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point of the raphe, which extends from the anus to the scrotum, and continue it downward and outward to a point half-way between the tuber ischii and the
Divide the tissues in this line until the groove in the staff can be felt. Guide the point of the knife, with its edge turned downward, into the groove. Push the knife, depressing its handle if the staff is curved, to make the point run in the groove into the bladder. Incise the neck of the bladder and the prostate, while withdrawing the knife in a more horizontal line than the skin incision. The finger introduced along the staff can now examine the interior of the bladder.
The left transversus perinei and superficial perineal arteries may be ligated.
To avoid wounding the rectum, introduce the left index-finger while cutting the tissues.
Introduce a chemise catheter as in the last operation.
b. In the Female.—The position is the same as that for operation on the male subject.
Pass a grooved staff into the bladder. Begin an incision just to the left of the clitoris, and continue it downward and outward one inch and a half parallel to the descending ramus of the pubes and ascending ramus of the ischium. Incise the tissues in this line until the groove of the staff can be felt near the neck of the bladder. Guide the point of the knife along the nail of the left index-finger into the groove of the staff, and incise the neck of the bladder downward and outward in the line of the incision. To avoid wounding the vagina, introduce the finger while incising the tissues.
The finger can easily explore the interior of the bladder through the incision.
Suprapubic Cystotomy.--Place the subject on the back, and shave the hair from over the pubes. Insert into the rectum beyond the external sphincter a rubber bag. Distend the bag with about twelve ounces of water, after introducing a catheter into the bladder. Inject into the bladder through the catheter from six to ten ounces of water, and plug the catheter.
Stand on the left-hand side and begin an incision over the symphysis pubis, extending upward three inches in the median line of the body. Divide the integument and fasciæ. Separate the pyramidales and recti muscles. Divide the fascia transversalis on a director, and tease through the areolar tissue immediately above the symphysis pubis, until the bladderwall is uncovered. The bladder is recognized by its muscular fibers, its vessels, its color, and its feel against the beak of the catheter.
With the fingers separate the areolar tissue from the bladder upward, to the extent of two inches. Retract the areolar tissue, and hook a tenaculum into the bladder on each side of the median line. Make the point of the catheter to bulge in the wound, and examine the overlying tissue.
Direct with the left index-finger the point of the knife to the upper limit of the exposed bladder-wall. Pierce the. bladder-wall, holding the knife with its edge turned downward. Divide the bladder-wall in the median line down to the symphysis pubis.
Examine the interior of the crgan with the finger. (In introducing the forceps the tenacula must still retain their hold to prevent the walls of the bladder from being pushed backward.) Allow the water to escape from the rubber bag.
Insert into the bladder through the wound the end of a large drainage-tube, leaving the other end outside. Stitch the wound. Remove the bag from the rectum.
In the adult female, the vagina instead of the rectum may be distended with the rubber bag.
This requires a suprapubic cystotomy. The opening into the bladder is made large enough to admit the index-finger and a bougie.
Follow with the left index-finger the anterior wall of the bladder downward in the median line. Feel the smooth floor of the bladder at the neck (trigone) and hook the finger forward into the urethral opening. Pass a bougie along the finger, and direct it into the urethra.
The end of the bougie can be felt through the perinæum. The bougie may be passed through the whole length of the urethra.
RESECTION OF THE SCROTUM.
Place the subject on the back. If the operation be practiced on one side, the testicle of that side must be pushed up to the external abdominal ring.
Stretch uniformly the half of the scrotum to be operated upon. Make a row of interrupted quilt sutures one half inch above the proposed section at intervals of one quarter of an inch. Allow sufficient space for the introduction of drainage-tubes, by omitting the first and last sutures. The line of sutures
should make an acute angle with the median raphe of the scrotum.
Sever the part of the scrotum one half inch below the line of quilt sutures. Introduce the drainagetubes, and bring the edges together by means of the continuous suture.
If the operation be: bilateral, both testicles are pushed upward near the external abdominal rings. The row of sutures is made horizontally or slightly curved, with the concavity upward, across the stretched scrotum. Allow for drainage at each end. Sever the portion of the scrotum one half inch below the row of quilt sutures, and proceed as in case of the unilateral operation. Several small arteries may be found and ligated.
Henry's clamp, if used, simplifies the operation.
Place the subject on the back. Mark the skin of the prepuce on a level with the meatus of the urethra.
Catch the end of the foreskin above with a pair of forceps, and with a second pair catch the end below. One of the blades of each forceps should fasten the mucous membrane, and the other the skin. Pull upon the forceps, at the same time separating them to put the foreskin on the stretch. Clamp the foreskin on a line with the mark made before it was stretched. (The clamp should be placed perpendicularly and not obliquely, as often advised.) Sever the portion of the foreskin beyond the clamp. The artery of the frænum may be ligated.
The skin will retract so as to uncover about one
half of the glans penis. Slit up the mucous membrane in the median line along the dorsum to the level of the retracted skin. Pare off the mucous membrane in a line from the lower border of the meatus urinarius to the central point of a line along the middle of the dorsum of the glans penis.
Separate any adhesions of the mucous membrane to the glans. Stitch the contiguous cut edges of the skin and mucous membrane together.
The mucous membrane is shortest along the dorsum, and the skin is cut circularly, hence the resulting foreskin slants obliquely downward and forward. The frænum permanently secures this shape to the new foreskin.
AMPUTATION OF THE PENIS.
Place the subject on the back.
Pierce the penis horizontally from side to side, between the corpora cavernosa and the corpus spongiosum, with an acupressure-needle. The penis must be pierced nearer the body than the line of the amputation. Tie a tape around the penis above the acupressure-needle. Divide the integument circularly one half inch below the proposed division of the corpora cavernosa. Retract the skin and divide with a narrow-bladed knife the corpora cavernosa. Turn the edge of the knife forward and cut between the corpora cavernosa and the corpus spongiosum. Divide the corpus spongiosum one half inch in front of the division of the corpora cavernosa. The dorsal arteries of the penis and the arteries of the corpora cavernosa may be ligated.
Divide the protruding corpus spongiosum verti