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“Whenever this membranous fence exists, or whenever the orifice of the urethra, from any cause, is smaller in its diameter than that of other parts of the canal, a sudden check is opposed to the free exit of the urine or semen at each attempt to propel them, and the increased muscular action, which is induced by the revulsion of those fluids upon the membranous part of the urethra, becomes at length the foundation of some of its diseases... .“ Patients who have not been aware of this peculiarity of structure at the extremity of the urethra, have frequently, on my pointing it ouç to them, described to me the painful check and sense of distension they have experienced at each act of passing urine or semen; but for which they could never before satisfactorily account. . .6 The presence of this membranous fence, besides being the cause of derangement in the membrane of the urethra, also becomes the means of retarding its recovery, after disease has been there established: it aggravates all the symptoms in gonorrhea, and if stricture has taken place, the removal of that state of membrane will be interrupted by the difficulty of introducing a bougie of sufficient size to make the necessary pressure on that part where the stricture is situated.”
If we understand Mr. Ramsden aright, this mal-formation of the extremity of the urethra, to which he gives the odd term MEMBRÁNOUS FENCE, is not the immediate but the remote cause of indurated testicle. It produces that unobserved morbid state of urethra, bere called latent irritation, from which arises a gradual, and for a considerable time, unnoticed enlargement of the gland. As this morbid state of the canal of the urethra, arising from the membranous fence, is nnknown to the patient, and, according to Mr. Ramsden's statement, hitherto, as well.as the membranous fence itself, unobserved by the 'surgeon, it will require a peculiar dexterity in the management of the hougie, and an extraordinary portion of delicacy in the tactus, however erudite on other occasions, to ascertain its situation. On this subject the following instructions are given.l!'.: ' “ Latent irritation may be established at any part of the urethra be. tween the bulb and the bladder. . When this is the consequence of previous inflammation, it is confined to some distinct and acutely sensible point of the membrane, which bleeds on the slightest pressure of the bougie. H
ii i .: > " When it is the result of preternatural muscular action, or of excite. ment, it is not copfined to so distinct a point, neither is it so acutely sensible; but consists rather of a tenderness of the inembrane, and particularly of that part of the canal which is within the prostate gland; it will also bear the pressure of the bougie without either bleeding fat all; or not to that degree as in the former instance. :::.. tinn - " As the state of membrane which constitutes a source of derange ment to the testicle is only discoverable by the bougie, and the imme. diate object of the enquiry is to detect an uphealthy state of urethra not indicated by obstruction, and sometimes confined to a minute point, the wiosissimo mi. ..,
. 269 greatest gentleness and accuracy will be requisite in the examina. tion.
“ The bougie should be larger at one extremity than at the other, and should be of sufficient size at its larger end to occupy the whole diameter of the canal without distressing it by distension : previous to its being used the bougie should be oiled, and drawn through the fingers until it has acquired a proper degree of curvature to correspond with the sweep of the urethra : if a bougie be introduced which does not fill up the area of the canal, it will not only be liable to entangle in the lacuna and thus embarrass the enquiry, but will miss or pass over any obscure point of įrritation, upon which some degree of pressure ought to be made. A bougie also which has not been previously tempered and curyed will stop at the sweep of the canal, and will not pass forward into the bladder, until sufficient force has been applied to make it, by pressure against the membrane, adapt itself to the rising course of the passage. Such a degree of pressure will produce some hesitation and a sense of pain in the most healthy urethra, which may lead an inexperienced practitioner to suppose he has detected a stricture or un.' healthy state of membrane, when in reality no such state exists.
“ The bougie, prepared as above described, is to be gently and gra. dually introduced with its larger extremity foremost : when it reaches the seat of irritation, which I have before said will be found between the bulb and the bladder, if such seat be confined to a distinct point of the membrane, the patient will express an acute pricking sensation, and the bougie on being withdrawn will generally be followed by some drops of blood. But when the seat of irritation consists in a derangement of a greater extent of membrane, the patient will describe a 'sensation of tenderness or soreness rather than of acute pricking, and the removal of the instrument will be seldom followed with any appearance of blood.
« In each of these deranged states of the canal, more or less of spasm will occasionally occur during the act of passing the bougie ; if the un. healthy state of membrane is limited to a distinct point, the spasm will be momentary, and the bougie will be felt as if suddenly to start from the affected part ; but where a greater extent of membrane is deranged, the spasm will be of longer duration, and the extremity of the bougie will appear to be gently grasped during the remainder of its passage into the bladder.”"
