THE
MEDICAL EXAMINER,
AND
RECORD OF MEDICAL SCIENCE.
NEW SERIES.—NO. LXV.—MAY, 1 8 50.
ORIGINAL COMMUNICATIONS.
Hydrocele of the Neck. By Thomas D. Mutter, M. D., Professor
of Surgery in Jefferson Medical College. With cases and illus-
trations. (Clinic of Jefferson Medical College.)
Case 1.—On the 1st of November, 1848, Mrs. G. was delivered
of a female child, well formed, with the exception of several tumours
of considerable size, which covered the chin, anterior part of
the neck, and the upper part of the sternum. From this period
they continued to increase in size, and to extend more and more
into the surrounding parts. (See fig. 1.)
About a week after birth, the child was sent by Dr. Bibighaus,
the physician of the mother, to the clinic of the Jefferson College,
where Prof. Mutter diagnosed the case. The fluid was observed
to be contained in several sacs, of varied size, and each appa-
rently independent of the others. It was finally resolved to draw
off the contents of one or more of the sacs from time to time, as
occasion might demand, in the faint hope of being thus enabled
to preserve life until increased age and vigor would give greater
chance of success to the employment of some such remedy as the
seton.
To verify the diagnosis, acupuncture was employed, and during
the same day nearly half an ounce of straw-colored fluid was forced
out drop by drop through the aperture thus made. The ease
which this gave clearly pointed out the relief to be obtained from
operating, and accordingly on the 23d, when the symptoms grew
rather urgent, Dr. Mutter drew off three and a half ounces of dark,
amber-hued serum, from the upper left side tumor. Almost
immediately, respiration became easier, and the slight cough dis-
appeared.
I carried away the serum to watch and examine it more closely.
Eight hours after removal, a dense coagulum nearly filled the
bottle, and the fluid had darkened very much. Twenty-four hours
after, the coagulum had shrunk, expelling a good deal of con-
tained fluid from its substance. Dr. Leidy, who examined it at
Dr. Mutter’s request, ascertained that it consisted of serum, with
few or no blood discs.
On the 25th, the fluid had again returned, and by the 27th had
distended the sac to its former size ; the general symptoms keeping
pace with its growth. On the 30th, the trocar was again resorted
to, in order to relieve the sufferer, and three ounces of serum
withdrawn, the same happy effects as before following the ope-
ration.
No other resort to the trocar was made until the 13th of Decem-
ber, when three ounces of a darker serum were removed from the
lower cyst of the left side. From this tirhe I continued to see the
patient constantly, and the trocar was used as often as occasion
demanded.
Jan. 1Ath. I found the child much thinner, and laboring under
an oppressing cough, which the mother called whooping cough,
and which sounded not a little like it. On the 21st, although the
debility was marked, the cough had decreased, and the child seemed
but little worse than usual. Dr. Mutter resolved to operate again
on the following day, but during the night she began to sink
rapidly, and about three, A. M., died with scarcely a struggle, and
before any physician could be called to her aid.
Thirty-six hours after death, Dr. I. V. Paterson opened the body
in the presence of Dr. Mutter, Dr. Bibighaus, Mr. Zimmerman, and
myself. An incision was carried from the chin to the middle of the
sternum, and the closely adherent and hardened skin dissected from
the walls of the sacs. Three large and two small sacs were now
seen, running up as far as the pterygoid processes of the sphenoid
bone, lying on the anterior part of the spine, and one of them
covering the sternal end of the left clavicle and the sternum itself.
Numbers of smaller cysts lay scattered along the trachea and
through the cellular tissue of the neck, but each was distinct from
the others, and none had any communication with the cavity of
the thorax. The lowest tumor, on the left side, contained, besides
the serum, which was common to all, several clots, some loose and
some attached by bands of fibrin to the walls of the cyst, which
were thrown into curious folds, so assto give to the whole an
appearance much resembling that of the heart with its musculi
pectinati. The other sacs presented a similar surface, but in a
less degree.
The larynx and trachea were now opened, when the most im-
portant lesion was at once revealed. The mucous membrane of the
larynx was faintly reddened, and the rima glottidis almost closed
by effusion into the sub-mucous tissue. The child died then of
oedema glottidis, brought on, I have no doubt, by the irritating
pressure of the distended sacs. This consequence of external
tumours of the neck, though rare, is not, I think, wholly unprece-
dented, as aneurisms have sometimes given rise to it. The
viscera, and even the thyroid gland, were perfectly healthy, and
no other lesion of much importance was observed.* S. W. M.
