CLINICAL LECTURES 
ON 
SURGERY, 
DELIVERED AT 
STARLING MEDICAL COLLEGE 
BY / 
J. H. POOLEY, M.D., 
Professor of Surgery. 
[ Reprinted from the Ohio Medical and Surgical Journal.'] 
COLUMBUS: 
N E V I N 8 A MYERS, BOOK PUBLISHERS. 
1878. CLINICAL LECTURES ON SURGERY. 
Delivered at Starling Medical College, Columbus, Onio, by 
J. H. Pooley, M.D., Professor of Surgery. _ 
LECTURE II. 
Hydrocele. 
The patient before you, Mr. S , aet. 28, a native of the 
United States, and a plasterer by occupation, is afflicted with the 
very common surgical malady known as hydrocele of the tunica 
vaginalis testis, a disease to which I propose to direct your atten- 
tion this morning. 
But before doing so I will first mention, and briefly comment 
upon, a somewhat unusual circumstance in this patient’s history. 
It is this: 
Four years ago he first noticed this hydrocele, which is on the 
right side; it grew slowly but steadily, until it hung half way 
down his thigh, and he had to have allowance made for it in the 
construction of his pantaloons. Such was his condition, and such 
had it been for some time, when, on April 18, 1877, he fell from 
a step-ladder, a distance of about six feet, striking upon his side 
and shoulder. He is quite sure he did not strike or hurt his scro- 
tum in any way, and he felt no pain there at all. 
He went home and lay down, feeling rather bruised and shaken 
by his fall, and about an hour and a half after the accident, on 
feeling for his hydrocele, to his surprise it was not to be found, or 
at least a wonderful change had taken place in it. 
The swelling was diminished more than one-half in size, it had 
lost its definite outline and tension, and instead of the familiar, 2 
hard, globular enlargement of the right side, there was a general, 
soft, boggy swelling of the scrotum. He was very much alarmed 
by this state of things, unnecessarily, of course, and sent for his 
physician, who never having seen or heard of anything of the 
kind before, and not knowing exactly what to make of it, brought 
him to me for opinion and advice. I saw him April 20th; the 
scrotum was then very nearly of the natural size, with its integu- 
ment very much thickened and corrugated, both testicles plainly 
felt in their natural situation and free from swelling or tender- 
ness. 
There was considerable ecchymosis; indeed, the scrotum was 
almost as black as a negro’s, and this discoloration extended, 
though in a minor degree, over the penis, and up for a consider- 
erable distance on the right inguinal region. He was free from pain 
or inconvenience of any kind ; his anxiety was easily dissipated ; 
all he wanted was an explanation of his curious adventure, and 
opinion as to the probable result. The explanation was not dif- 
ficult; there could be no doubt that he had ruptured his tense 
hydrocele sac by the mere concussion of his fall; its contents had 
been discharged into the loose meshes of the neighboring con- 
nective tissue, and before I saw him, completely absorbed, whereas, 
the accompanying blood, or its coloring matter at least, had not. 
Never having seen a case of this kind before, and not being 
well prepared to give an opinion, I confidently told him that his 
hydrocele would not come back; in other words, that he was per- 
manently cured. But the result has not verified my prediction, 
for in about three months from the time of the accident, the sac 
began slowly to refill, and now, nine months afterwards, is about 
as large as ever, and presents all the ordinary characteristics of a 
hydrocele. 
The accidental rupture of the sac of a hydrocele is quite a rare 
event, and does, in the majority of instances, though not in all, 
as we have evidence before us, result in a permanent cure of the 
disease. I mentioned this case soon after it happened, at a meet 
ing of the Columbus Academy of Medicine, when Dr. N. S. T ow n 3 
shend, of the Ohio Agricultural and Mechanical College, who was 
present, related the following, as having occurred in his practice 
many years before : 
A man, who had a large hydrocele, was chopping wood, with 
the handle of the axe between his legs, and while thus engaged, he 
struck his scrotum a severe blow either with the axe-handle, or 
his doubled fist; he could not tell which. He suffered severe 
pain ; the tumor almost instantly lost its defined character, and' 
soon disappeared entirely. There was considerable ecchymosis of 
the scrotum, penis, and groin, which lasted a long time. The 
cure in the case was permanent, as the man was under observa- 
tion ten years afterwards, and there was no return. 
Percival Pott records the following case : “A middle-aged man 
showed me a hydrocele of the vaginal tunic, which had been near 
two years collecting, but from which the water had never been 
drawn. I advised him to have it done soon, and he fixed on the 
next morning. On his way home he got fuddled ; fell down into 
the area of an empty house, and, in his fall, struck his scrotum 
against a piece of scaffolding. In the morning, early, he sent for 
me. I found him in bed, with a great ecchymosis under the skin 
of the scrotum, which was much swollen and very painful. I 
would have persuaded him to have permitted me to let the water 
out (thinking, thereby, to have taken off part of the tension), 
but he would not consent, and I was obliged to have recourse to 
fomentation, cataplasm, etc. 
