RADICAL TREATMENT OF HYDROCELE.* 
By Thomas S. K. Morton, M. D., 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC. 
It is intended upon this occasion to briefly outline the 
methods of radically treating hydrocele of the tunica 
vaginalis, in the adult, and to give a summary of conclu- 
sions arrived at from a recent study of the literature of the 
subject combined with the writer's personal experience. 
But, in passing, it may be remarked that aseptic tapping 
or aspiration of a simple hydrocele is still the popular and 
best method of treatment, when radical cure, for any reason, 
is not to be attempted. 
Those radical methods which may fairly be considered 
obsolete and undeserving of remark are: by setons, tents, 
caustics, or by the injection of alcohol, port wine, chloride 
of zinc, perchloride of iron or hot water. Practically the 
only procedures used at present in attempting the radical 
cure of hydrocele may be conveniently divided into four 
principal methods. These are: 
1. Tapping and injection of tincture of iodine. 
2. Tapping and injection of carbolic acid. 
3. Incision and subsequent drainage. 
4. Incision and excision of parietal layer of tunica 
vaginalis. 
Tapping and subsequent injection of tincture of iodine 
was introduced by Ronald Martin in 1832 and at once 
attained almost universal popularity. This preeminence 
was retained almost without challenge until the methods of 
carbolic acid injection and aseptic incision were introduced 
a few years ago. The general employment of the iodine 
*Reprinted from The Philadelphia Polyclinic, Vol. I, No. 3, September, 
1892. 2 
MORTON, 
injection has since been steadily, but by no means rapidly, 
upon the decline. 
The method of injecting iodine is as follows : The sac is 
emptied of all fluid by tapping in the usual manner after 
the parts have been well scrubbed and douched with 1-1000 
bichloride solution. The canula of the trocar is left in 
position and a syringe that snugly fits it is applied and 
from 3 j to 5 iv of pure tincture of iodine (according to size 
of the sac) is injected into the hydrocele cavity. A finger 
is then placed over the opening of the canula and the latter 
withdrawn, leaving all of the iodine within the sac. It is 
important to do this in such a manner that none of the 
iodine will get into the cellular tissues as the instrument is 
withdrawn. Abscess or sloughing may follow this accident. 
After the canula has been thus carefully removed the 
scrotum is manipulated for a few seconds so as to work the 
irritating injection over all portions of the tunic. The 
wound made by the trocar should be protected with an 
ordinary antiseptic dressing, or by a small six-ply square 
of aseptic gauze, plastered down by collodion. 
This injection is usually accompanied by intense pain 
and more or less shock. Subsequently plastic inflamma- 
tion ensues and, if the case does well, the cavity of the 
tunica vaginalis is obliterated by universal adhesion of its 
walls. Prof. Simes has proposed the injection of several 
drachms of cocaine solution into the cavity after tapping, 
leaving it there for a few moments and then allowing it to 
run out through the canula before injecting the iodine, 
with the object of avoiding the intense pain that arises 
when the irritant is thrown in. This certainly accomplishes 
its object but has proved to be a very doubtful expediency 
owing to the erratic and sometimes fatal constitutional effects 
of cocaine, especially when it is accidentally injected into 
the cellular tissues. Dr. Simes himself has abandoned its 
use in this connection. Drs. Weir and Gordon Buck have 
advocated rough manipulation of the scrotum on the second 
or third day after injection when inflammation is at its 
height and claim by this means to secure a larger percent- RADICAL TREATMENT OF HYDROCELE. 
3 
age of permanent cures. But, for obvious reasons, they 
have had few followers. 
By the iodine injection method about 80 per cent., of 
cases suited for it (see conclusions) are radically cured, and, 
when done aseptically, complications are uncommon. The 
patient is disabled for from one to two weeks. 
Carbolic acid was proposed as a substitute for the iodine 
injection, by the late Dr. Richard J. Levis of Philadelphia, 
in 1881. This agent has steadily been increasing in pro- 
fessional esteem from that time to the present. By it, pain 
and shock are all but eliminated, complications are rare, 
the patient is not usually incapacitated for more than a day 
or two, and permanent cures are more frequent than where 
iodine is employed. 
The acid is introduced by means of a syringe with a 
nozzle which almost fits the canula and long enough to 
project into the sac a quarter of an inch beyond the end of 
the canula. Pure carbolic acid, the crystals melted with five 
per cent, of glycerin, is employed. More dilute solutions 
are prone to induce suppuration or sloughing. From nixx 
to sj of this mixture, according to the size of the hydrocele, 
is injected and allowed to remain in the sac. The syringe 
and canula are then withdrawn and the scrotum manipu- 
lated for a few seconds so that the acid shall be brought 
into contact with all portions of the sac. The trocar wound 
is dressed in the usual manner. It is well to direct the 
patient to lie down for two or three days or until the sore- 
ness and swelling that appear on the second day begin to 
subside. 
