applications as for epididymitis (see below). The chronic form requires the removal of the causative lesion, a suspensory bandage, inunctions of ichthyol or mercurial ointment, and iodid of potassium by the mouth. Strapping may do good. Castration may be required.

Castration (Excision of a Testicle).—In this operation an incision is made over the cord, commencing just outside the external ring and running down over the base of the tumor. Clamp the cord and divide near to the ring, remove the testicle, ligate the spermatic artery alone, and then ligate the entire thickness of the cord. The cord is sutured with chromic gut or silk. Drainage is not required. It is often advisable to remove a considerable amount of scrotal skin.

Epididymitis, or inflammation of the epididymis, is usually due to inflammation of the urethra. It is apt to occur in the stage of decline of a gonorrhea, and is announced by a complete cessation of the discharge. It may result from the passage of a urethral instrument, the voiding of urine which contains fragments of calculi, or as a complication of prostatic hypertrophy. Acute epididymitis is characterized by swelling about the testicle, pain in the groin, and tenderness over the posterior part of the testicle. The pain becomes. acute, swelling rapidly increases, and the constitution sympathizes. The swelling is due partly to engorgement of the epididymis and partly to fluid in the tunica vaginalis (acute hydrocele). Chronic epididymitis is usually linked with orchitis, and it follows an acute attack or a chronic urethral inflammation.

Treatment by puncture with an aseptic tenotome, if fluctuation is marked, relieves tension and pain. Leeching over the external abdominal ring, use of an icebag, elevation, lead-water and laudanum, laxatives, and opium are used in the acute stage. Painting with 15 drops of guaiacol in I dram of olive oil relieves the pain greatly. Strapping is employed as the inflammation subsides. The treatment of the chronic form is the same as that for chronic orchitis.

Hydrocele (chronic hydrocele) is a collection of fluid in the tunica vaginalis testis. An enlargement of the testis may cause it, but in most instances the cause is unknown and no signs of inflammation exist. The fluid is albuminous, but it does not coagulate spontaneously; it is thin, straw-colored, and may contain crystals of cholesterin. The testicle is at the lower and back part of the sac. The pyriform mass fluctuates, is translucent, grows from below upward, and the

introduction of an exploring-needle permits the yellow fluid to flow out.

Treatment. Simply tapping the sac with a trocar is only palliative; air must run in as fluid runs out, and suppuration may occur, which will be dangerous without drainage. Never tap a rigid sac. The injection of irritants should be abandoned, as it exposes the patient to serious danger because of inflammation occurring without provision for drainage. Hearn incises the sac, dries its interior with bits of gauze, swabs it out with pure carbolic acid, packs it with iodoform gauze, and dresses it antiseptically. The packing is removed in twenty-four hours and the wound is allowed to close. If the sac is rigid and will not collapse, either stitch it to the skin and pack it or excise a large portion of its parietal layer and insert a drainage-tube (Volkmann's operation). It has recently been proposed to tap the sac with a trocar and cannula, to leave the cannula in place as a drain for some days, and to dress antiseptically.

Congenital hydrocele is hydrocele through an unclosed funicular process into the tunica vaginalis. If the pelvis is raised, the fluid runs back into the peritoneal cavity, from which it originally came. The treatment is a truss to obliterate the funicular process.

Infantile hydrocele is a collection of fluid in a funicular process and the tunica vaginalis, the funicular process being closed above, but not below. The treatment is to puncture the sac and to scarify the sac-wall with a needle.

Encysted Hydrocele of the Cord.-In this variety the funicular process is obliterated above and below, but it is patent between these two points, and fluid collects. The treatment is the same as that for infantile hydrocele. If this fails, incise and pack.

Funicular Hydrocele.-The funicular process is closed below, but is open above. Raising the pelvis causes the fluid to trickle back into the peritoneal cavity. The treatment is a truss.

Encysted hydroceles of the testicles and of the epididymis may occur. Diffused hydrocele of the cord is simply edema of the cord. Hydrocele of a hernia is the distention of a hernial sac with peritoneal fluid.

Hematocele.-Vaginal hematocele is blood in the tunica vaginalis, the result of traumatism, a tumor, or the tapping of a hydrocele. There is a pyriform tumor, which fluctuates, but which gradually becomes firmer; the scrotum is livid, and the testicle is below and posterior to the tumor.