* This case closely resembles one of those reported by Mr. Cesar Hawkins,
and I am indebted to my intelligent young friend, Dr. S. Weir Mitchell, for the
excellent report of its progress and result.	T. D. M.
Case 2.—During the winter course of 1845-6, Mr. A. G., a
farmer, aged 45 years, and in excellent general health, presented
himself at the “ Clinic ” for the purpose of having an immense
tumour removed from his neck. It appeared that two years before
he had suffered from a severe attack of acute inflammation of the
throat, which gradually subsided, leaving an induration the size
of a marble, near the parotid space. For several years this swel-
ling remained indolent, but
at length, without any mani-
fest cause, it began to in-
crease, and gradually attain-
ed its present bulk. The
tumour occupied the left
side, and extended from the
ear down upon the chest.
(See fig. 2.) It also in-
volved the larynx and tra-
chea, and passed across the
neck behind. Its surface
was perfectly smooth, hard,
and of the natural color of
the integument. When
stricken, a sense of oscilla-
tion, rather than fluctuation,
was developed. There was
no pulsation at any point,
nor was there much suffering. Occasionally, a sharp lancinating
pain would occur; but the chief inconvenience was referable to
the weight of the mass.
After a careful examination, I arrived at the conclusion that it
was a cyst, and to verify the diagnosis, introduced a small grooved
needle. On withdrawing the instrument, a few drops of a dark
chocolate colored fluid escaped, which indicated at once the nature
of the tumour.
As the walls of the cyst were somewhat dense, I had no hope
of curing the patient radically by any other method than the
“ seton,” but as he objected to this, and begged for a palliative
operation only, I used the trocar, introducing the instrument at
the most dependant part of the tumour, and as the fluid escaped,
scratched the surface of the cyst with its point. The object of this
measure was to excite, if possible, sufficient inflammation to cause
the effusion of plasma, and the consequent obliteration of the sac.
The fluid, forty-four ounces in quantity, and of a dark, chocolate
color, having been entirely evacuated, a firm compress and roller
were applied over the now flaccid sac, and the patient ordered to
remain at rest. His diet was also restricted, and directions given
to have his bowels kept in a lax condition for a few days.
It is needless to follow the case through a simple course of treat-
ment, which occupied some two weeks ; suffice it to say, that at
the expiration of this period, marked by the development of no
bad symptoms, the patient returned to the country perfectly free
from every vestige of his tumour.
This relief continued for several months, when, as I understand,
the fluid again accumulated, and was drawn off by some surgeon
in his neighborhood.
This case illustrates the benefit to be derived from simply draw-
ing off the fluid from an hydrocele, but it is the duty of the sur-
geon in similar ones, to state candidly to the patient that from
this measure alone a radical cure cannot usually be expected. If
satisfied to submit to repeated operations, he has certainly the
right to do so. In young persons, and in recent cases, occasion-
ally, frequent tappings may prove sufficient to accomplish a per-
fect and thorough cure.
Case 3.—In the fall of 1847, a woman named Jane Gordon,
aged 35, of good health, and the mother of several children, came
into the institution for the purpose of having a tumour removed
from the left side of her neck. It occupied the parotid space,
extended from the lobe of the ear nearly to the clavicle, and
equalled in general bulk a large sized goose egg. It had existed
for some five or six years, and could not be traced to any exciting
cause. Its growth was gradual, and unaccompanied by pain.
Like most tumours of this class, it was smooth, elastic, colorless,
obscurely fluctuating, and more or less moveable. Having ex-
plained to the patient the nature of her complaint, and also the
different methods of treatment, she decided to submit to the radi-
cal cure.
For the accomplishment of this end, I introduced a seton, (by
a method hereafter to be described,) and after the escape of the
fluid, dressed the wound with a poultice and roller. A general
antiphlogistic regimen was ordered, and continued during eight
weeks. At the expiration of this period the patient was dis-
charged, cured ; and it may be well to state, that no bad symptom
of any kind showed itself pending the entire treatment of the case.
The fluid drawn off was straw colored, and contained crystals
of cholesterine. It also presented all the traces of an albuminous
solution.
