present complication by the defined form of the tumor above ; and from a vagi- nal hydrocele of the hour-glass form, by fluctuation being limited to the separate swellings. 4. Oscheo-hydroeele. — Scrotal hernia may be combined with vaginal hydrocele, each disease being marked by its peculiar symptoms. A voluminous hydrocele, if un- supported, appears to be highly favorable to the occurrence of hernia and the exten- sion of the sac, by dragging down the peri- toneum. M. J. Cloquet dissected the body of an old man, the subject of inguinal hernia on the right side. The sac was four inches in length; its orifice was large and rounded, and its cavity was separated into two parts by a fibrous project- ing ring. Below the. latter the peritoneum was thick, whitish, and very adherent to the external coverings; above, it was thin and trans- parent, as in the abdomen. The descent of the fibrous ring, and consequently the elongation of the sac, appeared to be owing to the weight of a voluminous hydrocele of the tunica vaginalis, which intimately adhered to the loAver part of the hernial tumor. A fold of small intestine, two inches and a half long, and unadherent, occupied the upper division of the sac. M. Cloquet has related the particulars of another case of inguinal hernia, complicated with a very large hydrocele, in which he observed, on raising the tumor and gently drawing up the peritoneum of the abdomen, that the hernial sac receded and diminished in extent. The sac contained omentum, which was reducible, and the hernia was situated behind Simple hydrocele combined with diffused hydrocele of the cord. (After Scarpa.) 1—1. Fur- row marking the division between the tumors. COMPLICATIONS OF HYDROCELE. 173 the hydrocele.1 The occurrence of these two diseases is not an uncommon complication; in most of the cases which I have met with the hydrocele was placed below, and free of the rupture, and in a few only in front of it. I have never found the hernial sac covering the forepart of a hydrocele. The ordinary relations of hydrocele and scrotal hernia may be seen in the accompanying woodcut. In Fig. 11 the sac of an inguinal hernia is represented at some little distance, above a small hydrocele. Dupuytren states, that Avhen a hydrocele is placed in front of a hernia, a part of the omentum or intestine descends into a cyst, which projects into the hydrocele, and is formed of the hernial sac and serous fold of the tunic of the testicle. Out of six cases of this kind which came under his observation, in two instances he found symptoms of strangulation to depend on constriction at the part where the viscera were engaged in the serous pouch of testicle.2 This complication is of the nature of the hernia infantilis, described by Mr. Hey, and called by Sir A. Cooper encysted hernia of the tunica vaginalis. When the hydrocele is large and the hernia irreducible, the diagnosis of these cases is sometimes difficult, in consequence of the hernial tumor pressing on the upper part of the sac of the hydrocele, and conveying an impulse on coughing to the whole body of the fluid contained in the latter. The nature of the case may be ascer- tained on examination of the tumor by transmitted light. The coexistence of hernia and hydrocele does not in general con- stitute an objection to the performance of the radical operation for the latter. But the surgeon should be particularly cautious not to excite too much inflammation; and in cases where the contiguity of the tAvo sacs is close and extensive, and in those in which the hernial sac projects into the hydrocele, he should recommend the patient to be content with the palliative treatment. The hernia should ahvays, if possible, be reduced before the tunica vaginalis is punc- tured. A large pyramidal hydrocele reaching to the ring not only 1 Recherches Patholoiiiques sur les Causes et l'Anatomie des Hernies Abdominales, p 22. 2 Lemons Orales, liru>sels edit. t. iv, p. 233. 174 COMPLICATIONS OF HYDROCELE. interferes Avith the application of a truss, but may render one unne- cessary by closing the operiing and effectually preventing the descent of the bowel. In a case of the kind, in which I removed by tapping thirty ounces of fluid, a large hernial protrusion occurred as the hydrocele subsided during the operation. Scarpa has described a case of strangulated inguinal hernia, complicated with encysted hydrocele of the spermatic cord, in which it was necessary to operate.—A student, about twenty-nine years of age, was attacked with symptoms of incarcerated hernia. He had been-subject to a rupture on the left side of the scrotum for more than fifteen years, but had not been able to fit a proper ban- dage. The hernia was tense, and above Fis- 24- the moderate size, and the bottom of the tumor was unusually raised, and as it were pushed upAvards, by a body situated behind the hernia; which body was undoubtedly not the testicle, as the gland was felt in the bottom of the scrotum, and lower down than the hernia. The symptoms being very urgent, the patient was operated on in Scarpa's presence. The hernial sac was found to contain a very small quantity of water, and a loop of small intestine lightly tinged of a brown color, and about three or four inches in length. After division of the neck of the sac and the ring, and also after reduction of the intestine, there still remained ex- ternally a soft tumor, elastic, and evi- dently full of fluid. An incision was made into this tumor, and a considerable quantity of serous fluid discharged. At the bottom there appeared a vesicular gelatinous, substance, which was cut away ; and it was clearly perceived that .the intestinal scrotal hernia was accompanied posteriorly with an encysted hydrocele of the sper- matic cord. In the course of six weeks the patient Avas completely cured of both these diseases.1 This is a somewhat rare complica- 1 Treatise on Hernia, tr. by Wishart, p. 231. HYDROCELE OF THE HERNIAL SAC. 17o tion, and I have met Avith but few instances of it. In all it occurred on the right side, and the patients were adults. In one, who died of peritoneal inflammation, Avith the hernia unreduced, I made a dissection of the parts. The hernial sac was greatly thickened, and coated with lymph, and contained a small fold of intestine surrounded by turbid serum. Directly below it there was a hydro- cele of the cord of an oblong shape, and more than two inches in length, the parietes of which differed from the hernial sac in being thin and transparent. The testicle hung lower than natural, and was so displaced that its antero-inferior edge presented directly downwards (see Fig. 24). In another case the patient was a young man, twenty years of age, and the hydrocele and hernia were both recent, and had formed about the same time. In encysted hydrocele of the spermatic cord the parts are gene- rally in a condition favorable to a hernial descent, the cyst being most commonly the result of an indisposition of the peritoneum in the course of the cord to unite, or become obliterated after the arrival of the testicle in the scrotum ; and it often happens in these cases that the peritoneal process above the hydrocele remains patent, and in communication with the cavity of the abdomen. Thus, at p. 104, I have narrated two cases of encysted hydrocele of the cord, in which, on dissection, I found an empty hernial sac above the cyst of the hydrocele. If the hydrocele extended high up, it Avould prevent the proper adjustment of a truss, and would therefore require to be cured before the application of any instru- ment. This was the case with a middle-aged man sent me for ex- amination by the late Mr. Avery. The hydrocele was on the right side, and being only a short distance beloAV the external ring, in- terfered with the application of a truss, on which account I re- commended it, though small in size and not otherwise inconve- nient, being injected. SECTION VII. Hydrocele of the Hernial Sac. A hernial sac sometimes becomes the seat of dropsical effusion, the connection with the abdomen being interrupted by adhesion at the neck, or by a portion of adherent intestine or omentum block- in o- up the orifice. Thus the continued application of a truss some- 176 hydrocele of the hernial sac. times causes obliteration of the neck of the sac, and the radical cure of the hernia ; but the lower part, remaining patent, is liable to become the seat of an effusion of serum. A man was admitted into the hospital of La Charite in Paris, under Boyer, Avith a tumor in the right groin, which was found to be hydrocele of an old her- nial sac. The hernia had been cured by the obliteration of the neck of the sac, and the serous pouch had remained for a time wrinkled up in the course of the cord, but it afterAvards became the seat of dropsical effusion.1 Mr. Pott has narrated two inte- resting cases of a collection of fluid in the sac of a congenital hernia.2 In one the opening of the sac was closed by adherent omentum; in the other it was blocked up by intestine. Pelletan has recorded two cases of hydrocele of the hernial sac (one of them congenital), in Avhich the communication with the abdomen was closed by adherent omentum.3 Hydrocele of the hernial sac is certainly a rare affection, and I have witnessed only a few cases of it. In one which occurred some years ago at the London Hospital, the hydrocele was double; the tumors were very large on each side, quite unconnected with the testicles, and resulted from the constant wearing of a double truss for a period of thirty- five years. Le Dran has recorded a remarkable case of triple hydrocele on the same side, a hydrocele of a hernial sac having been combined with a hydrocele of the cord and with a simple hydrocele, which together formed a tumor the size of a small melon. The hydrocele of the hernial sac was consequent upon the radical cure of a hernia, the obliteration of the neck of the sac having been caused by the pressure of a truss.4 Diagnosis.—In hydrocele of the hernial sac, the absence of a defined margin at the upper part of the tumor, together with the swelling at the abdominal ring, and the inability of feeling the spermatic cord, being also marks of scrotal hernia, tend to render the diagnosis of this rare form of hydrocele somewhat obscure. But the detection of fluid by the transparency and evident fluc- tuation of the tumor, and a careful attention to the history of the case, are sufficient to enable the practitioner to avoid any serious ' La Lancette Francaise, FeVrier, 1837. 2 Lib. cit. p. 463, Cases XXXIV and XXXV. 3 Clinique Chirurgicale, torn, iii, pp. 22, 108. 4 Observations on Surgery, tr., Case LXXV, p. 260. HYDROCELE OF THE HERNIAL SAC. 177 error. There is generally, also, an absence of any impulse on coughing; though sometimes, in consequence of the swelling ex- tending up into the inguinal canal, an impulse is communicated to it from the abdomen, which increases the difficulty of the diagnosis. The extension of the swelling to the abdominal ring, and the tes- ticle being distinct from the tumor at the bottom of the scrotum, are sufficient to distinguish hydrocele of the hernial sac from simple hydrocele. Some difficulty might be experienced in diagnosing a small hydrocele of the hernial sac from an encysted hydrocele of the cord high up. They are both distinct from the testicle, and their relative situation and even mode of formation are very similar ; the only essential difference being that the process of peritoneum constituting the former had once contained either intestine or omentum. A hydrocele of the hernial sac occurs somewhat late in life, is usually of some considerable size, and its fluid contents are of an amber or dark color ; whilst an encysted hydrocele of the cord generally appears before puberty, is rather small in size, and contains fluid which is generally colorless and nearly free from albumen. Attention, therefore, to these circumstances, but more especially to the history of the case, would leave but little room for doubt. The following case will illustrate the difficulties of the diagnosis. J. B., a shoemaker, aged fifty-eight, came under my care at the London Hospital, March 25, 1843, on account of a painful swell- ing in the left groin. There was a tense tumor, the size of a hen's egg, just below the external abdominal ring, and about two inches above the testicle, from which it was quite separate. It received no impulse on the patient coughing, fluctuated indistinctly, and was very tender when handled. The spermatic cord could be traced from the testicle to the back part of the swelling. The tumor was defined below, but extended by a broad neck into the inguinal canal. The patient Avas placed in a dark room, and the swelling examined by transmitted light, and found to be transparent, but its want of prominence and small size rendered this mode of examination very difficult. He stated that the SAvelling first came about two years ago, after a blow in the groin, Avhich he received by running against a post. It came gradually in the course of a month after the acci- dent, and has never since disappeared. He was seized three days before he came to the hospital with vomiting, and pain which ex- 12 178 HYDROCELE OF THE HERNIAL SAC. tended from the tumor into the abdomen, and pain was still felt on pressure in the vicinity of the abdominal ring. He had expe- rienced a similar attack about nine months previously. I con- cluded that this was a case of hydrocele of the hernial sac, a piece of intestine or omentum being adherent at the ring and slightly in- flamed. The pain just above the tumor, and the diffused character of its upper part, induced me to suppose that it was not an en- cysted hydrocele of the cord. Eight leeches were applied to the upper part of the swelling, and afterwards a cold lotion; a dose of castor oil was given, and the patient kept at rest in bed. 28th. The swelling was less in size and not so tender, and he was re- lieved of the pain in the abdomen. Five more leeches were applied, and the lotion continued. April 3d. The swelling was further diminished, and all tenderness removed. I ordered a blister over the part. From this time the tumor continued steadily to decrease, and on the 17th all the fluid had disappeared. On placing the hand on the groin a distinct impulse, arising from a slight protru- sion, Avas felt when the patient coughed. A truss was applied. This restrained the protrusion, and the patient was discharged cured without the slightest swelling remaining in the course of the sper- matic cord. Treatment.—Cases of hydrocele of the hernial sac arising after the radical cure of a rupture, the neck of the sac beino- perma- nently obliterated by adhesion, should be treated on the same prin- ciples and in the same manner as simple hydrocele. In the treat- ment of cases Avhere there is reason to believe that the opening of communication has become closed by the adhesion of a portion of omentum or intestine, more care is required, and the surgeon should be content with palliative means. Some years a°-o I saw a case of hydrocele of the hernial sac through which a seton had been passed for the radical cure, but with a fatal result. The neck of the sac was found after death closed by adherent omentum, which was highly inflamed, marks of peritonitis existing in its vicinity. Spurious Hydrocele of the Hernial Sac—Cases of a chronic collection of fluid in the sac of an old hernia, in which the commu- nication with the abdomen has been permanently obliterated by adhesion at the neck, either of the sides of the sac, or of a portion of omentum or intestine, must not be confounded with cases of HYDROCELE OF THE HERNIAL SAC. 179 scrotal hernia attended with a remarkable effusion of fluid. The latter affection may be denominated spurious hydrocele of the hernial sac, a term that would include all cases of hernial sac coupled with serous effusion, whether the communication with the peritoneal cavity be closed or open, and the fluid reducible into the abdomen. The second case, related by Mr. Pott, to which I haA-e alluded, seems to have been an example of this kind. Symptoms of strangulation ensued in a man, aged twenty-two, who had been subject to rupture. Mr. Pott divided the integuments of a large scrotal swelling as in the operation for hernia, and on opening the sac let out about half a pint of clear limpid water, upon the dis- charge of which the Avhole tumor of the scrotum subsided, and it was supposed that he had mistaken a hydrocele for a hernia. But the tumor and hardness about the abdominal ring still remained un- altered, and on passing the finger upwards a small portion of intes- tine was found engaged in the abdominal ring, and bound extremely tight. The stricture Avas diA'ided; but the gut could not be returned, until an adhesion which connected it to the lower border of the opening was discovered and also divided. The patient recovered. Scarpa well remarks, " Whatever difficulty these complications may oppose to the exact diagnosis of reducible intestinal scrotal hernia, they do not occasion any with regard to the operation, whenever the hernia is affected with strangulation ; as the symptoms accom- panying the incarceration of the intestine show clearly the nature of the principal disease, and render the operation necessary, by means of which Ave have at the same time the advantage of laying bare what formed the complication of the hernia, and of curing radically both diseases."1 He has related an example of acute hy- drocele of the hernial sac, complicated with intestinal scrotal hernia, which illustrates the difficulty of the diagnosis also in these cases. A man, tA\enty-five years of age, stout and very fat, was affected with incarcerated scrotal hernia of enormous size. The hernia was of eight years' standing. The day before the incarceration, he was obliged to make a rapid journey on horseback, his truss broke on the way, and on alighting he found the scrotum of extraordinary size; he was likewise affected with nausea, acute pain in the groin, and inclination to vomit. The tumor was fully sixteen inches in circumference, and almost entirely concealed the penis : it was broad 1 Treatise on Hernia, tr. by AVishart, p. 230. 180 HYDROCELE OF THE HERNIAL SAC. at the bottom, narrow at the upper part towards the ring, equal and smooth in almost its whole surface, and elastic. It resembled a large hydrocele, and might have been taken for one, if there had not been evident marks of incarcerated intestine. Scarpa remarks, " I could with difficulty persuade myself that this large tumor was formed for the most part by water collected in the vaginal coat of the testicle, or in the hernial sac, as the patient never had the smallest mark of serous effusion in the scrotum, as well as because, from the repeated assertion of the patient, the hernia in the course of eight years had never exceeded the size of a hen's egg, and there was no reason to suppose that so much water had descended from the cavity of the abdomen into the scrotum in a young man in other rCspects very healthy and strong. I rather suspected, considering the fatness of the patient, that by the exertion of the riding a great mass of omentum had descended, although there still remained some doubt hoAv, in so short a time, the hernial sac could have yielded to so great a distension, and because the tumor had rather the appear- ance and elasticity of a large hydrocele than of a large hernia com- posed of intestine and omentum." There was no doubt as to the impossibility of reducing the parts without an operation, as the symptoms of strangulation increased in violence every minute. On the first cut into the hernial sac, about three pounds of yellowish serum were discharged. It was a common scrotal hernia. At the upper part of the sac there was a loop of small intestine about two inches long, but no omentum. The stricture was divided, and the intestine returned. The patient recovered, the wound having healed in seven weeks. A somewhat similar case of large strangulated scrotal hernia, in which the bulk of the tumor was formed by serous effusion, is recorded by Mr. Shaw, of the Middlesex Hospital.1 Nothing is more common than the presence of fluid in the sac of a strangulated hernia, though it rarely exists, as in these cases, in such abundance as to cause any difficulty in the diagnosis. I have met with three cases of strangulated scrotal hernia, in which several ounces of fluid were contained in the same sac with the protruded viscera, and in which the rupture being congenital no testicle could be distinguished; but the previous history, fulness at the abdominal ring, and well-marked symptoms of strangulation, were sufficient to indicate the true nature of the complaint. In one of these cases, 1 Lond. Med. and Phys. Journal, vol. lvi, p. 18. HYDROCELE OF THE HERNIAL SAC. 181 which was operated on by Mr. Hamilton, the stricture was divided external to the sac ; and the fluid which had concealed the intestine, adherent omentum, and testicle, remained after the operation, but became absorbed as the patient recovered. Had Scarpa, in the case related above, examined the tumor by transmitted light, he could scarcely have suspected that the bulk of the swelling consisted of omentum. In those cases of spurious hydrocele of the hernial sac in which the fluid and intestine or omentum are reducible, the complication may be made out by returning the contents of the sac into the abdomen, the patient being in the horizontal posture ; when by pressing the finger gently on the abdominal ring, and allowing the patient to rise, the fluid will slip down into the scrotum, and produce a transparent tumor or hydrocele. On entirely remitting the pressure, the intestine or omentum will be felt descending into its former situation. In the following case, which was shown me by Mr. Adams, the symptoms produced by spurious hydrocele of the sac of a congenital hernia closely resembled those of a congeni- tal hydrocele.—A lad, aged twelve, applied as an out-patient at the London Hospital, on account of a swelling which occupied the left side of the scrotum. It was a transparent tumor, of an oval form, reaching upwards into the abdominal canal, which fluctuated, com- pletely filled the scrotum, and received an impulse on coughing. The left testicle Avas imperceptible. On making gentle pressure the swelling disappeared rather suddenly, and then the testicle could be readily distinguished, and Avas found less than half the size of the gland on the right side. The sac Avhich contained the fluid felt a good deal thickened. The boy stated that the swelling had existed since he was tAvo years of age. This appeared to be a case of congenital hydrocele, of which, indeed, it presented all the usual symptoms, except that on pressure the swelling disappeared sud- denly instead of gradually. The boy was accordingly directed to haAre a truss to press on the abdominal ring. After it had been worn for three weeks, the fluid was found to have entirely disap- peared from the sac, and none descended on the removal of the truss. When, however, the boy coughed, a small intestinal hernia came down. It then became clear that this had been a case of spurious hydrocele of the hernial sac ; and thus was explained the only symptom unusual in congenital hydrocele, viz. the sudden dis- appearance of the tumor on pressure, the fluid passing into the 182 HYDROCELE OF THE HERNIAL SAC. abdomen together with the intestine, which it had completely masked from observation. M. J. Cloquet has detailed the particulars of the dissection of the parts, in a case of congenital inguinal hernia on the right side, found in the body of a man, aged thirty, affected with ascites, Avho had worn a truss. The testicle, which had not descended lower than just outside the abdominal ring, had formed a valve, which admitted the passage of fluid into the sac, but prevented its re- turn into the abdomen.1 The testicle, in this case, seems to have acted much in the same way as the valvular fold of peritoneum which exists at the ring in many quadrupeds. In operating for the remoAral of fluid in cases in which there is reason to suspect that intestine or omentum is also contained in the hernial sac, the surgeon should proceed in the most cautious man- ner. Monro, senior, relates the following case.2—" An old man had long labored under a hernia, which had not been reduced for many years. The tumor became at last of a monstrous size, descend- ing nearly to his knee, and having a proportional transverse dia- meter : he was confined to lie on his back, had violent pain both in the tumor and his loins, and his flesh and strength wasted. In some places a plain fluctuation was perceived, without any of the unequal solid substances felt everywhere else. Neither the water nor solid substances could be pushed into the belly. The tumor being pressed, so as to make one of those parts where the fluctua- tion was most evident and the teguments were thinnest as tense and prominent as possible, a trocar, as small as a crowquill, was thrust very slowly through the teguments and cyst. Whenever the bag was pierced the stilet was taken out, and the canula was pressed a little forward, through which six pounds of clear serous water ran out; then the convolutions of the intestines and the knotty parts of the omentum were plainly felt, but none of them would reduce." The patient was greatly relieved of his pain, and no further opera- tion Avas thought proper. Unless the fluid should accumulate in so large a quantity as to cause serious inconvenience to the patient, as in this remarkable case, an operation for its removal would not be proper; for the surgeon is not warranted in opening a serous sac containing intestine on slight grounds. If it became necessary ' Recherches sur les Causes et l'Anatomie des Hernies Abdominales, p. 97. Medical Essays and Observations, vol. v, p. 314. HEMATOCELE OF THE TESTICLE. 183 to get rid of the fluid, acupuncture would be the plan best suitable to such a case. If the intestine or omentum were reducible, the application of a truss would be the treatment required. CHAPTER V. HEMATOCELE. Hematocele denotes the swelling occasioned by effusion of blood in the sac of the tunica vaginalis, or in a cyst connected Avith the testicle. It is also applied to tumors produced by extra- vasation in the substance of the spermatic cord, or in the sac of an encysted hydrocele of this part. The following table exhibits at one vieAV the different forms of this affection: {Simple. Associated with Hy- drocele. Hematocele ^ Of the Spermatic Cord Diffused. Encysted. SECTION I. Hematocele of the Testicle. In vaginal hematocele, which is by far the most common form of this affection, the extravasation may take place in a healthy state of the parts, or it may succeed or be combined with hydro- cele. The first variety of vaginal haematocele occurs from the accidental rupture of some bloodvessel. It is usually produced by a blow. Thus it is liable to happen to a person on horseback, from the testicle being struck against the pommel of the saddle; or it may be occasioned by violent efforts made in straining, as in the attempt to raise a heavy weight. In these cases the testicle imme- diately enlarges, sometimes to more than double its natural size, from 'the rapid distension of the tunica vaginalis with blood. 184 hematocele of the testicle. The second variety of vaginal hsematocele, in which the extrava- sation takes place in combination with hydrocele, is of more fre- quent occurrence than the first. It may also be produced by a blow, or by the wound of some vessel in the operation of tapping. The testicle, owing to its free mobility, does not often suffer from mechanical violence; but when hydrocele exists, the tumor, from its prominence and size, is exposed to injury. A blow occasions a slight rupture of the tunica vaginalis, and of some of the enlarged vessels ramifying outside it; and the blood which escapes passes into the sac and mixes with the fluid of the hydrocele, producing a sudden increase in the size of the tumor. The quantity of blood effused under these circumstances varies considerably. It may be merely sufficient to impart a red tinge to the serum. In general, however, it is greater in amount, and coagula are formed, which remain undissolved in the fluid. A haematocele may be produced, in the operation of tapping a hydrocele, in two ways. 1. It may be occasioned by the accidental wound of some Aressel ramifying over the tunica vaginalis, which, instead of bleeding externally, or into the connective tissue of the scrotum, pours its blood into the sac of the hydrocele. This accident may occur when the opera- tion is performed with a trocar, but is more liable to happen Avhen the lancet is used. 2. A hsematocele may be caused by the trocar or lancet penetrating too far, and wounding the testicle or sper- matic artery. A case in which a hsematocele was occasioned by a wound of the artery is recorded by Scarpa.1 Mr. Fergusson relates that a man, in the habit of performing acupuncture for himself with several needles, on one occasion left a needle in the sac, which was quickly followed by the formation of a hsematocele. The tunica vaginalis was laid open, the needle extracted, and the patient cured.2 In hsematoceles consequent on contusions, an opportunity of tracing the source of hemorrhage is very rarely obtained. When the parts are in a healthy state the bleeding probably pro- ceeds from a rupture of some of the vessels ramifying between the tunica albuginea and the tunica vaginalis testis. In cases of hydro- cele the parietal portion of the tunica vaginalis is ruptured, the blood being derived from the vessels of the scrotum. In the case of a man who had long had a hydrocele, and had received a severe 1 Treatise on Hernia, tr. by Wishart, p. 76. 2 Lond. and Edinb. Monthly Journal, July, 1843. HEMATOCELE OF THE TESTICLE. 185 blow upon it, which suddenly increased the swelling, bruised the scrotum, and produced great pain from distension, Sir A. Cooper, on making an incision into it and discharging a large quantity of water and coagulated blood, found a rent in the tunica vaginalis, between one and two inches in length, covered with coagulum.1 The blood effused often acts as a foreign body, and excites active inflammation in the tunica vaginalis, lymph is exuded, and this mix- ing with blood and serum modifies the appearance of the contents of the cyst, rendering it turbid and of a lighter color. The inflam- mation may go on to suppuration in the sac. It usually extends from the tunica vaginalis to the surrounding connective tissue and fascia, which in recent cases are found infiltrated with serum and lymph. In a case of haematocele, occasioned by the wound of a vessel in tapping a hydrocele, in which I was consulted, the inflam- mation which ensued caused in the course of a fortnight great thickening of the tissues external to the sac, and the formation of an abscess in the scrotum on one side of the hsematocele. The in- flammation is not always, however, of this active character. A chronic form of inflammation is sometimes set up in the sac as Avell as in the surrounding fascia and connective tissue. In these cases the internal surface of the tunica vaginalis is lined with plastic lymph, and instead of presenting its natural smooth and polished surface, is rough, granular, and irregular, and sometimes feels as tough as a piece of leather, having lost all the characters of a serous membrane. The sac and its investing tissues not only become extremely dense and firm, but sometimes acquire as much as half an inch in thickness. In old hsematoceles the blood becomes changed into a substance resembling coffee-grounds, of a broAvnish- red, or chocolate color, and more or less fluid. The coagula some- times present a cellular or honeycomb appearance, the cells being filled Avith a reddish serum. Occasionally the blood is found con- verted into a solid fibrinous substance, of a yelloAV or fawn color, arranged in firm layers, similar to the coagula lining the sac of an aneurism. In hematocele the testicle preserves the same relation to the remainder of the tumor as in simple hydrocele, being situated at the posterior part, and rather below the centre. Its position, howeA'er, is liable to similar alterations as occur in hydrocele, and they are 1 Lib. cit. p. 212. 186 HEMATOCELE OF THE TESTICLE. dependent upon the same causes. I once witnessed an untoward event, which happened in the practice of a surgeon Avho Avas un- aAvare of the testicle being out of its usual position. A young man with an inverted testicle became affected with hydrocele.1 The case was converted into a hematocele by the wound of a vessel in the operation of tapping. Inflammation ensued, and it became neces- sary to lay open the sac. The surgeon, in carrying the incision to the lower part of the tunica vaginalis, divided the vas deferens, and severed the sound testicle nearly in two with his bistoury, the thickening around the sac having prevented him from detecting the gland in its unusual situation in front of the sac. This unfortunate accident obliged the surgeon to perform castration instead of inci- sion. In describing the difficulties of distinguishing the position of the testicle, I shall have occasion to mention another case of hema- tocele occurring to an inverted testicle in which a similar injury Avas inflicted in the operation of incision, and the testicle was removed in consequence. In chronic hematoceles it is said that the glandular structure of the testicle sometimes disappears as in old cases of hydrocele, atrophy being occasioned by the long-continued pressure arising from the extravasated blood. On examining the body of an elderly negro avIio died of disease in the lungs, Sir B. Brodie observed on the right side of the scrotum a large tumor, which was formed by the tunica vaginalis, distended with about twelve ounces of fluid having the appearance of coffee-grounds, with numerous masses of solid substance, manifestly fragments of coagulum, floating in it. The tunica vaginalis itself was much thickened. The substance of the testicle, the tunica albuginea, and the tunica vaginalis imme- diately covering it, were entirely destroyed, so that not a vestige of these parts could be discovered. The vas deferens adhered to the posterior part of the tumor, and was imperceptibly lost at the part where it usually joins the testicle. Sir B. Brodie likewise met with another case in which the appearances on dissection were precisely similar ; but here also he unfortunately lost an opportunity of learn- ing the history of the case during the patient's lifetime.2 Judging 1 In the first edition of this work I erroneously described the altered position of the testicle in this case to have arisen from adhesion of the gland to the front of the sac. I have since examined the parts, and have clearly made out the existence of an inversion. 2 Lond. Med. and Phys. Journal, vol. lviii, p. 299. HEMATOCELE OF THE TESTICLE. 187 from my own observations complete wasting of the testicle is a rare occurrence. In the examination of a large hematocele which had existed for many years, and was removed by operation under the impression that it was a solid enlargement of the testicle, I found the tunica vaginalis nearly half an inch thick, and full of a soft Fig. 25. friable substance of a chocolate color; the testicle, which was situ- ated at the posterior part of the cavity, was somewhat flattened, and partly embedded in the thickened cyst; but the glandular structure was perfectly healthy, and the bulk of the organ scarcely less than natural. The hematocele, with the sac and testicle laid open, is represented in the accompanying engraving. The struc- ture of the testicle is usually, indeed, sound in hematocele, though its nutrition may be liable to become impaired when the disease is of very old standing. Symptoms.—The first variety of vaginal hematocele appears sud- denly after a strain or the receipt of some injury. The testicle quickly enlarges to more than double its natural size, and forms a tumor, which°is of an oval shape, tender, tense, and fluctuates in- distinctly. If the affection be occasioned by a blow, this enlarge- 188 HEMATOCELE OF THE TESTICLE. ment is accompanied with extravasation in the connective tissue of the scrotum, Avhich conceals the hematocele. In one case Avhich came under my notice, the amount of blood effused into the scrotum was so great that the hematocele was not detected for a week, the enlargement consequent upon the effusion into the vaginal sac being obscured and concealed by the blood extravasated around it. As the latter became absorbed, the former was rendered distinct, and subsided much more slowly. Slight pain and tenderness continue for some days, and then subside, leaving the swelling but little altered, except that it feels rather more solid than at first. In the second variety, in which a hydrocele becomes converted into a hematocele, the tumor undergoes a sudden increase in size, and becomes more or less painful. It still preserves its pyriform shape and even uniform surface; but it feels very tense, and heaA'ier and more solid than before, and fluctuates very indistinctly. In the course of a few hours, or on the following day, inflammation arises, the part feels hot and tender, the scrotum becomes tense and some- times injected, and further enlargement ensues. These symptoms are attended with more or less febrile disturbance. Occasionally there is excessive pain, and high symptomatic fever; and the inflam- mation, if allowed to proceed, goes on to suppuration. In other cases the tumor from the first assumes an indolent character, becomes more firm and solid, and feels heavier than before, but undergoes no alteration in size. It may remain stationary in this condition for many years, producing no inconvenience beyond that which arises from its bulk and weight, which are sometimes con- siderable. Diagnosis.—A vaginal hematocele may be distinguished from a hydrocele by the absence of transparency, the obscure character of the fluctuation, the heavy feel of the tumor when balanced in the hand, and the sudden and accidental mode of its occurrence. In old cases, in which the tunica vaginalis and its envelopes have be- come much thickened and indurated, the tumor possesses so firm a character, feels so heavy and solid, that it is very liable to be mis- taken for a chronic enlargement of the testicle; and the diagnosis, at all times difficult, in some instances cannot be satisfactorily made out by the nicest manipulation of the most experienced hands. The records of surgery furnish many cases in which castration has been performed from a mistaken diagnosis : I have known three instances HEMATOCELE OF THE TESTICLE. 189 of the kind myself. In chronic swelling of the testicle, whether from malignant deposit or other disease, the gland loses for the most part its natural sensibility ; but in hematocele pressure on the back part, where the testicle is usually situated, occasions the pecu- liar pain always experienced when the organ is compressed. When the least doubt exists, it should in all cases be remoATed by the in- troduction of a lancet or trocar before any further operation is undertaken. SAvelling of the scrotum from extraArasation of blood in its loose connective tissue may arise someAvhat suddenly after a blow; but the diffused nature of the tumor and its extension to both sides of the scrotum, the concealment more or less of both testicles, doughy feel, and red or dark color of the skin, are characters too clearly expressive of the nature of the case to mislead the practi- tioner. Treatment.—In the first variety of hematocele, if the quantity of blood effused into the tunica vaginalis be small, the treatment should be simply antiphlogistic. The patient is to be kept in the recumbent position, with the testicle supported; a cold lotion is to be applied to the part, and the boAvels must be gently acted upon. If the tenderness be considerable, or symptoms of inflammation arise, a few leeches should be applied to the scrotum, or, if there be much contusion of the part, to the corresponding groin. By such means inflammation may be prevented, and in the course of time the effused blood becomes absorbed. In general, this takes place very gradu- ally and slowly, and several weeks may elapse before the blood is entirely remoAred. If the quantity of blood extravTasated be large, so as to cause great tension of the tunica vaginalis and severe pain, and endanger the nutrition of the testicle, it would be necessary to lay open the sac by an incision, and to remove the blood. The part would afterAvards heal by granulation. I have never had oc- casion to perform this operation in any case of injury, and I believe that it is very rarely called for. When hematocele succeeds or is combined with hydrocele, the practice formerly, was at once to make an incision into the tunica A'aginalis, and discharge its contents. This is not generally neces- sary. The blood effused, especially when in small quantity, often produces but little irritation, and becoming mixed with the fluid of the hydrocele may be readily removed by tapping, and the opera- tion can be repeated afterAvards at intervals until the fluid is free 190 HEMATOCELE OF THE TESTICLE. from any red tinge. Even when inflammation arises the surgeon should not be too hasty in laying open the tunica vaginalis, for even then by emptying the sac wTith a trocar so as to relieve the tension, and afterwards by rest and antiphlogistic treatment, the inflammation may subside, and the operation may be avoided, as in the following case.—J. D., an ostler, aged forty-three, Avas admitted into the hospital on account of a large heavy scrotal swelling, which was highly inflamed, oedematous, and very tender. It appeared that he had been subject to hydrocele for some years, and that it had been tapped by a surgeon. When the swelling returned he punc- tured it himself with a penknife, and got rid of the water without any ill consequence. About a month before his admission he re- peated the operation, but this time was not so fortunate, for the part soon became painful and enlarged. The swelling was afterwards increased by a kick from a horse. I kept him in bed, leeched the scrotum, and applied cold lotions for three days. Finding the swell- ing to be increasing, I inserted a large trocar, and drew off eight ounces of dark fluid blood with some small coagula, and ordered calomel and opium to be taken at night. The swelling returned quickly, but there was less pain and tenderness, and the oedema subsided. In four days I drew off five ounces more fluid blood. The part again enlarged for a few days, and then gradually sub- sided until all fluid had disappeared, and he Avas discharged, cured both of hydrocele and hematocele, seventeen days after his admis- sion. In -another case of hematocele from injury, in which the inflammation was less severe than in the preceding case, the hydro- cele, which was of old standing, disappeared after the bloody fluid had been twice removed and the inflammation had subsided. When however, the quantity of blood effused is large, and the inflamma- tion very acute, with considerable local swelling and increasing thickening of the parts, absorption cannot be expected, and delay in operating will only lead to suppuration. The tunica vaginalis should be punctured with a lancet at its upper part, a director or the finger introduced, and the whole extent of the sac then laid open by an incision with a bistoury carried quite to its lower part, in order to prevent any bagging of the -discharge afterwards. This must be done with care, so as to avoid wounding the testicle. In a hematocele with a very thickened sac, the difficulty of detecting beforehand the precise situation of this organ is very great, the HEMATOCELE OF THE TESTICLE. 191 only available guide to its position being the peculiar sensation caused by its compression. But Avhen the testicle is small, wasted, or Avell protected by the dense and thickened tissues, and when the tumor is so sensitive or the patient so timid, that he complains wherever pressure is applied, it is almost impossible for the surgeon to ascertain exactly the site of the gland. It is not therefore sur- prising that in hematoceles requiring incision, when the testicle is out of its usual position it should be extremely liable to injury. I have already alluded (p. 186) to a case of inversion in which the organ had been wounded in the operation. The following instruc- tive case exhibits difficulties Avhich would have embarrassed any surgeon, even the most experienced and cautious.—A Portuguese Jew, aged twenty-six, recently arrived in England, applied to me on account of a disease of the right testicle. The organ was en- larged to more than thrice its natural size, was opaque, felt firm, Aveighcd heavy, and afforded an indistinct sense of fluctuation. The man looked healthy, and stated that the enlargement had existed twelve years, but had increased a good deal lately. In the expectation of finding fluid, I thrust a fine exploring trocar into the upper part of the swelling, but nothing except a few drops of blood appeared. Mercury was then taken until the mouth became sore, Avithout any effect on the tumor. Being strongly impressed that fluid existed, I next introduced the exploring trocar into the lower part of the swelling, but with the same result as before. The punc- tures did not give rise to any increase of tenderness. The patient was now admitted into the London Hospital, and a consultation held on the case. The senior surgeon being of opinion that the disease mio-ht be the result bf chronic orchitis, the tumor was strapped, and iodide of potassium given internally for a fortnight, Avhen a slight in- crease rather than improvement being manifested, the plan was dis- continued. At a second consultation it was determined, as the tumor had not yielded to treatment, that it should be removed by opera- tion. It was supposed that the disease might be cystic. A very careful examination was made, and firm pressure exercised at different parts, in order, if possible, to ascertain the site of the testicle, but the man being very timid and sensitive to pain, and unacquainted with the English language, no information in reference to this point could be obtained. He was placed under the influence of chloro- form, and, as a measure of precaution, a full-sized hydrocele trocar 192 HEMATOCELE OF THE TESTICLE. was plunged into the upper and front part of the tumor where fluc- tuation seemed manifest. After the instrument had penetrated solid tissues of considerable thickness, resistance ceased, and on withdrawal of the trocar a small quantity of dark red grumous fluid loaded with cholesterine escaped. Suspecting now that I had to deal with a hematocele, a free incision was made in front of the tumor just below the puncture, when the appearance of tubuli con- vinced me that the disease was either cystic with the glandular structure spread over the surface, or a hematocele with the testicle occupying an abnormal position in front of the sac. The latter seemed most probable; and as it was considered that the gland had been seriously wounded both by puncture and incision, and that the sac was much diseased, castration was advised, and immediately performed. The case proved to be a chronic hematocele of an inverted testicle. The vas deferens passed down the front of the sac to the testicle, Avhich Avas sound in structure, but flattened and spread out so as to occupy a great part of the front of the thick, dense, leather-like sac in Avhich it was embedded. The trocar had transfixed its upper part. The patient recovered favorably. Had it been possible to ascertain the nature of the case and situation of the testicle before the operation, the tumor might have been incised at its back part and the testicle thereby preserved. If in a recent case the spermatic artery or a vessel of any size be found wounded, and bleeding, it can be easily secured. In the case related by Scarpa, preAdously alluded to, the wounded spermatic artery was seen, after the tunica vaginalis had been laid open, pumping out blood. A poultice or the water-dressing is the only application necessary afterwards. The surgeon may leave a piece of lint between the edges of the wound to prevent union by the first intention; but it should not be carried to the bottom of the sac, or be placed in contact with the serous membrane. Severe symptoms and a good deal of constitutional irritation sometimes follow this operation: they are occasioned by acute inflammation of the exposed sac, which when large and dilated affords a con- siderable extent of surface. But in general the inflammation is relieved by the incision and consequent loss of blood, and under mild treatment the local irritation soon subsides. In old per- sons gangrene has arisen from the incision of a hematocele ; and formerly, when it was the practice to stuff the bottom of the wound HEMATOCELE OF THE TESTICLE. 193 with lint or other extraneous substances for the purpose of insuring sufficient inflammation, the operation was not altogether free from risk, especially in large hematoceles, and in persons of an un- healthy constitution. I have recorded in the Medico-Chirurgical Transactions1 the case of a gentleman, aged seventy-nine, to whom I was summoned on account of an attack of retention of urine from enlargement of the prostate gland. He had also, on the left side, a chronic vaginal hematocele, which had attained so large a size as to inter- fere with the introduction of a catheter. The tumor reached half- way down the thighs, and the penis was so completely buried in it that I was unable to reach the glans at the navel-like orifice in the integuments to pass the catheter. I had no alternative, there- fore, but to lay open the hematocele, from which three pints of dark grumous blood were discharged. The thickening of the sac prevented its collapsing after the incision. The patient died a week afterwards. This is the only case of hematocele terminating fatally which has come under my observation. In a very large chronic hematocele with great consolidation and thickening of the sac, the best operation, in persons advanced in life, is the excision of the whole of the mass. The loss of the testicle in such a case is of little importance; and the scrotal integuments contract so much after the removal of large tumors, that the Avound would not only be comparatively small in size and much less than if the hematocele Avere incised, but would also heal readily instead of being the seat of protracted suppuration. This course was adopted by Mr. Bowman in the following case, which he kindly afforded me the opportunity of seeing in King's College Hospital, in January, 1853.—A laborer, aged fifty, two years before received a blow on his left testicle, which afterwards gradually enlarged until it reached the size of a goose's egg. This swelling was also struck accidentally, and from this time rapidly increased to *a great size. The tumor was pyriform in shape, firm, tense, opaque, but not at all tender. It reached nearly half-way down the thighs. By firm pressure at a spot in the back part I was able to make out the position of the testicle. Mr. Bowman punctured the swelling with a trocar, and gave issue to about fifty ounces of dark red fluid, which partly coagulated, and 1 Vol. xxxiii, p. 241. 13 194 HEMATOCELE OF THE TESTICLE. contained abundance of red globules. The tumor in a week regained nearly its former size. Having evacuated about a pint of dark-brown fluid by puncture, Mr. Bowman excised the whole mass, and after tying numerous vessels, closed the wound with sutures. The patient recovered favorably.in about a month. The tunica vaginalis was greatly thickened by extensive layers of fibrine deposited within the sac. The testicle was sound, but concealed and flattened by the fibrinous exudations. Encysted Hematocele of the Testicle occurs when a cyst deve- loped from the epididymis becomes the seat of bloody effusion, instead of the fluid which it usually contains. It may arise from external violence, as in the following case.—My former colleague, Mr. Hamilton, requested me to examine a painful tumor connected with the testicle of a patient in the hospital. He was a Jew, aged eighteen, who had received three months before an injury of the left testicle. He stated that the scrotum became much swollen, and that the tumor was observed afterwards. I found a swelling the size of a chestnut just above the testicle, quite movable and loose in the scrotum, but attached to the upper part of the gland by a small neck. It was firm, but gave an indistinct feeling of fluctuation when examined. Handling caused pain. Mr. Hamilton punctured the cyst Avith a lancet, and discharged a quantity of dark coagula contained in a thick firm cyst, lined by a rough false membrane. The part healed favorably by granulation. The patient had no recollection of any tumor connected with the testicle before the injury ; but knowing how frequently small cysts springing from the epididymis are present without being noticed, I have little doubt that one existed in this instance, and that the injury had caused effusion of blood into the cyst. This produced inflammation and thickening of the sac, and accounted for the tumor becoming painful and enlarged. The following complicated case of twofold hematocele, an old and a recent one combined on the same side, affords a good exam- ple of encysted hematocele of the testicle.—In 1853, a man, aged forty-nine, who had had a swelling of the left testicle for thirteen years, came under my care at the London Hospital in consequence of the tumor becoming rapidly larger and very painful. It reached half-way down the thigh, and was heavy, firm, and very tender. Finding an obscure feeling of fluctuation, I punctured the swelling HEMATOCELE OF THE TESTICLE. 195 avith a trocar, and removed twenty-four ounces of a thick dark grumous fluid. Considerable thickening remained at the upper part, Avhich was also extremely tender. The testicle was felt quite at the bottom of the thickened sac. The tumor quickly increased nearly to its former size. Six days after the puncture I drew off ten ounces of a similar fluid, and then made a free incision along the front of the sac, dividing tissues of great thickness and density. The incision exposed a quantity of soft dark recent coagula at the upper part of the tumor, and opened below a very large cyst thickly coated with tough layers of lymph, the inner surface of which was rough and of a reddish-brown color. The walls did not collapse. Considering that castration was attended with less risk than leaving the parts to suppurate, especially as the man was not in sound health, and that he was not likely to feel the loss of a testicle, I excised the Avhole of the morbid parts. On dissection, the large sac proved to be an encysted hydrocele of the epi- didymis converted into an old hematocele, the recent coagula being lodged between the thick layers of adventitious membrane lining the cyst. The testicle Avas found distinct at the bottom of the sac, and not embedded in the thickened walls as in vaginal hematocele. The surfaces of the tunica vaginalis Avere adherent, partly by old and partly by recent adhesions. The epididymis Avas draAvn up and lost in the walls of the large cyst. Recent depositions in a beaded form were observed in the testicle, and the ducts Avere loaded with a granular substance, the result of fatty degeneration. The patient's recovery proved tedious. Sir A. Cooper has recorded a case of hematocele, the cyst of which, avc may safely conclude from his description, was originally an encysted hydrocele of the testicle ; but this eminent surgeon does not appear to have recognized its true character.1 This form of hematocele is very little knoAvn, and when it occurs is liable to be mistaken for a vaginal hematocele or a hematocele of the spermatic cord. It may generally be distinguished from the former by the presence of the testicle distinct from the tumor, and beloAv or in front of it, for even in cases where the sac is dense and much thickened the gland is not sunk and buried in the tumor as in vaginal hematocele, but in a careful examination may be de- 1 Lib. cit. p. 210. 196 HEMATOCELE OF THE SPERMATIC CORD. tected on the surface. The treatment applicable to encysted hema- tocele is the same as that required for vaginal. SECTION II. Hematocele of the Spermatic Cord. Hematocele of the spermatic cord occurs in two forms, the dif- fused and encysted. Diffused hematocele was first noticed by Mr. Pott. It is liable to be produced by the accidental rupture of a spermatic vein during violent and sudden exertion, as in straining to lift a hea\ry weight, when blood immediately escapes into and infiltrates the loose con- nective tissue along the cord, where it accumulates, its further dif- fusion being prevented by the fascious envelope of this part. Mr. Pott has related three cases, all of which occurred in this Avay. Diffused hematocele of the cord may also be occasioned by con- tusion. It may happen, in both ways, to persons in good health, and whose genital organs are free from disease, but a varicose state of the veins or fatty degeneration of the arteries are condi- tions favorable to its occurrence. The complaint is rather rare. The symptoms of this affection are very similar to those of diffused hydrocele of the cord; from which however it may be distinguished by its sudden appearance, and in cases where it results from contusion, by ecchymosis of the scrotum and groin. I have met with slight hematocele of the cord coupled with more or less effusion of blood in the scrotum in several instances. The swelling of the scrotum did not prevent my detecting a defined tumor of the cord, but in one case the hematocele was not recog- nized for several days, the effusion in the scrotum concealing the hard and defined swelling produced by the effusion in the sper- matic cord. Mr. Pott relates the following case.—A laboring man who had fallen down with a load on his back, was brought into St. Bartholomew's Hospital for a supposed rupture, a swell- ing having appeared in the groin and scrotum immediately after the accident. The tumor seemed to occupy the whole sperma- tic process, which was so enlarged by it that it was impossible to feel the passage of it from the abdomen through the muscle; but the testicle below it was perfectly distinct. The appearance of a tumor, the suddenness of its formation, the distinct fluctua- HEMATOCELE OF THE SPERMATIC CORD. 197 tion of the testicle below, and the circumstance of the man's not having had a stool for tAvo days past, inclined Mr. Freke to believe it to be hernia, and to treat it accordingly. After fruitless attempts at reduction, he determined upon an operation. He divided the superficial parts and tendinous opening in the abdominal muscle, and made several trials to reduce what he supposed to be the gut Avithout opening the sac, but ineffectually. He was 'at length obliged to lay open the containing membrane, when a large quan- tity of blood, partly fluid and partly grumous, burst forth, and the whole tumor subsided. The parts were Avashed, and search made for the bleeding vessel, but it could not be found. The wound was dressed, and the man got well.1 In this case it does not appear that there were any urgent symptoms of hernia demanding an ope- ration. The costive state of the bowels was an accidental circum- stance, Avhich might havre been shortly remoAred by the exhibition of a purgative. An operation can very rarely be required in any case of diffused hematocele. If left alone, the blood will in the course of time be removed by absorption. All that appears to be required in the way of treatment is to check any tendency that may arise to inflammation. If the tumor, hoAvcver, should continue to increase, hemorrhage still going on and infiltrating the con- nective tissue, it may become necessary to make an incision, in order to secure the bleeding vessels. This appears to have been necessary in the folloAving case detailed by Mr. Pott.—A young fellow straining at stool felt a sudden pain in his left groin; and, upon examination, found a SAvelling extending from thence into the scrotum. He took it for a rupture, and immediately applied to an advertising operator, who, after unsuccessful attempts to reduce it applied a truss. After some days, during which the pain and swelling increased, he was seen by Mr. Pott. The tumor was large, and had somewhat the feel of an omental hernia ; the abdominal aperture seemed dilated; the testicle was tolerably distinct below; pain in the erect posture was considerable, but in a supine one very little: he had neither heat, quickness of pulse, hiccough, nor vomiting, and had been thrice at stool that day. Notwithstand- ing he was bled freely and kept in bed, the pain and tumor in- creased, and fluctuation became palpable. Thinking that the fluid might possibly be collected in the sac of an omental hernia, Mr. 1 Lib. cit. Case XXX, p. 456. 198 HEMATOCELE OF THE SPERMATIC CORD. Pott made a puncture with a lancet, and let out some ounces of clear blood. The hemorrhage continuing for three or four days, an incision of some length was made up to the groin, and the cel- lular membrane of the spermatic process was found loaded with extravasated blood. The wound was dressed with lint pressed out from a styptic; but an alarming return of the hemorrhage soon after induced Mr. Pott to perform castration.1 Modern surgeons will not be inclined to admit that castration was " the only remedy in this case." Had diligent search been made for the vessel, I should think it might have been found and secured. Mr. Bowman has recorded2 a very remarkable case of hemato- cele of the spermatic cord, in which the tumor attained an extraor- dinary size, and ultimately proved fatal. The subject of it was a farmer nearly sixty years of age. About ten years before his death he was thrown from his horse, and received a blow on the right groin, which gave rise to a SAvelling confined to the inguinal canal and resembling a hernia. It could not however be reduced, had no impulse from coughing, and was accompanied with ecchymosis. The pain and ecchymosis subsided, and he resumed his ordinary pursuits; but the swelling, which was as large as a hen's egg, oval, firm, and elastic, remained nearly stationary for seven years, when, during exertion in walking, it became suddenly larger and heavier, blood being also largely effused in the scrotum. After the disap- pearance of the ecchymosis, the tumor manifested a disposition to augment. A surgeon introduced a trocar, which was followed by a gush of blood. The puncture healed, but the tumor continued to increase until it attained a vast size. Mr. Bowman, on visiting the patient, found him confined to his bed from sheer inability to drag so great a substance about with him. As represented in Fig. 26, the tumor reached to the patella, had an oval shape, and was so heavy that it required two hands and no slight effort to raise it. Its surface was crossed by very large veins. The right testicle was at the lowest part of the tumor, resting on the knee-joint, and formed no part of the diseased mass. The tumor was tympanitic at its most elevated parts, and seemed to contain air mixed with fluid. This sign with a low irritative fever rendered it probable that the contents had become decomposed since the last puncture. It was therefore deemed desirable to lay open the part to give vent 1 Lib. cit. Case XXXI, p. 458. 2 Lib. cit. HEMATOCELE OF THE SPERMATIC CORD. 199 to the gas and other putrid matters. Mr. Bowman made an open- ing three inches in extent, and discharged a large quantity of dark-brown putrid blood of the consistence of treacle mixed with large masses of old coagulum, altogether nearly filling two large wash-hand basins. In the reduced condition of the patient, it was not con- sidered safe to attempt the removal of the entire tumor. A counter-opening was made at the lower part without interfering with the testicle. The walls of the cavity being firm and solid collapsed but little. He survived the operation only five days. No post-mortem examination was made, and it must remain doubtful whether the origin of the hematocele was arterial or venous. Encysted Hematocele of the Spermatic Cord.—The Pathological Museum of St. Bartholomew's Hospital1 contains a speci- men of this disease. The cyst is empty; but it it described to have contained blood, and its walls are deeply stained with the color of partially decomposed blood. Its lining membrane is wrinkled and coarsely granular, and the tissues around it are thickened, brawny, and adherent together. In the Hunter- ian Museum there is a specimen (No. 2460) of old encysted hema- tocele of the spermatic cord. (Fig. 27.) A good-sized cyst, lined by a membrane, polished and a little wrinkled, is filled with a soft tawny-looking granular matter (3), resembling the altered coagulum of blood observed in ordinary hematocele after long maceration in spirit. The tissues around the cyst are thickened and indurated, just like those around an old hematocele of the testicle. There is a hernial sac immediately above it (2), and a hydrocele below, with the sac open for some distance up the cord as far as the cyst of the hematocele. The latter does not communicate either with the tunica vaginalis or the hernial sac. In the Muse'e Dupuytren in Paris there is also a preparation of this affection which occurred in the practice of M. Blandin. 1 Series 22d, No. 11, in printed Catalogue. 200 ORCHITIS. This form of hematocele is very uncommon, the small size of the cyst and its protected situation fully accounting for the rarity of the contents of an encysted hydrocele of the cord becoming mixed with or changed to blood. Its diagnosis is extremely diffi- cult ; indeed the nature of the case could hardly be determined positively without a puncture. We should expect that an ex- isting hydrocele of the cord would sud- denly enlarge and become painful; that it would lose its transparency, fluctuate less distinctly, and feel more firm and solid than before. Two cases in which an en- cysted hematocele of the cord was met with during life, and its character determined by an opening made into the cyst, are re- corded by M. Beraud.1 One occurred to M. Velpeau, the other to Dr. Cabaret. The latter was complicated with vaginal hydro- cele and enlargement of the testicle. An encysted hematocele of the cord should be treated in the same way as a hematocele of the testicle. In slight cases sufficient relief may be afforded by rest and antiphlogistic measures: if the tumor should become painful and inflamed, or shoAV no disposition to disperse, the blood must be liberated by an incision, and the wound be encouraged to heal by granulations from the bottom of the cyst. This treatment was adopted with success in the two cases mentioned by M. Beraud. CHAPTER VI. ORCHITIS. Inflammation of the testicle occurs in two forms, acute and chronic; and it may commence either in the body or secreting part 1 Archives Gene"rales de Medecine, 4e se'rie, t. xxv, p. 299. ACUTE ORCHITIS. 201 of the organ, or in the epididymis. Inflammation beginning in the body of the testicle may be idiopathic, or may be excited by ex- ternal violence; the disease is at first confined to the interior of the organ, the epididymis and tunica vaginalis being affected only secondarily, and sometimes entirely escaping. Orchitis is far more frequently a consecutive affection than a primary, the inflammation being transmitted from the urethra along the vas deferens. In this latter form of orchitis, which is familiarly known by the term hernia humoralis, the epididymis is first attacked, and the tunica vaginalis generally participates in the disease. SECTION I. Acute Orchitis. Few pathologists have examined a testicle in a state, of acute in- flammation, and I am unacquainted with any authentic account of the alterations in structure from inflammation originating in the body of the gland. Many years ago I tAvice had an opportunity of in- specting a testicle affected with acute secondary orchitis ; and the following description of the pathological appearances is drawn up from these examinations, and from the account of the dissection of two testicles affected with gonorrhceal inflammation recorded by M. Gaussail.1 The tunica vaginalis is more or less distended with lymph, or albuminous matter infiltrated with reddish serum, which form loose adhesions between the opposed surfaces of the mem- brane ; these adhesions are so slight as easily to admit of being broken down with the finger. The membrane is injected with a mul- titude of minute red vessels, which ramify in various directions, and form a compact network. At a later period red vessels may be traced, proceeding from the free surface of the tunica vaginalis to the false membranes forming the adhesions. The volume of the testicle is very little, if at all increased, the great bulk of the tumor being occasioned by the swollen epididymis and effusion into the serous sac. When cut Into, the gland appears somewhat darker than natural, from a congested state of its vessels. The epididymis, particularly the lower part, is enlarged to twice, and sometimes thrice its natural size, and feels thick, firm, and indurated. This ' Memoire sur l'Orchite Blennorrhagique, Archives Gendrales de Medecine, torn. xxvii, p. 210. 202 ACUTE ORCHITIS. enlargement is produced by the exudation of a brownish deposit in the connective tissue between the convolutions of the duct. The coats of the vas deferens are thickened, and the vessels ramifying near them injected, sometimes along the whole extent of the duct. Exudation matter is found in the connective tissue around the tor- tuous part of the vas deferens and tail of the epididymis, which frequently forms the bulk of the swelling observed in these cases. Owing to the epididymis being the part chiefly and most constantly affected in consecutive orchitis, the disease is frequently called epi- didymitis. In treating of the acute inflammatory changes in the tunica vagi- nalis (p. 106), I remarked that the inflammatory action was very liable to extend to the substance of the epididymis, but not to the body of the testicle; and I noticed the pathological law enunciated by Gendrin .by which this circumstance was accounted for. We find, too, that inflammation of the epididymis is much more readily propagated to the tunica vaginalis than inflammation originating in the glandular structure of the testicle. When inflammation com- mences in the body of the gland, the enlargement takes place slowly, and is seldom considerable until the disease has existed for some length of time, which is easily explained by the unyielding texture of the tunica albuginea, and the circumstance of the tunica vaginalis remaining unaffected. Suppuration occasionally takes place in this form of orchitis, whereas in consecutive inflammation the formation of pus in the substance of the gland is of very rare occurrence. I do not mean, however, to assert that the glandular structure of the testicle never suffers in consecutive orchitis, for I believe that it does so in some instances; but, according to my observations, it very commonly escapes, the inflammation not extending further than to the epididymis. Inflammation of the testicle rarely terminates in suppuration. But when it occurs, owing to the thickness and density of the tunica albuginea, the matter is slow in making its way externally. It bur- rows in the gland, and disorganizes its delicate structure. The matter sometimes becomes encysted, forming a separate abscess. In these cases, after all inflammation has subsided, the more fluid particles becoming absorbed, the pus remains for a considerable time in the form of an indolent concrete mass, which has been mistaken, after death, for tubercular deposit. The pus, when found in this ACUTE ORCHITIS. 203 Fiz. 28. concrete state, appears at first sight very like crude tubercular de- posit ; but on further examination, it will be found to be contained in a distinct cyst, from which it may easily be separated; whereas in tubercular disease the morbid deposit is in immediate contact with the disorganized tubules. Concrete pus may likewise be mis- taken for the firm yellow exudation matter effused in chronic inflam- mation. It differs from it, however, in being friable and easily broken up, and also in being inclosed in a cyst; whereas the yellow fibrinous substance is homogeneous and consistent, and almost in- separably connected with the tubuli around it. The distinctive characters just described will be easily recognized on comparing the accom- panying representation of concrete pus encysted in the testicle from a prepara- tion in the collection of the late Sir A. Cooper, Avith Figs. 31 and 36. I ex- amined two enlarged testicles taken from a man who died somewhat unexpectedly from a disease of the larynx. Both glands had formerly been attacked with acute inflammation, and for some months be- fore death they had been the seat of chronic pain. In the left testicle, Avhich was the larger of the two, from two to three drachms of thick yellow inspissated pus Avere contained in a distinct cyst, which occupied the centre of the gland. There was no trace of tubuli seminiferi, but the remainder of the organ was composed of a fibrous tissue: the sac of the tunica vagi- nalis was obliterated by close adhesions. The tunica vaginalis of the right testicle contained about half an ounce of yellowish serum; in the centre of the gland there was a small concrete abscess, but the tubular structure was apparent, and apparently very little dis- eased. Pus existing in this concrete or inspissated state may keep up pain and irritation for a long period, and render the testicle liable to repeated relapses of inflammation. Suppuration also occurs in the epididymis. In neglected cases of consecutive orchitis an abscess sometimes forms in the connective tissue around the termi- nation of the epididymis and inflected portion of the vas deferens, and bursts at the most depending part of the scrotum. 