above, often the seat of superficial ulceration. Here lies the stricture; behind it there rises another oedematous fold, usually smaller than the one in front.

If the stricture of the prepuce is tight enough to arrest the circulation, it may finally cause the destruction by gangrene of all tissues lying in front of it.

Treatment. The first point to decide in a case of paraphimosis is in regard to strangulation. If it exist, delay is inadmissible; if not, temporizing expedients may be resorted to, to reduce inflammation, before appealing to forcible reduction or operation. The test is simple. In strangulation the glans penis is turgid, swollen, blue-black, cold, devoid of sensibility, and perhaps shows already points of commencing gangrene. If there be no strangulation, the glans may be normal, or, if swollen, is red-at least not black-warm, and by compression the blood may be driven out of it; sensibility is also preserved. A paraphimosed glans penis may be inflamed, but still not strangulated.

FIG. 4.

PARAPHIMOSIS WITH STRANGULATION. -In these cases ether should always be administered. Often under the relaxation of anesthesia reduction is accomplished with comparative ease. Ice should be first used locally to produce shrinkage, and a few small punctures may be made to let out serum from the ridge in front of the stricture, if the swelling be excessive. The following are the best methods of reduction: Seize the penis behind the strictured prepuce in the fork of the index and middle fingers of both hands, one placed on either side. This gives more even pressure forward than when one hand only is used. Now make pressure with the thumbs on both sides, in such a direction as to compress the glans laterally, rather than from before backward, and at the same time pull the strictured portion of the prepuce forward, the idea being to make the glans as small as possible by compression, and rather to pull the stricture over the glans than to push the glans through the stricture. The latter attempt is liable to do more harm than good, by flattening out the glans over the stricture, and rendering reduction less possible than before. The corona and a little of the mucous layer of the prepuce beyond should be slightly oiled, and an attempt may be made to insinuate the edge of the thumb-nail under the stricture to assist in lifting it over the corona.

In some cases it is preferable to encircle the penis with one hand, using the other for manipulation. Finally, Mercier's method might be tried. The surgeon stands on the patient's right, places the index

and middle fingers of his right hand longitudinally along the lower surface of the penis, and the pulp of his thumb on the dorsum of the glans penis and the oedematous ridge in front of the point of stricture. By firm pressure crowding down the

swollen mucous layer of the prepuce, he endeavors to insinuate the end of the thumb-nail under the stricture. If he succeeds in this, grasping the penis and the two fingers of the right hand beneath in a circular manner with the left hand, he draws the strictured point up over the thumb-nail. Bardinet's* method-inserting the rounded end of a hair-pin under the stricture on each side, and with these making lateral pressure upon the glans while the prepuce is worked forward-is simple and often effective.

If a prolonged, careful attempt at reduction fails, the strictured point must be divided. To accomplish this subcutaneously, a tenotomy-knife is introduced flatwise along the sheath of the penis under the stricture, and is made to cut

FIG. 6.

outward, until all tension is relieved. Instead of this, a simple incision may be made through the skin down to the sheath of the penis. Inflammatory consolidation of tissue may make it necessary to divide the stricture at several points.

After reduction, the treatment consists in position, rest,

and cleanliness, syringing the preputial cavity with warm water holding a small amount of disinfectant, or mild astringent, in solution. If any contagious ulcer has been the cause of paraphimosis, the surgeon should carefully examine his fingers for cracks or fissures before commencing manipulation. So much handling is required that infection is very apt to occur unless the epidermis of the hands is sound.

In PARAPHIMOSIS WITHOUT STRANGULATION, if the case is recent, reduction must be effected or inflammation will surely set in and complicate the situation. Reduction may be accomplished as detailed above, or by the method successfully employed in the Children's Hos

*"L'Union Médicale," 1873, p. 900.

pital at Pesth.* Here the penis, prepuce, and glans are together subjected to strong continued pressure. Several narrow strips of adhesive plaster are applied longitudinally from the middle of the penis, over the apex of the glans, to the middle of the penis opposite the starting-point. The meatus urinarius is left uncovered. In this way the organ is surrounded and compressed by longitudinal strips. Over these, commencing just behind the orifice of the urethra, a narrow strip of plaster is wound spirally, using pretty firm pressure, until the penis is covered by its circular bandage up to the middle. The application is not painful. In twenty-four hours reduction may be accomplished; a thin rubber bandage is more simple in its application, and more promptly effective.

In old or anæmic patients, having gonorrhoea or an ulcer about the head of the penis, accompanied by lymphangitis, and where the prepuce is short, a large amount of serum may collect in the prepuce, roll it back, and render paraphimosis imminent. The best treatment here is a little rest, with elevation of the penis and application of a twenty-grain solution of tannin, followed by free use of collodion as soon as the patient rises. Unlike the scrotum, the prepuce bears collodion well.

In the majority of cases, when complicating chancroid, herpetic, or other ulceration, paraphimosis is purely the result of inflammation and oedema, and there is no strangulation. Here the main inflammatory condition must be treated, aided by position, pressure, puncture, evaporating and astringent lotions. These will usually be sufficient, but in severe cases a sharp watch should be kept up for any evidences of commencing strangulation. Should it occur, the point of stricture must be straightway relieved. (For other diseases of the prepuce, posthitis, herpes, vegetations, cancer, etc., refer to diseases of glans penis.)