Case 4.—In the spring of 1848, I was requested by Mr. Young,
residing in Dyllwin street above Noble, to examine a tumour about
the size of a small walnut, situated just below the lobe of the left
ear, which had existed for some time, and was now increasing
with considerable rapidity. I found it smooth, elastic, pale in
color, painless, firmly attached to the parts in its vicinity, and
fluctuating obscurely. The youth, and excellent general health of
the patient, led me at once to the conclusion that nothing malig-
nant could be suspected, and the sense of fluctuation indicated
that the tumour contained fluid. The diagnosis was, therefore,
sufficiently clear, and I advised the patient to submit to the re-
moval of the disease.
Accordingly, in the presence of my class, I dissected out the cyst,
which contained a dark colored fluid. The wound was closed by
a suture, and the cold water dressing applied. No untoward
symptoms supervened, and a radical cure was accomplished in the
course of a few days.
REMARKS.
Definition and History.—The term “ Hydrocele,” so gene-
rally employed to designate collections of serum in the genital
organs of both sexes, was first applied by Professor Maunoir,
of Geneva, to tumours containing a fluid, but located in the
neck. In the year 1815, a memoir in relation to the subject
was submitted by Professor M. to the Royal Institute of France,
and afterwards to the Academy of Natural Sciences. By the
latter body, Baron Percy was selected to report upon its merits;
and strange as it may seem, this distinguished savant not only
denied the claims of Prof. M. to the discovery of a new disease,
but declared that all the cases of the Professor were nothing more
than “ softened bronchoceles.fi a class of tumours described or men-
tioned by many of the older surgeons, especially Celsus, Albu-
casis, Helwig, Heister, Petit, Plouquet, Louis, Tenon and Pelle-
tan. Others, and among them Fodere, have adopted the same
view of the nature of the complaint, but as we shall have occasion
to show, without any foundation. That the affection has existed as
long as any other disease to which the human frame is liable,
there cannot be a doubt, but it must also be confessed that up to
the period of the publication of the essay of Prof. Maunoir, its
true character had been overlooked, and hence to Prof. M. belongs
all the credit of having first pointed out the essential peculiarities
of this interesting malady. Within a few years, numerous ex-
amples of “ Hydrocele of the Neck ” have occurred in the practice
of different surgeons, and valuable details of cases have been fur-
nished by Dupuytren, Bransby Cooper, O’Bierne, C. Hawkins, and
others, all of whom unite in defining the disease in question to
be “ a tumour or tumours filled with a serous fluid, and occupying any
portion of the neck,”—thus confirming the view of Prof. Maunoir,
who declares it to be “ simply a collection of serous or lymphatic
fluid.”
Causes.—Two varieties of the complaint in question are met
with. The first is congenital, the second results from the operation
of some cause, acting after birth, and may be termed the accidental
or acquired.
It is exceedingly difficult to assign any proximate cause for the
congenital variety, and in the attempt to do so, the whole subject
of the “ development of cysts ” is at once called up ; and did the
occasion permit, the investigation of this interesting point in
pathology would prove to you no less interesting than instructive.
That there exists, in the laxity of tissues and weakness of vessels
of this region, in the foetus, a predisposing cause of effusions of
serum, is sufficiently obvious ; but what determines positively and
directly the separation of this fluid from the blood, is beyond our
ken. Once separated, its collection in sacs or cysts is easily
understood.
In that form of the complaint arising after birth, various causes
operate in its development. For example: any agent capable of
exciting inflammation in the cellular tissue of the neck, may pro-
duce an hydrocele, particularly if the diathesis of the individual
attacked be such as to favor the separation from the blood of serum
rather than lymph. It is also possible, as Vidal suggests, for the
tumour to originate in “ deposites of blood itself, encysted, and gra-
dually transformed into a serous fluid.” In other cases the sac
appears to be a mere development of a mucous bursa, an opinion
expressed by Boyer, in speaking of those cysts which are formed
in the space between the thyroid cartilage and os hyoides.
Location of the Tumour.—With the exception of the conge-
nital cases, in which the tumours occupied both sides of the
throat, observation, so far, goes to prove that the left side is
the most common seat of the affection. The swelling frequently
commences in the lower part of the neck, just above the collar
bone, and gradually involves neighbouring portions of this region ;
but it also originates in other places, particularly the space cover-
ing the parotid gland. In determining our diagnosis, the usual
location of the hydrocele should be borne in mind.