204 ACUTE ORCHITIS. I have not myself met Avith any instance in Avhich acute orchitis had ended in gangrene. The late Mr. Harvey Ludlow has recorded, in his Prize Essay, a case of acute inflammation of the body of the left testicle occurring to a man in St. Bartholomew's Hospital, who was in feeble health, and had suffered much from stricture. In consequence of the severity and obstinate character of the pain, Mr. Stanley made an incision into the testicle. A very small quantity of ichorous pus issued, but a cavity was exposed, the walls of Avhich were formed by the glandular substance in a black gan- grenous condition, and exhaling an offensive odor. On examination of a portion of the black substance in the microscope, it was found to consist of tubules with air bubbles between and inside of them. The testicle subsequently protruded; and after death, which oc- curred chiefly from peritonitis, nearly half the gland was found to have perished. The epididymis was unaffected : the gangrenous inflammation had been confined to the body of the gland. In many instances, after acute orchitis has subsided, the testicle is restored to its natural condition ; in other cases, permanent changes of a serious nature are the consequence. I have observed in testicles that have been affected Avith inflammation some time before, that the septa appear to be more distinct, and to enter more largely into the composition of the gland than is natural; that the seminal tubes are less numerous and apparent; and that a great part of the organ is converted into a dense white fibrous tissue, without the presence of tubuli. In these cases the lymph exuded * in the connective tissue between the tubes, instead of being absorbed, becomes changed into the dense tissue just described; the ducts also undergo fibrous degeneration, and disappear. Complete atrophy is one of the most serious results of acute inflammation. In Chapter II, the disturbance in the organization of the testicle consequent upon inflammation was noticed as the most common cause of wasting, and several examples of it were adduced. Consecutive orchitis, if neglected at its onset, seldom subsides without leaving behind dis- tinct traces of its existence, which never disappear entirely during the remainder of the patient's life. The epididymis frequently remains enlarged, presenting an indurated irregular knotty swelling, seated usually at its lower part, which is occasioned by the presence of a dense hard deposit between the convolutions of the duct and around the inflected portion of the vas deferens. On making a ACUTE ORCHITIS. 205 section of the epididymis in this state, I have often observed not only a highly thickened condition of its duct, but also, in some instances, very considerable dilatation; so that the point of a fine probe might be introduced into the canal without difficulty, its area being increased four or five times. These remarkable dilatations are OAving to seminal engorgement consequent on obliteration from inflammatory exudation of the excretory duct in the tail of the epididymis or inflected portion of the vas deferens. The occasional occurrence of such obstructions has been fully confirmed by the researches of M. Gosselin. In the examination of several testicles taken from bodies after death, he found the duct of the epididymis dilated, the canal at the seat of induration in the globus minor being at the same time impermeable to the finest injections.1 In old cases the tail of the epididymis acquires great density and consistency, and sometimes becomes the seat of earthy deposits. These changes are rarely found without the presence of old adhesions, obliterating partially or completely the sac of the tunica vaginalis. The coats of the vas deferens are also found for some extent thickened and indurated. The alterations noticed in the body of the testicle have been observed, in some instances, coexisting with those in the epidi- dymis ; but in by far the majority of cases, the glandular structure is unimpaired. In only tAvo cases in which the epididymis was thus diseased, have I remarked a decidedly atrophied condition of the organ.2 1 Archives Ge'ne'rales de MeYlecine, 4e se"rie, t. xiv et xv. 2 The view that the glandular structure of the testicle commonly escapes in con- secutive orchitis has been called in question (Brit, and For. Med. Review, vol. xvii, p. 77), and said to be opposed to the opinion of Sir A. Cooper, who remarks, " In general I observe that when there are marks of inflammation upon the tunics of the testis, such as, for example, adhesion, the substance of the gland itself is changed, the septa are much more apparent than natural, the seminiferous tubes appear to be less in number, are undoubtedly much reduced in size, and many become cords instead of tubes." Consecutive orchitis is so common an affection, and inflammation of the tunica vaginalis and epididymis is so frequently excited in the treatment of hydrocele, that the question at issue is of no light importance. I have paid further attention to the subject, and must adhere to my original statement, " that in by far the majority of cases, the glandular structure is unimpaired;" an observation intended to apply also to its secreting powers. That repeated attacks of orchitis, occurring from disease in the urethra, will occasionally prove injurious to the structure and affect the functions of the testicle, I have by no means denied ; indeed, as I shall show in treating of chronic orchitis, that form of inflammation (which is often excited by disease in the urethra) usually occasions more or less disorganization of the gland. My observation applies to ordinary consecutive orchitis, which is so commonly met with in practice. 206 ACUTE ORCHITIS. The observations made in Chapter I (Section II) are sufficient indeed to show that an obliteration of the excretory duct of the testicle may, and commonly does, take place AA7ithout impairing the nutrition of the testicle, and without affecting the desire for and power of coition. But such an obstruction, if complete, must of course prevent the escape of the sperm, and when existing on both sides cause sterility. M. Gosselin has made some curious researches in relation to this subject.1 He carefully examined the semen in twenty individuals who had been attacked with double epididymitis after gonorrhea. In fifteen of these cases, which Avere compara- tively recent, a callosity existed in the tail of the epididymis at the time that they seemed to be cured. In all, the genital func- tions appeared fully restored and the sperm normal. The semen was repeatedly examined at intervals of several weeks, but no sper- matozoa Avere detected. M. Gosselin lost sight of all but tAvo cases, and in these the return of spermatozoa in the semen occurred after some months, and coincidently with the complete disappearance of the induration in the epididymis on one side. In the remaining five of the tAventy cases the double epididymitis had occurred seve- ral years previously. One man, aged forty-five, had been attacked twenty years before, but the left callosity no longer existed, and spermatozoa were found in the semen. In another man the disease dated back five years, and had left a considerable induration at the lower part of each epididymis. The general health was good : no spermatozoa could be detected. In the three other cases the dis- ease had occurred ten, six, and four years before. There was hard- ness on both sides. The testicles were otherwise unaltered. The indications of virility were quite satisfactory, and the semen pre- sented its usual appearance. The individuals had all been married several years, but had no children. The sperm was carefully exa- mined, and found destitute of spermatozoa. One of them had had children by a former wife before the attack of double epididymitis. My experience induces me to question whether an obstruction to the course of the semen, from the organization of lymph exuded around and within the convoluted duct, occurs in epididymitis, either tem- porarily before the removal of induration, or permanently in ne- glected cases, so frequently as M. Gosselin's researches would lead us to suppose. I cannot attempt to supply data of the same cha- 1 Archives Generates de Medecine, 5e sene, t. ii. ACUTE ORCHITIS. 207 racter as those which he has furnished; but I have met with several cases of double epididymitis attended with considerable swelling and induration, and the subjects of the disease have certainly not afterwards been Avanting in the power of fecundating the ovum. He has shown in these inquiries that the callosity obstructing the canal may disappear at the end of three, four, five, and even eight months, and leave the course of the semen free. The rarity of any evidence of such obstructions in my own practice is probably owing, therefore, to the care taken in the treatment to prevent their occurrence; and I quite agree in M. Gosselin's practical conclu- sion, as to the importance of obtaining an absorption of the exuded lymph in these cases, for, as he has clearly ascertained by anato- mical investigation,1 the plastic effusions amongst the convolutions of the tube occurring in inflammation sometimes produce permanent obliterations of the duct. Acute orchitis may arise from various causes. It may be pro- duced by contusion, as from a kick on the part, or a bloAv against the pommel of a saddle, the patient being jerked forwards in riding; or by compression occasioned by crossing one thigh upon the other, or by other accidental injury. It sometimes appears to arise from ex- posure to the vicissitudes of the weather, assuming a rheumatic cha- racter. Great excitement of the sexual organs, without the oppor- tunity of indulging the passions, may also lead to inflammation of the gland; in many instances the disease is developed without any evident cause. The testicle is liable to inflammation during the subsidence of an attack of cynanche parotidea or mumps. The orchitis is usually slight, and seldom requires any other than mild treatment. M. Rilliet, in a careful account of an epidemic visitation of mumps, which prevailed at Geneva in the years 1848 and 1849,2 noticed that the orchitis usually appeared on the sixth or eighth day, reach- in<* its height in from four to six days. The body of the testicle rather than the epididymis was attacked. When the latter was affected, it was to a less extent than the testicle, and never exhi- bited the hardness observed in gonorrheal orchitis. The cord was sometimes a little enlarged. The greatest number of persons at- tacked Avere between twenty-three and thirty-eight years of age: ' Archives, 4e serie, t xiv et xv. 2 Gazette Medicate de Paris, t. 1, p. 42. 208 ACUTE ORCHITIS. the youngest was fourteen, the eldest forty-five. It is supposed that orchitis in mumps arises from the translation of inflammation from the parotid to the testicle. But M. Rilliet observed no case of metastasis, properly so called, nor any example in which the orchitis suddenly disappeared and the parotitis returned. The or- chitis was oftenest unilateral, while the parotitis was most frequently double. In twenty-three cases, orchitis was observed on the right side in thirteen, on the left in six, and in four it was double. In two cases there was orchitis without parotitis. It is commonly believed that wasting of the testicle is a frequent result of this com- plaint. Sir A. Cooper met with no instance of the kind in his own practice ; and no case has come under my observation,1 nor have I heard of any amongst the different medical friends of whom I have made inquiries. Dr. R. Hamilton, the first writer who gave a par- ticular description of this affection, has related two cases of atro- phy of the testicle, succeeding the orchitis, occurring in mumps. One was the case of a gentleman about forty years of age. On the morning of the fourth day of the attack the testicles began to swell. On the fifth day both glands were much tumefied, the right by far the most so. After all disease had ceased, the right testicle, which had been chiefly affected, continued gradually to waste away, till at length a mere empty bag, consisting of the coats only, re- mained. The second case was that of a young man, twenty-five years of age, who was attacked by this distemper. Upon the tumid sali- vary glands subsiding suddenly, the testicles became affected. One of them was much more swelled than the other, and was found when the swelling was reduced, to be diminished more than one half of its natural size, at which it remained two months afterwards.2 M. Rilliet noticed in two of the cases observed in Geneva, a marked diminution in the size of the testicle. In one the organ was reduced in size one-half, and the atrophy remained ten months after the attack. I have remarked that inflammation of the testicle is far more frequently met with as a consecutive affection than as a primary. This gland is directly connected through the medium of the vas deferens with the urinary organs, the lining membrane of its nu- merous minute ducts being continuous with the mucous membrane 1 A middle-aged married man in the London Hospital on account of lumbar ab- scess had one of his testicles completely wasted, which he attributed to an attack of mumps in his youth; but whether correctly so I had no means of ascertaining. 2 Trans, of Royal Society of Edinburgh, vol. ii, art. ix, p. 59. ACUTE ORCHITIS. 209 of the urethra. Any irritation, therefore, affecting that part of the urethra where the vasa deferentia terminate, is liable to be propa- gated to the testicle, and to cause it to inflame. In cases of gonor- rhea, in Avhich the inflammatory action has reached that part of the canal, or of stricture, in which the portion of the urethra behind the obstruction has become diseased ; when the urethra has been irritated by foreign bodies, as calculi or instruments, or by an en- larged prostate gland, or disease of the vesicule seminales; in mor- bid states of the prostatic part of the canal, from the excitement of excessive onanism or sexual indulgence, and after its division and laceration in the operation of lithotomy, the irritation and inflam- mation are frequently transmitted to the testicle, and give rise to orchitis. Of all the causes here mentioned gonorrhea is by far the most common. Orchitis is indeed so frequent a sequel of gonor- rhea, that it is generally treated of by writers in connection Avith this affection, and feAv pathologists have drawn any distinction between this and the idiopathic and accidental form of the disease. Secondary orchitis differs, hoAvever, from the latter, in many impor- tant respects. Orchitis may arise at all periods of a gonorrheal discharge, during its early and acute stage as well as toAvards its termination, though it more frequently commences when the pain and discharge begin to subside. It is a common observa- tion, that Avhen inflammation of the testicle supervenes in gonorrhea, the pain in making water and urethral discharge cease altogether, or undergo considerable diminu- tion, but return as the orchitis sub- sides ; which has led to the opinion that the orchitis is occasioned by a metastasis, or sudden translation of the inflammation from the ure- thra to the testicle. The doctrine of metastasis, to explain the phenomena of disease, has been too often adopted on insufficient grounds. It is extremely questionable whether anything of the kind ever takes place in gonorrheal li Fig. 29. Acute Orchitis attendant on Gonorrhoea. 210 ACUTE ORCHITIS. orchitis. Assuredly it does not in the majority of cases, in which the inflammatory action may be traced gradually creeping along the vas deferens to the epididymis. In these cases, nevertheless, the pain and discharge from the urethra diminish generally, though not constantly, during the early stage of the disease. SeA'eral of the French pathologists have taken considerable pains in investiga- ting the connection supposed to exist between the state of the dis- charge and the inflammatory action in the testicle. In sixty-seven of seventy-three cases observed by M. Gaussail, the discharge and other symptoms of gonorrhea diminished more or less from the first appearance of the disease. In fifty-eight out of eighty-one patients noticed by M. Aubry, there was a considerable diminution of the discharge at the commencement of the attack.1 M. D'Espine states that in six out of twenty-nine cases, the discharge underwent no modification on the accession of orchitis. In twenty-tAvo cases the discharge was variously modified: it was either increased, dimi- nished, or suppressed; but more frequently these modifications oc- curred only before or after the orchitis, the amendment of Avhich was not in general folloAved by a return of the discharge to the state in which it existed before the inflammation of the testicle. In only three cases did the running, after having been suppressed at the commencement of the affection, reappear and increase as the acute symptoms of orchitis subsided.2 Mr. Hunter states, that he has known cases where the testicle has swelled, and yet the dis- charge become more violent; nay, that he has seen some instances where a SAvelling has come on after the discharge had ceased, yet the discharge has returned with violence, and remained as long as the swelling of the testicle.3 The recurrence of the pain and dis- charge is not essential to the doctrine of metastasis ; on the other hand, the marked amelioration of the gonorrheal symptoms cannot be regarded as adequate proof of its occurrence. It is well known that when a part becomes actively inflamed, the symptoms of in- flammation going on in another part, especially if it be in near proximity, usually diminish, though the two parts are not directly connected or continuous with each other. The effects of blisters 1 Recherches sur l'Epididymite Blennorrhagique, Archives Generates de Medecine, Mai, 1841. 2 Memoire Analytique sur l'Orchite Blennorrhagique, Memoires de la Sode'iS Medi- cate d'Observation, torn, i, p. 494. 3 Treatise on the Venereal Disease, 4to. p. 55. ACUTE ORCHITIS. 211 and other counter-irritants in relieving inflammation of internal organs afford a familiar illustration of this remark; and I once had an opportunity of observing, in a case of orchitis occasioned by a Woav, that the symptoms of a gonorrhea, with which the patient was affected at the time of the injury, subsided, as is often witnessed in ordinary cases of secondary inflammation of the gland. It is clear that Mr. Hunter entertained considerable doubt as to the in- fluence of metastasis in these cases—a doctrine which was generally admitted in his day. Thus he remarks, " Although an action in the urethra is the remote cause, yet it is still impossible to say Avhether it be the cessation of that action that is the cause of the swelling of the testicle, or the swelling of the testicle the cause of the cessation." Inflammation frequently attacks the epididymis and testicle of persons laboring under gonorrhea, apparently Avith- out any previous affection of the vas deferens. It is in such cases only that the orchitis can be attributed to a metastasis. But when we consider how readily inflammatory action may be propagated from one part to another along a continuous membranous surface, as from the mucous membrane of the bladder to the kidney; how rapidly this transmission may take place Avithout the inflammation remaining fixed in any part of the continuous membrane a sufficient time to produce any evident signs of disease; how rarely it happens that the gonorrheal symptoms entirely subside as the orchitis be- comes developed; and hoAV seldom orchitis occurs Avhen the dis- charge is quickly arrested by specific remedies or injections ;—we cannot readily admit that the affection of the testicle commonly oavcs its origin to a translation of disease from the urethra, or assent to the doctrine of a metastasis in these cases. In the sympathetic form of gonorrheal orchitis just alluded to, in AAdiich the testicle is attacked, apparently Avithout any previous affection of the vas deferens, the inflammation likewise commences generally in the epididymis. This form of the disease, though less common than the other, is by no means of unfrequent occurrence. Of one hundred and four cases of gonorrheal orchitis noted by M. Aubry, in thirty-one the disease was sympathetic; in the remaining seA'enty-three, the inflammation first attacked the vas deferens. It is the opinion of many surgeons, that orchitis most frequently arises in cases in which the discharge has been somewhat suddenlv arrested by cubebs or copaiba, or astringent injections. 212 ACUTE ORCHITIS. More mischief is perhaps ascribed to these remedies than they can justly be said to produce. I have prescribed copaiba and cubebs sepa- rately or conjointly in all stages of gonorrhea, and have not found the patients to whom they Avere exhibited more liable to be attacked with orchitis than others treated differently. With regard to injec- tions, my own experience leads me to conclude that when employed of a proper strength they are very little liable to excite orchitis. It is only Avhen used improperly, Avhen too strong and injected too freely, so as to aggravate or too suddenly suppress the urethral inflammation, that they tend to produce inflammation in the testicle. According to my obseiwation, orchitis most frequently arises in those cases in Avhich the affection of the urethra is allowed to linger for want of a due exhibition of the remedies alluded to, particularly when the prostatic part of the canal is affected. Some patholo- gists have gone so far as to say that the chances of a swelled testicle are increased in direct ratio to the continuance of the disease in the urethra. Certainly most practitioners will allow that the occurrence of orchitis during the early and acute stage of gonorrhea is comparatively rare. In chronic gonorrhea, stricture, and morbid states of the prostatic part of the urethra, the patients are liable, especially at night, to distressing and painful erections, accompanied Avith abnormal sexual excitement and seminal emissions. In these cases the testicle often feels heavy and uneasy, and tender on pressure; and in this irritable state is disposed to inflammatory action. Accordingly we find that slight circumstances, Avhich would produce no ill effect at other times, then appear sufficient to excite orchitis. Slight blows or pressure, horse exercise, any excess in stimulating drinks, and neglect of the use of a suspender, are commonly suffi- cient to induce the disease. There can be no doubt that some per- sons are naturally more susceptible to attacks of orchitis than others. Thus there are many individuals who never contract a gonorrhea without its being followed by inflammation of the testicle, notwithstanding every precaution taken to prevent the attack; whilst there are many others, who, though repeatedly affected with gonorrhea, yet altogether escape an attack of orchitis. We do not find, too, that those who suffer most severely from gonorrhea are the most liable to orchitis. The persons most sus- ceptible of the disease are the scrofulous, and those of a weak ACUTE ORCHITIS. 213 habit, Avho, though they suffer less in the first instance, find great difficulty in getting rid of the discharge, and more frequently experience relapses; whilst the robust, and persons of a naturally good and strong constitution, who, when they contract gonorrhea, experience its effects in an acute form, sooner get rid of the disease, and more commonly escape its after-consequences, orchitis and stricture. Consecutive orchitis is generally supposed to occur more fre- quently on the left side than on the right, but statistical inquiries shoAV the fallacy of this opinion. Thus, in seventy-three cases of orchitis observed by M. Gaussail, in forty-five the disease was on the right side, and in twenty-four on the left; four were double. In twenty-nine cases of gonorrheal orchitis, M. D'Espine found tAvelve on the right side, eleven on the left, and six double. I have registered only a few of the cases which have occurred in my practice. Of thirty-six cases of consecutive orchitis, twenty-one occurred on the right side, and fourteen on the left; one only was double. My observations, therefore, agree Avith those of the above writers in indicating the right testicle to be the one most frequently attacked. Taking the three series of observations together, we have 138 cases of orchitis; of these, the right testicle was the seat of disease in seventy-eight, the left in forty-nine, and both glands in eleven. In cases of orchitis arising from chronic disease in the urethra, both organs are more commonly attacked than appears from these statistics. Symptoms.—A testicle attacked with acute inflammation in a feAV hours becomes swollen, hard, and tender, and feels heaA-y and painful. It increases to twice or nearly thrice its natural size, but without alteration in its oval form. The enlargement is attended Avith a sense of Aveight, Avhich is a good deal increased in the erect posture. The pain is of a constant dull, aching description, and extends upwards to the loins, where it is often severe. It not unfrequently takes a reflex course, extending downwards to the hip, upper part of the thigh, and crista of the ilium, in the direc- tion of the branches of the different lumbar nerves. As the dis- ease advances, the sAvollcn testicle becomes so tender that the patient can scarcely allow the part to be touched, and cannot bear even the contact of the thigh. The scrotum becomes injected, and is found red, hot, smooth, and slightly edematous. 214 ACUTE ORCHITIS. The constitutional symptoms vary a good deal, but are sometimes seArere. The pulse is rapid and hard, the skin hot, and the tongue white and furred. The patient suffers often from nausea and occa- sionally from vomiting. After the acute symptoms have existed for a period varying from forty-eight hours to a week or more, they begin to disappear, subsiding more gradually and slowly than they set in. But the duration of the disease is much influenced by the activity of the means adopted for its removal, as well as by the constitution of the patient. In many persons, more particularly in those of feeble constitution or advanced in age, the inflammation soon assumes a subacute form. The swelling increases without producing much suffering, and afterwards subsides slowly; the disease being often obstinate and lingering, and subject to relapse. Consecutive orchitis is usually preceded by uneasiness in the course of the vas deferens; the patient occasionally experiences distress and irritation about the bladder, and is troubled with a frequent desire to pass water, which is shortly followed by a dull aching pain and slight fulness in the groin. On examination of the sper- matic cord, it feels full, and sometimes edematous, and the vas deferens is found to be tender and enlarged. The thickening is sometimes so great, that the duct feels nearly as large as the little finger. The epididymis soon afterwards becomes swollen and painful: the tumefaction commences at the lower part or tail, and increases very rapidly. It forms an irregular elongated or crescentic swelling at the back of the testicle, which is fuller and larger than the gland itself, and extremely tender, whilst the body of the organ in front may often be pressed without causing uneasi- ness. The epididymis may remain affected for many hours, and even a day or two or longer, before the inflammation extends fur- ther ; and if checked in time it may never reach the tunica vagi- nalis, or body of the gland. The tunica vaginalis, however, often becomes affected; and then so much tumefaction ensues that the inflamed mass forms a uniform tumor, in which the epididymis can scarcely be distinguished from the other parts ; but fluctuation may generally be distinguished in the front part. In the sympathetic form of consecutive orchitis, the swelling of the epididymis takes place without the symptoms indicative of a previous affection of the vas deferens. There is much variety in the intensity of the symp- toms. In some cases there is merely a slight dull pain, with little ACUTE ORCHITIS. 215 enlargement, and scarcely any constitutional disturbance. Some- times the swelling is from the first very considerable, the volume of the gland becoming three or four times larger than natural, the pain being acute and constant, and the symptomatic fever severe. In other cases the swelling, though considerable, is quite indolent, and its progress sIoav and of long duration. But, in general, the symp- toms continue to increase in intensity for several days till about the seventh or eighth, when they begin to disappear, the febrile disturb- ance and pain entirely subsiding, and shortly afterwards the tume- faction. As the swelling diminishes, the epididymis becomes distinct, forming an indurated, knotty, and irregular swelling, at the back part of the testicle, which often lasts for many months, and in some instances never disappears entirely during the remainder of the patient's life. In fifteen cases observed by M. D'Espine Avhich Avere Cured, the mean duration of the disease Avas thirty- three days and a half. This closely accords with the observa- tions of M. Gaussail, who found the mean duration of seventy- three cases to vary from thirty to thirty-five days; but in my ex- perience it much exceeds the period usually occupied by acute orchitis under suitable treatment. The cure of the disease is liable to be interrupted and its duration prolonged by relapses, which are readily induced by any neglect or imprudence. A testicle which has been attacked Avith inflammation is after- wards more liable to orchitis than before. The gland, too, some- times remains more sensitive ; feels uneasy under gentle pressure, or Avhen the patient gets out of health ; and sometimes becomes painful and swollen from slight causes. Acute orchitis occurs occasionally in young infants. The symptoms are acute, and the SAvelling considerable ; but the inflammation soon subsides, and is generally confined to one testicle.—A Jew child, only five months old, was brought to me at the London Hospital on account of a swelling in the left groin and scrotum. The mother first observed it the day before on washing the child: he afterwards cried the greater part of the night. The tumor extended from the external ring to the bottom of the scrotum, was full six times the size of the right testicle, felt firm and hard, and received no im- pulse Avhen the child cried or struggled. The scrotum Avas dis- tended, and very red and hot. I ordered the application of a leech and cold lotion, and tAvo drachms of castor oil to be given. 216 ACUTE ORCHITIS. In two days I found the swelling reduced about one-third, and much less tender ; and the infant appeared free from suffering. I directed four grains of the hydrarg. cum cretd to be given every night. Under this treatment the swelling and induration soon subsided, and in a week the gland was nearly reduced to the size of the right testicle, but the cord still remained thickened and hard. Three weeks after the attack first commenced, I found the parts perfectly natural.—In 1842 I was requested to see in consultation a little boy, two years of age, who, on recovering from an inflammatory attack of the chest and head, was seized with an affection of the testicle. It appeared that, before his illness, there was a small hydrocele on the right side. A feAv days previous to my visit the scrotum became red, tender, and edematous. I found a swelling of the right testicle nearly the size of a hen's egg, which fluctuated in front, felt solid at the back part, and Avas hot and very tender. I considered this to be a case of acute inflammation of the tunica vaginalis and testicle. The child wTas weak, irritable, and emaci- ated, and had recently taken mercury to some extent. I ordered a leech to the scrotum, the parts to be frequently fomented and Avell supported, and the child to be kept in the recumbent position. I saw him again at the end of a week. The tunica vaginalis had suppurated, and burst through the scrotum in front, and had dis- charged a quantity of thick matter. The swelling was much re- duced in size ; but the testicle as well as the cord Avas still en- larged and indurated. A small quantity of matter continued to be discharged. He was ordered quinine and a nourishing diet; and a month afterwards I Avas informed that the opening had closed, .and that the boy was restored to health, slight induration only re- maining at the back part of the gland. I have seen several cases of a similar kind. Diagnosis.—No difficulty is experienced in distinguishing a tes- ticle swollen from inflammation from a strangulated inguinal hernia. In both, there may be a scrotal swelling, accompanied with pain and tenderness of the abdomen, vomiting, obstinate constipation, and a good deal of constitutional disturbance. The true nature of the case, when these symptoms exist, can always be ascertained very readily by the absence of tension in the abdomen ; the limita- tion of the pain and tenderness to one side; inability to feel the tes- ticle of its natural size beloAV the swelling (supposing the hernia not ACUTE ORCHITIS. 217 to be congenital, and if so the history of the case would set all doubts at rest); and by the tumor when handled being found harder, more solid, and more painful than a hernial swelling, and, unless there is much swelling of the spermatic cord, being clearly de- fined at its upper part. When a testicle detained in the groin be- comes inflamed, the diagnosis is much more difficult, a tense ingui- nal swelling being coupled Avith sickness, pain in the abdomen, and sometimes constipation. The .empty state of the scrotum Avould always be sufficient to excite suspicion, and an active purge to set all doubts at rest. The active character of the symptoms renders acute orchitis unlikely to be mistaken for the more chronic diseases of the gland. Secondary orchitis differs from inflammation of the body of the testicle in being preceded generally by SAvelling, and tenderness of the spermatic cord and in the course of the vas deferens ; in the epididymis being invariably the part of the organ first affected ; in the more rapid formation and greater size of the swelling ; in the disease being of a more chronic character, and in the pain and constitutional suffering being less severe. It rarely leads to suppuration, disorganization, or atrophy of the gland, but often leaves the epididymis enlarged and indurated. Treatment.—Acute orchitis must be treated Avith antiphlogistic remedies, the activity of the means being proportioned to the in- tensity of the inflammatory action and the constitution of the patient. In the gonorrheal form of the affection, all means Avhich may have been resorted to in order to arrest the discharge must be abandoned. In cases in which it can be managed without incon- venience, I usually direct the patient at the onset to maintain the- recumbent position, either on a sofa or in bed; and in very acute cases I even elevate the pelvis by a pillow placed under the nates. The scrotum and its contents must also be Avell supported in a sus- pender. The parts maybe effectually sustained in a silk, or, better still, a cambric handkerchief, doubled so as to form a triangle, the middle of the base, to which a piece of double tape has been sewn, being applied to the perineum, and the extremities of the handker- chief carried forAvards and attached in front to a band round the Avaist, whilst the ends of the tape being secured to the band behind prevent the handkerchief slipping forAvards. Patients suppose that the recumbent position obviates the necessity for support; but this 218 ACUTE ORCHITIS. is a mistake, the effects of gravitation being further counteracted, and much relief afforded by raising the testicle from its position upon or betAveen the thighs. In the majority of cases of gonor- rheal orchitis patients do not find it convenient to lay up, and are content with the relief afforded by a suspender, which in mild cases proves sufficient. The patient's diet must be restricted, and the bowels gently purged. Acute orchitis, if treated quite early with nauseating doses of tartar emetic, usually subsides rapidly, so that this plan renders local depletion unnecessary ; and as the de- pressing influence of the remedy is only temporary, the patient quickly regains his health and strength. I have seen very acute orchitis arrested and subdued in thirty hours by keeping up con- stant nausea with antimony. I usually prescribe the tartar emetic in a camphor mixture, with small doses of sulphate of magnesia and tincture of henbane. The pain and constitutional derangement are much relieved by two or three grains of calomel combined with eight or ten grains of Dover's powder, or with half a grain of morphia taken at bed-time. In both forms of acute orchitis con- siderable benefit is derived from mercury. After the bowels have been fully acted on, and the pulse lowered by antimony, mercury may be giAen, and continued until the gums become slightly affected. I am confident that by this treatment the duration of the disease is materially abridged, and, what is of no little importance, it is suc- ceeded by much less induration and thickening of the epididymis, and less risk of a permanent obstruction of the excretory duct than when mercury has been deferred to a later period. In the treatment of orchitis in private practice it is generally de- sirable to avoid local bloodletting, but in cases of a severe or obstinate character, depletion sometimes becomes necessary. From six to twelve leeches, according to the circumstances of the case, are to be applied, and if no relief be experienced in from twelve to sixteen hours, they can be repeated. I usually direct the leeches to be ap- plied in the course of the cord just above the inflamed testicle, the parts being previously shaved. The leech-bites are followed by less irritation in this situation than in the lower part of the scrotum. The flow of blood maybe encouraged, after the removal of the leeches, by a warm hip-bath or a light poultice. In consequence of the mess produced by leeches and the itching and soreness of the leech-bites afterwards, many surgeons prefer the abstraction of blood from the ACUTE ORCHITIS. 219 veins of the scrotum. The patient should be directed to stand up and foment the scrotum for a few minutes Avith warm water. Three or four of the distended veins are then to be punctured with a lan- cet. After enough blood has been Avithdrawn, the patient must lie doAvn and raise the scrotum, when the bleeding in general immedi- ately ceases. If blood should still flow, it may be readily arrested by attaching to the wounded parts the small suture forceps. Local venesection usually answers Avell enough, though in some instances the blood has not floAved with readiness, and I have even failed in removing a sufficient quantity. The scrotum is not ahvays tense and distended, nor are the veins ahvays apparent and prominent. The local application most generally applicable to the inflamed testicle, is a piece of lint dipped in Avarm water, or an infusion of poppy-heads, covered with oiled silk to keep it moist. This pro- motes the action of the skin, and is a grateful and soothing applica- tion. Cold lotions are not generally convenient. They can only be used with effect whilst the patient remains at rest in bed with the clothes kept from the parts. In severe cases of acute orchitis, both consequent on injuries and occurring idiopathically, in Avhich. the pain Avas considerable and the constitutional disturbance great, I have had recourse to the local application of ice with marked bene- fit. The plan of proceeding is to keep the patient in bed, with the testicle well supported by a handkerchief in the way already de- scribed, or, what is better, by a crutch-pad applied transversely beneath the testicles, the piece of bandage attached to each end of the pad being passed above the crest of the ilium and secured around the body. The ice is to be applied to the testicle by en- closing it in a small bladder or in an india-rubber bag with a some- Avhat narrow neck, the cold being sedulously maintained by frequent renewal of the ice. The patient should be provided with two blad- ders or bags, one to take the place of the other as the ice melts. The effects of the application are remarkable. The scrotum becomes blanched, shrunk, and corrugated; the pain and heat are entirely removed, and in a few hours the enlargement of the gland is found much diminished. The advantages of this treatment consists in the early and complete relief of the pain from the benumbing effects of the cold; in its decided antiphlogistic influence, arising both from the reduction in temperature and the even and steady compression of the testicle by the strong tonic contraction of the dartos ; and in 220 ACUTE ORCHITIS. the saving of the patient's strength by the avoidance of all deple- tory measures, the only other treatment required during the acute stage being restriction in diet and a purge. The efficacy of this plan of treatment, however, much depends on its early application, and steady continuance for a period of from twenty-four to fifty- two hours. After orchitis has existed a day or two, the application of ice does not appear to answer. The cure of orchitis has been facilitated by the application of a mode of treatment which has been found of great sendee in reliev- ing certain forms of inflammation in other parts of the body, Ariz. compression. The object of compression is to afford support to the weakened vessels ; and in inflammation of the integuments, Avhen properly applied for this purpose, and not so firmly as to produce pressure and arrest the circulation, it often proves a very valuable method of treatment. Dr. Fricke, of Hamburgh, first suggested the practice of treating both acute and chronic orchitis by com- pression, applied to the testicle by means of adhesive plaster. In an early report of this practice, he states that out of fifty-one cases of acute orchitis eighteen were treated by the ordinary means, and thirty-three by compression. In the latter cases the average dura- tion of the disease was nine days, whilst in the former it Avas thir- teen. In cases treated more recently, after improvements had been made in the mode of applying the compression, the result was still more favorable.1 This practice has since been extensively adopted both in this country and on the continent. Some care is required in making the application, which I perform as folloAvs. The patient being placed in the recumbent position, Avith the testicle raised, is to remain there three or four minutes, in order to alloAV the vessels of the gland to become as empty as possible. The parts are to be shaved; and some adhesive plaster on chamois leather must be cut into strips, about three-quarters of an inch in Avidth, and eight or nine inches in length. The opposite testicle and side of the scrotum being drawn away from the diseased one, so as to render the integu- ments of the latter quite tense, the first strap is to be placed circu- larly round the cord, just above the testicle, as tightly as the patient can bear it. A strip of lint may be placed beneath the edge of 1 Zeitschrift fur die Gesammte Medicin, as quoted in the Gazette Medicate de Paris, ann^e 1836, p. 182. ACUTE ORCHITIS. >21 the plaster to prevent its irritating the scrotum. The second strap is to be placed in an opposite direction, from behind forAvards, at the side of the testicle near the septum. The third strap is to be applied below the first, so as partly to over- lap it; and the fourth in like manner, inter- nal to the second; and so on in succession, until the straps meet, and the whole of the testicle is covered, and evenly compressed. A feAv additional straps may afterAvards be applied Avhere most needed to afford support, and keep the others in place; the parts are afterwards to be supported in a suspensory bandage. The strapping generally requires to be reapplied in the course of twenty-four hours. AY hen the patient rises after its ap- plication, he feels relieAred from the aching pain and sense of Aveight. The application of compression has been recommended at the onset of the inflammatory attack, but in acute orchitis it is better to com- mence with antimony, ice, or depletion, and to have recourse to strapping when the active symptoms are yielding. At this period compression Avell applied often greatly facilitates the cure, promo- ting the rapid subsidence of swelling and the removal of plastic exudation, and of the thickening of the epididymis. This may be further promoted by small doses of mercury, or by the iodide of potassium. When there is much effusion in the vaginal sac, strap- ping the tumor does not seem to act with much effect. In these cases, and also when it is inconvenient to reneAV the strapping, Avhich usually soon gets loose, counter-irritation may be kept up by painting the scrotum over the affected testicle with the tincture of iodine, repeating the application every third or fourth day, until the gland is restored to its healthy state. It has been attempted recently, in cases of orchitis, to obtain the same effect as that produced by strapping, by coating the scro- tum with collodion. This application has been used chiefly by the French surgeons, some of Avhom have reported favorably of it. I haA'e tried it in several cases, but have not found it answer. Collo- dion, Avhen applied to the scrotum, causes a certain amount of con- traction, the effects of which are exerted chiefly on the skin and subcutaneous connective tissue; but its compressing influence on 222 ACUTE ORCHITIS. the inflamed gland is extremely feeble. Besides, it is very liable to produce considerable irritation, and even sores on the scrotum, which are very annoying to the patient. On this account, elastic collodion, a mixture of this substance with castor oil, has been em- ployed. This I have also used. It certainly produces less irrita- tion than ordinary collodion, but, on the other hand, has less con- stringent power. Many ingenious attempts have been made to construct an appa- ratus capable of producing equalble compression of the testicle. Amongst others, Mr. Hutchinson has invented a caoutchouc bag, the cavity of which may be lessened to any amount by inflation of its walls. By the agency of this contrivance permanent and equa- ble compression may be exerted on the testicle without the neces- sity of removing the instrument. An inconvenience of this appa- ratus arises from the confinement of the perspiration, causing moisture on the surface of the skin and a sense of heat. It is well adapted, however, to produce compression when we wish to combine local applications with this treatment, which cannot well be effected with strapping over lint and mercurial or iodine ointments. In some constitutions, after the more active symptoms of orchitis have subsided the inflammatory action persists, and continues in a " subdued and chronic form. This is observed in persons of a weak frame, who appear pale, and as if they did not habitually enjoy good health. In these subjects the orchitis even at the onset is often neither acute, nor accompanied with any marked constitutional disturbance. Neither depletion nor the application of ice makes much impression on the inflamed testicle, which continues swollen and tender, whilst the loss of blood renders the patient weak and irritable, and retards his recovery. In these cases of subacute or- chitis the diet should be nourishing, but not stimulating. Three or four grains of blue pill, combined with the same quantity of the extract of henbane ; or five grains of the hydrargyrum cum cretd and of the pulvis ipecacuanhas comp., may be given night and morning. In some cases I have found much benefit result from the decoction of bark or of sarsaparilla with the sixteenth of a grain of the bichloride of mercury taken three times a day. The diseased testicle should be carefully strapped; but in those cases in which the enlargement of the epididymis is accompanied Avith effusion in the vaginal sac, the scrotum should be painted with the ACUTE ORCHITIS. 223 tincture of iodine until the fluid is absorbed, when compression may be applied Avith advantage. The advice given by Bromfield and other surgeons of his day in cases of gonorrheal orchitis, to introduce a bougie into the urethra, or to inoculate it afresh in order to bring back the discharge, was founded on the erroneous idea, that the acute symptoms of orchitis are never dissipated till the return of the discharge from the ure- thra. These are absurdities which the common sense of modern surgeons has completely banished from practice. Copaiba, cubebs, and remedies of this class, as well as injections, must not, hoAvever, be employed so long as any active disease is going on in the testicle; and even after the symptoms of inflammation have disappeared, they must be used with caution and in moderation. Though I have rarely found them give rise to orchitis, I have known them, when injudiciously used, produce a relapse after all inflammation had ceased. In 1811, Mr. Ramsden published some observations,1 to shoAV that chronic enlargement and induration of the testicle, to which he applied the term sclerocele, were dependent on some affec- tion of the urethra, and that they were to be cured by remedies directed to correct the diseased condition of the canal. His views never made much impression on the profession. He was wrong in regarding the disease in the urethra as the invariable cause of the affection of the testicle, instead of an occasional one; but he com- mitted a greater error in practice by chiefly applying his remedies to the part supposed to be the original source of irritation, instead of the actual seat of disease, and in considering the use of the bougie an essential part of the treatment of these cases. Mr. Ramsden's observations, however, were useful in directing attention to the frequency of the connection between morbid states of the urethra and testicle, which exists more commonly than Avas sup- posed. In cases of stricture, it often happens after an attack of acute orchitis that the epididymis continues for several weeks, and even months, tender and enlarged, and the cause of annoyance to the patient, owing to a low degree of inflammation still lurking in the part. In seAeral of these cases, after the stricture has been cured by instruments, the affection of the testicle has subsided with- out any other treatment being necessary than simply supporting • Practical Observations on the Sclerocele and other Morbid Enlargements of the Testicle, &c. 224 ACUTE ORCHITIS. the organ. I believe, too, that in the majority of cases in which the inflammation of the testicle exhibits a tendency to return, or in which relapses occur, there is some disease or source of irritation in the urethra. In the treatment, therefore, of consecutive orchitis of an indolent or obstinate character, it is often prudent to pass a bougie in order to ascertain the state of this passage. AVhen suppuration occurs, the scrotum must be fomented and covered Avith a poultice or the simple water-dressing; and as soon as matter can be detected by fluctuation, a lancet is to be introduced and the pus discharged, in order to obviate the sinuses and fistulous passages liable to be occasioned by the confinement of matter within the tunics. In consecutive inflammation the small isolated collec- tions of serum often formed between the adhesions of the tunica vaginalis, w7hich fluctuate distinctly, and sometimes evince little disposition to disappear, are apt to be mistaken for deposits of pus. When any doubt exists, a grooved needle can be introduced to re- move it. The opening made for the escape of matter should not be allowed to close too soon. I have not considered it necessary to draw any distinction in the treatment of primary and of consecutive orchitis, the same general principles being applicable to both forms of the disease. But the pathological distinction Avhich has been observed is not without practical interest, and should not be lost sight of in the treatment of these cases. As inflammation originating in the body of the testicle is of a more destructive character and more injurious to the organ than that commencing in the epididymis, and as the pain and constitutional derangement are greater in the former, as a general rule the treatment of primary orchitis should be more active than that of consecutive, and this form of the disease more generally requires local depletion. The prognosis in consecutive orchitis is more favorable than in primary: on the other hand, after inflam- mation has ceased, consecutive orchitis is more exposed to relapses, and the SAvelling and induration accompanying it subside less readily and quickly than in primary orchitis. I have already noticed (Chapter I, Section III) the liability of a testicle detained in the groin to be attacked with inflammation, and of the tumor to be mistaken for a strangulated hernia or a bubo. It is only necessary to add that a case of the kind should be treated actively, to prevent the inflammatory action extending to the peritoneum, and giving rise to dangerous symptoms. CHRONIC ORCHITIS. 225 SECTION II. Chronic Orchitis. The testicle is liable to a form of inflammatory swelling of a distinct and chronic character, which occasionally succeeds acute orchitis, but far more commonly arises spontaneously. The disease is of importance ; for, if unchecked, it tends to disorganize and destroy the gland. The chief anatomical character of this form of orchitis is the exudation of a peculiar yellow homogeneous substance in the body of the testicle. This substance when first formed is of somewhat soft consistence, but afterwards becomes firm and solid, and so closely adherent and intimately blended with the proper structure of the organ, as not to admit of separation without much difficulty. In general there is a single deposit of this sub- stance in the centre of the glandular structure, Fis- 31. as in the preparation from which the annexed woodcut was taken. In a case of chronic enlargement of both testicles taken from a patient who died of ramollissement of the medulla spinalis, I found six or seven separate deposits of this yellow matter in the substance of the right testicle, and a single one only in the body of the left. The presence of several separate deposits, however, is by no means a common occurrence. The small masses as they enlarge coalesce, or the single one increases, until the whole testicle presents a uniform yellowish-white appearance. I have never succeeded in injecting this deposit or tracing vessels into it. The vessels of the testicle generally are enlarged. AVhen chronic orchitis is preceded by epididymitis, this part is found thickened and enlarged from adventitious deposit between the ducts. The epididymis, however, is most generally unaffected. There is often effusion of serum within the cavity of the tunica Araginalis, seldom amounting to more than two or three ounces, and sometimes also an exudation of lymph. The sac may even be partially or totally obliterated by adhesions. Ij 226 CHRONIC ORCHITIS. On a minute examination of testicles affected with this disease, it appears that the deposit consists principally of a substance exuded in the connective tissue between the tubuli. This substance is a tenacious lymph with a fibrillated basis, in which corpuscles are either wanting or very sparingly present. The tubuli are also filled with a darkish yellow matter, of a friable character, contain- ing abundance of corpuscles, and resembling scrofulous matter. In the vicinity of the chief mass of the deposit the walls of the tubes were found in some instances thickened, and their cavities distended by the matter within, but there Avere no local dilatations. Some of the tubes were found slit up lengthways, the matter within the tubes thus becoming mingled with the intra-tubular substance. In a specimen of old-standing disease many of the tubes were found degenerating and becoming fibrous, their tubular character ceasing, and their extremities being mingled with the fibrillated deposit in the body of the organ.1 It thus appears that two distinct products are observed in this disease;—one effused between the tubes and of a fibrinous character, the other intra-tubular, mainly corpuscular, and re- sembling scrofulous matter. Chronic orchitis, however, is of a very different nature from tubercle, and as the two diseases have been often confounded, and require very different treatment, it is most important to recognize the pathological distinction. The tubules are not observed to be irregularly dilated as in tubercle (vide p. 253); but, what is more marked and more important, no softening process ensues in the morbid product; and instead of its being diffused, and occurring especially in the epididymis, like tubercle, it is formed in the body of the gland, and, however largely developed, occurs generally in a single or isolated mass. In tracing the progress of the disease we shall find that it rarely occurs in early life; that if allowed to proceed unchecked, it does not commonly, like tubercle, break up and disintegrate the tubules or give rise to abscess, but leads rather to their wasting from the outside pressure of the lymph and interference with nutrition, or to their fibrous degeneration. And here it becomes a question of no slight interest to determine, whether the two products, the intra- tubular and corpuscular, and the extra-tubular and fibrinous, are 1 These observations have been limited, the curable nature of the disease having prevented my obtaining many specimens, especially recent. CHRONIC ORCHITIS. 227 merely modifications of one and the same exudation; whether, in fact, the exudation which assumes a fibrinous character between the tubes becomes so changed in its passage through them as to lose its tendency to fibrillate, and acquires that of becoming corpuscular; or whether, as seems to me more probable, the two products are different, the one being purely lymphatic and prior in point of time, the other developed in the tubes as the result of a disturbance in their nutrition, being really of a scrofulous character, but differing from ordinary scrofulous matter in that it springs from purely local and not from constitutional conditions. The yelloAV substance exuded in chronic orchitis is sometimes called the yellow tubercle of the testicle, but as the disease differs from scrofula in several essential points, and cannot be regarded as the local manifestation of tuberculosis, the term is an objectionable one, and liable to lead to error. This yellow matter under appro- priate treatment undergoes complete absorption, the testicle being left in a condition to perform its natural functions. It sometimes happens, however, that ulceration ensues in its tunics and integu- ments, and that a fungous-looking growth gradually protrudes through the opening which is thus formed. This fungous growth, properly termed benign, is sometimes called granular swelling ; it has also received the name of hernia testis, being formed in a manner very analogous to that of a hernia cerebri, in which the substance of the brain is protruded through an ulcerated opening in the dura mater. It appears that the yellow deposit after some time excites ulceration in some part of the tunica albuginea. The tunica vaginalis, and afterwards the skin, become adherent at this spot, and likewise inflame and ulcerate. The resistance afforded by the dense unyielding tunica albuginea being thus removed, the adventitious deposit gradually presses out the tubular structure, which forms a projecting tumor consisting of the tubuli mixed up with this yellow substance, and also of ordinary granulations. The mass often projects so much that scarcely any part of the organ is contained within the integuments, the tunica albuginea being partially everted, and the scrotum, relieved from tension, being retracted all round the opening by the action of the dartos. It can be clearly shown by dissection and microscopic examina- tion that the projecting fungous mass when of large size is composed of the tubules of the testicle and of lymph interspersed amongst 228 CHRONIC ORCHITIS. Fig. 32. w. n them, together with ordinary granulations springing from those tubes which are near the surface. The smaller fungous groAvths consist simply of the gland-tissue extruded from the everted tunica albuginea, protected or coated on the surface with prominent granu- lations of lymph. In Fig. 32, taken from a preparation in the London Hospital College, and representing a section of a benign fungus, nearly the whole of the glan- dular structure of the testicle is seen to be exterior to the scrotum, the me- diastinum testis being above the level of the integuments. In minute examina- tions of these fungous growths I have rarely found any great amount of ex- uded matter. The ulceration of the coats of the testicle, and consequent protru- sion, appear to have beneficial influence as respects the nutritive condition of the glandular structure. The tubuli and bloodvessels are relieved from the in- jurious effects of compression, the circu- lation is re-established, and, in many instances, the exuded lymph undergoes absorption, and the morbid product disappears from the interior of the tubes. The tunica albuginea is commonly thickened around the margin of the opening, the edges of which are everted. The margin of the scrotal integument immediately around the fungus in old cases is generally indurated and thickened, and is sometimes also slightly undermined. It is only in recent years that this hernial protrusion, or benign fungus of the testicle, has attracted particular attention. In 1808, Mr. LaAvrence explained its true nature in a paper illustrated with several cases ;] and his observations on its causes, symptoms, and progress have been confirmed by all succeeding writers on the dis- eases of the testicle.2 Though the benign fungus occurs most fre- 1 Edinb. Medical and Surgical Journal, vol. iv, p. 257. 2 In 1852 this affection was the subject of an animated and protracted discussion in the Academy of Medicine of Paris. The discussion arose on the reading of a memoir on the treatment of tuberculous ulcers of the testicle by M. Malgaigne, who described a special fungus connected with tubercular fistulae which required excision. I cannot recognize any such growth in tubercular disease of the organ. The lymph which Section of a benign fungus:—A, A, the projecting fungus ; B, B, scro- tum ; C, C, everted tunica albuginea. CHRONIC ORCHITIS: 229 quently as a chronic change in this form of orchitis, it is occa- sionally the result of acute inflammation supervening upon the chronic disease, and terminating in suppuration in the substance of the gland. In a case of this kind, in addition to the glandular swelling, there are sinuses more or less numerous which burrow in the interior of the testicle, and discharge pus mingled with the yelloAV matter. An attack of orchitis originally acute, going on to suppuration, is also liable to be followed by a fungous protru- sion of the secreting structure of the gland. In the latter case the growth is not so exuberant, owing to the absence of the yellow exudation matter ; but there are generally sinuses which furnish a purulent discharge, sometimes mixed with semen. A testicle, after becoming somewhat enlarged from chronic in- flammation, often continues indolent and stationary for years, giving rise to very little inconvenience. On examining the organ in this state, the yellow adventitious deposit is found to possess conside- rable firmness and consistency; the tunica albuginea is thickened, and in some places as dense and indurated as cartilage; and the surfaces of the tunica vaginalis are closely connected by old adhe- sions. The glandular structure is atrophied by the pressure of the yelloAV matter; and after some time both become converted into fibrous tissue or undergo a slow process of wasting, so that an en- larged and indurated gland is progressively reduced, until scarcely anything remains beyond a mere nodule of fibrous tissue of the size of a nut at which the spermatic cord terminates. I found, on examination of the body of a man who some few years previously had suffered from chronic inflammation of the testicles, both glands much indurated, but about the natural size. In both the tubular structure was very deficient, its place being supplied by a dense fibrous tissue. At the upper part of the right gland there was a yellowish deposit almost as dense as cartilage, and exhibiting very little trace of vascularity. A testicle in this indo- lent state, when examined in the hand, often feels as hard nearly as a stone; and formerly the term scirrhus was applied to such tends to force out the tubuli in chronic orchitis after the coats of the testicle have ulcerated, is formed in the connective tissue outside the ducts, and does not therefore readily destroy them, and is, moreover, confined generally to the body of the testicle. But tubercles are developed, as I shall hereafter show, within the tubes, and more commonly affect the epididymis than the body of the gland, both the secretory and excretory apparatus being-more or less destroyed. 230 CHRONIC ORCHITIS. enlargements. In these indurated testicles, the epididymis often escapes the morbid alteration affecting the body of the gland ; in other cases, however, the epididymis is also found nodose, irregular, and hard. It will be perceived, from the preceding observations, that the tendency of this chronic disease is gradually to destroy the integrity of the testicle. If the inflammation be checked in an early stage, the gland is left unimpaired; if its course be not arrested until a later period, the secreting structure is partly disorganized and re- duced in size; but if the disease be allowed to continue unchecked by treatment, the organ is totally destroyed, either by suppuration and ulceration, or by the slower process of wasting and fibrous degeneration. AYhen both testicles are attacked the sexual de- sires and powers decline in proportion to the damage resulting from the disease. The causes of chronic inflammation of the testicle are various. It often takes place after a slight contusion, the first effects of Avhich were so inconsiderable as to be very little regarded by the patient, the testicle not beginning to swell nor to give pain till some weeks after the accident. Occasionally it arises a short time after the cessation of an attack of acute orchitis, more particularly when the patient has been guilty of some imprudence in drinking or sexual indulgence. Persons suffering from stricture, and other affections of the urinary organs causing irritation in the urethra, are pecu- liarly liable to it; and the inflammation, though usually idiopathic, may sometimes be traced creeping along the vas deferens to the epididymis, and thence to the testicle, as in consecutive orchitis. It occasionally arises during an attack of gout, and in persons suffering from rheumatism, in which cases it has partaken of the characters of these constitutional maladies. Sir A. Cooper took a just vieAV of the disease in considering it to be mainly dependent on impaired health and a feeble constitution. He remarks, " AATith respect to the causes of this disease, it is wrong to view it merely as a local affection; for there is in persons prone to this complaint a constitutional tendency to the malady. It often occurs in those who have been scrofulous in their youth. It is frequently the product of a constitution worn and broken by intemperance. It often follows a long-continued course of mercury; and it arises in habits in which the vital powers are diminished, and in which Ave CHRONIC ORCHITIS. 231 so often find sloughing of -the cellular membrane, in the form of chronic carbuncle. Frequent exposure to wet, cold, or fatigue, and an excessive indulgence of the passions, also dispose to its pro- duction. The most frequent occasional cause is urethral disease, whether it be irritation only, exciting a sympathetic influence, or an organic change in the mucous membrane; and many of those causes which I have mentioned, in speaking of acute inflammation of the testes, are, in different cases, the precursors of this disease; the chief difference in the nature and production of the two com- plaints being in the state of the constitution."1 Symptoms.—The symptoms of this disease are uniformly of an indolent character. At the commencement the testicle feels some- what tender; and after a short time the patient detects a slight enlargement, and an irregular induration in some part of the organ. This induration often commences at the lower part of the epididy- mis ; but not always, nor so frequently as is supposed by many pathologists. The body of the gland and the epididymis shortly become involved in one common swelling, which feels smooth, firm, inelastic, and of uniform consistence, and is of an oval form, with the sides somewhat flattened. The enlargement advances slowly, but goes on steadily increasing until the organ is at least tAvice its natural size. The swelling is attended with slight pain of an obtuse character, and a sense of weight in the part and in the loins. The pain on pressure is also dull; and when the disease continues for seven or eight weeks or longer, the organ loses in a great degree its peculiar sensibility. The spermatic cord is not generally indu- rated ; but it feels full, and its veins are rather swollen. The term sarcocele was applied formerly to this state of the testicle, as well as to other enlargements of the gland of a very different nature. The confusion thus produced led to the disuse of this term, which is noAv seldom met with in surgical works. There is often some effusion in the vaginal sac around the enlarged testicle, constituting the affection to Avhich the term hydrosarcocele was applied. The effusion is seldom considerable; indeed I have rarely found it exceed two or three ounces. It is frequently collected at one spot, its diffusion throughout the sac being prevented by adhesions. It occasionally happens that both testicles become affected, inflam- mation having commenced in one gland shortly after the enlarge- 1 Lib. cit. p. 39. 232 CHRONIC ORCHITIS. ment of the other, or, having ceased in one, then appearing in the other. Sometimes fluid is effused only on one side; in other cases there is double hydrocele, coupled with morbid enlargement of both testicles. So little inconvenience is usually experienced from this disease, that the testicle sometimes acquires a considerable size before the patient's attention is seriously attracted to it. He finds relief, perhaps, from a suspensory bandage, and continues his usual occu- pations, exercise, and mode of living, without paying any further attention to it, until fresh inflammation is excited by a slight blow, or excess in drinking or venery; when, the symptoms becoming suddenly severe or increased, he is induced to seek for surgical assistance. After the disease has existed for many weeks, or even months, the skin at some part of the scrotum, usually the front, grows thin and prominent, and becomes red and inflamed. In a short time it breaks, and a fungous-looking substance, and sometimes a small quantity of pus, are discharged ; and this is soon followed by a pro- trusion of the substance of the testicle, which gradually increases, until the part presents the characteristic appearance of the benign fungus. This consists of a protuberant mass, presenting an ash or yellowish-white appearance, varied by irregular patches of a pale red hue, and sometimes of black, from inspissated blood. As on other granulating surfaces the eminences are more or less promi- nent, but in some instances are quite indistinct, the surface of the tumor being even and smooth. The projecting growth is surrounded and often closely girt by the skin of the scrotum, the ulcerated edges of which are thickened and everted. It furnishes a scanty thin sanious discharge, occasion- ally mixed with the seminal fluid. It is nearly insensible to friction, the action of caustics, and incisions with the knife. The spermatic cord may be distinctly traced to the base of this morbid protru- sion of the gland, which often projects so much that scarcely any part of the organ can fairly be said to be contained within the scrotum. The disease in this stage is very indolent, and if not interfered with lasts many CHRONIC ORCHITIS. 