AN Hydrocele is so irksome a disease to the indigent and la­borious, furnishes even the easy and opulent with such disagreeable ideas and apprehensions, and is to all who are afflicted with it so troublesome and in­convenient, that every rational attempt toward relieving mankind from such an evil, will, I make no doubt, be favour­ably received.

It is now some years since I first began to make particular inquiry into the nature of this, and some other diseases of the testicle, and the usual methods of treat­ing [Page 2]them; an inquiry, which they ap­peared to me, for many reasons, both to deserve, and require. The result I com­municated to the public, under the title of, A "Treatise on the Hydrocele, or Watry Rupture, and other diseases of the testicle, its coats and vessels;" in which I endeavoured to be as precise, and as explicit as I could.

One part of this tract contains an exa­mination of the various means, which have at different times, either accidentally produced a radical cure, or have been professedly proposed, and practised for such purpose.

Among other means used to obtain this end, I mentioned the Seton; and spake of it as that, which for many reasons, appeared to me to be prefera­ble to all others; as a method which I [Page 3]had for some time practised with great success, and as that, which if nothing should occur to induce me to change my opinion, I should continue to make use of.

Since that time I have had frequent opportunities of repeating the experi­ment, and it has so constantly, and uni­formly answered my expectation, that my opinion concerning it is determined, and I am convinced, that it is the most successfully efficacious of any.

This might be urged, and would per­haps be admitted as a good reason for laying my thoughts on the subject again before the public; but I have others also to plead in vindication of the few following pages.

In the first place, I think that I have considerably and materially improved the operation and process; and have render­ed it less painful, and more certain.

In the second, I find, that what I said of it in the general treatise, has not been so clearly and perfectly understood as I could have wished; and in consequence either of brevity and obscurity on my part, or misintelligence on the part of some of my readers, my true meaning has not been received, and I have been subjected to the frequent interruption of troublesome correspondences on the sub­ject.

And, in the third place, I might add, that some few gentlemen of consequence, who have by this means been cured, have requested this publication.

A minute account of the nature and circumstances of the disease, would be a mere repetition of what I have already said at large in the book referred to; would be therefore unnecessary, and be­side my present purpose; a short and cursory one may perhaps throw just as much light on the subject, as may serve to render the description of the opera­tion, and the treatment after it, more easily intelligible.

The common bag in which both the testicles are included, is called the Scro­tum, and consists of epidermis, skin, and that loose cellular membrane, which is here called the Dartos; to which might perhaps be added, the expanded fibres of the cremaster muscle on each side. The proper coats of the testicle, are, the tunica albuginea, and the tunica va­ginalis. The former of these immedi­ately [Page 6]invests the vascular compages of the testis, and is that coat with which it is covered while within the cavity of the abdomen, before birth. The latter is form­ed on the outside of the said cavity, is a process of the peritoneum, and is placed ready for the reception of the testicle when it shall be thrust forth, thro' the groin, into the scrotum. Between the vascular structure of the testicle, and the tunica albuginea, there is no vacuity, but the external surface of the gland, is in every part firmly adherent to, and connected with the internal one of the investing coat; the tunica vaginalis forms a hollow cavity, or bag, which loosely, and unconnectedly envelopes the testicle, covered by its albuginea.

When I say loosely and unconnected­ly, I would wish to be understood aright. I do not mean that the testicle hangs [Page 7]in the middle of the tunica vaginalis, (like a clapper within a bell) and has no connection with it; I mean, that all the superior, anterior, and lateral parts of the tunica vaginalis are loose from, and un­connected with the testicle, which is at the same time firmly united to its poste­rior part, in such manner, that if the cavity of the tunica vaginalis was to be distended with wind, such wind would occupy, or fill all the loose, and uncon­nected part, and produce a tumefaction not unlike to a hydrocele, while the te­sticle would be found firmly and im­moveably attached to the hinder part of the said cavity so distended.

