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The use of a probe or grooved director to tear up the adhesions is rarely though sometimes necessary. Dilatation by dressing forceps or special phymosis forceps is only occasionally required. Uterine dilators, tracheotomy forceps, and various forms of instruments specially constructed have been used for this stretching process, but as one increases in dexterity from practice he will find them of but little importance, as stripping by the thumbs is ordinarily easily accomplished. Slight edema, and painful micturition will follow this operation for a few days, but emollients are sufficient for relief. A hot hip-bath will greatly facilitate the passage of urine, Retraction and cleansing should be persistently employed thereafter, and the nurse instructed that daily attention is to be practiced. Later the patient should be taught to wash the penis just as he washes his face and hands for cleanliness sake.

There are many who deny that reflex phenomena are caused by phymosis, but the proofs are too positive to admit of disbelief, and Sayre deserves much credit for emphasizing the importance of this adhesion in the production of ataxic conditions. One may well differ from him as regards the remedial measures required, but not as to this causal element in muscular incoordination.

I have before contended and still maintain that the most perfect penis and the one least liable to disease or to induce masturbation is one in which the prepuce moves freely over a normal glans, and that this can be secured in nearly all young children by the simple stripping already described. In a few cases, when this result is not attainable, circumcision may become necessary; and when failure to produce the desired freedom occurs, I do not hesitate to practice the more severe operation. In large boys and in adults all the circumstances are different, and dilatation is rarely beneficial without removal of the foreskin; but in infants and in boys from two to eight one need rarely ask for better results than are secured by the thumbs alone.

Dr. Ellwood Wilson, who for many years has had one of the most extensive practices in this city, recently informed me that he had employed stripping of the glans since my recommendation of the operation in 1883, and that he has now acquired such dexterity of manipulation that he could uncover the glans in almost every young child without the use of any instrument. He now rarely resorts to circumcision, although he formerly practiced it largely. His experience coincides with that of all who have tried the plan. Until the surgeon has acquired this skill, it will be well for him to retract the fold as far as possible, and

while holding it firmly in this position to sweep a probe around the circumference of the head, thus loosening the anterior adhesions. Retraction, which before seemed impossible, will now be a simple matter, since it is the adhesions that produce the apparent contraction. The operation may be done as early as the second day of life.

The retention of the head of the organ beneath the foreskin is said to debar the individual from the full enjoyment of sexual intercourse in later years, but as there does not seem to exist any crying need for incentives in this direction, and as the obtunding influence of friction upon the exposed epithelium is similar in its action and especially as there is no need of any glans being covered provided early stripping is practiced, I still believe that a non-adherent prepuce is the healthiest condition. Moreover, a glans covered by a freely sliding foreskin is certainly better capable of appreciating the sexual orgasm than one that is calloused. Cold water used daily is also more helpful than circumcision in the prevention of disease.

It has already been stated that circumcision is occasionally necessary in children and frequently in adults. The rule should be to expose the glans freely for cleansing purposes whenever the slightest irritation arises. This condition should be secured by a cutting operation provided the simpler method fails. In skillful hands this will be at rare intervals, but when required in infants with excessively long and narrow foreskins, the removal of a ring is better than slitting up the fold, since thickened masses on either side of the frenum are liable to follow the latter operation and greatly disfigure the organ.

A large number of forceps have been devised for this particular operation, many of them ingenious and useful, but entirely unnecessary since a bistoury and forceps are equally good, and are always at hand. The section can always be made anterior to the forceps. Care should be taken in the ordinary circumcision to draw upon the mucous layer more strongly than on the skin, and thus remove a sufficient portion of the former, since if this is not done, slitting and trimming is necessary to remove the contraction, followed by careful stitching. Wire is no better than silk and is much more annoying and painful during the next few days. On account of the great edema of the loose connective tissue which is sure to follow, black sutures are more easily distinguished than white ones. In order to secure the most speedy union, the wound should be washed with a 1 to 5000 bichloride solution, and covered with a large wad of feebly sublimated cotton, which can be renewed at each

urination. The best bandage is an ordinary diaper. The vessels will rarely require either a silk or catgut ligature. Hemorrhage is rare. A fatal case is occasionally, however, reported. The stitches should be removed by the fourth day, and undue inflammation subdued by cooling lotions.

In summing up it can be said that stripping in young infants is one of the simplest and easiest of operations. In children it is still easily accomplished in the majority of cases by the help of a grooved director or probe. After twelve, if the glans has not been uncovered, circumcision will usually be necessary as dilatation is rarely successful in giving that freedom of motion which is essential in all cases.

Exposure of the glans is always necessary for cleanliness sake, and should be secured without fail whenever any nervous or reflex symptoms are present.

