HYDROCELE- ITS RADICAL CURE. BY Orville Horwitz, B.S., M. D., Clinical Professor of Genito-Urinary Diseases in Jefferson Medical College ; Professor of Genito- Urinary Surgery, Philadelphia Polyclinic ; Surgeon to Philadelphia Hospital, etc. REPRINTED FROM THE Journal of Cutaneous and Genito-Urinary Diseases for September, 1896. [Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases for September, 1896.] HYDROCELE-ITS RADICAL CURE. By ORVILLE HORWITZ, B. S., M. D., Clinical Professor of Genito-Urinary Diseases in Jefferson Medical College; Professor of Geni- to-Urinary Surgery, Philadelphia Polyclinic; Surgeon to Philadelphia Hospital, etc. AS the writer lias had more than a usual number of cases of hydro- cele under his immediate care within the last five years, it is l thought that a few observations upon the disease and the methods pursued for its radical cure may not be uninteresting to the profession. This dissertation is based upon the experience deduced from the treatment of one hundred and ten cases, of which fifty-nine were treated at the Jefferson Hospital, six at the Philadelphia Hospital, four at St. Joseph's Hospital, four at the Polyclinic, and thirty-six in private practice. Of these, five began as acute hydrocele, ultimately becoming chronic and requiring radical operations; three were due to gonor- rhoeal orchitis; one case followed traumatism; one was intercurrent with an attack of acute articular rheumatism; and in one the hydro- cele was double. The varieties and the different forms of the disease are shown in the following table: Ordinary hydrocele: fluid distending the tunica vaginalis. . 54 Congenital hydrocele 1 Infantile hydrocele 22 Inguinal hydrocele, associated with undescended testicle... 1 Encysted hydrocele of the epididymis 4 Encysted hydrocele of the testes 1 Hydrocele of the cord 13 Hydrocele of the tunica vaginalis, with encysted hydrocele of the testes 1 Hydrocele complicated with inguinal hernia 12 Hydrocele occurring in an old hernial sac, the inguinal canal having become obliterated by the long use of a truss. . . 1 Total 110 Copyright, 1896, by D. Appleton and Company 2 Original Communications. Table exhibiting the Various Ages of the Patients. From one week to eighteen months 5 Between eighteen months and fifteen years 18 Between fifteen and twenty-one years 4 Between twenty-one and twenty-five years 9 Between twenty-five and thirty-five years 42 Between thirty-five and forty-five years 21 Between forty-five and sixty years 8 Between sixty and sixty-nine years 3 An examination of these tables shows that effusion of serum into the tunica vaginalis is by far the most common variety, fifty-four of the one hundred and ten cases being ordinary hydrocele; also that the condition is most frequently met with between the ages of twenty- five and thirty-five years. Of the number treated, the effusion was present on the left side in sixty cases, on the right side in thirty-seven case, and the hydrocele was double in thirteen; of these, four began as an acute form of the affection, following gonorrhoeal orchitis. Hence it would appear that the left is more frequently affected than the right side, though this differs from the experience of other observers, who seem to have found the right and left sides equally liable to the disorder. Treatment is usually divided into palliative and radical. Treat- ment by the palliative method-that is, by draining off the fluid by means either of an aspirating needle or by a trocar-will not be consid- ered in this paper. The cases that are properly treated by the palliative method are those occurring in the very aged; persons who are broken in health or debilitated; who are suffering from some chronic disease of the vis- cera rendering a radical operation unjustifiable; those whose business engagements prevent them giving the necessary time required for a radical operation; and, finally, individuals who refuse other means of relief. There are four methods of radical treatment recommended by writers on hydrocele: 1. Tapping the sac and injecting with an irritating fluid. 2. The Volkmann method. 3. Antiseptic incision. 