A CASK OK 
APPENDICITIS IN THE SCROTUM. 
Removal of Pus by Aspiration ; Excision 
of the Appendix during a Remission ; 
Recovery. 
BY 
GEORGE H. MONKS, M. D., 
SURGEON TO THE CARNEY HOSPITAL, SURGEON TO THE BOSTON DISPENSARY, 
AND ASSISTANT IN OPERATIVE SURGERY AT THE HARVARD 
MEDICAL SCHOOL. 
Reprinted from the Boston Medical and Surgical Journal 
of June 5, iBgo. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
xSgo, S. J. PARKHILL & CO., PRINTERS 
BOSTON A CASE OF APPENDICITIS IN THE SCROTUM; 
REMOVAL OF PUS BY ASPIRATION; EX- 
CISION OF THE APPENDIX DURING A RE- 
MISSION; RECOVERY.1 
Surgeon to the Carney Hospital, Surgeon to the Boston Dispensary, 
and Assistant in Operative Surgery at the Harvard Medical School. 
GEORGE H. HOURS, M.D., 
A boy, of Portuguese parentage, and about two 
years old, was referred to me some months ago by 
Dr. W. D. Hodges, while I was on duty in the Sur- 
gical Department at the Boston Dispensary. The 
child had a swelling occupying the whole of the ante- 
rior part of the right side of the scrotum and extending 
a short distance on to the abdomen and inguinal region. 
About mid-way between the external ring and the testi- 
cle, this swelling was more prominent than elsewhere and 
was quite red. On touching any part of it the patient 
winced and cried. Upon questioning the father, I learned 
that the attention of his wife and himself had been first 
called to the child’s condition about two months before, 
and that there was first noticed a hard bunch in about 
the same situation as the most prominent part of the 
swelling above referred to, and that this bunch appeared 
to grow larger and larger, and more and more red and 
tender, and finally, presented the condition already 
described. 
On more carefully examining the swollen tissues, I 
could indistinctly make out a deep-seated tumor whose 
centre corresponded with the spot of greatest swelling 
and tenderness referred to above. This tumor appeared 
to be about the size of a large olive and was quite 
hard, its axis corresponding with that of the cord. A 
very narrow neck extended from its upper extrem- 
1 Read at the meeting of the Surgical Section of the Suffolk Dis- 
trict Medical Society, on March 5,1890. 2 
ity to the external ring. There was no impulse 
when the child cried. I pushed the needle of an 
aspirator into the centre of the tumor, and drew 
out one or two drops of a yellowish fluid, which, 
examined under the microscope, were found to con- 
tain pus cells. I then made a free incision down 
to the tumor and pushed a director into its centre. 
Nothing escaped through the hole. I then dressed the 
wound and sent the patient home, giving directions 
that a poultice should be applied every three hours. 
A day or two later I succeeded in getting the patient 
admitted to the Children’s Hospital; and Dr. E. H. 
Bradford, into whose wards he came, most kindly 
invited me to take full charge of the case and to do 
whatever operation I might think necessary. As the 
child was puny, the operation was postponed for about 
two weeks until he should gain a little flesh and strength. 
A poultice was applied to the wound, and the swelling, 
heat and redness gradually disappeared. As the child 
would now allow a thorough examination of the parts 
without making a disturbance, the “ deep-seated tumor,” 
was repeatedly examined. In spite of this, however, 
no new facts of diagnostic value were brought out. 
About two weeks after the aspiration referred to, I 
operated, Dr. Bradford kindly assisting. A long 
incision in the direction of the cord exposed the 
anterior surface of the tumor, which was then grad- 
ually separated from the surrounding parts. This 
was easily done below (on the end toward the tes- 
ticle), but behind, the cord appeared to be imbedded 
in the substance of the tumor, and considerable dis- 
section was necessary in order to set it free. From 
the upper end of the tumor extended in the direction of 
the external ring a structure about two inches in length, 
and of about the thickness of an ordinary lead pencil. 
In order to examine this more satisfactorily, the cut 3 
was extended to the external ring and as the “ neck” 
was seen to enter it, the ring was freely laid open. 
It was then noticed that the neck was slightly larger in 
the vicinity of the canal than below ; and that near the 
tumor it was somewhat flattened and gave the impres- 
sion to the fingers (as they rolled it between them) of 
being a collapsed hollow tube. On the surface were 
to be seen numerous small bloodvessels regularly 
distributed. Gentle traction was made on this neck and 
a piece of intestine was pulled out of the ring for a short 
distance. This intestine proved to be the caecum. 
The neck then was the appendix and the “ tumor ” 
was presumably inflammatory induration about the tip. 
A large part of the appendix together with the adhe- 
rent “ tumor ” was removed. The edges of the stump 
were then inverted, sewed together, and the whole 
returned to the abdomen. The pillars of the ring 
were stitched firmly together, and the edges of the 
skin wound united. 
The specimen removed was sent while yet fresh, to 
Dr. R. H. Fitz, who kindly examined it and made the 
following report: 
“ The specimen was an elongated cylindrical mass 
of tough tissue. On section the amputated vermiform 
appendix filled the centre and its peritoneal surface 
was so intimately fused with the surrounding, dense, 
fibrous tissue as to prevent detachment. The canal of 
the appendix was open, its mucous lining free from 
abnormal changes. A narrow sinus, presumably due 
to the exploratory operation, extended from the surface 
of the specimen to its interior, near the tip of the 
appendix. The condition was evidently a chronic ad- 
hesive peritonitis, the result of an appendicitis obliterat- 
ing the peritoneal pouch in which the appendix lay.” 
The child’s recovery was somewhat interrupted by 
a suppuration around one of the deep sutures. For a 4 
few days after the operation there were also certain 
threatening symptoms, such as tympanites, high tem- 
perature, some abdominal tenderness, etc., but soon these 
disappeared and the wound granulated, and the child 
was discharged from the hospital about five weeks 
after the operation in excellent physical condition 
and with the wound firmly healed. 
Remarks. The true state of things was not recog- 
nized in this case until, during the operation, the 
tumor and the neck had been dissected out and lifted 
from their bed. The whole clinical history of the case 
then became clear. It was then evident that when 
the child was first brought to the Dispensary he was 
suffering with acute appendicitis in the scrotum ; that 
the aspirator needle removed all the pus present at the 
seat of inflammation ; and that when the director entered 
the tumor, there was no more there to come out; that 
the acute symptoms subsided rapidly and that the tumor 
disclosed at the operation was nothing more than 
chronic inflammatory indurated tissue formed about 
the tip of the appendix. 
It is rather disappointing on reviewing the history 
of the case to be obliged to admit that there was 
nothing sufficiently distinctive to be of any great 
assistance in a diagnostic way in any future case 
where a similar condition may exist. It is, how- 
ever, well to bear in mind that a well-defined, though 
small, cord running out of the right external inguinal 
ring and passing downwards into the scrotum, lying su- 
perficial to the spermatic cord and more or less parallel 
with it, may be the vermiform appendix which has de- 
scended from the abdominal cavity, and, having acquired 
adhesions in the scrotum, cannot return. Possibly the 
adhesions will have formed so appreciable a tumor as to 
attract the principal attention of the surgeon, as in the 
case just reported. THE BOSTON 
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