“In about a fortnight, all the ecchymosis was dissipated, and 
all the swelling from the sound side of the scrotum ; and both the 
patient and myself thought that the tumor from the hydrocele 
was considerably less than it was before the .accident. By per- 
sisting in the same method, for about three weeks more, the whole 
of it disappeared, nor has it returned since. Nor have I, ever 
since, seen the same attempt succeed.” 
In this case the cure was remarkably slow and tedious, the ab- 
sorption of the fluid after accidental rupture generally taking place 
in a few days. Mr. Bransby Cooper, in his “ Lectures on Surgery,”' 4 
mentions the following: “A gentleman consulted me who had 
been the subject of hydrocele for two years, and had twice sub- 
mitted to evacuation of the fluid by surgical operation. The fluid 
had, however, again accumulated; but, on the day before he ap- 
plied to me, he had run against a post, and struck the scrotum. 
This had produced considerable inflammation, but no sign of the 
bursting of the tunica vaginalis. I ordered antiphlogistic reme- 
dies, and recommended that he should remain in a recumbent 
posture. This led not only to the relief of the inflammatory 
action, but, to my great surprise, the fluid became absorbed, and 
the hydrocele was permanently cured.” 
Notwithstanding Mr. Cooper’s opinion to the contrary, we can 
not help thinking there may have been a rupture of the sac in this 
case. 
Sir Astley Cooper, to whom we may confidently look for infor- 
mation on almost any subject connected with surgery, says: 
“ Hydrocele is not always cured by a blow which tears the tunica 
vaginalis. I once attended a gentleman who consulted me for a 
hydrocele, and who, while riding in the neighborhood of Gibral- 
ter, was thrown upon the pommel of his saddle, and received a 
severe blow on the scrotum. The hydocele, in a few hours, dis- 
appeared ; but, in six months, again formed, and was, he thought, 
as large as before. I injected it about two years after the above 
accident.” 
Sir Benjamin Brodie relates a case of a hydrocele ruptured and 
cured by an accidental blow. Mention is also made, on what 
authority I know not, of the sac having been ruptured by cough- 
ing, with a similar result. 
And, finally, several cases are on record in which hydrocele, in 
the adult, has disappeared spontaneously, without any blow, rup- 
ture of the sac, or anything of the kind. This, which, in chil- 
dren, is common enough, as we shall presently see, is very rare in 
the adult. 
But I think the most curious and interesting history on record 5 
of its kind is the following, which I quote from the Ohio Medical 
Recorder, November, 1877 : 
“ Mr. A. C. T., aged forty-five, a resident of Belmont county, 
Ohio, gave the following unique history: About five years ago, 
he observed a swelling which seemed to involve the left testicle. 
It gradually increased in size until it was as large as the largest 
cocoanut, and was very hard. One day, in 1873, in the harvest- 
field, he happened to put his hand to the parts, when this hard 
mass was gone, and in its place was a soft diffuse swelling, involv- 
ing the prepuce, the covering of the penis, the walls of the scro- 
tum, etc. It was not attended by any uneasiness whatever, and 
did not deter him from proceeding with his work. In like man- 
ner, in February following; then in September, 1876, and again, 
in August, 1877, the same occurrence was repeated. Within a 
few days after each of these ruptures, these soft swellings pretty 
much disappeared, leaving the parts highly colored for five or six 
days, and the tunica vaginalis apparently empty. Since the last 
rupture, the sac has refilled quite slowly. The patient thinks its 
present size, although it is more than two months, is only about 
one-third its full size; yet, on tapping, eighteen ounces of fluid 
of a dark grumous color was removed. The testicle being healthy, 
two ounces of a fluid, consisting of equal parts of water and 
tincture cf iodine, were thrown into the sac, and allowed to 
remain a few minutes, and then drained away.” 
Though we have spent so much time over the subject of rupture 
of the sac by violence, or otherwise, which our case suggested, 
we have still some time left to devote to the general ‘subject of 
hydrocele, to which, accordingly, I now invite your attention. 
