It is a remarkable feature of this case that so little pain was complained of. It was so slight that the patient never took any medicine especially for it, though the pain is generally a prominent concomitant of these growths. The constitutional symptoms were also late in their development, whereas the converse is the rule. The ill health of the patient in his own estimation had been so slight that he thought he was ailing from a bilious attack and would soon be up again. Although a man of ordinary intelligence he could not be made to realize that his disease was likely to terminate fatally at any moment, and to the last day he expected to recover.

Correspondence.

MR. EDITOR-In the last number of the JOURNAL there appeared a communication on the "Radical Cure of Hydrocele," by Z. H. Evans, M. D., and although it is impossible for me, to either admire the doctor's logic, or approve of the spirit of his criticism, I am far from being unwilling, to discuss the subject or to give so far as I can, a reason for the faith that is in me."

As this is the first time that my doctrines, or my methods of teaching have been publicly called in question, perhaps it will not be out of place for me to refer, very briefly, to some of the general principles which I endeavor to follow in the discharge of my responsible duties, as a teacher of Surgery.

In the first place, while endeavoring to foster a spirit of reverence for the great names in medical literature, and a due regard for well established principles, everything like blind unquestioning faith is discountenanced, and a spirit of scientific scepticism is strongly encouraged. Inductive is preferred to deductive reasoning, and the student is urged to make his own observations and experiments, and draw his own conclusions. In the second place, when two or more views of any subject appear to divide professional authority, about equally

between them, all are fairly stated, and the student is urged to form his own opinions deliberately. In the third place, when a given doctrine, or say, a particular method of treatment, of a given affection, has received the sanction of numerous high authorities, and has also been thoroughly tested in my own practice, I feel not only justified, but compelled, in duty to my pupils, to speak with an air of authority, which if taken apart from my general encouragement of the spirit of scepticism, might justify a charge of dogmatism against me. I do not waste the precious time at my disposal, and exhaust the student's patience, and confuse his ideas, by relating every old and exploded proposition, still less every untried and new-fangled suggestion, which for aught I can know, may have no better foundation to rest upon than a single case, which has happened to make a good recovery.

The responsibility of a clinical teacher, has always seemed to me to be very great, and for him to speak with uncertainty and hesitation, when he would be entitled to do so with firmness and apparent dogmatism is, in my humble opnion, as great a dereliction of duty, as it would be for him to dogmatize, when neither professional nor personal experience can sustain him.

But to return to the communication of Dr. Evans. In the first place the doctor argues that the testimony of our best surgeons does not corroborate the statement that "the practitioner is able to assure the patient of speedy, safe, painless. and permanent relief." And, in the second place, he states that the treatment on which I so confidently teach my pupils to depend, is not the same as that which those gentlemen recommend, who feel themselves compelled to give a less favorable and positive prognosis.

Now, taking the Doctor's two statements together, I submit that they constitute a very strong argument in favor of the practice which I am in the habit of inculcating. I do not for a moment contend that the experience of any single individual should be permitted to outweigh the experience of the wellknown gentlemen referred to by the Doctor; but positive evidence is always more valuable than negative, and moreover, I

venture to believe that, even Dr. Evans will be able to see that the testimony of his witnesses is out-weighed and that his sarcastic quotation was out of place; at any rate, in all kindness, I say to him, in the words of his own chosen poet: "Read o'er this; and after, this; and then to breakfast, with what appetite you have."

"The most convenient plan, and the one which from the small proportion of failures seems to deserve its present popularity, is to throw into the sac two, three or more drachms of the tincture or some solution of iodine, and to allow it to remain ; when the canula is being withdrawn after the injection, the sides of the sac should be nipped between the finger and thumb to prevent the escape of the iodine from the sac; and the scrotum may be shaken a little roughly so as to insure the contact of the fluid with all parts of the interior of the sac."-Holmes System of Surgery-vol. iv p., 554.

"Most of our leading surgeons have now resorted to this practice with iodine, but the amount of experience acquired by the professor (Martin) among the natives of the East, who seem peculiarly liable to this disease, puts all that can be stated by a European practitioner into small compass, for whilst a surgeon possessing even tolerable opportunities here, can speak only of his dozens of cases, or hundreds at most, Sir Ranald Martin can adduce thousands! and these, too, treated within the short period of eight years.