Symptoms.—The symptoms in this disease must depend upon the
size, location, variety of cyst, and the nature of its contents.
Usually the tumour is smooth upon the surface, of the natural color
of the integument, fluctuates, and is free from all pulsation, unless
placed directly over a large artery, or partially emptied. It is im-
portant to recollect the last circumstance, as it offers one of our most
valuable diagnostic signs in establishing the true character of the
tumour. In congenital cases, or in thin persons, the sac is some-
times almost diaphanous, but from the nature of the fluid con-
tained, is rarely transparent when examined by transmitted light.
Unless some important organ, as the larynx, trachea, a large
vessel or nerve of the neck, or the oesophagus, is involved, the
swelling causes little or no inconvenience, other than that pro-
duced by its size and weight. In case No. 2, the patient com-
plained of an occasional darting, sharp pain, of an instant’s dura-
tion, but with this exception, there was no suffering whatever,
except from the weight, (42 ozs.,) which drew his head to one
side. When involving the respiratory organs of the neck, the
breathing is often very'much oppressed, and death, (as in case No.
1,) may ensue from this cause alone. WTe may also have, as in
case No. 2 of Mr. O’Bierne, violent, spasmodic cough. Where
the vessels are involved, hemorrhage from the nose, headache,
tinnitus aurium, and vertigo, increase the inconvenience and
add to the dangers of the case. Deglutition is also sometimes
interfered with, when the tumor is located along the oesophagus.
In nearly all cases the patient states that the tumour began as a
small, firm, distinctly circumscribed insensible lump, growing im-
perceptibly and slowly, until from some cause calculated to irritate
it, or possibly without any such, it suddenly increased in size and
grew rapidly. In some instances, the original tumour is traced to
pre-existing inflammation, or to the reception of a blow ; in others,
no possible cause can be assigned.
Such are the ordinary symptoms of a hydrocele of the neck, but
there exist modifications of these phenomena, or others of an
entirely different character may be added. For example, in case
No. 1, the tumour, instead of being one smooth uniform mass, was
divided into several distinct sacs, not communicating with each
other, and in the centre of the upper sac appeared two hard and
prominent points. In case No. 2, of Prof. Maunoir, the same fact
was observed,—the hard points, corresponding to the location of
the thyroid gland. In case No. 3, of Mr. O’Bierne, “the surface
projected irregularly at several points, which had a soft, elastic,
fluctuating feel ; and the skin covering these points was thin, and
of a livid red color; and when looked at from a distance, the
general appearance of the tumour was such, that it might easily be
mistaken for ‘fungus hcematodes.'’ The patient also complained
of ‘ stinging pains, darting occasionally through the tumour.’ ”
In the case of Dupuytren, (Revue Medicale) the tumour was
“ situated between the os hyoides and the thyroid cartilage, so
that a finger, passed deep into the mouth, could feel its base
behind the tongue.” Here “ the breathing was so much obstructed
that the patient was in constant dread of suffocation ; and his
speech became so much affected that he could with difficulty
pronounce any long word.” In Mr. Bransby Cooper’s case, the
tumour presented “ three distinct sacs, not communicating.” And
in case No. 3, of Mr. C. Hawkins, “the tumour was composed of a
vast number of sacs of different sizes, filled with fluids, differing in
color and consistence, and intimately connected with the large vessels
of the neck.” There also existed “ a varicose condition of the vessels
of the cheek, resembling that in the vicinity of sanguineous tumours.”
Diagnosis.—Prof. Maunoir well observes that the disease under
consideration must have been often seen without its true character
being known. In fact, many of the older surgeons have reported
cases of serous tumours of the neck, but always confounded them
with Goitre. As already mentioned, Baron Percy adopted the same
view, and proposed the introduction of the term Hydrobronchocele,
as better calculated to convey the precise character of the disease,
viz., “ a solid bronchocele converted into an aqueous tumour.”
But all recent observation goes to prove that “ hydrocele of the
neck” is essentially distinct from “ bronchocele,” under any cir-
cumstances. In the first place, most of the tumours in hydrocele
occupy regions of the neck far removed from the thyroid gland.