233 months without undergoing" any perceptible change. As soon as the scrotum has thus given way all pain abates, and the scrotal swelling partly subsides. Though chronic orchitis not unfrequently affects both testicles, the benign fungus has been rarely observed in both organs at the same time. I have met with it in only one instance. Mr. Lawrence, in his original memoir, describes two cases in which the organs were successively attacked with chronic enlargement followed by granular swelling. Very few cases of this affection have fallen under my notice within the last few years. The disease appears to reach this stage less commonly in the pre- sent day than was the case formerly, owing, without doubt, to the profession generally having become better informed in the diseases of the testicles, and to the success attending their improved treat- ment of them in the early stage. I have spoken at p. 202 of the deposition of matter in the sub- stance of the testicle and epididymis in cases of acute orchitis, and have mentioned the concrete form of this deposit, and chronic state of the symptoms which occur after all active disease has subsided. Suppuration occasionally takes place in the chronic form of orchitis, which I am now describing, in connection with the yellow fibrinous exudation matter, and in a case of the kind pus-corpuscles were found Avithin the tubuli. Both pus and plastic matter may be effused in the substance of the testicle ; or lymph may be deposited in the testicle, whilst suppuration occurs in the epididymis alone. The formation of pus in these cases is a serious aggravation of the disease, and much lessens our prospect of being able to save the testicle. When effused in the body of the gland it disorganizes the delicate structure ; and when ulceration ensues and the matter es- capes, leaves behind sinuses communicating with the interior of the organ, which evince but little disposition to close. These sinuses discharge a thin pus, mixed in some cases with thes seminal fluid, forming consequently a spermatic fistula. Sir A. Cooper has remarked that the testicle, even in very young children, sometimes becomes enlarged and very hard, but without pain or any inconvenience; and the disease is accidentally dis- covered by the parent or servant. In this state of indolent increase it remains for many weeks, months, or years; and then, under im- provement of the general health, the enlargement subsides, and the 234 CHRONIC ORCHITIS. gland resumes its natural state.1 Some years ago my late colleague, Mr. Hamilton, showed me an infant ten months old, who Avas under his care at the London Hospital on account of a chronic enlarge- ment of both testicles. These glands were observed to be rather large at birth, but they had since greatly increased in size. The right was nearly as large as a plover's egg; the left was someAvhat smaller. They were of an oval shape, and quite hard, had a smooth and even surface, and did not appear at all tender Avhen handled. The infant was in pretty good health. The case had been under observation three weeks, during which time they had remained sta- tionary. I have since seen two or three similar cases, but have had no opportunity of ascertaining the pathological nature of this chronic enlargement of the testicle in young infants. I believe Sir A. Cooper to have been in error in describing the disease as tuber- cular. The fact that the enlarged gland usually resumes its natural state, the even character of the swelling, and the absence of scro- fula in other parts, are unfavorable to this view of the nature of the tumor. I had not met with any case in which the disease had given rise to the benign fungus at this early period of life until the summer of 1854, when, being in Dublin, I was shown by Dr. Fleming, sur- geon of the Richmond Hospital, a well-marked case of granular swelling in a child about tAvo years of age, and also the drawing of the scrotum of another child with a similar affection. In a commu- nication with which I have very recently been favored, Dr. Fleming informs me that he has met with several cases of chronic orchitis, both single and double, in different stages, in children applying for relief at the Netterville Institution. The drawing above alluded to was taken from a child, aged twenty months, born of healthy parents, Avho was seized with chronic orchitis first in the left testi- cle, and afterwards in the right. This occurred about six weeks or two months before application was made for relief. At this time, the local signs of the double disease were as graphically marked as in the best selected case of the adult, and the enlarged left testicle bulged forwards through an ulcerated opening in the scrotum and presented the peculiar appearances of the granular swelling. The right side of the scrotum Avas faintly tinged with red, edematous, and at one part adherent to the testicle. During the stay of this 1 Lib. cit. p. 97. CHRONIC ORCHITIS. 235 child in hospital the curative process proceeded favorably under the usual treatment, but the child was removed before the cure Avas completed. Dr. Fleming mentions two other cases of benign fun- gus, in children about three years of age, one testicle only being affected. In none of the cases which have fallen under his notice has he been able to trace the disease to any syphilitic taint in either of the parents. The treatment adopted was alterative doses of the gray powder combined with rhubarb and carbonate of soda, fol- lowed by iodide of potassium in syrup of bark and sarsaparilla, or the iodide of iron. The sulphate of copper and strapping were used locally. This treatment proved very successful. Diagnosis.—An enlargement of the testicle from chronic orchitis may be mistaken for encephaloid cancer of the organ, and for a hematocele. It differs'from the former in the surface of the gland being more uniform and regular, in the tumor being of less size, and in the absence of any concomitant affection of the cord and lymphatic glands in the groin. In some cases the origin of the disease in the epididymis also serves to indicate the nature of the case. In the early stage, however, of encephaloid cancer, the cha- racters of the tumor are so similar to those of chronic orchitis that the diagnosis is extremely difficult, and sometimes Ave have no other guide on which we can rely than the influence of remedies on the disease.—A few years ago a gentleman residing in a midland town came to London to take the opinion of surgeons respecting a disease of his testicle, which had existed eighteen months. The organ was much enlarged, and very hard and heavy, and the vaginal sac con- tained a small quantity of fluid. His general health was somewhat impaired. He had taken mercury, iodide of potassium, and iodide of iron, and used mercurial and iodine applications locally, but without effect in reducing the tumor. This gentleman saw Sir B. Brodie, Mr. LaAvrence, and myself separately. Neither of us ven- tured to pronounce a positive opinion of the nature of the disease, but we Avere inclined to regard it as malignant. As it appeared that the mouth had not been made sore, a further trial of mercury carried to salivation was recommended, and if the enlargement did not subside under this treatment, we all agreed in advising castra- tion. The disease, which I presume was chronic orchitis, subsided under mercurial treatment, and the patient was cured in three months. The tumor produced by chronic orchitis is more solid, 236 CHRONIC ORCHITIS. and not so elastic as a hematocele. It very rarely, too, attains so large a size as the latter, without causing ulceration of the tunica albuginea, and a fungous protrusion of its glandular structure. On inquiry into the history of the case the disease will be found to have come on very gradually, and not to have occurred suddenly after a blow, or to have succeeded a hydrocele, as is the case with a hema- tocele. The diagnosis is usually very easy; indeed, I have not witnessed any case of chronic orchitis in which there Avas any diffi- culty in distinguishing the disease from a hematocele. A hydro- sarcocele can only be distinguished from a hydrocele by an exami- nation of the part, after the fluid has been evacuated, unless the serous effusion be very small in quantity, or the sac should happen to be loose and not fully distended, in which case the enlarged and indurated testicle may be detected through the fluid. A chronic inflammatory is very liable to be mistaken for a true tubercular enlargement of the testicle. The mode of distinguishing the two affections will be found described at p. 259. The benign fungus of the testicle, until recent years, Avas com- monly confounded with malignant fungoid disease of the gland. Such a mistake is not likely to be made in the present day by any well-informed surgeon. The granulating character of the protrud- ing mass, its consistency, and the absence of bleeding, plainly in- dicate the nature of the SAvelling. The circumstance, too, that pressure on the tumor causes the ordinary pain of a compressed testicle, whilst in malignant disease force so applied produces no such sensation, will further assist the diagnosis in any instance of doubt. Treatment.—Chronic orchitis, if treated early, is very amenable to remedies. Depletive measures are seldom necessary. A few leeches may sometimes be applied with benefit after a fresh or sudden accession of inflammation; but even local depletion is rarely required. Mercury is the chief remedy, and generally proves very effectual before the occurrence of suppuration. As soon as its influence on the system begins to be manifested, the pain and tenderness cease, the swelling diminishes, and the indura- tion gradually disappears. Five grains of blue pill, with a quarter of a grain of opium, may be given twice daily; and the dose can afterwards be increased or diminished according to its effects; or mercurial inunction may be substituted for the pills. No object is CHRONIC ORCHITIS. 237 gained by making the mouth very sore; but it is desirable to affect the gums slightly, and to keep the patient under the influence of the remedy until all swelling has subsided, and the induration is nearly removed, which takes place slowly, and usually occupies four or five weeks. It must be borne in mind that we have to treat a low form of local inflammation in a constitution, generally, some- what enfeebled and impaired. The patient should therefore be allowed a nutritious diet—meat once a day, and in some instances malt liquor or wine. In persons of weak constitution the sulphate of .quinine may be given during the mercurial course with much advantage,—say, two grains twice or three times a day. It must not be understood that chronic orchitis cannot be cured without mercury; but this remedy is so eminently beneficial, that where the constitution can bear it, mercury should always form an important part of the treatment. At first I generally recommend the patient to keep constantly in the recumbent position, in bed or on a sofa; but this is not absolutely necessary, and may often be dispensed with during the treatment and when the inflammation is slight. Compression by means of strapping, applied in the manner already explained, tends to promote the absorption of the adventitious deposit, and hasten the resolution of the swelling. The efficacy of mercury is so great that I have seldom employed compression with- out it, but I have several times combined the tAvo apparently with much benefit. In these cases I generally strap with the Emplastrum ammoniaci cum hydrargyro. The reduction of the swelling and induration may also be promoted by applying to the scrotum the Unguent um Iodinii C, or the Ceratum Hydrargyri C, or by painting the scrotum every alternate day Avith the tincture of iodine. These local applications are particularly applicable to those cases in which the presence of fluid in the tunica vaginalis prevents the advantageous use of compression. It is often necessary to continue the local means and the exhibition of small doses of mercury for several weeks, before the effects of the disease are entirely removed. But it is not necessary that the patient should be strictly confined all this time. He may pursue his usual occupation in-doors, and even take gentle exercise in the open air. One great advantage of compression is, that it dispenses Avith con- finement to the recumbent position in most of the cases in which it is employed. In cases where it is necessary to discontinue the use 238 CHRONIC ORCHITIS. of mercury in consequence of its injurious effects on the constitu- tion, the decoction of sarsaparilla, Avith four or five grains of the iodide of potassium, may be given Avith much benefit in getting rid of the swelling and induration. The iodide of quinine or of iron are also suitable remedies under such circumstances. During the treatment the patient must strictly abstain from the excitement of venery. The successful result of treatment necessarily much depends upon the period at which the case comes under the surgeon's care. If the disease has not existed longer than five or six Aveeks, the restoration of the testicle is complete; but if its duration be greater, the structure of the gland often suffers, though the organ may still be saved from complete destruction. AArhen inflammatory action has been' allowed to go on for many months, the testicle generally becomes so disorganized that all we can hope for is to arrest the progress of a disease which is a source of suffering, keeps up irritation, and tends to impair the general health; a.nd in some instances the amount of exuded matter is so great as to be beyond the influence of absorption, and there is then no alternative but to remove the gland. This operation, however, is very rarely required; and in no instance of chronic orchitis, without suppura- tion, occurring in my own practice, have I had occasion to resort to it. As the inflammation of the testicle subsides, the fluid effused into the vaginal sac usually becomes absorbed; so that the hydro- cele seldom requires any other treatment than that employed for the removal of the disease which produces it. Sometimes, how- ever, these means prove insufficient to get rid of the hydrocele, and an operation becomes necessary to make a complete cure. There should be no hurry in resorting to active measures for this purpose; for it often occurs as the patient recovers from the effects of the disease and the treatment, and his health becomes fully re-esta- blished, that the fluid in the tunica vaginalis is slowly absorbed. When, therefore, after the removal of the disease of the testicle, the quantity of fluid is so considerable as to produce a tumor of inconvenient size, the surgeon should perform acupuncture, or in- troduce a trocar, and having drawn off the fluid wait the result. If it should collect again he can then have recourse to iodine injec- tion which must be employed with more than usual caution, in order CHRONIC ORCHITIS. 239 to avoid exciting fresh inflammation in the substance of the testicle. In a case which I injected lately, about six months after the cure of chronic orchitis, the operation caused a solid enlargement, from effusion in the vaginal sac, of great size; I was induced to give mercury, and afterwards tonics, under which treatment the swelling slowly but steadily subsided. The folloAving case will serve to illustrate many points in the history and treatment of this affection.—A captain of a ship, a man of SAvarthy complexion and muscular frame, aged twenty- seven, who had just returned from a voyage to the West Indies, was brought to me, October 1st, 1840, by a medical friend, for my opinion respecting the state of his testicles. It appeared that the right gland had begun to SAvell about a twelvemonth previously, and that six months afterAvards the left had also increased in size, and they had since continued to enlarge. The inconvenience which he suffered was so slight that no attention had been paid to his com- plaint, which did not appear to affect his health. He was engaged to undertake another voyage in a few days; but he thought proper to consult his usual medical attendant before joining his ship. On examination I found a hydrocele of moderate size on the right side, and could without difficulty detect the testicle behind by the solidity and firmness of the tumor at this part, which were greater than usual. There was a hydrocele also on the left side, which extended some way up the cord ; but OAving to the looseness of the sac, and the presence of only a small quantity of fluid, I could easily feel the left testicle, Avhich was evidently enlarged and indurated. The slight inconvenience which the patient experienced appeared to arise from the size and weight of the tumors. I drew off about six ounces of serum from the hydrocele on the right side with a trocar, and then found this testicle larger even than the left, and also very hard. In both the induration Avas in the body of the gland. The patient stated that he had not been subject to any complaint of the urinary organs during the last two years, and he ascribed the origin of the disease of the testicles to excessive venereal indulgence. The importance of abandoning his intention of shortly going to sea wTas strongly urged, and reluctantly consented to. The following treatment Avas adopted:—Rest in the recumbent position; three five-grain blue pills in the day; and the application of the linimen- tum hydrargyri to the scrotum.—Oct. 17th. Although the pills 240 CHRONIC ORCHITIS. had been increased to four daily, the mouth was scarcely at all affected by the mercury. The testicles were less tender, and a little diminished in size. The hydrocele on the right side returned a few days after the operation. He was now ordered to rub in a drachm of strong mercurial ointment on the inside of the thighs night and morning, and to take two blue pills daily. On the 22d the mouth was rather sore, and the fluid was entirely absorbed from the left side; and the testicle was softer, and partly reduced in size. The right testicle and hydrocele were also diminished. The treatment was continued.—Nov. 3d. The mouth was very sore: the blue pills had been omitted since the 27th ult. Both testicles were much diminished in size; but they felt irregular, and were still heavier and harder than natural. A small quantity of fluid was yet remaining in the tunica vaginalis on the right side. I ordered Decoct. Sarzce. cum Potass. lodid. gr. v. ter die; pit. hydrarg. gr. ij. o. n.; and the scrotum to be painted every alter- nate day with Tinct. Iodinii C. This treatment was continued for about two weeks. The patient was allowed good diet, and to take exercise; and as his health became re-established all effusion disappeared, and both testicles Avere restored to their natural size, a little induration only remaining at the end of ten weeks after I first saw him. In the benign fungus of the testicle the treatment formerly re- sorted to was castration. A knowledge of the morbid changes pro- ducing this affection naturally led to better modes of practice, and now nearly all cases of this affection are found to be remediable without recourse to excision of the gland. The merit of this im- provement'in surgery is justly due to Mr. Lawrence, who observes that, in many instances, if the complaint were left entirely to itself the SAvelling would subside, the fungus shrink, and a complete cure ensue without any professional assistance. But this can seldom be the case, for the anatomical condition of the parts producing the fungus tends powerfully to prevent a natural restoration. The chief obstacle to the healing of the wound being the impediment offered by the protuberant fungous mass, it was naturally supposed that the first object in treatment was to reduce this projecting growth to the level of the surrounding skin. For this purpose pressure and vari- ous escharotics were applied to the surface of the swelling. These applications, though effectual in reducing the granulations and set- CHRONIC ORCHITIS. 241 ting up a healing process in the surrounding skin, especially when pressure and the caustic were combined, often proved tedious, and in some instances failed in obtaining a cure. Mr. Lawrence was, in consequence, led to recommend the removal of the fungus with the knife, as the shortest and most effectual mode of treatment. Sir A. Cooper also practised an operation by which, he states, "the part is excised, leaving the epididymis and testicle uninjured." But the mode of proceeding described by this distinguished surgeon would certainly not save the secreting part of the organ from extir- pation. Excision of the fungus cannot indeed be regarded as a satisfactory operation. It has been seen that the projecting growth partly consists of tubuli seminiferi, and in some instances includes nearly the whole of the glandular part of the testicle, so that its removal becomes an operation which in effect is but little short of castration. It may, indeed, be doubted whether the secreting structure protruded in this affection can be so far restored as to be enabled to perform its proper functions; but it does not appear that in most of these cases the gland tissue, though more or less injured, is Avholly destroyed, or beyond recovery. That the tubuli are capa- ble of secreting whilst projecting from the scrotum has in a few instances been proved by the appearance of spermatozoa in the dis- charge ; and I see no reason why they should not be able to continue their functions after the testicle has resumed its right place, and the sore has closed. In one case in which I had an opportunity of examining the part several weeks after cure of a large fungus with- out excision, there was no indication of atrophy; no reason to ques- tion that the greater part, if not the whole of the tubular structure, had been preserved in a condition fit for the office of secretion.1 The following case, recorded by Dr. Duncan (Northern Journal of Medicine, June, 1845), bears on the point. A man, aged twenty- eight, was admitted into the Royal Infirmary of Edinburgh, with fungus of the left testicle. The protruded part was about the size of a large Avalnut, and appeared to include the greater part of, if not the entire, gland. The fungus was consequent upon disease of 1 Wax models of the fungus, and of the organ after cure, are preserved in the Lon- don Hospital College, and duplicates of them were presented by me to the Royal Academy of Medicine in Paris. The healthy state of the other testicle prevented my ascertaining with certainty the secretory powers of the one which had been diseased. The case, a syphilitic one, will be found related at p. 250. 16 242 CHRONIC ORCHITIS. four months' standing. The right testicle had been diseased at a former period, and no trace of it remained. The scrotum was in- cised on each side of the fungus, and the organ replaced, as sug- gested by Mr. Syme, and partial union took place by the first intention. In about six weeks the patient left the hospital with the wound quite healed. At this time Dr. Duncan ascertained that the man's sexual feelings were unimpaired; and, at a later period, had reason to believe that the powers had been tested. The result of treatment in this case seems to have been satisfac- tory, but as the report was a recent one, and as it does not appear that the secretion was examined, the efficiency of the organ cannot be said to have been fully ascertained. The object of the surgeon should be to endeavor to place the dis- eased organ as nearly as possible in its former site and condition, and the greater his success the more perfect will be the character of his practice. Upon this principle the extirpation of any part of the gland is objectionable, especially as it seldom happens that the healing of the Avound cannot be obtained by other treatment almost as readily as by excision of the fungus. The same objection as that made to excision applies to the practice also recommended of tying a ligature tightly round the base of the projecting tumor, in order to produce strangulation and the death of the part; a plan of treat- ing these cases which is not only more tedious, but more painful than excision.1 I have stated that when the fungus protrudes, in consequence of the glandular tissue being relieved from pressure, the original disease becomes less active, and often subsides, and that the pain likewise ceases. It would be wrong, however, to con- clude that the exuded lymph, though ceasing to act injuriously by pressure, always becomes absorbed, and that the structure of the testicle at once recovers its healthy state. The constitutional de- pravity leading to the disease often remains, and the size of the projecting fungus, a size often much greater than would result from granulations on the surface of the extruded tubuli, indicates the presence of adventitious deposit in the substance of the organ. This would seem to have been lost sight of in the treatment until Sir B. Brodie recommended, in addition to the application of escha- 1 In the ninth case described by Mr. Lawrence, the ligature is reported to have caused severe pain, followed by sickness and pain in the cord and loins, indicating that the part constricted comprised glandular structure. CHRONIC ORCHITIS. 243 rotics, recourse to the usual remedies for chronic orchitis.1 This practice, combined with an effectual mode of repression by com- presses and strapping, was advocated by me in 1843,a on the ground of practical experience of its efficacy. In 1845, Mr. Syme, of Edinburgh, who seems to have been under the impression that the treatment generally adopted was to excise or cauterize the fungus, communicated to the profession3 what he considered to be an improved mode of practice, by which the tes- ticle was preserved entire, and the period of cure shortened. He described the principle of this mode as consisting in the application of compression, simply by enclosing the fungus within its proper covering of the scrotum, which he effected by an operation. He cut round the fungus, and extended the incision upwards as well as dowmvards, so as to give it an elliptical form. The integuments were then separated on each side, and brought over the growth, where they were retained by stitches. The scrotum was supported by plasters and a bandage. Mr. Syme states that the surface of the fungus being coated by granulations unites with the surface of the integuments as soon as it becomes incrusted with effused lymph; and in order to facilitate the healing process he recommended the removal of the hard ring of skin through which the fungus pro- trudes. Two cases are described: in one the part healed in four weeks, and in the other in three weeks. Though this operation is in many instances uncalled for, the case readily admitting of cure without it, the conception was a good one, and in certain cases this plan undoubtedly promotes and hastens the healing process. But the operation is unfit for those cases in which much enlargement of the exposed gland still exists from adventitious deposit in its sub- stance ; at any rate until partial reduction of the growth has been first obtained by constitutional treatment and rest. In several of the cases operated on in London, respecting which I have obtained information, the flaps did not readily unite over the fungus, but receded considerably after division of the sutures, alloAving a certain amount of protrusion, so that the wound afterwards healed slowly by advancing cicatrization, as in the treatment by pressure and escharotic applications. 1 Vide Medical Gazette, vol. xiii, p. 222. 2 A'ide first Am. edition of this work, p. 345, in which the treatment by ligature and excision was strongly condemned. 3 London and Edinburgh Monthly Journal, Jan. 1845. 244 CHRONIC ORCHITIS. Having given a brief account of the various modes of treating the benign fungus of the testicle, which have been adopted since its true nature was explained by Mr. Lawrence, in order to place in a clear light the successive improvements in practice, I proceed to describe the treatment which I believe to be best suited to the affection in the circumstances under which we meet with it. In cases of a recent character the patient should be directed to keep in bed; and if there is any tenderness or pain in the testicle, to take four or five grains of blue pill night and morning, until all symptoms of morbid action are removed. A piece of lint of suffi- cient size to cover the sore, having been dipped in a solution of the nitrate of silver in the proportion of ten grains to the ounce, is to be placed on the part. One or two compresses of lint are to be applied over this, and tolerably firm compression is then to be made by several strips of adhesive plaster, and the whole is to be secured by a bandage. This is to be repeated daily; and as the protrusion recedes the scrotum is to be drawn over it, and the edges of the wound are to be gradually approximated by narrow strips of plaster. Under this treatment cicatrization takes place, and the testicle steadily resumes its place in the scrotum, remaining firmly adhe- rent to the new skin. In cases where there is no enlargement and no occasion for the exhibition of mercury; or after its discontinu- ance, if the general health be impaired, the sulphate of quinine, iodine, or steel medicines, may be combined with the local remedies. Other escharotics are also effectual in keeping down the granula- tions and promoting a healing action, such as a solution of the sul- phate of copper, and the ointments of the nitric oxide of mercury, or of the red iodide of mercury. When the fungus ceases to pro- ject, the black wash makes a good application. In those cases in which the fungus projects considerably, its neck being girt by the scrotum ; and in old-standing cases, in which the integuments around the fungus are thickened and unhealthy, the ope- ration practised by Mr. Syme will much assist the cure and shorten its duration. In some instances I have been content with dissecting away the thickened margin of skin encircling the fungus, and free- ing the integument only at the part girting the base of the project- ing tumor, by an incision an inch and a half long, and dissecting back a triangular flap of skin on each side, leaving the sore, as the fungus is repressed by pressure, to close by gradual cicatrization. CHRONIC ORCHITIS. 245 I have described the occurrence of suppuration in the testicle followed by the formation of troublesome sinuses. We cannot, of course, treat these sinuses as we should similar passages in other parts, by injecting them, or laying them open from the bottom. We can only endeavor to remove any existing disease by the ordi- nary remedies for chronic inflammation, in the hope that as the health improves they may be induced to heal. Their cure may be a good deal promoted by keeping the testicle steadily compressed by means of strapping. In some instances these fistulous passages prove so tedious, and so affect the general health, that it becomes desirable to resort to the operation of castration. I once witnessed the removal of a testicle from an elderly man on this account. On examination the epididymis was found encased in the serous mem- brane, much indurated and thickened; the tunica vaginalis con- tained a quantity of serum. There were three distinct deposits of inspissated pus in different parts of the epididymis, and at its lower part a suppurating cavity, lined by a rough-looking membrane: the cavity opened externally by a fistulous passage leading to the bottom of the scrotum. The body of the testicle was quite sound. The patient had suffered from the disease for eight months, and it had resisted the ordinary treatment. In cases, too, of pus effused in the testicle without finding any vent, there is often an indolent intractable enlargement of the gland, which continues stationary, does not yield to remedies, and is attended with very little or no pain; but still causes so much annoyance to the patient, and so disturbs his mind, that he becomes desirous of parting with the organ in order to regain his health and resume his customary occu- pations.—In March, 1841, I was requested to visit the master of a ship, a man aged forty-three, in consequence of a chronic enlarge- ment of the right testicle, which had been gradually forming formany months. The mouth had been made sore by mercury, and various sti- mulating applications to the part had been used, without any effect on the disease. He did not suffer much, and was desirous of return- ing to his ship; but Mr. Arthur, his medical attendant, considered it unsafe for him to go to sea again with such a disease unrelieved. As the SAvelling had not subsided under the remedies which had been judiciously tried and persevered with, I recommended the re- moval of the gland, to Avhich the patient readily consented, rather than submit to any long confinement. I accordingly performed the 246 SYPHILITIC ORCHITIS. operation, from which the patient recovered, so as to be able to join his ship in a month. The testicle was enlarged to more than thrice its natural size. The surfaces of the tunica vaginalis were closely adherent. On making a section of the tumor no trace of the natu- ral texture of the gland was apparent, its place being supplied by irregular masses of lymph and soft purulent deposits, separated by thick septa of fibrous tissue. In some instances, when pus is pent up in the testicle, the organ continues enlarged and tender, and the seat of a dull chronic pain, the matter proving a continual source of irritation. These symp- toms may be relieved by rest, local depletion, and mercury; but the benefit is in general only temporary, the patient continuing to suffer more or less, and frequently experiencing relapses. For this state of the organ there is seldom any other remedy than castra- tion. The following case is related by Sir A. Cooper.—" A sur- geon in the cavalry had an inflammation and chronic enlargement of the testicle, which had been repeatedly relieved by the recumbent position, local depletion, and the use of mercury; yet when he re- turned to the exertions necessary to the due performance of his military duties, the symptoms were renewed. Tired by these re- peated disappointments, and unable to pursue his profession satis- factorily, he requested me to remove the part, to which I consented, and found, upon dissection of the testicle, a chronic abscess in the centre, which kept up irritation of the part, and repeatedly repro- duced the inflammation."1 In cases of this nature the presence of pus cannot be ascertained with any degree of accuracy. No sur- geon, therefore, would think of resorting to castration till after a persevering trial had been made, with the usual remedies for the reduction of chronic inflammation of the gland. SECTION III. Syphilitic Orchitis. Persons affected with syphilis are subject to a chronic morbid en- largement of the testicle, known by the term syphilitic sarcocele, it being considered one of the sequele or constitutional effects of the venereal poison. This affection of the testicle occurs in two stages of the disease, as a symptom of secondary and of tertiary syphilis. 1 Lib. cit. p. 44. SYPHILITIC orchitis. 247 It is a form of chronic orchitis, and though essentially of the same nature in the two stages of syphilis, differs materially in its progress and in its readiness to yield to remedies at these periods of the constitutional disease.1 When the testicle is affected during secondary syphilis, the orchi- tis occurs generally within a twelvemonth after the primary infec- tion, but is a late symptom of this stage of the disease. It is usually accompanied with a pustular or scaly eruption, or ulcers in the throat, and sometimes with iritis and periosteal inflammation. The enlargement takes place slowly and in the same manner, is accompanied with the same dull pain and sense of weight, and the disease maintains the same indolent character throughout its entire course, as in chronic orchitis. It commences in the body of the gland, seldom affects the epididymis, and rarely terminates in sup- puration, or in the production of a hernial fungus. A granular swelling may occur, however, as in the case related at p. 250. The disease is generally limited to one testicle. In cases of tertiary syphilis, orchitis is liable to occur at any period of the disease, and often does not appear till four or five years after infection, and sometimes even, not till later. The con- stitutional symptoms consist of subcutaneous tubercles, unhealthy ulcers, phagedenic sore throat, and nodes in various parts, especi- ally the latter. The local changes are nearly of the same character as in secondary syphilis. They are still more indolent, an enlarge- ment of the testicle often occurring without the patient being aware of it; and the disease sometimes ends in suppuration. The epidi- dymis is liable to be affected in this stage of syphilis, its upper part, the globus major, becoming hard and nodular. Both testicles com- monly become diseased, either simultaneously or in succession. The subjects of this form of orchitis are pale, emaciated, and feeble, their constitutions having been seriously impaired by the venereal poison, and often by the treatment employed for its removal. Chronic orchitis is liable to occur in persons who have suffered from syphilis after the constitutional symptoms have nearly or com- pletely disappeared. In such cases it becomes questionable whether • The occurrence of orchitis in the two stages of syphilis, and the modifications of treatment applicable at these periods, were particularly noticed by Mr. John Hamil- ton, of Dublin, in a valuable practical Essay on Syphilitic Sarcocele, published in 1S49. 248 SYPHILITIC ORCHITIS. the disease of the testicle is not the result of a depraved state of system, rather than a symptom of the syphilitic poison. Like other syphilitic symptoms the chronic enlargement of the testicle is apt to recur after subsiding under treatment insufficiently prolonged. Mr. H. Ludlow has described the case of a man in St. Bartholomew's Hospital on account of syphilitic orchitis, Avhose tes- ticle had enlarged fives times within three years. It invariably resumed its natural state under the use of mercury or iodine. Sir A. Cooper mentions1—" A man applied to me in November, 1807, with a testicle diseased, and hard as a marble. Four years before he had a venereal complaint, and in a few weeks afterwards the testicle became enlarged; but under the use of mercury it was re- duced in a month. In four months after the swelling in the testicle returned, and in two months it again disappeared by the same treat- ment. Tavo years ago it swelled again, and was again relieved; and in the last spring it became again swollen, and now, in the month of November, it is of large size." Owing to the curability of syphilitic orchitis, I have had no oppor- tunity of investigating the morbid changes Avhich occur in this dis- ease. Sir B. Brodie mentions one instance in which he examined the venereal testicle, and found the morbid appearance to corre- spond with those observed in simple chronic inflammation,2 a state- ment which is confirmed by the observations of Cruveilhier and Mr. Hamilton. The latter particularly notices also the occurrence in the diseased testicle of advanced syphilis, of yellow deposits of a tubercular character, both in the body of the gland and in the globus major of the epididymis. It does not appear that the tuber- cular character of the yellow substance has been determined by microscopic examination, but it is highly probable that Mr. Hamil- ton's view of its nature is a correct one. In describing the changes occurring in simple chronic orchitis, I noticed the presence of two morbid products, one fibrinous and extra-tubular, and the other tubercular and intra-tubular; and I suggested that the latter was probably the result of a local disturbance in nutrition, not the local manifestation of a constitutional disorder. But in tertiary syphilis the enlargement of the testicles takes place in persons whose constitutions are enfeebled and seriously impaired by long- existing general disease, the blood being depraved, and the nutri- 1 Lib. cit. p. 107. 2 Medical Gazette, vol. xiii, p. 379. SYPHILITIC ORCHITIS. 249 tive functions badly performed. And as we know that in this con- dition tubercles are not unfrequently developed in the lungs, it seems a reasonable conclusion that in the Avorst forms of vene- real testicle, the tubercular product prevails locally to a greater extent than in simple chronic orchitis, or than in the orchitis of secondary syphilis. Syphilitic orchitis disorganizes and destroys the testicle in the same way as ordinary chronic orchitis. After the exuded matter has disappeared under treatment, the organ sometimes suffers com- plete fibrous degeneration. Mr. Hamilton has related the case of a man, aged thirty-six, both of whose testicles had been attacked with the disease, and had undergone this change, of course, with com- plete loss of his virile powers. Suppuration may occur, and also en'd in atrophy of the gland. Treatment.—The disease of the testicle occurring in secondary syphilis should be treated on the same principles as ordinary chronic orchitis. The striking efficacy of mercury in the latter affection has been already pointed out. In syphilitic orchitis mercury is required not only for the removal of the disease in the testicle, but also for the cure of the other syphilitic symptoms. It is necessary, too, to continue the mercury for six or eight weeks,— to keep up its influence on the system for a longer period than in simple chronic orchitis. I prefer, on the whole, mercurial inunc- tion, a drachm of the strong mercurial ointment being Avell rubbed in on the thighs daily. I often prescribe, however, five grains of blue pill Avith a quarter of a grain of opium, to be taken night and morning, or, if the bowels are irritable, five grains of chalk and mercury with a quarter of a grain of opium may be given three times a day. The decoction of sarsaparilla, with small doses of the bichloride of mercury, and the iodide of mercury, are also Avell suited to this disease. In persons of weak constitution the sulphate of quinine may be combined with the mercurial remedies, especially with inunction. Though I have no great confidence in any other treatment than the mercurial in effecting a permanent cure, it sometimes happens that the remedy proves so depressing, or renders the constitution so irritable, that it is impossible to per- severe Avith it. In such cases the iodide of potassium may be sub- stituted with much benefit, or this valuable remedy may be given after a short mercurial course, as in the following case, in which extensive deposition in the testicle had caused the investing tunics 250 SYPHILITIC ORCHITIS. to give way, and an unusually large benign fungus to protrude. The disease yielded very slowly, but steadily to the mercurial and iodine treatment.—J. S., aged twenty-nine, a stoker, came under my care in the London Hospital in December, 1851, on account of a large benign fungus of the left testicle. He had contracted syphilis about a year before, and there was a large dark-brown patch covered with a thin scab on the fore part of the left thigh, and a similar blotch in front of the left leg. He first noticed a swelling of the testicle about two months previously, the gland slowly increasing until it attained a considerable size before the integuments gave way, which occurred about a month after the com- mencement of the swelling. On examination I found the testicle greatly enlarged; a fungus, measuring no less than two inches and a half in length, and nearly two inches in width, projected in front of the scrotum. This fungus had an even rounded surface, and was of a dusky red color. It overlapped the thickened margin of the scrotum, especially at the lower part where the skin slightly girted the neck of the SAvelling. He had been a strong muscular man, but was looking pale, and out of health, and had lately lost flesh considerably.—Dec. 11th. I divided the integument girting the lower part of the fungus by an incision an inch and a half long; dissected back a triangular flap of skin on each side, and excised some of the margin of the thickened integument. The solid nitrate of silver was afterwards applied freely to the surface of the fungus; and a thick dossil of lint being placed on the part, the integuments Avere drawn forwards with strips of plaster. I ordered him to bed, and to take Pil. Hydrarg. gr. v. c. Op. gr. ss. n. et m., and the application of the lunar caustic and the dressings to be repeated daily. In about ten days the mouth became sore, and the fungus was found considerably reduced in size, but the integument around evinced very little disposition to heal. The influence of mercury was kept up until the 29th, when it was discontinued, and Dec. Sarzce c. Pot. lodid. gr. v. ter die prescribed. Six ounces of wine were added to his full diet. The black w^ash was applied to the fungus, which was covered with a compress and strapped as before. On Jan. 10th, 1852, the patient's health was much improved. The syphilitic blotches had nearly disappeared, and the fungus was found by measurement reduced to a third of its original size and cicatrization was advancing at its base. The same treatment was continued, but he was allowed to leave his bed. From this time TUBERCULAR DISEASE OF THE TESTICLE. 251 he mended steadily. He entirely regained his health, and became stout, but the healing process advanced so slowly that the sore had not entirely closed before March 18th. AVhen he was examined five weeks later, the testicle appeared of ample size, and perfectly restored. At the end of two months the patient was still in good health. The treatment of the orchitis of tertiary syphilis must depend very much on the patient's general condition, on the duration of the syphilitic disease, and the extent to which the constitution has been impaired by the poison. In many instances, unfortunately, the orchitis is the least important of the local affections from Avhich the patient suffers. AVhen mercury can be safely given, this remedy in small doses, combined with the iodide of potassium, and long continued, indeed for two months or longer, will be the best mode of thoroughly eradicating the disease, reducing the enlargement of the testicle, and rendering the organs safe from a relapse. If the patient be allowed at the same time a good nutritious diet, meat twice a day, with wine or porter, the constitution will be so strength- ened as to bear the influence of this remedy. In cases unfit for mercury we must rely on the iodide of potassium alone, which should be given in doses of from three to five grains three times a day for some months. M. Ricord and M. Vidal, the distinguished surgeons of the Venereal Hospital in Paris, have great confidence in the efficacy of the iodide of potassium in these cachectic cases of syphi- litic orchitis. The observations on the local treatment of simple chronic orchitis are equally applicable to the syphilitic disease of the testicle. CHAPTER VII. TUBERCULAR DISEASE OF THE TESTICLE. Tins disease generally attacks primarily the epididymis, occur- rino- in the form of yellow crude tubercle. In the body of the testicle it usually appears at first as small pearly or grayish bodies of the shape and size of millet seeds, Avhich are ranged in lines like strung beads, being however less abundant and less regular at the front of the testicle than towards the rete testis, Avhere they are closely set, 252 TUBERCULAR DISEASE 34. and sometimes confluent. These little bodies coalesce, increase, and become changed into a yellow friable cheesy substance, which at a later period softens, and is often broken up into a curdy purulent fluid. Crude tubercle commonly forms several distinct deposits in different parts of the tes- ticle at the expense of the glandular struc- ture, which disappears as the disease ad- vances. The epididymis is not only more frequently attacked than the body of the testicle, but when both parts are affected, the disease is always more advanced in the former than in the latter. In a specimen taken from a man who died of phthisis (Fig. 34), I found the whole of the epididymis occupied by crude tuber- cular matter with scarcely a trace of ducts, whilst the body of the gland, though small, was free from morbid deposit. In several instances I have observed small bead-like bodies in the substance of the gland, which was but little enlarged, -whilst the epididymis was swollen to double or treble its proper size, and filled with a yellow caseous deposit. Tubercle is liable to form in all parts of the epididy- mis, but it occurs first in the head, and is generally most advanced in this part; whereas in orchitis the tail is the part primarily and most frequently affected. In Fig. 35 iso- lated tubercles are seen in the body of the testicle, appearing more nu- merous towards the rete testis, where they are seen coalescing and form- ing a number of closely set yellow lines or processes. Suppuration has taken place in the head of the epi- didymis, and a mass of caseous deposit occupies its lower part. 1 In the first edition of this work this figure was erroneously described as a repre- entation of chronic orchitis. A careful microscopic examination of it, recently made by Dr. Andrew Clark and myself, has fully satisfied us of its tubercular character. Fig. 35. 1. Fistulous sinus, leading to a suppurat- ing cavity in the head of the epididymis j 2. Caseous deposit in its tail.1 OF THE TESTICLE. 253 Fig. 36. In cases where In testicles which have been affected for some time, the greater part of the gland is invaded by the morbid deposit. This was the case in both testicles removed from a middle-aged man who died of phthisis. They were injected with colored size, and a section of one of them reduced in size is represented in Fig. 36. These and some others in which the disease was similarly ad- vanced, made beautiful preparations, the yel- low tubercular matter contrasting in a marked degree with the vermilion hue of the inter- vening remnants of glandular structure highly injected. In a later stage of this disease the characteristic deposit becomes softened doAvn and converted into a yellow pultaceous substance; inflammation is set up, new products are evolved, and pus is formed. The abscess extends to the scro- tum ; and after it has burst, and the matter has escaped, cavities and sinuses are left which resemble tubercular cavities in the lungs. the disease has been largely developed, the whole gland is tunnelled by fistulous passages. In tubercular testicles the tunica vaginalis usually contains a small quantity of serum, and its inner surface exhibits marks of inflammatory action, the opposing surfaces being partially connected by lymph either recently exuded or of older date. The vas deferens in many instances is also loaded with scrofulous matter. A minute examination of the tubercular testicle clearly proves that the disease is originally developed within the tubules or ducts. The following account of the histology of these deposits is the result of careful investigation, in which I have to acknoAvledge the valuable aid of my colleague, Dr. Andrew Clark. The small isolated yelloAvish-gray bodies found in the testicle in the early stage of the disease are composed of coils of diseased seminal tubes with altered contents, a little fibroid tissue, and branches of disintegrating blood- vessels. The tubules most distant from these bodies are usually healthy, but as they approach the tumors they are irregularly dis- tended at intervals, and their fibrous coat is observed to be thickened, opened up, studded with fat-granules, and splitting. Their contents consist mainly of large cells, some of Avhich exhibit vesicular nuclei, 254 TUBERCULAR DISEASE and are disintegrating; of smaller shrivelled cells, of irregularly shaped nuclear particles, and of a small quantity of granulo-mole- cular matter. The distension of the tubules in some places is Fig. 37. A coil of seminal tubes affected with tubercle (about 80 d.).—a, a. Thickened walls of the tubes ; b, Dilated tubes; c, c. Constricted tubes. sudden and globular, so that the distended portion with its contents represents a small tumor. From the circumference the tubules may be traced into the larger tumors, which are composed of their coils. The walls of the tubes and their contents become gradually changed as they reach the centre. The bloodvessels surrounding them may be observed disintegrating, and the nucleated fibroid walls broken up. The matter which occupies the diseased tubes and forms the tumors in the body of the testicle, as also that deposited in the epi- didymis, corresponds to the scrofulous or tubercular matter observed in other organs. This matter originally forms within the tubes, and accumulates there until the tubes burst and their contents are extravasated into the surrounding tissues. Its production is pre- ceded by a state of congestion, but does not appear to be followed by the exudation and growth of organized lymph. " This matter," OF THE TESTICLE. 255 Dr. Andrew Clark observes, " arises by a process of abnormal nu- trition in the cellular contents of the tubes, the different aspects of its structural elements being determined by the different phases of retrogressive metamorphoses through which it passes. In the early stage this matter consists mainly of large cells and the products of disintegration. Some of these cells become filled with fat-granules, and after a time become broken up; others develope nuclei, which are afterAvards extruded and persist; a third class simply shrivel and disintegrate. During these latter stages much moleculo-granu- lar matter and free fat accumulate; and this, with the free nuclei and shrivelled cells, constitutes the leading structural feature of the deposit. AVith further disintegration more molecular matter and fat are developed, and at last earthy salts." Coincident with the changes occurring in the contents of the tubes, their walls and the small bloodvessels become variously changed, split up, and disinte- grated, so that their elements after a time become mixed with the original deposit chiefly in the form of nuclear fibres and nucleated fibroid tissue. AVhen the deposit has proceeded to such an extent Fig. 38. Fig. 39. as to rupture the tubes and cause extravasation, the local circula- tion becomes embarrassed and frequently, though not always, an exudation occurs from the bloodvessels which infiltrates the deposit and adjacent parts. Such an exudation usually retards the pro- gress of the deposit, and especially its disintegration. 256 TUBERCULAR DISEASE Earthy matter, exactly similar to the dry-putty-looking chalky matter observed in the lungs and bronchial glands of persons who have been affected with tubercular disease, is sometimes found in the testicle, most commonly in the epididymis. There is every reason to suppose that in these cases the gland had at some former period been the seat of tubercular deposit. A good specimen of this calcareous matter in the epididymis, from the collection of the late Sir A. Cooper, is represented in Fig. 38. The epididymis is enlarged, and contains three separate deposits of this matter, whilst the body of the testicle is perfectly sound. The earthy matter, re- sulting from the transformation of tubercle, has also been distinctly recognized in the tubuli of the testicle, which appear irregularly contracted as in Fig. 39. Tubercle, though sometimes formed in the testicle in the earlier periods of life, does not usually occur till after the development of the organ at puberty. We have very little information respecting the relative frequency of this deposit in the testicles, as compared with other organs. In the tables of Louis, Lombard, and Papavoine, no mention is made of the testicle. Rokitansky places these organs low in the order of frequency. I have seen a large number of cases of tubercular testicle, and believe the disease to occur primarily in this organ more frequently than is generally supposed. In many instances only one gland is attacked ; but not unfrequently both are affected simultaneously, or one shortly after the other. The occurrence of this disease in the testicle must, no doubt, be viewed as one of the manifestations of the peculiar morbid state of constitution commonly known by the term scrofula or tuberculosis. It appears, however, that a weak condition of the organ, or an im- paired organization consequent upon previous disease, tends greatly to favor the development of tubercle in this part. Thus, in two cases of phthisis in wdiich I met with it, the patients were both affected with obstinate strictures, and had suffered from consecutive orchitis in early life. Symptoms.—The disease commences insidiously, and is indolent in its progress. The patient's attention is usually first attracted by a slight uneasiness in some part of the gland, generally the epididy- mis, which on examination is found to be somewhat enlarged, prominent, and hardened. Sometimes the whole organ feels slightly enlarged and indurated, though it more frequently forms a tumor OF THE TESTICLE. 257 with an unequal and irregular surface. The state of the testicle, however, is often masked by small local effusions of fluid in the tunica vaginalis, the surfaces of this membrane being partially ad- herent. Very little pain is experienced in the part, and there is but slight tenderness on pressure. After the disease has lasted for some time, many months or even a year and more, making little progress, and often remaining Stationary, one of the prominences begins to increase, so as to be observed externally, and to feel pain- ful and tender; the skin over it becomes adherent, changes to a livid hue, ulcerates and bursts, giving vent to a soft caseous matter mixed with pus. This is followed by the formation of a fistulous sinus, which discharges a scanty thin serous pus, mixed with parti- cles of tubercular matter, and often with semen, particularly after venereal excitement. Similar changes may take place in other parts of the testicle, occasioning two or more sinuses leading to the inte- rior of the gland. These sinuses sometimes communicate, and they may continue open and discharging for a great length of time. After the deposit has all come away, if the original disease be arrested, and no more tubercular matter formed, reparative changes sometimes take place ; the discharge ceases; the fistule close up, leaving the organ more or less diminished in size or entirely wasted, according to the extent to which it had been disorganized by the tubercular deposit. A small pit or depression with adhesion of the cicatrix to the testicle remains to indicate the spot where the fistula opened. The bursting of the abscess and escape of the tubercular matter is rarely followed by any hernial protrusion of the testicle, the seminal tubes being largely destroyed at this stage of the disease. Strumous disease of the testicle is not often seen in the suppura- tive stage in children, or before the age of puberty.—A little boy, aged five years, with fair complexion, bright eyes, and florid cheeks, was brought tome at the hospital in March, 1842, on account of an affection of the left testicle. This gland was three or four times the size of the right; of an oval form, with an uneven surface, so as to feel nodular ; extremely indurated, indeed almost as hard as cartilage; and was nearly insensible to pressure. I ordered small doses of the hydrarg. cum cretd, and the campho- rated mercurial ointment to the part. As the swelling remained but little changed at the end of three weeks, I prescribed the 17 258 TUBERCULAR DISEASE decoction of bark, with iodide of potassium, and some iodine oint- ment to be applied to the testicle. In May the skin became adherent to the lower part of the gland; an abscess formed, and about the middle of June burst, and discharged some caseous mat- ter and thin pus, and left a fistulous opening. The health began to fail, which induced me to substitute some steel medicine for the iodide of potassium. The mother became phthisical and too ill to bring the boy, and I saw nothing more of him till the father brought him to see me in the following November, when I found the fistula closed, the testicle a good deal reduced in size, but still hard and nodular, and adherent to the loAver part of the scrotum. The boy's health was much improved. Another small abscess sub- sequently formed and burst as before, since which I lost sight of the patient. Mr. Lloyd relates the following case.—A child, three years and a half old, was brought to him with the right testicle affected. The whole scrotum was distended with matter, and ap- peared like a scrofulous abscess in any other part of the body, and the skin was so thin that you might see the matter through it. A poultice was applied, and in a few days the abscess burst; and the aperture soon enlarged so much that full half of the gland pro- jected through the scrotum, and was converted into a mass of yel- Ioav scrofulous matter, which a few days after separated, leaving the remainder of the gland enlarged and hardened. This was, however, rapidly diminishing, and seemed likely to entirely waste away.1 The testicle alone may be affected with tubercle, but the disease is more commonly associated with scrofulous affections of other parts.2 The patient is either phthisical, or subject to strumous swellings of the lymphatic, or mesenteric glands; or affected Avith disease of the spine, hip, knee, or some other articulation, and manifests the ordinary characteristics of a scrofulous constitution; so that in many cases, certainly in the majority of those which have come under my notice, the affection of the testicle was of secondary importance to disease existing in other organs, and to the morbid state of the system generally. The constitution, also, is very slightly affected by, or sympathizes very little with, the morbid changes going on in the testicle. 1 Treatise on Scrofula, p. 93. 2 The vesiculas seminales are also very liable to be affected with the same disease. OF THE TESTICLE. 259 Diagnosis.—Tubercular disease of the testicle may be mistaken for chronic inflammatory, and malignant enlargements of the gland. AVriters often confound the former of these affections with the tubercular, being misled by the indolent nature of the swelling and the yellow appearance of the morbid deposit in chronic orchitis. The strumous differs, however, from the chronic inflammatory swelling in being more indolent; in making even slower progress, and 'being attended with still less pain and inconvenience; in the irregular surface and smaller size of the swelling; and, when the epididymis is attacked, in the globus major being the part principally affected, instead of the lower part, which is usually first enlarged in chronic inflammation. The diagnosis, however, may be extremely difficult, as in both cases the changes in the gland or in the epididymis are liable to be masked by inflammatory effusion in the tunica vaginalis. It is of much importance to make a right distinction, for the remedies proper for orchitis, if given in tuber- cular disease, may do considerable harm. In one case of error which came under my notice phthisis Avas rapidly developed at the conclusion of a course of mercury. The disease may be distin- guished from malignant enlargements of the organ by the smaller size, uneven surface, and more indurated nature of the swelling, and by its very chronic progress. In all cases the judgment of the surgeon will be materially assisted by his noting the general characters of the constitution, and whether there is any concomitant affection of other parts. Treatment.—From Avhat has been remarked in reference to this disease, it will naturally be inferred that the remedies of most con- sequence are those calculated to correct the morbid state of con- stitution which predisposes to local scrofulous deposit. The patient should reside in a pure air in the country, and, if possible, by the sea-side, for many months. He should take gentle exercise. The diet should be nutritious, consisting of a due proportion of animal and vegetable food; and stimulating viands and drinks must be prohibited. Malt liquors, as light pale ale, or a glass or two of wine, may, hoAvever, be taken in many cases with advantage. Medicines which tend to improve the appetite and give tone to the digestive organs are required. The sulphate of quinine, the pre- parations of steel, and cod-liver oil are appropriate medicines. There is, however, no remedy which exerts a more beneficial in- 260 CARCINOMA OF THE TESTICLE. fluence in this affection than the iodide of potassium. I usually prescribe for the adult the decoctum sarzcv, with two or three grains of the iodide of potassium, to be taken three times a day for some length of time, directing it to be discontinued for two or three days or a week, and again resorted to. AVhen the patient is in a good air the constitution and local symptoms often mend in a remarkable degree under this treatment. Mercury, AAdiich is so eminently beneficial in chronic inflammation of the testicle, is sel- dom of service in this disease ; indeed, as in strumous affections generally, its influence is usually prejudicial. Small alterative doses, as four grains of Plummer's pill, taken at night, or the six- teenth of a grain of the bichloride of mercury given in the decoc- tum sarzce twice or thrice in the day, have sometimes been resorted to with advantage; but my experience generally leads me to regard the use of mercury in any form as improper in this affection. When inflammatory symptoms exist they must be combated.by the application of leeches, fomentations, and rest in the recumbent position. Antiphlogistic measures are not often necessary. In all cases the gland must be supported. In the indolent stage of the disease the local treatment consists in painting the scrotum with the tincture of iodine every alternate day, or in applying the Ung. Iodinii Comp., mixed with an equal proportion of lard. When sup- puration ensues the part is to be poulticed; and after the abscess has burst, the orifices of the sinuses must be kept open, to allow of the free escape of the morbid deposit. In certain cases in which tubercle is largely developed, and is not thus got rid of; and in others in which the sinuses tunnelling the gland show no disposition to close, but remain obstinate and troublesome, castration may be necessary. This operation, however, is seldom required, and it should never be performed when signs exist of advanced disease in the lungs. CHAPTER VIII. CARCINOMA OF THE TESTICLE. Carcinoma occurs in the testicle under the three forms of Scir- rhus, Encephaloid, and Melanosis. SCIRRHUS OF THE TESTICLE. 261 SECTION I. SCIRRHUS OF THE TESTICLE. Carcinoma seldom affects the testicle in the dense form which it commonly assumes in the breast. Sir A. Cooper describes a scir- rhous affection, in which the testicle is invaded by a large white mass in lobes or tubercles. The spermatic cord is attacked with a similar disease, and the glands of the abdomen become converted into a white solid texture, unlike that of the fungoid disease. The organ affected feels tubercular, irregular, and excessively hard, and is the seat of severe pain, which extends to the loins. The morbid mass never becomes soft, nor so large as the encephaloid cancer, nor does it produce a fungoid or bleeding surface. Ulceration, in- deed, rarely occurs, but the patient becomes cachectic ; his coun- tenance appears sallow, and he sinks under impaired digestion, pain and tumor in the abdomen, with edema of the lower extremity on the side affected, and sometimes ascites. This form of cancer is characterized chiefly by its slow progress and great hardness during the whole continuance of the disease, and also by its irregular and tuberculated feel. It occurs less fre- quently in different parts of the body at the same time than ence- phaloid cancer, and is slower in proceeding to a fatal termination. This carcinomatous affection of the testicle is rare, and only a feAV cases have come under my notice. The following examples will serve to illustrate some of the chief features of the disease.— In July, 1844, a corpulent gentleman, aged fifty-eight, consulted me on account of a disease of the left testicle. He stated that he first perceived a hardness in the gland about five years before. He paid no attention to it for two years, when the part became en- larged and inflamed, and an abscess formed in the scrotum, and after-it burst he got relief. The opening closed, but the increased enlargement only partially subsided. I found the left testicle con- verted into an irregularly shaped body the size of a large orange, and extremely indurated. The scrotum was puckered, and adhe- rent to its front part. Firm pressure caused Aery slight uneasiness. The spermatic cord Avas also very much enlarged, and formed a thick rounded body extending far into the inguinal canal. The right testicle was sound, but there was a swelling the size of a hen's 202 ENCEPHALOID cancer egg in the right groin. He suffered occasional pains, chiefly in the left testicle and right groin ; but they did not disturb his rest, lie had no uneasiness in the loins. This gentleman appeared in tole- rable health. His appetite was good, and he was able to walk several miles. The disease slowly increased without producing any severe suffering, and he died in December, 1845. On examination of the body the disease was found to consist of hard cancer, which had extended into the abdomen and involved the bladder. The abdominal viscera were unaffected. There was no attenuation, the abdomen being thickly covered with adipose tissue.—J. M., aged fifty-two, a carpenter, came under my care at the London Hospital in 1849, on account of scirrhous disease of the right testicle. He stated that the organ had been squeezed about seven years ago, which caused swelling. It became hard and enlarged four years afterwards. The organ was about three times its natural size, and almost of stony hardness, especially at its back part. There was also an indurated tumor half the size of the diseased gland, in the spermatic cord, extending to the abdominal ring. No swellings could be detected in the lumbar region, nor did he complain of un- easiness there. He suffered severe pain in the testicle, especially at night. He remained under observation several months, during which period the disease made scarcely any progress. These two cases are well-marked examples of hard cancer of the testicle. The first is remarkable for the small amount of pain at- tending the development of the disease, and the slight degree in which the constitution suffered from it. In both instances the pro- gress of the cancer was extremely chronic. There is no other remedy for this disease but castration, which must not be delayed so as to endanger a production of the disease in the spermatic cord, or the growth of a tumor in the abdomen. SECTION II. Encephaloid Cancer of the Testicle. Encephaloid or medullary cancer is by far the most frequent dis- ease of a malignant character to which the testicle is liable. It usually commences in the production of one, two, or more small masses amongst the tubuli, which become gradually destroyed as the morbid deposit increases. The matter is \erj rarely infiltrated. OF THE TESTICLE. 263 The testicle at this early period is extremely full, firm, and hard, owing not to the solid nature of the deposit, but to the excessive distension of the unyielding tunica albuginea. The glandular structure soon entirely disappears, the whole organ being occupied by the new growth, intermixed with and sustained by the septa and fibrous processes from the mediastinum and tunica albuginea. The morbid mass sometimes accumulates in large lobes invested with fibrous tissue. More rarely the disease is first developed in the rete testis. In this case the glandular structure is found at an early period surrounding a solitary deposit in the centre of the tumor, but at a later stage, and even when the tumor has attained a' considerable size, the tubuli may be seen expanded in a thin layer around a mass of encephaloid matter. This characteristic appearance is remarked only in those cases in which the cancer originates from the rete testis. As the disease advances the tunica vaginalis becomes distended with serum, not, however, in any con- siderable quantity. The effusion is caused by inflammation excited by the presence of the encephaloid deposit. It sometimes produces adhesion and partial or complete obliteration of the cavity of the tunica vaginalis. The tough tunica albuginea gradually yields, and allows the mass to accumulate within it to a great size. The mor- bid growth at length penetrates the fibrous tunic, and a portion protrudes, forming a mass projecting from the body of the tumor. This sometimes occurs in more places than one. The epididymis remains for some time unaffected ; but as the disease increases, this part likewise becomes implicated and destroyed. In one instance I found the tubes in the head of the epididymis (the only part of the gland not destroyed) filled with white carcinomatous matter. The scrotum in time becomes fully distended by the diseased mass, which presents the well-known appearances of encephaloid cancer.1 Small cysts containing serum or a bloody fluid and nucleated cells, are sometimes mixed with the disease. In diseased testicles of some considerable size, yellow deposits, not unlike in appearance crude tubercular matter, are occasionally interspersed amongst the carcinomatous matter. Similar deposits are observed in encephaloid cancer of the kidney, ovarium, and 1 I have described only the peculiarities which encephaloid cancer presents in the testicle. For an account of the general and minute characters of the disease, I must refer the reader to the works of Paget, Lebert, and Rokitansky. 