310 The Philippine Journal of Science 1921 
skin of the penis was normal, the whole of it was left and after 
two years the skin was still perfectly sound. 
Again it used to be urged that all diseased skin should be 
removed. If, as sometimes happens, the skin of the anterior 
ubdominal wall is extensively involved, to remove the whole 
skin of this region is to make a huge wound without any real 
advantage to the patient. 
Again a man of 60 years should not be treated like a man 
of from 25 to 30 years. In the latter case, to leave unhealthy 
skin is to court recurrence; in the former, it is most unlikely 
that there will be anything of the kind, and the attention of the 
surgeon should be rather drawn in the case of the older man 
to the provision of flaps, so as to insure a quick recovery. 
The same discretion must be shown in dealing with the tes- 
ticles. In a young man these must be certainly preserved, but 
in an old man, if atrophied, and their removal will facilitate 
healing, one or both may be removed. In a case complicated 
with hernia, it is good practice to remove the testicle on the 
side of the hernia. One can then be sure of closing the abdo- 
minal wall securely, and in this case there is the additional 
advantage that the operation is thereby shortened. 
Speaking generally, I use two main forms of incision, one when 
using a tourniquet and another when operating without it. 
When not using a tourniquet, the incisions are made as follows: 
The first is in the median line from the region over the pubis 
to the urinary orifice. Generally, as the tumor grows, the pre- 
puce is inverted, and the glans may be several inches (centi- 
meters) from the external orifice. A finger of the left hand is 
inserted into this orifice, and the incision is rapidly deepened. 
It is very easy to tell when one has exposed the penis. Using 
a pair of scissors, and with the aid of one’s finger as a director, 
the prepuce is opened along the dorsum as far as the glans. All 
smegma is carefully cleaned away, and the lining membrane of 
the prepuce is dissected off and left attached to the glans penis. 
The penis is now to be thoroughly separated from its sur: 
roundings from the suspensory ligament outward, taking care, 
below, not to cut the artery of the frenum. If it is wounded, it 
is better to ligature it at once. Above, care must be taken of 
the vessels on the dorsum of the penis, the vein being always 
very large. If due care is taken, it ought not to be wounded. 
The penis, having been separated, should be wrapped in gauze 
and turned upward. 