The word hydrocele is formed by the combination of two Greek 
words, and means literally a watery tumor, or a tumor containing 
a watery fluid. Accordingly, we hear and read of hydroceles of 
the neck, referring to certain peculiar cysts of that region, a use 
of the word which I deprecate as confusing to the mind, preferring 
to confine the term to serous collections in the region of the scro- 
tum, testicle, or spermatic cord. Even when thus limited, it 6 
includes numerous species, such as hydrocele of the testis, encysted 
or diffused hydrocele of the cord, congenital hydrocele, etc. But 
when the term hydrocele is made use of simply and without any 
qualifying word, it is understood to mean a collection of serous 
fluid in the closed sac of the tunica vaginalis testis. To this com- 
monest form of the disease, this hydrocele par excellence, so to 
speak, we shall devote our attention at this time, leaving its varie- 
ties and complications for a future occasion. Hydrocele, then, 
we may define as follows: an accumulation of fluid in the tunica 
vaginalis testis, producing a pyriform, fluctuating, and generally 
a translucent swelling in the scrotum. 
It is a very common disease, more so in tropical countries than 
elsewhere. If we except the years of infancy and early child- 
hood, when, however, it is generally of the variety known as con- 
genital, not that it exists at birth, but for the same reason that 
certain herniae are called congenital, viz., because it exists with 
an unclosed communication between the tunica vaginalis and the 
peritoneal cavity—it is more frequent in advanced periods of life. 
It occurs, generally, on one side only of the scrotum, and about 
as oiten on one side as the other. Sometimes, however, it is found 
on both sides at once, constituting a double hydrocele. 
Ordinarily, the sac of a hydrocele, consisting, as it does, sim- 
ply of the distended tunica vaginalis, is single and pyriform in 
shape, gradually diminishing in size from below upwards, and 
ending at the external ring in a well-marked constriction. Some 
interesting variations from these characteristics are occasionally 
noticed; -it is sometimes quite globular, sometimes cylindrical, 
sometimes lobulated by the formation of pouch-like diverticuli 
from the main sac, sometimes hour-glass in shape from constric- 
tion about the middle of the sac, the portions above and below 
the constricted parts at times completely cut off from each other, 
so as to constitute really two sacs, but generally communicant by 
an opening more or less ample. Though, as remarked, the sac 
of an hydrocele generally terminates abruptly at the external ring, 
instances have been reported where it has been prolonged upwards  7 
into the abdominal cavity without communicating with the per- 
itonaeum ; and this occult hydrocele has been found to contain 
nearly as much fluid as the external one, and sometimes to be sep- 
arated from it. At times the hydrocele cavity is traversed by 
bands or trabeculae, stretching across it from side to side. All 
these variations in the form of the sac are quite rare, the rule of 
its pyriform shape, with the base downward, being all but univer- 
sal. 
The sac is generally quite thin, being composed of the distended 
tunica vaginalis, and this, with the tenuity of the overstretched 
strotal integument, whose wrinkles are all obliterated, leads to one 
of its most characteristic features and one extremely valuable for 
diagnostic purposes, namely, its power of transmitting light. The 
longer an hydrocele exists, as a rule, the thicker does its sac be- 
come, till, in some cases, it is a very tough, fibrinous resisting 
membrane. Calcareous deposits in isolated plates sometimes take 
place upon its inner surface; and these have, in some cases, ex- 
tended by coalescence over the whole sac until it has become a 
solid, calcareous shell—a sort of earthenware jug. 
The testicle is generally situated at the posterior and upper part 
of the tumor, out of harm’s way, but sometimes, for reasons that 
have never been satisfactorily explained, it is found in front; this 
fact, as we shall have occasion to remark further on, is one of 
practical importance. In ordinary hydrocele, the testicle is gen- 
erally quite healthy, and remains unaffected by its unusual sur- 
roundings, being neither larger nor smaller than its fellow. 
The fluid of an hydrocele, as you have repeatedly witnessed in 
this clinic, is a clear, transparent, amber or straw colored fluid, 
and, as I have demonstrated to you, by heating it in a test-tube 
in your presence, highly albuminous. Its specific gravity is about 
1,025, and it contains, in addition to albumen and ohter organic 
matters, a small proportion of salts. 
I have never witnessed any remarkable variations in this fluid, 
having never seen anything more unusual than a few curds or flakes 8 
of lymph floating about in it. But it does sometimes vary very 
widely from its ordinary and well known appearance. It is some- 
times dark colored, brown, greenish, blood-stained, and so on ; 
sometimes thick and greasy, or gelatinous; sometimes grumous, 
or like coffee grounds. At times, and it is said especially in old 
people, shining scales of cholesterin may be seen sparkling and 
scintillating in it in great numbers. 
There is an account in the American Medical Recorder, for 
October, 1821, of a case of hydrocele in a boy, aged thirteen, in 
which a quantity of sabulous matter was discharged along with 
the fluid. 