264 encephaloid cancer other parts, but not so often as in the testicle. They consist of considerable portions of cancer structure which has undergone fatty degeneration, the cells being withered and imperfect. Masses of enchondroma are sometimes found conjoined with encephaloid growths. The cartilage is probably first developed within the tubes, as in cystic disease of the testicle, although the destruction of the ducts generally renders it difficult to trace the origin of the enchon- dromatous masses. In a specimen which I examined, the cartila- ginous mass was composed of a number of small but distinct por- tions of enchondroma closely clustered, which in a section resembled very much the little masses commonly seen in cystic disease of the testicle. AVhen the tunica albuginea and scrotum give way, the morbid growth projects as a bleeding fungus. The mass then be- comes less firm, and its consistence varies very much in different parts, the morbid matter being in some a mere pulp, or resembling a creamy fluid. It is interspersed with round or irregular patches of dark-looking coagula, and when incised often presents in differ- ent places dark minute spots of various sizes, produced by coagu- lation of blood in the vascular network, usually mixed up with the morbid deposit. On macerating these tumors, or on pouring a stream of water on them for some time, a granular substance, the cancerous matter, is washed away, leaving behind a filamentous shreddy tissue or meshes of a delicate cellular texture, which may often be found connected to a denser fibrous substance, the remains of the tunica albuginea. The spermatic cord is often invaded by a similar substance; and in an advanced stage of the complaint, large bodies of the same kind, originating in disease of the lumbar glands, are found on the sides of the vertebre, reaching as high up as the diaphragm. The abdominal aorta and ascending vena caAra become surrounded by them, and are often displaced or com- pressed. I have knoAvn the circulation through the vena cava com- pletely obstructed by the pressure. This vessel has also been found filled with, and obliterated by, encephaloid matter. The kidneys are sometimes encroached upon by the disease. The spine too may be implicated, the bones of the lumbar vertebre being more or less destroyed by the morbid growth, which, indeed, spares no parts or textures in its progress. The glands in the groin of the side corresponding to the diseased testicle escape contamination more frequently than those in the loins; still they often become affected. OF THE TESTICLE. 265 It has been said that they do not enlarge until the disease has reached the scrotum. Such, however, is not always the case ; for I have seen them affected before any appearance of disease in this part. Mr. Abernethy describes a case in which the glands in both groins became so enlarged that the skin over them ulcerated, with- out the scrotum being involved.1 As the lumbar glands enlarge, the peritoneum covering them and the various viscera are pushed forwards, and there is often serous effusion in the cavity of the abdomen. In some instances the mesenteric glands are diseased, and carcinomatous tubercles are found dispersed through the liver. Masses of a similar kind are sometimes also found in the lungs, the thoracic cavities being occupied by serous effusion. The carcinoma- tous matter is often deposited in such abundance as to form a tumor of very considerable size; indeed, there is no other disease of the testicle Avhich occasions solid enlargements of so great a magnitude as encephaloid cancer. M. P. Boyer removed a testicle converted into an encephaloid tumor which Aveighed more than nine pounds.2 The vessels of the cord undergo great enlargement in this disease; in one case which I examined the spermatic artery Avas found as large as the radial artery at the wrist. Encephaloid cancer of the testicle occurs at all ages; for though it is met with most commonly at the middle period of life, no age can be said to be exempt from it.3 Sir W. Blizard extirpated the carcinomatous testicle of a child two years and a half old. The late Mr. H. Earle published an account of a case in which the disease attacked the testicle of an infant very little more than a year old. The part was removed, but in a few months he died of the same dis- ease in the brain and other parts.4 Mr. Langstaff preserved the testicle of a child, Avhich began to enlarge when he was ten months old. It increased rapidly, and in two months acquired the magni- 1 Observations on Tumors, p. 52. 2 Revue Medicale, Nov. 1839. 3 Mr. H. Ludlow (Prize Essay) collected 34 cases of encephaloid cancer of the tes- ticle, and having added to them 17 tabulated by Lebert, found the ages to be as fol- lows: Before the age of 5...........5 cases. From the age of 15 to 20...........1 " " « 20 " 30...........11 " « " SO '• 40...........22 " " " 40 li 50...........6 " k " 50 " 70...........6 " 51 * Medico-Chirurgical Transactions, vol. iii, p. 59. 266 ENCEPHALOID CANCER tude and figure of a hen's egg. Castration was performed, but the patient lived only six months afterwards. The lumbar glands, lungs, and dura mater were found affected with the same disease.1 The Museum of the College of Surgeons contains a medullary testicle removed from a child only seven months old (No. 2401). The dis- ease, as I have already remarked, more commonly occurs in the middle period of life, or between the ages of twenty and forty; but I have met with it at a much more advanced age. A patient died in the London Hospital, of carcinoma of the testicle at the age of sixty; and I once had under my care a man, aged sixty-four, whose left testicle formed a tumor the size of a large orange, Avhich had been coming about six months. The glands in the groin were en- larged, and the left leg was edematous. The disease afterwards made rapid progress. The testicle and swellings in' the groin in- creased to a great size: the scrotum ulcerated, and a bleeding and sloughing fungus protruded. The man died about two months after I first saw him. It very rarely happens that both testicles become affected ; and in this case the right, though completely enveloped in the morbid deposit, was found after death quite sound. There are feAV organs in which the origin of soft cancer can be so frequently and distinctly referred to some injury of the part as the testicle. In 'these instances we must assume that the constitu- tion was predisposed to the disease, but that the local injury stirred up the morbid action, and determined the seat of its manifesta- tion. Symptoms.—The disease commences in an enlargement, with con- siderable induration of the body of the testicle, which preserves its oval form and even surface. The enlargement is attended with slight tenderness, a dull pain, and occasionally with a little effusion into the tunica vaginalis. The growth of the morbid deposit varies, and is very unequal. It is sometimes very slow, the disease making but little progress in several months; at other times it increases rapidly. Its growth is liable to be accelerated by a slight blow or exercise. As the gland enlarges it becomes uneven, loses, too, its indurated character, and softens, but more so in one part than in another, and acquires an elastic feel. As the disease advances the pain increases, but still amounts to little more than a dull sense of weight extending up to the loins, and is sometimes quite absent. 1 Catalogue of Preparations, p. 372. OF THE TESTICLE. 267 The spermatic cord becomes thick and full, owing to the enlarge- ment of the various bloodvessels. The scrotum is at first unaltered; but as it becomes distended by the increasing size of the tumor, its veins are obstructed, and appear swollen and varicose. By this period the glands in the lumbar region usually become diseased and enlarged, and the lower extremity of the side affected swells from edema.1 The surgeon may in a short time, especially in a thin subject, distinguish the swellings on the sides of the spine by making pressure over the abdomen. The pains in the loins and abdomen soon become constant, and the patient's sufferings are altogether much increased. The general health, which was at first but little affected, now exhibits a material alteration. The patient loses flesh and strength, his countenance assumes a peculiar sallow hue, his tongue is furred, and his appetite and digestion are more or less impaired. As the enlargement goes on the scrotum becomes adhe- rent to the tumor in one or more places; then ulcerates, and allows the protrusion of the morbid mass, Avhich projects as an open bleed- ing fungus, discharging a thin fluid mixed Avith blood, and having a disagreeable faint odor. The disease then makes very rapid progress; the fungus spreads ; sloughs form on its surface ; coagula separate ; bleeding repeatedly occurs ; and the patient at length sinks, dying from the drain on the system, or from the interference of the mor- bid deposit with the functions of the important internal organs. Mr. Paget estimates the average duration of life of persons with medul- lary cancer of the testicle, at about twenty-three months. The diseased testicle usually attains a large size without the ap- pearance of a bleeding fungus, as the scrotum admits of great dis- tension before ulceration ensues. In the Musee Dupuytren in Paris, there is a wax model of a scrotal tumor produced by a cancerous tumor of the testicle, of enormous size, without any breach of sur- face. Mr. AVardrop remarks, indeed, that in no case has he even been able to learn that the integuments have given way, and a fungus grown from the diseased testicle; and Sir B. Brodie like- wise states that it has not fallen in his way to observe a tumor in this advanced stage.2 At p. 266, I have briefly related the parti- culars of a case that came under my notice, in which the disease 1 In a case related at p. 275, the swelling of the lower extremity occurred after castration on the side of the sound testicle. The lumbar glands on both sides were found diseased after death. 2 London Medical Gazette, vol. xiii, p. 4US. 268 ENCEPHALOID CANCER extended so as to produce a bleeding fungus; but as the testicle is usually removed before the disease reaches this point, it is rarely that an opportunity is afforded to the surgeon of witnessing it. Besides, as the scrotum admits of very considerable distension Avith- out ulceration being induced, the patient's life may be destroyed by a similar affection of the internal organs before the skin gives way. In the case of the old man who died in the London Hospital to which I have referred, life was destroyed by internal disease before even the tunica albuginea had given way. The disease in the lum- bar glands generally causes but slight pain and inconvenience, yet in some instances the suffering is severe from pressure produced by the morbid mass on the lumbar nerves. Sir B. Brodie mentions the case of a gentleman whose testicle was removed for this disease. He afterwards became completely paralyzed, and on examination of the body, a large tumor in the loins was found to have affected the vertebre, and to have pressed on the medulla spinalis. Cruveilhier has also recorded the case of a man, aged tAventy-seven, whose tes- ticle was extirpated on account of malignant cystic sarcoma. The disease did not return in the part, but made its appearance in the body of the sixth and seventh cervical vertebre and the posterior extremities of the two first ribs, and caused death by pressing on the medulla spinalis, and producing paralysis of the parts below.1 There are many cases on record of carcinoma affecting testicles retained in the groin. Some of these are noticed in the chapter on castration. Mr. Pott met with a case in which the disease pro- ceeded to ulceration. There was a large sore with high callous edges in the right groin of a man fifty-five years old. After death the lumbar glands, liver, and right kidney were found affected with the same disease.3 Diagnosis.—Encephaloid cancer of the testicle may be con- founded with hydrocele, with hematocele, with the cystic disease, and in its early stage with chronic orchitis. It differs from hydro- cele in being of an oval shape; in its sides being somewhat flat- tened ; in the circumstance that the enlargement takes place uni- formly, and not from the bottom, as in hydrocele ; in the uneven surface of the swelling ; in the absence of transparency; and in the greater Aveight of the tumor when balanced in the hand. Encepha- 1 Anatomie Pathologique du Corps Humain, liv. v, p. 1. 2 Works, 4to. Edin. p. 357. OF THE TESTICLE. 209 loid cancer, Avhen handled, gives an indistinct feeling of fluctuation, which has often proved very deceptive, and puzzled the most expe- rienced surgeons. By a careful examination, however, the differ- ence may generally be detected, as the consistence and obscure sense of fluctuation vary in different parts, the tumor being softer in one place than in another. A hematocele, especially if the sac be much thickened, is more difficult to be distinguished from this disease than a hydrocele, the tumor being heavier and wanting transparency, and fluctuation being very obscure or imperceptible ; circumstances in which I have stated that the encephaloid disease differs also from hydrocele. The other distinguishing marks men- tioned, together Avith a patient inquiry into the history of the case, will generally enable the practitioner to distinguish these two affec- tions. In a case of difficulty, all doubt might be set at rest by a puncture with a trocar or lancet. If the SAvelling should happen to prove carcinomatous, there would be a flow of blood, and perhaps an escape of a small quanity of brain-like matter. But, in general, the bleeding soon ceases. Sometimes the great vascularity of the tumor causes a free discharge of blood, but then it flows of a bright color, and is not attended with a corresponding decrease in the size of the swelling, as in hematocele. Encephaloid cancer may very readily be mistaken for the cystic disease, before at least the former arrives at that stage when no prudent surgeon would contemplate an operation. The tumor caused by the malignant disease makes more rapid and more variable progress, and its surface is less even, and its consistency less uniform than cystic sarcoma ; but in other respects, the characters of the swelling in these tAvo diseases are so similar, that no certain directions can be given for distinguishing them. The necessity for making the distinction is perhaps less, since in both cases no other treatment is of service but an opera- tion ; after Avhich an examination of the diseased organ will afford the surgeon the opportunity of pronouncing an opinion as to the security obtained from future disease. A ery great difficulty is ex- perienced, in distinguishing encephaloid disease, in its early stage, from the enlargement produced by chronic inflammation of the body of the testicle ; and, as the success of an operation in malignant disease, depends very much upon the period at Avhich it is per- formed, it is of no slight importance, that the nature of the affec- tion should be detected as early as possible. As there are no ex- 270 ENCEPHALOID CANCER ternal marks that can be relied on for distinguishing the tAvo dis- eases, the only course that can be adopted is to exhibit mercury so as to make the gums slightly sore; when, if the induration and en- largement should happen to depend on chronic orchitis, the gland will gradually begin to soften and diminish, and if the remedy be persevered in a little longer will be restored to its natural state. If, on the contrary, no change ensue, or if the testicle continue rather to increase in bulk, it may be pretty certainly concluded that the alteration in structure is of a malignant character, or that it results from a disease for which there is no remedy but the knife, and we should therefore be justified in recommending an operation. I have already related (p. 235) a cas*e of difficult diagnosis in which this course was pursued with advantage. The following example will serve to illustrate some of the diffi- culties of the diagnosis in these cases, and to point out the kind of careful investigation necessary to enable the surgeon to form a cor- rect opinion respecting the nature of the disease.—A healthy- looking man, aged thirty-four, married, and by trade a carpenter, applied for relief on account of a chronic enlargement of his left testicle. About nine or ten months previously he first perceived an increase in the size and weight of the organ, which occurred with- out any apparent cause or the receipt of any injury to the part. He continued at his occupation, taking little heed of the swelling, until at length becoming alarmed by its increasing to seven or eight times the size of the other testicle, and experiencing considerable inconvenience from its bulk and weight, he was induced to seek surgical assistance. There was a large tumor occupying the left side of the scrotum. It was of an oval form ; its surface was pretty even, except at the upper and front part, which had a slight, smooth, and round projection. The skin covering the swelling was sound, and not adherent; but the subcutaneous veins were a good deal dilated. The consistence of the swelling generally was about that of a hematocele; but then it was unequal, being firmer in front than at other parts. On seeking for fluctuation, the obscure sensation produced was more like the resilience of a soft elastic solid than the displacement of a fluid. The small projection above, however, communicated a more evident feeling of fluid. The weight of the tumor was greater than that of a hydrocele, but might be about that of a hematocele or a soft solid growth. The OF THE TESTICLE. 271 swelling was not transparent, and had little sensibility, firm pres- sure causing merely a dull pain. The testicle completely escaped detection: it could be distinguished neither by its form or consist- ence, nor by the character of the pain usually experienced from compression. The spermatic cord Avas full and large, but otherwise natural, and it passed to the posterior part of the tumor. The lumbar and iliac glands appeared to be free from disease. The important internal organs performed their functions properly, and there Avas no indication of a morbid state of constitution. Such, then, were the characters of the tumor, and the symptoms by which it Avas to be ascertained whether the disease was a hydrocele with thickening of the investing tunics, a hematocele, cystic sarcoma, or encephaloid cancer. Against the supposition of a hydrocele there Avas the oval shape, uneven surface, greater weight and irre- gular consistence of the tumor, the absence of transparency, and the impossibility of detecting the testicle by firm pressure at the part where the gland is usually found in cases of effusion into the tunica vaginalis. Opposed to the idea of a hematocele there was not only the irregular surface, varying consistence, and impossibi- lity of detecting the testicle by pressure; but also the mode of growth, the tumor in hematocele being of sudden or rapid forma- tion, more often occurring from some injury, and when formed afterwards remaining little altered for a considerable period: whereas in this case the swelling arose spontaneously, took nine or ten months to acquire its large size, and still continued to increase. It was concluded, then, that the tumor must be either cystic sar- coma or encephaloid cancer, its mode of formation, shape, size, weight, and general consistence, and the state of the cord, being such as might correspond to either of these two diseases. The irre- gularity in the surface and consistence of the SAvelling, and the large development of the subcutaneous vessels, induced me to in- cline to the opinion that the growth was of a carcinomatous cha- racter ; and such proved to be its nature when the tumor was re- moved after an exploring puncture. There was no trace of the glandular structure of the testicle remaining; but the epididymis was sound, and situated at the upper part of the tumor, surrounded by the tunica vaginalis, which contained about six drachms of serum, and formed the indistinctly fluctuating projection observed at this part. 272 ENCEPHALOID CANCER But great as are the difficulties of the diagnosis with the testicle in the scrotum, they are so much increased when the diseased organ is retained in the groin, that it is almost impossible to pro- nounce a positive opinion of the nature of the tumor without an exploratory puncture or incision. A surgeon of sound judgment, Mr. Arnott, in describing a case of the kind,1 states that he was unable to determine its precise nature, Avhether hydrocele or hema- tocele with a thickened tunica vaginalis, cystic sarcoma, or malig- nant disease; and he quotes a case communicated to him by Mr. Hodgson, in which equal difficulty was experienced in deciding on the nature of a large tumor in the groin. The patient was seen by Sir B. Brodie, Mr. Key, Mr. Stanley, and others, all of whom coincided with Mr. Hodgson in the opinion that the case was most probably an undescended and diseased testicle; but they could not determine its nature. I have already alluded (p. 84) to a case re- corded by Dupuytren of tumor in the groin formed by a collection of fluid around a retained testicle, carcinomatous and much en- larged. The diagnosis was rendered extremely puzzling by the varying state of the swelling. There was an opening into the ab- domen which allowed the occasional descent of a hernia, whilst the enlarged epididymis formed a valve at the entrance of the ring, which prevented the surgeon returning the fluid into the abdominal cavity. Treatment.—In a disease of so fatal a tendency as encephaloid cancer, the only alternative left when it attacks the testicle is an early amputation of the organ. Unfortunately this resource is ex- ceedingly liable to fail, for the disease generally manifests itself afterwards in the lymphatic glands connected with the testicle, in the wound, or in some internal organ. Indeed, so unsuccessful has the operation proved, that the propriety of having recourse to it in any case has been called in question. Sir A. Cooper, whose experience was very great, has recorded five cases, in all of which the disease returned after the operation. He has not mentioned one in which the patient survived for any lengthened period. But although every practical surgeon acknowledges that the re- moval of a testicle affected with soft cancer cannot be undertaken in any case, with much hope of the patient remaining long free from a recurrence of the disease, still there are several reasons 1 Medico-Chir. Trans, vol. xxx, p. 10. OF THE TESTICLE. 273 why it is greatly to-his interest that the part should be excised. In the first place, there is a chance, small indeed, but still a chance of the disease being limited to the testicle, and being got rid of by the operation.—In April, 1845, I excised the right testicle of a gentleman, aged forty-four. It had been enlarging for tAvo years, and the disease 'was attributed to an injury. Sir B. Brodie was consulted, and recommended the operation; but owing to the dura- tion and size of the tumor gave little hope of a favorable result. On dissection and microscopic examination of the organ after re- moval, it was found to exhibit the characters of carcinoma.1 This patient has since remained under my observation, and at the pre- sent period, more than ten years after the operation, he is in good health.—January 2d, 1851, I removed the left testicle of a farm- laborer, twenty-seven years old, in the London Hospital. The organ had been rapidly enlarging for about four months. It was a well-marked specimen of soft cancer, and presented some yellow patches of degenerated carcinomatous matter. This man resides at Leytonstone, where he was quite recently at work in excellent health.—In 1846, Mr. Meade, surgeon of the Bradford Infirmary, removed the testicle of a gentleman, forty years of age, on account of a chronic enlargement which had existed about nine months. The diseased gland appeared to Mr. Meade, and to Mr. Teale, who assisted at the operation, to present well-marked characters of en- cephaloid disease ; and the morbid matter, on minute examination, exhibited nucleated cells elongated and fusiform in shape.2 In a note which I received in January, 1854, nine years and three months after the operation, Mr. Meade states that " the patient continues free from any return of the disease, and in a good state of health."—In October, 1841, Mr. Cesar Hawkins excised the testicle of a gentleman, aged forty-five, which had been diseased for tAvo years. There was no hesitation in considering it a speci- men of medullary disease. The tumor was Injected, and is pre- served in the Museum of St. George's Hospital, where I have re- cently examined it with Mr. Gray. AVe found no reason to question the view originally taken of the nature of the disease. It con- 1 The specimen is preserved in the London Hospital College.' 2 This case is recorded in the London Medical Gazette, vol. xliv, p. 702, 1849. 1 lately had an opportunity of examining the testicle. Though preserved in spirit, it was too decomposed to enable me to form a fair opinion of the nature of the disease. The appearances, however, were such as to sustain the view that it was soft cancer. 18 274 ENCEPHALOID CANCER sisted of a mass of encephaloid matter, with large patches of yellow degenerated carcinomatous matter. In 1853 this patient was living, and in good health. In these four cases, the true nature of the disease was satisfac- torily determined, by examination of the part after its removal. In the second case, the period which had elapsed* since the opera- tion (nearly five years) is limited; but the early age of the patient, and the rapidity with which the disease was advancing, would lead us to anticipate its early recurrence, if it were not eradicated from the system. It would thus appear that an encephaloid tumor of the testicle has, in some few instances, been removed, whilst yet a local affection, and that the constitution has escaped the infection. Dr. Baring, of Hanover, who has written an elaborate treatise on this disease of the testicle, gives the history of four cases, in which the operation of castration was performed by Rust, of Berlin; by Langenbeck, of Gottingen; and by Hagedorn, of Stade. In two of these cases a period of five years, in another of three years, and in the fourth of two years, had elapsed since the removal of the testicle; and the patients were still in the enjoyment of perfect health, and had not experienced the slightest return of the com- plaint.1 But there are strong reasons, in addition to the chance of eradi- cating the disease, for recommending castration. The uncertainty of the diagnosis in many instances renders the operation highly desirable. It is often impossible to determine exactly whether an enlargement of the testicle is carcinomatous or cystic, and in the more common form of the latter disease, the innocent, excision insures a cure. I shall have occasion to show in a future chapter that castration is an operation attended with very small risk to life. I have never lost a patient from it, and recovery is generally speedy, so that objection can seldom arise on the score of danger from the knife. And if, as most commonly happens, the disease should return, the operation, when performed sufficiently early, un- doubtedly tends to prolong life, and perhaps to save the patient the horrors and sufferings of external cancer; for death from internal disease is less distressing and painful than from an open fungoid sore. But castration should never be undertaken when the lumbar glands are enlarged, because the recurrence of disease will be 1 Ueber den Markschwamm der Hoden, Gottingen; also British and Foreign Medical Review, vol. i, p. 477. OF THE TESTICLE. 275 speedy, and the operation will not have the effect of prolonging life. A careful examination, therefore, should be made before- hand ; and if, by pressure on the abdomen at the sides of the lum- bar spine any solid swellings can be detected, or if either of the lower extremities be found edematous, no operation should be recommended. When, however, castration Is performed before the manifestation of internal disease, it rarely fails to prove beneficial. Its advantages, in promoting the comfort and welfare of the patient, are well shown in the following case.—In October, 1849, I saw, with Mr. Iliff, of Kennington, an eminent barrister, aged fifty- one, who had a solid enlargement of the right testicle of a ques- tionable character. He had previously consulted Mr. Lawrence, who had recommended his taking mercury, in which advice I fully concurred. Our patient took it until his mouth became sore, with- out any diminution in the size of the tumor. We then recom- mended castration, and this advice was strengthened by the opinion of Sir B. Brodie. The operation was performed by Mr. Lawrence, in December, 1849, and the recovery was rapid. The disease proved to be encephaloid cancer. Our patient continued well until December, 1851, when pains occurred in the back, and his left lower extremity shortly afterwards became edematous. He died in May, 1852, of disease of the lumbar glands on both sides of the spine. This gentleman remained in good health for two years after the operation, during which period he was largely engaged in the arduous duties of his profession. He continued, indeed, to go circuit until a few weeks of his decease. Had no operation been performed, it cannot be doubted that he would not have enjoyed health for two years, and continued the practice of his profession for two and a half to the great advantage of his family, but would have been disabled and destroyed at a much earlier period. A return of disease after operation is seldom delayed so late even as in the preceding case.1 The following remarkable case is ' Mr. H. Ludlow composed the following Table, consisting of 8 cases of his own and 15 of Lebert's, in order to show the period at which the disease recurs after operation. From 3 months to 6 months,.........7 cases. « 6 " 12 .........2 " " 12 " 18' " .........4 't '< 18 " 2 years,.........* " 2 years 3 " .........* ( " 4 " 10 " .........J_ 276 MELANOSIS OF THE TESTICLE. regarded by Mr. Paget1 as an instance of its tardy recurrence. J. R., aged thirty-nine, had his right testicle removed by Sir A. Cooper on account of medullary disease. The left had never descended. He enjoyed good health afterwards for nearly twelve years, when he fell off, and after an illness of nine months, attended with sickness and constipation, sank. On examination of the body, a white fungous mass, about the size of a large Seville orange, situated in front of the bladder and connected by a narrowish pedicle to the glands on the left side of the spine, was found to constrict the descending colon. The left testicle was not discovered. The glands on the right side were healthy. Mr. Paget, to whom I am indebted for the above particulars, states, in a note to me, that " he has no doubt that the diseased structures were cancerous." The occurrence of the disease in connection with the lumbar glands on the opposite side to that from which the testicle was removed, together with the late period of the formation of the internal tumor, leads me to the opinion that the pelvic growth was a new development of cancer, arid not the result of contamination from the former disease, of which the germs had long remained dormant. It seems highly probable also, that the internal car- cinomatous tumor was a disease of the retained testicle, which, it appears, was not discoverable at the examination. SECTION III. Melanosis has been observed in the testicle in only a few in- stances. Cruveilhier relates the case of a man who died at the age of forty-six of melanosis affecting the hand, lungs, heart, stomach, and other parts.2 The right testicle contained a little of the same matter, and the left a deposit the size of a nut. Some years ago Mr. Stanley removed from a man, aged thirty-eight, a patient in St. Bartholomew's Hospital, a testicle affected with medullary and melanotic cancer. The disease soon reappeared, and destroyed the patient. The Norwich Hospital Museum is said to contain a specimen of this rare disease. 1 Lectures on Pathology, vol. ii, p. 408. 2 Anatomie Pathologique, liv. xxx, pi. 3 and 4. CARCINOMA OF THE TUNICA VAGINALIS. 277 SECTION IV. Carcinoma of the Tunica Vaginalis. Carcinoma has, in some few instances, been found to originate from the tunica vaginalis, the glandular part of the testicle remain- ing unaffected. An important peculiarity in these cases is the circumstance that the effusion of fluid into the vaginal sac, to which the disease gives rise, renders it extremely difficult to ascertain its real character at the early period at which an operation would be desirable. The following case is recorded by Sir Everard Home. In December, 1781, a gentleman felt an uneasy sensation in the scrotum. On examining it he perceived the left testicle swelled, with a small degree of hardness to the touch. He immediately applied to a surgeon, who told him that the disease was a hydro- cele, and advised him to let it alone till it became large, when an operation would cure him. From that time to March, 1782, the swelling gradually increased, the pain became acute, and the hard- ness increased. About this period two other medical gentlemen saw him ; they were of opinion that the disease was complicated, and by no means a simple hydrocele ; therefore desired him to do nothing for a fortnight or three weeks, and then they would see him again. In the mean time he applied to a surgeon noted for curing this complaint, who made two or three punctures for the palliative cure of hydrocele, assuring the patient that the disease was of that nature. On finding a failure of the good effects which had been promised, he again applied to his former surgeon, with the inflammation, pain, and SAvelling much increased. At this time Mr. Hunter Avas called in, and it was thought advisable to open into the tumor, to ascertain the real nature of the disease, and then to pro- ceed accordingly. This Avas done; and, on examining the sub- stance of the tumor, it appeared to be composed of a thick coat, within AA'hich was a grumous and gelatinous substance. From this appearance of the tumor it was thought advisable to remove the whole, Avhich was immediately done. Some of the skin, which was diseased and adherent to the fore part of the tumor, was also removed. The tumor was found to consist of a thickened tunica vaginalis, filled with a firm coagulum of blood, which in some parts, 1 Observations on Cancer, p. 125. 278 CYSTIC DISEASE had lost its red particles, the whole appearing like a mottled swell- ing ; and the testicle entire in the posterior part, only appearing to be squeezed into a smaller size than natural, from the pressure of this substance in the tunica vaginalis. The parts healed up readily, but some months after a swelling of the abdomen was observed. This increased, and he became weak, hectic, and died. On examination of the body, large masses were found extending up the left side along the back, as high as the diaphragm. The epiploon appeared to have a large mass in it, connecting the colon, stomach, and other viscera together. The liver was studded full of small tumors of the same structure; and the spermatic cord out of the belly had become thickened in the same way. Sir A. Cooper has described a someAvhat similar case. In the Hunterian Museum there are two examples (Nos. 2462. 2463) of encephaloid disease of the spermatic cord, the testicle being unaffected. One of them occurred to Mr. Hunter, who gives a history of the case, showing that the disease originated in the cord. The patient died from cancer in the abdomen, implicat- ing the lumbar glands and omentum. CHAPTER IX. CYSTIC DISEASE OF THE TESTICLE. In this rare affection, commonly called Cystic Sarcoma, a tumor formed of compound or proliferous cysts is developed in the testicle. The morbid mass is developed within the tunica albuginea, which is generally a good deal thinned. The cysts of which it is com- posed vary very much both in number and size, and in the nature of their contents. They may be only a few in number, or they may exist in a countless multitude. They vary in size from that of a millet seed to the dimensions of a pigeon's egg, and are composed of a smooth membrane closely adherent, and containing a trans- parent light-colored fluid, or a fluid which is thick, viscid, and albuminous, or tinged with blood, and they are sometimes filled with coagula. The cysts are imbedded in a fibro-connective or OF THE TESTICLE. 279 fibrous tissue more or less dense, fibrinous plastic matter being often interposed between them. In cysts which have attained a large size, growths are frequently observed springing from the walls, and Fig. 40. Section of a cystic tumor of the testicle, showing a multitude of cysts of various shapes and sizes, with solid matter interposed between them. (From a specimen in the Museum of the Col- lege of Surgeons, No. 2389.) occupying more or less of the cavities. Some of these assume a polypus form; others have a lobular shape. In external appear- ance they resemble very much the intra-cystic bodies seen in cystic tumors of the breast. On minute examination of the intra-cystic growths in the specimen represented in Fig. 41, made by Professor Quekett at my request, they were found to possess a cellular struc- ture, and to be covered on the surface with cylindrical epithelium, like that covering the villi of the intestine. Small masses of enchondroma are often mixed up with the cystic disease. They are usually of an elongated form, and appear like pearly-look- ing bodies in sections of the tumors. The tubular structure may generally be found in the form of a thin layer spread over the 280 CYSTIC DISEASE cystic growth, or massed on its upper surface, and seated just beneath the thinned tunica albuginea. The gland tissue can be peeled readily from the surface towards the back part where it is attached. The cystic growth is generally separated from the glandular structure by a cap- sule of dense connective tissue. In tumors of considerable size, the tubular structure sometimes entirely disappears. The epi- didymis is at first unaffected, but becomes wasted and lost as the grow.th increases. The tumor produced by the cystic disease sometimes at- tains a great size. The speci- men represented in Fig. 40 measures five inches in its long diameter, and three inches in its transverse.1 Considerable doubt has long existed in respect to the nature and mode of origin of this dis- ease of the testicle. Sir A. Cooper, who described it under the name of "hydatid dis- ease," evidently supposed that the cysts might be formed of enlarged and obstructed tubuli; for he remarks, " although at first sight they appear to be cysts, yet when traced they are not distinct bags, but send out solid pro- cesses by which they are connected with other bags."2 In this opinion, I was disposed to concur, the disease appearing to me to be analogous to the cystic tumors of the breast which originate in a morbid dilatation of the lactiferous tubes. But having subse- quently observed in several specimens of cystic testicle healthy tubuli seminiferi forming a layer spread over the morbid mass, 1 The Museums of the College of Surgeons, and of the London, St. Thomas's, and St. George's Hospitals contain fine specimensof this disease. 2 Observations on the Diseases of the Testis, p. 83. Section of a cystic testicle in which the cysts are of larger size than in the preceding figure. (From a specimen in the Museum of the College of Sur- geons, No. 2390.) It was removed by operation from a man thirty-three years of age. There was no return of the disease. 1, 1, 1. Lobular intra- cystic growths. In both figures the tumor is re- duced in size about one-half. OF THE TESTICLE. 281 Laternl dilatation of a lube filled with dark gra- nular matter (250 d.) generally at its upper part, I was at a loss to reconcile the tubular origin of the disease with this condition of the organ, until the diffi- culty was solved by careful inquiries which I inade in a case favor- able for investigation, owing to the early stage of the cystic de- velopment. In December, 1852, a man, aged thirty-seven, consulted me on account of an en- Fig. 42. Fig. 43. ' „ , largement of the testicle, which was first observed about seven months pre- viously. Having no doubt that the disease Avas either carcinomatous or cystic, I recom- mended its re- moval, and per- formed the operation. The patient recovered favorably, and has since re- mained quite well. On making a sec- tion of the tumor, I found the tubular structure spread over a part of its sur- face just beneath the thinned tunica The morbid mass was a marked specimen of cystic disease. Some of the larger cysts measured half an inch in diameter, but the majority were much smaller, and many were no larger than millet seeds. A great many of the cysts contained a transparent limpid fluid, others a bloody fluid, a few coagulated blood, and several a solid whitish opaque matter. The cysts were imbedded in fibrous tissue, Avhich was particularly dense towards the centre of the groAvth. On examination of thin slices of the tumor in the microscope, the origin of the cysts in a dilatation of tubes was clearly made out. Thus, in some specimens, a tube could be traced to a termination in a dilated pouch (Fig. 42). In others a cyst appeared to arise from a lateral dilatation of a columnar tube, or at the extremity of a loop (Fig. 43); whilst in others the dilatation appeared to be uniform. These dilated tubes and cysts were lined /O$0°o0o' i O Seminal tube terminating in a dilated albuginea. pouch (130 d.) 282 CYSTIC DISEASE by a tessellated epithelium, and many of them contained a dark granular matter. The opaque whitish substance found in several ■ of the larger cysts consisted chiefly of a mass of modified tessellated epithelial scales, and corresponded to what is called cholesteatoma. No spermatozoa were detected in any of the cysts or morbid tubes.1 The minute examination of this specimen fully establishes the origin of the cysts in a morbid condition of the ducts. The cir- cumstance of the healthy tubular structure being found external to the morbid groAVth, shows that the ducts affected are not the tubuli seminiferi. If the latter were the seat of the disease, we should expect to find the tubes which remained sound, pushed to one side, or at any rate near, or mixed up Avith, the diseased ducts, and not spread over the surface and distinctly separated from the morbid growth. Nor can the diseased ducts be those of the epididymis, for I have invariably found this part unaffected or wasted and lost in the morbid mass. If the disease sprang from the tubes of the epididymis, the tubular structure of the gland, unless destroyed by pressure, Avould certainly be found in a mass enclosed in its own tunics, distinct from the morbid growth, and not extended over its surface. It being clear, then, that neither the tubuli seminiferi nor the ducts of the epididymis are the tubes which undergo the changes constituting the cystic disease, its seat may be considered as con- clusively traced to the ducts of the rete testis. Why they alone are subject to the morbid change, I admit my inability to explain. I have remarked that small masses of enchondroma are fre- quently mixed up with the cystic growth. It is clear from recent observations that the enchondroma is originally formed within the tubes and their cystic dilatations. I have examined with Professor Quekett several specimens of cystic testicle in which the intra- tubular development of the cartilage was quite manifest. The car- tilage occurs in elongated portions, which are easily detached from the cysts enclosing them. Enchondroma may be developed so abundantly as to encroach upon and obliterate the cysts, and to form the chief bulk of the tumor. This appears to have been the 1 A fuller account of these investigations, illustrated by plates, will be found in a paper communicated to the MedicO-Chirurgical Transactions (vol. xxxvi, p. 449). These observations have since been confirmed by examination of another specimen of the disease. OF TnE TESTICLE. 283 case in a testicle excised by Mr. Hancock, which I have had an opportunity of examining. It weighed four pounds six ounces, and is the largest cystic testicle I have met with. The development of the cartilage within dilated tubes in this specimen is described and figured by Mr. Hogg in the Transactions of the Pathological So- ciety.1 The minute examination of these cystic tumors shows the non- malignant character of the disease, which, moreover, is fully con- firmed by the accounts of those cases in which the history has been preserved, patients having lived many years after the excision of the organ, and died of a different disease. Yet cases occasionally occur, Avhich strongly tend to shake our confidence in this conclu- sion. Some years ago a medical friend, aged thirty-two, was at- tacked with disease of the testicle. It continued to increase in size, and at the end of eighteen months was excised. On a cursory examination of the tumor, I found it to exhibit the ordinary appear- ances of cystic disease, blood being, however, extravasated in two or three places, which was attributed to some exploratory punctures made previous to the operation. The patient never regained his health, but remained cachectic. In about six months he suffered from haemoptysis, which was followed by attacks of severe lumbar pain, and subsequently the liver enlarged to a great size. He died eighteen months after the operation. On examination of the body, masses of medullary cancer were found in the lumbar glands, lungs, and liver. In a visit which I paid several years ago to the Museum of St. George's Hospital, Mr. Csesar Hawkins showed me two specimens of Avell-marked cystic testicle which had been removed by opera- tion, the patients having died within two years afterwards of inter- nal tumors, and he expressed to me his opinion that this disease was a malignant affection. I have recently made a careful exami- nation of these preparations. The soft matter from the cysts of both tumors, when placed under the microscope, was found to con- sist of a mass of nucleated cancer-cells. Some of them contained numerous dark granules; and where the diseased mass Avas the softest, the granules Avere more abundant than the cells, the cell- walls in these instances having been most probably destroyed. In some of the masses portions of ducts filled with cells might be ob- 1 Vol. iv, p. 180. 281 CYSTIC DISEASE served. No epithelial scales could be detected in either of the specimens. In one of them there Avere some small portions of en- chondroma.1 It seems clear from these facts that cystic disease occurs in the testicle in two forms, a malignant and non-malignant, the former being by far the more rare. And if the histological observations be fully confirmed, the presence in the cysts of tessellated epithe- lium will indicate the character of the non-malignant, and the pre- sence of nucleated cancer-cells the nature of the malignant. We shall thus be furnished with the means of determining a most im- portant distinction in practice. In describing a malignant form of the disease I do not comprise cases of encephaloid cancer in which two or three cysts may be found mixed up with the cancerous matter, but tumors the great bulk of which is composed of cysts of various sizes. Indeed, in a specimen of this form of the cystic disease which I have recently examined, the appearances so closely resembled those of the non- malignant form of this affection, that it was impossible to distin- guish the difference without the aid of the microscope. It seems probable, howeArer, that although in the early stage of the malig- nant form the cystic structure prevails, that, at a later period the cysts become destroyed by the rapid growth of carcinomatous tis- sue. This had probably occurred in a specimen in the Hunterian Collection (No. 2416). It is a section of a large tumor of the tes- ticle, the upper part of which is composed of a multitude of small cysts, whilst the remainder exhibits the usual appearances of me- dullary cancer. The patient*died of internal cancer a few Aveeks after the removal of the diseased organ. In the preceding account of a cystic testicle I have ■ noticed the occurrence, in a few well-developed cysts, of a solid Avhitish matter, exhibiting the characters of cholesteatoma. I have observed iso- lated formations of the same kind in other cystic testicles, both malignant and non-malignant. In a diseased testicle removed by Mr. Henry Thompson last April, and kindly sent to me for exami- nation, I found a combination of cholesteatoma, enchondroma, and encephaloma, with cysts within the dilated and thinned tunica al- 1 Cruveilhier has described and figured a diseased testicle, which appears to have been a well-marked specimen of malignant cystic disease with enchondroma. This case has already been referred to at p. 268. OF THE TESTICLE. 285 buginea. The cholesteatomatous matter existed in great abun- dance, forming with numerous small deposits of enchondroma a por- tion of the tumor, the upper, distinct from the larger mass below, which consisted principally of encephaloid growths and cysts. The two portions were separated by loose seminal tubes. The tubes between the cysts were in some parts unaltered, and in others di- lated and filled with changed cells.1 The patient, a man aged tAventy- five, died about five months after the operation, of medullary cancer of the lumbar glands, lungs, and other internal parts. In this case, also, it seems probable, that the cystic structure was more perfect in the early period of the disease than at the time of the operation. Symptoms.—The swelling to which the cystic disease gives rise takes place imperceptibly, very slowly and without producing pain. After existing for several months, it occasions a chronic indolent tumor of an oval shape and elastic feel, which is scarcely at all tender or painful. The surface of the tumor is generally smooth and even, but is occasionally irregular. There is sometimes fluc- tuation consequent on the presence of a thin layer of fluid in the vaginal sac surrounding the cystic growth. When the tumor attains a large size it is inconvenient from its bulk, and unless well supported, it occasions a dragging sensation and uneasiness in the loins. The disease usually commences at the middle period of life : I have not myself met with it later than betAveen the ages of forty and fifty. Its origin is often ascribed to some accidental injury of the part. Diagnosis.—Cystic disease of the testicle may be mistaken for hydrocele, hematocele, and encephaloid cancer. The diagnosis from vaginal hydrocele is extremely easy. The tumor is of an oval shape, not pyriform, as in hydrocele; it feels heavier, and fluctu- ates less distinctly ; and there is an absence of the pain experi- enced in compressing the part usually occupied by the testicle in hydrocele. The swelling also is not transparent. Notwithstand- ing these distinctive marks, Sir A. Cooper considered that the sur- o-eon Avas very liable to err, and he admitted that he had been two or three times mistaken, and had put a lancet into the part expect- ing to find water issue, and a few drops of blood only have followed. The distinction from haematocele is much less marked, as the latter 1 For fuller particulars of the minute examination of this tumor by Dr. A. Clark and myself, vide Transactions of Pathological Society, vol. vi, p. 241. 286 CYSTIC DISEASE OF THE TESTICLE. has a somewhat solid feel, weighs heavy in the hand, is not trans- parent, and fluctuates less distinctly than a hydrocele. The ab- sence of pain on compressing the back of the tumor will be the best guide to distinguish the cystic disease from a hematocele. As I have remarked in the previous chapter, the characters of the cystic disease are in general so similar to those of encephaloid cancer, that I can give no satisfactory directions for distinguishing them. The surgeon must be guided in his opinion by inquiries into the history of the case, and by noticing the condition of the cord, and of the lumbar glands, and the state of the patient's health, Avhich are unaffected in the cystic disease, but are liable to suffer in malig- nant enlargements of the gland. The tumor produced by the latter affection is also less even and regular, and makes more rapid pro- gress than that occasioned by the cystic disease. In cases of difficult diagnosis the doubt may, in general, be safely remoAred by introducing a trocar into the front of the tumor. A hydrocele or haematocele will be at once made evident by the free escape of serum or blood, and a great reduction in the size of the swelling. If the case be cystic disease, only a small quantity of serum tinged with blood will flow ; and if it be a soft cancer, blood of a bright color will probably escape someAvhat copiously without producing any diminution in the size of the tumor. In some in- stances, the existence of the latter disease may be rendered yet more certain by the detection of cancer-cells in the soft matter or fluid found in the canula after its withdrawal. In performing this exploring operation the surgeon should use a common-sized hydro- cele trocar. The bore of the exploring trocar, and the groove of the exploring needle, the instruments commonly used, are not of sufficient size to allow of the ready escape of the grumous blood of an old hematocele, or of the matter of soft cancer. The wound of the trocar is quite unimportant. In cases in Avhich an operation is likely to be required, it will often be convenient to defer this exploratory examination until arrangements have been made for further proceedings if necessary. Treatment.—No kind of treatment, either local or general, is of any service in this disease, the morbid changes being quite beyond the influence of remedies. The only means that can be adopted is the removal of the tumor, which should be performed as soon as the surgeon is satisfied that the disease will not yield to FIBROUS TUMOR OF THE TESTICLE. 287 treatment. The morbid growth should afterwards be submitted to a minute examination, and if no cancer-cells be found, or if the cysts contain tessellated epithelium, he will be able, with some confidence, to assure his patient of his permanent recovery, and immunity from all risk of a relapse. CHAPTER X. FIBROUS TUMOR OF THE TESTICLE. In treating of atrophy of the testicle, and of the effects of or- chitis, I have stated that the gland sometimes undergoes a fibrous transformation, being converted into a fibrous tissue consisting in part of the processes springing from the tunica albuginea, and in part of a metamorphosis of the coats of the tubuli, and of the fibrinous matter exuded between them in inflammation. In some instances the structure into Avhich the organ is converted is a loose fibrous tissue, as in the case of detained testicle related at p. 73. More frequently the texture is close, dense, and firm, somewhat resem- bling the fibrous tumor of the uterus. Occasionally two or three small cells, containing a serous fluid, occur in the fibrous structure, and in old cases the tissue undergoes calcareous degeneration. In all these instances the testicle is more or less diminished in bulk, generally in a marked degree, and is sometimes reduced to a few filamentous shreds. Filamentous connective or fibrous tissue is sometimes abundantly developed in other morbid conditions of the testicle. I have de- scribed at p. 245 a case of considerable chronic enlargement of the testicle, in which the organ was composed of masses of fibrinous matter, and deposits of pus separated by thick and dense septa of fibrous tissue. In cystic sarcoma, also, this tissue is largely deve- loped, so much so that Mr. Paget, before the tubular origin of the cysts was made out, was inclined to regard the cystic disease as essentially a fibrous tumor in the testicle.1 But this chapter is intended to comprise cases in which there is more than a transformation of the natural tissue, or the debris of 1 Lectures on Surgical Pathology, vol. ii, p. 137. 288 FIBROUS TUMOR OF THE TESTICLE. the original structure—cases in which there is a new formation of fibrous tissue to a considerable extent without any other important change. For it appears, that in the testicle, as in several other organs, the healthy structure may be supplanted by an entirely fresh formation of this structure, attended with an increase in the bulk of the organ. This pathological change is extremely rare. In Cruveilhier's Anatomie Pathologique1 there is an excellent repre- sentation of the disease. The testicle was removed from a patient at the Hopital Beaujon, by M. Marjolin. It was tAvice the natural size, and very heavy. It offered a good deal of resistance to the knife, and creaked when cut; and it was entirely composed of a number of grayish-white fibres intersecting each other and arranged in lobules, similar to the fibrous tumor of the uterus. So far as I know, this fibrous growth is unattended with pain or any peculiar symptoms besides great induration of the whole organ ; and the change is one over which neither general nor local treat- ment can exert much control. Sir B. Brodie mentions, that he extirpated a testicle that had undergone this fibrous conversion ; between six and tAvehre months after the operation the other testicle became hard and enlarged, and apparently affected in a similar way. As an experiment he gave the patient iodine internally, and rubbed the iodine ointment on the testicle also. The hardness be- came in some degree diminished, and the progress of the disease stopped; and the patient left the hospital with the greater part of the remaining testicle in a sound state. This was no doubt a case of chronic orchitis, and I suspect that the fibrous tumor generally OAves its origin to chronic inflammation, the matter exuded in this disease, instead of becoming absorbed, undergoing conversion into this tissue. The fibrous tumor of the testicle is not a disease of a serious character; and as, in general, it produces little or no incon- venience, the extirpation of the gland is rarely required. Mr. Travers mentions a case in which the organ was removed, owing to the person affected being impatient for its extirpation, from appre- hension of the disease being scirrhous or malignant.2 The gland being quite useless when in this state, there is no particular objec- tion, after other means for the reduction of the induration have failed, to castration, to allay the patient's fears, and to remove a constant source of uneasiness from his mind; but it is not a disease which absolutely requires the operation. 1 Liv. v, p. 1, fig. 3. 2 Med.-Chir. Trans, vol. xvii, p. 327. CARTILAGINOUS TUMORS OF THE TESTICLE. 289 CHAPTER XI. CARTILAGINOUS TUMORS OF THE TESTICLE. In treating two important diseases to which the testicle is sub- ject, soft cancer and the cystic, I have had occasion to notice the disposition Avhich often exists in these affections to the development of enchondroma. In the former the cartilage, though sometimes mixed up with the soft cancer, is more commonly found as a dis- tinct mass in its substance, and separated from it by a capsule.1 In the cystic disease, the cartilage occurs in numerous small isolated masses, which are disseminated throughout the tumor. They are de- veloped within dilated tubes of the rete testis, and the little masses are easily shelled out from the cysts enclosing them. The forma- tion of cartilage in both these instances is subordinate to the other changes, and commonly limited in degree. But enchondroma has been observed in some rare cases so largely developed in the tes- ticle, as to constitute a separate or the principal lesion, and to pro- duce a considerable tumor of the organ. In a case referred to at p. 283, in wdiich a tumor of the testicle weighed four pounds and six ounces, the -disease was primarily and essentially cystic; but cartilage was developed in such great abundance as to encroach upon and obliterate the cysts, and to form the chief mass of the tumor. " Mr. Paget has recently recorded a remarkable case of car- tilaginous growth in the testicle, which presents many points of great interest to the pathologist.2 A man, aged thirty-seven, was admitted into St. Bartholomew's Hospital on account of a large swelling of the right testicle and spermatic cord. The diseased parts were excised, and the patient recovered favorably, but he re- turned to the hospital in about three weeks, much enfeebled and laboring under dyspnoea. This continued to increase until his death, 1 Baring (Ueber den Markschwamm der Hoden, PI. 11) has figured an encephaloid testicle exhibiting an isolated mass of cartilage in the substance of the tumor enclosed in a capsule. Mr. Paget also mentions three similar specimens. (Lectures on Patho- logy, vol. ii, p. 209.) 2 Medico-Chirurgical Transactions, vol. xxxviii, p. 247. This interesting case is minutely described by the author with his usual care and clearness, and is well illus- trated by figures. 19 290 CARTILAGFNOU.S TUMORS OF THE TESTICLE. which took place suddenly ten days afterwards. The oval mass oc- cupying the place of the testicle Avas composed of tortuous cylindri- form and knotted pieces of cartilage, which were from half a line to two lines in diameter, and was closely packed and imbedded in a tough connective tissue. Over parts of the outer surface of the mass a layer of seminal tubes was thinly spread out between it and the tunica albuginea. Surmounting this mass, and separated by a layer of connective tissue, there was a conical mass formed of simi- lar but smaller pieces of cartilage. These were found to be con- tained in tortuous but communicating canals. Above this second mass a series of smaller cartilaginous swellings extended along the whole course of the spermatic cord. It was evident that the disease consisted chiefly in morbid growths within canals; and dissection (the details of Avhich are minutely given by Mr. Paget) satisfactorily showed that these canals were lymphatics.1 From the scar of the operation-Avound two dilated lymphatics, filled with growths like those in the spermatic cord, passed upwards to a swelling of the size of a hen's egg (probably a diseased lymphatic gland), Avhich on sec- tion presented cavities filled Avith pellucid fluid, and partitioned by fibrous and cartilaginous textures. This swelling adhered closely to the vena cava inferior, and a cartilaginous swelling projected from it into the cavity of the vein. The only other diseased parts were the lungs. Both these organs were enlarged by formations in them of masses of cartilage, in such abundance that the two lungs together weighed eleven pounds and a half. The cartilage appears to have been developed in the rete testis, and its primary seat is supposed by Mr. Paget to have been the lymphatics of the testicle. He considers the case to present the most probable instance he has yet known of "a local disease becoming constitutional," and justly remarks, "The local origin and maintenance of those tumors in the testicle, that contain cartilage without cancer, are well established by the many cases in which no recurrence of the disease has fol- lowed their removal, as well as by the cases in which, cancerous growths being combined with the cartilaginous, the recurrent dis- ease has contained cancerous structures alone. In this instance, however, we must assume that the cartilaginous local growths, ex- 1 I am indebted to Mr. Paget for one section of the diseased mass, which is pre- served in the London Hospital College. The other is in the Museum of St. Bartholo- mew's Hospital. CALCAREOUS DEPOSITS IN THE TESTICLE. 291 tending into the blood, infected it. The quantity of cartilage found in the lungs gives a striking illustration of the enormous power of multiplication and increase of such structures, when in free contact with the blood. It may be estimated that, from the germs (if we may so call the material in whatever form) derived from the small growth that projected into the vena cava inferior, nine pounds of cartilage were developed in less than three months." I am not ac- quainted Avith any similar case of purely cartilaginous growths in the testicle leading to secondary deposits of a like kind. The case, so far as I know, is unique. CHAPTER XII. CALCAREOUS DEPOSITS IN THE TESTICLE. Earthy matter is met Avith in the testicle under two forms: 1. Laminated and often mixed up with fibrous tissue; and, 2, as an irregular amorphous mass. In the first form, it is usually deposited between the tunica vaginalis testis and the tunica albuginea, in little fibro-calcareous patches, similar to these occurring on the pleura.1 I have frequently found one or two irregularly-shaped projecting bodies of stony hardness, scarcely larger than a pin's head, attached to the tunica vaginalis, covering the upper part of the testicle. Laminated calcareous matter occurs also in old cases of hydrocele, being formed in false membrane lining the outer por- tion of the tunica vaginalis, where it is sometimes so abundant as to form a complete bone-like cyst. Tavo well-marked specimens of the kind have been lately shown me by Mr. Spence, of Edin- burgh. It has been said that the epididymis alone may be encased in calcareous matter, the testicle being free; but this I have never seen. Earthy matter occurs, however, in the substance of the epi- 1 100 parts of earthy matter from the tunica vaginalis, divested of membrane and dried, were found by Mr. Barry to consist of Phosphate of lime,.............45 Carbonate of lime, with a trace of magnesia, ... ... 17 Animal matter, .............ob 100 —Cooper on the Testis, p. 245. 292 CALCAREOUS DEPOSITS didymis, especially in the tail, from calcareous degeneration of the plastic matter exuded in inflammation. The body of the human testicle is more rarely the seat of earthy deposits. The matter exuded there in inflammation, especially in chronic, may, as in the epididymis, undergo calcareous degenera- tion. When atrophied and reduced to a mere fibrous tissue, the gland, after a time, becomes the seat of earthy deposits. Small masses of bony matter occur in enchondromatous testicles. The Museum of St. Thomas's Hospital contains a good specimen of mixed cystic and enchondromatous disease of the testicle, with cal- careous deposit in the substance of the cartilage. Nothing is knoAvn of its history. Mr. Quekett has described in the Catalogue of the Histological Series of the Hunterian Museum (Vol. i, PI. VII) sec- tions of a cartilaginous tumor of the testicle, each of which ex- hibits in its centre a small mass of bone. Although the bony matter is of some considerable thickness, it exhibits no trace of bone-cells. Mr. Quekett informs me that he has examined sevreral specimens of bony deposit in this organ, but has never observed any in Avhich bone-cells or lacunae Avere present, the bone being in every case of that kind termed false or abnormal.1 These changes possess, in general, more pathological interest than practical importance. Calcareous deposit in the testicle, how- eArer, though existing for a long time in an indolent state, may, at a later period, set up suppurative inflammation, and cause tedious and troublesome sinuses. Two such cases have come under my notice. — A soldier, about seventy years of age, whose left testicle was apparently converted into bone, and felt extremely firm and indurated, was an out-patient at the London Hospital 1 Calcification of the tubular structure of the testicle has been met with in several animals. A very beautiful specimen from the ram, belonging to a farmer in Wiltshire, has been described and figured by Mr. Joseph S. Gamgee. Another specimen, also from the ram, and formerly belonging to the late Mr. Langstaff, is in the possession of Dr. Crisp. In the collection of drawings by Dr. Carswell at University College, there is the figure of the testicle of a goat in a similar condition. In the two first-named cases the tubuli are converted into calcareous matter, but are of the natural size. The Museum of the College of Surgeons contains the testicle of a bull, in which this change is in an incipient stage, some of the tubuli being perfectly soft and of uniform diameter; whilst others are wholly or partially converted into calcified tubes pre- cisely the same as in the ram. This calcareous change does not appear to have been observed in the epididymis or vas deferens in these animals. I am not acquainted with any instance of calcification of the tubuli in the human testicle. IN THE TESTICLE. 293 under Mr. Adams for many weeks, on account of the organ be- coming painful and inflamed. After some time it suppurated ; and the pus, on being discharged, had the usual offensive smell of an abscess connected Avith dead bone. The earthy matter came away by degrees in small pieces, Avhich amounted to nearly one hundred, and the patient ultimately recovered with an atrophied testicle. A man, aged sixty-two, came under my care at the hospital on account of a painful swelling and fistulous sinus of the left testicle. He had been affected with acute orchitis twenty years previously, since which the organ had remained enlarged. Two similar attacks had since followed an injury of the part. The last occurred a few weeks before his admission, and ended in an abscess, Avhich had burst, leaving an open sinus. Another abscess formed, which I punctured, and on passing a probe to the bottom of the sac, it struck against a hard substance like bone. Some weeks afterAvards I seized this body with the forceps, and endeavored to detach it, but it was too firmly attached to come away. The part was not very sensitive, for the man himself endeavored to remove the hard substance with the sharp end of a common nail, but without success. The fistula continued to discharge thin pus for several weeks, and at length the man discontinued his attendance. In the second form, the earthy matter is deposited in an irregu- lar mass resembling mortar, and containing very little animal matter, being very similar to the earthy substance found in the lungs and bronchial glands. It is generally met with in the head of the epididymis, and sometimes in the lower part, and but very seldom in the body of the testicle. As I have already stated, this earthy matter results from the degeneration of tubercular matter deposited in the testicle in early life. (See observations at p. 256, and the accompanying figures.) CHAPTER XIII. LOOSE BODIES IN THE TUNICA VAGINALIS. Loose bodies are occasionally found in the cavity of the tunica vaginalis. They are small in size, and of an oval flattened shape; and their surface is smooth and polished. Their texture is in most instances elastic and homogeneous, or arranged in concentric laminae, and consists of a fibro-cartilage, or, as Lebert states, of a 294 LOOSE bodies in the TUNICA VAGINALIS. tissue resembling the elastic coat of the arteries. Ossific deposits are often found in them, indeed the loose body is sometimes entirely composed of bony matter. On examining a thin lamina of one in the microscope, I found well-defined bone corpuscles. Richter, of Gottingen, met with three round bodies in the tunica vaginalis, Avhich were quite hard, and of the size of a very large hazel nut; but they rarely attain so large a size as this.1 They seldom exceed three in number ; and they occur generally in combination with hydrocele, the loose bodies being the original disease, since in their movements in the cavity of the tunica vaginalis they promote a greater secretion of fluid from the serous membrane, in the same Avay as a loose cartilage in a joint excites an increased synovial secretion from the membrane by which it is lined. In some cases the surface of the tunica vaginalis is found thickened and uneven. The manner in which these loose bodies originate does not differ essentially from the mode of development of loose cartilages in the interior of joints. Deposition takes place beneath the tunica Araginalis testis, which is gradually protruded until the fibro-carti- laginous or ossific body forms a pendulous tumor, which, being attached merely by a slender stalk, is accidentally separated in the motions of the testicle, and is thus left loose in the cavity of the tunica vaginalis. These bodies have been observed in the various stages of their development. The Museum at Fort Pitt, Chatham, contains a testicle with a small fibro-cartilaginous body hanging by a peduncle from the head of the epididymis ; and also four other small bodies which were found loose in the vaginal sac. In a loose substance of the size of a small grape, of-firm consistence, and pos- sessing a bony nucleus, found in a case of hydrocele, Morgagni noticed a short and slender neck by Avhich it had been adherent.2 But in general there is no trace of the original attachment left on either the loose body or the tunica vaginalis. I have seldom observed these bodies except in connection with hydrocele. If pre- sent without the effusion of fluid, they admit of being moved around the testicle, and may in this Avay be readily detected. If inconvenient, the loose body might be pinched up and taken out by a small incision in the scrotum and tunica vaginalis. Chassaig- nac exhibited to the Surgical Society of Paris, a loose body, about three-quarters of an inch in length and half an inch in breadth, 1 Medical and Chirurgical Observations, tr. 2 Cooke's Morgagni, vol. ii, p. 429. FC3TAL REMAINS IN THE TESTICLE. 