layers of the prepuce are divided over the director with a single stroke of the scissors almost up to the corona glandis. After the division has been effected the prepuce must be readily retractable. Over the glans throughout the extent of the wound the mucous membrane of the prepuce is united with the skin by means of a series of interrupted sutures, or of a continuous suture.

Circumcision may be effected in various ways. The prepuce may be drawn forward as far as possible and be

OPERATION FOR SHORTENED FRENUM.

FIG. 211.-Transverse division of the frenum.
FIG. 212.-Union at right angles to the direction of the division.

divided just in front of the glans, after which the margins of the outer and inner layers of the prepuce are united by suture. In another method of circumcision the usual dorsal incision is first made, after which portions of the prepuce on either side of the incision are removed with scissors close to the point of reflection on the glans. Throughout the entire extent of the wound the skin is united with the inner layer of the prepuce.

Operation for Shortened Frenum.-Congenital shortness of the frenum, with a normal caliber of the prepuce, is

attended with numerous discomforts (pain in coitus, frequent laceration, hemorrhage). Simple transverse division of the band is not to be recommended on account of the hemorrhage that follows. Division with the Paquelin cautery secures immunity from the hemorrhage, but a considerable time is occupied in the healing of the wound. Functionally good results, with the possibility of securing union by primary intention, are yielded by the following minor plastic operation.

The frenum is divided with a single stroke of the scissors to such a depth that the prepuce can be retracted to a maximum degree without tension. The small wound thus made is united at a right angle to the direction of the incision (Figs. 211 and 212).

Amputation of the Penis.-Malignant neoplasms constitute the exclusive indication for amputation of the penis. This may be practised through the pendulous portion at a selected level by means of a circular incision. Under certain conditions the deeper portions of the member, the roots of the cavernous bodies, must be removed by operation. In all cases, after ablation of the parts, the urethra must be suitably situated and fixed in the wound.

In amputating the penis through the pendulous portion digital compression is exercised, while a circular incision is made transversely. The skin is, after division, retracted, when the operator divides the cavernous bodies transversely with an amputation-knife, cutting from the dorsal aspect toward the urethra. When the urethra is reached it is dissected free for a short distance toward the periphery and is divided transversely 2 cm. in advance of the line of incision through the cavernous bodies. The urethra is snipped through its inferior surface with a single stroke of the scissors, spread upon the wound and united by its free border with the margin of the skin by means of a series of sutures.

In amputating the penis in conjunction with its perineal connections the scotum is divided in a sagittal direction. In the gaping wound the roots of the cavern

ous bodies, with their attachments to the pubic bones, are readily exposed. The urethra is divided transversely through healthy structure, snipped on its lower surface, and sutured in the posterior angle of the wound (perineal urethrostomy).

The cavernous bodies of the penis are detached and reflected upward in conjunction with the peripheral portion of the urethra. If the detachment has been extended to the pendulous portion, the penis is after circular incision of the skin divided transversely at its scrotal attachment and removed. The scrotal wound is closed by suture up to the newly established orifice of the urethra.

Operation for Urethral Fistula.-As long as the fistulous passage is not covered over by skin spontaneous cure can be effected by local applications conjoined with dilatation of the urethra. Under the reverse conditions, and if the mucous membrane of the urethra is adherent to the skin, freshening of the margins of the wound, with suture, becomes necessary to effect a cure. If the fistula be small, an elliptic area is freshened and the defect is closed by transverse deep and superficial sutures (Fig. 213). In freshening an oval area the formation is recommended of lateral flaps by means of incisions made on either side close to the upper and lower extremities of the oval. These flaps are detached from the subjacent structures and after the introduction of buried sutures are brought together and united over the defect (Fig. 214). It is a useful procedure further, after freshening the margins of the fistula, to separate the skin from the mucous membrane throughout the extent of the defect by means of horizontal incisions, so that the margins of the mucous membrane can be approximated without tension. The mucous membrane is united over the defect by means of catgut sutures, and finally the wound in the external integument is closed. In the presence of an extensive defect in the urethra a tegumentary flap taken from the penis is brought over the freshened defect in such a way that its cutaneous aspect

is turned toward the lumen of the urethra. The second step consists in union of the wound in the skin.

Under the best of circumstances the success of any operation for urethral fistula will be rendered disappointing by reason of the discharge of urine, as well as through erections, with tearing out of the sutures. The evacuation of urine interferes with the process of healing whether a catheter is retained or spontaneous micturition takes place.

In the performance of extensive plastic operations upon the penis, therefore, the formation of a provisional vesical or deep urethral fistula during the time of healing is to be recommended.

Operations for Hernia.-Bloody operations for hernia are undertaken for the purpose of either releasing an existing strangulation or removing a free or adherent hernia (radical operation). The first form of operation

(herniotomy) consists in division of the coverings of the hernia, opening of the hernial sac, and division of the constricting ring. The further steps of the operation (reposition of the intestine, formation of a preternatural anus, resection of the bowel) will be governed by the conditions present in the individual case. The cutaneous incision is made in the longitudinal axis of the hernial tumor; in the presence of inguinal hernia in such a manner that the inguinal canal, as well as both inguinal rings, is included within its range. In the presence of femoral hernia the vertical incision passes over the greatest convexity of the hernial tumor. By careful dissection, layer by layer, after division of the subcutaneous connective tissue and the so-called proper fascia of the hernia, the hernial sac is reached. This presents a dull appearance, is in places the seat of small masses of fat, and is often so delicate that the hernial fluid can be seen through it. In the presence of inguinal hernia it will be necessary to divide in the upper portion of the hernial tumor the anterior wall of the inguinal canal, constituted by the aponeurosis of the external oblique muscle and fibers of the internal oblique and transversalis muscles, before the actual coverings of the hernial swelling are reached. The sac of the hernia is incised in the direction of the cutaneous incision, and, after the hernial fluid has been permitted to escape, the removal of the constriction is undertaken. In the presence of an inguinal hernia it will be possible always to expose the constricting ring by division of the anterior wall of the inguinal wall throughout its entire extent (Fig. 215). This is done carefully from without inward until all tension has disappeared.

In the case of femoral hernia division of the constricting band is effected from the cavity of the hernia by means of a blunt-pointed knife, or herniotome, under guidance of the finger, and always directed inward. The sharp margin of Gimbernat's ligament is incised and the constriction is thus removed. After the division of the constricting band has been effected the involved loop of