January 1,
1875.]
ON BLOODLESS SCROTAL OPERATIONS.?BY S. B. PARTRIDGE.
ON TIIE BLOODLESS REMOVAL OF ELEPHANTOID TUMOURS OF THE SCROTUM.
By Surgeon-Major
S. B.
Pautiiidge,
F.R
C.S.,
Officiating Professor of Surgery, Medical College, Surgeon, Me Heal College Hospital.
and first
13
[ though the amount of haemorrhage was very trifling. In the third case, however, the operation may fairly be said to have been absolutely bloodless; not a drop of blood was lost until all the visible vessels were secured and the band loosened, and the subsequent bleeding from small vessels could certainly not
have amounted to more than at the utmost two or three ounoes. fully believe that the adoption of these precautionary mea-
I
The three following cases of scrotal hypertrophy, for the notes of which I am indebted to my House-Surgeon, Baboo Dhurma Doss Bose, L.M.S., are illustrative of the applicability of the
will render the performance of the operation upon the tumours a matter of comparative safety, and that the risk of death from shock will almost disappear. sures
largest
principles of Professor Esmarch's system of bloodless operation to the removal of scrotal growths. For many years past it has been our practice at the College Hospital to reduce the amount
Ram Jebun Hazra, a Hindu male, aged 43, admitted into Partridge's ward, in the Medical College Hospital, oil the December 1873, with a large scrotal tumour.
circulating in large tumours, by placing the patient in a position, keeping the tumour itself elevated for some little time prior to the operation, and applying a bandage ; and latterly my old friend and colleague, Dr. Fayrer, introduced first the use of a metal clamp, and subsequently a cord applied round the base of the growth to restrict haemorrhage at the actual time of operating. The measures about to be described, therefore, present no features of actual novelty in principle, but in practice are infinitely more efficacious, the clastic compression ?when carefully applied thoroughly emptying the tumour, and the elastic cord thoroughly controlling the vessels without interfering
The growth apparently commenced about seven years prior to his admission, with marked febrile attacks accompanying scrotal congestion and enlargement, and recurring pretty regularly at about six months interval to within three months of the date
of blood
recumbent
with the necessary incisions.
The unfavorable constitutional state of the patient, whose case
is first
led
recorded,
me
to endeavour to overcome the
practical difficulties attending the thorough application of the elastic bandage. The tumour was a large one, the patient excessively anaemic, his pulse small and feeble and hi3 whole appearance that of a person prematurely aged ; he certainly could not afford to lose much blood, and hence my anxiety to adopt every possible means of limiting the hamiorrhage. The
plan
I
adopted,
and which with
followed also in the other two cases,
trifling modifications was
the
was
following:
A belt was firmly fixed around the patient's waist; on this were sewed two bands embracing the upper and inner part of the thighs in a loop-like manner, and these loops were
strong jean
connected together transversely by two bands, one above the pubis and the other behind the perineum. The accompanying rough sketch will perhaps give an idea of the apparatus. By tins
means
tinuous
a
con-
circle
of
loops was secured surrounding the base of the tumour without compressing it, and having a
firm
hack-pur-
chase upon the waist belt. With
jhe
aid
of these
loops no great difficulty was experienced in bringing to bear upon the end of the tumour the pressure of a bandage of broad elastic webbing passed alternate^ under the front and back bands, and from one lateral loop to the other; a few circular turns of the bandage then sufficed
to cover the growth completely, and to compress and f;mpty it efficiently. Leaving this pressure for a short time to tell upon the tumour, another elastic band tvas subsequently cightly tied around its base and drawn by tapes towards the waist band in front and behind so as, as far as
the lines of incision; in subsequent have also been used so as more efficiently to avoid any risk of the slipping of the compressing band prior to the of the divided vessels. The compressing band
possible,
to
freely 'expose
operations lateral
loops
ligature
having been carefully adjusted, the original bandage
was
removed,
the operation proceeded with in the usual way. In the *?'st case the success was necessarily somewhat imperfect, al-
of his admission, each attack leaving increasing permanent hypertrophy. At
Mr. 1st
behind
it gradually the time of his admission he was in a state of extreme anaemia and debility, with a small feeble pulse, but with uo evidence of the existence of any organic disease. Lungs and heart healthy; neither liver nor spleen enlarged ; urine normal in quantity, sp. gr. 1011, with no traces of albumen. The tumour was large, even in outline ; penis wholly imbedded; preputial orifice central; some vesicles on the surface of the growth exuding a small amount of translucent
albuminous
fluid.