More rarely, there have been discharged from a hydrocele bodies 
like the false or movable cartilages sometimes found in large joints, 
and these have been seen not only loose, but also hanging by long 
attenuated pedicles to the walls of the sac, showing that they are 
produced somewhat in the same way here that they are in the artic- 
ulations. 
This seems to have been the case with the celebrated John 
Wesley, who had a hydrocele, of the tapping of which he gives 
the following quaint account in his Journal: “ Mr. Wathen per- 
formed the operation, and drew off something more than half a 
pint of a thin, yellow, transparent water; with this came out (to 
his no small surprise) a pearl of the size of a small shot, which he 
supposed might be one cause of the disorder by occasioning a 
conflux of humors to the part.” 
Hydroceles vary very much in size, which is best expressed and 
appreciated by the measurement of the contained fluid, the quan- 
tity of which is often very extraordinary. One thing has invar- 
iably struck me in tapping an hydrocele, and that is that the quan- 
tity of fluid has always seemed much greater than might have been 
expected from the size of the tumor. The average of such hydro- 
celes as I have seen would certainly be as high as ten or twelve 
ounces, though twice this is not very unusual. It sometimes 
amounts to several pints. Mr. Butcher, of Dublin, mentions hav- 
ing withdrawn pints on one occasion. But even this is noth- 9 
ing compared to the enormous collection in the scrotum of Gib- 
bon, the celebrated historian, from which Mr. Cline drew off the 
astounding quantity of six quarts. This is, I believe, the largest 
hydrocele on record. A Mr. Davies, practicing, I think, at the 
time, in Ceylon, mentions, though in somewhat ambiguous terms,, 
a very large one. 
He relates, in the British Medical Journal, 1857, page 593, that 
he tapped an enormous hydrocele, hardly smaller than the body 
of a robust child, and removed a wash hand-basin full of serous 
fluid. There is a delightful uncertainty as to the amouut of aston- 
ishment one ought to feel at his oriental narrative, for the bodies 
of children, even robust children, and even robust Ceylonese chil- 
dren may, one should think, differ very considerably in size. 
If the case is not unique, certainly the comparison is. 
Hydrocele is essentially a chronic disease, which may last for 
many years, or a whole life-time, without having, as a rule, any 
tendency to recovery, or to do any harm beyond the growing 
inconvenience of its slowly increasing bulk. It seems to originate 
in an accummulation of the natural secretion of the part, deter- 
mined by loss of balance between the secerning and absorbing 
functions, generally without any inflammatory complications. Its 
cause is involved in obscurity, and generally none is known to the 
patient. Occasionally, it has been attributed to blows or other 
injuries, but even in cases supposed to have been thus caused, much 
doubt remains. Prof. Geddings, of South Carolina, says that it 
is generally caused by inflammation of the urethra, but so far as 
I know, he is the only author who makes the statement. He brings 
forward no facts to substantiate it, and, with all due respect to 
him, I believe it to be utterly without foundation. 
The diagnosis of hydrocele is not difficult, and yet mistakes 
with regard to it are so frequently made, that I need offer no apol- 
ogy for dwelling upon it at considerable length. The affections 
for which hydrocele is most liable to be mistaken, are hernia, var- 
icocele, hsematocele, and various enlargements of the testicle. 
The most common error is that of confounding it with hernia, 10 
and I may mention here, as a matter of curiosity, that the very 
nomenclature of the disease has been tainted with this confusion, 
for it is called by many of the common people, and in some of 
the old surgical treaties, water rupture, and by the Germans, by 
the exactly equivalent term, wasser-bruch. The following are the 
main diagnostic differences between hydrocele and hernia: 
In hydrocele, the swelling begins at the bottom of the scrotum 
and ascends towards the external ring, and is more or less dis- 
tinctly pyriform in shape, variations in this respect, as already 
stated, being very rare. In hernia, the swelling commences above 
and diminishes as it extends, being smaller at its lower part. The 
common hydrocele of adults, to which alone this lecture relates, 
is a permanent swelling, uninfluenced by position or manipulation. 
Hernia (except when irreducible) reccees when the patient lies 
down, or may be made to do so by manipulation, or taxis, as it 
is called, and returns when he assumes the erect position, or the 
pressure is removed. The tumor of hydrocele is dull on percus- 
sion ; a hernia is resonant, if not over its entire surface generally, 
at least in some part thereof, for it generally contains some intes- 
tine. In hydrocele, there is more or less sensation of fluctuation, 
and no impulse communicated to the fingers on the patient’s 
coughing; hernia does not fluctuate, and does give an impulse 
when the patient coughs. In hernia, the swelling is opaque, and 
does not transmit light or become translucent, when examined 
with artificial light, whereas an hydrocele does. This symptom is 
so important and peculiar that we must dwell on it for a moment. 
