BY CLAMS AND SUTURES. 545 



position ten days or longer without disadvantage, and need not be 

 removed, even though pus form, provided there is no constitutional 

 disturbance. Some operators prefer to allow the clam to fall off, 

 which usually happens between the tenth and fifteenth days'. Removal 

 of the clam before firm adhesion has been established between the 

 vaginal coverings is a frequent cause of failure of the operation. 

 When the clam falls off too soon prolapse of the bowel occurs and 

 the patient may die from peritonitis. 



Dieterichs recommends using a sterilised sponge temporarily to close 

 the tunica vaginalis. He opens the latter, ligatures the spermatic artery, 

 and then thrusts a sponge, provided with a central hole, over the spermatic 

 cord, and as high up as possible, so as to occlude the abdominal ring. The 

 clam is then applied to the spermatic cord, but removed again after twenty- 

 four hours, whilst the sponge is left in position until it comes away spon- 

 taneously. The disadvantage is, that should the sponge not be carefully 

 sterilised, which is very difficult to ensure, peritonitis occurs, as shown 

 by the experience of Bassi and others, and for this reason this method 

 cannot be recommended ; that above described is certainly to be preferred. 



(c) The method of ligaturing the tunica vaginalis with the 

 spermatic cord, though quite safe and effectual, has not found many 

 supporters. The ligature may not produce such perfect occlusion 

 as the clam, but when aseptic materials like braided silk, thick twist, 

 or £ inch tape are employed, the vaginal sac can be closed very securely 

 and somewhat higher on the cord. Two ligatures are applied ; one 

 is doubled and passed through the substance of the cord close to 

 the inguinal ring, the loop is then cut and the ends are tied on each 

 side ; the other ligature is passed two or three times round the covered 

 cord, just below the first ligature and securely tied. 



(d) Bouissy's plan of multiple ligation of the scrotum is inad- 

 visable, qecause of the danger of including a portion of bowel, and 

 to prevent this (even when using the clam over the tunica vaginalis), 

 it has been suggested to first incise the tunica, and, by introducing 

 the finger, to make sure that no intestine is present. This may be 

 useful in doubtful cases, but an external examination generally 

 suffices. 



(2) Closure of the internal inguinal ring. Many operators describe 

 having sutured the inner abdominal ring, but as the modus operandi 

 is never sufficiently well described to convince one of the correctness 

 of the assertion, the point must remain doubtful. In oid stallions 

 the narrowest portion of the inguinal canal lies f to 1| Inches below 

 the internal ring, and presents an almost insuperable difficulty If 

 the inner abdominal ring has ever been sutured, an abnormal condition 

 of the parts has clearly existed, to begin with. On the other hand, 