In
consequence
of his
condition
of extreme debility he was ment for a period of two
kept under preparatory tonic treatmonths, and then operated on under There was chloroform witli the precautions above detailed. some fluid in each tunica vaginalis, but the testicles were healthy. The tumor weighed after removal 351hs. Seventy-six ligatures were applied, and there was scarcely any bleeding until In dressing the wound a plan the circular band was removed. was adopted, which I have found very efficacious in preventing inversion of the lateral flaps of healthy skin and consequent delay in cicatrization ; a band being passed round the thigh the edges of the flap were stitched to it by three silk sutures which were maintained in position until the first dressing about 48 hours after the operation. His progress towards recovery was almost uninterrupted; the day after the operation there was slight febrile re-action, and for the first 24 hours his urine had to be On the ninth day he had a slight drawn off by the catheter.
attack of dysentery, which persisted for about
a
fortnight, but
from that time his progress was steady, and he was discharged cured 3 months and 28 days from the date of the performance of
the operation. Chotto Gossain, a Hindoo male, aged 35, admitted into Mr. Partridge's ward in the Medical College Hospital on the 18th January 1874., with a scrotal tumour. The growth of the tumour was spread over a period of about 9 years with the usual history of periodic attacks of fever and active growth, the intervals, however, being exceedingly irrebut no other curative gular. Four moxas had been applied, At the time of admission he was in appameasures adopted. disease? rently sound health, with no evidence of any organic even in contour, and the penis completely the tumour
large,
a week's rest, the operation was performed precautions as in the other case ; but little blood 83 ligatures were applied, the testicles were healthy, was lost; The tumour left side there was a slight hydrocele. the but on 2 oz. The patient's progress after removal weighed 29 lbs. towards recovery was uninterrupted, and he was discharged
imbedded. with the
After
same
cured on the 10th June 18/4.
Chandy Churn Biswas, a Hindoo male, resident of Ranaghat, Medical aged 36, admitted into Mr. Partridge's ward in the College Hospital on the 27th November 1874 with a large
THE INDIAN MEDICAL GAZETTE.
I4i crotal tumour. The dated back 14 years, occasional attacks of at irregular intervals,
commencement of the grow ill since wbich time he had been
probably subject to fever with scrotal enlargement occurring and persisting frequently for three or four days at a time. During the four years prior to his admission the rapidity of the growth of the tumour had been much accele-
[January 1, 1875.
to the abdominal belt tbe
by tapes following diagram :?
in the
manner
indicated
by
rated. His father suffered from a similar condition, but not so extreme in degree. At the time of his admission, he appeared 1n sound health, with no traces of organic disease. Urine free from albumen, but, as is not uncommon in these cases, of low specific gravity, 1008. The tumour was even in outline, dense in
penis imbedded ; preputial orifice central. The operaperformed on the 2nd December, the elastic bandage was of very carefully and successfully applied, thanks to the assistance well was Dr. the MeLeod; my colleague, compressing ligature drawn back by lateral tapes over the buttock as well as by anterior and posterier ones, and the result was a complete emptying of the tumor, which when cut into was perfectly pale and bloodless, and a thorough compression of the vessels, not one of ?which emitted a drop of blood until the elastic band was removed. Many of the vessels supplying the tumour were exceedingly large, and their open mouths without a trace of hcemorrhage presented a curious sight when the tumour was removed ; 65 ligatures were applied. The tumour on removal weighed 451bs. 15 oz. The loss of blocd from the minor vessels after the loosening of the constricting band could not have structure ;
tion was
amounted to
more
than two
or
three
ounces
at the utmost.
patient is still in hospital; his progress towards been unusually steady, the only inconvenience he from being difficulty in passing his water for days.
The
recovery has has suffered the first two
I have much pleasure in adding to the foregoing record the following notes of a case of scrotal tumour of large size, in ?which Professor Partridge's apparatus was employed with excelThe narrative is taken from notes recorded
lent results.
by
my
House Surgeon, Baboo Jogendro jNath Ghose, L.M.S.
Banerjea, a Hindoo priest, aged 40, an inhabitant Eanaghat, Nuddea district, was admitted into the second Surgeon's ward on the 3rd of October 1874 with a scrotal tumour of very large size. Earn Lai
of
The tumour had commenced to grow some 25 years ago, but slow progress until 12 years ago, when he suffered from intermittent fever. Within the last two year3 the growth has been very rapid, accompanied by strong attacks of fever.
made
On admission his to
scrotum within
disappeared lows
:
he presented
of
about within
a
6
an
enormous
pyriform shape hanging inches of the ground. the mass.
Its dimensions
of
hypertrophy from the pubis The penis had were
as
fol-
?