Its presence is proof positive in favor of hydrocele, although its 
absence is not decisive against it. It may fail to be present from 
dark color or turbidity of the fluid, or extreme thickness of the 
sac, but in the immense majority of hydroceles it is present to a 
more or less marked degree. In seeking to elicit this sign, the 
patient should lie taken into a darkened room, and while the tumor 
is grasped with the left hand, in such a way as to put the parts 
upon the stretch, a light is placed behind it, as near as may be 
without burning the patient, and shading the front of the scrotum 11 
with the right hand, the light may be seen shining through. 
Sometimes we may assist ourselves by looking through some tube, 
such, for instance, as a piece of stiff paper, rolled up into a hol- 
low cylinder. Another plan is to have the patient lying upon a 
table, in a convenient position, and while making the examination, 
the head of the examiner may be covered with a shawl, or screen 
of dark cloth, after the fashion of the photographer when looking 
through his camera, at his waiting victim. 
Finally, in cases of doubt, it is allowable to puncture the swell- 
ing with a fine exploring needle or trocar, which will settle the 
question. 
The diagnosis from varicocele, can not be difficult when we 
remember the following points in which it differs from hydrocele. 
Varicocele presents an irregular surface, and feels like a coil of 
earth-worms under the skin ; it slowly disappears when the patient 
maintains for some time a recumbent position, and is generally 
the seat of a dull, dragging pain, at least when of a considerable 
size. 
Hsematocele follows immediately upon an injury, and soon 
attains its maximum development; the fluid effused is dark col- 
ored, hence the tumor is without translucency, and there is fre- 
quently superficial ecchymosis about the scrotum. 
Enlargement of the testicle will often occasion great perplexity, 
and demand great care in the examination. Common orchitis, 
with its hard, heavy, painful tumor, can scarcely do so, but en- 
cephaloid, sarcomatous, and other growths may be very difficult 
of discrimination. For their proper appreciation we have only 
to remember and carefully apply the distinctive symptoms of 
hydrocele, and, in cases of doubt, resort to the exploring needle. 
This is all the more necessary and proper from the fact that these 
diseases are often complicated, with the effusion of more or less 
fluid into the tunica vaginalis. The prognosis of hydrocele, as 
already intimated, presents nothing of importance for our con- 
sideration ; it does not threaten life, it does not cause severe pain; 12 
it simply remains as a permanent inconvenience, liable to increase 
indefinitely, and with greater or less rapidity. 
We come, now, to the most important part of our subject, viz., 
the treatment. Having diagnosticated and prognosticated, like 
wise and learned men, what can we do to cure our patient? 
The treatment of hydrocele is divided into the palliative and 
the radical. By the first, we simply alleviate, for a time, our 
patient’s condition; by the latter, we remove the disease and 
prevent its return. The palliative treatment consists in evacua- 
ting the contents of the tumor, from time to time, as may be 
necessary, and thus keeping our patient in a condition of tolerable 
comfort. The operation of tapping an hydrocele may be done 
with a lancet or bistoury, but is very seldom so performed, a tro- 
car or canula being generally used as most suitable and convenient. 
A medium sized or rather small instrument should be made use of. 
Some surgeons prefer to make a little preliminary incision 
through the integument, but this is unnecessary unless you are 
aware, from previous experience, or otherwise, that you have to 
do with a very thick or tough sac. Ordinarily, the trocar may 
be used without the preliminary incision, and in the following 
manner: The scrotum is grasped and put upon the stretch by 
the left hand, and the trocar, its point having been dipped into 
sweet oil, is thrust perpendicularly through the various coverings 
of the hydrocele at its lower and anterior part, avoiding any 
superficial veins that may be present, and the testicle, whose sit- 
uation has previously been made out, and as soon as the instru- 
ment is felt to have entered, its direction is changed, and it is 
passed on obliquely upward, the trocar withdrawn, and the fluid 
evacuated through the canula. 
After tapping, the hydrocele sometimes, though rarely, does not 
refill, but is permanently cured. 
Much more frequently, however, indeed as a general rule, it 
fills up again in the course of a few months, and must be again 
emptied, and the operation has to be repeated at varying and un- 
certain intervals as long as the patient lives. 13 
Such is what is called the palliative treatment or tapping of 
hydrocele, and I think you will find quite a number of persons 
who will prefer it to any more radical treatment; indeed, in the 
aged, feeble, excessively timid, especially those who are in easy 
circumstances, I do not think it worth while to recommend any 
other. Dr. John Mason Warren said : “As a general rule, I have 
found that the wealthier classes in life prefer the palliative opera- 
tion of tapping. The laboring classes, who are more incon- 
venienced by it in their vocations, prefer the radical cure.” And 
in this, according to my experience, he was quite correct. 
