BY CLAMS AND SUTURES. 
287 
and more effectual way of closing the tunica vaginalis above the clam 
is to give a half turn, which may later be made a complete one, to the 
.tunica vaginalis and the spermatic cord before applying the clams. 
Displacement of the abdominal viscera is said to be prevented by the 
closure of the processus vaginalis, but this is dependent on the size of 
the abdominal ring; and where the latter is large the viscera not only 
interfere with closure, but may even cause rupture of the processus 
vaginalis. Though this danger is certainly decreased by twisting the 
processus vaginalis, it is not entirely removed, and, therefore, the 
process has been somewhat modified. The operation should be per¬ 
formed antiseptically under chloroform. As the chief difficulty in applying 
the clams high is occasioned by the outer skin and soft parts lying below 
it, a short but carefully disinfected pair of clams is selected, and an 
incision made through the skin, large enough to allow the clams to be 
pushed to the bottom of the wound, and to lie just under the inguinal 
ring. The skin is then brought over them and sutured, thus retaining 
them in the wound. If neither fever, swelling, nor other disturbance is 
marked during the next few days, the clams are allowed to remain in 
position for a week. On removal, healthy granulations will be found 
unaccompanied by pus formation, and the wound heals in a short time 
under aseptic precautions. 
J. F. Stockfleth operated in a similar way. He drew the lappets of 
skin over the clams, by means of purse-string sutures, but loosened the 
latter next day, and applied a ligature around the processus vaginalis 
and above the clams. If this be not done, it is well to fasten the clams 
to the neighbouring skin by a ligature. 
The clams must not be removed too soon. The longer they remain, 
the better the union between the surfaces of the processus vaginalis. 
Jessen found three days too little, and in his later cases left the clams 
on for five days. In the above operation they may remain in position 
still longer without disadvantage, and need not be removed, even though 
pus forms, provided fever does not set in. In any case, the clams 
should not be removed before the fourth or fith day. A bandage and 
dressing similar to that used in castration of cryptorchids (compare with 
this) can be applied, to assist in supporting the weight of the clams 
and preventing the tunica vaginalis tearing. 
Dieterichs recommends using a sterilised sponge to temporarily close the 
processus 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 clams 
are then applied to the spermatic cord, but removed again after twenty-four 
hours, whilst the sponge is left in position until it comes away spontaneously. 
The disadvantage is, that should the sponge not be carefully sterilised, which 
is very difficult to ensure, peritonitis often occurs, as shown by the experience 