Length 19 inches ; breadth 20 inches ; circumference 43 inches weighed when placed on a scale, 48 lbs. A few vesicles, exud ing when scratched a lymphous fluid, existed on its posterior surface. On examination through the preputial canal, the cords were found to be much thickened, but no hernia was detected on either side. The right testis was found to be normal, and the left enlarged, apparently from an accumulation of fluid in the tunica vaginalis. Patient was found to be well nourished
It
and free from
under
organic disease ; urine normal. He was kept observation until the 6tli cf November, when, nothing
contraindicating, the operation for the removal of the tumour was performed. The tumour was in the first instance compressed by a broad elastic bandage, as above described. Its neck was next tightly encircled by an elastic band wound
twice round the pedicle?see fig. This
was
secured
Abdominal Abdominalbelt. belt. B. B. Perineal Perineal (elastic) band. (elastic) band. A. A. B. B. Anterior bands. Anterior and and posterior connectingbands. posterior connecting O. C. D. D. Lateral infront frontof of thigh. Lateral ditto ditto passing thigh. passingin E. behind thigh. E. E. F. Lateral Lateral ditto ditto passing thigh. passing behind Not a single arterial jet was observed during the removal of the mass or after it. The operation presented no unusual feature. A. A.
The left tunica vaginalis Was found to be distended with fluid, and its lining membrane covered with cartilaginous plates. After all the visible vessels were secured, the tapes were several-
ly cut, as they
and small vessels which had bled. Very little blood was
tures were
removal;
required. the
The
mass
fluid contained
in
escaped notice were secured lost, though about 80 ligaweighed 41fbs 12oz after the left tunica accounting
for the difference. The patient had
a very mild amount of febrile re-action during the next few days, the temperature not rising above 101.? This pyrexia subsided on the 8th, and he has made a most excellent recovery without any symptom to occasion
anxiety,
lie has been occasionally slightly feverish towards evening, but latterly this has quite disappeared. He retained his flesh and appetite, and now the wound is in course of rapid contraction and cicatrization. The lateral perineal flaps were during the first 48
hours held aside by ligatures attached to
a band passed part of the thigh in the manner above described. Having previously performed a number of similar operations with the old cord, I am in a position to give my unqualified testimony to the great superiority of the apparatus employed in these cases.
round
the upper
The 24th December 1874.
X. McLeod.
1875.]
ON BLOODLESS SCROTAL OPERATIONS.?BY S. B. PARTRIDGE.
ON TIIE BLOODLESS REMOVAL OF ELEPHANTOID TUMOURS OF THE SCROTUM.
By Surgeon-Major
S. B.
Pautiiidge,
F.R
C.S.,
Officiating Professor of Surgery, Medical College, Surgeon, Me Heal College Hospital.
and first
13
[ though the amount of haemorrhage was very trifling. In the third case, however, the operation may fairly be said to have been absolutely bloodless; not a drop of blood was lost until all the visible vessels were secured and the band loosened, and the subsequent bleeding from small vessels could certainly not
have amounted to more than at the utmost two or three ounoes. fully believe that the adoption of these precautionary mea-
I
The three following cases of scrotal hypertrophy, for the notes of which I am indebted to my House-Surgeon, Baboo Dhurma Doss Bose, L.M.S., are illustrative of the applicability of the
will render the performance of the operation upon the tumours a matter of comparative safety, and that the risk of death from shock will almost disappear. sures
largest
principles of Professor Esmarch's system of bloodless operation to the removal of scrotal growths. For many years past it has been our practice at the College Hospital to reduce the amount
Ram Jebun Hazra, a Hindu male, aged 43, admitted into Partridge's ward, in the Medical College Hospital, oil the December 1873, with a large scrotal tumour.
circulating in large tumours, by placing the patient in a position, keeping the tumour itself elevated for some little time prior to the operation, and applying a bandage ; and latterly my old friend and colleague, Dr. Fayrer, introduced first the use of a metal clamp, and subsequently a cord applied round the base of the growth to restrict haemorrhage at the actual time of operating. The measures about to be described, therefore, present no features of actual novelty in principle, but in practice are infinitely more efficacious, the clastic compression ?when carefully applied thoroughly emptying the tumour, and the elastic cord thoroughly controlling the vessels without interfering
The growth apparently commenced about seven years prior to his admission, with marked febrile attacks accompanying scrotal congestion and enlargement, and recurring pretty regularly at about six months interval to within three months of the date
of blood
recumbent
with the necessary incisions.