295 which he had excised from the vaginal sac during life. It is described and figured by Lebert.1 CHAPTER XIV. F03TAL REMAINS IN THE TESTICLE AND SCROTUM. The remains of a foetus have, in some rare instances, been found in the scrotum in connection with the testicle. Dr. Verneuil, of Paris, has collected and carefully analyzed all the recorded cases Avhich he has been able to meet with, and as no instance of the kind has fallen under my observation, the substance of this chapter will be taken chiefly from his able and elaborate paper,2 recently published, to which I must refer the reader for fuller information on the subject. The cases collected by Dr. Verneuil are nine in number, and to these he has added one of great interest, observed by himself and M. Paul Guersant. The description of some of them is extremely concise or very imperfect. The tAvo best ob- served examples are—the author's, in Avhich, amongst other elements foreign to the part, such as skin and cartilage, he re- cognized the gray matter of the brain,—and Velpeau's well-known case of a man, twenty-seven years of age, from Avhose scrotum he excised a congenital tumor, which was found to be occasioned by the presence of nearly all the anatomical elements of a foetus.3 Of the ten cases, the side was noted in six, and in all of these was the right—a preference which has been also remarked in tumors of the ovary containing foetal remains. It was supposed by Velpeau and Ollivier, that in all these cases the inclusion4 is originally 1 Traite d'Anatomie Pathologique, p. 175. 2 Archives G^nerales de MSdecine, 5e serie, t. 5 et 6, 1855. But two cases have been observed in Great Britain which I know of. Dr. Duncan, of Edinburgh, removed a congenital tumor of the testicle from a boy eight years of age. Dr. Goodsir, who examined the tumor, found skin, hairs, and portions of cartilage in it. (Vide Northern Journal of Medicine for June, 1845.) Mr.Erichsen (Science and Art of Surgery, Am. Ed. p. 891) has briefly alluded to a case which occurred at the University Col- lege Hospital in 1852. A testicle, about the size of an ostrich's egg, was removed, by operation, from a man thirty years of age, by Mr. Marshall. The patient had been affected with the tumor from early infancy. It was found after removal to be composed of a large cyst filled with an oily fluid, like melted butter, which solidified on cooling. The cyst contained some foetal debris, but of what nature is not described. 3 Gazette Medicale de Paris, Fev. 15, 1840. 4 The reader will understand that the word " inclusion" signifies a form of double 296 ENTOZOA IN THE TESTICLE. abdominal; that is to say, that the organic debris are first situated in the abdomen along with the testicle, and accompany the' organ in its progression out of that cavity. Dr. Verneuil dissents from this opinion, and shows that, although in some instances the tumor is originally foreign to the scrotum, and is formed in intimate con- nection Avith the testicle before its transition, in other cases, the tumor is first developed in the subcutaneous tissues of the scrotum, independently of the testicle, though it commonly becomes con- nected to the gland in the process of growth. He believes, indeed, that the inclusion is commonly extra-glandular. But in whatever situation the tumor is developed the testicle generally suffers, becoming atrophied, or more or less altered by inflammation. The tumor remains indolent for a variable period, growing with the body, but afterwards enlarging until it attains in some instances an immense size. At length inflammation is set up, an abscess forms, and ends in fistulous openings, from which the foetal debris are discharged. This may occur in infancy, or be delayed till a later age, even, as in one of the cases, till the adult period. In infancy, the tumor, when solid and of large size, can scarcely be mistaken for any other disease of the part, and at all periods, the congenital nature of the affection would serve to indicate its true nature. It would distinguish it from soft cancer and tubercu- lar disease, the lesions most likely to occur to the testicle in early life. The excision of the tumor, including the testicle, is generally necessary. Velpeau managed in his case, by a very minute and laborious dissection, to save the organ; but the gland is, in most instances, so intimately connected with the tumor, and injured in structure, that the attempt to separate them can rarely succeed, or be desirable. In one instance, in an infant, the surgeon contented himself with incising the tumor, and extracting the foetal frag- ments. CHAPTER XV. ENTOZOA IN THE TESTICLE AND SCROTUM. The Entozoa very rarely indeed infest the testicle; in the exa- mination of a large number of testicles I have not met with a monstrosity, in which the small and imperfect germs of an individual are grafted on, or constitute a parasitic growth in the body of another of larger size, and for the most part well formed. (Vide Qeoffroy Saint-Hilaire, Hist, des Anomalies de l'Organisation.) SPERMATOCELE. 297 single example. Sir A. Cooper mentions an instance of an indepen- dent cyst, probably an acephalocyst, which was found accidentally on dissection in a sac connected with the epididymis. Dr. Baillie notices having seen a testicle with a small firm cyst adhering to it, which contained a filaria medinensis or Guinea Avorm.1 In the Hunterian Museum at Glasgow, there is a preparation (No. 66 S) of a cyst attached to the lower part of the vas deferens containing this worm, Avhich is very likely the specimen alluded to by Dr. Baillie. The man had probably visited some warm country in which the Guinea worm is found, and the animal having been de- veloped in the lower part of the scrotum had caused the formation around it of an accidental cyst, which had contracted an adhesion to the vas deferens. In the Museum of the College of Surgeons in Edinburgh, there is a tumor (No. 2554) taken from the scrotum of a Lascar, containing a Guinea worm which had died and become converted into a substance resembling adipocere. CHAPTER XVI. SPERMATOCELE. This term implies a tumor formed by a collection of the seminal fluid; but it has occasionally been applied by writers to swellings produced by varicocele and other affections of these parts. It is possible that the semen might collect in and dilate one or more of the seminiferous ducts in the body of the testicle, in consequence of some obstruction, and thereby constitute a swelling of a similar character to the lacteal tumor of the breast; but amongst the many hundred testicles I have examined, I have not met with a single in- stance of the kind. I have sometimes noticed, however, in testi- cles, otherwise healthy, small collections of thick caseous matter of a yellow color (apparently inspissated sperm) blocking up and dis- tending some of the efferent tubes of the epididymis, and the round dilatations frequently connected with them. Similar collections have been noticed by Mr. Gosselin, who ascertained that they were caused by obliterations of the excretory duct (vide p. 205). The 1 Morbid Anatomy, p. 237. 298 SPERMATOCELE. rarity of any considerable accumulation, causing a tumor obvious during life, to Avhich the term spermatocele might be applied, may be readily explained by the readiness with which the spermatic fluid becomes absorbed into the system. In the following instance, the dilatations consequent on the retained sperm were more remark- able than usual.—A man, aged forty-four, died in the London Hospital of phthisis. One testicle was quite sound. The body of the other was soft, pale, and somewhat enlarged. The epididymis was remarkably enlarged, and formed a saccular tumor. The sac- cules evidently contained fluid, and had a pearly lustre. The lower part of the vas deferens also exhibited frequent saccular dilatations, the coats of the duct at these points being thin and translucent. About the upper dilatation, and about an inch and a half from the tail of the epididymis, the vas deferens wras obliterated by a firm deposit, partly fibrous and partly earthy. The mucous membrane of the duct below this was rough, and studded with earthy particles which grated against the knife. The fluid in the head of the epi- didymis was opalescent, in the tail Avhite and thick, and in the vas deferens thin and gritty. There Avas no fluid in the duct above the point of obliteration. The fluid from the epididymis contained cells filled with spermatic filaments and free filaments in great abun- dance, and also a few altered cells, and others filled with fat gra- nules. The fluid from the vas deferens contained altered epithelial cells, some with fat granules, others with earthy granules; and also the debris of spermatozoa. The fluid contained, too, free earthy granules, and some peculiar delicate spear-shaped crystals. The obliteration was no doubt of old standing, and the result of inflam- mation, but I could obtain no history of the case. I have stated, that a swelling consequent upon an obstruction in the vas" deferens has rarely been noticed during life. I am in- debted to Mr. Crompton, of Birmingham, for the particulars of the folloAving interesting case.—A gentleman's servant came under his care for what appeared to be a neuralgia of the right testicle, and he was for some time treated for such complaint without effect. He was frequently quite free from pain, and otherwise healthy. He was a married man, but was unable to have connection with his wife from the excessive pain he suffered before and at the time. It was so seA'ere as to render him wet with perspiration, and .nearly make him faint. He was able, however, to do his Avork as butler IRRITABLE TESTICLE. 299 during the day. On examining him, Mr. Crompton found, distinct from the testicle and about the point Avhere the vas deferens com- mences, a small tumor, which was the seat of the severe pain. He could sensibly feel this tumor enlarging, until it became as large as a horse-bean, the pain increasing every moment. This was noticed on several occasions. If he suddenly examined the part, no tumor was to be found; but upon handling the scrotum the swelling com- menced, and increased until the pain became excessive. When no tumor was to be felt the man was easy. It was ascertained that, at the age of eighteen, he had an attack of gonorrhoea, and orchitis on the right side ; and a firm nodule still existed in the globus minor of the epididymis. Mr. Crompton supposes this case to have been one of stricture at the commencement of the vas deferens, in which opinion I am disposed to concur, though the gradual forma- tion of the tumor during an examination of the part is not very easy of explanation. He gave the bichloride of mercury and ap- plied belladonna to the part, but the patient got no relief, and his wife eloped with another man. CHAPTER XVII. NERVOUS AFFECTIONS OF THE TESTICLE. We may distinguish two kinds of nervous affections of the testicle. One, the more common of the two, consists in an exaltation of the natural sensibility of the part; and it is to this complaint that the term " irritable testis' used by writers more properly applies. The other is a true neuralgic affection of the spermatic nerves. SECTION I. Irritable Testicle. A patient suffering from an irritable testicle cannot bear the least pressure on the gland, in many cases not even the contact of his dress; he shrinks when the part is handled in the most gentle manner; and the motions of the testicle often occasion so much 300 irritable testicle. uneasiness that he is prevented from taking exercise, and is com- pelled to remain constantly at rest in the recumbent position. The morbid sensibility is not always confined to the testicle, but some- times extends up the cord to the loins, so that the passage of fasces through the colon and its distension by flatus are liable to cause uneasiness. The pain is in some degree increased when the patient is in the erect position and the testicle without support. It is fre- quently referred to one particular spot on the gland, which pos- sesses more exquisite sensibility than the surrounding parts. In some instances both testicles are affected, one perhaps more than' the other ; in other cases the morbid sensibility is confined to one side, generally the left. There is no perceptible alteration in the parts, except occasionally a degree of fulness, more particularly in the spermatic cord; slight varicose dilatation of the veins, and a relaxed state of the scrotum. The complaint is usually tedious, and lasts many months. The persons subject to it are those of a weak and irritable habit, who are dyspeptic or hypochondriacal, and unequal to much bodily exertion. In severe cases of this affection all enjoyment of life and its pleasures disappears ; the sufferers concentrate their thoughts upon their maladies; they fancy they shall never get cured ; and Avhilst some become uneasy as to the effect of the complaint in impairing the integrity of the gland, and rendering them impotent, others as urgently desire castration as the sole means of relief from their distress. Morbid sensibility of the testicles is in general intimately con- 4 nected with the state of the genital functions, and is frequently dependent on abuses of them. In several instances I have known it to be consequent on onanism, and on involuntary seminal emis- sions ; and I have found it disappear Avhen the seminal discharges ceased. It may arise from morbid irritation at the prostatic part of the urethra. In one of the most obstinate cases I have had to treat, the complaint was evidently dependent on irritation at this part of the urethra, consequent on an abscess in the prostate which formed during an attack of gonorrhoea, and burst into the canal. It sometimes occurs after cessation from free indulgence in sexual intercourse : and it occasionally affects persons exposed to sexual excitement, but who have not been able to indulge their pas- sions. In such cases the glands are very much in the same con- dition as the tender and swollen mammae at the commencement of irritable testicle. 301 lactation or of weaning. In several persons of chaste habits thus affected, the morbid sensibility disappeared on marriage. The testicles, like the mammae, often also become affected with morbid sensibility about the period of puberty. It sometimes succeeds an attack of consecutive orchitis, owing probably to a temporary closure of the excretory duct from inflammatory exudation, caus- ing an engorgement of the seminal tubes, especially after excite- ment. In cases in which an attack of orchitis has ended in * atrophy, the epididymis or remnants of the gland occasionally remain exquisitely sensitive. Though troublesome, this complaint generally disappears either spontaneously or under treatment after a longer or shorter duration. Treatment.—In the treatment of morbid sensibility of the testicle the first object is to endeavor, if possible, to get rid of the cause of the affection. In many cases, however, this cannot be ascer- tained, or is only suspected. Attention must be paid to the state of the general health and of the digestive organs. Steel medicines and quinine may often be given with benefit. In many cases much service is derived from change of air and scene, so as to amuse the mind, and prevent the sufferer from brooding over his complaints. It often happens that when the mind is occupied, and the patient obliged to exert himself, he is free from suffering. As in many other nervous affections, the complaint becomes worse and aggra- vated by too much attention being paid to it. Advantage is often derived from cold bathing, and sponging the scrotum with iced water. I have sometimes succeeded in procuring relief with the douche bath, by causing a stream of cold fresh-drawn spring water to be directed on the scrotum so as to produce a powerful effect. The application should be made at least once daily. Enclosing the scrotum in a belladonna plaster, and supporting the parts, also sometimes afford relief. The testicle may at the same time be pro- tected from the effects of friction and contact of the dress, when the patient moves about, by lining a full-sized suspender with a layer of soft wadding or wool. But the surgeon's success in the treatment of these cases mainly depends on his being able to ascer- tain the true cause of the complaint.—A young man, aged twenty- two, a sack-maker, applied to me for relief on account of distress- ing pains in the testicles. He stated that he was a single man, and had suffered from these pains for about two months. He was of a 302 irritable testicle. weak frame of body, thin and pale, and had a languid, melancholy countenance, and was subject to headache. His voice was feeble, and he trembled as he entered the room. The penis and testicles were small in size ; the latter were extremely tender when handled, so that he could scarcely suffer me to touch them. I directed them to be supported and kept cool, and as much as possible protected from friction, and ordered the shower bath and steel medicines. Suspecting, from his general appearance and the character of his countenance, that he was addicted to onanism, I twice questioned him upon the subject, but without eliciting that he was habituated to this vice. But after he had attended for some time, and the above remedies, as ay ell as arsenic, quinine, &c, had been tried Avithout any decided improvement, I made further inquiries, and ascertained that he had been for years subject to involuntary seminal emissions, which occurred without erections both in the daytime and at night, and often on evacuating the bowels. I introduced into the urethra a full-sized bougie, and found that it produced great pain on reach- ing the prostatic part of the canal. I then applied the nitrate of silver to this part. The application was transient, but the patient instantly fainted from the sharp pain which it produced. The effects of the lunar caustic subsided in about a week. No emissions occurred afterwards. The pains in the loins and morbid sensibility of the testicle soon completely subsided ; he lost his headache, and in a few weeks became much improved in health, when he was dis- charged cured. In other cases in which the morbid sensibility was connected with seminal emissions, or dependent on irritation at the prostatic portion of the urethra, I have applied the solid nitrate of silver to the part with a beneficial result. In the chapter on Varicocele I have related a case of extreme morbid sensibility of the left testicle, arising from dilatation of the veins of the sper- matic' cord, which was cured by the application of a truss to the outer abdominal ring. Castration should never be performed for this affection ; for the complaint generally ceases sooner or later, and can almost always be relieved by judicious treatment. Romberg relates,1 that he had a patient under his care Avho was attacked with this disease at the time he was engaged to be married. In spite of all the serious ob- jections of a distinguished surgeon whom he had called into consul- 1 Lehob der Nervenkrankheiten, S. 142. NEURALGIA OF THE TESTICLE. 303 tation, in spite of his own earnest representation, the patient insisted upon having castration performed; and the operation was accordingly done, that no greater mischief might ensue. Eight days afterAvards the old pain had taken up its seat in the other tes- ticle ; but this its owner preferred keeping, the marriage being at hand, and he very soon recovered completely. The testicle which had been removed, with the exception of a feAV dilated vessels, did not differ in the slightest degree from the normal state. SECTION II. Neuralgia of the Testicle. In the nervous affection just described there is merely morbid sensibility; pain seldom being experienced whilst the patient remains at rest, and the gland and spermatic cord are supported, and en- tirely free from pressure or rough contact with the dress. The nerves of the testicle are liable, however, to a more painful affec- tion, possessing the characters of tic douloureux or true neuralgia, in which the pain is sudden, severe, and remittent, and occurs in paroxysms of variable duration, generally at irregular, but occasion- ally at regular intervals. The pain is sometimes of an acute darting or lancinating description, at other times of a dragging or pricking nature; and is commonly attended Avith forcible retraction of the testicle to the groin by spasmodic action of the cremaster muscle, and occasionally with nausea and vomiting. Dr. Graves mentions a case in which the patient, when attacked with a paroxysm, would throw himself on the floor and roll about in the greatest agony, covered with a cold perspiration.1 During the intervals of the paroxysms the testicle may sometimes be freely handled without causing pain ; but frequently the neuralgia is combined with morbid sensibility, and a paroxysm is readily induced by the slightest pres- sure. In two cases, in which the neuralgic symptoms were slight, and appeared to depend on some affection of the kidney, the patient complained of a remitting pain or soreness at the crest of the ilium, near the anterior superior spinous process, though there was no tenderness on pressure. In most cases of neuralgic testicle, there is no disease or altera- tion in the gland ; but when the pains have been long-continued and 1 Dublin Journal of Medical Science, vol. xiv, p. 371. 304 NEURALGIA OF THE TESTICLE. intense, the testicle occasionally becomes swollen and tender, and affected even with a slight degree of inflammation. This painful affection is unaccompanied with fever; but the digestive organs are usually out of order, and the health deranged from the acute suffering and disturbance of the patient's rest. The neuralgia is almost always confined to the spermatic nerves of one side, whilst in morbid sensibility both sides are as frequently impli- cated. Neuralgia of the testicle occurs at all ages, and arises from vari- ous causes. We have examples of it in the uneasiness in the organ and spasm of the cremaster muscle occurring in diseases of the kid- ney, and in the severe neuralgic pains usually experienced during the passage of a calculus along the ureter to the bladder. In treat- ing of varicocele, I have stated that a dilated state of the spermatic veins is occasionally accompanied with neuralgic pains in the tes- ticle ; and as the latter occur subsequently to the appearance of the former, and subside on its removal, and often when the patient is in the recumbent position, we may conclude that the morbid condi- tion of the veins gives rise to the neuralgia. But the cause is seldom so obvious as in these instances. The testicle has been accurately examined, and the nerves of the cord have been carefully dissected out, but very rarely has anything which could account for this dis- tressing complaint been discovered.1 Its primary seat has been referred to the spinal cord ; in some instances it has appeared to depend on derangement of the digestive organs,2 and in others it was evidently connected with a disposition to gout. In several cases, also, it has succeeded an attack of orchitis, continuing to distress the patient after all inflammation has subsided. In these cases it may be dependent on an obstruction in the vas deferens, as in the case related at p. 298 ; but in the majority of instances it is very difficult, and even impossible, to make out the cause of the neuralgic pains. Treatment.—In cases of neuralgic testicle dependent on renal disease, the passage of a calculus along the ureter, or varicocele, the treatment must chiefly be directed to the relief of the com- plaints to which the nervous affection owes its origin. When the 1 A perfectly healthy testicle, extirpated by SirW. Blizard on account of this disease, is preserved in the Museum of the College of Surgeons. 2 Vide an interesting case related by Sir B. Brodie, London Medical Gazette, vol. xiii, p. 620. NEURALGIA OF THE TESTICLE. 305 disease is connected Avith derangement of the digestive organs, or a tendency to gout, measures must be taken for their correction. In all cases, particular attention should be paid to the condition of the urine. Cases of neuralgic testicle, in which neither the cause nor seat of disease can be discovered, must necessarily be treated em- pirically. Those of an intermittent character are sometimes bene- fited by quinine in large doses, as five grains three times a day, or the liquor arsenicalis. In Dr. Graves' acute case of neuralgia pre- viously alluded to, the complaint yielded to large doses of the ses- quioxide of iron freshly prepared, and frequent inunction of the testicle and cord with belladonna ointment. The oil of turpentine sometimes proves very efficacious in these cases, when not dependent on renal disease. Other remedies of reputed efficacy in neuralgia have been tried in this affection, but have all disappointed expecta- tions much oftener than they have cured. The various preparations of opium, hyoscyamus, and conium, often afford temporary relief; and they greatly contribute to mitigate the patient's sufferings, though incapable of removing the disease. The scrotum may be blistered, and the surface dressed with an ointment containing the acetate or muriate of morphia, in the proportion of five grains to the ounce. An ointment containing one grain of aconitina to a drachm of lard, smeared over the scrotum in the direction of the cord twice a day, will sometimes arrest the pains for many hours. The tincture of aconite, applied to the scrotum with a piece of sponge, produces a numbing sensation, and is efficacious in reliev- ing both the morbid sensibility of the testicle and neuralgic pains. A piece of lint soaked in chloroform, applied to the part and covered with oiled silk, Avill have the same effect: or a liniment composed of equal parts of chloroform and olive oil may be rubbed in the course of the spermatic cord. In cases in which remedies of every kind and in all shapes have been repeatedly tried, and have as frequently failed in affording more than temporary relief, the patient's life is sometimes rendered so truly miserable that he becomes anxious to undergo some ope- ration, and even that of castration, to get rid of a disease of so obstinate and harassing a character. Operations, however, for the cure of neuralgia are in general very precarious and unsatisfac- tory, and as our experience increases, the less encouragement we find to repeat them. When the diseaschas a constitutional origin, 20 306 NEURALGIA OF THE TESTICLE. or its true seat is at a distance from the part Avhere its painful effects are manifested, and beyond the reach of the knife, it would be unreasonable to expect any beneficial result from the division of the nerves, or the removal of the part to which the pains are re- ferred ; and we find, that in several of the cases in Avhich the operation has been resorted to, no benefit has resulted from it. Dr. Macculloch mentions a case of neuralgic testicle, in which, after a long period of suffering, the gland Avas extirpated in the usual manner, but the disease returned in the cord.1 Mr. Russell has given a brief account of three cases of this affection which occurred in Edinburgh. In one, in the person of a medical practitioner, castration was performed on account of the intolerable suffering and with perfect relief. The patient recovered his health, strength, and spirits, which had been impaired by the severity and continu- ance of his complaints. A practitioner, encouraged by the success of this operation, adopted a similar practice in a like case, which, however, was not followed by an equally favorable result; as the patient experienced in the first instance but imperfect relief Avhile the complanrt gradually returned, increasing in severity, till at last it attained its original violence. The next case that occurred was treated upon other principles. The practitioner advised the patient to submit to his sufferings wdth patience, in the hope that time would at last accomplish a cure. The patient followed this advice, and was relieved from his misery in the course of eighteen months.3 Sir A. Cooper resorted to castration in three cases of neuralgic testicle, in all of which the result proved satisfactory, the patients having recovered, and afterwards continued free from any return of the distressing complaint.3 If the details of these three interesting cases are carefully examined, the success of the operation can, I think, be accounted for. In all of them, it is clear, that the neuralgia had a local origin. In the second case, it was dependent on varicocele, and consequently admitted of per- fect relief by castration, the cause of the disease being removed together with the testicle, though the morbid condition of the veins might have been remedied by milder treatment. In the two other cases, it appears that the neuralgia Avas originally induced by an 1 Essay on the Marsh Fever and Neuralgia, p. 77. 2 Observations on Diseases of the Testicle, p. 186 et seq. 3 Lib. cit. p. 69 et s9q. FUNCTIONAL DISORDERS OF THE TESTICLE. 307 attack of orchitis ; and though it afterwards proA'ed irremediable by antiphlogistic means, and persisted after all inflammation had subsided, the nerves affected were evidently those immediately con- nected Avith the testicle, which, having been removed, the painful symptoms all ceased. In cases, then, in which the neuralgia has a local origin, is confined to one side, and is clearly dependent on some change in the state of the nerves of the testicle or cord, castration might be performed A\*hen the symptoms are sufficiently severe, and the patient is willing to undergo it, with a fair pros- pect of permanent relief.1 But in cases in which it is impossible to determine exactly the seat or the cause of the disease, the sur- geon incurs no slight risk of failure; and if he ventures to under- take the removal of so important an organ as the testicle at the earnest entreaty of the sufferer, it would be his duty, as well as his policy, fully to apprise his patient of the uncertainty of the result. CHAPTER XVIII. SYMPATHETIC AND FUNCTIONAL DISORDERS OF THE TESTICLE. Defective as is our knowledge of the sympathetic and func- tional disorders of the glands, there are few with Avhose derange- ments we are less perfectly acquainted than the testicles. The functions of these organs are so involved in the actions of other parts, are influenced by such peculiar causes, and are so dependent on and modified by particular events and circumstances, that the investigation of their disorders is necessarily complex and difficult. During life, the product of these glands is never afforded in a pure and unmixed state, so that it is almost impossible, either by che- • mistry or the microscope, to appreciate properly the qualities of 1 Mr. Harvey Ludlow relates in his Prize Essay the case of a man aged twenty, a patient in St. Bartholomew's Hospital, who had suffered for six years from neuralgia of the left testicle, which originated in an injury of the partfollowed by inflammation. AAer the trial of various remedies without success, Mr Stanley, with the concurrence of his colleagues, removed the organ. On examination, the surfaces of the tunica vagi- nalis were found partially adherent, the membrane being thickened ; and the epididy- mis was changed into a firm white fibrous substance. There had been no return of pain three months after the operation. 308 DEFECTS IN THE FUNCTIONS the secretion, and to note the changes dependent on disease. And as a repugnance is generally felt to such inquiries, it is not sur- prising that the functional disturbances of the testicle have been but imperfectly investigated, and rarely treated of by the patholo- gist and legitimate practitioner. The functions of the testicles, like those of other secreting or- gans, may become suspended and incapable of excitement; or they may be exerted to excess, improperly excited, and so abused, as to fail prematurely, or produce injurious effects on the constitution. SECTION I. Defects in the Functions of the Testicles. The testicles not being parts essential to life are subject to differ- ent laAvs from those Avhich regulate the actions of the vital organs. Their functions may be suspended, or they may remain in abeyance for an indefinite period Avithout injury to the glands, or any mate- rial effect on the constitution. In persons of recluse and studious habits these organs often continue dormant for years. Like the mammae in the unmarried female, though inactive, they remain sound and competent for secretion when duly excited and called upon to exercise their functions. The opinion, that in manhood the testicles waste from long-continued chastity, I believe to be as erroneous as its tendency is obviously injurious and immoral, in furnishing an excuse for illicit intercourse to those who cannot otherwise indulge the sexual appetite. The case is somewhat dif- ferent, however, late in life. Thus widowers, after remaining chaste for some time, on marrying have been doomed to disappointment. Inaction has hastened the natural decline. The impulse for commerce with the other sex exists in different degrees of force in different men, those of a sanguine temperament being most prone to indulge, and best able to do so without hurt. • In the adult the moderate exercise of this function is favorable to health, and to the maintenance of the powers both of the mind and body. A certain degree of vigor, hoAvever, is necessary to bear the nervous excitement attending it; hence in advanced years, and in weak and susceptible individuals, the frame is unable to sus- tain frequent coition with impunity. The old man often pays dearly for a matrimonial connection with a young woman by an OF THE TESTICLES. 309 attack of paralysis, or else an exhausted frame, premature debility, and death. Rules have been given for regulating the sexual func- tions and restricting the performance of them within due bounds. They are, however, of little value, for, as I have already mentioned, the poAvers vary greatly in different persons, and at different periods of life; and what is moderation in one man, or at one period of life, is excess in another man, or at another time of life. When- ever the sexual act is followed by a prolonged sense of debility and lassitude, an uncomfortable feeling in the head, and disinclination for either physical or mental exertion, the limits consistent with health have been exceeded. The hurtful effects of frequent sexual intercourse result less from the drain upon the system by the dis- charge of the seminal secretion than from the nervous excitement attending the act. In cases, also, of excessive masturbation, the amount of fluid evacuated bears no proportion to the exhaustion of the bodily powers, and the prostration of the mental faculties con- sequent on the practice. Not only is the enjoyment heightened, but the effects of coition on the constitution are far less depressing when the necessary energy is supplied by the stimulus of a warm attachment, than Avhen the appetite is irregularly indulged in for- nication. The nervous system is invigorated by the passion, and acquires a power which enables it to bear the excitement of repeated coition; Avhilst the debauchee often suffers as severely in his health as he always does in his morals, from the unrestrained gratification of his animal propensities. The testicles are under the influence of the brain, which animates and controls the desire for sexual enjoyment. An emotion of the mind, as sudden disgust or anger, arrests the secretion of these glands, and quenches sexual ardor as quickly and as effectually as a strong mental impression stops the secretion of gastric juice and takes aAvay the appetite for food. An attack of apoplexy often permanently extinguishes all desire as well as capacity for coition. In Chapter II, I have mentioned cases in which the procreative function has been annihilated and complete wasting of the testicles has resulted from injuries of the head, as well as cases of idiots whose genital organs were imperfectly formed, and who had expe- rienced no inclination for sexual pleasures. I will now adduce some additional facts in relation to the influence of the brain on the functions of the testicles.—Hildanus mentions the case of a man :)10 DEFECTS IN THE FUNCTIONS accused of impotency by his wife, who sued for a divorce. Nothing external was defective; but the man stated that eight years previ- ously he had received a blow on his head by a stick. From that period " confitebatur penem erigi non posse."1—Mr. B:, aged forty- one, a passenger on the railway between Boston and Providence, apprehending an accident, thrust his head out of the window at the moment that the train came in collision with another running in an opposite direction with fearful violence. Most of the pas- sengers were thrown out, and seriously injured. Mr. B.'s head and neck struck against the edge of the window-frame with great force; and he himself was thrown to the ground, where he remained for some time in a state of insensibility. He, however, regained his senses, and was conveyed home in a carriage. The surgeon, on visiting him, found him suffering with great pain in the occipital region and upper part of the neck; but there was no indication of fracture of the skull or spine. On the second day after the acci- dent he complained of a numbness in his right arm, and experi- enced difficulty in passing his urine. In the course of two weeks he was able to leave his bed, and walk in the street; but his vision was defective. Between the fourth and fifth week after his injury he made the discovery that he had lost the desire and physical power for sexual intercourse, and that no amorous sentiment, or the approach of a female, could excite it. Under appropriate treat- ment the bladder gradually recovered its power; and his vision be- came perfect; but the numbness of the right arm continued, and the generative functions remained impaired. His mental powers, particularly his memory of events, were also for a time seriously affected.2 Dr. Smyth, in some excellent observations on the subject of impotency, states that he has seen complete impotence (absence of erection) of three months' duration, accompanied by general emaciation and impairment of health, excessiAre irritability of both mind and body, and considerable shrinking of the penis and tes- ticles, occur in a strong young man of twenty-five from injury of the back part of the head. This gentleman being engaged in a quarrel, received a blow on the face Avhich stunned him; and having fallen backwards, first struck the ground with the tuberosity of the 1 Opera Observationum et Curationum Medico-Chirurgicarum, p. 574. 2 Case related by Dr. Fisher. American Journal of the Medical Sciences, Feb. 1839, p. 357. OF THE TESTICLES. 311 occipital bone, and sustained in consequence a concussion of the brain, manifested by insensibility and total unconsciousness of eight or ten hours. Being a diligent student of medicine, he continued his professional pursuits the following day, and without interrup- tion for six weeks, during which time he took no further notice of the occurrence. The general emaciation and failure of the sexual function were first perceived in a little more than a week after the injury.1 Dr. Gall mentions that at Vienna he was consulted by two officers who had become impotent in consequence of blows from fire-arms which had grazed the napes of their necks.2 When impotency depends on an injury of the head, the prospect of relief is in general far from promising. The event itself is one of the last to be detected, and is rarely perceived till all treatment of the injury has ceased, and the patient is in progress of recovery. In some instances it is first announced by the visible wasting of the testicles. When otherAvise, hoAvever, the surgeon must not despair of the patient's regaining his sexual powers as the other effects of the injury disappear. Thus one of the officers mentioned by Gall recovered by degrees the generative faculty, married, and became the father of several children. Purgation, followed by a slight alterative course of blue pill, effected a complete and speedy cure in Dr. Smyth's patient, after change of air and other hygienic mea- sures had been tried in vain : as the gums became tender the pa- tient began to recover flesh, and to experience a return of the pro- creative poAver. In the case of the patient injured on the railroad, the function Avas only partially restored. The treatment required in these cases is such as Avould be adapted to remove the other symptoms of cerebral mischief. If aphrodisiac medicines are used, they must be given Avith great caution. Electro-galvanism, applied from the occiput along the spine, might prove of service. The reader will recollect the singular case of arrest of the deve- lopment of the testicle related at p. 89, in which the organs acquired their normal size and assumed their functions at an unusually late period of life, as the dormant passions Avere aroused by a particular attachment. No doubt some men, especially those who constantly exert their mental powers in some engrossing pursuit, are less sus- ceptible to the influence of the female sex than usual; and in such i The Lancet, August 28, 1841, p. 784. 2 On the Functions of the Cerebellum, tr. by Combe, p. 46. 312 DEFECTS IN THE FUNCTIONS persons, until a suitable impression is made, and the instinct is ex- cited, the sexual organs may remain long inactive, and in abeyance. There are well-recorded instances of men, and of persons too of great intellectual attainments, Avho, though to all appearance robust and perfectly formed, have not only passed a life of absolute chas- tity, but have never even evinced the slightest disposition for sexual enjoyment. In the figurative language of Sir A. Cooper, " To such persons a Venus might display her charms, and on such her son might exhaust his quiver, in vain. No genial spring is here, no blooming summer, or fruitful autumn ; but all is winter—a dreary, desolate, and barren winter—in which the springs of life are frozen up, and the animal propensities destroyed.-' It is difficult to ac- count for such cold indifference ; but we may suppose that, in some instances, that particular part of the brain Avhich is the seat of the procreative function has been but little or imperfectly developed. The several facts stated in this Avork fully justify the inference that the functions of the testicles may remain unexercised, and that im- potence may ensue from a cerebral defect, or from the absence of the usual stimulus derived from the sensorium; and though more often occurring in idiots, I perceive no reason why such a fault should not exist in a brain otherwise in a high state of perfection. This constitutional and congenital form of impotency is sometimes, but not always, accompanied with arrest in the development of the sexual organs, and an effeminate appearance and frame of body. Impotency of a temporary nature may be the effect of violent emotions of the mind, as mental affliction, anxiety, and rage; in- deed any impulse sufficiently intense to absorb the attention to the exclusion of the sexual passion will extinguish desire, and arrest the secretion of the testicles. Thus sudden and exciting news, either good or bad, has been known to allay the sexual passion. When, hoAvever, the emotion subsides, and the mind becomes tranquillized, the generative instinct is again aroused. Disgust, also, is some- times a cause of sexual incapacity. Thus men, at other times com- petent to the act, have remained impotent in the company of cer- tain women, owing to a particular aversion to the uninviting person, or the coldness and indifference of their companion. For such cases of relative impotency the remedy is obvious. Not an unfrequent cause of a failure in the exercise of the repro- ductive powers is AATant of self-confidence,—excessive apprehension OF THE TESTICLES. 313 of inability to perform well the duty of the sex. When persons are so timid and diffident as to entertain these groundless fears, it may be long before success attends their efforts, every failure add- ing to the evil by.diminishing the reliance upon their powers. Mr. Hunter has treated this kind of impotency depending on the mind Avith his usual sagacity, and has related the following case.—He was consulted by a gentleman who had lost his powers in this way. The patient was subject to erections, accompanied with desire; but from doubt, or fear, or the Avant of success, was unable to copulate with a particular female. Mr. Hunter told him that he might be cured if he could perfectly rely on his own power of self-denial. He was then recommended to go to bed to this Avoman; but first to promise himself that he Avould not have any connection with her for six nights, let his inclinations and poAvers be what they Avould, which he engaged to do. This resolution produced such a total alteration in the state of his mind, that the power soon took place; for instead of going to bed with the fear of inability, he went with fears that he should be possessed with too much desire, too much poAver, so as to become uneasy to him, which really happened ; for he wrould have been happy to have shortened the time: and Avhen he had once broken the spell, the mind and powers went on to- gether, his mind never returning to its former state.1 Modes of varying this advice in the case of persons recently married, Avho may be affected with this form of impotency, will readily occur to the practitioner. Thus, some mild tonic may be prescribed, and the patient be directed to abstain from intercourse while under treatment, and the surgeon may rest satisfied that not many days will pass over before nature asserts her empire. These cases must, on no account, be lightly treated. The situation of the patient is often one of great distress of mind, and much relief may be afforded by the surgeon calmly reasoning with him on the subject of his complaint. He may be told that his case is not uncommon; the true cause of failure may be pointed out; and he may be confi- dently assured of the groundless character of his fears, and of the influence of his doubts and apprehensions in preventing him from fulfilling his desires. Kind and confidential advice of this nature, by encouraging the patient, will do more in effecting a cure than any sort of medical treatment or stimulating medicines. A single 1 Treatise on the Venereal Disease, 4to, p. 203. 314 DEFECTS IN THE FUNCTIONS success at once banishes all his fears, and gives security for the future. It has been confidently asserted that excessive indulgence in tobacco-smoking Aveakens or destroys the sexual. powers. I know of no facts to warrant the belief that tobacco exerts a special seda- tive effect on the genital organs, or that such injurious influence results from the habitual practice of smoking it in moderation. The Germans, whom we should regard as excessive smokers, evince no failure in the reproductive functions; and although the importation of tobacco into this country has largely increased in recent years, the Registrar General's Reports exhibit no corresponding decrease in the population. The intemperate use of tobacco, hoAvever, espe- cially by chewing, is very liable to impair the digestive organs, and lower the nervous force, and I have no doubt Avhatever that its de- pressing influence is likeAvise manifested in a diminution of the sexual powers. In several cases of impotency with dyspepsia in persons between thirty and forty years of age, which have fallen under my notice, I have found on inquiry that they were either in- veterate smokers or habitual chewers of tobacco,1 and no treatment proved effectual without great restriction in these customs. Opium, whether chewed or smoked, is still more hurtful than tobacco. There is ample evidence of impotence being a common effect of in- dulgence in this pernicious drug. Abuse of the sexual functions is a frequent cause of impotency, and of impotency very difficult to treat and remove; for moral as much as medical treatment is required, the mind being frequently more at fault than the body, and the surgeon finding it as necessary to urge the duty and importance of self-control as to prescribe for the patient's health. Such advice is particularly called for in per- sons Avhose inclinations are stronger than their powers of fulfilment. By indulging the mind in erotic thoughts, desires are created which lead to sexual excesses, imperfect performance, and ultimately to failure. Many men, usually persons in affluence or without occu- pation, allow their minds to be so constantly occupied with these functions, that they render themselves truly miserable,—become hypochondriacal, morose, and reserved, and unfitted for the social duties of life. They seem to consider that they are born for no other purpose than to gratify an animal passion, and it sometimes 1 One of these patients was an American, a mate of a ship. OF THE TESTICLES. 315 becomes the surgeon's duty to expose the folly and evils of such in- fatuation. Persons who indulge to excess sometimes become sud- denly impotent, »and a considerable period of rest may elapse before the organs are capable of resuming their functions. Such occur- rences are not unfrequent shortly after marriage. Addiction to sexual pleasure in early life often entails a permanent loss of power in middle age, at a period when most men still retain it in full vigor. This is often experienced in the despotic countries of the East. M. Volney,1 in his Travels through Asia Minor, mentions that the people of rank in that country, who can afford the expense of a harem, often complain of impotency at the early age of thirty. Mr. Russell, of Edinburgh, in some excellent observations on this subject, remarks, " that matters are not so bad in this country, though it is a well-known fact that young men of fashion, who in- dulge their amorous propensities at an early age, lose the power of procreating sooner than the more continent."2 Too great indulgence of the sexual appetite is productive, howeATer, of other effects be- sides premature impotency: as every practical surgeon is aAvare, it tends to derange the digestive functions, and to weaken the physical and mental powers. Sexual excesses are likewise a fertile source of the diseases of the testicle : persons affected with chronic inflam- mation and other disorders of the gland frequently, and I believe wdth justice, refer their complaints to an unrestricted indulgence of their passions. In men advanced in age, irritability of the bladder and chronic catarrh are not uncommon results of such excesses; and I presume that the frequent desire to micturate under these cir- cumstances gave rise to the ancient proverb, raro mingitur castus. Sexual indulgence late in life seems also to promote the enlarge- ment of the prostate gland; and I know of several instances of old men being attacked with retention of urine from congestion of this organ occurring after coition. I suspect, too, that these excesses, if long continued, are very apt to lay the foundation of disease in the kidneys. A gentleman, who when young had been much ad- dicted to the society of women, invariably suffered subsequently from pains in the loins, and alkaline urine, after intercourse with the sex. There can be little doubt, too, that the erotic longings which sometimes continue to distress the aged long after the period 1 Voyage en Syrie et en Egypte, torn, ii, p. 444. 2 Observations on the Testicles, p. 35. 316 DEFECTS IN THE FUNCTIONS at which in the course of nature they should have ceased, depend as much on physical infirmity as mental depravity, a diseased state of the prostate inciting and producing the morbid desires. By re- garding these propensities as symptoms of disease, and treating them accordingly, they would often subside, and the subjects of them would cease to indulge in vicious courses. One of the most common results of inordinate excitement of the genital organs is an excessive involuntary discharge of the sper- matic fluid, or spermatorrhoea, a subject which will be considered in Section II of this chapter. Diseases and injuries of the spinal cord, producing paraplegia, have no direct effect on the testicles, but destroy the power to copulate. In the chapter on Atrophy I have given instances of wasting of the testicles succeeding an injury to the spine. In general, desire remains, the seat of the instinct being unaffected; and I suspect that in the cases alluded to, in which wasting took place, the injury affected other parts besides the spinal cord. M. Brachet has recorded the folloAving curious case.—A soldier after several years' service experienced, in 1814 and 1815, rheumatic pains, particularly iii the lumbar region. In 1816 he had a fall from his horse. By degrees, the lower extremities and inferior part of the abdomen became completely paralyzed. For eight years the paralysis remained stationary. Whilst in this state he had two children. The spermatic fluid was secreted, erection took place, and ejaculation followed; but " sans secousse et sans sen- sation voluptueuse."1 We must suppose that in this case, although the sensibility of the penis was destroyed, the connection between the brain and testicles was still maintained by the sympathetic system, which communicated the necessary influence ; and that their functions Avere, accordingly, as little disturbed *by the affec- tion of the medulla spinalis as are those of the important organs of the abdomen in the same disease.2 But, notwithstanding the 1 Recherches Experimentales snr le Systeme Nerveux, 2d edit. p. 280. 2 M. Brachet performed the following experiments.—Having made sure that a cat a year old had covered several times a female cat with which he was shut up during the day, M. B. divided his spinal marrow between the third and fourth lumbar ver- tebras. All behind was paralyzed, the rectum and bladder equally so. He kept the animal three days; when, on examining the genital organs, he found them healthy, and the vesiculae seminales full of semen. This experiment was repeated three times with the same result. The next is given in the words of the experimenter: " Sur un chat de dix mois, je fis la section de la moelle spinale dans la region lcm'iaire. OF THE TESTICLES. 317 success of this old soldier, there are feAv in a state of paraplegia who would not find themselves physically incapacitated. The nux vomica is adapted not only to relieve the paralytic symptoms, but also to restore the sexual powers. Varicocele tends gradually to impair the nutrition and dimi- nish the secreting powers of the testicle.1 Hence the importance of not neglecting this complaint, though it may produce no painful symptoms. The influence of detention of the testicles in the abdo- den and in the groin external to the cavity, on the sexual functions, have been already considered in a previous chapter. Diseases which destroy the substance or produce wasting of the testicle necessarily prevent its secreting. The functions, hoAvever, of this gland are not very readily impaired by disease; and so long as a small part remains entire, the organ may be fitted to perform its office sufficiently for the end destined by nature. When the testicle is to a great extent disorganized by the exudation of lymph, and forms an open fungoid sore, secretion may still go on under excitement, as is evinced by the presence of spermatozoa in the discharge. This fact shows the importance of the surgeon striving to save the testicle when mutilated either by accident or disease. In double hydrocele the functions of the testicles con- tinue unaffected. After severe or repeated attacks of acute or- chitis the glandular structure of the testicle almost invariably manifests a diminution in bulk, and more or less impairment of its secreting powers. In inflammatory affections of the epididymis, although the plastic matter effused amongst the convolutions of the duct is liable to obstruct the tube, the effect is rarely more than temporary, owing partly to the readiness with which such exuda- Comme la paialysie du train derriere mettait cet animal dans l'impossibilite' d'exe-- cuter les manoeuvres du co'it, j'y fis supplier par une sorte de masturbation. II fallut plus de terns, mais elle finit par determiner une ejaculation. A'ingt-quatre heures apres, je fis rep6ter la meme manoeuvre ; et one nouvelle Ejaculation eut lieu ; je la fis encore repeter le lendemain avec le meme re'sultat." (Lib. cit. pp. 289-291.) These experiments, though interesting, as showing that the functions of the testicles may be carried on in paraplegia without sensation or any influence derived from the brain through the spinal cord, do not, as Brachet supposed, prove that the secretion of sperm is altogether independent of the influence of the spinal system. 1 M. Gosselin observed in a case of varicocele on the left side, in which the testicle was one-third smaller than the other, that after an attack of gonorrhceal orchitis in the right testicle, no spermatozoa could be detected in the semen. Archives Gen6- rales, 5e serie, t. ii, p. 268. 318 DEFECTS IN THE FUNCTIONS tions are absorbed, but chiefly to the absence of a strong fibrous envelope, and the yielding nature of the serous membrane by which it is invested; for, as I have already stated, after inflammation of the body of the testicle, Avasting and disorganization of its glandular tissue are not uncommon. Chronic orchitis, as I have previously remarked (p. 230), also proves more or less destructive to the organ. It is extremely difficult to obtain satisfactory evidence of the effects of disease on the functions of the testicle in cases -in Avhich there is no absolute diminution of its bulk, not only for the reasons stated at the commencement of this chapter, but also in consequence of the rarity of both glands being seriously affected, and the greater rarity of their both suffering in precisely the same degree. Vidal has adduced some cases Avhich bear on the point.—In a robust man, aged twenty-nine, affected with syphilis, the left testicle swelled to a great size, and was removed by operation. Two years after- wards the right testicle became very large and hard, and the seat of sharp lancinating pains. Viewing the disease as syphilitic, M. Vidal prescribed the iodide of potassium, under Avhich treatment the enlargement subsided, and the testicle recovered its normal state in three months. The man was afterAvards much addicted to sexual pleasures, and contracted gonorrhoeas.1 A carman had one tes- ticle, the right, undeveloped and detained outside the inguinal canal. The left was attacked with syphilitic disease, which sub- sided under treatment without impairment of sexual power.2 M. Vidal, Avhilst admitting the injurious effects Avhich generally result from syphilitic inflammation of the testicle, adduces these cases to show that the organ is not invariably damaged either in struc- ture or function by the disease, a conclusion which my own experi- ence enables me fully to confirm. He has also related a case in which, after an attack of double orchitis in a man aged fifty, one testicle became atrophied and the other hypertrophied. True hypertrophy of the testicle is so rarely observed under any cir- cumstances, even in early life, that we may fairly hesitate to admit the enlargement to have been due to an excess of nutrition. It was most probably occasioned by unabsorbed inflammatory exudation. The injurious effects of chronic orchitis ending in a fungous growth, and perhaps of the treatment by excision, are shown in the follow- 1 TraitE de Pathologie Externe, t. v, p. 461. 2 Mdmoires de la Societe de Chirurgie de Paris, t. iii. OF THE TESTICLES. 319 ing case described by Mr. Lawrence.1—In a man, aged twenty- three, the right testicle became hard and painful, and in four months the skin burst, and a growth projected which the surgeon gradually cut away, and the parts cicatrized. The cord could be traced to a small lump connected to the cicatrix. A month later, the left testicle became affected in a similar way, and a fungus arose, Avhich was destroyed by lunar caustic, and a cicatrix ensued. Mr. Lawrence adds that the man had lost all venereal appetite since the left tes- ticle began to sAvell. Certain affections, as carcinoma, generally extend until the glandular structure is Avholly destroyed. But, as I have just remarked, it is seldom that both testicles are disorganized ; and the remaining one, if sound and well developed, is fully sufficient for the purpose of reproduction. The same holds good when one testicle has been removed by operation ; but when both are extir- pated or destroyed, the patient becomes absolutely and permanently impotent. The question has been raised, and-was at one time much discussed in Germany, Avhether a person castrated after arriving at the age of puberty may not retain the power of procreating for a certain period afterwards. The following case bearing on the point is recorded by Sir A. Cooper.—A man had one of his testicles removed in 1799. In June, 1801, the other testicle was removed by Sir A. Cooper in Guy's Hospital on account of a chronic abscess. He had been married prior to the loss of one testicle. Four days after the second operation it Avas found that he had had during the night an emission, which appeared upon his linen. After he had recovered and quitted the hospital Sir A. Cooper repeatedly visited him for many years. For nearly the first twolve months he stated that he had emissions in coitu, or that he had the sensations of emission. That then he had erections and coitus at distant intervals, but without the sensations of emission. After tAvo years he had erections very rarely and very imperfectly, and they generally immediately ceased under an attempt at coitus. Ten years after the operation he said he had during the past year been once connected. In 1829, he visited Sir A. Cooper, because he Avas a severe sufferer from piles. He then stated that for years he had seldom any erection, and then that it was imperfect; that he had no emissions from the first year of the operation ; that he 1 Edinb. Med. and Surg. Journal, vol. iv, p. 262. 320 DEFECTS IN THE FUNCTIONS had for many years only a feAV times attempted coitus, but unsuc- cessfully ; that he had once or twice dreams of desire, and a sensa- tion of emission, but without the slightest appearance of it. The penis was shrivelled and wasted. He shaved once a week, and sometimes twice. His voice, naturally rather feeble, remained as at the time of the operation. Mr. Wilson performed the opera- tion of double castration on a married man for carcinomatous disease of the testicle. The wounds cicatrized in little more than a month, and he survived the operation two years. He assured Mr. Wilson that after the removal of the testicle he had occasional erections, not unaccompanied with desire, and which, when as a married man he indulged, were attended with the usual paroxysm and emission of some fluid.1 In determining the question alluded to, we must not confound the poAver to copulate with that of impregnation. It has been seen that the loss of the testicle so affects the brain as completely to extinguish the sexual instinct; but this is an effect Avhich is not immediate, but takes place gradually, as is clearly shown by Sir A. Cooper's case : hence we must admit that the castrated indivi- dual may experience desire, have erections, accomplish the coitus, and emit fluid for several Aveeks after recovery from the operation. But the fluid which is essential for the propagation of the species is the secretion of the testicles, none of which can of course be elaborated after the removal of both glands. The question then resolves itself into this,—how long may the seminal fluid already formed remain in the excretory ducts and vesiculse seminales in a condition to impregnate the female ? Much, of course, must depend on the state of the testicle or testicles at the period of the operation. If the gland last removed wTere thoroughly disorgan- ized, taking into account the period previous to the operation since which the organ could have been in a condition to secrete, and the time occupied in the healing of the wound, Avhich, together, cannot be estimated at less then eight or nine weeks, we may decide that in such a case the castrated patient would be unable to impregnate; since in the numerous examinations which I have made of the fluid taken from the .vesiculse seminales and vasa deferentia of hospital patients who have died of various chronic diseases, I have never found spermatozoa in them at a later period 1 Lectures on the Urinary and Genital Organs, p. 133. OF THE TESTICLES. 321 than seven weeks after their admission, or after they had possessed the opportunity of having sexual intercourse. In a case, hoAvever, in which the testicles were sound and capable of secretion at the time of castration, it must be concluded that a sufficiency of the spermatic filaments may remain in the excretory ducts and vesiculse for two or three weeks after recovery from the operation in the usual period, so as to allow of the possibility of impregnation being effected, improbable as such an occurrence must undoubtedly be regarded. Some error has prevailed respecting the effects of chronic con- stitutional diseases in impairing the functions of the testicles. Thus, consumptive individuals are supposed to be more than ordinarily addicted to sexual pleasure ; and it has been stated that they have retained the power and propensity to gratify it up to the very day of death. Louis made careful inquiries in re- ference to this point, and found in every instance that the tendency to sexual intercourse declined with the increase of general weak- ness and other symptoms, almost exactly as is the case with individuals laboring under any other affection. The accuracy of this statement is confirmed by my own observations and inquiries. I examined the testicles of four persons who had died of pulmonary consumption, and found that they were all below the average weight and size of those of healthy adults. In the testicles taken from the bodies of twelve phthisical patients examined in the London Hospital, no spermatozoa could be detected in the fluid obtained from the substance of the gland and epididymis. In several of these cases, the contents of the vesiculae seminales were likewise examined, and found destitute of spermatozoa.1 Rayer has also remarked that the vesiculse of phthisical patients afford few or none of these bodies.2 The testicles of persons who die of chronic lingering diseases are almost invariably soft and inelastic. Their glandular structure seems to contain but few bloodvessels, is pale, apparently shrunk and dry, and the little fluid that can be squeezed from it is destitute of spermatic cells. A fit of dyspepsia is an occasional cause of temporary loss of 1 Dr. Davy examined microscopically the fluid taken from the divided substance of the testicle of twelve persons who died of phthisis, but in no instance discovered spermatozoa; but he found them in several instances either in the vesiculae seminales or vasa deferentia. Edinb. Medical and Surgical Journal, July, 1838, p. 1. 2 Archives Gene'rales de Medecine, Aout, 1842, p. 487. 21 322 DEFECTS IN THE FUNCTIONS virile power. A gentleman, after a separation of many weeks from his wife, on his return Avas much alarmed by finding himself inca- pacitated. On inquiry, it appeared that he had dined imprudently, and had suffered from indigestion and heartburn during the night. Virility is more permanently affected by organic disease of the ab- dominal viscera ; but there are feAv complaints which have greater influence in impairing the generative functions than those of the kidneys. Diuretics, as the nitrate of potash, carbonate of soda, &c, are well known to act as anaphrodisiacs. In diabetes and al- buminuria the reproductive organs are weak and often quite inac- tive.—A married gentleman, aged forty-eight, at the request of Mr. Gardner, of Bayswater, consulted me on account of loss of sexual poAver. I found on inquiry that he voided urine in large quantity. It was pale, feebly acid, and slightly albuminous, its specific gravity being 1#012. Under treatment adapted to correct the disordered actions of the kidneys, he entirely regained his virile powers. Several similar cases have come under my notice. In irritative dyspepsia, with deposits in the urine of the earthy phos- phates or oxalate of lime, there is generally more or less inability. Impotency in these cases is only one of the manifestations of defec- tive assimilation and depressed vital force ; though it is often the symptom which chiefly attracts the attention of patients. They are observed to lose flesh, and to have a quick irritable pulse. They are weak and readily fatigued, feel unfit for either bodily or mental exertion, sleep badly, and are subject to excessive depression of spirits, and sometimes complain of a deep-seated dull aching sensa- tion in the loins. Though in both these forms of urinary disorder the generative force is generally deficient, the defect is greater and more marked in dyspepsia, attended Avith deposits of the oxalate of lime, than of the phosphates, and the power is often altogether lost. The late Dr. Golding Bird, Avho first drew the attention of the pro- fession to the oxalate of lime as a common deposit in the urine, ascribed the impotency attending it to the exhaustion produced by the excessive secretion of urea so common in this affection.1 Dr. Begbie has described the symptoms of the irritative form of dys- pepsia, in which the oxalate of lime abounds in the urine, with great accuracy; and in his valuable paper has related several well-ob- served cases of this affection. He noticed in the more confirmed 1 Bird on Urinary Deposits, 3d edit. p. 231. OF THE TESTICLES. 323 forms a complete prostration of the virile powers.1 In some of the cases which have fallen under my notice, the patient has been affected slightly with spermatorrhoea, to which the sexual weakness was attributed, the chief cause having been quite overlooked. On making a microscopic examination of the cloudy urine I have some- times excited surprise by the announcement that, instead of sper- matozoa, it contained abundance of octahedral crystals—an indica- tion of impaired digestion, not of seminal waste. It has been stated, that the presence of these crystals is a pretty sure indica- tion of the existence of spermatorrhoea. They are found, it is true, very generally in the urine of persons laboring under this complaint, but I quite agree with Dr. G. Bird that this salt constantly occurs where no suspicion of an escape of semen can be entertained. In all instances of dyspepsia with impotency, the surgeon should make a careful examination of the patient's urine, and by doing so he will often be able to detect a cause for the weakness quite within the reach of remedies. The treatment of such cases by careful regulation of the diet, and the administration of the mineral acids and other remedies calculated to check the formation of the urinary deposits, and to improve the general health, is indeed very-success- ful in restoring sexual vigor. The phosphatic deposits occurring in dyspepsia are in general more readily corrected by treatment than those of the oxalate of lime. Patients suffering from the lat- ter often require careful and prolonged treatment before the mal- assimilation Avhich leads to it is corrected. In cases in which the generative functions have been previously weakened, and the gene- ral health deranged by excessive indulgence in coition, masturba- tion, or long-continued involuntary emissions, the results are not ahvays satisfactory. Dr. Golding Bird mentions the case of a gentleman who committed the gross folly of testing his powers pre- vious to marriage, by sleeping with two women. The result was an epileptic fit; and from that moment he has been paying a heavy penalty for his indiscretion in the persistence of the symptoms of oxaluria in an aggravated form.2 Impotency sometimes occurs in middle life without any obvious cause. In such persons I have noticed a constitutional change, similar to that which takes place in eunuchs. They have been ob- served to grow sleek and corpulent, to have a scanty beard, and to 1 Edinb. Monthly Journal, Aug. 1849. 2 Lib. cit. p. 234. 324 DEFECTS IN THE FUNCTIONS be indisposed to active muscular exertion. In general, they evince no unhappiness at their altered condition. This state is far from hopeful, but the following case affords encouragement.—In 1853, I saw, with Mr. Arthur, of Shadwell, a publican, aged forty-one, of a full florid complexion, married, and the father of a family. He complained of defective sexual power, and stated he had been strong in this respect, and had experienced no failure until about twelve months previously, during which period he had grown re- markably stout. He experienced scarcely any inclination for sexual intercourse, and had lost almost entirely the ability to indulge in it. He had been slightly affected with gout a few weeks before, but he was quite free from it and in good health at the time of his consulting me. His chief annoyance arose from his wife sus- pecting him of infidelities in consequence of his neglect of marital duties. His testicles were of proper size, but somewhat soft and flaccid. I formed rather an unfavorable prognosis in this case, but recommended his taking the ergot of rye with quinine, plenty of exercise, and paying careful attention to his health. He took the medicine for a fortnight, and then left town for change of air. After his return, in about three months, he called on Mr. Arthur, who found that he had lost weight considerably, was more capable of taking exercise, and that he had no occasion to complain of in- ability. In the preceding observations, whilst explaining the various causes impairing the functions of the testicles, I have, for the most part, indicated the nature of the treatment required for their resto- ration. Certain medicines reputed to possess the property of sti- mulating and invigorating the sexual organs have been classed as aphrodisiacs ; and some of them are said to be used, especially in the East, by the sensualist, to excite the organs when exhausted by satiety and excess. Several of these remedies act on and stimu- late the urinary apparatus, and thereby give a temporary power to the function of erection; but they produce little or no effect on the special sexual organs. They act much in the same way as haemor- rhoids, affections of the prostate, and calculi in the kidney or bladder, the irritation of which often determines blood to the penis, and causes morbid erections without any voluptuous sensations or desires. Such appears to be the nature of the influence produced by cantha- rides, the most common of this class of medicines, and the chief OF THE TESTICLES. 