When an indurated enlargement of the testicle exists with either of the above states of the urethra ; that is, with a latent irritation, either arising from previous inflammation, from preternatural muscular action, or from excitement, Mr. Ramsden assures us that his experience authorizes him to say, that such derangement of the gland is to be considered as dependent upon the altered state of the urethra; and that the surgeon must direct his attention to the restoration of the natural state of that canal, in order to relieve the affection of the testicle."':.**.."
To this elucidation of the causes of disease in the testicle, investigations of particular morbid enlargements of that
gland gland naturally follow. These investigations begin with SCLEROCELE, or indurated testicle from latent irritation withir the urethra ; and its morbid characters and progress.
« The alteration which latent irritation first produces in the testicle, for the most part consists in an enlargement and induration of the epididymis, very much resembling that state in which the epididymis is frequently left after hernia humoralis. Sometimes, however, the body of the gland is the first part which becomes hardened, at others the induration will commence in the spermatic chord. As the induration ad. vances it acquires a peculiar callosity and cragginess ; and the vas deferens, the epididymis, the body of the testicle, and the spermatic chord, all partaking of the derangement, eventually become blended in one hardened, irregular mass, in no way, that I am aware of, differing in outward character, or immediately distinguishable, from that morbid alteration of these parts which has been generally denominated scirrhus.
** During the progress of such morbid alteration in the gland, an un, due effusion of serous fluid will occasionally take place within the tunica vaginalis, or underneath the coverings of the spermatic chord; in the former case producing a hydro-sclerocele, and in the latter a hydrospermato-sclerocele.f When a testicle has reached this state of disease, the progress of its farther derangement becomes uncertain and indefinite, but the most usual course is a languid suppurative inflammation at the lower part of the scrotum, with the projection of an irregular granula. ting fungus through the aperture of the abscess.
« Notwithstanding the sclerocele will in some few instances, on account of the constriction of fuid, become painful at a very early period of the induration, yet in most cases the morbid derangement is so subtle at its commencement, and its progress is so extremely gradual, that the disease 'seldom becomes the object of surgical care, until the patient's
* It is an observation of practical importance, that " when a testicle from any cause whatever becomes deranged, the true pathognomonic characters will be obscured or lost as soon as the painful or inflammatory state of such derangement commences : in other words, the sclerocele, the "scirrhus, the sarcocele, the scrophulous testicle, and that which has been called venereal, though characterized by certain distinct features previous and even up to the time when they become painful, or are rendered so by accident, will from that period all assume a common mixed character, so alike in appearance, that unless a surgeon'attends carefully to the preceding history of the disease, and to the symptoms which have marked the progress of such derangement, be will not be able to discriminate these diseases in their more advanced stages.". “ The features which distinguish the sclerocele, the scirrhus, and the sarco. cele from each other, will be found to be less strongly marked between the sclerocele and scirrhus, than between either' of those two affections and the sarcocele. The state of the testicle, which has been called venéreal, bears some slight resemblance to the sarcocele, but the serofulous testicle differs
. it This is a consideration of great importance, since fluid, when tightly
constricted, will oftentimes feel equally hard and resistent as the indurated gland or chord, and therefore add considerably to the obscurity of the case on examination," Fluid, when tightly bound down upon 'an irritabie testicle, is' also capable of producing general symptoms in the system which might seriously mislead an inexperienced practitioner. !!
áttention is either attracted by the inconvenient bulk of the tümor, or some accidental circumstance occurs, and diverts it from the, usual course. There is scarcely an instance of sclerocele of the testicle which does not corroborate this remark, by bearing incontestible evidences of its having existed long before the time at which the patient dates the discovery of his complaint. On this account a patient will frequently attribute the enlargement of the gland to hard riding, to a strain, to a cold, to a fever, or to some other occurrence which has had no influence in the production of the complaint, but merely induced disturbance in a testicle previously indurated, and ready to become enlarged upon the application of any exciting cause.
« We sometimes however meet with patients whose cases are to be considered as an exception to this general rule or course, in whom the common sclerocele of the testicle will advance with great rapidity, independently of any constricted Auid, and of all the accidental circumstances to which I have referred. These are persons who are constitutionally irritable, and in whom the testicle and membrane of the uretlira pártake of the general susceptibility of the system.