The unfavorable constitutional state of the patient, whose case
is first
led
recorded,
me
to endeavour to overcome the
practical difficulties attending the thorough application of the elastic bandage. The tumour was a large one, the patient excessively anaemic, his pulse small and feeble and hi3 whole appearance that of a person prematurely aged ; he certainly could not afford to lose much blood, and hence my anxiety to adopt every possible means of limiting the hamiorrhage. The
plan
I
adopted,
and which with
followed also in the other two cases,
trifling modifications was
the
was
following:
A belt was firmly fixed around the patient's waist; on this were sewed two bands embracing the upper and inner part of the thighs in a loop-like manner, and these loops were
strong jean
connected together transversely by two bands, one above the pubis and the other behind the perineum. The accompanying rough sketch will perhaps give an idea of the apparatus. By tins
means
tinuous
a
con-
circle
of
loops was secured surrounding the base of the tumour without compressing it, and having a
firm
hack-pur-
chase upon the waist belt. With
jhe
aid
of these
loops no great difficulty was experienced in bringing to bear upon the end of the tumour the pressure of a bandage of broad elastic webbing passed alternate^ under the front and back bands, and from one lateral loop to the other; a few circular turns of the bandage then sufficed
to cover the growth completely, and to compress and f;mpty it efficiently. Leaving this pressure for a short time to tell upon the tumour, another elastic band tvas subsequently cightly tied around its base and drawn by tapes towards the waist band in front and behind so as, as far as
the lines of incision; in subsequent have also been used so as more efficiently to avoid any risk of the slipping of the compressing band prior to the of the divided vessels. The compressing band
possible,
to
freely 'expose
operations lateral
loops
ligature
having been carefully adjusted, the original bandage
was
removed,
the operation proceeded with in the usual way. In the *?'st case the success was necessarily somewhat imperfect, al-
of his admission, each attack leaving increasing permanent hypertrophy. At
Mr. 1st
behind
it gradually the time of his admission he was in a state of extreme anaemia and debility, with a small feeble pulse, but with uo evidence of the existence of any organic disease. Lungs and heart healthy; neither liver nor spleen enlarged ; urine normal in quantity, sp. gr. 1011, with no traces of albumen. The tumour was large, even in outline ; penis wholly imbedded; preputial orifice central; some vesicles on the surface of the growth exuding a small amount of translucent
albuminous
fluid.
In
consequence
of his
condition
of extreme debility he was ment for a period of two
kept under preparatory tonic treatmonths, and then operated on under There was chloroform witli the precautions above detailed. some fluid in each tunica vaginalis, but the testicles were healthy. The tumor weighed after removal 351hs. Seventy-six ligatures were applied, and there was scarcely any bleeding until In dressing the wound a plan the circular band was removed. was adopted, which I have found very efficacious in preventing inversion of the lateral flaps of healthy skin and consequent delay in cicatrization ; a band being passed round the thigh the edges of the flap were stitched to it by three silk sutures which were maintained in position until the first dressing about 48 hours after the operation. His progress towards recovery was almost uninterrupted; the day after the operation there was slight febrile re-action, and for the first 24 hours his urine had to be On the ninth day he had a slight drawn off by the catheter.
attack of dysentery, which persisted for about
a
fortnight, but
from that time his progress was steady, and he was discharged cured 3 months and 28 days from the date of the performance of
the operation. Chotto Gossain, a Hindoo male, aged 35, admitted into Mr. Partridge's ward in the Medical College Hospital on the 18th January 1874., with a scrotal tumour. The growth of the tumour was spread over a period of about 9 years with the usual history of periodic attacks of fever and active growth, the intervals, however, being exceedingly irrebut no other curative gular. Four moxas had been applied, At the time of admission he was in appameasures adopted. disease? rently sound health, with no evidence of any organic even in contour, and the penis completely the tumour
large,
a week's rest, the operation was performed precautions as in the other case ; but little blood 83 ligatures were applied, the testicles were healthy, was lost; The tumour left side there was a slight hydrocele. the but on 2 oz. The patient's progress after removal weighed 29 lbs. towards recovery was uninterrupted, and he was discharged
imbedded. with the
After
same
cured on the 10th June 18/4.
Chandy Churn Biswas, a Hindoo male, resident of Ranaghat, Medical aged 36, admitted into Mr. Partridge's ward in the College Hospital on the 27th November 1874 with a large
THE INDIAN MEDICAL GAZETTE.
