19, 3 Maxwell: Filariasis in China 311 
The tumor is now pulled well over to the left, and beginning 
over the right external abdominal ring, a lateral flap is marked 
out, the incision ending in the middle line in front of the anus. 
The upper portion of this incision is now deepened, the vessels 
being picked up as cut. The external pudics will both be secured 
in this way. The skin left in this flap should be soft and plia- 
ble, and no cedematous, subcutaneous tissue should be left if it 
can possibly be helped. This incision and proceeding are re- 
peated in the same manner on the other side of the tumor. 
The upper ends of these incisions are now joined by a straight 
transverse incision, which crosses the upper end of that which 
has been used for separating out the penis. 
A free incision is now made over one of the testicles, begin- 
ning from one of the lateral incisions near the external abdominal 
ring. This is rapidly deepened till soft, cedematous tissue is 
reached, when the knife is laid aside and the fingers are inserted. 
With their aid, the edematous tissue, which runs with fluid, is 
torn open, and the testicle and cord are isolated. It is better 
to isolate the testicle first, as it is more easily found; the cord 
is not infrequently much expanded. The gubernaculum testis is 
in these cases very strong, and must be cut away with scissors or 
knife. The testicle is frequently compressed and deformed, and 
the cord is much lengthened, but this lengthened condition of 
cord soon corrects itself and needs no special treatment. If the 
testicle is hopelessly atrophied, then it is as well removed. 
Charles(8) speaks of congestion of the head of the epididymis, 
or fibrous induration of the same, in cases attended with 
hydrocele. I have looked for this and have not been able to 
satisfy myself on the point. ‘ 
The testicle having been freed, if there is a hydrocele, it 
should be cut open and the sac cut away, except a strip, which 
is left attached to the cord. The same procedure having been 
repeated on the other side, the testicles with their cords are 
then wrapped in gauze and turned up on the abdominal wall. 
The incisions already made for the flaps are now to be rapidly 
deepened, and the whole mass is cut away from above, all vessels 
being clamped as cut. 
“nae bie advise arresting hemorrhage by the clamp 
torsion method. I always ligature the vessels, using fine catgut. 
It is better not to employ silk for these large tumors as, Owing a 
the impossibility of complete disinfection of the skin, infection se 
the wound is by no means unknown, and in such case the silk 
