CLINICAL REPORT 
OF 
INTERESTING CASES 
IN 
PRIVATE PRACTICE, 
JOSEPH H. WARREN, A. M., M. D., Boston. CLINICAL REPORT 
OF 
INTERESTING CASES i Will PRffld 
JOSEPH H. WARREN, A. M„ M. D„ l 
Member of the Judicial Council of American Medical Association; Member 
British Medical Association; Member Massachusetts Medical Society; 
Honorary Member Vermont State Medical Society, etc., etc. 
SPERMATIC CORD, TESTES AND SCROTUM 
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Published by JAMES R. OSGOOD AND COMPANY. 
Boston. Reprint from ‘Virginia Medical Monthly,” 1883. 
J. W. FERQUSSON Si SON, STEAM PRINTERS. OLIIsTIO.A.IL REPORT 
OF 
Interesting Cases in Private Practice 
(/) A SOMEWHAT RARE DISEASE OF THE SPERMATIC CORD, 
TESTES AND SCROTUM. 
{2) ENCYSTED CANCER OF THE SPERMATIC CORD. 
(S) CASE SHOWING FAMILY HEREDITARY TENDENCY TO 
HYDROCELE AND DISEASES OF SCROTUM—REMARKS. 
Case I.—Mr. James G. W., of Hew Mexico, consulted 
me the latter part of January, 1883. The following is the 
history of his case as he wrote it out and gave it to me: 
“ While residing in San Francisco in the summer of 1878, 
I first noticed (by putting my finger on the ring) a round 
hard lump filling the opening. This became especially ap- 
parent when the legs were stretched somewhat apart. The 
lump appearing to increase in size, I consulted Dr. Dorr— 
then my family physician. He pronounced it to be a slight 
hernia of the omentum, and advised me to do nothing, as it 
wras not likely to give me trouble and would probably disap- 
pear in time. In a few months, the lump diminished and 
finally entirely disappeared. 
“ Three years later, in the summer of 1881, while residing 
in Santa F6, H. M., the lump again made its appearance in 
the same place with identical symptoms. For several months, 4 
I paid but little attention to it, thinking it would disappear 
as at first; but it gradually increased, coming down lower 
in the scrotum, until some five or six months after its ap- 
pearance I called on Dr. Longwell—a resident physician of 
Santa F6—to examine it. Dr. Longwell pronounced it to be 
inguinal hernia, and advised me to procure a truss as soon 
as possible. I found it difficult to believe that it was hernia; 
hut the Doctor was positive—‘ as positive,’ he said, ‘as if the 
parts were exposed and plain to view; there was no doubt 
about it.’ For a wTeek or two, I wore a home-made truss, 
hut pressure upon the lump caused intolerable pain. As it 
was impossible to procure a suitable truss in Santa Fe, I 
went to San Francisco in October, 1881; and, upon arrival, 
called upon Dr. McHutley—an eminent physician of that 
place. He was somewhat puzzled on examination of the 
lump; could not think it a hernia. ‘lt is,’ he said, ‘about 
the size of a testis; feels like a testis, and not unlikely it is an 
additional testis descending into the scrotum.’ He desired 
that I should advise with some other surgeon ; and upon his 
recommendation, I called at Dr. Hubbard’s office to get his 
opinion. On examination, Dr. Hubbard pronounced it in- 
guinal hernia, and made an attempt to reduce it. The effort 
giving me some pain, he stated that he could reduce it, but 
would have to put me under ether. On the next day, after 
advising with Drs. McHutley and Hubbard, I was examined 
by Dr. Isaac Rivers (then attending physician upon my wife’s 
family), who was unable to form an opinion of its nature, 
but requested that he might bring a friend of his, Dr. Re- 
vecci, an Italian surgeon of some note, to examine it. On 
the next day Drs. Revecci and Rivers made a thorough ex- 
amination, and found it to be hydrocele of the cord. Three 
days later, these physicians operated upon the tumor, aspi- 
rating it, entirely emptying the sac, and tightly bandaging 
over the place. This proved ineffectual to effect a cure—the 
lump appearing one week after the operation. For some 
months, I paid little attention to it, it giving no inconve- 
nience at first. In February, 1882, the tumor was again 
operated upon by Dr. Seiber, of Santa F6, H. M., and iodine 
was injected. A good deal of inflammation ensuing, con- 
fined me to my bed some ten or twelve days, but the tumor 
shortly after made its appearance. I sought advice from Dr, 
Symington, of Santa F£, Dr. Bertelette, of the United States 
Army, stationed at Santa Fe, and some others; and on one 
occasion had the tumor tapped and a portion of the con- 
tents withdrawn. By this time, however, the substance form- 5 
ing the tumor had become so thick that it was found impos- 
sible to empty the sac, or withdraw more than a portion of 
its contents. At this stage, during the latter part of the 
year 1882, the tumor slowly increasing in size, I decided to 
come East to have an effectual operation performed. Ar- 
riving here [Boston] January 26, 1883, I called upon Dr. 
