FREE TORSION.
Free torsion, or that in which the hands alone are employed in the operation, may be performed, as before stated, either above or below the epididymis.
Above the Epididymis.—The first is one of the oldest modes of castration known; one which must have been practiced contemporaneously with the use of clamps, or in the first age of surgery. The first steps of the operation required for the exposure of the testicles are the same as have already been detailed. When this is accomplished the steps of torsion and rupture are then performed in the following manner: The operator, grasping the testicle, carefully draws out the spermatic cord, and with a pointed bistoury makes a transverse incision, above the tail of the epididymis, through the posterior septum of the cord, involving what we know as the white muscle of Bouley, the efferent canal, and the small testicular artery. He then seizes the anterior fasciculus of the cord between the thumb and index finger of the left hand, squeezing it as tightly as possible, and having with the other hand secured the cord at a short distance below the point where the left hand has already been placed, performs the torsion by a rotatory movement given to the testicle itself, the motion having for its result the twisting and tearing of the cord when long enough continued to overcome the tenacity of its fibres. Fifteen or twenty turns of the organ will usually be found sufficient to effect the rupture. A considerable degree of strength in the fingers is required in this movement, and for this reason the torsion may take effect further up than may be desired, and beyond the point designed, which may result in an unnecessary amount of irritation and injury. When the torsion has gone so far that the rupture of the cord has been effected, the stump is released, and retracts in the inguinal canal to a certain height limited by the presence of the posterior septum, which holds it in place, and to a great extent prevents its return through the superior orifice of the inguinal canal.
Below the Epididymis.—This, the fourth step of the operation, consists in the separation of the testicle from the epididymis and the torsion of one upon the other. The testicle being exposed, the operator, taking hold of its appendix, the epididymis, with the left hand, and of the gland with the right, their cellular serous attachment is divided by the thumbs from the posterior to the anterior extremity, from the tail to the head of the twisted efferent canal. If this cannot be done with the hand, the convex bistoury must be called into action. This accomplished, the head of the epididymis is firmly secured with the fingers of the left hand, and the right hand, left free, gives to the testicle the number of rotatory motions necessary to separate it from its excretory canal—that is, from eight to ten. When the testicle is thus severed, the stump of the end, with the epididymis, is pushed back into the vaginal sac, where it is confined by the application of a suture upon the middle of the edge of the scrotal wound.