4. Partial excision of the sac. Hydrocele-Its Radical Cure. 3 Tapping the sac is to be performed under the most rigid anti- septic precautions. After the fluid has been drawn off the cavity is to be injected with some irritating liquid, such as tincture of iodide or carbolic acid. The patients usually suffer a great deal of pain after the operation. Very often the sac rapidly fills up, becomes as large as or larger than before the operation: and frequently the individual is confined to his bed for a period of from eight to ten days. There are many cases of suppuration following the treatment. There is danger, too, of the escape of the tincture of iodine or of the carbolic acid into the scrotal tissues, either at the time of the injection or on withdrawing the trocar; of slow absorption of the new fluid; suppuration of the tissue of the sac, and of renewed accumulation of fluid. Dr. J. Murphy, in the New York Medical Record for June 20, 1891, reports the fatal termination of a case after the injection of car- bolic acid, when death could only be attributed to the toxic effect of the remedy. Of the fifty-four cases of ordinary hydrocele operated on by the writer, thirteen had been previously treated by other surgeons, by withdrawing the fluid and then injecting either tincture of iodine or carbolic acid. All had promptly relapsed. When performing the open operation on these patients, no sign of inflammatory changes could be detected; in a few cases the tunica vaginalis was possibly somewhat thicker than normal; in every in- stance the testicle was found to be freely movable. Personal experience of this method of treatment has been unsatis- factory, and other means for the cure of hydrocele have long since been adopted by the writer. Some years ago, when assistant to the late Prof. Samuel D. Gross and to Dr. Richard Levis (the surgeon who first suggested the use of carbolic acid in the treatment of hydrocele), many opportunities were presented for observing the effect of the injection of tincture of iodine and of carbolic acid; and the result was the conviction that it did not compare with the open method of treatment. The open method of treatment of Volkmann. which is the next to be considered, is performed by making a free incision over the long axis of the tumor, opening the tunica vaginalis, stitching it to the skin, packing the wound with iodoform gauze, and then dressing the part antiseptically, the wound being allowed to heal by granulation. The writer has performed this operation on two patients, the first case being one of ordinary hydrocele. The wound required from three to four weeks to close, when a large, unsightly cicatrix remained. 4 Okiginat Communications. The second case was one in which the tunica vaginalis had under- gone calcareous degeneration. As much as possible of the calcareous matter was removed by means of scissors and curette, and the wound packed with iodoform gauze. The patient made a slow but steady recovery. Neither our personal experience nor what we have observed of cases in the hands of other operators allows us to advise the employ- ment of this operation, except in those rare instances where calcareous changes have taken place in the sac. The length of time required for recovery is too great, and the operation is apt to result in a large everted scar. The third method to be considered is that of antiseptic incision with drainage. Of the fifty-two cases of hydrocele, thirty-one were treated by this mode. The operation itself is a simple one. The part having been shaved and antisepticized, the patient is etherized, when the tumor is grasped by the operator and made tense with the left hand. An incision an inch and a half in length is rapidly made at the lower portion of the tumor, and the tunica vaginalis is opened. An assistant grasps the tunic with a pair of haemostatic forceps affixed laterally on each side of the cut, and pulls it forward into the wound. The fluid contents are allowed to escape, and the surgeon by means of a piece of bichloride gauze thoroughly dries the cavity; then the whole internal surface, together with the testicle, is thoroughly swabbed with pure carbolic acid by means of absorbent cotton attached to the end of an applica- tor; after which, the sac is loosely packed with iodoform gauze and the wound dressed antiseptically. The iodoform gauze is kept in place for twenty-four hours, when it is removed, and the cut surface of the tunica vaginalis drawn together. Within a few hours the serous sur- faces adhere, and communication of the sac with the atmosphere is cut off. The patient is generally enabled to leave his bed and the hospital on the fourth day, with but a small granulating wound of the scrotum remaining, which, under the application of the ordinary antiseptic dressings, heals kindly within a week. There is usually a slight painless enlargement of the testicle following the operation, which, however, subsides in a few days. In no case under the supervision of the writer did the temperature rise above 99°. So far as is known, recurrence took place in but two instances; in each case the tunic was opened, and the sac, as far as possible, was re- moved. Hydrocele-Its Radical Cure. 5 The result of our observation, based on the experience derived from these cases, is the belief that this method of treatment is indicated when the affection is of recent origin, provided the sac has not been hith- erto tapped, has not been injected with an irritating fluid, and when, on cutting down, the sac is found to be greatly thickened, and the tumor does not extend into the inguinal canal. Partial Excision of the Sac.