Reference to the cases reported substantiate this point. In the
second—the disease generally exists independently of any affec-
tion of the thyroid gland. While then, we admit that the thyroid
gland is often converted, by softening, into a cyst, it is at the
same time evident that “ hydrocele of the neck ” is a disease dis-
tinct and apart from any such affection of that body.
As the tumour may occupy any region of the neck, and from
certain peculiarities may want some of the most striking evidences
of its precise character, the diagnosis as regards other tumours of
the throat becomes sometimes difficult. For example, in the case
of Mr. Cooper, the sac was so deeply situated, and so firmly
bound down by fascia, that the tumour was supposed to be solid,
and not until laid bare, was its true nature ascertained. In
such cases our only certain method of arriving at an accurate
knowledge of the character of the swelling is to introduce carefully,
either an acupuncture or grooved needle, or else a delicate trocar.
The absence of resistance, and the freedom with which its point
may be moved in different directions, enables us to detect with the
acupuncture needle the existence or non-existence of fluid in the
tumour, and where the grooved needle or trocar is employed the
escape of the fluid renders the diagnosis at once clear.
Fatty tumours, from their yielding a sort of fluctuation, from the
absence of pain, from their being smooth on the surface, and from
their being usually circumscribed, have been comfounded with hy-
drocele, but if the least obscurity in the diagnosis exists, exploration
with the needle or trocar settles the matter immediately.
Simple glandular tumours have also been confounded with hydro-
cele ; but the history of the case, the general condition of the
patient, the inflammatory pain, the ordinary symptoms of suppu-
ration, present in most of these affections, should render the nature
of the complaint sufficiently apparent; but here, as in other cases,
exploration will always give us correct information.
Chronic abscess of the neck, from the fact that in physical cha-
racteristics it closely resembles hydrocele, may be mistaken for the
latter complaint. I have, in fact, witnessed this error. But the
diagnosis is rendered simple by resorting, in all cases of doubt, to
the needle or trocar.
When occupying the parotid space, and firmly bound down
by the fascia of this region, it is often difficult to determine the
precise character of a small hydrocele. It is firm, smooth, natural
in color, painless, and circumscribed. Here are all the usual cha-
racteristics of parotid tumour in its commencement. When of large
size, the diagnosis is much more simple. As the prognosis and
treatment turn, in such cases, upon an accurate understanding of
the nature of the tumor, the surgeon should proceed with great
caution; and, if he cannot arrive at his conclusions without,
must resort to the needle.
Herniabronchalis, a rare disease, occurring in persons who habit-
ually strain their voices, and which is nothing more than a pro-
trusion of the mucous membrane through the rings of the trachea,
or the cartilages of the larynx, has been mistaken for hydrocele;
but the soft, elastic feel of the tumour, the fact of its disappearing
under pressure, and its rapid growth from violent exertion, should
enable any one to form a just estimate of the nature of the case.
Aneurism, too, has been mistaken for a serous cryst; and this
error it appears was committed by even the celebrated Percy,—
at all events, he contends, with Albucasis and some of the older
writers, that “ all tumours composed of dropsy and goitre, pulsate
synchronously with the action of the heart and subjacent arteries.”
Now, all observation goes to show that just the reverse is the case,
unless the cyst be partially filled and placed directly upon the
vessel. In no case have I ever observed any pulsation, and Heis-
ter, Maunoir, Lawrence, Delpech, Fleury, Dupuytren, Sabatier,
Vidal, O’Bierne, C. Hawkins, B. Cooper, Phillips, in short, all
those who have recently reported cases, make a similar statement.
The absence of pulsation is, then, a characteristic of hydrocele
of the neck, and this fact should ever be borne in mind in making
up our opinion in doubtful cases.
O’Bierne has well explained the cause of the absence of pulsa-
tion, even where the tumour is in contact with an artery. He
observes, “ In every stage of the tumour, the sac is so filled, that
little or no motion is permitted between the particles composing
its fluid, and consequently, according to a received axiom in phy-
sics, these particles are incapable of transmitting, in any sensible
degree, the impulse communicated to them by the beating of sub-
jacent arteries, until a certain portion of the fluid contents shall
have been evacuated.”