The more rational and modern treatment of hydrocele 
dates from the year 1876, when Volkmann introduced the 
operation of aseptic incision and drainage of the hydrocele 
sac. This is performed in the following manner: The 
scrotum and pubis are shaved, scrubbed, and douched with 
1-1000 bichloride of mercury solution. The patient is then 
etherized and a vertical incision to the full length of the 
cyst is made upon the anterior surface of the scrotum. This 
is carried down to and into the sac, which is then divided 4 
MORTON, 
to the full length of the skin incision. Clip forceps are put 
upon all bleeding points and the interior of the tunic 
examined for other cysts, cartilaginous deposits, or evidences 
of testicular disease. A small percentage of hydroceles will 
be found to consist of more than one cyst. These should 
be successively opened by knife or scissors and scraped out. 
Careful inspection will frequently reveal the presence of 
numerous very small cysts taking origin around the globus 
major or minor. These should be sought for, and, if found, 
opened and curetted out. Loose cartilaginous bodies 
or attached plates of cartilage, or bone, or even hairs, or 
actual dermoid cysts are occasionally found within a hydro- 
cele sac. These when present should always be carefully 
dissected out. Excision of portions of the sac may be neces- 
sary to thoroughly eradicate these growths. Next, all 
hemorrhage is to be checked by fine cat-gut ligatures and, 
after a washing with 1-1000 bichloride solution, sutures are 
introduced in such a manner as to unite the edges of the 
skin and sac wall along each side of the scrotal incision 
from end to end. A rubber drain tube of one-quarter inch 
calibre is then introduced to the uttermost recess of the 
cavity and cut off one-half inch outside the wound. A 
copious dressing of bichloride gauze is finally applied to the 
entire scrotum and secured by a suitable gauze bandage. 
This dressing should be renewed at least every second 
day or whenever it becomes soiled by excrement or other- 
wise. At each dressing the wound should be washed or 
sprayed out with peroxide of hydrogen (full strength) solu- 
tion, and, afterwards, with a 1-2000 mercuric chloride solu- 
tion. The drain tube should be shortened half an inch 
every second day, and even more rapidly if pushed up by 
granulations from the bottom of the wound. In about ten 
days or two weeks the granulations will be level with the 
surface and cicatrization will proceed rapidly. If the 
narrow line of granulations which finally remains to mark 
the line of incision is tardy in cicatrizing or if they become 
exuberant it is well to paint them with the nitrate of silver 
stick. RADICAL TREATMENT OF HYDROCELE. 
5 
In from ten days to three weeks after operation by this 
method the patient should be able to resume his occupation. 
He should however be advised to wear a suspensory bandage 
until all swelling has departed from the scrotum and cord. 
Suppuration and inflammation are practically the only 
complications that ever occur and must be met, when they 
unfortunately do occur, by frequent dressings, vigorous use 
of the hydrogen peroxide and bichloride solutions, cutting 
away all sutures, and dustings with iodoform or aristol. 
Burgmann in 1885 modified Volkmann's operation by 
excising the parietal layer of the tunica vaginalis and 
suturing the wound closely about the drain tube. The 
tube is removed on the second day and primary union is 
expected. I am informed by Dr. John Ashhurst, Jr. that 
the late Dr. Henry H. Smith of Philadelphia was accus- 
tomed to excise the parietal layer of the sac in treating 
hydroceles radically for many years before Bergmann pub- 
lished his paper on the subject. 
This operation has not become as popular as was at first 
expected for a number of reasons. Chief of these are: the 
procedure is often an exceedingly difficult one; the testicle 
or cord may be injured or deprived of sufficient blood 
supply and subsequently slough or atrophy; hemorrhage 
is sometimes troublesome; complications are not infre- 
quent ; some recurrences take place; and, finally, while the 
operation is so much more severe and difficult than simple 
incision and drainage it is no more successful in producing 
cures than is the more simple and less dangerous method 
of Volkmann. 
