INDEX. Excision in the Treatment of Spina Bifida,... Poisoning by Carbolic Acid... 447 459 Experiments with a New Preparation of Iron and Manganese. 462 PHYSICIANS' SUPPLIES, CRUTCHES, TRUSSES, MEDICAL BATTERIES, ABDOMINAL SUPPORTERS PHYSICIANS' OFFICE FURNITURE, HOSPITAL OUTFITS, THE DENVER MEDICAL TIMES. Conditions Justifying Removal of the Testicle in Radical Operations for Inguinal Hernia; with a Report of Three Successful Cases.* BY THOMAS S. K. MORTON, M. D., Professor of Surgery in the Philadelphia Polyclinic; Out-Patient Surgeon to the Pennsylvania Hospital; Assistant Surgeon to the Orthopedic Hospital, etc. FELLOWS OF THE ACADEMY OF SURGERY: Prior to making my remarks upon the above subject I desire emphatically to impress the fact that I am not here to advocate the indiscriminate sacrifice of an organ usually so highly prized as the testicle, but simply to point. out certain of the conditions which would appear to me to justify the procedure and to relate three cases in which I have considered it best to resort to it. These cases represent the total number in which I have deemed it prudent to add ablation of the gland to formal procedures for the radical cure of inguinal hernia, for instances are rare in which this course may be considered justifiable, and may become constantly more and more so as radical procedures become perfected. With the operations proposed by Bassini, Postempski, and Halstead, with their modifications, where the cord is displaced entirely. from the inguinal canal, and, in the latter, even removed from the *Philadelphia Academy of Surgery. internal ring to an entirely new opening made for the purpose in the muscular structures of the abdominal wall; with these operations, I say, the presence of the cord has almost ceased to be a hindrance to seemingly ideal radical cure. Hence any temptation to sacrifice the testicle vanishes, and the conditions necessita ting or permitting such removal become correspondingly more circumscribed. Removal of the testicle in operations for inguinal hernia would, therefore, in my estimation, be practically limited to the following conditions: 1. Certain cases of undescended testicle. Here, if the testicle had entered the canal and was degenerated or otherwise diseased, or could not be separated from the sac without endangering its vitality, or where it was manifestly functionless, it might be removed without reluctance. But if it were normal, or almost normal in all respects save position, it would be best, if possible, to displace the cord from the canal by one of the modern methods and attempt to bring the organ into the scrotum and there fix it by sutures; or it might be pushed within the abdominal cavity through the internal ring, and there permitted to remain after close suture of the ring. 2. In some rare cases of congenital hernia. Removal here must be very exceptionally called for with so many modern operative resources at hand. 3. In certain cases of chronic or acute disease of the testicle or cord complicating hernia demanding removal of the organ upon its own account. 4. In rare cases in which severe traumatism has occurred to testicle or cord during or before operation. Accidental division of some or all of the vessels of the cord would not necessarily demand excision of the testicle unless other severe complications were present. Wounding or section of the vas deferens likewise might be consistent with retention of the organ. But where the gland has been stripped entirely from all other connections such injury to its vascular supply would produce so much danger of necrosis that ablation would become imperative. 5. In certain cases where sloughing of the sac or interrupted circulation of the cord or testicle has involved these latter structures in a suppurative or sloughing process. 6. Perhaps occasionally in the very aged, to simplify or shorten operation, or for some of the before mentioned conditions of less degree than would justify the procedure in a younger individual. There are no conditions, of course, except senility, that would excuse the removal of a testicle under circumstances where it was the sole reproductive gland possessed by the individual; even more rare would be the conditions justifying removal of both testicles in double herniæ. Surgeons must be exceedingly cautious not to interfere with go highly valued a part without either a very clear understanding with the patient before witnesses (and preferably in writing) preliminary to the operation, or else be certain that the conditions for which the organ is removed will be convincing to others of the necessity for such removal. It is obviously important also for the operator to carefully preserve the specimens for protection in case of dispute. One word more of caution. It is not the easiest matter to tie off the testicular cord in such a manner as to leave it absolutely secure against recurring or secondary hemorrhage after its return to the abdominal cavity; and bleeding from it originates a peculiarly dangerous form of shock quite independent of the amount of blood lost, which often is speedily fatal. Moreover, the bleeding will not be likely to cease spontaneously in the warm and moist peritoneal cavity to which the ligated stump has been returned, and operation to secure it more firmly (if diagnosis is made in time) would be a very formidable complication. Hence, excessive care must be exereised in its primary ligation. It should be transfixed and tied off in at least two portions. Silk is the only fit material for this purpose. A good button of tissue should be left above the ligatures, and, to be doubly sure, any apparent vessel ends should be separately ligated upon the end of the stump before it is returned to the cavity. Searing the stump with a cautery below the main ligatures would be equally, perhaps more, efficient than the separate ligatures to the vessel ends. If the cord were very large or oedematous it should be ligated in even smaller portions. Case 1. Huge Strangulated Inguinal Hernia; Radical Operation with Removal of the Testicle; Recovery.-Mr. M. C. B., a strong, healthy man of nearly fifty-seven years, strained himself fourteen years ago while pulling a heavy satchel across the floor. It caught on a splinter, and, as a result of straining to dislodge it while in a stooping position, he felt something give way in the left groin, and became exceedingly faint. Shortly after this a small reducible but constantly reappearing tumor came into the scrotum, and, as time went by, became gradually larger and larger. Several years after the first appearance of the tumor, and when it had attained quite a large size, he became subject to occasional attacks of strangulation, which always required anesthesia for reduction. Then, after one of these attacks, a large portion of the tumor became irreducible, and so remained. After this when the seizures came on strangulation could always be overcome by reduction of a portion of the hernial contents, but the entire tumor could never be reduced. Several more attacks of strangulation occurred at varying times after this, when more intestine would become prolapsed, but relief was invariably obtained upon reduction of the newly prolapsed and strangulated portion. While strangulation lasted his chief symptom was always an agonizing dragging pain at the epigastrium. By wearing a truss over the site of the external abdominal ring, that portion of gut which prolapsed and produced strangulation was more or less effectually kept up. About 8 o'clock P. M., April 10, 1889, he felt the hernia slip out, and became a little faint and sick; but after lying down for a short time continued at his desk until midnight. At 1 o'clock A. M. he reached his home in West Philadelphia by a street car and foot from the city. His sensations were then different from anything that he experienced before, and he was certain that he was about to dieon similar occasions he had always been most confident and hopeful. At 3 o'clock A. M. he was seen by the late Dr. Michael Lampen, who always heretofore had been able to reduce the strangulation by taxis. The doctor, therefore, promptly placed the patient under anæsthesia, but was unable to reduce the tumor after an hour's application of taxis. He, however, could not let up the ether on account of the |