-Incision with partial removal of the sac is to be resorted to when the sac is found to be thickened, or where it protrudes far into the inguinal canal. Twenty-one of the fifty-two cases already referred to were thus treated. A modification of this operation is suggested by the writer, which it is believed will greatly simplify the usual procedure: It is performed by making a free incision over the long axis of the tumor, dividing the structures down to the sac, at the same time being careful not to open it. By means of an Allis's dry dissector, the scrotal tissues are to be quickly separated from the tunic, which is to be left slightly adherent posteriorly; this being the portion of the sac which covers the cord, and is not to be disturbed. The sac is then made tense, fixed by means of a tenaculum, opened by a touch of the knife, and the fluid allowed to escape. The sac, having been thoroughly dissected from the scrotal tissue, is to be removed in a single piece by means of the curved scissors. The bleeding vessels are ligated and the wound dried. Should there be much haemorrhage from the edges of the cut sac, it must be controlled by a continuous suture passing completely over the margin. The portion of the tunica vaginalis lying over the cord is to be swabbed with carbolic acid, the wound irrigated with l-to-1,000 bichloride solution, a small drainage tube inserted, and the parts closed by silkworm-gut suture. An antiseptic dressing is then applied. The drainage tube is to be removed after twenty-four hours; the sutures after the seventh day. In but two cases has the writer seen any trouble arise from this operation. In one the patient returned to the hospital six months after having been discharged, suffering with a sinus in the scrotum, which had presented itself three months after he had quitted the insti- tution. On examination a silk ligature was discovered, which being removed, the opening promptly healed. The second case occurred on a man whose bed in the hospital was near the toilet room; unseen by the nurse, he arose and went to the closet, where he removed the dressings; being unable to properly re- place them, the parts were exposed for some hours before his condition was discovered. The wound became infected; suppuration ensued; 6 Original Communications. it became necessary to remove the sutures, and to pack the parts with iodoform gauze. The patient recovered in about four weeks. Recurrences after partial excision of the sac have been reported, but no relapses have taken place in cases treated by this method. The advantages of dissecting the sac free from the scrotal tissues are: 1. Saving of time. 2. The removal, without difficulty, of all that is necessary to be cut away without tearing the tunic into strips or patches. 3. There is less haemorrhage; the sac which is removed being distended with fluid, the small vessels from the surrounding tissues are torn and do not bleed. But if the membrane be opened and the fluid allowed to escape, the tissue has necessarily to be dissected away with either scissors or knife, resulting in the cutting of numerous small vessels, requiring the application of the catgut ligature. Congenital hydrocele can generally be cured by means of a prop- erly adjusted hard-rubber truss, the fluid being removed from time to time by acupuncture. Should this fail, it is recommended to draw off the serum with a small trocar and inject either tincture of iodine or carbolic acid into the cavity, care being taken to have a well-fitted truss applied during the operation; an antiseptic incision is, however, much to be preferred, not only because it is safer, but because it admits of a radical operation for hernia, should such a complication be present. An open operation in the case of infants is not recommended, as it is quite impossible to keep the wound in an antiseptic condition when infection might ensue. Should the child have reached the age of nine years, the operation may be performed with safety. In a case upon which the writer operated, the parts were sterilized and an incision made over the lower part of the inguinal canal and the upper portion of the scrotum, precisely as though operating for hernia. The funiculo-vaginal process was separated from the cord, the serous membrane divided immediately above the testicle, and parted from the adjacent structure as far up as the internal ring. It was then twisted, tied with catgut ligature, and the portion below the liga- ture cut away. A very small drainage tube was inserted for twenty- four hours. The patient promptly recovered, and thus far there has been no recurrence of the malady. It may be well to state that the internal ring can be readily reached without making a very large in- cision, if the upper part of the wound be well retracted. Infantile Hydrocele.