In the presence of a tense, hard, irreducible tumor, which the history has shown to have existed for a long time without impairing the general condition of health, a diagnosis of hydrocele should be made. The only real difficulty might occur in a female child, where such a tumor might either be a hydrocele or a prolapsed ovary, but the painfulness of the latter on pressure will facilitate the diagnosis.
I am unable to approve of test punctures of the tumor. At least they impair diagnostic precision which can be attained by the aid of all the existing symptoms. It will not be difficult to recognize complica tions by hernia, if all symptoms are carefully sought for and considered.
Prognosis.—The course is characterized, as in other cysts, by slow but steady growth. In young children, especially where there is a com munication with the peritoneal cavity, the communicating passages may undergo spontaneous obliteration. This may also occur if, in the pres ence of phimosis, constipation, etc., the abdominal pressure is reduced by removing the causative factors.
Treatment.—Inunction with iodine ointment has been recommended for the purpose of accelerating absorption, but I have never been con vinced of its practical utility. The simplest remedy is puncture, which is carried out in the following manner: The tumor having been disinfected, it is punctured at the dome and the fluid evacuated. Care should be taken to avoid the testis and epididymis.
We have discarded injections of tincture of iodine, alcohol, adrenalin, etc., because they frequently lead to severe exudations, causing unneces sary complications.
In all manipulations of the scrotum of the newborn, it should be remembered that the skin is very tender and not well nourished. In a case where kelene (ethyl chloride) was applied to the skin, I saw cutaneous gangrene occur over the entire area where the anxsthetic was employed.
The usual treatment instituted in our clinic is as follows: Small hydroceles of the testes in nurslings are left untreated; factors causing increased abdominal pressure, such as difficult micturition and phimosis, are removed.
Larger hydroceles which are closed off from the peritoneal cavity are punctured without making any subsequent injections. If there is a relapse after two punctures have been made, the radical operation is resorted to. In communicating hernia the processus vaginalis is imme diately closed. (See operation for Hernia.) The radical operation for hydrocele consists in the extirpation of the tumor, the necessary precautions being observed as described for hernial operations.
Incision into the scrotum should be avoided, owing to the danger of infection. The incision should be made as high as possible, because the
tumor can be removed through a high incision by the manipulation described in hernial operations. Besides, such an incision can also be used for the closure of an open inguinal canal or for the radical operation of an accompanying hernia.
The preferable method is enucleation of the tumor as a whole, if such be possible. Attention should be paid to the pellicle, which should be ligated if, as is often the case, it is adherent to the inguinal canal. Should the tumor burst during the manipulation, it will often be difficult to dissect the tender scrosa from the other structures, and in that case Winkelmann's operation is indicated. The hydrocele sac is incised, avoiding all visible vessels, and everted so that the inner serous mem brane will have an outward aspect. In this position it is fixed by a few sutures, and the testicle, which is now situated at the outer surface, is replaced, together with the structures to which it adheres. This should be done in such a way that the serous surfaces will not face each other, as this may cause a relapse through the formation of a serous sac.
Andrews's "bottle operation" is intended to prevent such a con tingency. A small incision is made at the neck of the tumor, through which the testicle, together with the inner membrane, is everted. No suture whatever is necessary after this operation, owing to the small ness of the incision. The results are very good, and there has never been a relapse in my experience.
The "Ralf method," devised by Klapp to prevent relapses, consists in the following proceeding: The sac having been incised, a few silk threads arc drawn through its inner membrane, which is collected into a bundle by tightening the threads. The tissue structures are said to become absorbed within a year. This method has certainly great advan tages in operations on adults, while in children I prefer the method above described, avoiding buried sutures as far as possible Differentiation and of the testicle occurs if the latter is arrested at any part of its way from the lumbar vertebra; to the scrotum, and remains in that position after birth. [1.7ndescencled testicle.] If later in life this position, as occasioned by the embryological development, is changed either by gravity or other physical laws, caus ing the testicle to find its way into other cavities, or by its being dis placed in another direction from pathological causes (crural canal), we have a condition called ectopia of the testicle.