paratively cheap; further they do not warp and get out of shape when not worn for a few days, as do corsets of wood. Leather, as applied by Vance, is a very good material, but is very expensive and difficult to apply. It can not be worked on a plaster cast, as can wood and cellulose, but necessitates the making of a wooden model.*

And here just a word about apparatus and appliances in general. Any appliance which is so complicated as to require a skilled mechanic to apply it and keep it in order is too complicated to be employed by the orthopedic surgeon. In the whole of orthopedic practice the instrument-maker is needed only to make stirrups and jury-masts, and to hammer out steel plates for the treatment of flat-foot. Every thing else can and should be made by the orthopedist himself. No apparatus should ever be made according to measure; all should be made according to model, and can only suit the one patient. No methods are so simple and cheap as those of Lorenz, and some of other apparatus are constructed on altogether wrong principles.

Gonitis. A fixation splint (wood, cellulose, leather, plaster-paris) is applied and carried well up the thigh, so that tuberosity of ischium rides on rim of splint, which is well padded. A stirrup can be applied to this if desired with a high shoe on the other foot. If necessary, extension can be made by means of an anklet and rubber tubing fastened to rings in the angles of the stirrup. In old cases the modelling method (modellir Verfahren) is to be practiced. This consists in gradually but forcibly effecting the desired correction in narcosis and during one sitting, even if the procedure require three fourths of an hour. The point is not to use brisement forcé, but to stretch so gradually as not to break or rupture any thing. This stretching can be done by hand or by means of Lorenz's osteoclast, which will be hereafter described.

Ankle Joint. In disease of this joint it is usually only necessary to fix in a plaster-paris dressing and allow patient to get about with joint so protected. If painful, a protection splint, on rim of which tuberischii rides, can be applied.

Genu Valgum. Redress forcibly with or without narcosis, and with or without assistance of osteoclast, in one sitting, by stretching the resisting ligaments. Put on a plaster-paris bandage, and then cut it down and remove it at once, in order to make a cast of the limb in the corrected position. Apply another plaster-paris bandage, fixing limb in the cor

The writer has since had the opportunity of seeing leather worked in the hands of Dr. Vance, and finds Prof. Lorenz is mistaken in this latter statement. Vance softens the leather in hot water and applies it directly to the patient's body, making the patient serve as the model on which the leather is molded.

rected position. The limb remains so fixed for four weeks, when the plaster-paris is removed and support apparatus applied; this has been made in the mean time to fit exactly the cast of the limb. This apparatus is jointed at the knee, permits of motion in walking, and at the same time holds the position already attained. It incommodes the patient very little, and should be worn for a year.

When redressement does not succeed by stretching ligaments and soft parts, it is possible with the osteoclast to grip above the joint on the lower end of the femur and effect redressement by impacting this lower end of the femur, without, however, producing a fracture. Lorenz has done hundreds of operations with this osteoclast, and has always succeeded in effecting the redressement desired. McEwen's operation is to be reserved for adults and rachitic (ebonized) bones.

This plan of redressing genu valgum slowly, with help of osteoclast if necessary, but in one sitting, is in contrast to the plan of Wolff, of Berlin, who redresses so much to-day, fixes in plaster-paris, and then again redresses so much next week, and so on until the desired amount of redressement is effected.

In so far as cosmetic effect is concerned, there is no comparison between this "modellir Verfahren" and osteotomy or osteoclasis. Osteotomy for genu valgum requires always a very long confinement, while this modelling method can place a man again on his feet with a jointed splint in six weeks. As illustrative of this it is interesting to know that in Berlin the Mutual Co-operative Society of Bakers, who are much given to this deformity, made the request at the general hospital that no more bakers be osteotomized, as the society was not able to stand the expense of the long confinements.

Crus Varum. In ordinarily bad cases correction is effected by osteoclasis of the leg, using the osteoclast presently to be described. In very bad cases, where it is necessary to break both tibia and femur, osteotomy is indicated rather than osteoclasis. Lorenz has tried osteoclasis in one such case, with the result of producing a compound fracture at the seat of first fracture while attempting to effect the second.

LOUISVILLE.

[TO BE CONTINUED.]

THE OPERATIVE TREATMENT OF VARICOCELE.*

BY A. B. COOKE, A. M., M. D.

When the pathological condition termed varicocele is sufficiently grave to call for treatment, treatment means or should mean operation. The gravity of the disease, however, is often mistaken. Where a man's generative organs are involved, anxiety and apprehension are his constant companions, and the most trivial ailment often gives rise to serious mental concern. This intimate relation between the mind and the reproductive apparatus is one of the most significant as well as beneficent of nature's provisions. First among the animal functions, both in immediate and far-reaching importance, stands that of reproduction, and, assailed from so many sides and by so many foes, its protection and preservation are as difficult as they are essential. The growing boy instinctively regards his sexual organs with far more solicitude than he does his mental powers or the comeliness of his physiognomy, and this solicitude remains with him throughout his sexual life. This, I think, furnishes the explanation and at the same time the justification for the various palliative remedies and measures recommended for the relief of varicocele. In the non-operative cases treatment of any kind is chiefly of value for its psychic effect. Moral advice and reassurance are among our best resources in this class of cases. Satisfactory marital relations offer perhaps the most rational as well as the most certain method of cure, but the conscientious physician is loth to assume the responsibility of advising marriage under any circumstances, and so it is that sundry topical applications, the suspensory bandage, etc., find a more or less useful part to play.