Jos. H. Warren and Dr. Cheever—the latter stating upon 
examination that he suspected a complication of inguinal 
hernia together with the hydrocele ; and that very probably 
I should always have to wear a truss after any operation, and 
further that an operation would relieve only the hydrocele, 
but would involve some risk, etc. 
“ Dr. J. H. Warren examined it, and considered it to be a 
diffusible hydrocele, having become thickened in its conteuts 
much like an ovarian cyst in the female, and I submitted to 
his operation on the 30th day of January, 1883.” 
With the assistance of Drs. Temple and C. E. Warren, I 
performed the following operation, after etherizing, under 
strictly antiseptic precautions:—l commenced my incision 
about half an inch above the epididymis of the testis, and 
extended it up to the outer inguinal ring. Before making 
this incision, I passed a fine explorating trocar down to 
within half an inch of the bottom of the tumor; and find- 
ing no fluid, tipped the sharp end of the trocar upward and 
brought it put about one inch above its entrance. Now, 
after the incision, I cut down through the sac to the trocar; 
and after dissecting very carefully, I came upon the contents 
of the tumor. The sac of the tunica vaginalis I found very 
much thickened and very tough to cut. It was about the 
thickness of a good chamois skin, and felt so to the touch, 
though it was roughened on the inner surface. It was like 
a skin dressed out to be softened before rubbing. I now 
laid open the sac the whole length of my first external in- 
cision, and found it filled with multilocular cysts that con- 
tained a jelly-like substance, much like that seen in ovarian 
tumors ; and in appearance and consistency, resembling the 
common calf’s foot jelly used on the table. These cysts va- 
ried in size, some not larger than a pea, others as large as an 
English walnut, and a few that were detached while opera- 
ting on the upper part of the cord had a very small, fringe- 
like pedicle attached to the walls of the sac. The blood- 
vessels, nerves and spermatic cord passed freely through the 
tumor and the walls of the sac, which were adherent all the 
way from the bottom of the sac of the tumor to within an 
inch of the internal ring. There was a very long and tedious 6 
process of dissection to separate and remove the sac from the 
spermatic vessels, which was finally accomplished, the opera- 
tion thus being necessarily very much prolonged, occupying 
nearly two and a half hours. After separating the sac and 
tumor we drew down the same through the outer ring; and, 
having satisfied ourselves that we had got above the tumor 
and all diseased tissue, a stout silken ligature, well carbolized, 
was passed through the centre, and each part was firmly 
tied. Then the ligatures were passed around the entire 
pedicle, making a firm fastening, and it was treated in every 
way as suitable to the pedicle of an ovarian tumor. About 
half an inch below this ligature, a galvano-cautery loop was 
passed around, and the tumor was separated between the 
outer and inner rings. And now the stump was pocketed, 
the wound drawn together, the silken ligatures allowed to 
protrude from the external opening of the wound to act as 
a drainage above, and a small rubber drainage tube was 
passed in up to the end of the parts where the tumor was 
severed. 
The tumor was examined by Dr. Temple and my son, and 
the following is the report of the same: 
“ The tumor consists of numerous cysts; held together by firm 
fibrous tissue. The cysts vary in size from a pea to a walnut. The 
wall of each individual cyst seems to vary with its size, being thicker 
in the larger cysts. The contents of the cysts is the same, irrespec- 
tive of size; it consists of a thick, gelatinous mass of a pale amber 
color, similar to the so-called colloid of the ovarian cysts. 
“Microscopically, the mass was composed of numerous large, 
round epithelium cells, a few columnar epithelia, a few red blood 
globules, some few fat; many granular cells about the size of renal 
epithelium; these are round, transparent—the granules having a 
well-defined outline. The cyst wall was composed of fibrous tissues, 
the interstices containing cells of the same granular character as 
those above described ; these increased in number from the outer 
towards the inner surface, where they were clumped together, 
forming an almost uninterrupted line. These cells were not affected 
by ether or acetic acid. The wall also contained blood-vessels filled 
with corpuscles.” 