"I have learnt from others who have practised in India, that the method has answered equally well in their trials of it, and I believe it has proved beneficial in equal proportion in other parts of the world. Within the last thirty years, I have almost invariably adopted this practice, when a radical cure was advisable, and have rarely seen it fail."-Sir Wm. Furguson, Bart., 5th Edition, 1870, p. 668.

"It is not necessary to review all the various plans which have been and are now employed for the permanent cure of hydrocele of the tunica vaginalis; it will be more to the purpose, to give the line of practice which is most successful, and which at the same time is very simple, viz: the injection of the cyst with

a solution of iodine." "Acupuncture has been advised, but it has no practical advantage over the simple tapping, and it is certainly less successful in its result."-Bryant's Practice of Surgery, 1873, p. 558.

"The injection of the tincture of iodine, originally introduced by Sir J. R. Martin, whilst practising at Calcutta, is now commonly preferred as a more certain and safer mode of treatment than any other."-Erichsens Science and Art of Surgery, 1873, p. 828.

Much more evidence to the same effect might, if it were at all necessary, be adduced, but I will content myself with calling just one more witness, one whose testimony is as unequivocal as his authority is unimpeachable.

One of Dr. Evans' own witnesses says: "Of the many methods of treating simple hydrocele, only two need be detailed, as they are applicable to all cases, namely, injection and incision, including excision of the tunica vaginalis. A small seton may sometimes be permitted in the case of a child, but with the adult it ranks with tent and caustic as too severe. All simple hydroceles which are translucent, no matter what their age or how great their size, are amenable to treatment and cure by injection."—Genito-Urinary Diseases with Syphilis. Van Buren & Keyes, 1875, pp. 402-3.

"HYDROCELE, Case I.-Simple Hydrocele.

"A. C., aged 61, was admitted into the hospital on account of a large hydrocele in the right tunica vaginalis, of two years' standing. It was immediately evacuated, and injected with tincture of iodine (zij Ed. Pharm.), which was allowed to remain, after being diffused over the whole surface by a rough shake of the scrotum. On the third day the subsequent swelling was at its height, on the fourth day it was diminishing. On the seventh day the patient was dismissed cured.

"This case is selected, not from being of an exceptional character, but because it affords an example of the result which usually, or, as I should rather say, invariably attends the operation employed. In former times candidates for graduation at

this university used frequently to choose hydrocele as the subject for a thesis, from the variety of opinions entertained in regard to its treatment, and the different procedures employed for this purpose, affording convenient materials for discussion. Thus it was said that port wine, when injected, was apt to fail, and also to produce very serious consequences if it happened to enter the cellular texture of the scrotum-the operations of incision and excision were bloody and painful-the seton was no less tedious than irksome -and so on.

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"But since the use of iodine has been introduced, the theses on hydrocele have gradually become fewer, until they have entirely disappeared; whence I conclude, that the advantages of this means were so manifest that they had led to the abandonment of all the others, and left no room for discussion. I was therefore, accustomed to quote this unanimity of practice as an illustration of what might happen, if through time and careful observation all surgical derangements should come to be treated in accordance with the principles which judgment and experience had decided to be the best for each. But the hopelessness of any such aspirations for the perfectibility of surgery, has been lately well shown, by a strenuous attempt to substitute for the treatment by injection with iodine, the old and justly abandoned procedure of seton, which it was proposed should consist of silver wires, instead of the silk threads formerly employed. It is difficult to imagine that such an absurdity could be adopted by any surgeon of ordinary intelligence, and yet if the medical journals can be regarded as affording indications of professional opinion, it might for some time have appeared that a real improvement had been introduced, instead of a proposal implying the most lamentable lack of practical principle.

"The injections of iodine, in order to be effectual, must be performed with attention to the following circumstances: In the first place, the patient should stand while the sac is tapped, in order to let the water be drained off completely. Then zij of the Edinburgh tincture of iodine, which is much stronger than that of the London Pharmacopæia, should be injected, unless the tumor is either very large or very small, when there may be a corresponding increase or diminution of the quantity employ