325 ingredient of quack remedies for impotency. There are, however, feAV cases of defective sexual power in which the use of cantharides would be proper. In an atonic state of the organs, in which the erections are feeble, unstable, and insufficient, a small dose of the tincture of cantharides may be given every three or four hours for a short period before the occasion arises for the exercise of their functions. Bayle states that Leroy and Bouttatz experimented on themselves with phosphorus, and found that it produced strong ex- citement of the genital organs. The same was observed in animals to whom Leroy gave this remedy.1 Phosphorus seems to act much in the same way as cantharides, irritating and stimulating the uri- nary organs, and determining the blood to these parts, and no doubt its effects would be equally injurious in many cases of impotency. In certain atonic cases a trial may be made of phosphorus, in doses of gr. ^oth made into a pill with bread crumbs, and given three times a day, or at the periods indicated for the exhibition of cantha- rides. I have found the ergot of rye combined with quinine one of the best and safest temporary stimulants to the generative organs. Nux vomica is also in repute as a remedy in these cases, and I have given it in a few instances with apparent advantage. M. Trous- seau found nux vomica successful in impotence, but he noticed m some cases, that its effects, like those of other stimulating remedies, were manifested only whilst the patients were taking the medicine. A young man, twenty-five years of age, of an athletic constitution, who had been married for eighteen months without having any other than almost fraternal communications with his wife, acquired his virility under the use of nux vomica, though he again lost it soon after leaving off its employment.2 M. Duclos, of Tours, speaks highly of the efficacy of the alcoholic extract of nux vomica. He divides 75 grains into 100 pills, of which he gives one every night, gradually increasing the number every five days until three or four are taken night and morning.3 In addition to these remedies, sti- mulating liniments may be rubbed into the loins and nates. The condition to which these aphrodisiac remedies are applicable, is chiefly that in which the intromittent organ is but feebly excited, and does not maintain the physical state necessary for penetration, 1 Bibliotheque de The'rapeutique, torn, ii, p. 124. 2 Pereira's Materia Medica, 2d edit. vol. ii, p. 1305. 3 Bull, de Th6rap. t. xxxvi. 326 SPERMATORRHEA. or the period of congress. Such torpidity may exist in persons in whom desires are at times strongly felt, and the functions of the testicles properly performed. In these cases, also in timid persons, and in others whose organs are inexcitable from long disuse, stimu- lating treatment may conduce to success, and insure confidence for the future. But these remedies exert no animating influence in that apathy of the sexual faculty alluded to at p. 310. They also have rarely more than a temporary effect; and in persons advanced in life, when the parts, having fulfilled their office, are experiencing the natural decline, they operate injuriously, and, I believe, tend to produce congestion of the prostate, and local disease. In those cases, also, in which the sexual organs are weakened or prematurely exhausted by excess, they are likeAvise hurtful as well as fruitless. After such abuses, a period of repose is required, and by the avoid- ance of all sources of excitement, and by a diet and remedies adapted to invigorate the body, we may hope for a gradual restora- tion of the procreative functions. SECTION II. Spermatorrhea. It often happens that the passions are excited without an oppor- tunity being afforded for their gratification. The active secretion which takes place under these circumstances is sometimes attended with uneasy sensations in the testicles. In this state, the loaded ducts and seminal receptacles are relieved by ejaculations of the spermatic fluid during sleep. Nocturnal emissions occurring under these circumstances, and most continent persons in the vigor of manhood are subject to them, are followed by a sense of local relief and mental ease, and they thus appear to be a salutary provision to obviate the inconveniences which might arise from unsatisfied desires. The emissions may, however, be more frequent than is consistent with health, and too readily excited, so much so, indeed, as to affect virility, and to give rise to constitutional symptoms of a serious character. These excessive spermatic discharges constitute the complaint termed spermatorrhoea. This affection had attracted but little attention from the profession until the publication of Pro- fessor Lallemand's well-known work on the disease. His descrip- tion of its causes and symptoms is impaired by much bad taste and SPERMATORRHOEA. 327 exaggeration, but he has the merit of having recognized the true character of the complaint, and of having pointed out its injurious effects. Spermatorrhoea comes on very gradually. It commences by a precipitate emission of semen either in coition or during lascivious dreams. There exists a state of morbid irritability of the organs. The emissions consequently are premature, and without force, and the erections slight and incomplete, and soon subside. As the affection increases, the emissions become more frequent and more readily excited, and are induced merely by erotic ideas or the least contact or titillation, and take place without erection and without pleasure. In this weak and susceptible condition of the organs in- voluntary pollutions are liable to occur both day and night, consti- tuting a state of passive spermatorrhoea, which often lasts for many months, gradually undermining the health. The patient becomes thin, pale, and feeble; has impaired vision, and a sickly languid look ; suffers pains in the head and back; is hypochondriacal and apathetic, and unfitted for active bodily or mental occupation. He often experiences uneasy sensations in the testicles, which are soft, and hang low. The scrotum is pendulous and lax, and the sper- matic veins are sometimes large and varicose. His symptoms are aggravated after each emission, which is usually followed by a pain- ful sense of fatigue, and malaise, that last many hours. Spermatorrhoea may be induced in various ways. In persons of strong passions, Avho make no efforts to subdue them, but indulge in lewd thoughts or in erotic conversation and reading, the testicles are stimulated to active secretion, and if no relief be afforded by commerce with the other sex, emissions are liable to become fre- quent, and the habit being established, the parts get weakened and irritable, so that the discharges occur under slight provocation. The complaint may also be brought on by excessive indulgence in sexual intercourse. But its most common cause is long-continued and frequent self-abuse, those who give way to this vicious habit being little aware of the evils it engenders. The practice occasion- ally acquires a complete mastery over the reason and will. In some cases not even the strongest self-control can repress the disposition to abuse ; and persons fully aware of the evil results, and actually dreading the consequences, are unable to restrain their fatal desires. In these cases there is a peculiar morbid condition of the nervous 328 SPERMATORRHEA. system. Indeed, the debilitating and enervating effects of this affection are far greater than would be occasioned merely by a drain of the amount of the fluid emitted, which is to be ascribed to the nervous exhaustion especially attending the reproductive function. The patient's mind is constantly absorbed with his sufferings ; he gives an exaggerated account of his symptoms, finds great difficulty in abstracting his attention from them, and occupying himself with other matters, and eagerly peruses anything relating to his com- plaint ; a circumstance well known to the empirical authors, who are constantly advertising their works on the subject. The condition of these persons is melancholy enough. Aware of the abhorrence with which their practices are regarded, they hesitate to consult the regular practitioner, and fly for relief to ignorant but artful quacks, by whom their pecuniary resources are drained, for which they only meet in return with bitter disappointment. Such is the heavy penalty often paid by man for gross indulgence in sensuality—a degraded nature and a ruined constitution imbittering the best days of his existence, and sometimes even leading to insanity or suicide. One of the sad results of habitual self-abuse and excessive sper- matorrhoea is a morbid condition of the brain, giving rise to epi- leptic symptoms. In most cases it will be found that the cerebral affection had existed previously, but had become confirmed and aggravated under the excitement and nervous exhaustion conse- quent on the practice. In others the epileptic paroxysms appear to be caused solely by excessive masturbation. The matter emitted in spermatorrhoea is thin, and more liquid than healthy semen; but that it is really spermatic is proved by the spermatozoa which it is found to contain. Lallemand, who carefully examined the fluid voided in all stages of the complaint, found the zoosperms less abundant, and less developed and lively, in proportion to the severity of the disease, until at length in very advanced cases they almost entirely disappeared. The discharge is largely diluted with the secretions of the vesiculse seminales and prostate; and in bad cases of the complaint the fluid emitted con- sists almost entirely of the latter, mixed with purulent matter, and sometimes a little blood. Occasionally the spermatic fluid, and even the prostatic secretion, pass into the bladder and mix with the urine, with which they are voided. Directions have been given for distinguishing the semen under these circumstances, but they SPERMATORRHEA. 329 are not to be depended on; and the only sure mode of ascertaining the existence of semen in the urine is a microscopic examination of the fluid in order to detect the spermatozoa. In cases of this dis- order there is often an escape of spermatic fluid with the last drops of urine in micturition. A similar discharge also occurs in defeca- tion, being occasioned by the pressure on the vesiculse. In some cases this only attends a costive evacuation, but in others is of con- stant occurrence. Although this complaint is usually considered and treated as a functional derangement, there are few cases in which the parts re- main long in a perfectly sound state. It will be found that the patient experiences a frequent desire to void his urine; that the evacuation is sometimes attended with slight scalding; that he occa- sionally feels pain and heat in the prostatic part of the urethra; and that if a bougie or catheter be introduced as far as this por- tion of the canal in the most gentle manner, it causes a sharp pain, and sometimes strong spasmodic contractions, the instrument being at the same time grasped in the canal. The prostatic and mem- branous parts of the urethra are indeed in a state of morbid irrita- tion ; and I believe that the increased secretion of the testicles, the hasty ejaculations, and inordinate desire for sexual indulgence or self-abuse very greatly depend on this morbid condition of the mucous membrane. Nor is it surprising, considering how much this part of the urethra is concerned in the function of generation, that a permanent state of disease should be produced by the fre- quent excitement of sexual excesses. Involuntary spermatic dis- charges are sometimes induced by gonorrhoea affecting the prostatic part of the urethra. Their origin has also been ascribed to certain affections of the prepuce and of the rectum and skin ; but these are quite secondary causes, and are incapable of producing involuntary emissions without a more direct source of excitement, or a state of morbid irritability at the orifices of the ejaculatory ducts. I know of no instance in which an opportunity has been afforded of making an anatomical examination of the parts affected in the early stage of the complaint. Lallemand examined them in two very severe and complicated cases of the disease, in which the patients labored under symptoms of cerebral congestion before death. I also carefully dissected them in an aggravated case, in which the patient was comatose for several hours previous to dissolution. 330 SPERMATORRHEA. In all three the morbid appearances were of the same character. The mucous membrane at the prostatic part of the urethra Avas swollen and injected. The prostate was nearly destroyed, and con- verted into a multilocular abscess, or a number of alveolae or cells, communicating with each other; and the diseased mucous membrane covering it was riddled with holes, formed by a considerable en- largement of the original orifices of the gland, through which pus or altered secretion freely escaped on pressing the prostate. As Lallemand aptly remarks, the membrane at this part covers the multilocular cavity of the prostate, much in the same way as the cribriform plate of the ethmoid bone covers the nasal fossa in the dried skull. One or both vesiculge seminales were infiltrated with pus, and their walls thickened by inflammation. The orifices of the ejaculatory canals were enlarged and abraded. When the pros- tate is affected, slight pain is occasioned by pressing on it through the rectum, and there is usually a discharge from the urethra when the patient is at stool. The morbid condition of the mucous membrane of the prostatic part of the urethra, though not the original cause of spermatorrhoea, when established, tends materially to excite both the excessive semi- nal discharge and the secretions of the prostate, and to produce that morbid craving for indulgence and abuse which persons who have brought themselves to this state find so difficult to repress and resist. It is Avell known that any irritation at the orifice of an ex- cretory duct usually acts as a stimulus to the secretions of the gland. Thus hurtful matter in the duodenum produces a flow of bile ;■ and a foreign body on the conjunctiva, as an inverted eyelash, a discharge of tears. So it is Avith the testicle when irritation exists at the orifices of their excretory ducts. The disorder at this part, moreover, appears to react on the brain, and to become in part the cause of the patient's mind being constantly occupied with subjects of sexual excitement, and of his indifference and apathy in respect to other matters. So that the local disease induced by abuse power- fully aids in perpetuating the mischief, and consequently becomes the object to which, in many instances, our treatment should be first directed. Certainly, in severe and confirmed case3, until the morbid condition of the mucous membrane of the urethra is cor- rected, we can scarcely hope to relieve the seminal emissions, or to recruit the patient's health and strength ; and when it is removed, SPERMATORRHEA. 331 there is far less difficulty in inducing him to abandon his injurious habits, and in improving his general condition by other treatment. In some persons there appears to be a predisposition to this com- plaint, which is indicated by feeble sexual powers, irritability of the bladder, and incontinency of urine in early life. It is necessary to remark, that in persons whose constitutions are suffering from frequent seminal emissions, it is not always easy to ascertain the real cause of impaired health. Either from not sus- pecting it, or unwillingness to confess, patients are apt to refer their complaints to anything but the true cause. They complain of indigestion, palpitations, pains in the head, and other anomalous symptoms, but neglect to mention the emissions; so that some tact and cautious inquiry are often necessary in order to discover the nature and source of the malady with which they are afflicted. There is something, however, in the appearance and bearing of many of these persons,—their shy and furtive glance, pallid and pasty complexion, want of frankness and incoherent account of their symptoms,—which generally enables the. practitioner to form a shrewd guess as to the true cause of the mischief. In a great proportion of the cases which come under notice in practice, the complaint is extremely slight, or more mental than real. The ability to perform well the duties of the sex is a matter of such concern to most men, that it is not surprising that timid or weak persons, misled by artful advertisements and empirical works, should sometimes be troubled Avith unfounded fears, and fancy that they are incompetent and laboring under spermatorrhoea when no such disorder exists. The minds of these persons are usually more or less unhinged by dyspepsia, and the discharges natural in health are regarded as morbid. They are reminded, in the writings alluded to, of having once practised the foolish habits common in schools, and too little restrained by teachers, but which have been long abandoned and have left no permanent ill effects. I have met, indeed, with men, even of great intelligence, who have been so im- pressed with the conviction of being seriously affected with sperma- torrhoea, and Avho have been so unhappy in consequence, without any real cause, that their condition has amounted almost to mono- mania. Care is required in dealing with these cases. Medical men are too apt to treat the complaints of such patients lightly, making no efforts to allay their anxiety—a course which often leads them 332 SPERMATORRHEA. to apply for aid in illegitimate quarters, and to become the victims of unprincipled men. The surgeon should endeavor to obtain the patient's confidence, and whilst paying due attention to his gene- ral health, should strive to convince him of the groundless nature of his fears, and of the unimportant nature of his local complaint. Solitary abuse is sometimes practised in infancy; and cases have come to my knoAvledge in which it occurred at the early age of between three and four years. The sexual organs were not pre- maturely developed, but in one of them the child had passed a small calculus. The vice has been ascribed to the irritation pro- duced by worms in the rectum; but I believe it is more often in- duced by the foolish habits of children and their associates. Though little fluid is emitted, the practice is very injurious to the constitu- tion by its effects on the nervous system, and prevents the develop- ment of the sexual powers. As in the adult, it produces a morbid sensibility and condition of the urethra, which is to be treated on the same principles. Treatment.—The treatment proper in spermatorrhoea varies greatly in different cases, depending much upon the patient's mental condition, physical powers, and general state of health, as well as upon the cause, degree, and duration of the complaint. In slight and recent cases connected with dyspepsia, attention to diet and remedies which correct the unhealthy actions of the alimentary canal, and medicines taken at bedtime to relieve or prevent acidity during the night, coupled with cold bathing and active exercise, will be sufficient to stop the frequent discharges. When the complaint occurs to persons of depressed vital poAvers, and is accompanied with deposits of the phosphates or oxalates in the urine, diet of a tonic character, quinine with acids and tincture of henbane, relief from mental toil, exercise without fatigue in a pure dry air, and in some cases an opiate at bedtime, are the remedies calculated to give relief. Indeed, in the class of cases alluded to, the spermatic dis- charges are only symptoms of general derangement to which the patient has ascribed undue importance ; and as the health improves under treatment, the discharges become less frequent and less a source of anxiety. When the complaint is slight or chiefly mental, and unattended with weakness or impairment of the general health, the most effec- tual remedy is moderate but regular sexual intercourse. It tends SPERMATORRHEA. 333 to correct the irritable condition of the' organs giving rise to pre- cipitate ejaculation, and removes the disposition to self-abuse. There are some obvious difficulties in the way, and persons who have never ventured on connection, or have failed in the attempt, have to overcome the apprehension of incapacity. In robust per- sons avIio remain continent, but do not exercise sufficient restraint on their thoughts, athletic exercises, active occupations of various kinds, indeed any engrossing pursuit, will materially assist the cure. One patient, a gentleman of great intelligence but without occupation, assured me that his recovery was greatly promoted by his engaging in the study of chemistry, to which he applied him- self with great zeal. In some cases, certain sedatives, such as lupulin, camphor, and henbane, may be taken at bedtime with advantage. They quiet the mind, promote repose, and allay irri- tability in the sexual organs. In cases of spermatorrhoea, slight but of some duration, and in- duced by abuse, the local irritation and morbid state of the pros- tatic part of the urethra may generally be corrected by the occa- sional introduction of a plated steel sound. I usually employ one of the size of No. 10, pass it very gently about once a week, and retain it in the canal for five minutes. Its influence may be aided by the cubeb powder. In persons of feeble or impaired constitu- tion I give it with the compound infusion of roses and dilute sul- phuric acid, and often combine the sulphate of quinine. Or I pre- scribe the tonic medicine for the day, and order at bedtime a draught containing two scruples of cubeb powder, five grains of carbonate of ammonia, and half a drachm of tincture of henbane. In persons Avhose general health remains sound I often give small doses of the bicarbonate of potass with the cubebs three times a day. Under this treatment, variously prolonged and modified, the morbid condition of the prostatic part of the urethra is corrected, the health improves, the discharges become less frequent, and cease to occur without erection or to be a source of weakness. At this period, moderate sexual intercourse contributes to the patient's permanent recovery, and prevents a return to bad habits, though in the earlier stages of treatment it is improper. In bad and confirmed cases of this disease the local application of the nitrate of silver is the most effectual means of restoring the prostatic part of the urethra to a sound state. It allays the mor- 0 0,| oo-t SPERMATORRHEA. bid sensibility and corrects the altered condition of the membrane and orifices of the ejaculatory canals, and thus arrests the excessive secretions of the testicles, vesiculae, and prostate. The nitrate of silver when applied to the diseased part of the urethra, appears to act on the seminal vesicles and follicles of the prostate gland, very much in the same way as a stimulating application to the con- junctiva of the eye relieves a morbid condition of the membrane of the nasal sac or duct by being absorbed at the puncta lachrymalia. The dissolved caustic entering at the enlarged orifices at the sides of the veru montanum thus reaches the interior of these glands. The beneficial effects of the nitrate of silver in this affection appear to have been known to Sir E. Home, who, in his work on Stric- tures,1 has recorded two cases of seminal emissions consequent upon onanism, which were much relieved by the application of the armed bougie. His mode, however, of using this remedy was very defec- tive ; and the plan of treatment does not seem to have been fol- lowed by other surgeons in these particular cases. It is to Lallemand that we are indebted both for showing the value of the caustic treatment of this complaint, and for devising an improved instrument for making the application. Lallemand's instrument consists of a slightly-curved platina canule or tube, rather smaller than a middle-sized catheter (Fig. 44, 1, a), through which plays a caustic-holder, having at its fur- ther extremity a narrow groove, eleven lines in length (b), for the purpose of receiving the caustic. After filling the groove Avith the nitrate of silver by fusing it over a spirit lamp, the caustic be- comes so securely fixed that there is no danger of its escaping. At the other end there is a sliding screw or stop (c), by which means the application of the caustic may be limited to any extent less than the length of the groove which contains it. In employing this instrument I proceed as follows:—Having regulated the caus- tic-holder so as to admit of nearly the whole of the groove being uncovered, and having closed the instrument so as to con- ceal the caustic (Fig. 44, 2), I introduce it well oiled as far as the prostatic part of the urethra, its arrival there being easily ascer- tained by the pain experienced by the patient, and by my being able, after the instrument is depressed and has passed the trian- gular ligament, to carry it freely onwards. I then thrust forAvards 1 Vol. ii, p. 427. SPERMATORRHEA. 335 Fig. 44. A the caustic-holder, and after passing it once or twice backwards and forAvards instantly close the apparatus, and then withdraw it. The dissolved caustic readily reaches all the parts to Avhich the application is required. Other forms of instrument for applying the nitrate of silver have been suggested and recommended, but I have found none more convenient or better adapted to the purpose than Lallemand's. It is important that the knob at the extremity of the caustic-holder should be of sufficient size to project beyond the canule, or else the mucous membrane is very liable to be caught at this point in the closing of the instrument, and a portion of the membrane to be stripped off in its re- moval from the canal. When used in the transient manner I have just described, the caustic occasions a sharp smarting sensa- tion, which subsides, however, in about ten minutes. On making water afterwards the patient experiences scalding, and usually passes a little blood with the last drops of urine, and sometimes has a slight purulent discharge, which continue for twenty-four or thirty-six hours, and then gradually cease. If much pain or retention of urine should result from the application, it may be relieved by a warm hip-bath, and opiate suppositories or injections. I have never found the caustic produce so much hemorrhage and such severe symptoms as are described by Lallemand occasionally to arise from it, which I attribute to the more gentle manner in which the application is made. The only instance in which retention of urine has occurred, in my practice, was in the case of a gentleman who neglected my injunction to remain at rest after the operation, and he was instantly relieved on taking a warm bath. The patient should remain quiet at home for tAventy-four 336 SPERMATORRHEA. hours, and take - no walking exercise, or malt liquor or wine, until after the slight bleeding has quite ceased. I usually order, for a night or two after the operation, some opium or henbane to procure rest and allay irritation, and order the patient to take freely of demulcent drinks. In general, the emissions gradually cease to be too frequent, and to occur without erections, after one or two applications of the caustic: I have rarely had occasion to repeat it a third time. Indeed, if the remedy does not succeed in giving tone to the parts, and in checking the discharges after one or twro applications, they are not likely to be removed by more frequent renewal. The cauterization should not be repeated sooner than a month or six Aveeks. It is impossible to judge fairly of its effects in a shorter period, and I most commonly Avait three months. In all cases, I pass, after a few weeks, a No. 10 sound, in order to satisfy myself that the canal has not been injured by the treatment. In the many cases in which I have used the caustic, with two exceptions, I have never observed any subsequent ill effects which could be ascribed to the remedy. In the exceptional cases alluded to, a stricture formed at the membranous part of the canal. In one, the contraction was extremely slight and yielded readily to dilata- tion. In the other, the contraction Avas closer, and the passage of sounds was required for six weeks, but the stricture was at length quite cured, and was found to have remained so six months after the dilating treatment had ceased. Since the publication of Lallemand's work, the caustic has been extensively resorted to in spermatorrhoea, but much difference of opinion exists in respect to its value. It is regarded by some sur- geons, who have never tried it, as a remedy worse than useless, and others who had employed it, expecting perhaps too much, have been disappointed. This discrepancy is not surprising when we consider that the caustic treatment has not only been unduly extolled, but has been used in unfit cases, as well as too freely and too fre- quently. In the cases in which I have recently resorted to this treatment, it has rarely failed to afford more or less relief. The caustic must not, however, be expected to operate like a charm. The irritation which it produces sometimes even increases the emis- sions for a time, and it is only as the parts recover from its first effects that any benefit is manifested. Nor does the caustic super- SPERMATORRHEA. 337 sede other treatment. It must be viewed as only one of the means necessary in certain cases for the cure of the complaint. Seda- tives, tonics, and moral treatment are required to assist its action, or confirm the good effects obtained from it. But, it must be admitted, that the caustic is an uncertain remedy, and those who reckon too confidently on its favorable influence will sometimes meet with disappointment. In many cases it acts with marked benefit; whilst in others but little, if any, advantage is derived from it. It need scarcely be added, that no method of treatment is likely to be successful or permanent, without the most rigid and persevering abstinence in respect to the exciting causes of the complaint. All subjects capable of exciting erotic ideas should therefore be strictly avoided; and it must be recollected that a relapse is readily induced by the least imprudence or excess. Per- sons suffering from spermatorrhoea are often recommended to marry. In severe cases of the complaint this advice is not only unsound, but actually injurious ; and if followed, which I believe rarely happens, would be a cause of much misery. Persons thus affected are by no means in a condition to enter the marriage state ; they are in fact impotent; and nothing is more calculated to aggravate their complaints and impede recovery, than the exciter ment of the sex and fruitless attempts at sexual indulgence. The indications afforded in these cases are, to arrest the debilitating dis- charges ; to obtain a period of rest during which the parts may recover their tone, the health may be reinstated, the constitution invigorated, and the appetite recalled by abstinence. When this is effected, but not till then, marriage is desirable, as it takes away the temptation to solitary vice, and is favorable to regularity and moderation in the performance of the reproductive functions, and thus obviates the tendency to a relapse. As the local affection subsides, we must have recourse to remedies to improve the general health. Thus steel medicines, quinine, cold bathing, a nutritious but not stimulating diet, due regulation of the bowels, change of scene and exercise in an open pure air, and cheerful occupation, prove very beneficial in these cases. Solutions of the nitrate of silver and stimulating ointments have also been applied to the prostatic part of the urethra by means of instruments constructed for the purpose. I have tried them in a few cases, but have found them less effectual than the solid caustic. 22 338 SPERMATORRHEA. There are certain remedies which are reputed to have a special influence in checking atonic spermatorrhoea. M. Duclos reports strongly in favor of the extract of nux vomica (see formula at p. 325), combined with frictions on the loins and inner and upper part of the thighs with a stimulating liniment. The ergot of rye has also been recommended in these cases, in doses of a quarter of a grain night and morning. Mechanical contrivances to prevent patients sleeping on the back will sometimes help to arrest the night discharges. In some cases the removal of an elongated prepuce has been attended with a good effect. In lads addicted to mastur- bation this operation is very effectual. It at once breaks the habit, which, in many instances, is not afterwards renewed. Persons troubled with seminal emissions which no effort of the will can prevent their provoking, or which persist in spite of medical treatment, have in some instances been solicitous for the removal of the testicles, to get rid of the disgusting complaint; and indivi- duals have even been known to perform the operation of castration on themselves.1 Some years ago I received from a patient thus affected two letters urgently requesting me to remove his right tes- ticle, his left having been extirpated by a surgeon some time pre- viously. This man refused to submit to any other treatment for his complaints, being impressed with the idea that this operation was the only remedy that could relieve him. He was a patient of the late Mr. Avery, who, as well as myself, was teased with re- peated solicitations to castrate him ; and he at length succeeded in inducing a surgeon to perform the operation. Castration is not justifiable in any case of mere involuntary seminal emissions ; nor is any surgeon warranted in complying with the unreasonable wishes of a monomaniac. Unless important organic changes have taken place in the genito-urinary organs, the affection is certainly remediable by judicious treatment steadily pursued; whilst the ope- ration of castration, even if effectual in relieving the symptoms, would leave the patient in a state of mutilation which might after- wards prove a source of the most bitter regret. I have been in- formed by a professional friend of a case in which double castration was performed, at the urgent request of the patient, on account of most distressing self-pollutions, that had a very lamentable result. The patient, a gentleman in the upper ranks of life, committed » 1 Several cases of self-castration are related in Chap. Ill, Sect. II. CASTRATION. 339 suicide ; and the surgeon, who had been rash enough to emasculate him, was threatened by the patient's friends with an action at law for performing so unwarrantable an operation. CHAPTER XIX. CASTRATION. Castration, or excision of the testicle, is an operation of great antiquity, and was formerly one of the most common in surgery. Even at the present day it is frequently performed by the barbar- ous people of the East to deprive their slaves of manhood; but this cruel practice is now rarely resorted to in Europe, except for the remoA'al of disease, being uncommon even in Italy, Avhere it was once frequently performed on account of its effects on the vocal organs. The diseases which may lead to the necessity for castration are the different forms of carcinoma, incurable struma, abscesses and tedious sinuses consequent on inflammation, and cystic disease. The circumstances under which the operation is admissible in these various diseases have already been considered. Castration is an operation simple, easy of performance, and nearly free from danger ; but painful, owing to the large number of nerves and great sensibility of the parts incised. Patients generally prefer, therefore, being rendered insensible by chloroform. The hair must be first cleanly shaved off from the pubes and scrotum. The only instruments required are a straight bistoury or large scalpel, a pair of forceps, tenaculum, and curved needles armed with ligatures. The patient is to recline upon a table of convenient height, and the operator is to place himself on the right side ; or he may seat him- self between the patient's legs. An incision is to be made from about half an inch below the external ring, along the front of the tumor to the bottom of the scrotum. The envelopes of the cord and testicle, the layers of thickened fasciae, and the cremaster muscle are then to be freely divided, nearly as high up as the abdominal ring. If this part of the operation be interrupted by bleeding from any of the branches of the external pudic artery, it will be well to 310 castration. secure them with ligatures. In detaching the diseased gland from the scrotum, the surgeon may employ traction, so as to lacerate the connective tissue. In chronic cases of disease, this tissue is often too condensed and thickened to admit of being thus torn: and in nearly all instances the dense adhesion between the lower part of the testicle and the scrotum requires division Avith the knife. When the tumor is of large size, care is necessary to avoid wounding the urethra and corpus cavernosum, and also the opposite gland, which should be drawn aside by an assistant. As soon as the spermatic cord is detached from the surrounding parts and fully exposed, it is to be grasped between the finger and thumb of an assistant to prevent its retraction within the inguinal canal after being divided, and it is then to be cut across by a single stroke of the knife. Some surgeons are accustomed to secure the cord by passing a tena- culum or needle and ligature through it; a plan which need only be adopted when it is necessary to divide the cord very high up, as in general the fingers of an assistant are sufficient for the purpose, and give less pain and produce less disturbance of the parts than the other method. The arteries of the cord can now be secured. The spermatic artery is soon found, and is to be tied separately. The • artery of the vas deferens must next be sought for near the duct, and also tied. This vessel is so small that it is not always appa- rent ; but the surgeon should endeavor to secure it, as it is some- times the source of a troublesome hemorrhage after the conclusion of the operation. The vessels of the scrotum are next to be tied ; if the tumor be large, or the disease of long standing, they are likely to be numerous. The ligatures attached to the cord being carried to the upper angle of the wound, the divided edges are to be brought together by three or four sutures or more, according to the length of the incision. Strips of plaster are not sufficient, as the natural contractility of the scrotum tends to separate and evert the edges of the wound. Its closure is to be completed by a com- press of lint retained by plaster and a T bandage. The wound usually heals in from fourteen to twenty days. There are some few circumstances of importance to be attended to in this apparently simple operation, and certain modifications are sometimes required. The operator should be careful to carry the first incision to the lowest part of the scrotum, as by this means he not only facilitates the detachment of the tumor, but afterwards CASTRATION. 341 prevents the bagging of matter in the scrotum. If the gland be of very great size, or if the skin be adherent to it and diseased, it will be advisable to remove a portion of the scrotum. Instead, there- fore, of a single straight cut, two lunated incisions should be made, so as to include an oval piece of the integuments. By this means, if the skin be adherent, a tedious dissection is avoided; or, if the tumor be very large, the inconvenience of a bag of useless integu- ment may be obviated: the hemorrhage, also, will be less; and the vessels requiring ligatures will not be so numerous. It must be borne in mind, however, that the scrotum contracts so much after the removal of its contents, that in tumors of considerable size there is seldom a necessity to excise any portion of the integuments. In the excision of such tumors the drawing up of the cord after its division is liable to become a source of embarrassment and delay. The retraction is usually ascribed to the action of the cremaster ; but as the greater part of this muscle, together with the organ upon which its action is exerted, is cut off at the division of the cord, the retraction must be chiefly due to the elasticity of this part, so that, after the cord has been relieved of the Aveight of the enlarged tes- ticle by which it was dragged doAvn, it recovers its former position. The surgeon should take care to divide the muscular and fascious envelope of the cord before cutting it across ; as, if this be neglected, some difficulty is likely to be experienced in tying the vessels after its division. In cases in which the cord has retracted within the abdominal ring, the surgeon has been obliged to divide the tendon of the external oblique muscle, in order to get at the bleeding ves- sels. In a case Avhich came under the observation of Sir A. Cooper, the bleeding from the vessels of the retracted cord was so profuse, that the operator was convinced he had wounded the iliac artery, and unfortunately proceeded to place a ligature on that vessel. The patient died the day after the separation of the ligature. The iliac artery, though not wounded, had been tied securely enough; but the vessels of the cord, the source of the hemorrhage, had been neglected. Mr. Benjamin Bell mentions two instances of patients having lost their lives from hemorrhage, in consequence of retrac- tion of the cord before the vessels were properly secured.1 This ought never to happen; for the bleeding arteries may always be reached by laying open the inguinal canal. But this proceeding 1 Treatise on the Hydrocele, &c. p. 265. 342 CASTRATION. increases the dangers of the operation, in consequence of the proxi- mity of the peritoneum. Mr. Fergusson mentions a case in which the operator had to pursue the vessels into the canal; inflammation within the abdomen ensued, and carried the patient off within three days.1 When the vessels of the cord are not properly secured, and afterwards bleed, the connective tissue becomes so infiltrated with blood that the surgeon not only experiences great difficulty in find- ing the bleeding vessel, but the disturbance occasioned by the effusion is liable to induce inflammation and suppuration; and abscesses from this cause have been known to extend to the iliac fossa. It was formerly the practice to arrest the bleeding from the arteries of the cord by tightly tying all the parts composing it in a single ligature. This rude proceeding, by compressing the sper- matic nerves, occasioned severe suffering and inflammation, and sometimes was the cause of tetanus. It was consequently pretty generally abandoned, though I find it is still recommended in the removal of the testicle when affected with malignant disease, on the ground that it enables the surgeon to divide the cord higher up than he otherwise could. A case, however, in which the disease had extended so far up as to need a high division of the cord would scarcely be fit for an operation. Unless care be taken, the operation of castration is liable to be succeeded by secondary hemorrhage. In morbid enlargements of the testicle the scrotal vessels as well as the spermatic undergo con- siderable increase in size, and pour out blood freely when divided. Mr. Sharp castrated a man whose testicle weighed above three pounds, where some of the vessels were so exceedingly varicose and dilated as nearly to equal the size of the humeral artery.2 I have myself found the spermatic artery of a testicle Avhich was removed in consequence of its being affected with malignant disease, as large certainly as the radial artery at the wrist. From exposure to the cold atmosphere and the corrugation of the skin, or in consequence of the patient becoming faint, the bleeding from many of the vessels of the scrotum often stops in the course of the operation; but as soon as the patient becomes warm in bed, and the scrotum relaxes and the circulation is restored, the vessels again begin to pour out blood. On this account many surgeons prefer waiting an hour or 1 Practical Surgery, third edition, p. 762. 2 Treatise on the Operations of Surgery, p. 52. CASTRATION. 343 two after the patient has been put to bed before closing the wound, in order to insure him from so unpleasant and painful an occurrence as the disturbance of the dressings and reopening the wound to arrest a secondary hemorrhage; and this precaution I should ahvays recommend, whenever vessels particularly large and numerous ap- pear to cease bleeding from the effects of syncope or cold. Gentle pressure on the scrotum by a dossil of lint applied over the wound, and retained by strips of plaster or a bandage, is usually, how- ever, sufficient to prevent a return of hemorrhage. There is cer- tainly less bleeding from the vessels of the scrotum when the con- nective tissue has been lacerated, than after it has been divided with the knife. In one case, in which I operated in this way, although the testicle was of considerable size, not a single scrotal vessel required ligature, and there was no after-hemorrhage. There is a very rapid mode of performing castration which an- swers very well when the diseased testicle requiring removal is quite small in size. The surgeon, grasping the gland in his left hand, and dragging it forwards so as to put the integuments on the stretch, may excise it with one stroke of the catlin. The Aressels are then to be secured, and the wound closed with sutures. The disease of the testicle requiring castration may be compli- cated with scrotal hernia. In such a case the parts must be re- turned, if possible, into the cavity of the abdomen, and protrusion prevented during the operation by the fingers of an assistant; and the surgeon should carefully endeavor to dissect away the cord with- out wounding the hernial sac. In one case of extirpation of the testicle, Sir E. Home relates, " After the operation was completed, and the wound dressed, the patient being seized with a fit of coughing, to the astonishment and dismay of the surgeon, the dressings were forced off by a protrusion of several convolutions of small intestines: from this it was proved that the patient had had a hernia; but the diseased enlargement of the testicle had acted as a truss, and prevented the rupture from coming down."1 If the diseased gland be of great size, the prac- titioner will do well to satisfy himself respecting the existence of hernia before commencing this operation, as it is liable to be over- looked. On removing a large carcinomatous testicle, I accidentally opened, on dividing the spermatic cord, a hernial sac containing a 1 Observations on Cancer, p. 236. 344 CASTRATION. small piece of omentum, of the existence of which I was not aware. A compress was applied at the groin, and no ill effect resulted: the patient recovered favorably. Dr. Wedemeyer, of Hanover, removed the left testicle of a patient who had also, on the same side, a re- ducible scrotal rupture of considerable magnitude. The rupture, which was reduced at the time of the operation, did not subse- quently protrude. Considerable inflammation supervened after the operation; and it is presumed that the descent of the intestine was prevented by adhesions formed during its process in the track through which the rupture had originally passed.1 Several instances in which a testicle retained in the ino-uinal canal has become so diseased as to lead to the necessity of castra- tion are on record. Mr. Pott mentions a case of diseased testicle in the groin successfully removed by operation at St. George's Hos- pital.2 In 1823, Manzoni, of Florence, extirpated a cancerous tes- ticle retained within the abdominal ring. A similar operation was shortly afterwards performed at Pisa for the removal of an enor- mously enlarged cancerous testicle, and the canal was laid open even into the abdomen. The patient recovered from the operation; the disease, however, returned in the glands of the mesentery, and he died two years afterwards from the relapse.3 Professor Naegele extirpated an enlarged and diseased testicle from the left groin of a man twenty years of age. The peritoneum was wounded, and a portion of epiploon protruded. The man survived the operation ; but the disease, which is said to have been carcinomatous, returned a month afterwards at the cicatrix of the wound.4 The excision of a testicle detained in the groin and affected with encephaloid cancer has been performed in London, in late years, by Mr. Arnott, at the Middlesex Hospital,5 and by Mr. Robert Storks, of GoAver Street.6 In both instances, the enlarged gland was re- moved without opening a communication with the abdomen. In Mr. Arnott's case, the patient proceeded favorably up to the twelfth day, 1 Journal ftir Chirurgie, band ix, stuck 1; as quoted in London Med. and Phys. Journal, vol. lvi, p. 482. 2 Lib. cit. 4to edit. p. 356, Case III. 3 Fragments d'un Voyage MSdicale en Italie, par T. J. E. Petrequin; Bulletin M6dicale, Beige, Juin, 1837. 4 Quoted from a German Journal in Archiv. Gen. de Me'decine,t. xiii, p. 423, 1837. 5 Medico-Chirurgical Transactions, vol. xxx, p. 9. 6 London Medical Gazette, vol. xxxix, p. 101. CASTRATION. 345 Avhen he was attacked with erysipelas of the face and head, of which he died in three days. On examination, a small deposit of ence- phaloid substance was found on the right spermatic cord just within the inner ring, and a large mass in the root of the mesentery, which, owing to his being fat, had not been detected during life. In Mr. Stork's case the patient survived the operation fourteen months, when he died of the same disease developed to a great extent in the abdomen. The excision of a diseased testicle from the groin, even when the tumor is of large size, is not a difficult proceeding. But in conse- quence of the obscurity of the diagnosis, which is much increased by the situation of the gland, the operation, in the first instance, must be simply exploratory. The incision should be made in the same direction as in operating for inguinal hernia, but a little higher up. The tendon forming the anterior boundary of the canal might be divided upon a director introduced at the ring, so as to expose the diseased gland. The surgeon, having opened the tunica vaginalis, would then proceed according to circumstances. The danger is certainly greater than after the excision of a testicle from the scrotum, owing to the liability of wounding the peritoneum, opening a vaginal sac communicating with the abdomen, or inter- fering with a testicle adherent to intestine or omentum. A dis- eased testicle, therefore, in this position is unfavorably situated for an operation, especially if the subject of malignant affection, since it would be impossible to determine beforehand with any degree of accuracy, to what extent the disease had reached. In Mr. Arnott's patient there was evidently carcinomatous disease in the abdomen at the time of the operation. I have remarked that castration is not, under ordinary circum- stances, a dangerous proceeding. I have performed and witnessed about thirty operations, and not one of them terminated fatally. In a table of operations performed at the Hotel Dieu,1 it appears there were five deaths in twenty-nine cases of castration, being in the ratio of 1 in 4 J, which is certainly a high rate of mortality for this operation. In the first edition of this work I gave to C. J. Maunoir, of Geneva, the credit of having first proposed an operation for the cure of sarcocele, without recourse to the excision of the testicle. 1 Gazette MeU de Paris, Dec. 17, 1842. 346 CASTRATION. The operation consists in cutting down upon and tying the sper- matic artery, and thus interrupting the supply of blood to the dis- eased organ. In making this statement, I was not aware that our immortal countryman, Harvey, had not only suggested this opera- tion, but had successfully performed it.1 Maunoir has detailed two cases in which he adopted the practice with the effect of producing wasting of the enlarged gland.2 I know of no forms of morbid en- largement to which the operation is properly applicable. In in- tractable diseases of the gland with an open sore, castration would be preferable ; as cutting off the supply of blood would not assist in healing the wounds, and in malignant affections such an operation would be quite out of the question. 1 Vide Anatomical Exercitations concerning the Generation of Living Creatures, English edition, 1653, p. 113. 2 Nouvelle Me"thode de traiter le Sarcocele sans avoir recours a. l'extirpation du testicule. DISEASES OE THE SPERMATIC CORD. CHAPTER I. VARICOCELE. The term varicocele is sometimes applied to designate a varicose enlargement of the veins of the scrotum, whilst the term cirsocele is used to denote a varicose state of the veins of the cord and tes- ticle ; but as the scrotal veins are not subject to a degree of en- largement amounting to disease, it is more usual to restrict the term varicocele to a morbid dilatation of the spermatic veins. On dissecting the spermatic veins when varicose, they are found dilated, elongated, and more tortuous than natural, and apparently more numerous, owing to the enlargement of the smaller vessels. In an advanced stage of the disease, their coats are thickened; so that when divided the vessels remain patent, and thus present the appearance of arteries. The enlarged veins hang down below the testicle, and reach upwards into the inguinal canal; and when very voluminous conceal the gland, encroach on the septum, and extend to the other side of the scrotum. In a specimen which I carefully dissected, the vessels were arranged in three clusters (see Fig. 45). One formed of the larger vessels proceeded from the inferior ex- tremity of the testicle ; the second, in which the vessels were less in size, but more numerous and tortuous, arose from the upper ex- tremity of the organ; whilst the third and smallest cluster sur- rounded and accompanied the vas deferens (1). The dilatation is not confined to the \reins exterior to the testicle: even those in the gland itself are varicose, and enlarged veins may often be 348 VARICOCELE. Fig. 45. distinctly seen ramifying between the tunica vaginalis and tunica albuginea. The veins occasionally contain phlebolites, Avhich are lodged in round dilatations of the ves- sels. The veins of the left testicle are more subject to varicocele than those of the right. In upwards of 120 operations per- formed by Breschet, in only one instance was the varicocele on the right side.1 Pott met with this disease on both sides of the body in only one case. The dis- ease, however, is far from being so rare on the right side as is generally supposed, and often exists on both at the same time, although the varicose state of the right spermatic veins is nearly always much less than that of the left. Of 3911 re- cruits rejected for varicocele in Great Britain and Ireland during the ten years ending 31st March, 1853, 282 had the disease on the right side, 3360 on the left, and 269 on both sides.2 Landouzy, who has written a work on this affection con- taining much accurate information, states, that in eight cases out of seventeen he found the veins" of the right testicle more dilated than natural, though they were much less in size than those of the left. This writer endeavored to ascertain whether -any relation subsists be- tween varicocele and varices in other parts. In fifteen individuals affected with varicocele whom he examined, only one had varicose veins of the lower extremities; and in twenty persons with varicose veins of the leg, not one had a varicocele, and no connection could be traced between varicocele and haemorrhoids. This does not agree with my observations, for in cases of varicocele I have fre- quently found the superficial veins of the thigh and leg weak, large, and dilated. 1 Landouzy, Du Varicocele, p. 24. 2 Statistics of Recruiting, compiled from the Returns in the Army Medical Depart- ment. I am indebted to Dr. Smith, the Director-General, for the opportunity of ex- amining these returns. VARICOCELE. 349 Of the causes of varicocele, some operate on both sides, others only on one. The most influential of the former is the hydrostatic pressure consequent upon the depending position of these veins, which have to support the weight of a column of blood extending from the testicle to the second dorsal vertebra. The absence of valves is mentioned as a circumstance conducing to this disease : but this is an error, for the larger spermatic veins are ahvays fur- nished with valves, though the dilatation which takes place in vari- cocele prevents them performing their office. There are several anatomical circumstances Avhich, taken together, are sufficient to explain the frequency of varicocele on the left side. On the right side the spermatic vein joins the vena cava, nearly parallel to the axis of that vessel, so that the blood enters in the course of the circulation; but on the left side the spermatic vein terminates in the emulgent vein at a right angle, and in a direction perpendicular to the venous current from the kidney, which is less favorable to the return of blood from the testicle, since the two currents pursue a different direction. The left testicle hangs lower than the right; con- sequently the veins must be longer, and the pressure produced by the column of blood greater on the left side than on the other. The accumulation of the faeces in the sigmoid flexure of the colon previous to an evacuation tends to produce pressure on the sper- matic vein, and impede the return of blood from the left testicle, especially in persons whose bowels are habitually constipated. Some persons subject to varicocele suffer from it only when the bowels are in this condition. But even the natural daily accumu- lation may be sufficient to produce obstruction. To this cause we must chiefly attribute the circumstance, that a varicose dilatation of the veins of the ovary in the female is nearly ahvays confined to the left side. The occasional causes of varicocele not depending on organ- ization include all those circumstances which tend either to de- termine the blood in an inordinate degree to the testicles, or to impede ita return to the heart, and which operate chiefly by weakening the coats of the vessels. In the first class are abuse of venery, masturbation, and attacks of acute orchitis. The second class comprehends tumors developed in the abdomen ; enlargement of the lumbar glands; hernial swellings Avhich press on the cord; trusses improperly adjusted ; an accumulation of fat in the omentum 350 VARICOCELE. • and mesentery ; and belts worn round the abdomen. The effects of these mechanical impediments are observed chiefly in persons somewhat advanced in life. Certain kinds of exercise greatly pro- longed, as riding and rowing; and sudden and violent efforts, as in straining, also give rise to varicocele. A gentleman consulted me on account of a varicocele, which he attributed to prolonged waltz- ing. One patient first noticed the complaint after hard cricketing ; and another after an attack of hooping cough. That a strain powerfully conduces to the production of a dilatation of the sper- matic vessels, may certainly be concluded from the circumstance that the stress to which they are subjected during violent exertion is sometimes so great as to occasion rupture of their coats and extravasation of blood, as was pointed out in treating of haemato- cele of the spermatic cord. Want of the proper support afforded to the testicles and spermatic vessels by the contractility of the scrotum likewise predisposes to this disease. It is partly on this account that varicocele is more common in warm than in cold cli- mates, and in persons of a weakened and relaxed habit than in those of a robust and vigorous constitution, and is more trouble- some in warm than in cold weather. In the slight degree and chronic state in which we most fre- quently meet with this affection, no injurious effect is produced on the testicle; but when highly or rapidly developed, the dilata- tion of the veins interferes so much with the nutrition of the gland as to occasion wasting. A partial atrophy of the gland, coexisting with varicocele, has come under my notice in numerous instances; indeed, in nearly all cases in which there was a decided dilatation of the spermatic veins on one side only, the testicle of that side was the smaller of the two. In a man, aged fifty-six, with a vari- cocele on the left side, the testicle was so reduced that it scarcely exceeded the usual size of the organ in an infant. Some years ago a tall sailor was under my care on account of a varicose ulcer on the left leg, who had a large varicocele on the left side, and a testicle so wasted, that it could scarcely be felt through the tunica vaginalis, which was loosely distended with fluid. We have evidence too that the secreting powers of the gland are impaired, and sometimes even destroyed by this disease. In forty-five cases in which Landouzy noted the age at which varicocele was first observed, ten having been taken from authors, VARICOCELE. 351 and thirty-five having come under his own observation, the age was as follows :— From 9 years to 15,........13 15 "25,........29 25 " 35,........3 45 The results agree very nearly with my own experience. I noted the ages of the last fifty patients who came under my notice; they were as follows:— From 10 years to 15,........2 15 "25,........26 25 "35,........14 35 " 45,........5 45 "65,........3 50 Many of these patients had been subject to the complaint for months or years before consulting me, which may account perhaps for the ages being greater than in the cases noted by Landouzy. These tables show that the period of puberty is the time at which varicocele most commonly occurs. I have met with it before that period in but few cases.—A lad, aged eleven, was brought to me with a marked varicocele on the left side. About three months previously he had injured himself in jumping on the back of a boy at school. He was kept on a couch for some weeks, and when he commenced moving about the swelling of the spermatic veins was noticed.—A boy, aged thirteen, had a varicocele on the left side, which was first observed after a fall about a week before I saw him. In both these case's the periodic growth of the testicles had not taken place, and the left gland was smaller than the right. Varicocele is a common affection, more common, indeed, than is generally supposed; Its prevalence is best shown by the large number of recruits annually rejected for this disease. Of 166,317 recruits medically inspected in the districts of Great Britain and Ireland during the ten years ending 31st March, 1853, 55,474 were rejected. Of the latter, 3911 or 70-5 per 1000, were rejected for varicocele, a greater number, indeed, than the rejections for hernia.1 There are certain occupations which favor the development of 1 The rejections for hernia were 1804, or 32-5 per 1000. 352 VARICOCELE. varicocele. I have seen many policemen with this affection. The habit of sauntering and standing about for many hours daily tends to produce the disease in those naturally predisposed to it. Seve- ral of my patients have been publicans, Avho are occupied on their feet a great part of the day. The complaint, too, is not uncom- mon in the men of cavalry regiments. Tall men, also, are more subject to it than short persons. I have alluded to the thickened condition of the spermatic veins sometimes observed in confirmed cases of varicocele. This thicken- ing is due to chronic inflammation of the outer coat of the vessels. The dilated veins are also liable to diffusive inflammation or phle- bitis. This dangerous affection may occur after operations for the obliteration of the plexus, but is undoubtedly rare, and no case of the kind has fallen under my observation. Dr. Escallier has re- corded two interesting cases of suppurative inflammation of a large plexus of dilated spermatic veins. They occurred in Paris to persons who Avere natives of a warm climate, one of them a black from Gua- daloupe, the other a merchant from the Brazils. Both cases termi- nated fatally in a few days, the symptoms simulating those of stran- gulation.1 Symptoms.—A varicose distension of the spermatic veins, in general, takes place so gradually, and produces so little inconveni- ence, that it is often not detected until the affection has made some progress. When someAvhat advanced, it occasions a sensation of weight in the testicle, and a feeling of uneasiness in the course of the spermatic cord, which often extends to the loins, and is aggra- vated by exercise, as riding or walking. The patient is then apt to carry his hand to the scrotum to relieve the sensation of Aveight, or to give the part a more favorable and convenient position in his clothes. On examination, the scrotum is found to be long, pendu- lous, and lax; and in persons of a thin and delicate skin has a slight livid appearance, the color of the blood in the veins being indistinctly visible through the integuments. An irregular swell- ing, of a somewhat pyramidal form, is observed in the course of the cord. This swelling when handled has a soft, doughy, inelastic feel, and communicates to the fingers a sensation which has been compared to that of a bundle of ropes or earthworms. The dilated veins may be traced upwards into the inguinal canal in advanced 1 Me"moires de la Societe" de Chirurgie de Paris, t. ii, p. 66. VARICOCELE. 353 cases; and when very pendulous they sometimes form a double cone, the testicle being nearly in the centre, and the varicose veins above and below it. In bad and long-standing cases, the veins of the scrotum are also affected, appearing large and tortuous. The swelling is diminished by cold and the recumbent position; and on the other hand is increased by warmth, the erect position, and by straining and coughing. The disease, indeed, is sometimes first dis- covered by the patient whilst taking a bath, or during an attack of catarrh. The distension of the vessels is also greater towards even- ing than in the morning. Landouzy has noticed a curious fact in connection with this disease ; viz. the marked relief experienced by patients during and immediately after coition, followed by a severe exacerbation of the symptoms the next day.1 This is owing to the support afforded to the vessels of the part by the tone and con- traction of the scrotum, and the increased vigor of the circulation during the venereal orgasm ; but as this is only temporary, when relaxation and lassitude ensue the symptoms of varicocele return with greater severity than before. I can confirm the latter observation ; patients having several times complained to me of their symptoms being aggravated for several days after sexual connection. Varicocele, Avhen slight, often remains stationary for a consider- able time, neither increasing nor producing inconvenience. This is more particularly the case with varicocele in old people, and also on the right side; so that patients, who have discovered the disease on the left side, remain for years in ignorance of anything wrong on the right, which they believe to be sound, though it contains the rudiments of the same affection that exists on the left. Varicocele on the right side is less voluminous, occasions less uneasiness, and leads to consequences less grave than the same affection on the left. If a patient affected Avith slight varicocele avoids fatigue and the exciting causes of the disease, and wears a suspensory bandage, its progress is usually arrested; but if permitted to increase, it is liable to become a source of much annoyance. Slight exertion, Avarmth, or excitement of any kind increases the local uneasiness; so that the patient is prevented from taking exercise, and is dis- abled from earning his livelihood by labor. The pain and distress occasioned by this disease vary, however, a good deal, and are not exactly proportionate to the size of the varicocele. In varicoceles 1 Lib. cit. p. 76. 23 354 VARICOCELE. of large size, the pain is sometimes very slight; whilst in others, small in volume, it is occasionally vrery severe. Some persons ex- perience uneasiness from a varicocele only when out of health, or laboring under indigestion. Persons afflicted with it at an early age, on the whole, suffer more than those who become affected later in life. The former sometimes labor under a degree of mental distress very much out of proportion to the actual disease. These hypochondriacal symptoms are often connected with spermatorrhoea and dyspepsia, but they sometimes arise from an apprehension, by no means unfounded, of the disease impairing the nutrition of an organ which exercises a marked influence on the characters of the sex. The pain sometimes partakes of a neuralgic character, and is so excessive and intolerable, that patients have gladly submitted to the operation of castration for their relief, Avhich has been performed at the urgent request of the sufferer by Gooch,1 Brodie,2 Key,3 and others. Though varicocele usually occurs as a chronic affection, it some- times forms suddenly and advances rapidly, appearing shortly after a severe injury or strain, which had probably occasioned a dilata- tion of the coats of the veins from which they were unable to recover. There may have been a previous tendency to the com- plaint ; but patients often ascribe its origin to some sudden effort, since which they had experienced the annoying symptoms of the disease. In these acute cases, which nearly always occur in early life, the suffering is much greater than in the more chronic cases. Varicocele has also been knoAvn to occur as an acute affection shortly after an attack of orchitis. Mr. Pott has recorded three remarkable cases, in which Araricocele made its appearance, not only suddenly and Avith acute pain, but was attended with very rapid wasting of the testicles.4 There seems reason to doubt, how- ever, whether these were simply cases of varicocele.5 Diagnosis.—The symptoms of varicocele slightly resemble those of a scrotal hernia. Like hernia, the swelling in varicocele in- 1 Practical Treatise on Wounds and other Chirurgical Subjects, vol. i, p. 244. 2 London Medical and Physical Journal, vol. lvi, p. 299. 3 Sir A. Cooper's Observations on the Testis, p. 224. Vide Case by Mr. Thompson, of Stalybridge, Lancet, vol. ii, 1839-40, p. 137. 4 Lib. cit. p. 469, Cases XXXVI, XXXVII, and XXXVIII. 5 In the first edition of this work, I gave an abstract of these cases, and appended some observations in which I stated my reasons for questioning the propriety of con- sidering them to be examples simply of varicocele. VARICOCELE. 355 creases when the patient is in the erect position ; subsides spontane- ously, or on pressure, when he is in the recumbent; and soon reappears when he again assumes the erect posture. When the dilated condition of the veins extend into the inguinal canal the ring is enlarged, and the swelling increases, and receives a slight impulse in coughing. A varicocele, however, cannot well be mis- taken for an intestinal hernia; but the student may sometimes be unable to distinguish the feel of the tortuous and dilated vessels from that of an omental protrusion. The best mode of making the diagnosis is as follows. The patient having placed himself in the recumbent position, the testicle of the side affected is to be raised until the swelling disappears. The surgeon must then press gently with the fingers on the external abdominal ring, and direct the patient to rise. If the case be a varicocele, the swelling soon re- appears ; but if it be a hernia, the descent of the omentum is pre- vented by the pressure. As the swelling is reproduced, it commences, if a varicocele, from below ; if an omental hernia, from above. In making this examination, care must be taken that the pressure be not too great, or the veins will remain empty. A varicocele might possibly be mistaken for a congenital hydrocele, which likewise swells in the erect position and disappears in the recumbent: the transparency of the tumor in hydrocele is sufficient to set all doubt at rest. Though I have given the above directions, I must observe, that I have never met with a case of varicocele in which there was any difficulty in detecting the nature of the case, or in distinguish- ing the disease from other affections of the part. Treatment.