The growth resembled a long gourd, the larger end in the 
scrotum, and extending up near the inner inguinal ring. It 
was about five inches in length, and one and a-half at its 
lower end, and three-quarters at its upper part where we 
ligated and cut it off. There was no appearance, as exam- 
ined under the microscope, of any malignancy or cancerous 
growth about it. 
This is one of the rarest diseases of the spermatic cord and 7 
scrotum that I have ever seen. I can find no mention in 
Sir Astley Cooper’s work of anything like such a case, ex- 
cept where he speaks of a colloid cancer. Ho mention is 
made of it by Curling in his work on the Testes, nor do I 
find anything like this mentioned in any of the current 
works on surgery, nor have I seen a report of any such dis- 
ease in any of our medical journals. I think this is the only 
case of the kind operated on in this city, and the only time 
that the galvano-cautery has ever been used tasever a pedicle 
in a male patient, although very commonly used in the fe- 
male patients for this purpose. 
At one period of the operation I did not know but that I 
should have to open the abdominal cavity, as in some cases 
of herniotomy, to secure the diseased tissue high enough to 
remove it all; but owing to the lax and yielding nature of 
the external ring, and by the application of some considera- 
ble force, I was enabled to draw the tumefied mass through 
the external ring sufficiently far to gain ray point of ligation 
above all the diseased parts, or where it seemed to be free 
from all appearances of disease. The ligature came away 
on the fourteenth day, and the patient made a rapid recovery, 
so that on the 24th of February he was enabled to return 
.home to Hew Mexico—a well man. 
This tumor would seem to be in construction like an ova- 
rian tumor—as nearly like it as we can get one in the male. 
All who had operated on it examined it and made a wrong 
diagnosis, as well as myself. At the time of examining it, I 
felt greatly in doubt about the correctness of the diagnosis I 
had made. Some had pronounced it hydrocele of the cord 
and a hernia of the omentum combined; and it would seem 
that the patient had consulted some of the best surgeons we 
have. I thought it was a hydrocele of the cord with a greatly 
thickened sac without any rupture, and so pronounced it; 
but this, it would seem, although very near the mark, was 
not the true case, as was proved when 1 came to operate. 
I made out my diagnosis to be diffusible hydrocele of the 
cord for the following reasons: In hydrocele of the cord, 
cystic or diffusible, we get not entire disappearance within 
the rings of the diffusion, as we do in any kind of rupture, 8 
unless there are adhesions; and we can follow the adhesions; 
and then if it be omentum, or the intestines or gut, we have 
distinct and somewhat irregular lumps or bunches not un- 
like the feeling of the mesenteric glands as often felt through 
the very much emaciated patient’s abdominal walls. Again, 
the patient lying down, when the hernia is returned, it goes 
back with a sucking sound, sometimes making a gurgling 
noise, which failed to be produced in this case. In an erect 
position of the patient, a hernia—omentum or intestines— 
comes out gradually, not as in this case all at once; and it is 
at its full size and not any larger the longer it stands. But 
the tumor of this patient would continue gradually to grow 
larger and larger for a number of months. Then, again, we 
got no impulse by coughing, as we do in all cases of hernia, 
except in some large and adherent hernial omentum; but 
even in those extensive adhesions and thickenings of the 
sac, you will always get a perceptible impulse, as you could 
not in the case of this patient's tumor. But if you are in 
the habit of examining hernia, it is very generally apparent 
to see the difference in many ways from diffusible or cystic 
hydrocele of the cord, such as complained of by this patient. 
There is a sense of strangulation, of nausea and tenderness 
of the internal rings in almost all cases of hernia of the 
omentum or intestine. The rings are tender; when you 
press the finger into the rings the patient will flinch ; but in 
cases of hydrocele of the cord, there seems to be no great 
tenderness and soreness as in hernia; at least that is so in all 
the cases I have examined. Although it often requires a 
very fine distinction, yet by a careful analysis, we can gene- 
rally, with a certain amount of surety, make out a distinc- 
tion between the two affections—hernia and hydrocele. The 
light of a candle in a darkened room is an old and sure way 
of distinguishing the two affections; but by a little practice 
this may not be necessary to a correct diagnosis of these 
diseases. 
Case ll.—Encysted Cancer of the Spermatic Cord.—l next 
wish to call your attention to a rare affection, and that is an 
encysted cancer of the spermatic cord. 
