730 
SURGERY. 
may now be done without any risk of the knife slipping out. 
The knife may then be either withdrawn along the director, 
or the parts further dilated, according to the circumstances 
adverted to. Having delivered his knife to the assistant, 
the operator takes the staff in his right hand, and passing 
the forefinger of his left along the director through the open¬ 
ing in the prostate, withdraws the director, and exchanging 
it for the forceps, passes the latter upon his finger into the 
cavity of the bladder. 
“ In extracting the calculus, should the aperture in the 
prostate prove too small, and a great degree of violence be 
required to make it pass through the opening, it is advisable 
always to dilate with the knife, rather than expose the pa¬ 
tient to the inevitable danger consequent upon laceration.” 
The testicle is very liable to inflammation and in this 
state the disease is very absurdly styled hernia humoralis. 
According to Hunter, the first symptom of this complaint 
is a soft, pulpy, fulness of the body of the testicle, which 
is exceedingly tender when handled. This fulness increases 
to a hard swelling, accompanied with considerable pain. 
The hardest part is commonly the epididymis, and princi¬ 
pally the lower portion of it, as may be distinctly felt. The 
spermatic cord is often affected, and particularly the vas 
deferens, which is thickened, and, when touched, very ten¬ 
der and painful. The spermatic veins sometimes become 
varicose ; cholicky pains may be experienced in the bowels; 
and sickness is a common symptom, and even vomiting. 
In some cases, a great accumulation of air takes place within 
the alimentary canal, producing much oppression aud incon¬ 
venience. The bowels in other instances are obstinately 
constipated, and if this symptom be conjoined with inces¬ 
sant vomiting, a large tumour of the scrotum, and a great 
swelling and thickening of the spermatic cord, the case 
may partly resemble a hernia, from which, however, a 
surgeon well acquainted with all the characters of the latter 
disease, will have no difficulty in distinguishing it. A 
severe pain in the loins is usually attendant on the complaint. 
In addition to the preceding complaints, the patient in severe 
cases has a great deal of symptomatic fever, pain shooting 
down the thighs, and considerable heat and difficulty in 
making water. The description of the manner in which 
this disease commences, as delivered by some other writers, 
does not however correspond altogether to the foregoing 
account. Thus, Richter asserts, that the patient first com¬ 
plains of pain in the groin ; then the spermatic cord becomes 
swollen, particularly the vas deferens; and shortly afterwards 
the epididymis; but, says he, the testis itself always swells 
the last, and frequently not till some days have elapsed. 
The scrotum, in consequence of the distention which it 
suffers, becomes smooth, loses its corrugated appearance, 
and is redder than in the healthy state. The disease rarely 
affects both testes at once; though, as Mr. Hunter observes, 
it sometimes happens, that the swelling changes from one 
of these organs to the other with surprising rapidity. In 
slight cases, the vas deferens and epididymis may be affected 
alone; but in all usual examples, the body of the testes is 
equally implicated. Any man, says Mr. Hunter, who is 
accustomed to know the difference between a swelling of 
the whole testis, and that of the epididymis only, will imme • 
diately be sensible, that in hernia humoralis, the whole 
testis is commonly swelled. This organ assumes the same 
shape that it does from other causes, where we know from 
being obliged to remove it, that the whole has swelled, and 
the pain is in every part of it. Mr. Hunter has seen hernia 
humoralis suppurate at the anterior part of the swelling; he 
has known several instances, in which the complaint pro¬ 
duced adhesions between the tunica albuginea and tunica 
vaginalis, as was discovered after death, or in the operation 
for a partial hydrocele. Such changes, says he, could net 
have taken place, if the body itself of the testes had not been 
inflamed. 
