swelling. On this account some radical measure is usually demanded.

Having decided, after trying palliative measures, that an operation is necessary relieve the patient we must choose whether it shall be a simple dorsal incision or a circumcision. Dorsal incision should properly be called a palliative measure as it implies a secondary operation. We have seen cases in which nature had so well removed the excess of foreskin after this procedure that only a careful examination re

Inflammatory Phimosis due to syphilis; papular eruption present. Notice the ulceration which extends two inches onto the shaft of the penis. The meatus was seen protruding into the opening here shown as a dark triangle.

vealed the history, this though after sever l years. The large oedematous saddle-bags left on the sides after the swelling due to syphillis, disappear very slowly, and months afterwards we have found them to be little changed. These are often so large as to preclude the use of the penis for anthing more than a conduit from the bladder. However, there is one condition in which the dorsal incision is entirely proper. One who has had to deal with the circumcision woun| infected with chaneroid, will quickly appreciate the smaller wound and

the fact that the resulting scar is in a place to be removed. Circumcision done in the presence of chancroid demands a general anæsthetic when done after the present methods and is often a failure in spite of the greatest care against infection. Fortunately we have found chancroids rarely a cause of phimosis, thus differing from the chancre, which is such a frequent cause. We remember one case in particular which had two chancroids over and near the fraenum with a prepuce normally very tight and long. This case recovered without trouble, while some papillomata which sprang up on the resulting scar became sufficiently inflamed to produce a phimosis and demand circumcision.

As we are not always able to say what is under the prepuce we prepare for a circumcision. The necessity of stopping with a dorsal incision, the large, hard, distorted tissues, the ulceration of the skin often present, all turn us from the use of a clamp, and we must discard that favorite method used in simple uncomplicated

cases.

The long hairs about the pubic region are clipped. The penis having been thoroughly cleansed, including antiseptic irrigation of the sub-preputial space, the penis is isolated from surroundings by being pulled through a closely fitting hole in a sterile towel. We notice carefully how much foreskin we have. Wrap two layers of gauze around the penis as near the base as possible, this to protect from the small rubber tubing which is now tightly wound over the gauze. Do not use a large heavy catheter but a small tube of soft rubber. This does not disturb relations at all if carefully applied, produces little trauma, and perfect constriction as can be determined by the appearance of the part.

With an ordinary hypodermic syringe we begin to inject a two per cent. aqueous solution of cocain, the first puncture being made half way between the extremity of the prepuce and the swelling showing the position of the corona-glandis. This insures plenty of skin flap when completed. The needle is now threaded along under the skin as far as the amount of swelling will permit injecting a drop at intervals. By always keeping a small space in front of of the needle injected the patient should only feel the first puncture. Here we wish

to say that the more swelling and infiltration present the easier it is to induce anæsthesia.

Having anæsthetized a line for the skin incision we begin at the extremity of the prepuce and inject the mucous membrane as far as we can see. The patient usually

feels this first puncture slightly. We clip, or better, cut, with a bistoury, this anæsthetized area, thus getting more room for further injection which we carry up a middorsal line until the corona-glandis has been freed. If chancroids are found they are cauterized with pure carbolic, as also the wound edges, and dusted with iodoform, the operation not proceeding further. Otherwise, we continue injecting and cutting along lines radiating from the upper extremity of the first incision to the fraenum, leaving a cuff of mucous membrane about of an inch wide around the glands. When the fraenum is reached we inject it freely and here we have the pain of the third needle puncture. The fraenum is the most sensitive part with which we have to deal and requires the most care. Pulling the fraenum out from the shaft and with scissors almost parallel we excise it. This we do in order that we may not have the large lump of tissue always left when the fraenum is not excised. This excess of tissue atrophies very slowly as it carries in it an artery, and is always a source of much worry to the patient who never fails to notice it, the cosmetic effect being verv bad. The subcutaneous areolar tissue is next picked up with the dissecting forceps and clipped out around the entire incision thus giving better approximation.

We now remove the constricting band and tie the arteries with fine cat-gut. The fraenal artery should always be found and tied, one or two dorsal arteries usually require this also. Pinching and twisting will not suffice and tying will avoid later mishaps. The bleeding which has taken place in the meantime washes away most of the cocaine not removed with the foreskin, so we need have no fears of getting toxic effects.

The first suture should be silk and should pass through the two corners of the flaps left from the fraenum and through the median raphe as shown in cut No. 2. Perfect alignment of the raphe and fraenum now being assured the next suture,

Showing ventral surface of penis, flaps and method of inserting sutures after fraenum has been excised. The stitches are shown nearer the margins of the flaps than is desirable in operation. Drawn by Dr. H. A.. Ashouer.

compressed with sponges wrung out of hot water. This depletes it, and it is wrapped in dry gauze and a bandage tightly wound around. As soon as this begins to cause pain, usually in about an hour it is removed and the penis loosely inclosed in gauze thickly spread with a sterilized 5 per cent. borated vaseline ointment. The wholeis laid upon the groin and retained by at

jock-strap supporter. This done when the patient can leave the office. He returns each day to have it redressed, a dressing smeared with the ointment always being used prevents sticking. This greatly facilitates healing by keeping the parts protected from contamination and undi-turbed as they might be by dressing which is continually adhering. In one week to ten days the dressing is left off.