-Of the twenty-two cases of this variety that Hydrocele-Its Radical Cure. 7 came under the writer's observation, seventeen were cured by means of numerous punctures made with a Glovins's needle. The needle should be sterilized and the skin antisepticized in the usual manner. The operator grasps the tumor with the left hand, makes it tense; then, taking the needle in the right hand, between the thumb and fore- finger, he rapidly makes six or eight punctures into the sac, rotating the needle once or twice with every perforation, at the same time being very careful not to wound the testicle, and bearing in mind to hold the scrotum tensely until the serum contained in the sac is evacuated. This procedure has usually to be repeated at intervals of from eight to ten days. Five or six operations are necessary to effect a cure. In five cases in which this mode of treatment failed, an antiseptic incision was resorted to; the cavity was dried, swabbed out with carbolic acid, and packed with iodoform gauze in the manner previously de- scribed. The patients all made prompt recoveries. Hydrocele associated with undescended testicle is by no means common. I n the single case upon which the writer operated, the tumor was situated at the abdominal ring, projecting partly into the canal, and was about the size of a turkey's egg. The undescended testicle was on the left side; the scrotum was fully developed. A free in- cision was made over the tumor and scrotum. The tunica vaginalis was then dissected loose without opening the sac. The tunic was next incised, and the fluid allowed to escape; the testicle was brought down and stitched in place at the bottom of the scrotum. A drainage tube was inserted and the wound closed. The patient made a favorable recovery. The cases of encysted hydrocele of the epididymis or cord were treated by making a free incision, opening the tunica vaginalis, and by means of a dry dissector removing the sac in its entirety, and then closing the wound. In one instance, when operating upon a case of hydrocele of the cord, while attempting to excise the sac, it was suddenly ruptured and it became necessary to freely open and remove the membrane. Hydrocele of the tunica vaginalis with encysted hydrocele of the testes is a very rare condition. But one case has been under the writer's charge. The tumor had been growing for seventeen years; its length was twenty-six inches, and it was eighteen inches in circumference at the base; it contained four quarts of fluid. In operating on this case a free incision was made over the long axis of the tumor, and the tunica vaginalis opened, when a large quantity of fluid escaped, expos- ing the testicle, which was about the size of the head of a foetus at term. 8 Original Communications. The cord was isolated, tied, cut, and the testicle removed. On open- ing the testicle after castration it was found to be nothing more than a large sac formed by the tunica albuginea containing fluid. Every vestige of the glandular structure had long since disappeared; the re- dundant scrotum was retrenched, a drainage tube inserted, and the wound closed. The patient quitted the hospital on the thirteenth day. Of the twelve cases of hydrocele complicated with inguinal hernia no difficulty was experienced in operating; care being taken to apply an accurately fitting truss with antiseptic gauze, prior to commenc- ing proceedings, in order to retain the rupture in place. Seven cases were treated by antiseptic incisions together with car- bolic acid. In the remaining five the sac was partially removed. In two of the cases, the consent of the patients having been obtained, the operation by the Halstead method for the radical cure of the rupture was performed. The patients recovered without any untoward symp- toms. In a case of effusion of serum in an old hernial sac where the in- guinal canal had become obliterated, an incision was made down to the sac, which was dissected loose from the adjacent structures with- out penetrating it. It was then removed at the external abdominal ring, care being taken not to open the tunica vaginalis. In the thirteen cases of double hydrocele, the open operation was performed on both sides simultaneously. They all made rapid recov- eries. The details of the treatment of the cases of hydrocele by the meth- ods advocated in this paper would seem to warrant the belief that where proper antiseptic precautions are observed, the open method of operating is not only the most satisfactory, but the safest method of procedure; by it the operator is enabled to know exactly with what condition he is dealing, and at the same time the patient is offered the best chance for a permanent recovery, with little or no attendant pain.