PARAPHIMOSIS.
The sooner the strangulation is reduced the easier will the operation be, and if attempted immediately after the foreskin has been drawn hack a cutting operation is very seldom required.
The surgeon, grasping the penis behind the glans between the middle and index fingers of his interlocked hands, pulls the foreskin forward, whilst at the same time he presses back with both thumbs the swollen glans till it slips behind the constriction. This is the usual method. The writer prefers to grasp the penis behind the glans, between the index and middle fingers of the left hand, near to the metacarpo-phalangeal joint, whilst with the index finger and thumb of the right hand, or with the last joints of all the fingers of the right hand, he surrounds the swollen glans, and patiently reduces the swelling by gentle continuous pressure till its bulk becomes greatly reduced, when it generally slips through the constrict ing band, sometimes painlessly. The success of the ordinary method is chiefly due to the forcible traction of the prepuce forwards, and in the latter method to the reduction of the glans through the strictured ring almost by the same gentle manipulation as in hernia. The cause of difficulty in reduction is the oedema of the glans. When the •edema
disappears under pressure reduction follows.
When reduction by taxis fails, chloroform narcosis being induced, the operation may be again tried, and if reduction is not easily accomplished the surgeon should divide the constricting orifice of the tight prepuce upon the clorsum of the penis by a vertical incision close to the glans behind the swollen collar of preputial tissue, after passing a fine grooved director under it, which prevents the risk of injuring the penis or of dividing any of the large subcutaneous veins.
The glans should he forcibly depressed by the tip of the left thumb as the incision is being made, and as the narrow preputial orifice is divided reduction is easily accomplished.
The gap made by the incision is liable to lead to some deformity of the prepuce, and some surgeons always remove a ring of the reflected mucous membrane with a thin circle of skin, after which the skin of the prepuce is sutured to the ring of membrane surrounding the corona. This method of circumcision also prevents a recurrence of the strangulation, and is generally done at the time.