The Radical Cure of Hydrocele. Read in the Section on Surgery and Anatomy, at the Forty-sixth Annual Meeting of the American Medical Association, at Baltimore, Md., May 7-10, 1895. BY D. C. HAWLEY, A.B., M.D. ATTENDING SURGEON MARY FLETCHER HOSPITAL; ATTENDING SURGEON FANNIE ALLEN HOSPITAL; SECRETARY VERMONT STATE MEDICAL SOCIETY. BURLINGTON. VT. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, JULY 0, 1895. CHICAGO: American Medical Association Press. 1896. THE RADICAL CURE OF HYDROCELE. D. C. HAWLEY, A.B., M.D. The only known method of effecting a certain, ab- solute and permanent cure of a hydrocele, is to bring about the complete obliteration of the cavity of the tunica vaginalis.1 The methods usually employed by surgeons at the present time for the radical cure of hydrocele, are the injection method and the method by open inci- sion. The treatment by injection fails in some cases, from the fact, no doubt, of its being improperly or poorly done. Again, it often fails in cases of very large hydrocele, and invariably in cases in which there is mch thickening of the tunic, thereby preventing perfect collapse of the same. Treatment by iodin injection is usually painful, and is attended with intense swelling and tenderness of the scrotum. Three to five days must be spent in bed, and three or four weeks are often necessary for perfect recovery. Injection of carbolic acid is, in my experience, less painful and more efficacious, but requires about the same length of time for a cure. In the operation by incision, as usually practiced and as described in the text-books, an incision about two inches long is made along the anterior surface of the tumor, which thoroughly opens and drains the sac. The edges of the tunica vaginalis are stitched to the skin by catgut or silk sutures, and a rubber drainage tube is inserted, or the cavity is packed with gauze. The after treatment consists in a daily dressing, i Treves. 2 when the tube is gradually shortened or the packing is renewed. The patient must remain in bed for ten or twelve days, and eighteen to twenty-eight days or more are required for a cure in most cases of opera- tion by incision. I wish now to describe, briefly, a method which I have employed for two or three years past, in my service in the Mary Fletcher Hospital and in private practice. I consider it almost unnecessary to say, at the present day, that the operation must be done aseptically. The usual incision, two to three inches in length, is made along the anterior surface of the tumor, tak- ing care always not to injure the testicle. The fluid is allowed to escape and the sac is irrigated. The margin of the tunic is stitched to the skin by six or eight black silk sutures. I use black silk, as it can be more readily found and removed. The interior of the sac is now irritated over every part of its surface by being rubbed with the finger tips. This is not done roughly, but gently and thoroughly. The sac is packed with strips of iodoform gauze, the usual dressings applied and the patient kept in bed. At the end of twenty-four hours the strips of gauze are removed and the cavity is irrigated. The entire sur- face of the tunica vaginalis will now be found to be covered with inflammatory lymph. Further packing or drainage is not used. The opposing surfaces of the sac are brought into thorough coaptation by compression, applied by means of strips of adhesive plaster. A light dress- ing of gauze is placed over the wound of incision and the adhesive strips are applied systematically around the scrotum over this dressing, so as to produce firm and even compression. The dressing should be in- spected occasionally at first to see that it does not become loosened. If it does so, it must be reapplied at once. At the end of four or five days the dressing is taken off and the silk sutures removed. At this time the cavity of the sac will be found to 3 have been obliterated, the opposing surfaces having united by adhesive inflammation. Should a sinus be found, which, however, has happened but once in any of my cases, it should be treated on general princi- ples and allowed to heal from the bottom. The wound is again dressed and mild compression continued. Two or three more dressings are all that are required, and at the end of six to twelve days the wound will be entirely healed. A slight dressing may be neces- sary for a few days to prevent chafing, and a suspen- sory should be worn for several weeks. The strips of gauze used for packing should be counted and a note made of the number, to avoid the possibility of one of them being left at the time of the first dressing. But little swelling follows the operation, and I have seen no cases in which orchitis has supervened. The patient need be kept in bed but three or four days, but the scrotum should be sus- pended whenever he is allowed to get up. Case.—George W., age 54, carpenter by trade, was admit- ted to the Mary Fletcher Hospital with a history of double hydrocele having existed for ten or twelve years. Both had been tapped several times. On Oct. 16, 1894, I operated on him under ether, in the manner described. The left hy- drocele contained a pint of fluid and the right more than a pint. The case was dressed the next day, when the packing was removed and the surfaces of the sacs were brought together and held in apposition by a well-fitting dressing. This was left five days and on October 22, six days from the time of operation, the case was again dressed and both sides were found entirely healed, excepting the incisions through the scrotal tissues. There was no pus. Dressed again on October 24, or the eighth day, and the patient allowed to go home as he resided in the city, with instructions to return in four days. He returned as directed on October 28, when both incisions were found entirely healed, and he was dis- charged cured—twelve days from the date of operation. He went to work at once at his trade, having lost less than two weeks’ time. At the present writing he is perfectly well, with no sign of a return of the trouble. Another case of single hydrocele containing a half pint of fluid was operated on by the same method nearly two years ago, and was well in six days, and 4 no sign of a return of the hydrocele up to the pres- ent time. In one case, a small sinus was found at the second dressing, which was one inch in depth and a little larger than a good-sized probe. This closed perfectly in three or four days. Every case operated on thus far, by this method, has been successful. The advantages claimed for this operation over any other, in all cases of old or large hydrocele, are the shorter duration of the treatment, together with the probability of a radical cure in every case. The treatment by the injection method requires a long time for the restoration of the parts to their normal condition, while at the same time the result is uncertain, for the reason that the inflammatory process set up by the injection may not be sufficient to produce a cure. On the other hand, it may be so severe as to cause extreme swelling and much suffering. The operation by injection is an unscien- tific and haphazard method, while this operation is a scientific procedure based on modern aspeptic principles. The special objection to the open incision method is the long duration of the treatment. The patient must remain in bed from six to twelve days, which time measures the duration of the treatment by the method I have described. This method is, I believe, applicable to all cases requiring an operation. It is not open to the objec- tion that the patient must take an anesthetic, for if there is any special reason why he may not do so, or if he will not submit to it, the operation may be done with cocain.