The encysted form of hematocele of the cord is a hydrocele of the cord into which bleeding has occurred. The diffused form is due to extravasation of blood into the cellular substance of the cord. Encysted hematocele of the testicle is due to effusion of blood into an encysted hydrocele of the testicle. Parenchymatous hematocele is extravasation of blood into the substance of the testicle.

The treatment of a recent case of vaginal hematocele is to put the patient to bed, support the scrotum, and apply an ice-bag over the testicle. If the swelling does not soon abate, incise, irrigate, and pack.

Varicocele is varicose enlargement of the veins of the pampiniform plexus. An irregular swelling exists in the scrotum and extends up the cord. This swelling feels like "a bag of earth-worms;" it exhibits a slight impulse on coughing; the scrotal skin and cremaster muscle are attenuated; the testicle lies at the bottom of the swelling and is softer and smaller than normal; the swelling diminishes on lying down and increases on standing or on making pressure over the external ring. There is usually some discomfort, aching, or dragging in the testicle or the groin, and even neuralgic pain in the cord. There is sometimes mental depression and hypochondria.

Treatment. In treating varicocele, reassure the patient: tell him there is no real danger of impotence; order cold shower-baths, correct constipation and indigestion, give occasional tonics, and order the patient to wear a suspensory bandage. If the testicle becomes much atrophied, if the pain and the dragging are annoying, or if the mind is much depressed, operate (see page 261).

XXXVII. AMPUTATIONS.

An amputation is the cutting off of a limb or a portion of a limb. Removal of a limb or a portion of a limb at a joint is known as "disarticulation." Amputation may be necessary because of the existence of severe injury, of gangrene, of tumors, of intractable disease of bones or joints, of ulcers which will not heal, of traumatic aneurysm, etc. A re-amputation may be required because of the existence of a defect or disease in the stump.

Classification.-Amputations are classified as follows: (1) As to time of operation after the injury: a primary amputation is performed soon after the occurrence of the accident -as soon as the sufferer reacts from shock, and before he

develops fever; a secondary amputation is performed some time after the accident, suppuration having supervened (Stokes); and an intermediate amputation is performed during the existence of fever, but before the development of suppuration. (2) As to the situation, where the bone is divided or according to which joint is cut through. (3) As to the form and situation of the flap.

In performing an amputation maintain rigid asepsis; completely remove the hopelessly-damaged portion; sacrifice as little of the sound tissue as possible; prevent hemorrhage during the amputation, and carefully arrest it after the operation; have enough sound tissue in the flap to cover the bone, and enough skin to cover the muscles; and secure drainage at a dependent point.

Hemorrhage is prevented by the elastic bandage of Esmarch (Fig. 306). In an ordinary case apply this bandage from the periphery to well above the line of the prospective incision,

H

FIG. 306.-Esmarch's elastic bandage.

FIG. 307.-Application of tourniquet.

encircle the limb with the elastic band (not a thin tube), and remove the bandage. The bandage and band, which are asepticized before using, are applied to the limb, which has been carefully sterilized. After the band has been applied the limb should not freely or forcibly be moved, because of the danger of tearing muscles which are firmly set by the compressing band. When elastic compression is used in an operation the surgeon should be very careful to tie every visible vessel.

The paralysis of the small vessels induced by pressure often prevents bleeding, and unless their mouths be found and the vessels be tied reactionary hemorrhage will occur. Reactionary hemorrhage is the great danger after the use of the Esmarch bandage, and paralysis or sloughing may also follow its employment. If there be an area of suppuration or of gangrene or an extra-osseous malignant growth, do not apply the bandage as directed above. One bandage can be applied from the periphery to near the lower border of the area of growth or infection, and another, from near the upper border of this area, up the limb. The contents of the area (tumor-cells and fluid or septic products) are not squeezed into the circulation. In cases like the above many surgeons hold the extremity in a vertical position for five minutes, lightly stroking it toward the body with the hand, and at once apply the constricting band. As a matter of fact, this plan satisfactorily empties the limb of blood, and it is not necessary in any case to force the blood out by elastic compression. Some surgeons prefer the tourniquet. Figs. 308 and 309 show two forms of tourniquet. apply Petit's tourniquet, place the plates in contact, apply

To

a small firm compress over the artery and a broad thick compress over the outer surface of the limb, buckle the tapes around the limb so that the plate is over the broad pad, and tighten the tourniquet by separating the plates with the screw (Fig. 307). When a tourniquet is applied to