Subcutaneous ncevus, a most fearful complaint when it occurs
as a congenital defect, and involves, as it often does, the whole
front of the neck, has likewise been confounded with hydrocele. I
recollect having seen a case of this kind, several years since, with
my friend Dr. Janney, in which the deformity was terrible, and from
the effects of which the child subsequently died. The soft pulpy
feel of the tumour, its variation in size at different times, the
usual purplish color of the skin, and the unusual vascularity of
the parts in the vicinity, are generally sufficient to distinguish the
former from the latter affection. However, in the case of Mr.
Hawkins, in which a vast number of small cysts, some half
empty, occupied the anterior region of the throat, the diagnosis
was very difficult.
Malignant tumours of the neck, might possibly be confounded
with hydrosele of the multilocular variety, wherever the skin
becomes red, (as in the case of Mr. O’Bierne,) and the tumour pain-
ful ; but the general health of the patient, and the history of the
case, will usually be sufficient to prevent the commission of any
serious mistake.
Prognosis.—The prognosis here depends upon circumstances. In
nearly every case of congenital hydrocele, the patient has lived but
a few months, and every variety of treatment has failed to accom-
plish more than a mere palliation of symptoms. When developed
at a subsequent period,the prospect of relief is much more decided,
and, in fact, when properly managed the disease, for the most
part, readily yields. When important organs are involved, it will
be easily understood that serious inconvenience, and even death,
may result from this cause alone. Again, the dangers of the dis-
ease are much increased by improper treatment; where, for exam-
ple, the fluid is allowed to escape into the cellular tissue of the
neck, during or after an operation, speedy suffocation, or subse-
quent serious inflammation might supervene ; and if the surgeon
attempts, in young subjects especially, to cure the disease by
“ stimulating injections,” or by “filling the sac with lint,” as
advocated by some, experience proves that great danger, arising
from inflammation, will in nearly every case so treated, sooner
or later be developed.
Dissection.—Examination with the knife indicates to us that the
sacs here, like those developed in other parts of the body, may pre-
sent either the simple, multilocular or included variety. In all, we
have the peculiar arrangement of tissue which belongs to “ serous
cysts,” either natural or acquired. In some cases, more particu-
larly the congenital variety, the sac is so thin as to render the
tumour partially diaphanous ; in others, the sac is so thick and
dense, as to offer a serious obstacle to the radical cure of the com-
plaint. In case No. 2 it was at least four lines in thickness
throughout. The effect upon adjacent organs will, of course,
depend upon the size, duration, and direction of growth of the
tumour. According to some, the sac may be composed of a dilated
mucous bursa, as when the disease is situated between the os
hyoides and thyroid cartilage. Degeneration of the sac is rare, but
in one case reported by Fleury, “ it was found very hard and
resisting, and its interior lined with a fibro-cartilaginous covering!”
Character of the Fluid contained in the Tumors.—The fluid
contained in these cysts varies very much in different cases.
It has been found limpid, turbid, yellowish, reddish, greenish,
and, lastly, coffee or chocolate colored. The last is by far the
most common variety, and owes its hue, in all probability, to
the presence of the coloring matter of the blood. In consistence
it also presents various modifications. Usually it resembles, in
this respect, thick cream, but I have known it as thin as water,
and again so thick as scarcely to flow through the canula. It is
at first inodorous, but changes from exposure to the atmosphere,
and becomes very disagreeable, smelling like putrid blood. It is
heavier than water, sinking when poured into this fluid, and
possesses a sweetish taste like that of pus. In some cases after
cooling, the surface is covered with micaceous scales, and in others
the microscope detects other ingredients. It is also usually
albuminous and coagulates with heat; in some cases it coagulates
on exposure to the atmosphere.
I am indebted to Dr. Leidy for the following interesting account
of his examination of the fluid drawn from case No. 1.
“ The matter contained in the bottle which you sent me for ex-
amination, has the appearance and general characters of a coa-
gulum of fibrin from lymph. Chemically it is certainly a proteine
compound. Soluble like fibrin or albumen in
liquor potassee, proteine is precipitated from the
solution on the addition of an acid. Boiled with
hydrochloric acid it gives the characteristic blue
color of proteine compounds. With nitric acid
and ammonia it becomes yellow, from the for-
mation of xantho-proteate of ammonia. If it
coagulated spontaneously, it is undoubtedly fibrin. Microscopi-
cally examined, it presents a homogeneous, faintly granular mate-
rial, with yellowish nuclear bodies diffused through it.” (Fig. 3.)
