ClECUMCISION.—Operation for the re moval of the prepuce is indicated in chronic balanoposthitis with or without adhesions; certain cases of paraphimosis; to prevent masturbation; when the sex ual orgasm is too early induced; to pre vent gangrene of the glans penis eon secutive to concealed ulceration; tubaroulosis, and epithelioma.
New operation for phimosis. which eau only he performed upon a normal, un foreskin. Two incisions are made in the miter layer of the prepuce from one point at its edge, at a right angle to each other, as far as the corona glandis. As the foreskin is retracted, a denuded surface, oblong in shape, is seen, which is sutured to form a transverse line. Then the wide prepuce can he re placed over the glans as a protection. The technique is described and illus trated by diagrams. Phimosis cannot recur. This operation is only possible when the two layers of the prepuce are freely movable. Sehoffer (Centralb. f. ChM., June 29, 10611.
The usual antiseptic precautions are to be observed. With a pair of flicord's phimosis-forceps the prepuce is grasped just at the corona glandis, parallel to its obliquity, and the prepuce is drawn in front of the glans as the forceps are locked. With a sharp-pointed straight bistoury the prepuce is divided with a sawing motion through the fenestra of the forceps. The skin now retracts be hind the corona, exposing the inner or mucous layer of the prepuce still cover ing the glans. With a fine pail of scissors this is now divided in the median line to the corona. The two flaps remaining are then cut Off close to the edge of the corona, leaving just sufficient tissue to hold a stitch. This will prevent the scar from slipping in front of the corona, thus causing a return of the phimosis. The fnenal artery is now twisted or li gated with fine catgut. and the wound closed with fine black silk sutures. The first suture should be introduced at the frrenum, the second at the dorsun, and two or three at intervening points on both sides; care should be taken that the raw surfaces be accurately approximated. A gauze bandage wet with a 25-per-cent. boroglyeeride solution should be applied as a dressing. The bandage should be removed daily or every other day and the parts irrigated with 1 to 5000 nitrate of-silver solution, and the boroglyceride dressing be applied.
When the penis is large, the operation may be done without the aid of forceps. A grooved director is introduced between the glans and the prepuce exactly in the median line, and on it, both layers of the prepuce are divided at one time by scis sors to the corona. An assistant with dissecting forceps makes slight traction upon the triangular flaps remaining, and with curved scissors the skin and mucous membrane are cut off close to the line of the corona as above described.
Paraphimosis.—Inability to draw for ward a retracted prepuce from behind the corona glandis may be caused by gonorrhoeal balanoposthitis, chancres, chancroids, violent coitus, retraction of a tight prepuce, and any lesion of the glans or prepuce attended by swelling.
Symptoms.—As a result of the me chanical constriction of the prwputial orifice, the glans penis rapidly swells, and becomes red and tense. Over and behind the coronary sulcus is a brawny swelling, which represents the mucous layer of the prepuce. Behind this an other deep groove is seen, which cor responds to the pweputial orifice, the seat of constriction. If left untreated, gangrene may result; or it may remain chronic, the retracted tissue becoming inelastic and indurated.
Treatment.—When paraphimosis is of sudden development and not dependent upon cedema consecutive to ulcerative lesions, reduction should he attempted immediately. The organ should be ren dered bloodless either by gentle pressure or by the application of a small finger bandage. The parts are then greased well with sweet oil, the index and middle fingers of each hand are crossed behind the glans penis, and with the thumbs attempt should be made to force the glans penis through the swollen tissue. When reduction is possible, the foreskin will slip forward with a characteristic snap. Failing in this, the prmputial orifice is to be divided in the second groove on the dorsum with a curved sharp-pointed his toury, cutting from within outward. Hot compresses should be applied for several hours to restore the circulation and favor the absorption of the cedema.