VANLAW'S OPERATION FOR SCROTAL HERNIA 363 



outer integument only. The tunica vaginalis is temporarily 

 left intact, while it is separated from the outer integuments 

 by tearing, as far up as the internal inguinal ring. When the 

 sac formed by the tunica vaginalis is thus separated from the 

 surrounding attachments and now hangs out in the shape of 

 a pear, the posterior part is examined for large blood ves- 

 sels, which frequently are found entering the sac. If these 

 vessels are found to exist, as is generally the case in old her- 

 nias, they are ligated at two places about one inch apart and 

 then divided between the ligatures. 



Second Step. — Reduction of the Contents and Castration. 

 — The contents, if not previously reduced by gravity, are, if 

 possible, pressed into the abdominal cavity, leaving only the 

 testicle within the sac. The sac is then incised and the tes- 

 ticle ablated just above the epididymis. 



Fourth Step. — Ligation of the Sac— The sac is then- in- 

 spected internally to determine whether the contents have 

 been safely returned into the abdomen. If irreducible by 

 gravity it may be necessary to press them up with the fingers, 

 and when this fails the orifice may be enlarged in the forward 

 direction with the probe-pointed bistoury, guided with the 

 index finger. If the- irreducibility is due to distention of the 

 bowels, the gas is evacuated with the trocar and canula. 



The sac, including the spermatic cord, as near to the inter- 

 nal inguinal ring as possible, is then transfixed with a double 

 strand of braided silk. Each half is tied separately with tightly 

 drawn knots and the protruding ends are then wrapped sev- 

 eral times around and then tied again to assure against slip- 

 ping. 



The sac and the spermatic cord below the ligature- (as if 

 in standing position) is then cut off transversely about one 

 inch from the ligature. 



Fifth Step. — Dressing. — The scrotal cavity is packed- with 

 an antiseptic gauze or cotton, retained with two of three in- 

 terrupted sutures. The object of the packing is that of pro- 

 viding a support for the intestines that will keep them from 

 bagging into the orifice until swelling develops to perform 

 that mission. 



AFTER-CARE.— The packing is removed at the end of 

 forty-eight hours, after which the cavity is syringed out daily 

 with iodoform-ether, five per cent, until the ligature has 

 sloughed off and cicatrization is well advanced. In addition, 

 the patient is kept in the standing position for four to five 

 days immediately following the operation. 



SEQUELS. — (I) Peritonitis, manifested by the ap- 



