io62 Ve/ennary Obstetrics 



ligature is tied tightly around the entire cord. Having been 

 passed through the cord, the ligature is insured against slipping. 



While catgut presents the advantage of being absorbed by the 

 tissues, its use is excluded in this operation because it quickly 

 softens and relaxes to such a degree as to permit hemorrhage 

 from the .spermatic arteries, or the ligature slips and prolap.se of 

 the intestine or mesentery occurs. In one case, where we ligated 

 carefully with catgut, severe and dangerous hemorrhage occurred, 

 although the ligature remained in position. The cord had to be 

 later ligated with strong silk in order to save the patient's life. 



After the ligature has been securely placed about the parts, the 

 ligated ti.ssues may be severed with a scalpel, or preferably with 

 sci.s.sors, at a distance of not less than i inch beyond the point 

 of ligation. Great care should always be taken to leave a suflfi- 

 ciently long stump. The pressure of intestines or omentum 

 above tends to pull a portion of the ligated inguinal wall out of 

 the ligature, even though it has been passed through the cord and 

 investing ti.ssues. 



If the hernial ring is comparatively small, the wound through 

 the skin and dartos may be allowed to remain open, but we be- 

 lieve such a course inadvisable, and would recommend the closing 

 of the scrotal wound by means of sutures. If the ring is very 

 capacious, and the hernia very large, the cremaster muscle may 

 be so much attenuated that it does not offer sufficient strength to 

 render the maintenance of the weight of the viscera secure 

 against prolapse of the intestine. In order to guard against this, 

 it is essential that the .scrotal wound be closed. If the sac is 

 very large, the ligation of the cremaster and peritoneum, and the 

 suturing of the wound of the skin and dartos, may not prevent 

 the intestinal mass from breaking through to constitute prolapse. 



As a further guard against the descent of the viscera, a portion 

 of the scrotal .sac may be removed, after which the suturing of 

 the margins of the wound stretches the .skin across the external 

 abdominal ring and exerts some pressure upon the parts. This 

 pressure may be accentuated, and rendered far more efficient, by 

 inserting into the external abdominal ring, against the ligated 

 stump of the cord and exci.sed cremaster, a large mass of anti- 

 septic gauze, so that, when the .skin and dartos are brought to- 

 gether and sutured over it, a distinct pre.ssure and support is 

 obtained. Other means for insuring ample pressure upon the 



