HYDROCELE.
Strictly speaking the term hydrocele means accumulation of watery fluid in any pre-existing cavity. By universal consent, unless some other cavity be specified, the tunica vaginalis is understood. The consequence is a more or less distended sac of serous fluid, which first occupies a position in front, but finally is spread around the lateral portion of the testicle, and may form a tumor the size even of the individual’s head. It is an innocent collection of serum, but the walls of such a sac will be thickened in proportion to its age and size, and may in the course of time undergo such degenerations as the calcareous, for instance, by which it becomes more or less infiltrated or encrusted with calcareous material. Thus I have in my possession a tumor of this kind, nearly the size and almost as hard as an ostrich egg, the old tunic being converted practically into a shell.
Acute hydrocele occurs, as above mentioned, in connection with the acute infections, but is then ordinarily a matter of but a few days or weeks.
Hydrocele, as usually implied by the term, is an exceedingly chronic and almost painless affection, which may follow injury, but which comes often without any known cause. Many theories have been advanced to account for it, but none are generally satisfactory. These cases, however, occur usually after the fortieth year of life, but may be seen in the young. Their greatest unpleasantness is that produced by the weight of the mass as it drags upon the cord and the scrotum.
The tumor is pear-shaped, and abruptly circumscribed at its upper limit, below the external ring (unless there be also involvement of the cord), and gives no impulse when the individual coughs. By these features it is distinguished from hernia, for which it is often inexcusably mistaken. A hernia is a distinct prolongation from above, whereas a hydrocele terminates below the hernial outlet, and by its smaller extremity. The distended sac will fluctuate, and will return clear fluid upon puncture with a hypodermic needle, and is so translucent that light may be transmitted through it when it is interposed between a candle-flame and the surgeon’s eye. (Serious thickening of the sac may interfere with the value of this test.) A congenital form of hydrocele is also known, due to failure of obliteration of the canal of Nuck, and it might be possible in some such cases to get a slight impulse on coughing, as when the sac connects with the abdominal cavity, in which case it should be possible to gently press its contained fluid back into the abdomen above. In most congenital cases there is a tendency to spontaneous cure, at least to obliteration of the canal.
Occasionally both sides are involved, or the sacculation may be multilocular, or accompanied by cystic extensions along the cord.
Treatment.
—In regard to methods of treatment, but two will be considered here, aspiration with injection of carbolic acid, and extirpation. The former consists in the insertion of an ordinary (small) trocar, which is thrust in from below upward, care being taken that its point avoid the testicle, which is always found to the posterior and inner side of the sac. Through this trocar the contained fluid should be completely evacuated, so that the sac is practically dry. Into it is now injected with some force from 2 to 6 Cc. of absolutely pure carbolic acid, after which the trocar is instantly withdrawn, pressure made upon the opening, and massage made upon the scrotum and the contained testicle, in order to distribute the acid freely over the serous surface. Its effect is to completely sear the entire surface so that the mouths of all the absorbents are closed. In this way danger of carbolic poisoning is quite avoided, a danger which would be imminent were the acid reduced in strength. But little pain is caused by the procedure. Its immediate effect is to produce exudate, with some recurrence of swelling, which ordinarily rapidly absorbs, while the exudate, coagulating, serves to produce obliteration of the cavity of the sac. This is the carbolic method of Levis, who introduced the acid as a substitute for the iodine formerly employed, upon which it was a great improvement. For cases of moderate age, whose sacs are not too thick, it often proves satisfactory. Having failed, or the case being considered not adapted to it, the other method is that by open incision and extirpation.
This open method consists in making an incision through the skin, down upon and into the sac, which, being thus instantly evacuated, will collapse. It is now possible to make a more or less complete enucleation of the sac wall, stripping it from the external tissues to which it adheres, as it is not necessary to separate it from the testicle itself. It has been found that when the major portion is thus removed the condition is effectually combated. The cavity may be drained with silkworm strands or with a small tube, but only for a short time, if the technique have been correct.