THIS is one of the most melancholy Operations in the Practice of Surgery, since it seldom takes place but in Disorders into which the Patient is very apt to relapse, viz. those of a Schirrhus, or Cancer; for under most of the Symptoms described as rendering it necessary, it is absolutely improper; such as a Hydrocele, Abscess of the Testis, an increasing Mortification, or what is sometimes understood by a Sarcocele; of which last it may not be amiss to say a Word. In the utmost Latitude of the Meaning of this Term, 'tis received as a fleshy Swelling of the Testicle itself, called likewise Hernia Carnosa; or in some Enlargements, such as in a Clap, more frequently Hernia Humoralis; but generally speaking, is considered as a fleshy Excrescence formed on the Body of the Testis, which becoming exceedingly hard and tumefied, for the most part is supposed to demand Extirpation, either by cutting or burning away the Induration; or amputating the Testicle: But this Maxim too precipitately received, has, I apprehend, very Much misguided the Practitioners of Surgery.
In order to conceive better of the Distinction I am going to make, it must be remembered, that what is called the Testicle, is really composed of two different Parts; one Glandular, which is the Body of the Testicle itself; and one Vascular or Membranous, known by the name of Epididymis, which is the Beginning of the Vas Deferens, or the Collection of the excretory Ducts of the Gland.
Now it sometimes happens that this Part is tumefied, independent of the Testicle; and feeling like a large adventitious Excrescence, answers very well to the Idea most Surgeons form of a Sarcocele; but not being aware of the different Nature and Texture of the Epididymis, they have frequently confounded its Disorders with those of the Testicle itself, and equally recommended Extirpation in the Induration of one or the other. But without tiring the Reader with particular Histories of Cases relating to this Subject, I shall only say, That from diligent Enquiry I have collected, that all Indurations of the glandular Part of the Testicle not tending to Inflammation and Abscess, generally, if not always, lead on to Scirrhus and Cancer; whereas those of the Epididymis seldom or never do. It is true, in spite of internal or external Means, these last often retain their Hardness, and sometimes suppurate, but however without much Danger in either Case.
It will not be hard to account for this Difference of Consequences, from Tumours of seemingly one and the same Body, when we reflect how much it is the Nature of cancerous Poisons to fix upon Glands, and how different the Epididymis is from a Gland, tho' so nearly in the Neighbourhood of one.
I would not have it supposed from what I have said, that the Epididymis never becomes cancerous; I confess it may, so may every Part of the human Body: But I advance that it rarely or never is so, but from an Affection of the glandular Part of the Testicle first, which indeed seldom fails to taint, and by degrees to confound it in such a manner, as to make one Mass of the two.
Before we castrate, it is laid down as a Rule to inquire whether the Patient has any Pain in his Back, and in that case to reject the Operation, upon the reasonable Presumption of the spermatic Vessels being likewise diseased; but we are not to be too hasty in this Determination; for the mere weight of the Tumour stretching the Cord will sometimes create the Complaint. To learn the Cause then of this Pain in the Back, when the spermatic Cord is not thickened, let your Patient be kept in Bed, and suspend his Scrotum in a Bag-truss, which, will relieve him, if disordered by the Weight only; but if the spermatic Cord is thickened or indurated, which Disease, when attended with a Dilatation of the Vessels of the Scrotum, is known by the Greek Appellations Circocele and Varicocele, the Case is desperate and not to be undertaken. But supposing no Obstacle in the way to the Operation, the Method of doing it may be this: Lay your Patient on a square Table of about three Feet four Inches high, letting his Legs hang down, which, as well as the rest of his Body, must be held firm by the Assistants. Then with a Knife, begin your Wound above the Rings of the Abdominal Muscles, that you may have Room afterwards to tie the Vessels, since for want of this Caution, Operators will necessarily be embarrassed in making the Ligature: then carrying it thro' the Membrana Adiposa, it must be continued downward, the Length of, it being in proportion to the Size of the Testicle. If it is very small, it may be dissected away without taking any part of the Scrotum; but I am not very fond of this Method, because so much loose flabby Skin is apt to form Abscesses afterwards, and very frequently grow callous. If the Testicle, for Instance, weighs twenty Ounces; having made one Incision about five Inches long, a little circularly, begin a second in the same Point as the first, bringing it with an opposite Sweep, to meet the other in the inferior Part., in such a manner as to cut out the Shape of an Oval, whose smallest Diameter shall be two Inches : After this, dissect away the Body of the Tumour with the Piece of Skin on it, from the Scrotum, first taking up some of the Blood-vessels, if the Hæmorrhage is dangerous. Then pass a Ligature round the Cord, pretty near the Abdomen; and if you have Space between the Ligature and Testicle, a second about half an Inch lower, to make the Stoppage of Blood still more secure. The Ligatures may be tied with what is called the Surgeon's Knot, where the Thread is passed thro' the Ring twice. This done, cut off the Testicle a little underneath the second Ligature, and pass a Needle from the Skin at the lower Part of the Wound thro' the Skin at the upper Part, in such manner as to envelope in some degree the sound Testicle, which will greatly facilitate and quicken the Cure; or if one Stitch will not answer the Purpose, you may repeat it in such Part of the Wound, where the Skin on each Side lies most loose.
The Method I have here described is what I have most frequently practised; but I think I have of late years performed the Operation with more Dexterity, where I have divided the Testicle from the Cord, before I had dissected away the Skin from the Body of the Testicle; for having had by this means an Opportunity of laying hold of its upper Part, I could separate it from the Scrotum with much more Ease, than without that Advantage.
I once castrated a Man whose Testicle weighed above three Pounds, where some of the Vessels were so exceedingly varicous and dilated, as nearly to equal the size of the Humeral Artery; however, I took up two or three of the most considerable, and pursued the Operation, cutting away near three fourths of the Skin, by which means I avoided a dangerous Effusion, as by dividing the Vessels before they were much ramefied, I had fewer Ligatures to make: The Success answered the Design, and the Patient survived the Operation and healing of the Wound; but the cancerous Humour falling on his Liver some time after, destroyed him. In large Tumours, such as the last I have mentioned, it is adviseable to cut away great part of the Skin; for besides that the Hæmorrhage will be much less in this Case, and the Operation greatly shortened; the Skin by the great Distension having been rendered very thin, will great part of it, if not taken away, sphacelate, and the rest be more prone to degenerate into a cancerous Ulcer.
It may be observed, I do not, in order to avoid wounding the Spermatic Vessels, recommend pinching up the Skin before the Incision, and afterwards thrusting the Fingers between the Membrana Cellularis and the Testicle, to tear the one from the other; the first is not dextrous; and the other is painful; and both of them, in my opinion, are calculated to prevent what there is little or no danger of.