To prevent the accretion of these coats in those parts where they ought to be unconnected, and perhaps for some other purposes, the cavity of the tunica vagi­nalis is furnished with a fine lymph [Page 8]constantly exsuding into it; which lymph is as constantly absorbed by proper vessels; so that, in a healthy and natural state, there never is any more of this fluid, within the bag, at a time, than may just serve (beside what other purpose it may be intended for) to keep the two mem­branes from coming into immediate dry contact, and cohesion with each other. This small quantity is sufficient to pre­serve the proper and natural cavity of the tunic, but never occasions any de­gree of intumescence, or any unnatural or diseased appearance of the part.

A deficiency, or total failure of the secretion of this fluid, will be followed by a partial, or total coalescence of the two coats, with each other; and conse­quently a total or partial abolition of the cavity, a super-abundance, or a se­cretion of more than the absorbent vessels [Page]

[Page 9]can take up, must, on the other hand, inlarge and distend, the said cavity, by carrying all the loose unconnected part of the bag farther and farther from the testicle, in proportion to the quantity ac­cumulated. The former, I do know to be sometimes, and I verily believe most frequently is, the consequence of a severe hernia humoralis, as well as of other in­flammations of the testicle. The latter among other diseases produces the hy­drocele or watry rupture.

This being the case, that is, the in­tumescence of the scrotal bag, being caused by the gradual accumulation of a fluid, which ought to have been absorbed, it is almost always produced gradually; and therefore has, in most instances, made some progress before it is taken notice of; especially by careless and in­attentive people. For the same reason [Page 10]it will be found, that as it depends upon the circumstances of secretion and ab­sorption, it will in different people, make quicker or slower progress, according as the deposition shall happen to be quicker or slower, and the absorbent faculty, only more or less impaired, or totally obstructed. As this disease is confined to the cavity of the tunica vaginalis testis, and as this bag has no commu­nication with the cavity of the belly, the tumefaction can never be lessened by any attempt toward reducing or re­turning it into the abdomen. For the same reason, it never is, nor can be liable to any alteration of size, or temporary distention from the efforts, or actions of coughing, sneezing, expulsion of foeces, &c. For the same reason, (I mean the confinement of the fluid within the ca­vity of the tunica vaginalis) the intu­mescence, when early attended to, will [Page 11]always be found in the lower part, and does not rise above the upper-part of the testicle, until the disease has made some progress, and the quantity is be­come considerable; therefore the sper­matic process, will always, in the early stage of this distemper, be capable of be­ing felt perfectly and distinctly; altho' when the tumour has arrived to any con­siderable degree of size, the fluid does so conceal the testicle, as to render it not a very easy matter to find it. The three last circumstances, well attended to, will always serve to distinguish the hydro­cele from the intestinal hernia or com­mon rupture, at least in the beginning. To these might be added, several other characteristical marks of this distemper; such as, that being neither accompanied by, nor occasioning any inflammation, or irritation, it never gives pain, unless it be very rudely handled, or be permit­ted [Page 12]to attain such size as to be trouble­some from its weight, or to be subject to excoriation from its magnitude; which may serve to distinguish it from the her­nia humoralis, an inflammatory, and often a very painful disorder. That if the fluid be thin and limpid, and the vaginal coat and membranes of the scro­tum not thick, the tumour is often in some degree transparent; that is, the light of a candle or lamp may be seen through it. That constipation of belly does not render it at all more tense, or produce any uneasiness in it while it lasts; neither does the removal of such obstruction or constipation at all lessen its volume, or make any alteration in it either to the eye, or to the finger. To all which ought always to be added, the fluctuation of the fluid.

The size and figure of the tumour caused by this disease are liable to con­siderable variety, dependant upon the quantity and consistence of the fluid accumulated, the time such accumula­tion may have taken up, the thickness, or thinness of the vaginal bag, and mem­branes of the scrotum, and the equal or unequal manner in which these parts may have given way to the distention. Hence the tumour will be larger or smaller, round, flattish, pyriform, or globular; will be firm, tense, and resi­stent, or lax, soft and easily compressible; smooth and regular in its surface, mak­ing one uniform figure, or divided by a kind of depression or stricture, which will make it appear as if the water was in two distinct sacculi or bags; it will also be more or less tense, as well as regular in its surface, as the contractile power [Page 14]of the scrotum, by means of the cre­master muscles, shall be more or less.