Simple as is the operation of tapping a hydrocele, there are one 
or two points about it worthy of attention. First, always, if pos- 
sible, ascertain the exact position of the testicle before proceed- 
ing. As already said, this is generally at the upper and back part 
of the sac, but it may be in front. A slight prick of the testicle 
will not do any serious harm, but it gives unnecessary pain, which 
is alwhys unsurgical and to be avoided. Should it be in front, 
however, and unrecognized, you might thrust your trocar quite 
through it, or, wounding it deeply, still fail to reach the fluid, 
much to your patient’s disadvantage, and your own disgrace. 
Above all, never tap an hydrocele when in a state of active 
irritation or inflammation ; to do so is very dangerous, and may 
result most disastrously. I could cite several cases where tapping, 
under such circumstances, has led to a fatal result. 
The radical cure of hydrocele has for its object either the oblit- 
eration of the sac, or such a change in its lining membrane as shall 
prevent a re-accumulation of the fluid. For this purpose there 
have been quite a number of operations proposed and practiced 
from time to time. 
Before proceeding to speak of these, I will just mention, as 
mere curiosity, and for your delectation, one or two old ideas on 
the subject of the treatment of hydrocele. Dr. James, an English 
writer of 1745, and very old-fashioned, even for that time, says 
that the best remedy in new-born infants is for a man in good 14 
health and fasting, to chew some nutmeg, and breathe often, every- 
day for some time, upon the affected scrotum. 
He adds, “ I the more readily recommend this, as I have fre- 
quently seen the good effect of it. In the meantime, we do not 
despise the holding spirit of wine in the mouth, and at the same 
time breathing upon the scrotum.” 
Marini, an Italian surgeon, forbids any operation to be per- 
formed while the sun is in Scorpio, which he says will protract the 
cure. 
Among the operations for the radical cure of hydrocele, we may 
mention incision, excision, caustic, seton, suture, and injections 
of various kinds. The operation by incision is an old one. It 
consists in laying the sac freely open, by a large anterior incision, 
after which the older surgeons introduced into the cavity some 
irritant material, such as the red oxide of mercury. This part of 
the proceeding is now omitted, the sac being simply filled with 
dry lint, and allowed to fill up with granulations. 
This mode of treatment is unnecessarily severe, and should be 
reserved for such cases as prove rebellious to milder methods, 
which, however, will not be very numerous. There are two cases 
on record, in old numbers of the Lancet, of the cure of hydro- 
cele by the accidental incision of the sac, which, I think, are 
interesting enough to be worth recital: 
A French naval surgeon says: “On board of our ship, while 
in Toulon Roads, was one Napoleon Agostini, a Corsican by birth, 
who had on the left side an enormous hydrocele, which he refused 
to have operated on. He had been allowed to go ashore, where, 
with some of his shipmates, he entered a cabaret, where he stayed 
drinking for some hours. Having all got intoxicated, they quar- 
reled and fought, and one of the men made a blow at Agostini 
with a knife, by which his trousers were cut from below the waist- 
band, half-way down the thigh. An incision, about an inch and 
a quarter in length, had been made in the scrotum, which not only 
suffered the fluid but the testicle also to escape. Next day, 
before the effects ot his drunkenness had disappeared, the man 15 
was brought on board. The testicle was cleaned, returned into 
its proper situation, and retained there by four sutures. Moderate 
adhesive inflammation was set up, and the wound had healed by 
the fourteenth day. Three months have elapsed, and the hydro- 
cele has not returned.” 
The other case is given in the following words, by P. Ingram, 
surgeon: “The account of the cure of a hydrocele by a stab, 
in the Lancet, of last week, reminded me of a similar occurrence, 
which took place when I was in Calcutta, in 1835. A Sepoy, in 
a state of intoxication, repaired to the Soba Bazaar to purchase 
a pumulo, a species of fruit similar to an orange, but generally 
about six times larger. The Hindoo, who kept the shop, very 
quietly informed the Sepoy that he had sold all his fruit of that 
description, and, of course, could not, at that time, supply him 
with one. 
“ The Sepoy became quarrelsome, and the Hindoo, in his turn, 
quarreled with the Sepoy, stoutly denying that he had any pumu- 
los in his possession. 