I lately had a young man, twenty-one years of age, other- 9 
wise well, a native of Maine, on whom I had operated early 
in the fall for a scrotal hernia, and cured by the subcuta- 
neous method which I practice freely. At the time of ope- 
rating on him for the hernia, I noticed he had a varicocele, 
and a hard, little, encysted tumor just above the epididymis— 
say about a half or three-quarters of an inch above. The va- 
ricocele was cured together with the hernia; but this hard 
tumor which he had noticed began growing within the last 
year, and seemed to be now rapidly developing and growing 
larger week by week. 
On February Ist, with the kind assistance of Dr. Temple, 
I operated and removed this little encysted tumor which had 
grown to the size of an English walnut; and as far as the 
appearance of it went, without the aid of a microscope, it 
was that of a scirrhous tumor or cancerous growth. It was 
somewhat hard and gritty, of a dark bluish appearance, 
looking, through the walls of the cyst, something like a very 
large varicose vein. The structure was quite hard, and yet 
could be easily turned, and when separated, it had a sharp, 
roughened feeling, and a sensation of decomposing tissue 
that was pretty hard or as if partially dried a number of 
hours after removal. The parts were brought together, a 
small rubber drainage tube inserted, a dressing of carbolized 
cotton applied and some considerable suppuration followed, 
but it healed without any trouble by granulation. The pa- 
tient is now well. 
Soon after operating he had considerable pain in the in- 
guinal region, and this pain, I have noticed, always, or most 
always, follows an operation for varicocele or any similar 
affection, of which I have treated quite a number—not far 
from one hundred and fifty—within the last few years. 
In those cases of varicocele which I have treated by two 
small, short incisions in the scrotum and passing a silver 
wire around the varicose veins and returning into the scro- 
tum again, I have been successful with the exception of one. 
This one, the son of a physician and a student of Harvard, 
aged 21, very strong and athletic and a runner and per- 
former of other gymnastic exercises, I operated on in this 
way, which was almost subcutaneous as described above; 
but in about a year afterwards he came to me with a varico- 
cele nearly as large as at my previous operation. He had 
been exercising very freely, and after a long race this came 
on. I operated according to the method of Dr. H. Harrison, 10 
of Liverpool, by cutting down and tying a large number of 
veins—about seven. To the net-work that is distributed 
through the vas deferens and the epididymis, I applied the 
actual cautery to destroy the greater portion of this net- 
work of veins, leaving only sufficient to carry on the future 
nourishment of the testis. Considerable swelling and sup- 
puration followed, but in fifteen days my patient was fully 
cured, and that most substantially. 
I would, in all operations for varicocele which are very 
large, and where the subcutaneous method might be doubt- 
ful in promise, resort to this operation of Dr. Harrison, as it 
is a most beautiful and favorable operation to effect a per- 
manent cure. 
Case III.—A Remarkably Interesting Case, Showing a 
Family Hereditary Tendency to Hydrocele and Diseases of 
Scrotum.—ln the spring of 1854, W. P. E,, aged 22, na- 
tive-born, of goodly American parentage, consulted me for 
a hydrocele elephantiasis of the scrotum and cancer of the 
right testis. His history was that soon after puberty, while 
at play with some companions at foot-ball, he received a kick 
in the scrotum that was intended for the ball by one of his 
companions. From that time, he began to notice an enlarge- 
ment of the parts with a very gradual distension of the scro- 
tum. This gave him but little acute pain, though he ex- 
perienced a sense of great fatigue and weight from any ex- 
ercise like walking or standing, and this increased so as to 
become almost unbearable. From his occupation as a school 
teacher, he was necessarily on his feet much of the time, and 
this greatly increased his embarrassment from the rapid dis- 
tension and increased weight of the parts; at the time of my 
seeing him, it had extended to his knees. He became very 
importunate for me to do something to relieve him of his 
present embarrassment and suffering, which had become very 
depressing—morally as well as physically. 