The qualities of consistence and co­lour in the contained fluid is also various: it is thin, aqueous, roapy, viscid, lim­pid, citrine, greenish, brown, bloody, clear, or turbid; from each of which some small differences in the aspect, feel, weight, transparency or obscurity of the tumour will arise; but are of no con­sequence with regard to any method of treatment, palliative, or radical.

The methods of cure of a hydrocele are said to be two, one called the Pal­liative, the other the Radical; the lat­ter of which alone deserves the name of cure.

The former consists merely in letting out the water occasionally, and is so simple and so trifling an operation, that I shall say nothing more of it, than that I think a small trochar a much preferable instrument for this purpose on all accounts to the lancet, or any other.

The radical cures, as they are called, may be collected from the writings of several of our predecessors. The general means they made use of were cautery, caustic, ligature, and tent. For the particulars relative to each of these, I must beg leave to refer my reader to the writers themselves, a minute detail of them not being consistent with the plan of these few sheets. But without entering into such disquisition, I believe I may venture to say, that whoever will give himself this trouble, will find, that [Page 16]all the means which were either pro­fessedly used to obtain a radical cure, or which ultimately and accidentally pro­duced such event, were put in practice for three general reasons, or under the influence of three general opinions; the first of which was, that the fluid found in the sac of a hydrocele was always originally formed in the cavity of the belly, and descended from thence into the scrotum; the second, that it was a disease of the habit, as well as of the particular part; that is, that it was gene­ral, as well as local; the third, that the collection of liquor found in it, was either the necessary cause, or the con­sequence, of a diseased state of the testis.

From these flow the applications of cautery, and caustics to the groin, and of ligatures on the spermatic process. [Page 17]From these are derived all the cautions to undertake the cure guardedly, to conduct it slowly, and to attend rigidly to the pa­tient's general state by cathartics, altera­tives, specifics, issues, &c. &c. &c. and to these we owe the experiments made to induce suppuration from the parts affected.

Not being acquainted with the anato­mical structure and disposition of the parts concerned in the disease, they had very terrible as well as very erroneous no­tions concerning it. They supposed that the fluid contained in the cyst was thrown off from the habit as a kind of crisis; that the general constitution of the patient was by such deposition much relieved; that it prevented many other, and those worse disorders; and, either that a morbid state of the testicle and epidydimis concurred in producing the fluid, or that the same parts necessarily became diseased from ly­ing in it. They therefore concluded, [Page 18]that although a radical or perfect cure might be obtained by certain means, or that certain means having been found now and then to have produced such event, they might with probability be expected to answer such purpose, yet the attempt ought never to be made without a strict attention to the general evils which might ensue, as well as to the particular ones proceeding from the supposed morbid state of the parts.

Inquiry and experiment have taught us better, have given us truer notions of the nature of the complaint, have induced us totally to lay aside many of the means used by our fore-fathers, and although we do still in some sort continue some of them, yet it is upon different principles, and with very different views.

The noxious quality of the fluid, the diseased state of the parts whence it pro­ceeds, or wherein it is deposited, the cri­tical, or depuratory nature of the deposi­tion, the necessity of drawing off the wa­ter partially and at short intervals, and the fear of curing it locally lest the general habit should suffer, are all now known to be groundless apprehensions; and it being also known that the collection of fluid is originally made in the tunica vaginalis only, and that it does not descend from the belly, all attempts toward preventing such descent are become equally absurd.