Attention is called to the following points: This treatment is carried out in our office with local anesthesia, without pain to the patient save three needle punctures. It does not interfere with daily vocation. Union of parts always takes place kindly though there is much infective material present. Syphlitic infection, if the patient is put on proper treatment in n way influences healing nor is there any untoward scar. Always use the oil dressing and the jock-strap supporter which immobilizes and protects the part while pursuing regular work. The fraenum should be excised and the fraenal artery tied.

The prospect of this operation of necessity will often decide patients with an uncomplicated phimosis to accept circumcision as a prophylactic measure.

743 Virginia avenue.

AFFECTIONS OF THE HANDS AND FEET.

BY DR. ISADORE DYER, NEW ORLEANS, In the New Orleans Medical and Surgical Journal.

In the summer many people complain of the hands and feet perspiring, and this may often result in a chronic condition of hyperidrosis, and is often complicated with a tendency to inflammation, causing much pain, and possibly confining the patient to bed. The condition is apparently easy to treat: 1. Advise the use of white castile soap and restrict excessive drink. Give a small dose of strychnia internally for at long period, about six weeks. For the hands, the use of a three to five per cent. alcoholic solution of salicylic acid frequently during the day; for the feet, a like remedy in powdered form, namely, salicylic acid half dram, tannin one dram. powdered arrowroot and rice starch, of

each half an ounce, dusted in the stockings every day. Where the feet are inflamed and not blistered, simple bathing for twenty to thirty minutes in hot water, with four ounces of laundry starch to the gallon, should be of service before the use of powder. In the more chronic condition lead water may be used on cloths applied at bed-time, and if the blisters suppurate, nothing relieves better than a five to ten per cent. solution of ichthyol. The commoner conditions of the nails of the hands and feet are: Ingrown nails, run-arounds, hangnails, horn-nail, and felon. The hangnail often causes paroychia, and as often the felon. It should be held in place and collodion painted over it. When infection occurs, touch the spot with carbolic acid and mop afterward with alcohol, or touch it with nitrate of silver. If the infection goes further, nothing is so good as a 1 to 1,000 bichlorid dressing kept constantly wet, which often aborts felons, and is much better than the soap and sugar and other compounds of household prac-. tice. The ingrown nail can be treated by . scraping a notch and clip to keep the flesh. away from the nail. In severe cases it may require the removal of a portion cf the nail and redundant skin. Warts will almost always disappear under daily painting with salicylic acid in collodion (5 per cent.) solution, excepting in the acuminate type. Other remedies which he uses are formalin solution, corrosive sublimate, and sulphur. Corns and bunions are sacrifices to civilization, and the original conditions are relieved by the wearing of properly adjusted shoes and protecting the part with a simple cotton and collodion dressing. A useful and convenient remedy is tincture of iodin. Bathing in starch water is also advisable, and should be practiced twice a day. He speaks in condemnation of the commoner practice of letting chirpodists work on the feet with a knife that is always unclean, helping only to promote disease and the practice of the operator. Salicylic acid plaster, 10 per cent., is useful for flat corns not especially painful. Most of the local applications are suitable, but the above seem to be the ones here especially recommended.

MISCELLANY.

A Wet and Cold April.

According to the monthly summary of the weather bureau for last April, the mean temperature for the month was colder than for any April since 1874, when the mean was just the same, 46. During the last thirty-four years, 16 was the lowest mean temperature for any April, and the mean temperature for the last thirtyfour Aprils was 52. The highest temperature last month was 78, on the 23d; the lowest was 25, on the 20th; the greatest daily range was 28 degrees, on the 15th, and the least daily range was 6 degrees, on the 26th.

During the month there was more precipitation, 5.53 inches, than there had been since 1893, when there had been 8.6 inches. The average precipitation for the last thirty-four Aprils was 3.46 inches. The accumulated excess in precipitation since January 1 was 9.59 inches, at the end of April. There were heavy frosts on the 14th and the 17th and light frosts on the 4th, the 5th, the 18th and the 21st.

April was a bad pneumonia month all over the country. In Chicago with a population of two million, there were 2,328 deaths from pneumonia and 1,154 from consumption. The rate of deaths in children was low; only 7 from measles and the same from whooping cough. Scarlatina claimed 83, diphtheria 136. The death rate was 15.89. The open houses of May mean the exit of pneumonia.

'An echo of the Bulletin of November 7, 1903-in which it was urged that "Pneumonia is a disease begotten of over-housing, over-crowding, over-clothing, overeating and drinking, over-coddling," and that its restriction is to be sought through "a simpler housing, with abundant facilities for the access of sunshine and fresh air, and space enough for each individual," etc.-is heard in these closing sentences of an editorial on "The Value of Fresh Air" in the current issue of the Journal of the American Medical Association:

"In the course of civilization man has gotten very far away from Nature-part of this of necessity and part from luxurious indulgence and the neglect of proper elements of health. We would be a hardier

race if we coddled ourselves less, and the worst form of coddling from which we suffer is in our over-heated and ill-ventilated apartments. Steam and hot-water heated flats, with storm windows and rubber-stripped doorways, are direct possibilities of lung and other infection. The awakening of the people to this fact, as well as to the dangers of crowded assembly rooms, street cars and other conveyances where fresh air is a dreaded and carefully avoided intruder, is an excellent thing."