The subject of this paper, however, is not varicocele, but the operative treatment of varicocele. I wish to reiterate as my positive conviction the statement with which this article begins, viz., that when a varicocele has reached such a stage as to demand active treatment, that treatment should be operative. This assertion will doubtless be challenged by some present as extreme, and the treatment proposed as unnecessarily heroic and radical. But I maintain that there is no other curative treatment, and that, when properly performed, the operation. occasions only trifling inconvenience, and is almost wholly devoid of danger. By properly performed I mean not only with due dexterity

*Read before the Bowling Green and Warren County Medical Society, February 2, 1895.

and thorough technique, but also with the observance of strict asepsis in every detail. Modern surgery has come to require something more than merely a theoretical knowledge of the principles of asepsis and antisepsis. Bacteriological infidelity no longer serves as a cloak for ignorance and negligence, and unless these principles are systematically incorporated into the daily work the slightest operation is fraught with danger, and the operator is culpable to nothing short of a criminal degree.

Varicocele is an affection of male adolescence, and is practically limited to the left side. It does occur upon the right side, but with such extreme infrequency as to be regarded a curiosity when met with in that situation. Without entering into the anatomical details of the parts involved, the explanation of this phenomenon may be summarized as follows: (1) The left testicle hangs lower than the right, and the left cord is consequently placed at greater tension; (2) men habitually rest their weight more upon the left foot than the right; (3) the veins of the left side are larger, poorly supplied with valves, and empty at right angle into the left renal vein instead of, as upon the right side, at an acute angle into the ascending vena cava, and (4) it is possible that the position of the sigmoid flexure and rectum upon the left side have some causative significance in this connection.

The diagnosis of the condition is never in doubt, and as before observed the indication is operation. In the selection of a method of operation only two should be considered. A description of Keyes' timehonored method of subcutaneous silk ligature may be found in any work on surgery. This operation has been more extensively employed than any other, and has proven generally satisfactory. It has to recommend it, that it can be done without anesthesia, and requires no aftertreatment. But it also has its disadvantages, the most serious of which is the greater or less liability of recurrence.

But the operation par excellence for this condition, and the one which I would recommend above all others, is the excision or open method operation, either with or without ablation of the scrotum, as the case may require. It is performed as follows: The vas deferens, having been carefully isolated, is held out of the way, and an incision an inch and a half to two inches in length is made, extending downward over the engorged veins from about a half inch below the external abdominal ring. Without disturbing the fascia which binds them together, a ligature of strong catgut is thrown around the entire bundle of veins which constitute the

pampiniform plexus and tightly tied at the upper end of the incision. The same procedure is gone through with at the lower end of the incision, leaving an interval of one or more inches, as the amount of elongation may indicate, between the ligatures. One end of each ligature is left long, and, the intervening section of the veins having been excised, the two ends are brought together, securely tied, and dropped back into the scrotum. The incision is then closed either with catgut or silk. Unless the scrotum is very redundant this completes the operation. Ablation of a portion of this structure, however, when necessary is quickly accomplished, and does not to any extent either complicate the operation or retard recovery. It is effected by picking up the scrotum in the line of the raphe from below, removing as much as may be indicated symmetrically from both sides, and closing with a continuous A scrotal clamp is a useful instrument for this purpose, but may be satisfactorily substituted by the handle of a long pair of scissors or dressing forceps having a French lock.

suture.

The chief advantage of this operation is that, if properly performed, it can not fail to effect a perfect cure. True, it requires anesthesia and a day or so in bed, but these are inconsiderable features in comparison with the perfection of the result secured. The explanation of this uniformly favorable result is briefly this: The veins of the pampiniform plexus are entirely obliterated and become converted into a strong fibrous cord, which serves as an additional support for the testis and renders a future varicosity in this situation an anatomical impossibility.

The present teaching in regard to ablation of the scrotum is that it is necessary only in exceptional cases, as it soon contracts and adapts itself to the new condition. This is doubtless true, but unless shortened at the time of operation the large amount and relaxation of the superfluous scrotal tissue require that the weakened cord be provided with an artificial support for a much longer time, and recovery is neither so rapid nor so complete.

Within the past few months my associate, Dr. Grinstead, and I have twice performed this operation, in each instance removing a portion of the redundant scrotum. The results obtained in each of these cases were so satisfactory both to ourselves and the patients as to warrant the claim that this is one of the best and most perfect operations of modern surgery.

BOWLING GREEN, KY.