“ The enraged Sepoy then made a thrust with his bayonet at 
the Hindoo’s langooty, (a handkerchief used for the purpose of 
concealing and supporting the scrotum, similar to a suspensory 
bandage), swearing that he had one concealed there 3 when, to 
the surprise of all present, the shop of the Hindoo was immedi- 
ately inundated with water. The bayonet had perforated a very 
large hydrocele. The Sepoy was immediately taken into custody, 
and after he became sober, expected nothing less than hanging for 
murder, but he was only slightly punished, and the Hindoo had 
the happiness, sometime afterwards, of thanking the Sepoy for 
removing his pumulo, alias curing his hydrocele.” 
In the operation by excision, not only is the sac laid open, but 
a portion of it, more or less extensive, laid hold of by forceps, 
and dissected away. As far as I know, this operation is never 
performed at present. The cure by caustic consists simply in 
removing a portion of the anterior wall of the scrotum and sac, 
by the application of caustic potash, or some other powerful 16 
estharcotic; it must be both a painful and tedious process, and is 
justly abandoned. 
The seton was first mentioned as a means of curing hydrocele 
by Guido di Cauliaco, in 1498. 
In modern times the celebrated English surgeon, Mr. Percival 
Pott, preferred it to every other means, until the latter part of his 
career, when he adopted the method by injection, which he had 
previously spoken of in terms of strong disapprobation. I shall 
not stop to describe the method of introducing the seton, as it is 
now seldom, if ever, used. Various forms and substances have 
been recommended, among others a loop of silver or iron wire 
left in the scrotum for a certain time, but this does not seem to 
possess any real advantage over the more ordinary materials. The 
objection to the seton is that it often produces a very high and 
unmanageable degree of inflammation, and death has even taken 
place from this cause. Dr. J. Mason Warren reports that in one 
case where he employed the seton, it led to a very severe hemor- 
rhage. The celebrated Ricord, of Paris, at one time used a plan, 
which I have called suture, but which may, perhaps, be looked 
upon as a modification of the seton. He passed double threads, 
or ligatures, through the scrotum antero posteriorly, and tied the 
ends before and behind over pieces of bougie, after the manner 
of the so-called quill suture. Ricord, as far as I know, has never 
had any imitators in this mode of practice. 
Of late years, the treatment by injections of various kinds has 
almost entirely superseded every other plan. The first use of 
injections for the radical cure of hydrocele is attributed to a Brit- 
ish army surgeon named Monro, who employed spirits of wine. 
The method was first brought extensively into notice by Sir James 
Earl, who published a work on the subject in 1791, and recom- 
mended for the purpose wine diluted with one-third part of water. 
Earl, and those who followed him, injected a sufficient quantity of 
the irritating fluid to distend the sac to nearly the dimensions it 
had before the hydrocele was drawn off. It was allowed to remain 
in a few minutes, or until decided pain was produced ; it was then 17 
allowed to flow out through the trocar; the patient was put to bed, 
and the resulting inflammation, though quite manageable, was 
generally sufficient to lead to the desired cure; and the method 
must be allowed to be an improvement on all that had gone before 
it. A great variety of fluids were made use of, such as alcohol, 
wine, cold water, lime water, solutions of alum, tannin, corrosive 
sublimate, iodine, sulphate of zinc, and so on. A case is men- 
tioned by Sir Astley Cooper in which milk was injected on the 
supposition of its being a mild, unirritating fluid ; however, very 
severe inflammation followed, and an abscess in the tunica vag- 
inalis. When an opening was made the milk came out in curds. 
Spirits of turpentine has also been used, with what result I do not 
know. Of all the substances recommended for injection by this 
method, a solution of sulphate of zinc, 3i. to the pint of water, 
is, in my opinion, decidedly the best. I have used it on several 
occasions with complete success. Care is necessary in making 
these injections that the trocar is kept well in the sac of the tunica 
vaginalis, and that the fluid is all withdrawn before the trocar is 
removed. If this be not done, some of the irritating fluid may 
find its way into the loose areolar tissue of the scrotum, and pro- 
duce inflammation, or sloughing. I remember a case of the kind 
in my early practice, which gave me a good deal of uneasiness. 
From some unlucky movement of the patient, some of the solution 
of zinc found its way into the scrotal tissues, and a circumscribed 
slough, about as large as a quarter, took place. This did no harm, 
but rather made the cure more complete. But it is a disagreeable 
accident, and might have very serious consequences. 
In a paper published in the Transactions of the Medical and 
Physical Society of Calcutta in 1834, and subsequently in a paper 
read before the London Medico-Chirurgical Society, November, 
1841, published in the Lancet November 20th, 1841; and in an- 
other paper in the Lancet for April 30th, 1842, Dr. J. R. Martin, 
of India, recommended the injection of a small syringeful of a 
mixture of tincture of iodine 3i and water 3iii, which was thrown 
in and allowed to remain. 18 
Dr. Martin supports his recommendation by the experience 
of over two thousand cases, with less than one per cent, of fail- 
ures. 
