result, recourse must be had to surgery—not, however, if already the scrotum and neighboring genital parts have changed their color to a black, livid, bluish or some other unnatural hue, or if the hernial tumor manifest a round rather than an elongated shape, for all these signs are harbingers of death; and, as further unfavorable signs, should be reckoned a livid or black mucous membrane of the patient's mouth, contracted nostrils, and an appreciably sunken condition of the eyes. But if, on the other hand, the scrotum possess a natural color and if it have not a spherical form but rather an oval shape, then it is proper, after a failure to secure the desired reduction by the internal use of medicine, to resort to a surgical operation.
For the proper performance of this operation the surgeon should be provided with a nicely rounded metal staff, flat on one side, and a little larger than a goose's quill. [Paré's grooved sound or director, says von Gurlt, had not yet at that time been invented, and this staff was intended to serve, in a crude fashion, the same purpose.] The first step is to make an incision in the upper part of the scrotum, the direction in which it is to be carried being toward the symphysis pubis. When the hernial sac is reached the staff is introduced into the slit and pushed upward between the wall of the sac and the fleshy part of the penis, the flat side of the instrument being kept uppermost, as it is upon this surface that the cutting with the scalpel or the razor is to be done. After the end of the staff has been pushed well upward the flesh of the scrotum is to be divided upon the flat surface of this instrument; all danger of injuring the intestine being thus avoided. Then the attempt should cautiously be made to reduce or replace the intestinal folds. But if these efforts fail,—owing to the excessive distension of the bowel or because the constricting band has not yet been sufficiently relaxed,—then the following steps should be taken:—Grasp the spermatic cord ("didymis"), lift up its enveloping membranes one by one with hooks, and divide each one of them completely upon one's finger nail, up to the point where the intestine is encountered. Then, having established, between the intestinal wall and the membranous coverings of the cord, an aperture large enough to admit the end of the metal staff, push the instrument onward and upward while at the same time it is held as it were balanced in the air, so that early warning may be communicated to the holding fingers in case the instrument, as it travels onward, should become caught in the folds of the intestine—an accident, however, which the slippery nature of the outer sur-