In that taken from case No. 2, Dr. H. T. Child found the
appearances so well exhibited in fig. 4, and so clearly described
in the following note :
Philadelphia, 3d month 4th, 1850.
Dear Doctor,—Enclosed I send the drawung of the fluid from
the hydrocele of the neck.
1 lg. A represents a section oi the field ot the microscope, with
a thin stratum of the fluid upon it. In it we find, 1st, Numerous
crystals, of the same
form and physical cha-
racters of those shown
me by my friend, the
late Dr. Southwick, who
published a report of a
case of steatomatous
tumors containing crys-
tals, in the Medical Ex-
aminer, of this city, vol.
vi., p. 283, 1843 ; they
answer the chemical de-
scription given by him,
being insoluble in water,
slowly soluble in alco-
hoi, and readily dissolved in turpentine. I have seen similar
crystals in pathological specimens since that time. They are
probably cholesterine.
Fig. B, is a drawing of these magnified about 800 diametres,
without any of the surrounding mass. These crystals form slowly
upon the glass, and, I presume, do not exist in the fluid before it
is evacuated, other than as a crystallizable matter. They were
more numerous in portions, the consistency of which was increased
by evaporation.
2d. There is a great number of neucleated cells dispersed
through every part of the fluid, and, as will be perceived, in seve-
ral instances these were arranged in a linear form, showing an
attempt at organization.
3d. Epithelial cells. These varied in different specimens, but
were found in all of them. They were evidently thrown off from
the walls of the cyst.
4th. Pus globules. A few of these were found in several speci-
mens, but their number was inconsiderable.
5th. The remainder of the mass appeared to consist of the debris
of the various ingredients, some of these presented a caudate
appearance.
With sentiments of regard and esteem, I remain thy friend,
H. T. Child.
To Prof. Mutter.
Treatment.—The various methods of treatment to which atten-
tion has been mainly directed are the following :—
1st. Excision.
2d. Repeated tappings.
3d. Acupuncture.
4th. Free incision, followed by pressure.
5th. Incision, followed by stimulating applications to the surface
of the sac.	/
6th. Injections.
7th. The seton.
1st. Excision.—It must be obvious that this method should be
confined to cases in which the tumour is small, circumscribed, and
superficial, and where the existence of a small scar is of not much
importance. Here nothing could answer a better purpose. The
patient is speedily and radically cured, and with but little pain or
inconvenience. The operation can be performed in one of two
ways. Either the skin maybe freely divided from without inwards,
and the cyst dissected out entire ; or else a sharp pointed bistoury
passed through the base of the tumour, and made to cut its way
out, dividing the cyst in halves, each one of which may be dis-
sected, or drawn out with a pair of forceps. A simple dressing
completes the operation.
2d. Repeated Tappings.—The operation of repeated tapping
may be had recourse to, either as a palliative or radical measure.
The objection made to it, that infiltration of the cellular tissue is apt
to follow its performance, holds good only when the tumour is but
partially emptied. If all the fluid is drawn off, the small opening
in the cyst made by the trocar will be closed before any amount
of serum can be again secreted. When this is neglected, the
effusion, as in one case of Prof. Maunoir, may develope serious
consequences. The surgeon should, consequently, never follow
the advise of Percy on this point, but carefully take away every
drop of fluid that can possibly be removed. Used as a palliative
measure alone, it answers a good purpose in congenital hydrocele,
when it would be improper to resort to any severe remedy, and
might even accomplish a radical cure, by keeping the sac con-
stantly emptied. It may also be employed in old cases, to relieve
urgent symptoms, or when the patient refuses to submit to any
more decided plan of treatment. To increase the chance of a
radical cure by this operation, we may here, as is often done in
hydrocele of the tunica vaginalis, scratch the surface of the sac
with the point of the trocar before the instrument is withdrawn.
In all cases it is well, after closing the external wound, to make
moderate and well directed pressure upon the sac, so as to favor
agglutination of its walls.
3d. Acupuncture.—Reasoning from analogy, it has been sup-
posed that, by establishing a “ new action,” in the secreting sur-
face of the cyst, a complete arrestation of the secretion might be
accomplished. With this view I tried acupuncture, in two
cases, and found here, as in ordinary hydrocele, that the tumour,
for a few days diminished in size, but the improvement was never
permanent, the secretion again forming, and the tumour becoming
as tense as before. This measure, therefore, I consider of no
practical value.