GLAUCOMA. Some very practical remarks of Dr. Javal on this subject will not be without interest for the general practitioner, for whom they were intended. "I desire to treat this subject for the reason that it seems well adapted to show the slight use there is in the pretended scientific exactitude which we eye-specialists sometimes are tempted to boast of. And I shall try to treat it in an elementary manner, though it is one of the most difficult subjects in ophthalmology. You know that this glaucoma in its advanced stage is characterized by an augmentation in the pressure on the eye, by a diminution of extent of the visual field, and by a weakening of sight, with conservation of the sense of colors. So that your smart specialist, after having examined the eye with his ophthalmoscope, hastens to measure the tension by means of the tonometre, the peripheric vision with his perimetre, and the color-sight by Wolfberg's method. I have all these things here; but what is the use of showing them to you? For, remark one thing at the commencement: at the period when it is important to establish the diagnosis, all this arsenal will not help you. The ophthalmoscope itself is of no use, for the famous excavation of the optic nerve so much spoken of does not come until later; and as for the pulsation of the central artery of the retina, it may fail you; and I have seen it also in a perfectly healthful eye. It is important that all should be able to recognize glaucoma from its beginning, for expectation is not permitted in this trouble, and the instillation of a single drop of atropine can produce an irremediable aggravation in an eye affected with glaucomatous prodroma. And I will add here

something quite new for you: which is that cocaine can produce just as bad effects in these eyes, notwithstanding the diminution of pressure that follows

its use.

Diagnosis. How will you know glaucoma? For those eyes that are hard to the touch and have perikeratic injection, with a pupil immobile and the cornea dulled and painful, you don't need even the ophthal moscope; but it is great art to catch them before this. The history mostly is that for months, or even years, the patients finds a slight loss of vision in obscurity, and he finds that in the evening there is a halo around the lights. If you are consulted by a person complaining of a loss of vision that has come on rapidly, and you see the slightest inequality in the pupils, the slightest weakness of the sphincter of the iris, be careful and don't put either atropine or cocaine in the eye; also don't forget that an eye with glaucoma is not always hard. The halos spoken of are an important symptom. They will see them mostly when a match is struck in the dark; but these halos may occur in other eye-troubles. In this case you have only to instill a little eserine in the eye, and if they disappear your diagnosis is fixed; and it is to this medicine that you must look to help you in this disease at first. The wholesale druggists now manufacture little gelatinous rings of eserine, each containing the onehundredth of a milligramme of the drug. These you mave give to your patient, and if two of them a day do not relieve the symptoms, then surgical interference is called for. I need not say that all alcohol must be stopped, and but little meat allowed, and that well masticated. This, with plenty of out-door exercise and clothing very loose, constitutes the hygienic treatment.

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Operative Treatment. If, with all your care, it continues, don't delay the operation. Sclerotomy should never be thought of. Iridectomy is the operation; and I presume that you will not care to perform it yourselves, although it is not so difficult with the aid of cocaine, which may be used only when followed by an operation. But there is one thing you can and should do, and that is when you find yourself in presence of an acute glaucoma, when moments are precious, practise a debridgement of the globe near its equator, between the rectus internus and rectus inferior muscles. A bistoury-cut of a few millimetres, as recommended by M. Parinaud, will often give immediate relief, and allow you the time to take the patient to some specialist to have a good iridectomy performed.

To sum up:

Abstain from atropine and cocaine, and use eserine in the first symptoms of glaucoma, and in case of acute glaucoma don't hesiitate to debrider the ocular globe."-Med. Times.

OBSTETRICS.

A FEW SUGGESTIONS FOR THE PREPARATION OF MILK FOR INFANTS. By John M. Keating, M. D., in the Medical News.

At the recent Sanitary convention of the Pennsylvania State Board of Health, I advocated the use of cow's milk prepared so as to resemble closely woman's milk as the best form of diet for at least the first three months, urging at the same time that a certain amount of a soluble salt of lime should always be added to an infant's food to counteract the great tendency to rickets which exists in all bottle-fed, and, indeed, in many of the nursed children of the day.

Let us take one of the given analyses (Percy) of cow's milk, that of an ordinary mixed dairy:

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If this is diluted with three times its bulk of water, it will give us the

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There seems to be some difference of opinion in regard to the quantity of casein and sugar (per cent.) in human milk. In every young infant it is better to have the minimum quantity as a basis to begin with, so that by diluting the milk as above we reach, accurately enough for practical purposes, the percentage as given by A. V. Meigs, viz:

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If to a four ounce mixture composed of one ounce of ordinary milk and three ounces of water, we add one ounce of ordinary cream (about fourteen and a half per cent. of butter), and about eighty grains of sugar

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