THE OPERATIVE TREATMENT OF

HYDROCELE.

/ By L. M. BANBRJI,

Asst.-Surgeon,

General Hospital, Howrah.

I have been following with interest the observations of your numerous correspondents with reference to

radical cure of hydrocele by the operative method. This has led me to describe my experience in about 250 cases operated on in the Medical College Hospital, while I was House-Surgeon there. The first case I saw operated on was by the old

excision method in which the excised margin of the sac was sutured to the skin incision and the whole left to

granulate up. I saw several cases done similarly and

found that they took a considerable time for the opera- tion itself, while in every case the patient was not

discharged till after three weeks. The attendant bleed-

ing after excision, and the time it took for suturing were serious drawbacks, not to mention the time that the

patient had to lay up for recovery. No doubt, these facts led Col. Pratf to devise the

simpler method of evagination of the sac and closure of the wound without any drainage. I cannot explain how this operation is described in the International Text-book of Surgery as the

" So-called Doyns's method." I notice that one of your correspondents has made a

similar remark in the August issue. The next method I saw was excision of the sac with

closure of the skin wound, leaving a small drain for 48 hours, after which the drain was removed and the wound left to heal up. This method shortened consider-

ably the stay in hospital for the patient, but the time it took do check the bleeding of the excised portion of the sac was about the same as in the lirst method. Besides it necessitated a change of dressings after 48 hours for removal of the drainage.

Lastly, the well-known Pratt's method was followed and it gave the very best results.

In the excision methods in which the wound was closed, there have been cases described in which recur-

rence had taken place, a very serious drawback amount- ing to its being a no better operation than the primitive tapping and injection method. But my personal experi- ence in this method of operation is almost nil, and I have never had any opportunities to watch its result afterwards.

During the time I was House Surgeon in the hospital, the evagination method was invariably followed. At first the incisions were always lateral and extending for the whole length of the hydrocele. In double ones there were made two lateral incisions, one for each side and were closod separately. The whole tumour was sepa- rated out from the wound, the sac opened, emptied and turned inside out and fixed in that position with a fine catgut stitch. The sac was never scraped unless it was extremely thick and had deposits on it. The whole wound -was wiped dry, the testicle reduced and the

skin incision closed with interrupted silkworm gut suture. The wound was covered with a piece of sterilized boric lint and dressed with sterilized per- chloride gauze with a firm double spica bandage of the perineum?" the bathing drawers bandage "?as it was termed by the late Major Moir. Such an operation for a single hydrocele, if done with regard to the time it

took, would be finished in 7 minutes, from the start to

finish, not including the time it took to get the patient under an anaesthetic. The dressings were never changed till the seventh day

when the wound was wiped clean with a little spirit lotion (Lotio Hydrag Bin. Tod. 1 in 500 of rect. spirit) and the stitches removed The wound was then sealed with a little cotton wool and iodoform varnish and the

patient told to stay in bed for another 24 hours, after which he was discharged from hospital. Almost all the cases with a very few rare exceptions ran this course, and every patie- t thus treated could get about and do his work on the 10th day if he wished too. The time for a double hydrocele operation would

necessarily be a little longer, but the period for recovery would be the same.

These are the cases with moderate sized hydroceles in which the sacs were fairly thin and smooth. In larger ones partial excisions of the sac, by pulling it off its sub- cutaneous tissues and then excising it, was resorted to, and this method generally gave some trouble on account of the attendant bleeding. In very big ones partial excision of the scrotum was performed, and it accounted to almost an operation for elephantiasis of scrotum. The first point to strike me was the question if we could not do away with the catgut stitch to retain the sac in its evaginated position, for to do away with the stitch was to save so much time as well as to do

away with the necessity of leaving a foreign body, how- ever aseptic and easily absorbable it might be, in the wound. It was then found that if we made the opening in the sac at the topmost part and just large enough to turn the testicle inside out, the sac when completely evaginated did not need a stitch to keep it so. This answered very satisfactorily and was always followed with the result that we never used ligatures, catgut or si'k in a hydrocele operation unless absolutely neces-

sary as in cases of persistent bleeding. Major Moir had always impressed on me the neces-

sity of watching the after-effects of all the operations as far as feasible in order that the defects in them may be

brought out and remedied in future ones, and I always requested my patients, when leaving the hospital, to

come and show themselves from time to time. Thus I had many opportunities to watch these cases even after a year had passed after the operation. And as I was

very much interested in the results of hydrocele opera- tion, I was constantly on the look out for such patient. The first patient that brought the question of skin in-

cisions in hydrocele to my notice, was a young Marwari who had been operated on nine months previously and who came to me complaining of thickening of the scro-

tum. He had been operated on for double hydrocele with two lateral incisions and evaginated sacs. He was

quite well for about nix months, after which he noticed that the scars became slightly inflamed and thickened and the thickening tended to invade the surrounding skin. The inflammation passed off in a few days but the

swellings remained and what is more was steadily growing. I promptly shewed the case to Major Moir and had him admitted into hospital again. I looked

up his old history sheet and found the particulars of his

operation mentioned before. He was operated on in a few days for complete excision of the scrotum and was

discharged in due course. I did not see him any more,

though I remained in the hospital for about l? years after his discharge. Sometime after I came across two other similar cases

which had similar operations done in them afew months previously, and who started thickening of the scrotum

Nov., 1907.] THE OPERATIVE TREATMENT OF HYDROCELE. 415

in a similar manner. Both cases were operated on for excision of the scrotum and went out cured.

In all these three cases both the testicles with their

sacs were firmly adherent to the subcutaneous tissues

of the scrotum and the sacs had atrophied up to mere membraneous fasciae, shewing the absolute efficacy of the evagination method of operation. But the thickening of the scrotum was a serious draw-

back as a result of the operation. The lateral incisions

had divided the lymphatic vessels of the scrotum and thus interfered with lymphatic circulation, resulting into a spurious form of elephantiasis.