The patient should be kept perfectly quiet, and in a hori¬ 
zontal posture in bed. If he be young and robust, the 
swelling of the part considerable, and the pain in the loins 
very violent, phlebotomy may be practised; the quantity 
of blood taken away, and the repetition of the operation 
being determined, by the patient’s ability to bear the evacu¬ 
ation* and by the state of the local disease. With regard 
to local applications, fomentations and poultices prove more 
beneficial than cold astringent lotions. But, an object, of 
the highest importance, is to keep the testicle constantly 
supported, by means of a bag truss, or suspensory bandage. 
Mr. Hunter states, that emetics have been known to re¬ 
move the swelling almost instantaneously. Without giving 
full credit to the literal meaning of this observation, it is very 
certain, that the great degree of swelling, in cases of hernia 
humoralis, often occurs and subsides more rapidly, than in 
any other inflammatory affection whatever. 
When the pain in the part and loins is unusually severe, 
opiates become necessary. 
After the inflammation is completely subdued, the hard¬ 
ness of the epididymis commonly remains. Sometimes, 
this may be lessened by frictions with camphorated mercurial 
ointment, or the use of discutient plaisters; but, in general, 
more or less of such induration continues during life. 
The testicle is liable to a particular sort of cancer, called 
the chimney-sweepers’ cancer; it was first described by the 
celebrated Mr. Pott. It is said to be endemial in this country. 
This disease almost always makes its first appearance in the 
inferior part of the scrotum, where, as Mr. Pott observes, it 
produces a superficial, painful, ragged, ill-looking sore, with 
hard and rising edges. With the exception of one case,, 
which was shewn to him by Sir J. Earle, and which oc¬ 
curred in a child under eight years of age, that eminent sur¬ 
geon never saw the complaint occur under the age of puberty. 
In no great length of time, it makes its way completely 
through the scrotum, and attacks the testicle, which it en¬ 
larges, hardens, and renders thoroughly distempered. Next, 
it extends up the spermatic cord, contaminating the inguinal 
glands, and parts within the abdominal ring, and then very 
soon becoming painfully destructive. The only treatment is 
extirpation. 
The veins of the testis are liable to varix, generally, in con¬ 
sequence of some enlargement of the gland ; and the sper¬ 
matic veins especially are liable to this disease, which has 
received the denomination of cirsocele. This dilatation of 
the veins being combined, in some instances, with a similar 
affection of the lower portion of the vas deferens, the con¬ 
voluted canal of the epididymis, and even of the tubuli 
seminiferi testis, compose an unnatural mis-shapen mass per¬ 
ceptible in the scrotum. 
Cirsocele frequently occasions great uneasiness, and some¬ 
times a wasting of the testicle. It is commonly limited to 
that part of the spermatic cord, which is below the abdominal 
ring; and the vessels are generally larger, the nearer they are 
to the testicle. It is attended with a sense of weight in the 
scrotum; an unequal knotty swelling; and, if the disease 
affects the whole corpus pampiniforme, with a sensation that 
seems to arise from a bundle of ropes, or earthworms. The 
disease generally begins at the lower part of the spermatic 
cord, by the side of the testis. Excepting the uneasy sen¬ 
sation of weight in the scrotum, and a little tenderness when 
pressed, the recent cirsocele is productive of only trivial, or 
even no inconvenience. But in an advanced stage of the 
disease, very severe pains gradually come on, somtimes ex¬ 
tending upward to the back and loins, and downward to the 
thigh. The case does not invariably make the kind of pro¬ 
gress above described: it is often confined to the spermatic 
cord, or epididymis; and it has been known to continue in 
this state for many years, without increasing, notwith¬ 
standing the patient’s employments were of a nature very 
likely to aggravate the disease. Standing long at a time, 
walking, horse-exercise, great exertions of the lungs, and 
every thing requiring forcible expirations, always augment 
the turgidity of the veins, and the painful sensations expe- 
perienced by the patient. The weight of the testis, when this 
organ is not wasted, appears also to have a similar effect. 
This disease is more frequently than any other, mis-. 
taken for an omental rupture. A bag-truss and astrin¬ 
gent lotions are the only agents necessary for treating this 
disorder. 