—Varicocele in the mild form that is commonly met with, produces little suffering or even inconvenience. The treat- ment required is to keep the scrotum and testicles well supported, in order to diminish the length of the spermatic veins and the weight of the column of blood circulating in them. For this pur- pose, the patient should wear a well-fitting suspensory bandage, and as it is desirable for the parts to be kept cool, the suspender should be made of open silk net. Those commonly sold are often badly constructed and do not fit well, so that it is necessary for the sur- geon to see that they answer the purpose intended. I prefer the bandage invented by Bourgeaurd, which is secured to the dress above, and is kept well in piace by elastic bands round the hips, without any abdominal belt. This suspender braces the parts well 356 VARICOCELE. up, and maintains its position in all the movements of the body. It is rendered more effectual by the upper band being connected with a loop which hangs round the neck. The patient should accustom himself either to souse the parts freely with cold spring Avater night and morning, or to take a cold hip-bath daily. His lower garments ought to be as light as comfort will admit of, and not tight about the abdomen. Fatiguing exer- cise, Avarm baths, excess in venery,—everything, in fact, Avhich tends to determine the blood to the testicles and scrotum, must be avoided. The bowels should be properly regulated, and any disposi- tion to costiveness obviated by gentle aperients, or, what is better, by enemata of tepid water throAvn well up into the colon every morn- ing, in order to remove the fseculent collections from this part of the intestine. By these means, if we cannot correct the dilated con- dition of the veins, we may generally prevent its increasing, and contribute to the comfort and health of the patient. For the purpose of supporting the testicle in cases of varicocele, Mr. Wormald, some years ago, recommended the following plan.1 The lower part of the scrotum, whilst the patient is in the recum- bent position and the veins comparatively empty, is to be drawn through a ring about an inch in diameter, made of soft silver wire of a suitable thickness, padded, and covered with wash-leather. The sides of the instrument are then to be pressed towards each other with sufficient force to prevent the scrotum escaping. Patients often find relief from this simple contrivance, and some prefer it to wearing a suspender. I have not found this, however, to be gene- rally the case. The ring is equally annoying to the patient's feel- ings, and cannot always be steadily fixed so as to answer the purpose intended. Mr. Coulson has informed me of a case, in which the patient compressed the ring so tightly as to cause a slough of the integuments, which, having separated, was followed fortunately by such contraction of the part as to raise the testicle, and afford relief from the uneasy symptoms of the complaint. In order to afford a permanent and more complete support to the testicle, and to render a suspensory bandage unnecessary, Sir A. Cooper practised a very simple operation; viz. the removal of a portion of the relaxed scrotum, leaving the remaining part to form adhesions and to constitute a natural suspensory bandage. He 1 Medical Gazette, vol. xxii, p. 194. VARICOCELE. 357 recommended this operation only in those cases of varicocele in which the patient suffers great local pain ; in cases in which he is most urgent to have the swelling and deformity of the part re- moved ; and more especially in those instances in which the function of digestion suffers, and there is a great degree of nervousness and of mental depression. In slighter cases he employed the suspen- sory bandage. In the paper1 in which this treatment is described, five cases are related. In all of them, the painful symptoms of varicocele are stated to have been fully relieved by the operation: four of the patients Avere operated on by Sir Astley himself, and the fifth by Mr. Key. The son of a medical gentleman of my acquaintance had part of his scrotum excised by Sir A. Cooper in May, 1840. In December, 1842, he had continued relieved from all uneasiness; and the testicle was of proper size, though the veins remained enlarged. In a case operated on by Dr. Watson, of New York, the patient was permanently relieved of the dragging sensation and pains of which he complained before the operation.2 In 1841, Mr. Luke performed this operation in the London Hos- pital on an engineer, aged twenty-one, who suffered considerably from the complaint. A large portion of integument was removed. The wound healed up very slowly, and did not close for six weeks. The testicles were then found to be well braced up and supported, and the man was a good deal, but not wholly relieved of the un- easiness in the groin and cord which he had previously experienced. He resumed work, and I have not since been able to obtain any further account of him. In other cases, the results of the opera- tion have been either unsuccessful or far less satisfactory. Some years ago I examined a man, part of whose scrotum had been excised by Sir A. Cooper for the relief of a varicocele, but so little benefit was derived from the operation that he afterwards submitted to castration. A medical friend informed me that in one of Sir Astley's published cases of success, the disease subsequently re- turned as bad as ever. In 1849, I was consulted by a man, aged tAventy-five, on account of a varicocele, a portion of whose scro- tum had been excised at York three years previously with only temporary relief. He still suffered a good deal of aching pain, especially toAvards evening, and required further aid. The late 1 Guy's Hospital Report, vol. iii. 2 New York Med. and Surg. Journal, Oct. 1840. 358 VARICOCELE. Mr. Bransby Cooper published an account of a case in which he performed the operation apparently at first with a successful result; but two years afterwards, it Avas found that the varicocele had re- turned, and the patient was obliged to wear a suspender.1 It is not surprising, when Ave consider the severity of excision of the scrotum, and the uncertainty of its success in the more painful cases of varicocele for which alone it was recommended, that feAV surgeons have been led to practise this operation. It is calculated, indeed, to arrest the progress of varicocele, and afford full and per- manent relief, only in the milder cases in which the uncomfortable symptoms of the complaint admit of temporary but complete re- moval by suspension of the parts in the band, or in a well-adjusted suspender; when the artificial contraction of the scrotum succeeds in compensating for the previous laxity of the tissues, gives adequate support to the dilated veins, and sufficiently diminishes the column of blood circulating in them. But as the same object may be equally well obtained in such cases by the use of a bandage, which can be worn without inconvenience, the operation is not advisable. The attainment of the objects contemplated in the preceding operation, viz., shortening of the scrotum and permanent support to the testicle, has been attempted by Dr. Lehmann, a German surgeon, in another way. His mode of operating, by invagination of the scrotum, is very similar to the plan which he has adopted for the radical cure of hernia; but as it does not appear to possess any advantage over the operation of excision of part of the scrotum, and must be liable to even a greater risk of failing in its object, it is unnecessary to detail the steps of the proceeding. Various attempts have been made to obtain a radical cure of varicocele by causing obliteration of the dilated veins. This has been effected in four different ways. 1. By division of the vessels ; 2. By ligature; 3. By compression; and 4. By excision. 1. Division of the Vessels.—This operation was first practised by Sir B. Brodie.—A man, twenty-one years of age, was admitted into St. George's Hospital with a varicocele on the left side, princi- pally situated at the posterior part of the epididymis, which, though not very large, caused a very considerable degree of pain, especi- ally in the evening, when the veins were more distended than in the morning. Finding that the pain was referred almost wholly to the 1 Lectures on Surgery; Lond. Med. Gazette, vol. xliii, p. 356. VARICOCELE. 359 cluster of varicose veins situated at the posterior part of the epi- didymis, Sir B. Brodie was induced to believe that the sufferings of the patient arose from the pressure of the tumor on some contigu- ous nerve or nerves, and that if the dilated veins forming it could be obliterated the pain would be relieved. With this impression on his mind, he performed the following operation. He divided, with a sharp-pointed bistoury, the skin and cellular texture at the poste- rior part of the scrotum, so as to expose the varicose cluster; and then, by a second incision, he divided the varicose cluster itself, cutting through its centre. When first exposed the cluster was of about the size of a horse-bean, of a purple color : on being divided it immediately collapsed, and there was a slight venous hemor- rhage. Some cold lotion was applied, the wound being allowed to remain open, in order to favor the escape of blood, and prevent its effusion into the cellular texture of the scrotum. Some inflamma- tion and tumefaction of the scrotum followed the operation; but there was no fever, nor much uneasiness of any kind. A month after the operation the wound was healed, and the patient was free from pain. A slight degree of hardness remained where the divided cluster of veins was situated. I have not heard that this operation has been adopted in other cases of the disease. 2. Ligature.—Celsus recommended cutting down upon the sper- matic veins, and the application of a ligature around them; an ope- ration which has been frequently performed since his day by many of the older surgeons. This operation is adequate to the cure of the disease; but is not free from danger, OAving to its liability to induce phlebitis. Sir Everard Home cut down upon and tied the spermatic Areins for the cure of varicocele in a patient in St. George's Hospital. In this case, according to Sir B. Brodie, venous inflammation took place, attended with so much constitu- tional disturbance that the patient nearly died.1 It is open, also, to the further objection of occasioning atrophy of the testicle. Delpech, a surgeon of distinction in France, was assassinated by a man whom he had cured of double varicocele a year before by tying the dilated veins. The patient's testicles were found after death wasted and soft. 1 Lond. Med. Gaz. vol. xiii, p. 379. I have been informed that several of the pa- tients whose spermatic veins were tied by Roux in Paris, for the cure of varicocele, died from the operation. 360 VARICOCELE. through them. To avoid the risks consequent upon the application of a ligature in the ordinary way, many modern sur- geons have had recourse to a plan for the obliteration of the dilated veins, Avhich was first tried by M. Davat on the veins of animals.1 This plan consists in passing a straight pin or needle through the scro- tum, and underneath the varicose vessels, between the latter and the vas deferens, and then twisting a strong silk ligature around the projecting extremities of the pin in the form of the figure 8, with suffi- cient tightness to compress and flatten the vessels, and arrest the circulation Inflammation is by this means excited in the coats of the vessels; and the sides of the inner one being re- tained in contact, the vessels soon become obliterated by adhesion. The pin after remaining in a few days is removed, and the sores produced by it soon heal up. Velpeau and Jobert in Paris have practised this operation with success, and it has also been performed in this country by Liston, Fergusson, and other surgeons with favorable results. The pins should not remain in longer than four or five days, or they are liable to occasion ulceration of the veins, and suppuration in the connective tissue of the scrotum. In large varicoceles, it is necessary to introduce a second or third pin at the distance of from half an inch to an inch from each other. M. Ricord, of Paris, improved upon the preceding method by applying the ligature to the spermatic veins subcutaneously. The operation is performed in the following manner:—The vas deferens being separated from the mass of veins, and the latter being pinched up with a fold of the scrotum, a needle set in a handle with the eye near the point, armed with a double-looped thread, is to be passed beneath them. When the needle has traversed from one side to the other, the loop is to be drawn out, the needle retracted, and the veins let go, the skin alone being now held up. A second needle, similarly armed, is then to be passed through, over the veins, entering at the same hole by which the first needle was thrust out, and emerging at the same hole by which it entered. ' Vide Archives Generates de Medecine, lie s6r. t. xi, p. 1,1S33. VARICOCELE. 361 The second loop is next to be drawn out, and the needle with- drawn. The bundle of veins is thus included between two double threads, of which one passes over, and the other beneath it. The ends of the thread on each side are then to be passed into the loop of the other, and noAv by drawing those ends in opposite directions the vessels are tied beneath the skin. By this mode of applying the ligatures, the vessels may either be suddenly constricted, or be tied gradually by means of an ingenious instrument—a serre-nceud. It Avould be a simpler proceeding to attach the ends of the ligatures to a ring of india-rubber on each side, which could be secured on the stretch to the upper part of the thigh. In this way traction might be steadily kept up and so regulated as not to cause uneasi- ness. The vessels are divided, and the ligatures come away in from the tenth to the twentieth day. In 1849 I visited the Venereal Hospital in Paris with M. Ricord, who informed me that he had met with no bad results from this mode of tying the veins ; and I saw a case under treatment in which the effects were quite mild. M. Vidal practises a mode of obliterating the veins by passing a Vidal's Operation for Varicocele. through the same apertures by which the pin passed. Compression is made by twisting the ends of the Avire round either end of the 362 VARICOCELE. pin, and is gradually increased by the surgeon turning the pin from day to day. The veins are in this way rolled up as well as com- pressed, until they become destroyed or cut through. The bridge of skin and the superficial veins in front are also divided, or incised on the fifteenth day.1 Some years ago I witnessed the treatment of a case of varicocele with ligature by Mr. Luke, who used an instrument he terms " a fistula tourniquet," for gradually tightening the ligature.—M. Q., a tall Irishman, aged tAventy-four, was admitted into the London Hospital on account of a varicocele on the left side. There was a considerable swelling formed by the varicose spermatic veins, and he experienced a dragging pain in the course of the cord, and an uneasy sensation of Aveight, which were only partially relieved by supporting the parts. He had been a private in the Light Dra- goons, and attributed the origin of his complaint to his testicle having been accidentally struck against the saddle in riding, and he had been invalided in consequence of it about two months. Mr. Luke, having separated the plexus of varicose veins from the vas deferens, passed a straight sewing-needle, armed with a liga- ture of strong dentist's silk, through the root of the scrotum be- tween these parts; and having attached the ends of the ligature to the tourniquet, secured them so as to make gentle pressure on the veins. The man was then sent to bed. Three days afterwards the ligature was tightened. As the ligature cut through the in- cluded parts and got slack it was again tightened. At the end of ten days he was allowed to walk about the ward. The ligature came away on the twenty-fifth day, and on the twenty-seventh the wound was healed. After leaving the hospital he took the situation of a policeman. I saw him at the end of nine months. He was then acting as a horse-patrol, and stated that he was quite cured. 3. Compression.—In the preceding operations the veins are pressed upon by the pin or ligature with which they are immediately in contact, and are thereby liable to become inflamed. To obviate this supposed disadvantage M. Breschet contrived a pair of forceps, to cause obliteration of the veins, by making firm pressure on them from outside the scrotum. By means of this instrument, the blades of which are well padded, and admit of being closed by screws, the walls of the dilated veins are at once brought into contact; blood ' Vidal, TraitS de Pathologie, t. v, p. 223. VARICOCELE. 363 coagulates in the vessels; and adhesion taking place, the danger to which the other plans are liable is said to be avoided, and by secur- ing the spermatic artery from compression atrophy of the testicle is also prevented. In thirteen cases in which this operation was performed there was only one relapse, which was owing to a vein not being included in the forceps.1 A writer who Avitnessed the treatment of several of Breschet's cases, and has reported favor- ably of the operation, has nevertheless represented the inflamma- tion and swelling consequent upon it as being considerable, and the cure as proving tedious.2 It seems, indeed, to possess no ad- vantage over the improved modes of applying ligatures to the veins. 4. Excision of the Spermatic Veins.—This operation has been practised by Petit and other surgeons. It is performed in the fol- lowing manner :—An assistant first separates the vas deferens, which he is to hold firmly and carefully between his thumb and fore- finger. An incision from two to three inches in length is then made in the integuments over the cluster of dilated veins. The veins which then protrude are excised with a pair of curved scissors, or divided with a bistoury, first above and then below. If any troublesome hemorrhage afterwards ensue, the bleeding vessels are secured by ligature. A needle and ligature are sometimes passed under the veins at the upper part of the wound, in order to secure them from retraction after their division. The wound is closed by a single suture and adhesive plaster; it often heals by the first in- tention. Dr. Warren states, that he has been in the practice of doing this operation for a number of years; that he has found it give great relief; that in no instance has it been necessary to repeat it; and that it has never been attended with unpleasant conse- quences, except in a single instance. In that case, bleeding ensued after the operation, from Avhich the scrotum became so enormously distended that it caused inflammation and sloughing of the cellular membrane and testicle ; after which the patient recovered.3 This is a more severe operation than compression, or the ligature, and is also liable to be followed by phlebitis and Avasting of the testicle. And besides, it is attended with risk of hemorrhage, and the pro- duction of a considerable and troublesome suppurating wound. 1 Landouzy, lib. cit. 3 Vide Observations on M. Breschet's Operation for the Radical Cure of Varicocele, by W. H. Walshe; Medical Gazette, vol. xv, p. 369. 8 Surgical Observations on Tumors, p. 441. 364 VARICOCELE. Experience has now fully shown, that the obliteration of the sper- matic veins by ligature, in the modes suggested by Davat, Vidal, and Ricord, is, in a great degree, exempt from the risk1 which attends the operation of exposing and tying vessels in the ordinary way, viz., of inducing diffusive inflammation of the veins. Ricord's subcutaneous ligature, aided by the traction of the india-rubber rings, is the plan to which I give the preference. It is simpler than the methods of Davat and Vidal, in which a portion of skin being included in the compression, there is more pain, and the in- tegument is liable to ulcerate or slough, inconveniences avoided in the subcutaneous operation, which is equally effectual in oblitera- ting the veins, and productive of but little pain and local irritation. Small, however, as is the risk from these improved operations, in no case, not even in the healthiest subject, can the tying of a bundle of veins of such size as the dilated spermatic be regarded as wholly free from danger; and it is fortunate that a plan of treatment which I have yet to describe, answers so well in relieving varicocele, that, except in some rare instances, no operation is required for this disease.2 Treatment of Varicocele by Pressure.—A surgeon suffering from a varix in the leg, having heard the late Sir Charles Bell state, in his lectures at the College of Surgeons, in illustration of the fact of the dilatation of a varicose vein being caused solely by the pressure of the column of blood, that if the distended vein be compressed with the finger the swollen condition of the vessel beneath shortly disappears, was led to apply the principle thus indicated to the treatment of his own case, which was attended with a satisfactory result. This gentleman mentioned the circumstance to the late Mr. Key, Avho was accordingly induced to adopt the same principle in the treatment of a case of varicocele. In a patient affected with this disease, if the spermatic cord be pretty firmly compressed between the fingers whilst the patient is 1 In the unfortunate case in which Delpech tied the spermatic veins, atrophy of both testicles resulted. I have heard of other instances in which the gland has wasted after operations for the obliteration of the veins. It is not improbable that in some of these cases the spermatic artery was also included in the ligature. 2 A patient who consulted me on account of a slight varicocele and an irritable urethra, afterwards visited Paris, where he submitted to Ricord's operation. On his return he assured me that he suffered more pain in the part than he had done pre- viously. VARICOCELE. 365 in the recumbent position and the vessels are empty, it will be found, on his assuming the erect posture, that the vessels, instead of swell- ing as before, still remain empty and contracted. Even, too, when the patient is standing, and the veins are full, if firm pressure be made on the cord, the vessels below, being thus relieved of the superincumbent weight of the blood, will often gradually diminish ^ind become partially emptied of their contents. It Avas natural, therefore, to conclude, that if the pressure could be steadily con- tinued for a sufficient length of time, it would enable the vessels to recover from the morbid state of dilatation in which they were pre- viously retained by the hydrostatic pressure of the blood. In the case of the varix in the leg, it is clear that the local pressure could have had no effect on the artery by which the vein was supplied, and we may reasonably conclude that the blood in the veins below the point of compression found its way back to the heart by col- lateral and healthy channels. When the spermatic vessels are com- pressed in the manner just described, the pressure does not appear to be sufficient to obstruct the spermatic artery; whilst the blood in the vessels below the part compressed, no doubt, returns by the smaller vessels, a sufficiency of which always exists in these cases in an adequately healthy state for the purposes of the circulation. The object, then, of this method of treatment may be stated to be, the maintenance, whilst the patient is in the upright position, of such a degree of pressure on the spermatic veins as may be suffi- cient to relieve them from the superincumbent weight of the blood, without at the same time endangering the integrity of the testicle by obstructing the spermatic artery, and without causing so much uneasiness as to render the remedy as painful as, or more difficult to be borne than, the disease. This pressure must be continued a sufficient time to enable the coats of the vessels to return to their natural dimensions, and to acquire strength to carry on the circula- tion. When this is effected the patient is cured. It is obvious, therefore, that the main difficulty of this treatment consists in the application of continuous local pressure. The only part where this can well be made on the spermatic veins is at the external ab- dominal ring ;x but unless the pressure be skilfully applied, patients 1 That pressure at the groin is capable of giving relief in varicocele has sometimes been found out by the patients themselves. Several have mentioned to me, that they had been in the habit, whilst walking about, of pressing on this part with the fingers, having found out that considerable ease could be obtained in this way. 366 VARICOCELE. are unwilling to submit to it. Indeed, several cases have come under my notice, in which disappointment has ensued, entirely from the imperfect application of this plan of treatment. The instrument which I have found, after pretty extensive experience, to be best calculated to meet the exigencies of the treatment by pressure is the moc-main lever truss. This truss (Fig. 49) consists of a pelvic band, to one extremity of which a pad (a) is attached. This pad is stuffed with moc-main, Fig. 49. £ w> a species of cotton, and covered with india- rubber or chamois leather. It must not be made too conical, so as to separate the veins. A lever spring is fixed to the back of the pad, and this spring is acted on by a thigh- strap ( been prepared without regard to expense, and will be found one of the handsomest specimens of typographical execution as yet presented in this country. Copies will be sent to any address, by null, free of postage, on receipt of nine cents in stamps. Catalogues of our numerous publications in miscellaneous and educational litera- ture forwarded on application. ¥W The attention of physicians is especially solicited to the following important new and new editions, just issued or nearly ready :— Ashton on the Rectum,..........See page Bumstead on Venereal............ Barwell on the Joints,........... Condie on Diseases of Children,......... Churchill's Midwifery,........... Druitt's Surgery,............ 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It has now been issued regularly for more than forty years, and it ha* been under the control of the pre>ent editor for more lhan a quarter ol a century. Throughoul this long period, it has maintained its posilion in the highest rank of medical periodicals both nl home and abroad, and ha> received the cordial support of the entire profession in this country. Its list of Collaborators will be found to contain a large number of the most distinguished names of the pro- fession in every section of the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. As the aim of the Journal, however, is to combine the advantages presented by ail the different varieties of periodicals, in its REVIEW DEPARTMENT ivill be found extended and impartial reviews of all important new work.s, presenting subjects o? Qovelty and interest, together with very numerous BIBLIOGRAPHICAL NOTICES, including nearly all the medical publications of the day, both in this country and Great Britain, with a choice selection ol the more important continental works. This is followed by the QUARTERLY SUMMARY, feeing a very full and complete abstract, methodically arranged, of the IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object ol especial eare on the part of the editor. It is classified and arranged under different heads, thus facilitating the re:-earehes of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch of medical science. The very extensive arrangements of the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, out also twenty or thirty of the more important Journals issued in Great Britain and on the Conti. nent, thus enabling him to present in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part of the civilized world. Tu their old subscribers, many of whom have been on their list for twenty or thirty years, the publishers feel that no promises for the future are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in the high position which it has occupied for so long a period. By reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information of the day, while the " Library Department" is devoted to presenting stand- ard works on various branches of medicine. Within a few years, subscribers have thu« receiver1 without expense, many works of the highest character and practical value, such as « Wagon's Practice," ''Todd and Bowman's Physiology," " Malgaigne's Surgery," "West on Children " » West on Females, Part I.," "Haber.-hon on the Alimentary Canal," &c. While the work at present appearing in its columns is CLINICAL LECTURES ON THE DISEASES OF WOMEN. By Professor J. Y. SIMPSON, of Edinburgh. WITH NUMEROUS HANDSOME ILLUSTRATIONS. These Lectures, published in England under the supervision of the Author, carry with them all the weight of his wide experience and distinguished reputation. Their eminently practical nature and the importance of the subject treated, cannot fail to render them in the hi°hest decree «ati* factory to subscribers who can thus secure them without cost. These Lectures are continued in the "News" for 1862. u It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber Will obtain a Quarterly and a Monthly periodical, ' ""^"oer EMBRACING NEARLY SIXTEEN HUNDRED LARGE OCTAVO PAGES, Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entttle them to the Journal only, without the News, and that they will be at he eLeZe of their own postage on the receipt of each number. The advantage of a remittance wkn order* tug the Journal will thus be apparent. eu oraer- Remittances of subscriptions can be mailed at our risk, when a certificate is taken from the Post- master that the money is duly inclosed and forwarded. Address BLANCHARD & LEA, Philad*lphia. AND SCIENTIFIC PUBLICATIONS. 3 ASHTON (T. J.), Surgeon to the Blenheim Dispensary, &c. °^ THE DISEASES, INJURIES, AND MALFORMATIONS OF THE REG 1 UM AND ANUS; with remarks on Habitual Constipation. From the third and enlarged London edition With handsome illustrations. In one very beautifully printed octavo volume. of about 300 pages. {Just Issued.) $2 00. Introduction. Chapter I. Irritation and Itching of the Anus. II. Inflammation and Excoria- tion ot the Anus. 111. Excrescences of the Anal Region. IV. Contraction of the Anus. V. f issure of the Anus and lower part of the Rectum. VI. Neuralgia of the Anus and extremity ol theKectum. VII. Inflammation of the Rectum. VHI. Ulceration of the Rectum. IX. He- morrhoidal Affections. X. Enlargement ofHemorrhoidal Veins. XI. Prolapsus of the Rectum. Xll. Abscess near the Rectum. XIII. Fistula in Ano. XIV. Polypi of the Rectum. XV. Stric- ture of the Rectum. XVI. Malignant Diseases of the Rectum. XVII. Injuries of the Rectum. XVI11. b oreign Bodies in the Rectum. XIX. Malformations of the Rectum. XX. Habitual Constipation. The most complete one we possess on the subject, the excellent advice given in the concluding para- Medtco-Cktrurgical Review. graph above, would be to provide himself with a \\ e are satisfied, after a careful examination of c >py of the book from which it has been taken, and the volume, and a comparison of its contents with diligently to eon its instructive pages. They may those of its leading predecessors and contemporaries, secure to him m iny a triumph and fervent blessing.— that the best way for the reauer to avail himself of Am. Journal Med. Sciences. ALLEN (J. M.), M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting. ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, lea- ther. $2 25 We believe it to be one of the most useful works upon the subject ever written. It is handsomely illustrated, well printed, and will be found of con- venient size for use in the dissecting-room.—Med. Examiner. However valuable may be the " Dissector's Ouides" which we, of late, have had occasion to notice, we feel confident that the work of Dr. Allers is superior to any of them. We believe with tiie author, that none is so fully illustrated as this, and the arrangement of the work is such as to facilitate the labors of the student. We most cordially re- commend it to their attention.—Western Lancet. ANATOMICAL ATLAS. By Professors H. IT. Smith and W. E. Horner, of the University of Pennsyl- vania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. H5F* See Smith, p. 331 ABEL (F. A.), F. C. S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 pages, with illustrations. $3 25. ASHWELL (SAMUEL), M.D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. The most useful practical work on the subject in I The most able, and certainly the most standard the English language. — Boston Med. and Surg, and practical, work on female diseases that we have Journal. I yet seen.—Medico-Chirurgical Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50. ^________________ BIRD (GOLDING), A. M., M. D., fee. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American, from the fifth and enlarged London edition. With eighty illustrations on wood. In one handsome octavo volume, of a30ut 400 pages, extra cloth. $2 00. (Just Issued.) The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to othei»hands, and in his performance of the duty thus devolving on him, Dr. Birkett has sedulously- endeavored to carry out the author's plan by introducing such new matter and modifications ol the text as the progress of science has called for. Notwithstanding the utmost care to keep the work within a reasonable compass, these additions have resulted in a considerable enlargement. It is, therefore, hoped that it will be found fully up to the present condition of the subject, and that the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken tor or associated with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts. pp. 130. $1 25. 4 BLANCHARD to LEA'S MEDICAL BUDD (GEORGE) M.D., F.R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 500. 83 00 Has fairly established for itself a place among the i is not pereeptibly changed, the history of liver dis- cl.issica 1 medical literature of England.—British | eases is made more complete, nnd is keptupon a level with the progress of modern science, ft is the best work on Diseases of the Liver in any language.— Lovdon Med. Times and Gazette. anil Foreign Medir.o-Chir. Review Dr. Budd's Treatise on Diseases of the Liver is now a standard work in Medical literature, and dur ing the intervals which have elapsed between the successive editions, tbe author has incorporated ii.to the texi the most striking novel! ies which have cha- racterized the recent progress of hepatic physiology and pathology; so thatalthougli the size of the book This work, now the standard book of reference on the diseases of which it treats, has been carefully revised, and many new illustrations of the views of the learned author added in the present edition.— Dublin Quarterly Journal. BY THE SAME AUTHOR. ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $1 50. BUCKNILL 'J. C), M. D., and DANIEL H. TUKE, M. D., Medical Superintendent of the Devon Lunatic Asvlum. Visiting Medical Officer to the York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology. Description, Statistics, Diagnosis, Pathology, and1 Treatment of INSANITY. With a Plate. In ore handsome octavo volume, of 536 pages. $3 00. The increase of mental disease in its various forms, and the difficult questions to which it is con>tantly giving rise, render the subject one of daily enhanced interest, requiring on the part of the physician a constantly greater familiarity with this, the most perplexing branch of his profes- sion. At the same time there has been for some years no work accessible in this country, present- ing the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane To fill this vacancy the publishers present this volume, assured that the distinguished reputation and experience of the authors will entitle it at once to the confidence of both i-tudent and practitioner. Its scope may be gathered from the declaration of the authors that "their aim ha.- been to supply a text book which may serve as a guide in the acquisition of such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently modern in it* views and explicit in its teaching to suffice for the demands of the practitioner." BENNETT (HENRY), M.D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which is added, a Review of the present stale of Uterine Pathology. Fifth American, from the third English edition. In one octavo volume, of about 500 pages, extra clo'.h. $2 00. BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp 270. $t 60. Mr. Brown has earned for himself a high reputa- j and merit the careful attention of every sunreoa- tion in the operative treatment of sundry diseases accoucheur.—Association Journal and injuries to which females are peculiarly subject. We can truly say of his work that it is an important V e nave no hesitation in recommending this bo' k addition to obstetrical literature. The operative I to Ll? ,1-,trelu1 attention of all surgeons who make suggestions and contrivances which Mr. Brown de- I fe,,1Hie oompiamts a part of their stio'v am1 practice. scribes, exhibit much practical sagacity and skiil, | — Oubtin Quarterly Journal. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- ncan,from the thud and revised English Edition. In one neat volume,royal l2mo. extra cloth with numerous illustrations, pp. 288. $1 25. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS Second American, from the second and revised London edition. With numerous illus- trations. In one neat vol., royal 12mo., extra cloth, pp.350. $120. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal l'2mo., extra cloth, pp. 296. 30 cents. BUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise, on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp.234. 80 cents. BUCKLER ON THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF FII5RO-BRONCH1- 1It> AND RHEUMATIC PNEUMONIA. In one 8vo. volume, extra cloth, pp.150. #125. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp.460. $1 25. BRODIE'S CLINICAL LECTURES ON SUR. GERY. 1vol.8vo. cloth. 350pp. $125. AND SCIENTIFIC PUBLICATIONS. .*> of BUMSTEAD (FREEMAN J ) M. D., Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. With illustrations on wood. Iu one very handsome octavo volume, of nearly 700 pages, extra cloth; S3 75. (Now Ready.) ,^e object of the author has been to prepare a complete work, which should present the results ■u, the mo.-t recent researches and modern experience on all branches of the subject, with special reference to the wants of the practitioner, theoretical disquistions being rendered subordinate to practical utility. To show the thoroughness of the outline which is thus filled up, a condensed synop.-is of the contents is subjoined. INTHOBUCTION. CONTENTS. P^T1.—Gonorrhoea AND ITS Complications.— Chapter I. Urethral Gonorrhoea in the Male. if Gleet HI. Balanitis JV Phvmosis. V. Paraphvmosis. VI. Swelled Testicle. VII. Inflammation of the Prostate. VIII. Inflammation of the'Bladder. IX. Gonorrhoea in Women. X. Gonorrhoea! Ophthalmia. XI. Gonorrheal Rheumatism. XII. Vegetations. XQI. Stric- ture of the Urethra. PART II.—The Chancroid and its Complications: Syphilis.—Chap. I. Introductory remarks. II. Chancres. III. Affections of the Lymphatic Vessels and Ganglia attendant upon Primary Sor^s. IV. General Syphilis—introductory remarks. V. Treatment of Syphilis. VI. Syphi- litic Fever—Slate of the Blood—Affections of Lymphatic Ganglia. VII. Svpnilitic Affections of the Sktn. VIII. Syphilitic Alopecia, Onychia, and Paronychia. IX. Mucous Patches. X. Gummy Tumors. XI Syphilitic Affections of Mucous Membranes. XII. Syphilitic Affections ol the Eye. XIII. Syphilitic Affections of the Ear. XIV. Syphilitic Orchitis. XV. Syphilitic Affections of the Muscles and Tendons. XVI. Syphilitic Affections of the Nervous System. XVII. Syphilitic Affections of the Periosteum and Bones. XVIII. Congenital Syphilis. BARCLAY(A.W.I, M. D., Assistant Physician to St. George's Hospital, &e. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. In one neat octavo volume, extra cloth, of 424 pages. $2 00. (Lately issued,.) The task of composing such a work is neither an easy nor a light one j but Dr. Barclay has performed it in a manner which meets our most unqualified approbation. He is no mere theorist; he knows his work thoroughly, and in attempting to perform it, has not exceeded his powers.—British Med. Journal. We venture to predict that the work wilt be de- servedly popular, and soon become, like Watson's Practice, an indispensable necessity to the practi- tioner.—N. A. Med. Journal. An inestimable work of reference for the young practitioner and student.—Nashville Med. Journal. We hope the volume will have an extensive cir- culation, not among students of medicine only, but practitioners also. They will never regret a faith- ful study of its pages.—Cincinnati Lancet. An important acquisition to medical liter iture. It is a work of high merit, both from the vast lm- por;ance of tlie subject upon which it treats, and also from the real ability displayed in its elabora- tion. In conclusion, let us bespeak for this volume that attention of every student of our art which it so richly deserves - that place in every medical library which it can so well adorn.—Peninsular Medical Journal. BARLOW (GEORGE H.), M. D. Physician to Guy's Hospital, London, &c. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M. D., author of" A Practical Treatise on Diseases of Children," &c. In one hand- some octavo volume, leather, of over 600 pages. $2 75. We recommend Dr. Barlow'sManualin the warm- est manner as a most valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, concise, practical, and sound. It is eminently a practical work, containing all that is essential, and avoiding useless theoretical discus- sion. The work supplies what has been for some time wanting, a manual of practice based upon mo- dern discoveries in pathology and rational views of treatment, of disease. It is especially intended for the use of students and junior practitioners, but it will be found hardly less useful to the experienced physician. The American editor has added to the work three chapters—on Cholera Infantum, Yellow Fever, and Cerebro-spinal Meningitis. These addi- tions, the two first of which are indispensable to a work on practice destined for the profession in this country, are executed with great judgment and fi- delity, by Dr. Condie, who has also succeeded hap- pily in imitating the conciseness and clearness of style which are such agreeable characteristics of the original book.—Boston Med. and Surg. Journal. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OP THE FEVERS OF THE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof. of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. Price $3 00. It is a work of great practical value and interest, stood deservedly high since its first publication. It containing much th»t is new relative to the several diseases of which it treats, and, with the additions of the editor, is fully up to the times. Thedistinct- ive features of the different forms of.fever are plainly and forcibly portrayed, and the lines of demarcation carefully and accurately drawn, and to the Ameri- can practitioner is a more valuable and safe guide tlian any work on fever extant—Ohio Med. and Surg Journal^ This excellent monograph on febrile disease, has will be seen that it has now reached its fourth edi- tion under the supervision of Prof. A. Clark, a gen- tleman who, from the nature of his studies and pur- suits, is well calculated to appreciate and discuss the many intricate and difficult questions in patho- logy. His annotations add much to the interest of the work, and have brought it well up to the condi- tion of the science as it exists at the present day in regard to this class of diseases.—Southern Med. and Surg. Journal. fl BLANCHARD & LEA'S MEDICAL BARWELL (RICHARD,) F- R. C. S., Assistant Surgeon Charing Cross Hospital, &c. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- ings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $3 00. (Now Ready.) "A treatise on Diseases of the Joints equal to, or rather beyond the current knowledge of the day> has long been required—my professional brethren must judge whether the ensuing pages may supply the deficiency No author is fit to estimate his own work at the moment of its completion, but it may be permitted me to say that the study of joint diseases has very much occupied my atten- tion, even from my studentship, and that for the last six or eight years my devotion to that subject has been almost unremitting.....The real weight of my work has been at the bedside, and the greatest labor devoted to interpreting symptoms and remedying their cause."—Author's Preface. At the outset we may state that the work is worthy of much praise, and bears evidence of much thoughtful and careful inquiry, and here and there of no slight originality. We have already carritd thit notice further thnn we intended to do, but not to the extent the work deserves. We can only add, that the perusal of it has afforded us great pleasure. Tue author has evidently worked very hard at his subject, and his investigations into the Physiology and Pathology of Joints have been carried on in a manner which entitles him to be listened to with attention and respect. We must not omit to men- tion the very admirable plates with which the vo- larme is enriched. We seldom meet with such strik- ing and faithful delineations of disease.—London Med. Times and Gazette, Feb. 9, 1861. We cannot take leave, however, of Mr. Barwell, to be of much use to the practising surgeon who may be in want of a treatise on diseases of the joints, and at the same time one which contains the latest information on articular affections and the opera- tions for their cure.—Dublin Med. Press, Feb. 27, 1861. This volume will be welcomed, both by the pa- thologist and the surgeon, as being the reeord of much honest research and careful investigation into the nature and treatment of a most important class of disorders. We cannot conclude this notice of a valuable and useful book without calling attention to the amount of bond, fide work it contains. In the present day of universal book-making, it is no slight matter for a volume to show laborious investiga- tion, and at the same time original thought, on the part of its author, whom ue may congratulate on without congratulating him on the interesting the successful completion of his arduous task. amount of information which he has compressed London Lancet, March 9, 1861 into his book. The work appears to us calculated I CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. In the preparation of this new edition, the author has spared no labor to render it, as heretofore, a complete and lucid exposition of the most advanced condition of its important subject The amount of the additions required to effect this object thoroughly, joined to the former large size of the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate them in his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- siology of Man, the work in its present condition therefore presents even greater claims upon the student and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's work has been considered by the profession gene- rally, both in this country and England, as the most valuable compendium on the subject of physiology in our language. This distinction it owes to the high attainments and unwearied industry of its accom- plished author. The present edition (which, like the last American one, was prepared by the author him- self), is theresult of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Phy- Biology. Nothing need be said in its praise, for its merits are universally known ; we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For Med.-Chirurg. Review. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscope. To eulogize this great work would be superfluous. We should observe, however, that in this edition the author has remodelled a large portion of the former, and the editor has added much matter of in- terest, especially in the form of illustrations. We may confidently recommend it as the most complete work on Human Physiology in our language.— Southern Med. and Surg. Journal. The most complete work on the science in our language.—Am. Med. Journal. The most complete work now extant in our lan- guage.— N. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of ecience. —JM. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter'! Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all cur medical schools, and its circula- tion among the profession has been unsurpassed bv any work in any department of medical science it is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of n sappearance will afford the highest pleasure to every student of Physiology, while it. perusa will be of infinite service in advanciM physiological science.—Ohio Med. and Surg. Journ. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taming the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher, eminently qualify him to produce what has long been wanted—a good text-book on the practical use ol the microscope. In the present volume his object has been, as stated in his Preface, " to combine, within a moderate compass, that information with regard to the use of his 'tools,' which is most essential to the working microscopist, with such an account of the objects best fitted for his *tudy, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microsco- pists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument'to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is hoped, will adapt the volume more particularly to the use of the American student. Those who are acquainted with Dr. Carpenter's previous writings on Animal and Vegetable Physio- logy , will fully understand how vast a store of know- ledge he is able to bring to bear upon so comprehen- sive a subject as the revelations of the microscope ; and even those who have no previous acquaintance with the construction or uses of this instrument, will find abundance of information conveyed in clear and simple language.—Med. Times and Gazette. Although originally not intended as a strictly medical work, the additions by Prof. Smith give it a positive claim upon the profession, for which we doubt not he will receive their sincere thanks. In- deed, we know not where the student of medicine will find such a complete and satisfactory collection of microscopic facts bearing upon physiology and practical medicine as is contained in Prof. Smith's appendix; and this of itself, it seems to us, is fully worth the cost of the volume.—Louisville Medical Review. BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of " Elements" is still retained as being more expressive of the scope of the treatise. To say that it is the best manual of Physiology i Those who have occasion for an elementary trea- now before the public, would not do sufficient justice to the author.—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subjectof Physiology. In the present, he gives the essence, as it were, of the whole.—iV. Y. Journal of Medicine. tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. The best and most complete expose1 of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80; leather, raised bands, $5 25. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and com- prehension of those truths which are daily being de- veloped in physiology.—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects— s. truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it is one no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, and of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable manner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.—Medical Times. BY the same author. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 8 BLANCHAKD to LEA'S MEDICAL CONDIE (D. F.), M. D., «tc. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large volume, 8vo., leather, of over 750 pages. $3 25. (Just Issued, 1859.) In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect "a complete and faithful exposition ol the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of practitioners and observers have been tho- roughly incorporated, and that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reierence in infantile affections. A few notices of previous editions are subjoined. We pronounced the first edition to be the best Dr. Condie's scholarship, acumen; industry, and practical sense are manifested in this.as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction.—Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. We feel assured from actual experience that nc physician's library can be complete without a copy of this work.—N. Y. Journal of Medicine. A veritable paediatric encyclopaedia, and an honoi to American medical literature.—Ohio Medical and Surgical Journal. work on the diseases of children in the English language, and, notwithstanding all that has l)een published, we still regard it in that light.—Medical Examiner. The value of works by native authors on the dis- eases which the physician is called upon to combat, will be appreciated by all; and the work of Dr. Con- die has gained for itself the character of a safe guide for students, and a useful work for consultation by those engaged in practice.—N. Y. Med Times. This is the fourth edition of this deservedly popu- lar treatise. During the interval since the last edi- tion, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said bt fore, we do not know of a better book on diseases of ehil- We feel persuaded that the American medical pro- dren, and to a large part of its recommendations we fession will soon regard it not only as a very good, yield an unhesitating concurrence.—Buffalo Med. but as the vert best "Practical Treatise on the Journal. Diseases of Children.»_^^enca» Medical Journal Perhaps the mostfnll and complete work now be- In the department of infantile therapeutics, the fore the profession of the United States; indeed, we work of Dr. Condie is considered one of the best may say in the English language. It is vastly supe- which has been published in the English language, rior to most of its predecessors.—Transylvania Med. — The Stethoscope. \Journal CHRISTISON (ROBERT), M. D., V. P. R. S. E., «tc. A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURKS OF THE JOINTS—Edited by Bransby B. Cooper, F. R. S., &c. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial 8vo., extra cloth, with 252 figures, on 36 plates. $2 50. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., ex- Ira cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 80 cents. CLYMF.R ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT In one octavo volume, leather, of 600 pages. SI 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition. revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts, dd 720 $3 50. rr CARSON (JOSEPH), M. D.. Professor of Materia Medica and Pharmacy in the University of Pennsylvania SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA' MEDIOA AND PHARMACY, delivered in the University of Pennsylvania Second and revised edi- tion. In one very neat octavo volume, extra cloth, of 208 pages. $150. «»«*« wii CURLING (T. B.), F.R.S.. Surgeon to the London Hospital, President of the Hunterian Society &o A PRACTICAL TREATISE ON DISEASES OF THE TESTIS SPERMA TIC CORD, AND SCROTUM. Second American, from the second and enlarged S"^ Uon. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. *2 W, AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treat^e on the Diseases of Children," toe With 194 illustrations* In one very handsome octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) This work has been so long an established favorite, both as a text-book for the learner and as a reliable aid in consultation lor the practitioner, that in presenting a new edition it is only necessary to call attention to the very extended improvements which it has received Having had the benefit of two revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- roughly brought up with the latest results of European investigation in all departments of the sci- ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty for the American editor to introduce, but he has endeavored to insert whatever has since appeared, together with such matters as his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. Tue result of all these additions is that the work now con- tains fully one-half more matter than the last American edition, with nearly one-half more illus- trations, so lhat notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction; the opinion of all writers of authority is given on questions of diffi- culty, as well as the directions and advice of the learned autnor himself, to which he adds the result of -statistical inquiry, putting statistics in their pio per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It ap- pears to be written with the true design of a book on medicine, viz : to give all that is known on the sub- ject of which he treats, both theoretically and prac- tically, and to advance such opinions of his own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Cnur- cnill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the student, and we hope it may be extensively pur- chased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press, June 20, 1860. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will bp found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but me work on midwifery, and permitted to choose, ive would unhesitatingly take Churchill.—Western yied. and Surg. Journal. It is impossible to conceive a more useful and jlegant manual than Dr. Churchill's Practice of Vlidwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric scienco which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the greatamountof statistical researeh which it contains, have served to place it in the first rank of works in this departmentof medical science. —N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for tho frequent consultation of the young practitioner.— | American Medical Journal. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. by the same author. (Lately Published.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M.D. In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of tiie Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. 10 BLANCHARD to LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., Sec. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." With nume- rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subjeot, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. —Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject fron the British press.—Dublin Quart. Journal. It comprises, unquestionably, one of the most ex- act and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet been published.—Am. Journ. Med. Sciences. This work is the most reliable which we possess on this subject; and is deservedly popular with the profession.—Charleston Med. Journal, July, 1857. We know of no author who deserves that appro- bation, on "the diseases of females," to the same DICKSON (S. H.)5 M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume, of 750 pages, leather. $3 75. (Just Issued.) The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) A work which like Druitt's Surgery has for so many years maintained the position of a lead- ing favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a scienee and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edilion, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artislical execution of the work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive work on surgery, has undergone many corrections, improvements, and additions, and the principles and the practice of the art have been brought down to the latest record and observation. Of the operations in surgery it is impossible to speak too highly. The descriptions are so clear and concise, and the illus- trations so accurate and numerous, that the student can have no difficulty, with instrument in hand, and book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much neglected department of medical education.—British and Foreign Medico-Chirurg. Review, Jan. I860. In the present edition the author has entirely re- written many of the chapters, and has incorporated nothing of real practical importance has been omit- ted ; it presents a faithful epitome of everything re- lating t) surgery up to the present hour. It is de- servedly a popular manual, both with the student and practitioner.—London Lancet, Nov. 19,1859. In closing this brief notice, we recommend as cor- dially as ever this most useful and comprehensive hand-book. It must prove a vast assistance, not only to the student of surgery, but also to the busy practitioner who may not have the leisure to devote himself to the study of more lengthy volumes.— London Med. Times and Gazette, Oct. 22,1859. In a word, this eighth edition of Dr. Druitt's Manual of Surgery is all that the surgical student the various improvements and additions in modern I or practitioner could desire. — Dublin Quarterly surgery. On carefully going over it, we find that ] Journal of Med. Sciences, Nov. 1859. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $4 00; leather, raised bands, $4 50. (Just Issued, 1861.) The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Im- bibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and the work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is in- tended It will be seen, therefore, that Dr. Dalton's best! efforts have been directed towards perfecting his ] work. The additions are marked by tiie same fea- tures which characterize the remainder of the vol- ume, and render it by far the most desirable text- book on physiology to place in the hands of the student which, so far as we are aware, exists in the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's book for the classes for which it is intend- ed, satisfied as we are that it is better acapted to their uee than any other work of the kind to which they have access.—American Journal of the Med. Sciences, April, 1861. It is, therefore, no disparagement to the many books upon physiology, most excellent in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the cur- rent year. It states in comprehensive but concise diction, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from the discussion of unsettled or theoretical points. Herein it is unique; and these characteristics ren- oer it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physi- ology thus presented that lies at the foundation of correct pathological knowledge; and this in turn is the basis of rational therapeutics ; so that patholo- gy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. —-Cincinnati Lancet, May, 1861. Dr. Dalton needs no word of praise from us. He is universally recognized as among the first, if not the very first, of American physiologists now Jiving. The first edition of his admirable work appeared but two years since, and the advance of science, his own original views and experiments, together with a desire to supply what he considered some deficien- cies in the first edition, have already made the pre- sent one a necessity, and it will no doubt be even more eagerly sought for than the first. That it is not merely a reprint, will be seen from the author's statement of the following principal additions and alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admira- ble tor their clearness in expressing exactly what their author intended.—Boston Medical and Surgi- cal Journal, March 28, 1861. It is unnecessary to give a detail of the additions; suffice it to say, that they are numerous and import- ant, and such as will render the worK still more valuable and acceptable to the profession as a learn- ed and original treatise on this all-important branch of medicine. All that was said in commendation of the getting up of the first edition, and the superior style of the illustrations, apply with equal force to this. No better work on physiology can be placed in the hand of the student.—St. Louis Medical and Surgical Journal, May, 1861. These additions, while testifying to the learning and industry of the author, render the book exceed- ingly useful, as the most complete expose of a sci- ence, of which Dr. Dalton is doubtless the ablest representative on this side of the Atlantic.—New Orleans Med. Times, May, 1861. A second edition of this deservedly popular work having been called for in the short space of two years, the author has supplied deficiencies, whicn existed in the former volume, and has thus more completely fulfilled his design of presenting to the profession a reliable and precise text-book, and one which we consider the best outline on the subject of which it treats, in any language.—N. American Medico-Chirurg. Review, May, 1661. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. toe. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *** This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical and.Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a The editors are practitioners of established repu- tation, and the list of contributors embraces many of the most eminent professors and teachers of Lon- don, Edinburgh, Dublin, and Glasgow. It is, in- deed, the great merit ol this work that the principal articles have been furnished by practitioners who have not only devoted especial attention to the dis- eases about which they have written, but have also enjoyed opportunities for an extensive practi- cal acquaintance with them and whose reputation s been to us, both as learner and teacher, a carries the assurance of their competency justly to work for ready and frequent reference, one in which appreciate the opinions of others, while it stamps modem English medicine is exhibited in the most their own doctrines wit! high and just authority.— I American Medical Journal. KIOUCIU uuft""- -——'---- —---*-------- advantageous light.—Medical Examiner. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases aad many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of 600 pages. $320. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. The last edition. In one volume, octavo, extra cloth, 548 pages. $2 80 DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. 83 00 12 BLANCHARD to LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, toe. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. in one very large and handsome octavo volume, of 992 double-columned pages, in small type; strongly bound in leather, with raised bands. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the pase. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publisher^ have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care hns been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition of which, it has betome our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of ever} medical term, that in this edition " about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to m:ike it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med.Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison and competition__Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, may be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, are the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example is something appalling to contemplate. The author tells us in his preface that he has added about sis thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language.—Silliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medica? terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 18S&. It is universally acknowledged, we believe, thai this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its prepa?ation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louis Med. and Surg. Journ., Jan. 1858. It is the foundation stone of a good medical libra- ry, and should always be included in the first list o4 books purchased by the medieal student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly tbe most perfect in the English language.—Med. and Surg. Reporter, Jan. 1858. It is now emphatically the Medieal Dictionary of the English language, and for it there is no substi- tute.— N. H. Med. Journ., Jan. 1838.. It is scarcely necessary to remark that any medi- cal library wanting a copy of Dunglison's Lexicon must be imperfect.—Cin. Lancet, Jan. 1858. We have ever considered it the best authority pub- lished, and the present edition we may safely say liai no equal in the world.—Peninsular Med. Journal, Jan. 1858. The most complete authority on the subject to b« found in any language.—7a. Med. Journal, Feb. '36. BY THE SAME AUTHOB. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and TL©- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. % Eighth edition. Thoroughly revised and exten- lively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 page*. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects ; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- plete repertory of tacts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.—Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a pcilc*. t mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.— Nashville Journ of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the sreatencyclopffidia on the subject, and worthy of a place in every phy- sician's library.—Western Lancet. BY the same author. (A new edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. In announcing a new edition of Dr. Dunglison's General Tnerapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he has made to the work, and the careful re- Vision to which he has subjected the whole.—N. A. Medico-Chir. Review, Jan. 1858. The work will, we have little doubt, be bought and read by the majority of medical studentsj us size, arrangement, xind reliability recommend it to all; no one, we venture to predict, will study it. without profit, and there are few to whom it will not be in some measure useful as a work of ref-r- ence. The young practitioner, more especially, will find the copious indexes appendtd to this etli:ion of great assistance in the sW-ction and preparation of suitable formulae.—Charleston Med. journ. and Re- view, Jan. 1858. BY THE SAME AUTHOR. (A new Edition.) NEW REMEDIES, WTTH FORMULA FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the " New Remedies" having been called for, the author has endesvored to add everything of moment that has appeared since the publication of the last edition. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as Tar as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection ; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.—Preface. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire tn examine the original papers.—The American Journal of Pharmacy. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which i« added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform The whole accompanied with a tew brief Pharmaceutic and Medical Observations. Eleventh edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy (Preparing.) 14 BLANCHARD to LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, tec. THE SCIENCE AND ART OF SURGERY; bring a Treatise on Sttroical In.iuriks. Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, leather, raised bands. $4 50. (Just Issued.) The verv distinguished favor with which this work has been received on both sides of the Atlan- tic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is, in our humble judgment, decidedly the best book of the kind in the English language. Strange that just such books are notoftener produced by pub [ic teachers of surgery in this country and Great Britain Indeed, it is a matter of great astonishment. but no less true than astonishing, that of the many works on surgery republished in this country within Che last fifteen or twenty years as text-books for medical students, this is the only one that even ap- proximates to the fulfilment of the peculiar wants of young men just entering upon the study of this branch of the profession.— Western Jour .of Med. anil Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard it the most serviceable guide which he can consult. He will find a fulness of detail leadinghim throLgh every step of the operation, and not deserting him until the final issue of the case is decided.—Sethoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express oui estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our text-books.— Nashville Journal of Medicine and Surgery. Prof. Enclisen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes ; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.— N. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. %3 00. We regard it, in point both of arrangement and of the marked ability of its treatment of the subjects, as destined to take the first rank in works of this class. So far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the diagnosis of doubtful cases, and in shedding light upon difficult phenomena.—Buffalo Med. Journal. A work of original observation of the highest merit. We recommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon cases numerically examined, it carries the evidence of careful study and discrimina- tion upon every pasje. It does credit to the author, and, through him, to the profession in this country. It is, what we cannot call every book upon auscul- tation, a readable book.