I4i crotal tumour. The dated back 14 years, occasional attacks of at irregular intervals,
commencement of the grow ill since wbich time he had been
probably subject to fever with scrotal enlargement occurring and persisting frequently for three or four days at a time. During the four years prior to his admission the rapidity of the growth of the tumour had been much accele-
[January 1, 1875.
to the abdominal belt tbe
by tapes following diagram :?
in the
manner
indicated
by
rated. His father suffered from a similar condition, but not so extreme in degree. At the time of his admission, he appeared 1n sound health, with no traces of organic disease. Urine free from albumen, but, as is not uncommon in these cases, of low specific gravity, 1008. The tumour was even in outline, dense in
penis imbedded ; preputial orifice central. The operaperformed on the 2nd December, the elastic bandage was of very carefully and successfully applied, thanks to the assistance well was Dr. the MeLeod; my colleague, compressing ligature drawn back by lateral tapes over the buttock as well as by anterior and posterier ones, and the result was a complete emptying of the tumor, which when cut into was perfectly pale and bloodless, and a thorough compression of the vessels, not one of ?which emitted a drop of blood until the elastic band was removed. Many of the vessels supplying the tumour were exceedingly large, and their open mouths without a trace of hcemorrhage presented a curious sight when the tumour was removed ; 65 ligatures were applied. The tumour on removal weighed 451bs. 15 oz. The loss of blocd from the minor vessels after the loosening of the constricting band could not have structure ;
tion was
amounted to
more
than two
or
three
ounces
at the utmost.
patient is still in hospital; his progress towards been unusually steady, the only inconvenience he from being difficulty in passing his water for days.
The
recovery has has suffered the first two
I have much pleasure in adding to the foregoing record the following notes of a case of scrotal tumour of large size, in ?which Professor Partridge's apparatus was employed with excelThe narrative is taken from notes recorded
lent results.
by
my
House Surgeon, Baboo Jogendro jNath Ghose, L.M.S.
Banerjea, a Hindoo priest, aged 40, an inhabitant Eanaghat, Nuddea district, was admitted into the second Surgeon's ward on the 3rd of October 1874 with a scrotal tumour of very large size. Earn Lai
of
The tumour had commenced to grow some 25 years ago, but slow progress until 12 years ago, when he suffered from intermittent fever. Within the last two year3 the growth has been very rapid, accompanied by strong attacks of fever.
made
On admission his to
scrotum within
disappeared lows
:
he presented
of
about within
a
6
an
enormous
pyriform shape hanging inches of the ground. the mass.
Its dimensions
of
hypertrophy from the pubis The penis had were
as
fol-
?
Length 19 inches ; breadth 20 inches ; circumference 43 inches weighed when placed on a scale, 48 lbs. A few vesicles, exud ing when scratched a lymphous fluid, existed on its posterior surface. On examination through the preputial canal, the cords were found to be much thickened, but no hernia was detected on either side. The right testis was found to be normal, and the left enlarged, apparently from an accumulation of fluid in the tunica vaginalis. Patient was found to be well nourished
It
and free from
under
organic disease ; urine normal. He was kept observation until the 6tli cf November, when, nothing
contraindicating, the operation for the removal of the tumour was performed. The tumour was in the first instance compressed by a broad elastic bandage, as above described. Its neck was next tightly encircled by an elastic band wound
twice round the pedicle?see fig. This
was
secured
Abdominal Abdominalbelt. belt. B. B. Perineal Perineal (elastic) band. (elastic) band. A. A. B. B. Anterior bands. Anterior and and posterior connectingbands. posterior connecting O. C. D. D. Lateral infront frontof of thigh. Lateral ditto ditto passing thigh. passingin E. behind thigh. E. E. F. Lateral Lateral ditto ditto passing thigh. passing behind Not a single arterial jet was observed during the removal of the mass or after it. The operation presented no unusual feature. A. A.
The left tunica vaginalis Was found to be distended with fluid, and its lining membrane covered with cartilaginous plates. After all the visible vessels were secured, the tapes were several-
ly cut, as they
and small vessels which had bled. Very little blood was
tures were
removal;
required. the
The
mass
fluid contained
in
escaped notice were secured lost, though about 80 ligaweighed 41fbs 12oz after the left tunica accounting
for the difference. The patient had
a very mild amount of febrile re-action during the next few days, the temperature not rising above 101.? This pyrexia subsided on the 8th, and he has made a most excellent recovery without any symptom to occasion
anxiety,
lie has been occasionally slightly feverish towards evening, but latterly this has quite disappeared. He retained his flesh and appetite, and now the wound is in course of rapid contraction and cicatrization. The lateral perineal flaps were during the first 48
hours held aside by ligatures attached to
a band passed part of the thigh in the manner above described. Having previously performed a number of similar operations with the old cord, I am in a position to give my unqualified testimony to the great superiority of the apparatus employed in these cases.
round
the upper
The 24th December 1874.
X. McLeod.