The testicle, although frequently some­what inlarged in its dimensions and re­laxed in its texture, is known to be sound, to be otherwise unaffected, and unaltered, and to be fit for, and capable of perform­ing the functions it was designed to exe­cute; the fluid is acknowledged to be in­noxious [Page 20]in its nature, neither proceeding from parts in a diseased state, nor causing any disease in the parts in which it is de­posited, and with which it is in contact; but being accumulated in consequence of constant secretion, and deficient, or non­executed absorption, the intention of every rational practitioner, when he aims at a radical cure, is, to abolish the cavity of the tunica vaginalis, and thereby to pre­vent any future collection.

Whatever means can accomplish this end with the least fatigue, pain, or hazard, are certainly the best.

Of the incision I shall in this place say nothing, except that it lies under so many restraints from a variety of circumstances, is so improper for the majority of per­sons afflicted with the disease, and requires such nice attention and such judicious ma­nagement, that it never can be recom­mended as fit for general practice.

The caustic, upon the rational principle of which I am now speaking, viz. that of abolishing the cavity of the tunica va­ginalis, has been practised by many, and that with such success as to induce some to think it the best and most eligible me­thod: Among these is Mr. Else, who has lately published his opinion on the subject.

The introduction of suppurative medi­cines by means of a tent, was practised by some of even our remote predecessors, and as they tell us with success, even in complicated cases; that is, in cases where a diseased state of the testicle has been ad­ded to the hydrocele: But whoever will attentively consider their accounts of this matter will see, that this method, what­ever might be its accidental consequence, was not intended for the purpose which I am now speaking of.

Perhaps there is no part of surgery which was less understood by our ances­tors, or concerning which they expressed themselves with so little precision as the subject of diseases of the testicle: they have multiplied and confounded them in such manner, and speak of them in such a jargon of unintelligible terms, that it is next to impossible to understand often what they really mean.

For a particular elucidation of this subject the chirurgic world are much ob­liged to the late Professor Monro of Edin­burgh, and Mr. Samuel Sharp, late of Guy's Hospital, now of Bath.

The accounts which many of the best among the writers in surgery, even quite into our own time, have given of the dis­eases of these parts under the terms sarco­cele, fungus attached to the spermatic vessels, fungus arising from the testis, hy­drocele [Page 23]and hydro-sarcocele, are error itself; and the operations which they describe and recommend are many of them coarse, and either impracticable, or very unfit for practice. But however from these ac­counts, strange and irrational as they are, we may collect that they conceived the dis­eases which they call the hydro-sarcocele, and the caro adnata ad vasa spermatica, to be (in contradistinction from the sarco­cele and the fungus springing from the testicle,) curable diseases, the one by extir­pation of the fungus, the other by sup­puration.

No precise definition of what they have thought proper to call the hydro-sarcocele has been given by them, and therefore we have no better method of forming a judg­ment concerning it, than by considering the event and success of their method of treating what they have so called, with what we know concerning the structure [Page 24]of the testicle, its disorders, the means which we now find to be successful in them, and the disappointments, and dis­agreeable circumstances which sometimes occur in them.

Frabritius ab Aquapendente has been particular on what he calls the hydro­sarcocele, and has given an account of his method of curing it; but whoever is ac­quainted with diseases of the testicle, and will compare with such knowledge what Fabritius has said concerning his method and its success^*, will, I am inclined to be­lieve, think on this subject as I do, which is, that the disease which he gives this hard complex name to, is nothing more than a [Page 25]true, simple hydrocele, in which the testis is somewhat inlarged beyond its natural size, and perhaps somewhat relaxed in its texture, in consequence of such enlarge­ment; but still sound, and free from dis­ease, still fit for, and capable of executing its office.

That by his method he obtained a radi­cal cure I make no doubt; his 'turunda digestivo, et pus movente medicamento imbuta,' would most probably occasion a sloughing of the tunica vaginalis, and con­sequently an abolition of the bag or ca­vity; but whoever knows any thing of these matters must know, that a testicle really and truly diseased, would not bear such treatment; and therefore that his success was owing to the state of the testi­cle not being what he supposed it to be, and what the term he makes use of im­plies.