—Am. Jour. Med. Sciences. BY the same author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $2 75. great forceand beauty, and, with his previous work, places him at the head of American writers upon diseases of the chest. We nave adopted his work upon the heart as a text-book, believing it to be more valuable for that purpose than any work of the kind that has yet appeared.—Nashville Med. Journ. With more than pleasure do ive hail the advent of this work, for it fills a wide gap on the list cf text- books for our schools, and is, for the practitioner, the n.ost valuable practical work of its kind.—N. O. Med. News. We do no* know that Dr. Flint has written any- thing which is not first rate; but this, his latest con- tribution to medical literature, in our opinion, sur- passes all the others. The work is most comprehen- sive in its scope, and most sound in the views it enun- ciates. The descriptions are clear and methodical; the statements are substantiated by facts, ai d are made with such simplicity and sincerity, that with- out them they would carry conviction. The style is admirably clear, direct, and free from dryness With Dr. Walshe's excellent treatise before us, we lu.ve no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language —Boston Med. and Surg. Journal. We have thus endeavored to present our readers with a fair analysis of this remarkable work. Pre- ferring to employ the very words of the distinguished author, wherever it was possible, we have essayed to condense into the briefest space a general view of his observations and suggestions, and to direct the attention of our brethren to the abounding stores of valuable matter here collected and arranged for their use and instruction. No medica1 library will here after be considered complete without this volume ; and we trusf it will promptly find its way into the hands of every Ame'ican student and physician.— N Am. Med. Chir. Review. This last work of Prof. Flint will add much to his previous well-enrned celebrity, as a writer of In regard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and ju- dicious. Considering the present state of science, such a work was much needed. It should be in the hands of every practitioner.—Chicago Med. Journal. But these are very trivial spots, and in no wise prevent us from declaring our most hearty approval of the author's ability, industry, and conscientious- ness.—Dublin Quarterly Journal of Med. Sciences. He has labored on wi'h the same industry and care, and his place among the first authors of our country is becoming fully established. To this end, the work whose title is given above, contributes in no small degree. Our spa e will not admit of sn extended analysis, :ind we will close this brief notice by commending it without reserve to every class of readers in the profession.—Peninsular Med. Journ. AND SCIENTIFIC PUBLICATIONS. 15 FOWNES (GEORGE), PH. D., &c. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. From the seventh revised and corrected London edition. With one hundred and ninety-seven illustrations Edited by Robert Bridges, M. D. In one large royal 12mo. volume, of 600 pages. In leather, $1 65; extra cloth, $1 50. (Just Issued.) The death of the author having placed the editorial care of this work in the practised hands ol Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been used to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- ment of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed within the convenient and portable limits of a'moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank Dr. Fownes' excellent work has been universally recognized everywhere in his own and this country, as the best elementary treatise on chemistry in the English tongue, and is very generallv adopted, we believe, as the standard text- book in all < ur colleges, both literary and scientific.—Charleston Med. Journ. and Review. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work. and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Scienct FISKE FUND PRIZE ESSAYS —THE EF- FECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin Lee, M.R.C.S , London, and THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES By Edward Warhen, M. D , of Edenton, N. C. To- gether in one neat 8vo volume, extra cloth. SI 00, FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. Ore volume, royal l2mo., extra cloth. 75 cents FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges M D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 00. *** Part II., completing the work from p. 431 to end, with Index, Title Matter, toe, may be had separate, cloth backs and paper sides. Price $2 50 From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been familiar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. No reader of English works on this science can afTord to be without this edition of Prof. Graham's Elements.—Silliman's Journal, March, 1658, From Prof. Wolcott Gibbs, N. Y. Free Academy. The work is an admirable one in all respects,and its republication here cannot fiil to exert a positive influence upon the progress of science in this country. GRIFFITH (ROBERT E.), M. D., Sec. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Phaxmacen. ^sts Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas M D Profe«so7o Materia Medica in the Philadelphia College of Pharmacy. In one large ard handsomeOctavo volume, extra cloth, of 650 pages, double columns. $3 00; or in sheep, $3 25. This is a work of six hundred and fifty one pages. ^bracing all on the subject of preparing and admi- ustering medicines that can be desired by the physi- It was a work requiring much perseverance, and when published was looked upon as by far the best work of its kind that had issued from the American press. Prof Thomas has certainly " unproved," as well as added to this Formulary, and has rendered it additionally deserving of the confidence of pharma- ceutists and physicians.—Am. Journalof Pharmacy. We are happy to announce a new and improved edition of this, one of the most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found of daily usefulness to practitioners ot medicine; it if better adapted to their purposes than the dispensato rie« —Southern Med. and Surg. Journal ian and pharmaceutist.— Western Lancet. The amountof useful, every-day matter.for a prac ticing physician, is really immense.—Boston Med and Surg. Journal. This edition has been greatly improved by the re- vision and ample additions of Dr Thomas, and is now, we believe, one of the most complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the recent improvements \ work of this kind appears to us indispensable to ihe it i« on.-of the most useful books a country practl-l physician, and there is none we can more cordially tioner can possibly Have.—Medical Chronicle. ' recommend. N Y Journalof Medicine. 15 BLANCHARD to LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, tec. Enlarged Edition—Now Ready, January, 1862. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Opera- tive. Illustrated by Twelve Hundred and Twenty-seven Engravinos. Second edition, much enUrg-d and ear-fully revised. In two large and beautifully printed octavo volumes, of about tweniy-two hundred pages ; strongly bound in leather, with raised bands. Price $12. The exhaustion in little more than two years of a large edition of so elaborate and comprehen- sive a woik as this is the best evidence that the author was not mistaken in his estimate of the warn which existed of a complete American System of Surgery, presenting the science in all its necessary de'ails and in all its branches. That he has succeeded in the attempt to supply this want is shown not only by the rapid sale of the work, but also by the vpry favorable manner in which it has been received by the organs of the profession in this country and in Europe, and by the fact that nd we accordingly welcome it. as a valu- able addition to medical literature. Intermediate fulness of detail between the treatises of S lar out with both branches of his subject in view. His description of each particular part is followed by a notice of its relations to tie parts with which it is connected, and this, too, sufficiently ample for all the purposes of the operative surgeon. After de- scribing the bones and muscles, he gives a concise statement of the fractures to which the hones of the extremities are most liable, together with the amount and direction of the displacement to which the fragments are subjected by muscular action. The section on arteries is remarkably full and ac- curate. Not. only is the surgical anatomv given to every important vessel, with directions for its liga- tion, but at the end of the description of each arte- rial trunk we have a useful summary of the irregu- larities which may occur in its origin, course, and termination.—N. A. Med. Chir. Review, Mar. 1659. Mr. Gray's book, in excellency of arrangement and completeness of execution, exceeds any w>rk on anatomy hitherto published in-the English lan- pey and of Wilson, its characteristic merit, lies in | guage, affording a complete view of the structure of the number and excellence of the engravings it contains. Most of these are original, of much larger than ordinary size, and admirably executed. The various parts are also lettered after the plan adopted in Holden's Osteology. It would be diffi- cult to over-estimate the advantages offertd by this mode of pic orial illusration Bones, ligaments, muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names; thus enabling the student to c( mprehend,ataglance, what would otherwise often be ignoied, or at any rate, acquired only by prolonged and irksome ap- plication. In conclusion, we heartily commend the work of Mr. Gray to the attention of the meuical profession, feeling certain that it should be regarded as one of the most valuable eontrinutions ever made to educational literature —N. Y. Monthly Review. Dec. 1859. In this view, we regard the work of Mr Gray as far belttr adapted to the wants of the profession, and especially of the student, than any treatise on anatomy yet published in this country. It is destined. we believe, co supersede ill others, both as a manual of oi6tections, and a standard of reference to the student of general or relative anatomy. — N. Y. Journal of Medicine, Nov. 1S59. For this truly admirable work the profession is indebted to ihe distinguished author of "Gray on the Spleen." Tne vacancy it fills has been long felt the human body, with especial reference to practical surgery. Thus the volume constitutes a perfect book of reference for the practitioner, demanding a place in even the most limited library of the physician or surgeon, and a work of necessity for the student to fix in his mind what he has learned by the dissecting knife from the book of nature.—The Dublin Quar- terly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present volume cannot but present many ad- vantages to the student of anatomy. To the zealous disciple of Vesalius, earnestly desirous of real im- provement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simply desirous of "cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of their development. The Btudy of these parts is thus made one of comparative efMirnt«. Hmirn inth. ......i... —. .j„*.„ iir...__ ▼ _ . this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation— Charleston Med. Journ. We know of no dictionary better arranged and adapted, ltisnotencumhered with theobsoleteterms of a bygone age, but it contains all that are now in down to the very latest date.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions w'e have, and ought always to be upon the Btudent's table__ Southern Med. and Surg. Journal. HOLLAND'S MEDICAL NOTES AND RE- FLECTIONS From the third London edition. In one handsome octavo volume, extra cloth. S3. HORNER'S SPECIAL ANATOAIV AND HlS- TOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, ex- tra cloth, of more than 1000 pages, with over 300 illustrations. $6 00. AND SCIENTIFIC PUBLICATIONS. 19 HODGE (HUGH L.), M.D., Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &c. ON DISEASES PECULIAR TO WOMEN, including Displacements of the ■Jlerus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 pages, extra cloth. $3 25. (Now Ready.) priate management—his ample experience, his ma- tured judgment, and his perfect conscientiousness— invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim.— Am. Journ. Med. Sciences, Jan. 1861. Indeed, although no part of the volume is not emi- nently deserving of perusal and study, we think that the nine chapters devoted to this subject, are espe- ciallv so, and we know of no more valuable mono- graph upon the symptoms, prognosis, and manage- ment of these annoying maladies than is constituted by this part of the work. We cannot but regard it as one of the most original and mjst practical works of the day ; one which every accoucheur and physi- cian should most carefully read; for we are per- suaded that he will arise from its perusal with new ideas, which will induct him into a more rational practice in regard to many a suffering female, who may have placed her health in his hands.—British American Journal, Feb. 1661. Of the many excellences of the work we will not speak at length. We advise all who would acquire a knowledge of the proper management of the mala- dies of which it treats, to study it with care. The second part is of itself a most valuable contribution to the practice of our art.—Am. Med. Monthly and New York Review, Feb. 1861. We will say at once that the work fulfils its object cnpnally well j and we will moreover venture the assertion that it will inaugurate an imnroved prac- tice throughout this whole country. The secrets of the author'6 success are so clearly revealed that the attentivestudent cannot fail to insure a goodly por- tion of similar success in his own practice. It is a credit to all medical literature; and we add, that the physician who does not place it in his library, and who does not faithfully con its pages, will lose a vast deal of knowledge that would be most useful to himself and beneficial to his patients. It is a practical work of the highest order of merit; and it will fake rank as such immediately.—Maryland and Virginia Medical Journal, Feb. 1861. This contribution towards the elucidation of the pathology and treatment of some of the diseases peculiar to women, cannot fail to meet with a favor- able reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obscuiity; the amount of malaise and even of actual suffering by which they are invariably attended; their obstinacy, the difficulty with which they are overcome, and their disposition again and again to leeur—these, taken in connection with the entire competency of the author to render a correct ac- count of their nature, their causes, and their appro- The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guy's Hospital, &c. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, CESOPHAGUS, STOMACH, CAECUM, AND INTES- TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra cloth $ 1 75. (Now Ready.) JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. JONES (C. HANDFIELD), F. R. S., &. EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. $3 75. obliged to glean froma great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work As a concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and Drevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.—Western Lancet. KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A new American, from the third and improved London edition. With two hundred illustrations. In one large and handsome royal 12mo. volume, leather, pp. 586. $2 00. (Lately Published.) This is a new and very much improved edition of Dr. Kirkes' well-known Handbook of Physiology. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.—Dublin Quarterly Journal. One of the very best handbooks of Physiology we possess—presenting just such an outline of the sci- ence as the student requires during his attendance upon a course of lectures, or for reference whilst preparing for examination.— Am. Medieal Journal Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs. Kirkes and Paget, have the gift of telling us what we want to know, without thinking it necessary to tell us all they know.—Boston Med and Surg. Journal. , For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know__Charleston Med. Journal. 20 BLANCHARD to LEA'S MEDICAL KNAPP'S TECHNOLOGY ; or, Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richardson, and Prof. W. R. Johnson. In two handsomi 8vo. vols., withabout 500 wood engravings. $6 00. LAYCOCK S LECTURKS ON THE PRINCI- PLES AND MKTHOhS OF AIKDICAL OB- SERVATION AND RESEARCH. For th« Use of Advanced Students and Junior Practitionrrs. In one royal 12mo. volume, extra cloth. Price$1. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE -CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lali.emand. Translated and edited by Henry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESICULA SEMINALES; and their associated organs. With special r.-ter- ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M.D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. From Professor S. H. Dickson, Charleston, S. C., September 18, 1855. A monument of intelligent and well applied re- search, almost without, example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in our city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this ible and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. BY THE SAME AUTHOR. PNEUMONIA ; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In oi e handsome octavo volume, extra cloth, of 500 pages. $3 00. LAWRENCE (W.), F. R. S., &c. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. LUDLOW (J. L.l, M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume, leather, of 816 large pages $2 50. We know 'if no better companion for the student I crammed into his head by the various professors to during the hours spent in the lecture room, or to re- whom he is compelled to listen.— Western Lancet, fresh, at a glance, his memory of the various topics | May, 1857. LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., toe, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. $rj 00. The work of Lehmann stands unrivalled as the The most important contribution as yet made to most comprehensive book of reference and informa- Physiological Chemistry.__Am. Journal Med. Sec- tion extant on every branch of the subject on which tnces, Jan. 1856. it treats.—Edinburgh Journal of Medical Science. by the same author. (Lately Published.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German. with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University ol Pennsylvania. With illus- trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. Prom Prof. Jackson's Introductory Essay. In adopting the handbook of Dr Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weight of his autho- rity in that important department of medical science are fully recognized. AND SCIENTIFIC PUBLICATIONS 21 LYONS (ROBERT D.l, K. C. C, Late Pathologist in-chief to the British Army in the Crimea, &c. A TREATISE OX FKVER; or. selections from a course of Lectures on Fever. Being part of a course of Theorv and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth; $2 00. (Now Ready.) From the Author's Preface. "lam induced to publish this work on Fever with a view to bring within the reach of the student and junior practitioner, in a convenient form, the more recent results of inquiries into the la(l("",0gy a»d Therapeutics of this formidable class of di-eases. " The works of the great writers on Fever are so numerous, and in the present day are scattered t" f°.many l8ng»ages, that they are difficult of access, not only to students but also to practitioners. 1 shall deem myself fortunate if I can in any measure supply the want which is felt in this respect. We have great pleasure in recommending Dr. Lyons' work on Fever to the attention ot the pro- fession. It is a work which cannot fail to enhance the author's previous well-earned reputation, as a diligent, careful, and accurate observer.—British M"i. Journal, March 2, 1861. Taken ai a whole we can recommend it in the highest terms as well worthy the careful perusal and study of every student and practitioner of medi- cine. We consider the work a most valuable addi- tion to medical literature, and one destined to wield no little influence over the mind of the profession.— Mei and Swg. Report' r, May 4, 1861. This is an admirable work upon the most remark- able and most important, class of diseases to which mankind are liable.—Med. Journ. of N. Carolina, May, 1861. MEIGS1CHARLES D.), M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. Though the work has received only five pages of enlargement, its chapters throughout wear the im- pressof careful revision. Expungingand rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions —Western Lancet, Jan. 1857. The best American work on Midwifery that is accessible to the student and practitioner—N. W. Med. and Surg. Journal, Jan. 1857. This is a standard work by a great American Ob- stetrician. It is the third and last edition, and, in the language of the preface, the author has "brought the subject up to the latest dates of real improve- ment in our art and Science."—Nashville Journ. of Med. and Surg., May, 1857. BY THE same author. (Just Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lec^ tures to his Class. Fourth and Improved edition. In one large and beautifully printed octave volume, leather, of over 700 pages. $3 60. In other respects, in our estimation, too much can- not be said in praise of this work. It abounds with brautiful passages, and for conciseness, for origin- ality, and for all that is commendable in a work on the diseases of ffmales, it is not excelled, and pro- b ibly not equalled in the English language. On the whole, we know of no worn on the diseases of wo- men which we can so cordially commend to the student and practitioneras the one before us.—Ohio Med. and Surg. Journal. The body of the book is worthy of attentive con- sideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external or- gans, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality.—The British and Foreign Medico-Chi- rurgical Review. Every chapter is replete with practical instruc- tion, and bears the impress of being the composition of an acute and experienced mind. There is a terse- ness, and at the same time an accuracy in his de- scription ol symptoms, and in the rules for diagnosis, which cannot fail to recommend the vol ime to the attention of the reader.—Ranking's Abstract. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the experience of many years.—Dublin Quarterly Journal. Full of important matter, conveyed in a ready and agreeaDle manner.—St.Louis Med. and Surg. Jour. There is an off-hand fervor, a glow, and a warm- leartedness infecting the effirt of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and mode to stand out in such bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. BY THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. The instructive and interesting author of this work, whose previous labors have placed his coun- trymen under deep and abiding obligations, again challenges their admiration in the fresh and vigor- ous, attractive and racy pages before us. It is a de- lectable book. * # * This treatise upon child- bed fevers will have an extensive sale, being des- tined, as it deserves, to find a place in the library of every practitioner who scorns to lag in the rear.— Nashville Journal of Medicine andSurgery. BY THE SAME AUTHOR ; WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style ol art. In one handsome octavo volume, extra cloth. $4 50. 22 BLANCHARD to LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $11 00. %* The size of this work prevents its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. No practitioner whose means will admit should fail to possess it.—Ranking^ Abstract. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- eal and Surgical Journal. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- eal Examiner. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. A work which has no parallel in point of accu- racy and cheapness in the English language.—N. Y. Journal of Medicine. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.—The Nei» Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.—The Western Journal of Medi- cine and Surgery. MILLER (HENRY), M . D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &o.; including the Treat- ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- tavo volume, of over 600 pages. (Lately Published.) $3 75. We congratulate the author that the task is done. We congratulate him that he has given to the medi- cal public a work which will secure for him a high and permanent position among the standard autho- rities on the principles and practice of obstetrics. Congratulations are not less due to the medical pro- fession of this country, on the acquisition of a trea- tise embodying the results of the studies, reflections, and experience of Prof. Miller. Few men, if any, in this country, are more competent than he to write on this department of medicine. Engaged for thirty- five years in an extended practice of obstetrics, for many years a teacher of this branch of instruction in one of the largest of our institutions, a diligent Btudent as well as a careful observer, an original and independent thinker, wedded to no hobbies, ever ready to consider without prejudice new views, and to adopt innovations if they are really improvements, and withal a clear, agreeable writer, a practical treatise from his pen could not fail to possess great value.—Buffalo Med Journal. In fact, this volume must take its place among the standard systematic treatises on obstetrics; a posi- tion to which its merits justly entitle it. The style is such that the descriptions are clear, and each sub- ject is discussed and elucidated with due regard to its practical bearings, which cannot fail to make it acceptable and valuable to both students and prac- titioners. We cannot, however, close this brief notice without congratulating the author and the profession on the production of such an excellent treatise. The author is a western man of whom we feel proud, and we cannot but think that his book will find many readers and warm admirers wherever obstetrics is taught and studied as a science and an art.—The Cincinnati Lancet and Observer. A most respectable and valuable addition to our home medical literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country prac- titioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the science; and we hope to see this American produc- tion generally consulted by the profession.—Va. Med. Journal. MACKENZIE (WJ, M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section ol the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with plates and numerous wood-cuts. $5 25. The treatise of Dr. Mackenzie indisputably holds the firstplace, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases of the Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the ■ubject, practically as well as theoretically,and the able manner in which the author's stores of learning and experience were rendered available for general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firmly established. We consider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make him- self familiar with this the most complete work in the English language upon the diseases of the eye. —Med. Times and Gazette. MAVNE'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. With every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formulae of the U. S. Pharmacopoeia, by R. E. Griffith,M.D 1 12mo. vol. ex.cl.,300pp. 75 c. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan, A.B.,M.D. WithnumerousiJlustrationsonwood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. $2 25. AND SCIENTIFIC PUBLICATIONS 2J MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. from the third and revised leather, of 700 pages, with two rruiessor 01 ourgery in me university 01 n.uiii PRINCIPLES OF SURGERY. Fourth American, : Edinburgh edition. In one large and very beautiful volume, hundred ami f'nrttr ;n.,ct..ot;,..^ „„ ,„„„a «q i<; idred and forty illustrations on wood. $3 75 aMUt W"rk of Mr- Mi'ler is too well and too favor- aniy known among us, as one of our best text-books, to render any further notice of it necessary than the announcement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high— we know not its superior__Boston Med. and Surg. Journal. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of principle or depth of reason- ing and research. No physician who values his re- putation, or seeks the interests of his clients, can acquit himself before his God and the world without making himself familiar with the sound and philo- sophical views developed in the foregoing book.— New Orleans Med. and Surg. Journal. BY THE SAME AUTHOR. (Just Issued.) THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. No encomium of ours could add to the popularity Of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to Which no conscientious surgeon would be willing to practice his art.—Southern Med. and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the "Principles" and the "Practice" of Surgery by Mr. Miller—ot so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one Bhould be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding theattention. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recom- mended.—Southern Journal of Med. and Physical Sciences. MORLAND (W. W.), M. D., Fellow of the Massachusetts Medical Society, &c. DISEASES OF THE URINARY ORGANS; a' Compendium of their Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, of about 600 pages, extra cloth. (Just Issued.) $3 50. refer. This desideratum has been supplied by Dr. Morland, and it has been ably done. He has placed before us a full, judicious, and reliable digest. Each subject is treated with sufficient minuteness, yet in a succinct, narrational style, such as to render the work one of great interest, and one which will prove in the highest degree useful to the general practitioner.—N. Y. Journ. of Medicine, Taken as a whole, we can recommend Dr. Mor- land's compendium as a very desirable addition to the library of every medical or surgical practi- tioner.— Brit, and For. Med.-Chir. Rev., April, 1859. Every medical practitioner whose attention has been to any extent attracted towards the class of diseases to which this treatise relates, must have often and sorely experienced the want of some full, yet concise rjcent compendium to which he could BY THE same author—(Now Ready.) THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY" SECRETION. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11, 1861. In one small octavo volume, S3 pages, extra cloth. 75 cents. MONTGOMERY (W. F.), M. D., M. R. I. A., tc, Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pages. (Lately Published.) $3 75. fresh, and vigorous, and classical is our author's style; and one forgets, in the renewed charm of •wery page, that it, and every line, and every word has been weighed and reweighed through years of preparation; that this is of all others the book of Obstetric Law, on each of its several topics; on all points connected with pregnancy, to be everywhere received as a manual of special jurisprudence, at once announcing fact, affording argument, establish- ing precedent, and governing alike the juryman, ad- vocate, and judge. — N. A. Med.-Chir. Review. A book unusually rich in practical suggestions.— Am. Journal Med. Sciences, Jan. 1857. These several subjects so interesting in them- selves, and so important, every one of them, to the most delicate and precious of social relations, con- trolling often the honor and domestic peace of a family, the legitimacy of offspring, or the life of its parent, are all treated with an elegance of diction, fulness of illustrations, acuteness and justice of rea- soning, unparalleled in obstetrics, and unsurpassed in medicine. The reader's interest can never flag, so MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, ol 570 pages, with over 500 engravings on wood. $2 75, BLANCHARD to LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital,&c; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 00. The very flattering reception which has been accorded to this work, and the high estimate placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with the advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by a slight enlargement of the page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge of the changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are acquainted.—Med. Examiner. Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class.—Transylvania Med. Journal In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. There is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the gradu- ates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.—The Stetho- scope NELIGAN (J. MOORE), M. D., M. R. I.A., &c. (A splendid work. Just Issued.) ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the profession some years since. The publishers feel justified in saying that few more beautifully exe- cuted plates have ever been presented to the profession of this country. give, at a coup d'ozil, the remarkable peculiarities of each individual variety. And while thus the dis ease is rendered more definable, there is yet no loss of proportion incurred by the necessary concentra- tion. Each figure is highly colored, and so truthful has the artist been that the mostfastid ous observer could not justly take exception to the correctness of the execution of the pictures under his scrutiny.— Montreal Med. Chronicle. Neligan's Atlas of Cutaneous Diseases supplies a long existent desideratum much felt by the largest class of our profession. It presents, in quarto size, 16 plates, each containing from 3 to 6 figures, and forming in all a total of 90 distinct representations of the different species of skin affections, grouped together in genera or families. The illustrations have been taken from nature, and have been copied with such fidelity that they present a striking picture of life; in which the reduced scale aptly serves to BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Third American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. The two volumes will be sent by mail on receipt of Five Dollars. OWEN ON THE DIFFERENT FORMS OF THE SKELJKTON. AND OF THE TEETH. One vol. royal 12mo., extra cloth with numerous illustrations. SI 25 PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania $3° 75 °ne VCry dS0me octavo volume> leather, of 780 pages, with 316 illustrations. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught.—The Stethoscope. Prof. Pirrie, in the work before us, has elabo- rately discussed the principles of surgery, and a safe and effectual practice predicated upon them Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery__ Nashville Journal of Medicine and Surgery. AND SCIENTIFIC PUBLICATIONS. 25 PARRISH (EDWARD), Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, *c. AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- mulae and Prescriptions. Second edition, greatly enlarged and improved. In one handsome octavo volume of 720 pages, with several hundred Illustrations, extra cloth. $3 50. (Just Issued.) During the short time in which this work has been before the profession, it has been received with very great favor, and in assuming the posilion of a standard authority, it has filled a vacancy which had been severely felt. Stimulated by this encouragement, the author, in availing himself of the opportunity of revision, has spared no pains to render it more worthy of the confidence be- stowed upon it, and his assiduous labors have made it rather a new book than a new edition, many portions having been rewritten, and much new and important matter added. These alterations and improvements have been rendered necessary by the rapid progress made by pharmaceutical science during the last few years, and by the additional experience obtained in the practical use of the volume as a text-book and work of reference. To accommodate these improvements, the size of the page has been materially enlarged, and the number of pages considerably increased, presenting m all nearly one-half more matter than the last edition. The work is therefore now presented as a complete exponent of the subject in its most advanced condition. From the most ordinary matters in the dispensing office, to the most complicated details of the vegetable alkaloids, it is hoped that everything requisite to the practising physician, and to the apothecary, will be found fully and clearly set forth, and that the new mailer alone will be worth more than the very moderate cost of the work to those who have been consulting the previous edition. That Edward Parrish, in writing a book upon practical Pharmacy some few years ago—one emi- nently original and unique—did the medical and pharmaceutical professions a great and valuable ser- vice, no one, we think, who has had access to its pages will deny; doubly welcome, then, is this new edition, containing the added results of his recent and rich experience as an observer, teacher, and practic tl operator in the pharmaceutical laboratory. The excellent plan of the first is more thoroughly, and in detail, carried out in this edition.—Peninsular Med. Journal, Jan. I860. Of course, all apothecaries who have not already a copy of the first edition will procure one of this; it is, therefore, to physicians residing in the country and in small towns, who cannot avail themselves of the skill of an educated pharmaceutist, that we would especially commend this work. In it they will find all that they desire to know, and should know, but very little of which they do really icnow in reference to this important collateral branch of their profession; for it is a well established fact, that, in the ecuration ot physicians, while the sci- ence of medicine is generally well taught, very little attention is pain to the art of preparing thein for use, and we know not how this defect can be so ' well remedied as by procuring and consulting Dr. Parrish's excellent work.—St. Louis Med. Journal. Jan. 1860. We know of no work on the subject which would be more indispensable to the physician or student desiring information on the subjectof which it treats. With Griffith's " Medical Formulary" and this, the practising physician would be supplied with nearly or quite all the most useful infornation on the sub- ject.—Charleston Med. Jour, and Review, Jan. 1800 PEASLEE (E. R.)5 M. D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- some octavo volume, of over 600 pages. (Lately Published.) $3 75. We would recommend it to the medical student and practitioner, as containing u summary of all that It embraces a library upon the topics discussed within itself, end is just what the teacher and learner need. Another advantage, by no means to be over- looked, everything of real value in the wide range which it embraces, is with great skill compressed into an octavo volume of but little more than six hundred pages. We have not only the whole sub- ject of Histology, interesting in itself, ably and fully discussed, but what is of infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pa- thology, which are here fully and satisfactorily set forth.— Nashville Journ. of Med. and Surgery. is known of the important subjects which it treats; of all that is contained in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, we would say to the medical student and practitioner—master this book and you know all that is known of the great fundamental principles of medicine, and we have no hesitation in saying that it is an honor to the American medi- cal profession that one of its members should have produced it.—St. Louis Mid. and Surg. Journal. PEREIRA (JONATHAN), M. D., F. R. S., AND L. 5. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. $y 00. *** Vol. II. will no longer be sold separate. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment ol Constitutional and Confirmed Syphi- lis, by a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- tions. From the Third and entirely rewritten London edition. In one neat octavo volume, extra cloth, of 316 pages. $175. ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations r» .»„« larw octavo volume, extra cloth, of about 700 pages. $3 00. 26 BLANCHARD to LEA'S MEDICAL RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W. V. Keating, M. D., Professor of Obstetrics, toe, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $5 00. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med and Surg. Journal. The publishers have secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We ltm.w of no text-book which deserves in all respects to be more highly recommended to students, and"we could wish to see it in the handsof every practitioner, for they will find it invaluable for reference.—Med. Gazette. RICORD (P.), M. D. A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F.R. S. With copious Additions, by Ph. Ricord, M.D. Translated and Edited, with Notes, by Freeman J. Bumstead. M.D , Lecturer on Venereal at the College of Physicians and Surgeons, New York. Second edition, revised, containing a resume of Ricord's Recent Lectures on Chancre. In one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. (Just Issued.) In revising this work, the editor has endeavored to introduce whatever matter of interest the re- cent investigations of syphilographers have added to our knowledge of the subject. The principal source from which this has been derived is the volume of "Lectures on Chancre," published a tew months since by M. Ricord, which affords a large amount of new and instructive material on many controverted points. In the previous edition, M. Ricord's additions amounted to nearly one-third of the whole, and with the matter now introduced, the work may be considered to present his views and experience more thoroughly and completely than any other. Every one will recognize the attractiveness and value which this work derives from thus presenting the opinions of these two masters side by side. But, it must be admitted, what has made the fortune of the book, is the fact that it contains the " most com- plete embodiment of the veritable doctrines of the HSpital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted,are incontestabiy dominant, have heretofore only been interpreted by more or less skilful secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- self forhis interpreters, and gives hisoriginal thoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say that this is incon- testabiy the best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope that it may find a place in the library of every phy- sician.— Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D. In one neat octavo volume, of 270 pages, extra cloth. $2 00. SLADE (D. D.), M. D. DIPHTHERIA; its Nature and Treatment, with an Account of the History of its Prevalence in various countries. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11,1860. In one small octavo volume, extra cloth; 75 cents. (Now Ready, 1861.) ROKITANSKY Curator of the Imperial Pathological Museum A MANUAL OF PATHOLOGICAL bound in two, extra cloth, of about 1200 pages king, C. H. Moore, and G. E. Day. $5 50. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough, and valuable books ever issued from tne medical press. It is sui generis, and has no standard of com- parison. It is only necetsary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has (CARL), M.D., and Professor at the University of Vienna, &c. ANATOMY. Four volumes, octavo, Translated by W. E. Swaine, Edward Sieve- bo charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.—Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it to the profession.—Charleston Med. Journal and Review. This book is a necessity to every practitioner.— Am. Med. Monthly. RIGBY (EDWARD), M. D., Senior Physician to the General Lying-in Hospital &c A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. BY the same author. (Lately Published ) ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. AND SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M. D. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. In two large and handsome octavo volumes, of 1789 pages. (Just Issued.) $8 00. This work is designed especially for the student and practitioner of medicine, and treats the various articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the lecture-room. While thus endeavoring to give all practical information likely to be useful with respect to the employment of"special remedies in special affections, and the results to be anticipated from their administration, a copious Index of Diseases and their Remedies renders the work emi- nently fitted for reference by showing at a glance ihe different means which have been employed, and enabling the practitioner to extend his resources in difficult ca^es with all that the experience of the profession has suggested. Rarely, indeed, have we had submitted to us a work on medicine so ponderous in its dimensions as that now before us, and yet so fascinating in its contents. It is, therefore, with a peculiar gratifi- cation that we recognize in Dr. Stille the posses- sion of many of those more distinguished qualifica- tions which entitle him to approbation, and which justify him in coming before his medical brethren as an instructor. A comprehensive knowledge, tested by a sound and penetrating judgment, joined to a love of progress—which a discriminating spirit of inquiry has tempered so as to accept nothing new because it is new, and abandon nothing old because it is old, but which estimates either accorcing to its relations to a just logic and experience—manifests itself everywhere, and gives to the guidance of the author all the assurance of safety which the diffi- culties of his subject can allow. In conclusion, we earnestly advise our readers to ascertain for them- selves, by a study of Dr. Stille's volumes, the great value and interest of the stores of knowledge they present. "We have pleasure in referring rather to the ample treasury of undoubted truths, the real and nssured conquest of medicine, accumulated by Dr. Stille in his pages ; and commend the sum of his la- bors to the attention of our readers, as alike honor- able to our science, and creditable to the zeal, the candor, and the judgment of him who has garnered the whole so carefully.—Edinburgh Med. Journal. Our expectations of the value of this work were based on the well-known reputation and character of the author as a man of scholarly attainments, an elegant writer, a candid inquirer after truth, and a philosophical thinker; we knew that the task would be conscientiously performed, and that few, if any, among the distinguished medical teachers in this country are better qualified than he to prepare a systematic treatise on therapeutics in accordance with the present requirements of medical science. Our preliminary examination of the work has satis- fied us that we were not mistaken in our anticipa- tions.—New Orleans Medical News, March, I860. The most recent authority is the one last men- tioned, Stille. HiR great work on " Materia Medi- ca and Therapeutics," published last year, in two octavo volumes, of some sixteen hundred pages, while it embodies the results of the labor of others up to the time of publication, is enriched with a great amount of original observation and research. We would draw attention, by the way, to the very convenient mode in which the Index is arranged in this work. There is first an " Index of Remedies;" next an "Index of Diseases and their Remedies." Such an arrangement of the Indices, in our opinion, greatly enhances the practical value of books of this kind. In tedious, obstinate cases of disease, where we have to try one remedy after another until our Btock is pretty nearly exhausted, and we are almost driven to our wit's end, such an index as the second of the two just mentioned, is precisely what we wa.nt.^London Med. Times and Gazette, April, 1861. We think this work will do much to obviate the reluctance to athorough investigation of this branch of scientific study, for in the wide range of medical literature treasured in the English tongue, we shall hardly find a work written in a style more clear and Bimple, conveying forcibly the facts taught, and yet free from turgidity and redundancy. There is a fas- cination in its pages that will insure to it a wide popularity and attentive perusal, and a degree of usefulness not often attained through the influence of a single work. The author has much enhanced the practical utility of his book by passing briefly over the physical, botanical, and commercial history of medicines, and directing attention chiefly to their physiological action, and their application for che amelioration or cure of disease. He ignores hypothe- sis and theory which are so alluring to many medical writers, and so liable to lead them astray, and con- fines himjelf to such facts us have been tried in the crucible of experience.—Chicago Medical Journal. SMITH (HENRY H.), M. D. AND HORNER (WILLIAM E.), M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlasi as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is <'got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D.f AND RICHARD QUAIN, F. R. S., Sec. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M D , Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00. _________ SIMPSON (J. Y. , M. D., Professor of Midwifery, &c, in the University of Edinburgh, &c. CLINICAL LECTURES ON THE DISEASES OF FEMALES. With nume- rotis illustrations. This valuable series of practical Lectures is now appearing in the "Medical News and Library" for 1860, 1861, and 1862, and can thus be had without cost by subscribers to the "American Journal of the Medical Sciences." See p. 2. SOI.LY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enTarged London edition. In one octave volume, extra cloth, of 500 pageB, with 120 wood- cuts. »2 00. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. $3 25. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one octavo volume, extra cloth, of 218 pages. $1 25. 2S BLANCHARD to LEA'S MEDICAL SARGENT (F. W.), M. O. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. vol., of nearly 400 pages, with 184 wooa cuts. Extra cloth, $1 40; leather, $1 50. The value of this work as a handy and convenient manual for surgeons engaged in active duty in the field and hospital, has induced the publishers to render it more complete for those purpo-es by the addition of a chapter on gun-shot wounds and other matters peculiar to military surgery. In its present form, therefore, with no increase in price, it will be found a very cheap and convenient vade-mecum for consultation and reference in the daily exigencies of military as well as civil practice. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge of the most frequently requisite performances of surgical art which cannot be entirely understood by attend- ing clinical lectures. The art of bandaging, which is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happily supplies.—Charleston Med. Journ. and Review. A work that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. We would remark, however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works are also very defective in their teaching on these small practical points. This little book will supply the void which all must feel who have not studied its pages.— West- ern Lancet. SMITH (W. TYLER), M. D., Physician Accoucheur to St. Mary's Hospital, &c. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. by the same author. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUC0RRH02A. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $1 50. TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. Second American Edition. In one neat volume, small 12mo., extra cloth, 87a cents. TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Fifth American, from the seventh improved anr enlarged London edition. "With Notes and References to American Decisions, by Edward Hartshorne.M. D. In one large 8vo. volume, leather, of over 700 pages. (Now Ready.) $3 25. This standard work having had the advantage of two revisions at the hands of the author since the appearance of the last American edition, will be found thoroughly revised and brought up com- pletely to the present state of the science. As a work of authority, it must therefore maintain its position, both as a text-book for the sludent, and a compendious treatise to which the practitioner can at a1! times refer in cases of doubt or difficulty. American and British legal medicine. It should be in the possession of eveiy physician, as the subject is one of great and increasing importance to the public as well as to the profession.—St Louis Mtd. and Surg. Journal. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest e.\tant on the subject of medical jurisprudence, it is certainly one of the most attractive bojks that we h«ve met with ; sup- plying so much both to interest, and instruct, that we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In the last London edition, all the newly observed and accurately re- corded facts have been insetted, including much that is recent of Chemical, Microscopical, and Pa- thological research, besidt s papers on numerous subjects never before published__Charleston Med. Journal and Review. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably; and none could be oflered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would be more likely to afford the aiu desired. We therefore recommend it as the best and safest manual for daily use.—American Journal oj Medical Sciences. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Ouy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it.—N. W. Medical and Surg, lournal It is at once comprehensive and eminently prac- tical, and by universal consent stands at the head of by the same author. (New Edition, just issued.) ON POISONS, IN KELATION TO MEDICAL J URISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition In one Ur«o octavo volume, ol 755 pages, leather. $3 50. in one large Since the first appearance of this work, the rapid advance of Chemistry has introduced into use many new substances which may become fatal through accident or design —while at the same time it has likewise designated new and more exact modes of counteracting or detecting tho^e previously treated of. Mr. Taylor's position as the leading medical jurist of England, has during this period conferred on him extraordinary advantages in acquiring experience . n these subiect nearly all cas-es of moment being referred to him lor examination, as an expert whose testimoni) is geneially accepted as final. The results of his labors, therefore, as gaihered together m th * volume, ctirefully weighed and sifted, and presented in the clear and intelligible style for whioh he is noted, may be received as an acknowledged authority, and as a guide to be followed with implicit confidence. wun AND SCIENTIFIC PUBLICATIONS 29 TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price $4 50. VST Gentlemen who have received portions of this work, as published in the " Medical News and Library," can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts I., II., III. (pp. 25 to 552), $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents, toe), $2 00. Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, toe), $1 25. A magnificent contribution to British medicine, and the American physician who shall fail to peruse it, wil. have failed to read one of the most instruc- tive books of the nineteenth century.—JV. O. Med and Surg. Journal. It is more concise than Carpenter's Principles, and more modern than cue accessible edition of MQller'e Elements; its details are brief, but sufficier. t; its descriptions vivid; its illustrations exact and copi- ous ; and its language terse and perspicuous.— Charleston Med. Journal. We know of no work on the subject of physiology so well adapted to the wants of the medical student. •Its completion has been thus long delayed, that the authors might secure accuracy by personal observa- tion.—St. Louis Med. and Surg. Journal. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, already tran- scends our limits ; and, with the indulg< nee of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands. — The Nirthwestern Med. and Surg. Journal. TODD (R. B.) M. D., F. R. S., Sec. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume, 284 pages. $1 50. BY THE SAME AUTHOR. (Now Ready.) CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra cloth. $1 75. TOYNBEE (JOSEPH), F. R. S., Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one . very handsome octavo volume, extra cloth, $3 00. (Just Issued.) The work, as was stated at the outset of our no- tice, is a model of its kind, and every page and para- graph oi it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated, and happily il- lustrated with cases and drawings—it is bv far the ablest monograph that has ever appeared on the anatomy and diseases "f the ear, and one of the most valu'ible contributions to theart and science of sur- gery in the nineteenth century.—N. Amer. Medico- Chirurg Jievitw, Sept. I860. To recommend such a work, even after the mere hint we htive given of its original excellence and value, would be a work of supererogation. We are speaking within the limits of modest acknowledg- ment, and with a sincere and unbiassed judgment, when we affirm that as a treatise on Aural Surgery, it. is without a rivt 1 in our language or any other.— Charleston Med Journ and Review, Sept. IS60. The work of Mr. Toynbet is undoubtedly, upon the whole the most valuable produciionof tne kind in any language. The author has long oeen known by his numerous monographs upon subjects con- nected with disease* of ihe ear, and is now regarded as the highest authority on most points in his de- partment of science. Mr. Toynbee's work, a0 we have already said, is undoubtedly the most reliable guide for the study of the diseases of the tar in any language, and should be in the library of every pnj - sician.— Chicago Med. Journal, July, 18GU. WILLIAMS (C. J. B.), M.D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE. An Eleraentaiy View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the pre- servation ofheallh. A new American, from thethirdanu revised London edition. In one octavo volume, leather, of about 500 pages. $2 50. (Just Issued.) We find that the deeply-interesting matter and style of this book have so far fascinated us, that we have unconsciously hung upon its pages, not too long, indeed, for our own profit, but longer than re- viewers can be permitted to indulge. We leave the further analysis to the student and practitioner. Our judgment of the work has already been sufficiently I deserved reputation.— Va. Med. and Surg. Journal. expressed. It is a judgment of almost unqualified praise.—London Lancet. A text-book to which no other in our language is comparable.—Charleston Medical Journal." No work has ever achieved or maintained a more WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised Londoi. edition. In one very handsome volume, royal 12mo., extra cloth. $1 00. To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner we and precision to carelessness, thiB little book is :u- have ever seen.—Peninsular Journal of Medictne. valuable.—N- H. Journal of Medicine. j 30 BLANCHARD to LEA'S MEDICAL New and much enlarged edition—(Just Issued.) WATSON (THOMAS), M.D., Sec, Late Physician to the Middlesex Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; the whole strongly bound in leather, with raised bands. Price $4 25. That the high reputation of this work might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases incident to our climate which are little known in England, as well as those points in which experience here has led to different modes of practice; and he has also added largely to the series of illustrations, believing that in this manner valuable assistance may be conveyed to the student in elucidating the text. The work will, therefore, be found thoroughly on a level with the most advanced state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an en- largement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at a price within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. The lecturer's skill, his wisdom, his learning, are equalled by the ease of his graceful diction, his elo- quence, and the far higher qualities of candor, of courtesy; of modesty, and of generous appreciation of merit in others. May he long remain to instruct us, and to enjoy, in the glorious sunset of his de- clining years, the honors, the confidence and love gained during his useful life.—N. A. Med.-Chir. Review. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth edition) have given it all the no- velty and much of the interest of a new book.— Charleston Med. Journal. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of anew—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been severely felt for the last three years. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work we find additions or altera- tions which prove that the author has in every way sought to bring up his teaching to the level of .he most recent acquisitions in science.—Brit, and For. Medico-Chir. Review. WALSHE (W. H.), M. D.f Professor of the Principles and Practice of Medicine in University College, London. &c. A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; including the Principles of Physical Diagnosis. A new American, from the third revised and much en- larged London edition. In one vol. octavo, of 468 pages. (Just Issued, June, 1860.) $2 25. The present edition has been carefully revised and much enlarged, and may be said in the main to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; the causes and mode of production of the more important affections, so far as they possess direct prac- tical significance, are succinctly inquired into; an effort has been made to bring the description ol anatomical characters to the level of the wants of the practical physician ; and the diagnosis and prognosis of each complaint are more completely considered. The sections on Treatment and the Appendix (concerning the influence of climate on pulmonary disorders), have, especially, been largely extended.—Author's Preface. %*# In press, by the same author, a volume on Diseases of the Heart and Aorta, to match the above. WILSON (ERASMUS), F. R. S., Lecturer on Anatomy, London. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. The fourth edition now appears, so carefully re- vised, as to add considerably to the value of a book already acknowledged, wherever the English lan- guage is read, to be beyond all comparison the best systematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with ihe advancing know- ledge of the day, and to bring the results of the labors, not only of physicians, but of chemists and histologists, before his readers, wherever they can be turned to useful account. And this is done with such a cordial appreciation of the merit due to the industrious observer, such a generous desire to en- courage younger and rising men, and such a candid acknowledgment of his own obligations to them, that one scarcely knows whether to admire most the pure, simple, forcible English—the vast amount of useful practical information condensed into the Lectures—or the manly, kind-hearted, unassuming character of the lecturer shining through his work. —London Med. Times and Gazette. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— London Lancet. AND SCIENTIFIC PUBLICATIONS. 31 New and much enlarged edition—(Just Issued.) WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged English Edition. Edited by W. H. Gobrecht, M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred and ninety-seven engravings on wood. In one large and exquisitely printed octavo volume, of over 600 large pages; leather. $3 25. The publishers trust that the well earned reputation so long enjoyed by this work will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and Ihe efforts of both have been directed to introducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appro- priate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. It may be recommended to the student as no less distinguished by its accuracy and clearness of de- scription than by its typographical elegance. The wood-cuts are exquisite.—Brit, and For. Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take up this volume without being struck with the great BY THE SAME AUTHOR. (Just Issued.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. at some of the more salient points with which it abounds, and which make it incompura oiy superior in beauty of its mechanical execution, and the clear- ness of the descriptions which it contains is equally evident. Let students, by all means examine tne claims of this work on their notice, before they pur- chase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. We regard it as the best system now extant for students.—Western Lancet. It therefore receives our highest commendation.— Southern Med. and Surg. Journal. The writings of Wilson, upon diseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The present edition isa great improve- ment on all its predecessors. To dwell upon all the great merits and high claims of the work before us, seriatim, would indeed be an agreeable service; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount of space in this Journal. We will, however, look excellence to all other treatises on the subject of der- matology. No mere speculative views are allowed a place in this volume, which, without a doubt, will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion.—Am. Jour. Med. Science, Oct. 1857. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the Skin. The plates are comprised in a separate volume, which we counsel all those who possess the text to purchase. It is a beautiful specimen of color print- ing, and the representations of the various forms of skin disease are as faithful as is possible in plates of the size.—Boston Med. and Surg. Journal, April 8, 1858. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delineation and perfect accuracy of illustration are concerned.—Medico-Chirurgical Review. Of these plates it is impossible to speak too highly. The representations of the various forms of cutane- ous disease are singularly accurate, and the color- ing exceeds almost anything we have met with in point of delicacy and finish.—British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25 BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00; paper cover, 75 cents. WHITEHEAD ON THE CAUSES AND TREAT- MENT OF ABORTION AND STERILITY. Second American Edition. In one volume, octa- vo extra cloth, pp. 308. $1 75. 32 BLANCHARD to LEA'S MEDICAL PUBLICATIONS WINSLOW (FORBES), M.D., D. C. L., Sec. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one handsome octavo volume, of nearly 600 page*. (Just Issued.) $3 00. We close this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work, by expressing our conviction that it is long since so important and beautifully writttn a volume has is- sued from the British medical press.—Dublin Med. J'ress, July 25, I860. We honestly believe this to be the best book of the season.—Ranking's Abstract, July, 1860. It cairied us back to our old days of novel reading, it kept us from our dirner, from our business, and from our slumbers; in short, we laid it down only when we had got to the end of the last paragraph, and evn then turned back to therepeiusal of several passages which we had marked as requiring further study We have failed entirely in the above notice to give an adequate acknowledgment of the profit and pleasure with which ive have perused the above work. We can only say to our readers, study it yourselves; and we extend the invitation to unpro- fessional as well as professional men, believing that it contains.matter deeply interesting not to physi- cians alone, but to all who appreciate the truth that: " The proper study of mankind is man."__Nashville Medical Record, July, I860. The latter portion of Dr. Winslow's work is ex- clusively devoted to the consideration of Cerebral Pathology. It completely exhausts the subject, in the same manner as the previous seventeen chapters relating to morbid psychical phenomena left nothing unnoticed in reference to the mental symptoms pre- monitory of cerebral disease. If, is impossible 10 overrate the benefits likely to result from a general perusal of Dr. Winslow's valuable and deeply in- teresting work —London Lancet, June 23, 1860. It contains an immense mass of information.— Brit, and For. Med.-Chir. Review, Oct. Ifc60. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF WOMEN. Second American, from the s-econd London edition. In one handsome octavo volume, extra cloth, ol about 500 pages; price $2 50. (Now Ready, July, 1861.) *%* Gentlemen who received the first portion, as issued in the "Medical News and Libraiy," can now complete iheir copies by procuring Part II, being page 309 to end, with Index, Title matter, &c, 8vo., cloth, price $1. We mustnow conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal. The conscientious, painstaking, practical physician isapparent on every page.—N. Y. Journal of Medicine, March, 1858. We know of no treatise of the kind so complete an'l yet so compact.—Chicago Med. Journal, Janu- ary, 1858. A fairer, more honest, more earnest, and more re- liable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal, January 1858. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language ; and that it stamps Dr. West as the facile princept of British obstetric authors.—Edinb. Med. Journ, As a writer, Dr. West stands, in our opinion, sec- ona only to Watson, the " Macaulay of Medicine;" he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleisure with profit, he leads his pupils, in spite of the ancient proverb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are seeking truth, and one that will convince the student that he has committed himself to a can- did, Bate, and valuable guide. We anticipate with pleasure the appearance of the second part of the work, which, if it equals this part, will complete one of our very best volumes upon diseases of fe- males —N. A. Med -Chirurg. Review, July, 1858. Happy in his simplicity of manner, and moderate in his expression of opinion, the author is a sound reasoner and a good practitioner, and his book is worthy of the handsome ga^b in which it has ap- peared from the press of the Philadelphu publishers. — Virginia Med. luurnal. We must take leave of Di. West's veiy useful work, with our commendation oi the clearness of its style, and the ini ustry and sobriety of judgment of which u gives evidence.—London Med Times and Gazette Sound judgment and good sense pervade every chapter oi ihe nook. From its perusal we have de- rived unmixed satisfaction.— Dublin Quart. Juurn BY THE SAME AUTHOR. (Just Issued.) LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Third American, from the fourth enlarged and improved London edition. In one handsome octavo volume, extra cloth, of about six hundred and fifty pages. $i 75. The three former editions of the work now before us have placed the author in tue foremost rnnk vf those physicians who have tevoted special attention to the diseases of early life We attempt no ana lj sis of this edition, but may refer the reader to some of the chapters to which the largest additions have been made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a prooi that the work is really a new edition; not a mere reprint. In its preient shape it will be lound of the greatest possible service in the every-day practice of nine- tenths of the profession.—Med. Times and Gazette, London, DtC. 10, 18,39. All things consid red this book of Dr. West is by far the best treatise in our language upon such mod iii nations of morbid action and disei.se as are witmssed when we have to deal with infancy and EniUlhood. It is true that it confines itself to such disorders as come within the proviace of the phy- sician, and even with respect to these it is unequal as regarus nunuteiuks ol consideration, and some diseases it omits to notice altogether. But those who know anything of the present condition of paediatrics will readily admit chat it would be next to impossible to effect more, or effect it better, tnan the accoucheur of St. Barlholomew's has done m a single volume. The lecture (XVI.) upon Disorurs of the Mind in chiloren is an admirable specimen of the value oi the later information convejed in the Lectures of Dr. Charles West__London Lancet, Oct. 22, 1859. ' Since the appearance of the first edition, about eleven years ago, the experience of the author has doubled; so that, whereas the lectures at first were founded on six hundred observations, and one hun- dred and eigniy dissections made among nearly four- teen thousand children, they now embody the results of nine hundred observations, and two hundred and eighty-eight post-mortem examinations made among nearly thirty thousand children, who, during the past twetty years, have been undei his cure — British Med. Journal, Oct. 1, 1859. BY THE SAME AUTHOR. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER. ATION UF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. NATIONAL LIBRARY OF MEDICINE NLM OanSMTM M NLM031924944