THE TREATMENT OF CONGENITAL PHIMOSIS.

458 every seven or eight minutes but were less severe,. by a tight ring of mucous membrane just inside the There was a slight expiratory cry, with arching of the bact: prepuce. The skin of the prepuce is, in my opinion, and retraction of the head, with general rigidity, for a fewv never redundant ; it is very elastic and is never the cause seconds, then a succession of very rapid and shallow breathss of the condition. If more proof is required that phimosis as if the diaphragm could work to a slight extent but wass is caused by a stricture of the mucous membrane let us hampered by the abdominal and thoracic muscular rigidity.. examine a case of paraphimosis which has been reduced This enabled a little chloroform to be absorbed and theeby cutting the tight band at the back of the glans. It breathing became normal and the muscles relaxed in a few, will be found that the incision is quite out of sight Now the cause of seconds. At about 5 A.M. the patient was unconscious and1 inside the orifice of the prepuce. the corneal reflex was absent. He was rather blue about thethe condition should guide us in the treatment of these lips and the face had a dirty septic-looking colour. The} cases and my operation consists of cutting the contemperature was 107°, the respiration was 54, and the pulsestriction and preventing its recurrence by the introducI have performed the operation in a was from 120 to 140 but difficult to count. He was spongedL tion of sutures. again and the foot was dressed with carbolic acid and gauze. number of cases and the result has always been perfectHe was fed at 6.50 A.M. He had a longer interval fromthat is, a glans covered by prepuce which is easily retracted spasms-about three-quarters of an hour. At 7.30 A. M. and replaced. Why the operation of circumcision has been the temperature was 105°. He had eight more spasms; so frequently performed I fail to see. The object of the between this time and 10.33 A.M., when he died in one of’ surgeon should be to leave the deformed organ in a normal condition and not to mutilate it by cutting away the covering them, the temperature just before death being 105°. Dr. F. W. Andrewes very kindly examined the piece ofof the glans. Let us apply our conservative surgery to the skin removed from the foot and reported that he had foundpenis and circumcision will no longer occupy a place in one or two long slender bacilli in the tissue-staining by modern surgery. Gram’s method-which were not sporing and hence could not My method of operation is to hold the penis between certainly be identified as tetanus ; that there was inflamma- the left thumb and forefinger, to retract the prepuce as tory infiltration consisting chiefly of polynuclear leucocytes far as it will go, and then with a pair of sharp-pointed beneath the site of the wound ; that horizontally I had cut scissors held in the right hand to cut the stricture first far wide of it, but vertically it extended to the confines of on the right side and then on the left side. It is the piece removed and probably deeper still. At the time I not necessary to slit up the mucous membrane far back but could not see with the naked eye that I had not got beyond it should be done equally on both sides. When the stricture the inflammatory area, nor feel any difference with the is relieved I retract the prepuce and separate the mucous membrane from the glans and also remove any smegma there finger. The convulsions throughout were mild in character- may be around the corona. Now by introducing one suture nothing more than one gets in ordinary epilepsy-and death into each cut the operation is complete. Each suture is appeared to have resulted from the high temperature and introduced so as to make what was a longitudinal incision exhaustion from the number of spasms. into a transverse one. This is done by joining the comThe antitoxin in this case appeared to have little or no mencement of the incision to its termination in the same way more effect than the chloral and bromide and the injection that simple stricture of the pylorus is now relieved. I use into the spinal canal to be no more efficacious than under the fine chromic gut and an ordinary sewing needle. No afterskin. The question of injecting into the ventricle of the treatment is necessary. The little wounds are inside and brain had been discussed but it was decided not to do so will heal readily if left alone. If the sutures do not come as there did not appear sufficient evidence that the results away of themselves they may be removed in a week or ten obtained justified the additional risks from the operation. days, when it will be found that the prepuce is easily Physostigmine has been used in some cases with success- retracted and replaced. Halifax. so, indeed, have many other drugs-and more often without. It is a distinctly depressing remedy and for that reason I did not feel inclined to use it. The serum treatment is not as generally successful as we could wish and it is to be hoped that further researches on toxins, immunity, &c., may result in the production of a serum that will be satisfactory in all It is quite possible that it may have had some effect cases. in mitigating the severity of the spasms. The local applica- Life and Labour of the People of London. By OHARLES BOOTH, JESSE ARGYLE, ERNEST AVES, GEORGE E. tion at the commencement might be of some use as an ARKELL, ARTHUR BAXTER, and GEORGE H. DUCEWORTH. addition to the injections. Final volume. Notes on Social Influences and ConEhrlich’s theory is a distinct advance in giving us a vague London : Macmillan and Co., Limited. New clusion. idea of the complicated chemical changes that occur in the York: The Macmillan Co. 1902. Pp. 451. Price 5s. body and makes one speculate on the effect of injecting net. If it were simply a question of neutralising a serum. poison there would be nothing to worry about, but when we THIS is the seventeenth and last volume of Mr. Charles think of the intricate chemical grouping of such complex Booth’s great work. Roughly speaking, the latter half of bodies as have been called amboceptors, haptophores, the it is to giving an abstract of the contents of the devoted various antibodies, toxoids, &c., one is inclined to marvel as The first series (of four to whether the injection of an antitoxin may not in some complete work (pp. 225-439). is with the natural of antitoxin to the interfere devoted second (of five volumes) by volumes) Poverty, way production the cells of the body, that is to say, interfere with the to Industry, and the third (of seven volumes) to Religious natural cure rather than promote it. The same reasoning, Influences. The final volume is entitled "Notes on Social however, probably applies to the action of drugs as well, of Influences and Conclusion." work now completed has "My which the medical man has been said to know little. been from first to last,"the author says, ’’ dedicated to my Perhaps we shall know more by the end of the century. wife without whose constant sympathy, help, and criticism it Crouch-end, N. could never have been begun, continued, or ended at all." And a noble work it is in its aim and in its execution. The THE TREATMENT OF CONGENITAL reader who looks for teaching finds facts from which he has PHIMOSIS. to construct his own inferences. " Some introduced views," BY J. F. WOODYATT, M.R.C.S. ENG., L.R.C.P. LOND,, Mr. Booth, " and convictions have been intentionally says PRINCIPAL MEDICAL OFFICER, HALIFAX UNION POOR-LAW HOSPITAL. allowed to show themselves here and there in comments I HAVE lately performed a new operation for phimosis made, but no body of doctrine is submitted." The idea with which Mr. Booth began his work was which is very simple and which gives better results than circumcision, inasmuch as after the operation the glans is that every fact which he needed was known to some left covered by a foreskin which is easily retracted and one-the information had only to be collected and put replaced. Before I describe the operation I should like to together. But it was necessary to see that the statements emphasise the fact that in congenital phimosis the constric- received were really facts ; they had, as he puts it, "to be tion which prevents retraction of the prepuce is caused reduced to some common measure of validity." Those

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