Hot feeling confident what was the wisest course of treat- 
ment to pursue in this case, I took him with me to consult 
the late Dr. John C. Warren. After arriving at the residence 
of Dr. Warren, I left the patient on the outer step to wait 
whilst I went in to see if the coast was clear for me to show 
Dr. Warren my patient. I was very timid, and had great 
respect for my seniors and superiors in the profession at that 
time, and no man ever impressed me with that God-like fear 
and awe before or since as did this distinguished and most 
courtly and stately surgeon. I still retain a vivid remem- 11 
brance of that proud, cold, aristocratic bearing, coupled with 
that graceful and gentlemanly professional air—an air ac- 
quired only by long continued and thorough culture and 
native-born refinement. I found Dr, Warren very much in- 
terested and occupied at this time with bird tracks on a large 
slab of shelving stone from the Connecticut Valley, sent by 
the late Dr Dean, of the western part of this State. After 
he had given me a lecture on ornithology and a general 
resume on all the then known tracks of birds that had been 
found and examined by him, and shown me many of those 
immense slabs of stone he had lining the entrance of his 
hall and the greater part of his lower library walls and floor, 
I endeavored to get an opportunity to speak to him of my 
patient. But, going from buzzards, web-footed water fowl 
to sand-snipe, so much enthusiam and interest did he display 
in his lecture on ornithology, that I felt I could not, without 
going from the sublime to the ridiculous, approach very easily 
the object of my call; and so retiring to call the next day by 
his invitation to assist and witness an operation for a small 
fibroid tumor on the hip of a very fat and puffy old lady, I 
went out and explained to my patient the condition of things. 
On the morrow, I showed Dr. Warren my patient, and 
after an examination, and when we had retired from the 
presence of the patient, he said, “Young man, you will have 
nothing to do with this case,” adding, “I have operated 
many a time for this and similar affections, and all the pa- 
tients have died at or near the time of operation; at most, 
but few have lived beyond a month or two from the time of 
my operation.” This was to me a sticker; so in my trouble 
I went to Dr. Edward Warren, who was living at that time 
near me in the town of JSewton. I explained to him the 
urgency of the case and the necessity of something being 
done. The patient was willing to undergo anything which 
would promise relief from his suffering, which had now be- 
come intense, and the patient had argued the irapotency of 
medical science; and his argument had gained strength from 
the fact that, as he said, he was willing to run any risk and 
abide by the result, and he could not see any reason why, if 
he was so freely to offer himself, our profession should not be 
willing to lend a hand and perhaps profit by his ease and ex- 
perience in some other future similar affection. His parents 
now joined their forces with those of my patient, and had no 
little effect. They were very apprehensive indeed of a fatal 
termination of his life by his own hands, as hypochondriasis 
had cast its gloom over the spirits of the patient. On fur- 12 
ther consultation with Dr. Edward Warren, we agreed to 
operate and see what could be done for him, although giving 
but little hope or encouragement of a favorable termination 
to whatever we might do. On the 10th of May, with Dr„ 
Edward Warren’s assistance, I operated by following near 
the natural line of demarkation between the right and left 
testes, and eastrating the patient on the right side; we found 
the skin and tissues comprising the scrotum and covering of 
the testes so thickened as to be fully an inch through. We 
ligated the spermatic and a branch of the sub-pubic artery. 
At this stage of the operation (I had some very coarse sad- 
dler’s silk ready prepared), and, to the surprise of Dr. War- 
ren, I began to fill in the cut, so as to enclose nearly a quar- 
ter of an ounce of this. I bad previously cut the silk in 
strands of some four or five inches long. Then I brought 
the parts together and secured them with silk stitches pretty 
finely inserted. I now explained to Dr, Warren my inten- 
tion of letting this silk act as a seton, and to withdraw now 
and then a strand at. a time—not allowing the parts to heal 
until I had seemingly let the greater part of this thickened 
tissue be reduced by suppuration and slow granulation, let- 
ting it fill up as I withdrew the silken strands. He expressed 
himself much pleased, and thought I would be successful,, 
and it proved so to be. 
I afterwards called on Dr. J. C. Warren, and found that 
his brother had told him my manner of treating this un- 
promising case. He was much pleased, and told me that if 
I would in all my future life lean on myself and do my work 
with the same original thought which bad been apparently 
used in this case, “following what seems the natural course 
to you,” be said, “in every operation, you will be useful to 
yourself and others in the profession; for this is the great 
fault with many men now coming into the profession. They 
do not think or have independence to act for themselves, but 
lean on the arms of others who will never assist them to ac- 
complish anything great in a professional life without the 
aid of their own best efforts. And while I would by no 
means have you ignore the instruction to be gained from the 
experience of others, yet to follow precisely in their tracks 
and call it conservatism, makes a very narrow path in any 
man’s progress, but particularly in that of the practice of 
medicine.” 
This patient bad a cancer of the testis, involving the 
greater part of the lower half of the scrotum, all having 
become completely fused into one solid mass of nerves. 13 
blood-vessels and veins. Two pints of syrupy, treacle-like 
fluid was drawn off at the time of operating. The patient’s 
progress was slow, but he made a full recover}7, and has had 
no recurrence of the disease, and has enjoyed good health 
ever since, being now the happy father of a son. 