The judgment of the writer is therefore in favor of the 
operation of a simple incision and drainage as advocated by 
Volkmann with this modification. Instead of the drain 
tube (which occasionally permits primary union of portions 
of the sac wall which later become retention cysts or new 
hydroceles) gauze packing of the entire sac cavity is resorted 
to. One long strip of iodoform gauze, one and one-half 
inches broad, is gently packed into every recess of the sac 
until the whole is distended. This packing is removed 6 
MORTON, 
every second day and replaced in diminishing quantities as 
granulations spring up from all sides of the sac; in other 
words, the sac as such is destroyed and replaced by connec- 
tive tissue, thus ensuring a permanent cure. For if no 
secreting membrane remains no fluid will be poured out 
after the wound has closed and it will be impossible for a 
hydrocele to reform. If this modification of the Volkmann 
method is employed the time required to effect a cure is not 
extended and the necessity for doing Bergmann's operation 
will only arise in certain cases where the vaginal tunic is 
infiltrated with cartilaginous or calcareous material, or 
otherwise seriously diseased. 
Conclusions. 1. Simple tapping, the injection of tincture 
of iodine or carbolic acid, and aseptic incision (with or with- 
out excision of a portion of the sac) are alone employed to 
any extent in the modern radical treatment of hydrocele. 
2. Although other injection materials-notably bichloride 
of mercury solution and iodoform-have been commended, 
yet clinical proofs of their efficiency are lacking. 
3. Simple tapping, under full antisepsis, may be relied 
upon to relieve any hydrocele and will cure a small per- 
centage of cases. 
4. The injection of moderate amounts of tincture of 
iodine (sj to siv) or carbolic acid (^xx to 5j) will cure 
about 85 per cent, of the simplest forms of hydrocele. These 
two agents appear at present to stand almost upon an 
equality as regards percentage of cures and complications, 
but the acid has the advantages of not giving rise to pain 
or shock and produces a much shorter period of disability; 
it appears also to be steadily gaining in popularity, and has 
cured many cases where the previous use of iodine had 
failed. 
5. Cocaine should not be employed to prevent the pain 
incident to injecting iodine, on account of its erratic and 
occasionally fatal constitutional effects. 
6. The following conditions should prohibit any attempt 
at radical cure by irritant injections : 
a. disease of the testicle or cord. RADICAL TREATMENT OF HYDROCELE. 
7 
b. hydrocele complicated by hernia or the presence of 
a hernial sac, or where there is any doubt as to the 
relations of the hydrocele sac. 
c. the presence of multiple cysts. 
d. cloudiness of contained fluid. 
e. thickening or tuberculosis of the cyst walls. 
/. presence of considerable pain. 
g. presence of syphilis, tuberculosis or any depraved 
physical condition. Potassium iodide will cure 
most hydroceles of syphilitic origin. 
h. where communication with the abdominal cavity 
cannot be excluded. 
i. the failure of previous attempts to cure in this 
manner. 
j. great size of cyst. 
k. extreme old age or wdiere the cyst is developed in 
childhood. 
7. A considerable time should be allowed to pass after 
reaccumulation of fluid following injection before under- 
taking other treatment as the effusion is apt to be inflam- 
matory and to disappear in time. 
8. While many complications and even deaths resulting 
from attempted radical cure by the injection method are 
on record, yet most of these can be traced to violation of the 
above mentioned contraindications, to the employment of 
too large a quantity of the irritant, to the neglect of anti- 
sepsis, and to injecting into cellular tissue. 
9. The method of tapping and injection is the method 
par excellence for those not familiar with the technique of 
surgery. 
10. Permanent cure may be anticipated with almost 
absolute certainty where the operation of incision and pack- 
ing of the sac is performed. Failures under the Volkmann 
method can often be traced to: 
a. overlooking small secondary cysts or cartilage-like 
bodies, or failure to recognize disease of the testicle 
or cord. 
b. attempting to secure primary union. 8 
MORTON, 
c. too early removal of the drain tube where that 
method of drainage has been made use of. 
d. too small an incision. 
11. The substitution of gauze packing for the drain tube 
in Volkmann's operation will probably prevent most of the 
complications that have been reported, and secure, with 
proper attention to minute secondary cysts, a uniformly 
radical and safe cure. 
12. The death rate from simple incision and drainage is 
no greater than is that from injection of iodine. Sepsis and 
careless hemostasis are responsible for almost all complica- 
tions and reported fatalities. 
13. Excision of a portion of the sac-Bergmann's operation 
-is probably unnecessary and unjustifiable except where 
the tunic is exceedingly thickened or otherwise extensively 
diseased, as when containing calcareous patches or tubercu- 
lar infiltration. 
14. Incision of the sac may be performed under any of 
the conditions which contraindicate irritant injections except 
extreme youth, and certain constitutional conditions. 
15. In double hydrocele both should never be injected at 
the same time, but double incision may be done when the 
local and general conditions are favorable. 
16. A radical cure can only be promised when incision is 
employed.