SURGERY. 733 
with hydrocele than any other disease ; for the swelling of 
the testicle is so elastic, and the feel which it communicates 
so like that of a fluid, that many surgeons of great judgment 
and experience have been deceived, and actually introduced 
a trocar into the substance of the tumour. 
The cure of hydrocele is very simple. We should first as¬ 
certain that there is no disease of the testicle, then we may 
plunge a trocar and canula into the scrotum and evacuate the 
water. This having been done, it will be found that the 
tumour is soon refilled, and that the operation is again re¬ 
quired. Our object now is to change the action of the se- 
cernents, or to promote adhesion of the tunics of the testicle, 
and thus the obliteration of the cavity which is between 
them and which contains the water. After puncturing it, 
therefore, we now inject red wine, weak solution of sulphate 
of zinc, or even common water, desire the patient to go to 
bed for a short time, and await the coming on of inflamma¬ 
tion. This should be watched and regulated, because, 
though rarely, instances have been known occasionally to oc¬ 
cur, of very formidable inflammation, followed by sloughing, 
&c., coming on. A small portion of the tunica vaginalis 
may be drawn through the opening made by the cannula and 
snipped off, and this little operation frequently brings on the 
requisite degree of inflammatory action. In injecting and 
puncturing hydrocele, the greatest care should be taken that 
neither the fluid to be removed nor that injected get into the 
cellular tissue of the scrotum, and also when any thing is 
injected that it be perfectly evacuated again. 
When the fluid collected in the scrotum is blood, the dis¬ 
ease is called hsematocele. It may be doubted whether 
there is any true secretion of blood in this situation. We 
may generally trace the disease to some blow or injury, or to 
some enlargement of the vessels which has caused the rup¬ 
ture of a blood vessel and consequent extravasation. 
When the case is clearly distinguished from a hernia, at¬ 
tempts must be made to promote the absorption of the extra- 
vasated blood, by applying to the tumour the lotion composed 
of spirit of wine, vinegar, and the muriate of ammonia, or 
even camphorated liniments. The patient, if young, or not 
too much reduced, should also be bled, and, as purgatives are 
of essential use in promoting the absorption of effused blood, 
their exhibition should never be omitted. A bag-truss is to 
be worn, and the patient kept in bed. When, under this 
treatment, the swelling, instead of diminishing, increases in 
size, the bag-truss may be tightened, and compresses laid 
upon the scrotum, wet with cold water. 
If the case should obstinately resist all these means, a 
thing which seldom happens, an incision must be made into 
the tumour, and if any bleeding point be discovered, it should 
either be tied, or stopped with a dossil of lint. 
The penis is sometimes amputated. Almost the only case 
that requires this operation, is cancer ; but if this exists to 
such an extent, as to involve the pubis or inguinal gland, the 
use of the knife is of course unjustifiable. Common warty 
excrescences have been mistaken for cancer of the penis. 
These, however, have a spreading, mushroom-like top, and 
slender base; and if the intermediate parts can be seen, they 
retain their natural appearance. A cancer begins with an 
irregular warty excrescence, having a broad base in the sub¬ 
stance of the prepuce, or on the fraenum. In a more ad¬ 
vanced and ulcerated stage, the sore is of a dark red colour, 
covered with a sanious discharge; its bottom is solid, and 
deep excavations, and irregular-cauliflower excrescences, 
present themselves. The neighbouring skin, of a purple 
colour, indurated, swelled, and tuberculated, stands out from 
the sore, while its irregular edge is turned inwards. The 
discharge has a peculiar smell, being highly offensive, and 
when the urethra is ulcerated, the urine gushes out from 
preternatural openings. 
Cancer upon the glands, also, usually begins in the form 
of a wart, or small, not very troublesome, induration, which 
gradually changes into a most painful ulcerated excrescence. 
The operation (not a very easy one, on account of the 
profuse haemorrhage that attends it, and the tendency to 
Vdl XXIII. No. 1604. 
retract themselves out of sight, that the corpora cavernosa 
have), is to be thus performed :— 
Having drawn the integuments as much forwards as pos¬ 
sible, and fixed them there with a circular tape, make an 
incision behind the tape, but only just deep enough to see 
the blood issue from the divided arterise dorsales, which 
should be immediately taken up with a tenaculum, and tied. 
Then cut straight down through the middle of the corpora 
cavernosa, until the blood gushes from two arteriaj pro- 
fundse, which are to be secured in the same manner. 
Lastly, the third sweep of the knife should cut the corpus 
spongiosum and its arteries, without, however, dividing 
the urethra completely through: then the arteries of the 
spongy substance are tied, and the part is afterwards entirely 
severed. 
When, from long continued irritation, a very narrow- 
stricture has been formed, any sudden accession of inflam¬ 
mation will completely close the passage, so that no catheter 
or other instrument can be passed. In these cases, if the usual 
means of reducing vascular action and relaxing spasm have 
been used without effect, it is necessary to puncture the bladder. 
There are two situations, in either of which the surgeon 
may make an opening into the bladder, viz., above the os 
pubis, and through the rectum. 
In the first, a perpendicular incision is made, about an 
inch and a half or two inches in length, through the integu¬ 
ments and fat, covering the lower part of the linea alba. 
The bottom of the incision should just meet the upper part 
of the above bone. A cut of the same length is next to be 
made between the pyramidal muscles, and, this being done, 
the surgeon can feel with his finger the prominent, distended 
bladder. A trocar, the curvature of which forms a segment 
of a small circle, is now to be introduced into the exposed 
part of this viscus. 
Many operators make no preliminary division of the in¬ 
teguments and fat, but introduce the trocar at once into the 
bladder. 
In the puncture through the rectum, the patient is to be 
put in the same posture as for lithotomy. An assistant is to 
make pressure on the abdomen, just above the os pubis, in 
order to make the prominence of the bladder more distinct 
to the surgeon’s finger in the rectum. A curved trocar, with 
its point drawn within the canula, is to be introduced with 
the right hand, and conveyed, upon the index-finger of the 
left, along the swelling, formed by the distended bladder. 
The instrument should be kept exactly in the central line of 
the front portion of the rectum, and, when conveyed suffi¬ 
ciently beyond the prostate gland, the point of the trocar 
is to be pushed into the bladder, through the anterior part of 
the intestine. 
This operation is so easy of accomplishment, and so very 
safe, that it certainly merits a general preference. The coats 
of the rectum and bladder, at this part, are in immediate con¬ 
tact, and the instrument has to penetrate no thickness of 
substance. The operation is not more painful than vene¬ 
section, and the distended bladder is so distinctly perceptible 
to the finger, that no mistake can well be made. The only 
chance of doing mischief arises from the situation of the vesi- 
culse seminales; but, all risk is removed, when the trocar 
and the finger are introduced sufficiently into the rectum, 
and the puncture is made exactly in the central part of the 
swelling. The curved trocar, about five inches long, is the 
most proper. 
The diseases of the rectum, with the exception of fistula, 
have already been noticed by us under Pathology. —Fistula 
in ano generally makes its attack, in the form of phlegmo¬ 
nous inflammation, attended by sympathetic fever. A part 
of the buttock near the anus is considerably swollen, and 
has a large circumscribed hardness. The middle of this 
hardness soon becomes very red, and matter forms in its 
centre. As Mr. Pott remarks, the pain is sometimes great, 
the fever high, the tumour large, and exquisitely tender; 
but, howeyer high the symptoms may have risen before sup¬ 
puration, yet, when that end is fairly and fully accomplished, 
9 A the 