The method of Fabritius was within a few years past adopted and practised by Ruysch.^*

The means and conduct were nearly the same, and I have no doubt that the success was equal. But the same objection still remained; which was, that not only a suppuration was brought on, but the whole tunica vaginalis was so irritated and inflamed, that it necessarily became sloughy, and was entirely destroyed. An objection which had been made to the method by caustic, and which I must ac­knowledge, [Page 27]is, in my opinion, an objec­tion to it still.

The late professor Monro, whose ob­servations on the diseases of the testicle are very pertinent and very ingenious, seemed to think that it was by no means impracticable, by means of a slight degree of irritation, to excite such an inflam­mation both in the tunica vaginalis and al­buginea, as might occasion a coalescence of them with each other, and thereby answer the end of abolishing the cavity without destroying any part of either tunic.

I made the experiment proposed by him, and found it sometimes successful, ne­ver hazardous, or prejudicial, but by no means certainly efficacious, or to be de­pended upon. The cannula by its hard­ness and resistance was a very unpleasant guest within the vaginal coat, and from [Page 28]its inflexibility, upon any unguarded mo­tion of the patient, injured the testicle and gave very acute pain; and the tent and bougie, which I occasionally substituted in its place, although they did not give so much pain, were liable to a considerable degree of uncertainty.

Uncertainty and hazard are certainly very different things, and the latter much preferable to the former: not to have injured a man by an experiment, affords some degree of consolation under a disap­pointment, but yet when it is considered, that an operation and process of this kind is submitted to from choice and not from necessity, if it fails of success, although no real harm be done either to the part, or to the constitution of the patient, both the loss of time and the confinement will become doubly irksome, as they will be found not only not to have answered the end proposed, but not to have brought [Page 29]the patient at all nearer to a cure than he was before the attempts. The reflexion is unpleasant to both parties.

Being, from the effects both of the ca­nula and tent, satisfied that there was no kind of hazard in the introduction of a fo­reign body into the cavity of the tunica vaginalis, nor from its remaining there; and having many opportunities of meeting with this disease in St. Bartholomew's, I de­termined to try what a seton would do to­ward raising such a degree of inflamma­tion as might occasion a coalition of the two membranes, and effect the purpose proposed by Professor Monro^*. The suc­cess fully answered my expectation.

In my general treatise on the diseases of the testicle, I mentioned and recom­mended it, but as I could not be certain what a greater length of time might produce to make me change my opinion, I mentioned it with some degree of cau­tion.

Since that time I have embraced every opportunity, both in the hospital and out, of practising it, and that under [Page 31]some improvements; and as I can now speak positively to its success, I thought it right to give it to the publick, who are always intituled to every benefit ari­sing from the labours of every man whom they have honoured with any degree of confidence, and this as well on a principle of humanity as of gratitude.

What I have said of it in the general treatise is in the following words, p. 176.

This method was, as I said in, general very successful; but repeated trials fur­nished me with objections to some parts of it, and induced me to think that such parts might be amended.

I found that cutting upon the end of the probe was troublesome, both from its smalness and from its flexibility, and also that it was sometimes difficult to keep it steady, for the same reasons, and that it always required the assistance of ano­ther person's hand besides that of the operator: a circumstance one would al­ways wish to avoid when possible. I found also sometimes that the seton of candle-wick cotton did not pass so easily as I could wish, and by rubbing the tunica albuginea too rudely gave more pain than I liked. The seton as made of cotton [Page 36]adhered in some instances too long and too firmly. From the intimate connec­tion of the parts of the wet cotton with each other, it could never be brought away but entire, which in some cases oc­casioned an unnecessary waste of time. And, what was still worse, in two in­stances it adhered so firmly, that I was obliged to make a small incision to get it away at all.

All these inconveniences and objections I have now obviated and removed.

