SECT. LXII.—ON HYDROCELE.
An inert fluid, collected about the parts which are enveloped by the scrotum, and occasioning a marked swelling there, has obtained this appellation. The fluid is, for the most part, collected in the tunica vaginalis around the testicle, at its anterior part; but the affection is sometimes, though rarely, formed externally to the tunica vaginalis. Often, however, it is collected in the proper tunic of the testicles, and surgeons call this affection hydrocele of the tunica adnata. If the complaint is formed from some preceding cause, such as weakness of the parts, the blood brought there for the purpose of nourishment is converted into an inert watery or serous substance. But if it is occasioned by a blow, a sanguineous or feculent substance constitutes its contents. The common symptom is a permanent swelling without pain about the scrotum, not disappearing under any circumstances, yet somewhat compressible when the collection is small, but not at all compressible when it is large. When the fluid is collected in the tunica vaginalis the swelling is globular, but somewhat oblong like an egg; and in these cases the testicle is not to be felt as being everywhere surrounded with the fluid. But that which is collected externally to the tunica vaginalis, is felt as through a small intervening substance. When it is formed in the adnata, being everywhere circumscribed and globular, the swelling has the appearance of another testicle. If the fluid be watery, the swelling is of one colour and transparent; but if it be feculent and bloody, it appears red or livid; and if these symptoms appear in both parts of the scrotum, you may be sure that there is a double hernia. We operate upon it in this manner. Having shaven the pubes and scrotum, unless the patient be a boy, we lay him in a supine posture upon a bench, and apply to his buttocks a cloth several times folded, and to the scrotum a sponge of considerable magnitude, and sitting at the left side of the patient, we give directions to an assistant sitting at his right side to draw the genital organs to the other side, and to draw up the skin of the scrotum to the abdomen. Then taking a scalpel we divide the scrotum longitudinally from its middle to near the pubes, making the incision straight and parallel to the raphe which divides the scrotum into two parts, and extending the incision down to the vaginalis. When the fluid is in the adnata, we make the incision where the apex of the tunica adnata makes its appearance, and separating the lips of the incision with a hook, and having dissected the darti with a knife for hydrocele and a scalpel, and laid bare the tunica vaginalis, we divide it through the middle with a lancet for bleeding, more especially in that part where it is separated from the testicle; and having discharged into some vessel the whole or most of the fluid, we cut away the vaginalis, especially its thinnest parts, with hooks. Afterwards, Antyllus uses sutures and the treatment for recent wounds; but the moderns have recourse to what is called the incarnative mode of treatment. If the testicle is found in a state of putrefaction, or otherwise diseased, the vessels which pass along with the cremaster are to be separately inclosed in a ligature, the cremaster cut, and the testicle removed. And when there are two hernias we may operate in the same manner twice, directing the incisions on both sides at the parts of the scrotum about the loins. After these things, having introduced the head of a probe through the incision below at the extremity of the scrotum, and elevating the scrotum upon it, we make an incision with a sharp-pointed scalpel in a convenient situation for the discharge of the coagulated blood and pus. By means then of the head of the probe we introduce an oblong pledget into the upper incision, and having sponged away the clotted blood, we introduce wool dipped in oil through the incision down to the testicle; and externally we may apply other pieces of wool dipped in wine and oil to the scrotum, hypogastrium, groins, perineum, and loins; and applying a compress three times folded upon them, and binding them with a six-legged bandage, and other proper bandages, we place the man in a reclining posture, putting wool under the scrotum for the sake of ease, and spreading the soft skin under him to receive the embrocations. We bathe with warm oil until the third day, after which having loosed the bandages we must use the ointment tetrapharmacon on a pledget, having changed the oblong one. Afterwards we may again apply the embrocations proper for inflammation until the seventh day, after which we have recourse to the medicine called motophylacion. After the ulcer has been cleaned and moderately incarnated, and the parts have been bathed, we must remove the oblong pledget, and have recourse to the subsequent treatment as formerly described. But if inflammation, hemorrhage, or any such disagreeable consequence come on, we must, in a word, treat each of these in a suitable manner, that I may not have occasion to make repetitions. But if we would rather have recourse to the cautery in cases of hydrocele (as is the practice of the moderns), we must follow all the directions given as to what is to be done before and after the operation, and also those given with regard to the operation itself, omitting only the incision with a scalpel, and the division for allowing the discharge of its contents. Wherefore having heated ten or twelve cauteries, shaped like the Greek letter Γ, and two sword-shaped ones, we must first burn the scrotum through the middle with the gamma-shaped, and having dissected away the membranes with a scalpel or blunt hook, we must burn with the sword-shaped as if cutting. Having laid bare the tunica vaginalis (which is easily recognized by its whiteness and density) with the extremity of a gamma-shaped cautery, we evacuate the fluid. Afterwards, when the whole is laid bare, we stretch it with hooks and remove it with a sword-shaped cautery.
Commentary. Celsus directs the surgeon, when water is contained in a hernial tumour, to make an incision in the groin, if the patient be a child, unless the largeness of the collection prevent; but in adults, and when the swelling is great, he recommends him to make it in the scrotum. Then if the incision be in the groin, the coats are to be drawn up there and the water discharged; but if in the scrotum, and if the disease be seated there, nothing more is to be done but to evacuate the fluid, and remove any membranes which may happen to contain it; after which the parts are to be washed with a solution of salt or soda. When the fluid is situated under the middle or inner coat (the tunica vaginalis and tunica albuginea?), all these tunics are to be removed without the scrotum and cut out. (vii, 21.) Celsus, as well as our author, describes the hæmatocele or bloody tumour, the existence of which is affirmed by Heister. (ii, 5, 123.)
Galen alludes incidentally to the evacuation of the fluid in hydrocele. (Meth. Med. xiv.) Sprengel and Guy de Cauliac affirm that he makes mention of the seton as a mode of cure; but if this assertion be correct we have not been able to find out the passage in which he does so.
Aëtius gives a very distinct account of the nature of hydrocele, but his description of the operation is by no means so accurate as our author’s. He trusts mostly to astringent and desiccative applications. (xiv, 22.)
Albucasis describes the operation in nearly the same terms as Paulus. His operation consisted of making an incision in the swelling and dissecting out the coats of the testicles. The dressings which he recommends are similar to those mentioned by our author. He also describes the operation by the cautery in nearly the same terms as Paulus. He adds, that if the patient be timid and do not choose to submit to these operations, the surgeon may let out the water either with a scalpel or the instrument used for tapping in dropsy. He states, however, that after this operation the water will collect again. (Chirurg. ii, 62.)
Avicenna briefly describes the operation of opening the tumour, and applying cauteries or strong medicines to the membranes. (iii, xxii, i, 6.)
Haly Abbas directs us to open the tumour, and cut out its tunics, and then to apply incarnative dressings. This treatment, he adds, the moderns prefer to the escharotic applications used by the ancients. (Pract. ix, 47.) He also describes the process of burning. (Pract. ix, 79.)
Rhases describes the operation of puncturing the scrotum for hydrocele. He also speaks of burning the part with a slender rod of iron, and of cutting out its tunics. (Cont. xxiv.)
The membrane called tunica adnata in our translation is the “ima tunica” of Celsus, and the “panniculus proprius” of the Arabian translation of Albucasis, and seems to be the same as the tunica albuginea of modern anatomists.
Sprengel gives an excellent history of the operation of hydrocele. (Hist. de la Méd. 18, 8.)