Since these publications, the iodine injection has been very gen- 
erally adopted, and is in favor with a majority of practical sur- 
geons. You have seen it done repeatedly in this clinic, and will, 
therefore, be the better able to follow the description of the opera- 
tion. After the evacuation of the contained fluid, taking care 
that the canula remains in the sac, so that the fluid is not deliv- 
ered into the meshes of the areolar tissue, you take a small syringe, 
the nozzle of which has been previously ascertained to fit closely 
into your canula, and load it with two or three drachms of the 
fluid you intend to inject, (I always use the common officinal 
tincture of iodine, full strength, and see no reason to dilute it, or 
mix it with any other ingredients,) then slowly throw it in through 
the canula, having withdrawn which you shake the scrotum or rub 
its sides together, so as to bring the fluid as thoroughly in contact 
with its interior as possible. Sometimes pretty smart pain is at 
once occasioned; occasionally it does not come on until some 
hours later, and now and then, as in the last case we had before 
us, scarcely any pain is felt, and I have known it to be entirely 
absent, without compromising the result, which was a perfect 
cure. 
The amount of reaction produced by the injection varies con- 
siderably, but seldom requires treatment. If it should do so, rest 
in the horizontal position, elevation of the scrotum, with the ap- 
plication of warm fomentation, generally suffices. Sometimes the 
swelling and inflammation subsides very slowly, requiring even 
weeks for their complete disappearance, but this is unusual. The 
iodine has been detected in the urine of the patient an hour and 
a half after the injection. 
In cases which resist the iodine treatment, Butcher recommends 
the introduction, by means of a probe passed through the canula, 
of a few grains of red oxide of mercury into the sac. Another 19 
writer, whose name I have forgotten, speaks of the same applica- 
tion, and says that one of his patients was salivated by it. 
Unless the circumstances of the patient make it imperative or 
highly desirable, the hydrocele should be tapped at least once be- 
fore resorting to the injection for radical cure; for sometimes, as 
already said, a simple tapping proves curative, though this is a 
rare event. It has often been taught that injections cure by pro- 
ducing adhesive inflammation and obliteration of the sac, but 
numerous dissections have proved that so far from being the rule, 
this very seldom occurs. Exactly how the curative influence is 
produced is by no means easy to say. Billroth, speaking of iodine 
injections in hydrarthrosis, says : 
“ The iodine is deposited in the surface of the membrane and 
in the endothelium ; it remains here for months, at least, and by 
its presence appears to prevent further secretion. At first there 
is a strong fluxion with serous exudation, but the serum is again 
absorbed by the still distended vessels, and subsequently the mem- 
brane shrinks to the normal volume by condensation of the con- 
nective tissue, which subsequently remains more dense.” He goes 
on to remark as follows: “So we may consider the process of 
cure as analogous to the similar process in the tunica vaginalis tes- 
tis in the cure of hydrocele; after injections of iodine in hydro- 
cele, there has been an opportunity of making many examina- 
tions, from which the course of cure appears to be as above stated ; 
the shrinkage of the serous membrane, with new formation of en- 
dothelium, seems to me to be the final cause of the arrest of the 
secretion.” 
When the hydrocele is very large, it is not safe to inject it after 
the first tapping; it should be tapped and allowed to partially 
refill before the injection is made. By this course of procedure a 
smaller surface is exposed to the irritant action of the remedy, 
and the effects are correspondingly less severe. 
I may mention here that I once cured an hydrocele merely by 
moving the trocar about rather roughly in the sac after evacuating 
it, but I can not recommend the plan for your imitation, for the 20 
reaction was much more severe than I have ever seen it after iodine 
injection, indeed, quite unpleasantly so. 
Several times I have seen hydocele cured by puncturing the sac in 
numerous places with a common exploring needle, and allowing the 
fluid to drain slowly away and to infiltrate the areolar tissues, but 
this plan is unreliable. 
Lately 1 have seen accounts in the journals of hydroceles almost 
instantly cured by electrolysis, but we need more experience on 
this point before we can speak definitely about it. Many years 
ago, Dr. Deblois, of Tournay, was in the habit of curing hydrocele 
by distending the sac with chlorine gas. Whether he ever found 
any imitators, I am unable to say. 
To sum up under the head of treatment, I would say to you, 
after a preliminary tapping, and this is imperative if the hydrocele 
be a large one, inject iodine; if this fail, which will be very sel- 
dom, then resort to incision. 
But remember that every case of hydrocele does not demand 
radical treatment. If the patient for.any reason prefers the sim- 
ple palliation of occasional tapping, he should by all means be 
allowed to have his own way.