The instruments I now make use of are in the annexed plate, and are,

A trochar, the diameter of whose can­nula is very nearly, but not quite, one fourth of an inch. Another cannula, which I call the seton-cannula, which is made of silver, and is of such diameter [Page]

[Page 37]as just easily to pass through the cannula of the trochar, its length five inches, and a probe of six inches one-half long, hav­ing at one extremity a fine steel trochar point, and at the other an eye which car­ries the seton; which seton consists of just so much strong, coarse, white, sewing silk as will without difficulty pass through the latter cannula, but at the same time will fill it.

With the trochar the inferior and an­terior part of the tumor is to be pierced, as in common palliative tapping: as soon as the water is discharged, and the perfo­rator withdrawn, the seton-cannula is to be passed through that of the tro­char, until it reaches the upper part of the tunica vaginalis, and is to be felt in the very upper part of the scrotum. This done, the probe armed with its seton is to be conveyed through the latter can­nula, the vaginal coat and integuments [Page 38]to be pierced by its point, and the seton to be drawn through the cannula, until a sufficient quantity is brought out by the upper orifice. The two cannulae are then to be withdrawn, and the operation is finished. It is executed in two or three seconds of time, and with little more pain than is felt in common tap­ping.

By this method, every advantage which attended the former operation is obtained, and every inconvenience which it was lia­ble to, is obviated and provided against.

The seton-cannula by its firmness bears tight against the place where the seton should be brought out, the trochar-point of the probe is kept from deviating by its confinement, and its point pierces through the skin immediately, and ex­actly in the place intended, while the se­ton by passing through the cannula is [Page 39]prevented from rubbing rudely over the testicle.

As soon as the operation is finished I put the patient into bed, and immedi­ately give him twenty or twenty-five drops of tinctura thebaica, which I re­peat or not, pro ne nata.

About the third day the testicle and scrotum begin to inflame and swell, and to put on the appearance of a hernia hu­moralis, or the swelled testicle which now and then attends a clap; and re­quires the same and no other kind of treatment; that is, fomentation, poultice, a suspensory bag, a cool temperate regi­men, and an open belly.

By these means the inflammation is soon and easily appeased. As soon as this end is accomplished, I permit the patient to get out of bed and lie on a couch, or [Page 40]sit in a great chair with his legs up, and I generally give the cortex in some form or other twice or thrice a day.

The soreness and tumefaction now di­minish apace, and as soon as the parts are quite easy, which is generally about the tenth or twelfth day, I begin to withdraw the seton, taking out, four, five, six, or seven threads of it at each dressing, which dressing consists of nothing more than a superficial pledget upon each of the ori­fices while they continue open, and a discutient cerate (such as the ceratum saturnin.) to cover the scrotum.

The discharge of matter from the ori­fices, is small and trifling, no more than might be expected; the tunica vaginalis does not become sloughy, but is preserv­ed intire, and the cure is accomplished, merely by the coalescence or cohesion of the tunica vaginalis, with the tunica al­buginea. [Page 41]An event, which from what has fallen within my observation, I am inclined to believe, is most frequently the consequence of a severe hernia humoralis.

In this circumstance, viz. the accom­plishment of the cure, by adhesion of the two coats together, without any de­struction of parts, consists the material difference between the method of cure by seton, and that by caustic.

All the practitioners who make use of the latter, allow that it produces a slough of the whole tunica vaginalis, that it de­stroys the whole bag or cyst, and that it is used with intention so to do.

In the cure by seton no slough is pro­duced, (at least I have never seen one) nor is the vaginal coat destroyed in any part of it, a firm cohesion is made be­tween the two membranes occasioned by [Page 42]the inflammation, and the cure is effected solely thereby.

I shall always most gladly embrace any opportunity to improve so noble and so really useful an art as surgery, but at the same time, should be very sorry to have it supposed that any partiality to my own opinion would make me misrepre­sent, or deviate from truth.

I have practised this method of obtain­ing a radical cure on a very large number of subjects, of all ages, from six years old, to sixty and upwards, in some sub­jects on both sides, and I have never seen any bad symptoms or any degree of hazard from it, nor have I once, since the pre­sent improvement, seen it fail of perfect SUCCESS.