His father, J. C. E., said he thought this affection had been 
hereditary in the family, particularly that of hydrocele, as 
he, himself, and his two brothers, had suffered from hydro- 
cele in their younger days. His own father had one also, 
something like the case of his son. Of his own case and 
that of his brother, it may be said they seemed to spon- 
taneously disappear after some fever, and, in his case, after 
a severe attack of diarrhoea. He said that the late Hon. 
Edward Everett, his cousin, had a large one. When a 
youth, they were both out in the field shooting, and when, 
after a long chase for a fox, he became so fatigued in the 
hunt, that his hydrocele became painful, and he had to lie 
down several hours, and he, J. C. Everett, had to adjust a 
silken pocket-handkerchief on to Edward so as to hold up 
the parts in order that he might walk home, some little dis- 
tance. He was cured by Dr. Holbrook, of Milton, by the 
injection of Port wine. He also knew of a number of his 
other cousins who had been affected with hydrocele. 
I have operated on two other cases similar to this, and with 
equally good results. I know not whether this is anything 
original or novel, although I have not seen a case reported 
as treated in a similar manner in any of my medical journals 
or text books. 
If we examine the tissues comprising the scrotum and sur- 
rounding parts, we perceive that they are peculiarly con- 
structed. So loose are they that from a very slight injury or 
any inflammatory process whatever, they will swell and 
thicken to an enormous size Owing to this open, loose and 
vascular structure of the tissue, I reasoned, anything that 
would act like a seton, causing a continued suppuration, 
would reduce this thickened tissue, as blistering of the parts 
will often do. I have seen a very large case of elephantiasis 
quickly yield after the insertion of a seton, or even by ex- 
tensively blistering the parts, and the application of mercu- 
rial ointment, reduced by these means to a normal size in a 
few weeks. It was this knowledge of the anatomical struc- 
ture and the pathological condition of this and similar affec- 14 
tions that these parts are liable to be attacked with, that in- 
duced me to fill the wound with silk to be left in to act in 
the manner I have described. 
Remarks.—These affections of varicocele, hydrocele and 
similar disorders of the scrotum generally appeal to us, not 
only from the great amount of physical suffering that they 
produce, but they have a most depressing effect morally, as 
we see in those college students, young men of the profes- 
sions of all kinds and merchants constantly coming to us; 
and we find that by putting them off from time to time, they 
yield to this hypochondriasis more and more until in some 
cases insanity is the result. And how often these highly 
sensitive and intellectual patients we have spoken of are in 
the habit of terminating their own existence for this and 
similar affections, it is impossible to calculate; but that such 
is the case we know from reports in every community where 
young men of the most exemplary life have chosen to put 
an end to their existence rather than to endure this slight 
bodily ill, which is rising in mountain height to them in 
imagination. This dread is often intensified by reading ad- 
vertisements in the daily press and circulars sent out by 
those soulless quacks to be found in every community who 
tell them of the fearful consequences, the loss of their man- 
hood and impotency that is certain to follow any of these 
afflictions, which we all know, as practical men in our pro- 
fession, seldom reach such severe results. So that it is wiser 
often for us to perform these operations which are compara- 
tively slight and insignificant, and give but little suffering, 
rather than to have the dread to hang over any young man 
as a cloud and as a shadow for all future life. For, reason 
and advise as we will as to the simplicity of his afflictions, 
he sees only a permanent phase; he examines himself often; 
and the oftener he does, the larger his ills seem to grow, and 
the more of decided reality to him. And thus turning from 
our wise and good advice, he falls back upon those who have 
written just to attract his attention—knowing of this weak- 
ness peculiar to the young men—and he believes them rather 
than us. I have never seen anything but good results at- 
tending any of those operations I have recommended for 15 
hydrocele, varicocele and similar affections of these parts; 
and I would heartily recommend them after seeing for years 
the good results that have come from resorting to one or the 
other of these simple operations. For at this period of a 
young man’s life, a kind word and a slight operation seem 
to give him renewed courage; and such a course lifts him 
up to a higher plain where he feels his independence and 
all his manhood most fully developed and strengthened. 
We must always remember that it costs this young man to 
consult us no little effort, and we should give to even what 
appears to us slight ills, our most serious consideration in 
our advice to him, for much will depend even on our direc- 
tions for his future good or ill.