Dr. Shrady on Vacations.

"To prescribe vacations for humanity at large," said Dr. George F. Shrady, “is like firing a shotgun at a black cat in the dark. You may hit the mark, but the chances are against it. The vacation must be adapted to the temperament, the disposition and the physical conditions in each case. cation implies a freedom from duty, a complete change of condition and environment. The moment pleasure becomes work it is a bore. When your outing bores you go back to work.

Va

"There are general principles which may be laid down with regard to vacations, and they are simple enough. The first thing is the ridding of the mind of business cares and worries. The sea voyage should furnish an ideal vacation, because on the ocean men are supposed not to be in touch with business. Its usefulness is likely to be impaired these days, though, by the wireless telegraph and the daily ocean newspaper. The telegraph and the telephone are bad enough and the mail is an evil when it invades the vacation. The resolution to receive neither letters nor telegrams and a healthy belief that no news is good news furnish a good foundation for a real vacation.

"One is likely to make a mistake if he follows his first impulse. Let him take his vacation if he can when he feels tired, not in accordance with a programme made up months in advance. The vacation is one begun when we give way to the whims of indolence."

Dr. Henry B. Savage, of New York, an expert in physical culture, says:

"Perhaps it could be hardly said that I prescribe vacations and diet and such things. I merely suggest. There is no

use trying to get a man to adopt anything which does not appeal to him.

To banker and broker and Wall street clerk who work about electricity and have. the click of the telegraph keys constantly in the 'r ears I would say, 'You have ragged nerves, therefore, recipe, Adirondack wilderness. Nothing is more beneficial for men whose nerves are constantly on edge than a rest of two or three weeks in the forest.

"To my mind, there is nothing better for the thin and nervous man than life by the seashore or an ocean voyage. The salt and ozone cause him to sleep and his nerves are soothed and rested. To the fat man I would say the mountains are what he needs. He requires some exercise, such as mountain climbing would give him, for instance.

"For a man who is run down nervously on account of a great mental strain or from over stimulation I have found that a generous diet, a little light exercise and plenty of sleep will work wonders.

"The ideal vacation for the business man and the clerk should combine plain food, moderate exercise, fresh air and plenty of sleep."

Tuberculosis in Indiana.

During the month of May there were 41 deaths from tuberculosis, 276 being females, 110 of whom died between the ages of eighteen and forty and left 220 orphans; 195 males, 41 of whom were married and who left 82 orphans. Thus consumption, in its invasion of 397 homes during the month, left upon the counties or friends the expense of 302 orphans.

Deaths from all causes during the month numbered 2,971, the rate being 13.1 per 1,000 people, or an increase of 2 per thousand more than in May last year. The death rate for Indianapolis was 15 in 1,000 and for Evansville 14. However, the general health was better in the northern counties than in the Ohio valley.

There were 259 cases of smallpox with 6 deaths reported from 36 counties. In the corresponding month last year there were 579 cases with 10 deaths from 59 counties. With this comparison there is a decided decrease to be recorded for this

disease. The smallpox deaths this month occurred, Wabash county 1, Vigo 1, Dubois 1, Greene 3.

What "Human Ostrich" Ate.

NEW YORK, May 4.-John Fasel, the "human ostrich," who swallowed objects made of iron and brass, was operated on yesterday for acute indigestion caused by partaking too heartily of a fricas-e of hardware. The operation began at 10 o'clock in the morning and was completed at 2 o'clock in the afternoon. The surgeon succeeded in extracting from Frasel's alimentary canal six knives, one gold chain, three ring chains, four keys, twelve wire nails of all sizes, eight horseshoe nails and a metal pin two inches long. It was said that the pin caused all the trouble by lodging in the intestines. Fasel is in a critical condition. This is the second operation of the same kind.

In Lighter Vein.

LOVE IN FICTION.

"Love in fiction is a convention, a tradition," said Mr. Howells, reflectively, "We still live more or less under the influence of Thackeray. He asks us to believe in lives spent in gentle melancholy on account of an early disappointment in love-'crossed in love is the expression coined for this bit of romanticism that, like most romanticism, is decidedly false to life, certainly to the life of our day. As a matter of fact men love, lose and forget-and women, too; life drives them on. Or they love and win and marry, and happiness is succeeded by placid contentment or internecine war ending in armed neutrality; but ever life drives them on. We have no time for either eternal regret or the constant renewal of an ecstasy of the past. Love is for the spring time of life; in maturity it pales, in the most fortunate cases into a beautiful friendship, into loyalty rewarded by contentment, which is a more enduring prize than the ill-defined state vaguely described as happiness. Broken hearts are healed by more urgent calls upon the energies, by vaster interests; the inexorable, prosaic daily round, ever widening, is a blessing."-The Lamp.