4th. Free incision.—Unquestionably the shortest plan of
curing one of these tumours, if superficial, of the simple variety,
and too large for complete removal, is that carried into execu-
tion by Heister, Delpech and Lawrence, viz., “free incision of
the sac, followed by moderate compression.” The operation is
soon over, and has hitherto proved successful, but there is one
serious objection to its employment, especially in females. It
must of necessity leave a long and unsightly cicatrix on the neck.
Other measures should, therefore, be preferred, unless the scar is
of no moment to the patient. In such cases it may be resorted to
with confidence. As it is sometimes followed by severe inflamma-
tion, it should not be performed upon young persons ; nor should
it be attempted in tumours deeply seated.
5th. From the fact that simple incision fails in some cases to
accomplish a radical cure, attempts have been made by different
Surgeons to render the operation more certain, by rapidly con-
verting the secreting surface of the sac into a granulating one.
For the accomplishment of this end, various agents have been
employed. Dupuytren introduced pieces of lint down to the bot-
tom of the wound, and allowed them to remain until suppuration
was fully established. Hawkins painted the surface over with a
solution of the iodide of potassium and iodine ; or tinct. of cam-
phor, or a mixture composed of muriate of ammonia, vinegar and
alcohol. Others have used port wine, sulphate of copper, &c. In
short nearly all the usual measures for changing a serous into a
granulating surface, have from time to time been had recourse to.
The operation, however, is one that should be employed with
caution; not only must it develope severe inflammation at the
time, but if successful, the cicatrix never fails to be irregular and
of great extent. It is also a tedious method.
6th. Injections.—To avoid the scar made by incision, and to
accomplish obliteration of the sac at the same time, the operation
“by injection,” as in ordinary cases of hydrocele, early presented
itself to the mind of Prof. Maunoir. He accordingly made the
attempt, but found the operation not only of no avail, but -when
any agent sufficiently powerful to make any impression upon the
dense cyst was employed, fraught with danger. To quote his own
words,—“ An injection,” he observes, “ which is not very stimu-
lating will effect nothing, or almost nothing, on a very thick, and,
in general, an old cyst. If a very active injection be employed, it
will cause great pain, and give rise to very alarming spasmodic
symptoms. Moreover, I have to observe, that sometimes enlarge-
ment of the thyroid gland complicates the treatment. In that
case, the object is not merely to produce adhesion of the walls of
the sac it will be necessary to employ a mode of cure by which
we may succeed at the same time in resolving this gland, when it
projects into the tumour, as I have seen in two patients.” The
cure by “ injection,” then, is one now almost abandoned.
7th. The seton.—The remedy in which most confidence is to be
placed in cases where extirpation, repeated tapping, or incision
followed by pressure, should not, from the nature of the tumour, be
attempted, or where, if put in practice, have failed, is the seton.
This measure was introduced by Prof. Maunoir, and most modern
Surgeons are disposed to agree with him in the estimate he makes
of its value. That it is inapplicable to cases of multilocular cyst,
unless several setons are used, and also to those occurring at birth,
will be readily acknowledged ; but nothing promises as much
when the cyst is simple and of long standing.
The best mode of passing the seton is that proposed by Mr.
O’Bierne, as it obviates the hazard of infiltration ; an accident very
likely to arise when the threads are passed through openings
made with a trocar. His plan consists in first making “ a free
incision not involving the sac, at the upper and lower extremities of
the tumour, by raising and afterwards dividing a transverse fold of
the integuments at each of these points.” Next “ the sac is opened
above, and a long probe, armed with a sufficient number of threads,
passed down to the most depending point, against which it is
firmly pressed.” Lastly, “ the sac is cut upon the probe, so as to
allow the instrument to pass, and the seton to be introduced.”
After the introduction a light emollient poultice makes the best
dressing for a few days, when a cerate cloth and simple roller
answers until the seton is removed.
This method of treatment is tedious, weeks sometimes elapsing
before the cure is completed, but it has the advantage of being
safe, easy of execution, but slightly painfiul, certain, and followed
by little or no scar. During the time of wearing the seton the
patient should be careful to avoid exposure, and must also lead a
temperate and regular life.