CLINICAL LECTURE ON HEMATOCELE.?BY K. McLEOD.

November, 1883.]

ORIGINAL COMMUNICATIONS. i

/

TOCELE.

College Hospital on the 25th September 1883, Surgeon-Major K. McLeod, a.m., m.d.,

Delivered at the Medical

f.r.c.s.e., Surgery and First

Professor of (From Notes by

Mr. M. A.

they present

a

natural appear-

The

size.

penis we may dismiss at once, as being quite healthy in every respect. The scrotum, you observe, is not quite so pendulous as it is naturally, and in the middle ance

as

regards

line there is

ulcer about

an

inch

and

long

broad, which is continuous with a cicatrix reaching from the root of the penis to the perinaeum, occupying in short the position of the raphe; you observe that on either side of this the skin constituting the scrotum is thin and moveable, and presents a different a

quarter of

one

inch

an

appearance from that of a natural scrotum in being smooth and not corrugated ; there is a

slight puckering

of the skin

but this

centrally,

The skin presents the that of the thigh, being in fact

is due to the cicatrix. same a

aspect as part of it, which has been dragged

over

the

The structures beneath the skin present induration ; the mass is soft and fairly move-

testes. no

able,

backwards and forwards and from side to

perineum. If we examine them more carefully we are able to distinguish the testes in their normal position and of natural size, moveable, but perhaps not so moveable as in side,

on

the

health: above the testes

healthy position

tween this scrotum and

existence of middle

line,

thinner than the scrotum

an

ulcer,

the skin

normal, as a

a

find the cord in

we

and state.

normal scrotum

being

cicatrized,

more

so

are

the

in the

stretched and

and the testes

whole not

a

The differences be-

almost

more

fixed?

pendulous.

The

capable of perfect erection ; the ulcer in raphe will cicatrize in a few days, and pigment will gradually be deposited on the

penis the

is

contrast the

we

on

a

very

result

satisfactory

present conditions with admission. The man is

about 35 years of age, he was admitted into hospital on the 23rd of July, so that he has been

a

little

over

two months under treatment.

organs on admission is described thus :?Scrotum swollen to about the The state of his

genital

size of a fcetal head, the skin thickened, indurated and immoveable, that is, fixed to the underlying

Surgeon. Courtney.)

I wish to draw your attention, in the first place, to the state of this man's genital organsYou observe that

Now,

when

those which existed

CLINICAL LECTURE ON HHEMA-

By

this is

cicatrix.

297

textures, the induration

more

marked

on

the

posterior aspect than on the anterior. The testes and cord not distinguishable, the lymphatic

glands

on

both sides

rated ; there is

an

ulcer

swollen, hard, on

and indu-

the anterior aspect of

the scrotum, and from this there is a constant discharge of unhealthy pus; fluctuation is felt under, neath the ulcer and also on the left side of the scrotum, the ulcer being in the middle line ; the skin of the penis is dragged down over the scrotum and

slightly cedematous; the glans and body of the penis are retracted into a sulcus* As regards the patient's general health there was nothing very special, the heart and lungs It were healthy, the spleen slightly enlarged. was he fever from that slight appears suffering on admission. Now what is the history of this condition, which consisted, in short, of elephantiasis of the scrotum associated with scrotal

abscesses either inside

or

outside of the

difficult to say which ? vaginalis?it It appears that he suffered from " disease of the

tunica

scrotum"

was

(which commenced as a swelling assofever) for 4 or 5 years. In fact he had

ciated with

the usual sequence of events

characterizing

the

commencement of scrotal tumour, recurrent fever

accompanied by a disorder of the lymphatic glands of the groin, which were swollen and indurated; this condition had lasted for 7 years, the scrotal swelling 4 or 5 years. There was also a history of a swelling of the left leg, apparently of an elephantoid nature, which appears to have subsided. It appears that 2 months before admission he got a fresh attack of fever, and along with it a marked increase of the swelling of the scrotum; at this time he also

experience pain

in the scrotum.

began

Tapping

to

was

'

29S resorted to

THE INDIAN MEDICAL GAZETTE,

both

sides, with the result that quantity of fluid was evacuated ; the evacuation, however, did not materially reduce the swelling, and the fever, pain and swelling

a

011

the

considerable

the vessels

hypertrophied tunica: according

to;the state in wh ich

The

put

man was

An incision

July. the penis

and

the table

on

commenced at the root

was

to'the

scrotal'swelling

perineum,

oval

an

each lateral aspect where being w?is healthy. This incision was then cut

'?

.f,?yjrr

?

1

f

Before one

'

this

on-each

two abscesses

side,

were

and about three

or

??

reached

?

?

r t

*

>

4

commuriicatcd

by

?

*

apertures

0

in

four ounce's

the

'

of grumous clots and siderable amount of purulent material.

tunicae

were

laid

thoroughly cleaned,

following changes :?They

|

other and to the surface of the" the

then

as

terior

of

the-

then

attached

to

them

were

diseased

then stitched

.

cellular tissue of the perinccum and

to

the

each other'

of

the tunic;e.

accomplished

were

Tlie"

c.sides

1

;j-

the

by

i :t

peeling off in the shape a clean granulating' surface

certain extent,'

which became mass

continuous 'with the

formed from the

lymph

effused

*

the testesiand '

had taken and;

having

hail.': been

?

embedded

been absorbed.

underwent ?

flaps in position 'Until adhesion place; the stitches then became loose 'rcilioved,:i those portion's t'-of them '

.were

which

tunicae to

1

around the testes, and between them and the flaps.: The wound now presented a smooth graniHat'ing' surface. |fXhe. catgut .stitches retained

>

the

to a

granulation

afrd

with 'the remainder of

results

appeared,

the in-

were

'!

eachod

to

perinheum.

.to i'the

thd testes,, and J;to

of sloughs; after this

could

remaining portions finally pockets were dug out" of the- iperihafcum in the u's'tfal way by-' separating the superficial from the-utep fascia. The testes'

scraped,'

sis

The

open, the cavities washed and wiped out ;

dissected off with knife and -scissors

adherent

adhered

agency of granulationi: material.j ii The lining membrane of the everted tunicae underwent necro-

con-

be taken away without endangering the vitality of the testes or the circulation of the cord, was

mass?to

These

a con-

as

became

flaps

freely

much of the diseased tunica?

presented by it lafterth'ei gradually exchanged-for ; one rethe : healthy' condition of the-genital appearance^

was

|

tunica

The cavities of the tunicae

quantity

a

the

pockets constructed for them haveiundergone the

vaginalis cavities, also that the tunicrc had undergone inch great thickening, the walls being about tained

degenerated^]

concealing

I have demonstrated to you.;' The organs, remnants',of the diseased tunica: fixed in the

with abscesses in the interior of those

in thickness.

lips projected

as

encountered

r

.

unsightly operation sembling

2

of grumous pus evacuated from each. It was 1 f found that on both sides the scrotal abscesses r

its

turbance,?once or twice slight fever reaching toc?. about i oo? F., but even this was foxceptiobfalnif The woflnd made Satisfactory progress,land; 'the

flap

!

were

very extensive and

Those of you who :have watched their, progress of this case, will have observed that the