In hmmatoceles which have existed for a long period, the blood becomes changed into a substance resembling coffee grounds, of a brownish-red, or chocolate colour, and more or less fluid. The coagula sometimes present a cellular or honeycomb appearance, the cells being filled with a reddish serum. Occasion ally the blood is found converted into a solid fibrinous substance, of a yellow or fawn colour, arranged in firm layers, similar to the coagula lining the sac of an aneurism. In many in stances the effused blood is felt as a foreign body, and produces inflammation in the tunica vaginalis, which becomes coated with lymph, and this mixing with blood and serum modi fies the appearance of the contents of the cyst, rendering it turbid and of a lighter colour. Sometimes the inflammation goes on to suppuration, in which case pus is also found in the sac. The inflammation usually extends from the tunica vaginalis to the areolar tissue and fascia external to the sac, which in recent cases are found infiltrated with serum and lymph, and in cases of old standing be come greatly thickened, indurated, and com pacted. In a case of hmmatocele, occasioned by the wound of a vessel in tapping a hydro cele in which I was consulted, the inflamma tion which ensued caused, in the course of a fortnight, great thickening of the tissues ex ternal to the sac, and the formation of an abscess in the scrotum on one side of the hmmatocele. I have found the tunica vagin alis and tissues investing it as much as half an inch in thickness, and very firm and dense.
These changes in the sac are produced by a more chronic form of inflammation of the fascia and areolar tissue investing the sac. In these old cases, the internal surface of the tunica vaginalis instead of presenting its na tural smooth and polished surface, is rough, granular, and irregular, and feels as dense and tough as a piece of leather, having lost all the characters of a serous membrane. In hmmatocele, the testicle preserves the same relation to the remainder of the tumour as in simple hydrocele, being situated at the posterior part, and rather below the centre. Its position, however, is liable to similar al terations as occur in hydrocele, and they are dependent upon the same causes. A young man had a hydrocele, which had succeeded to an attack of secondary orchitis, occasioning an adhesion of the gland to the front of the sac at its lower part. The case became con verted into a hmmatocele by the wound of a vessel in the operation of tapping. Inflam mation ensued, and it became necessary to lay open the sac. The surgeon, in carrying the incision to the lower part of the tunica va ginalis, divided the vas deferens and severed the sound testicle nearly in two with his bis toury, the thickening around the sac having prevented him from detecting the gland in its unusual situation. In hmmatocele, the
glandular structure of the testicle sometimes disappears in the same manner as in old cases of hydrocele, atrophy being occasioned by the long continued pressure arising from the ex travasated blood. Sir B. Brodie has recorded two cases of old hmmatocele, in which the testicle was completely atrophied.* In the examination of a large hmmatocele which had existed for many years, and was removed by operation, under the impression that it was a solid enlargement of the testicle, I found the tunics vaginalis nearly half an inch thick, and full of a soft friable substance of a chocolate colour ; the testicle, which was situated at the posterior part of the cavity, was some what flattened, and partly imbedded in the thickened cyst ; but the glandular structure was perfectly healthy, and the bulk of the organ scarcely less than natural. The hmnia tocele, with the sac and testicle laid open, is represented in the accompanying figure. The structure of the testicle is usually indeed sound in hmmatocele, but its nutrition becomes im paired when the disease is of very old stand ing.
Encysted hainalocele of the testicle, or effusion of blood in a cyst connected with the testicle, is an extremely rare affection. The following is the only case of the kind that I have met with. I was requested by one of my colleagues at the London Hospital to examine a case of painful tumour connected with the left testicle. The patient, aged eighteen, had injured the part three months before. The scrotum was much swollen at the time of the accident, and the tumour formed afterwards. It was about the size of a chesnut, quite moveable, but attached to the epididymis. The cyst was opened with a lancet, and exit given to a quantity of dark coagula lodged in a thickened cyst, the interior of which was lined by a rough false membrane. No doubt the cyst existed before the injury, which caused effusion of blood and inflammation, and thickening of the cyst.
Hematocele of the spermatic cord is an affection which was first noticed by Mr. Pott. It is generally produced by the accidental rupture of a spermatic vein, during violent and sudden exertion, as in straining to lift a heavy weight, when blood immediately es capes into, and infiltrates the loose areolar tissue along the cord, where it accumulates, its further diffusion being prevented by the fascious envelope of this part. Mr. Pott has related three cases, all of which happened in this way. I have met with this variety of hmmatocele, coupled with extravasation in the scrotum, in two or three instances of contusion, of this part. In one case in which the effusion in the cord was on the left side the spermatic veins were varicose.