This led Major Moir to follow the mesial incision

along the raphe where the vessels will be least inter-

fered with, and this method removed as well the neces-

sity of making two incisions in cases of double hydrocele, and thus saving more time and rendering the operation much quicker. This method answered very well for

sometime, especially in cases of double hydrocele. The scar would scarcely show after a little time and there would be less chance of interfering with the

lymple circulation. After a few months, a patient, a medical man, came

back to shew that he had adherence of the two testes

as a result of the operation. No doubt, the mesial incision had opened up the septum and had thus

brought the low surfaces of the two testes together which had formed adhesions between them. To remedy this, in all cases in future the septum was

brought over the skin incisions and fixed there by means of the same sutures, which closed up the skin. This method effectually prevented any adhesions be- tween the testes, as I had opportunity to examine several cases, after some months had elapsed since their operation. To sum up these, the method that was followed in

my wards in cases of double hydrocele was?a mesial scrotal incision along the raphe, the length of the inci- sion depending on the size of hydrocele ; separating one testicle from its surrounding tissues including the division of the ligamentum testis (this is important as without it the scrotum would have a tucked in appear- ance) ; opening up the sac at the highest part with an incision just large enough to let the testicle out; evaginating the sac and dropping the testicle back into its place: treatment of the other side similarly; then closing up the wound with the septum drawn up in between the skin incisions, ihe whole of this should not take more than 8 or 10 minutes. As to the after-result of the operation, there is very little chloro- form sickness (but this depended 011 the idiosyncrasy of individuals) owing to the patient having taken very little chloroform, very little pain, or other constitu- tional symptoms, retention (reflex) of urine in rare

cases, no change of dressings till the 7th day when the

stitches were removed Very little swelling not more than one would expect from the size of the sac, and the position of the scar which was scarcely recognizable in a month or two, and which interfered very little with the lymphatic circulation of the scrotum. The quickness of the operation is a very great advan-

tage, two skin incisions would take very much longer in sewing up.

I remember Major Moir doing this operation in three cases, two double and one single, in 20 minutes, while he was operating on one, the next was being anaesthe- tized, so that no time was lost. Major Moir was always fond of interrupted silkworm sutures which took more time in tying than the continuous suture, otherwise the time could be made even less.

Of other incisions, I have seen Major O'Kinealy doing the operation by theinguinial incision. He called me in several times to watch his operations and keep time for him. The quickest he did was a double hydrocele with two inguinal incisions for the two testes and it took him eleven minutes. He had not finished his experi- ments and observations when I left the College Hospital. In the last issue of the I. M. (?., Dr. Corrie Hudson

mentions such an incision. The greatest advantage in this incision is its situation away from the dependant parts when it could be contaminated. But it has the dis- advantage of having to do two separate operations at the same time for a double hydrocele, besides leaving inguinal scars which may be mistaken for venereal buboes later.

Of the infection of the wound and change of dressings, I may mention here that if for the first 3 days the dressings are kept dry and clean by the patient, there need be no occasion to apprehend any mischief. For the first few cases I used to change the dressings as soon as I found out that the patient had soiled them, later I found out that the dressings, if superficially soiled after the 3rd day, may be left with impunity and without any apprehension, though I do not advise this as a routine method.

In one of my cases, a medical student belonging to the Military Pupil Class, the patient was up and about on the second day. He would not stay in bed a moment during the day, after our rounds were finished ; but he kept his dressing in place and perfectly clean. His stitches were removed on the 6th day, on which day he went back to his quarters and joined his duties. He was under my observation for over 18 months and the result of the operation was very satisfactory. Of the three cases I mentioned as having come back

after a few months with thickened scrotum as a result of double lateral incisions, they were operated on soon after their admission, and the subcutaneous tissues presented characters of elephantiasis?cedematous blubbery mass starting from the incision scars and extending to the surrounding parts. All the three cases had been done by Pratt's method ; and in all the three cases the results were very satisfactory as far as the hydrocele was concerned. The whole surface of the sac was uniformly adherent to the surrounding subcuta- neous tissues, and what was more had shrivelled up into a thin membrane what was once a thickened sac. Another case, I remember, was one that came to have

the other side operated on after about two years. The natient could not name the operator who had done the first operation, and so I could not procure the records. The first operation had been a lateral incision and most nrobibly an evaginatiou method as far as could be iud?ed when exposed during the second operation by the^mesial incision. This case too was perfectly satis- factory and the testicle was almost, normal in size.

I come now to a series of five cases out of the total in which partial excision of the scrotum had been done with partial excision of the sac, the sacs having been large and very thick. The first of these, a school master complained of soaked dressings behind on the 9nd day. I opened up the dressings and found the flaps of the scrotum very much swollen and distended with a point of oozing from the incision. I promptly cut open all the stitches, turned all the clot out, found a

bleeding point in one of the testes, which had been excised of the sac and tied it. The rest of the wound I scrubbed gently with a coarse perchloride gauze, washed tho whole wound clean, dried it and closed it as before ? the wound healed by first intention. Major Moir gave me directions afterwards to treat all cases of haemorrhage similarly, which he thought was much better than chancing the prospect of a suppuration. The rest of the cases I did similarly and all healed by

first intention. Two of these cases did not shew any soaking from the dressings outside, but complained of intense tension in the wound, and knowing that there was not much tension at the time of closure, I suspected haemorrhage and proceeded as described. These five cases will shew the disadvantages of the excision method.

I would like to hear other operators experimenting on the mesial incision with the fixation of the septum afterwards and then giving their opinion of it in com- parison to the other skin incision, particularly watching the after result.