« But if a surgeon be consulted in a case of sclerocele of the testicle before the gland has taken on a diseased action of its own, the rapidity with which such derangement has proceeded will be found to be rather favourable to the cure than otherwise.
“ I have observed in cases in which the seat of irritation within the urethra is acutely sensible, and in which the enlargement of the testicle has been rapid, that the cure is much more obedient to the treatment by the bougie than in those in which the source of irritation is less seosible, and in which the gland has been more slowly habituated to its influence. In the former cases, also, the removal of the source of irritation will be always sufficient, alune, to perfect the recovery of the testicle ; but in the latter it will frequently be requisite after the cause has been removed from the urethra, to have recourse to local mercurial friction for the purpose of dispersing some remaining point of induration in the gland.
si The preceding observation, however, is to be considered as only applicable to that rapidity of progress in the sclerocele of the testicle which is solely dependent upon an increased degree of susceptibility in the seat of irritation within the urethra, and must on no account be confounded with the quickened course of disease, which is occasionally excited by general indisposition, or by injury to the gland itself. These cases differ essentially from each other, and require a very different mode of practice. In the former the early treatment of the urethra will stay the progress of derangement in the testicle, and probably effect a speedy cure ; but in the latter such resort to the immediate use of the bougie will frequently be injurious, and by aggravating all the symptums, may place the gland beyond remedy.
* If we reflect on the anatomy of the testicle, we must believe that when the breaking open or the actual exposure of its organic structure takes place, the functions of the gland will be destroyed; and this state of parts, which has been commonly called the “ spoiling of the tes. ticle," has at all times been admitted as a sufficient ground for advising the operation of castration. It must be of great importance, therefore, to ascertain whether we are not liable to be misled by appearances, and
to condemn a testicle to the knife, under the idea of its being spoiledig even whilst its vascular structure yet remains entire.
Of the several morbid affections of the testicle, which are presumed to be fatal to its vascular structure, the formation of matter within the body of the gland may be considered as the most frequent. I suspect, however, in many instances in which abscess takes place within an indurated enlarged testicle, that the suppurative process is restricted to the previously chickened cellular substance, which by its intervention must: necessarily be supposed to maintain the vascular structure of the body of the gland, as well as the continuous convolutions of the epididymis, in a state of extensive separation*. .
“When, in consequence of suppuration within the sclerocele, a fungus is projected from the lower part of the scrotum (which is a very common occurrence), such morbid affection has been extensively admitted as authorizing the extirpation of the testicle, and I will acknowledge I have myself, on some occasions, acted upon such opinion ; but later observatior: has shewn even this state of disease, in the early period of such fungated appearance, to be frequently confined to the cellular substance, or to the coats of the gland, and for the most part therefore totally independant of the vascular structure. ..“ If in true sclerocele the organic structure was liable to be « spoiled” at all times when suppuration takes place within the substance of the tu. mor, we should surely obtain frequent proof of such a fact, and yet I can truly declare (in cases in which I have had an opportunity of controling the derangement in the gland by the timely and early treatment of the urethra), I have scarcely seen a single instance where I had reason to suppose the functions of the gland to be eventually 6 spoiled," merely in consequence of matter having formed amidst the induration.
66 Allowing, however, the exposure of the organic structure of the indurated testicle to be sometimes an immediate consequence of suppura. tion within its substance, when such an effect results solely from a source of irritation within the urethra, it would by no means justify the early removal of the part as a measure of necessity.
“ Even under such distressful circumstances, if the patient be content to retain the gland in its defective state, the treatment of the urethra will, I believe, in most instances, prove competent to the preservation of the remaining portion, and render it in future perfectly inoffensive to the constitution, provided such treatment be resorted to, when the patient is not suffering under general indisposition, and before the neighbouring parts have taken on a diseased action in consequence of the Tong continuance of irritatiou.t
* It may be observed in the common varicocele of the testicle bow easily its organic structure admits of extensive separation.
† This is one of the circumstances which distinguishes the sclerocele essentially from the sarcocele. When the structure of the testicle is exposed by that suppurative process, which is merely a consequence of irritation within ļhe urethra, the gland may be restored to a quiescent state, and may be su far recoverable; but when the organic structure of the testicle is exposed by the progress of sarcocele, such a compromise must not be expected.
This observation applies also to the scrofulous testicle. Although large portions of the gland will slough away, in what is called the scrofulous testicle, yet in many instauces the remaining parts will heal up, and eontinue through life without oocasioning farther inconvenience.