DISEASES OF THE GLANS PENIS.

HERPES PROGENITALIS.-This affection consists in the development. of clusters of vesicles upon reddened patches on the mucous covering of the glans or on either layer of the prepuce-occasionally on other portions of the neighboring skin-attended by a slight sensation of heat and tingling. When occurring on the cuticular layer, herpes runs its course as it does elsewhere on the body; but, when vesicles develop within the preputial orifice, the eruption is modified. Under these circumstances the epithelium of the vesicles gets soaked off, little exulcerations result, more or less general inflammation is apt to arise from retention of the secretions, and balanitis, with posthitis, vegetations, and inflammatory phimosis, may be the ultimate result. In broken-down constitutions the ulcerations perhaps become deep and angry, diagnosis with chancroid difficult, while the glands in one or both groins may inflame and suppurate. These extreme results are rare.

* Schmidt's "Jahrbücher,” and Bumstead on “Venereal,” p. 122, 1870.

When the affection has once occurred, it shows a marked tendency to return. There is often a periodicity about the attacks. Tight prepuce and contact of irritating discharges act as predisposing causes.

Diagnosis.-Vesicles, usually in groups, always precede the ulcerations, while the latter are irregular in shape, superficial, and very rarely complicated by suppurating bubo. The pus is not auto-inoculable. Attention to these points will generally render diagnosis with chancroid easy; where grave doubts exist, auto-inoculation is the proper test.

Treatment is the same as for balanitis. In relapsing cases a long course of iron and arsenic internally often effects a permanent cure.

BALANITIS (Báλavos, a gland) is an inflammation of the surface of the glans penis. Posthitis (Toon, the prepuce) is an inflammation of the prepuce, chiefly affecting its internal surface. Neither can exist for any length of time without becoming more or less complicated by the other. For practical purposes they must be considered together.

cause.

Causes.-Persons of irritable skin and gouty habit are predisposed to this disorder. A long and tight prepuce is always a predisposing The exciting causes are mechanical irritation or uncleanliness from retention of smegma preputii (a white, curdy substance composed of epithelial cells in fatty degeneration and sebaceous matter), or from prolonged contact with gonorrhoeal, leucorrhoeal, menstrual, or other irritating fluids.

Symptoms. The membrane at first becomes reddened, then mottled and moist; next the epithelium comes off in patches, leaving irregular excoriations, which soon ulcerate and discharge a purulent fluid of greater or less consistence. These ulcerations are not preceded by vesicles. There is a burning soreness with itching at the end of the penis, usually scalding on urination. The whole substance of the prepuce may inflame, become intensely reddened around the orifice, and infiltrated with serum, producing inflammatory phimosis, especially if the prepuce is naturally long or tight. The ulcerations rarely become deep, and the inguinal glands do not often suppurate. They frequently become somewhat large and tender. In chronic balanitis with phimosis, the mucous surface of the prepuce is found upon exposure to be covered with granular prominences. Warty growths are not infrequent.

R. W. Taylor* has described a peculiar ringed affection of the prepuce and glans-narrow rings of reddened mucous membrane covered by a thin layer of epithelial scales. The inclosed area is normal, the rings vary from one-fourth to one-half inch in diameter. Sometimes there are segments of circles. The affection is sometimes painful or itching. The rings remain stationary for a time. Sometimes they come out in successive crops. They get well without scar, slowly, under the use of arsenic internally. They should not be confounded with lichen planus of the glans penis.

*"Archives of Medicine," vol. xii, No. 3, December, 1884.

Diagnosis.-Balanitis may be confounded with herpes, chancroid, chancre, or gonorrhoea. At the ulcerative stage it can not be distinguished from balanitis supervening upon herpes. In the early stage its vesicular origin distinguishes it. Chancre is usually single and indurated. In chancroid the ulcerations are deeper and the pus autoinoculable, yet both of these specific ulcers may be complicated by balanitis. Balanitis has been described under the name of external gonorrhoea. It may be mistaken for actual gonorrhoea, if there is phimosis, under which circumstance it is very apt to complicate the main malady. When the meatus urinarius can be seen, however, a little care will easily decide whether the pus comes from the urethra

or not.

Treatment. If the prepuce can be retracted, simple balanitis may be speedily relieved. Cleanliness is of the first importance, but soap should not be used. Warm water with the disinfectant, if needed, will remove all the discharges. After washing, the parts should be dried by gently touching them with a soft cloth, and dusted with a mixture of finely powdered calomel and calcined magnesia, or with calomel alone. If the ulcerations are deep, iodoform is preferable. A piece of lint or old linen, cut so as to be just large enough to cover the surface of the glans, is now to be moistened in one of the following lotions:

Simple dilute lead-water, or a gr. ij-iv solution of sulphate of zinc.

The linen so moistened is laid around the glans, leaving the apex and meatus uncovered; and, finally, the prepuce is pulled forward to its natural position. In this way friction between the inflamed surfaces is avoided, all the discharges are absorbed, and a mildly stimulating fluid is kept in constant contact with the ulcerated or abraded surfaces. The dressing should be repeated twice to four times daily, according to the discharge. After recovery a dry piece of linen should be kept between the glans and prepuce for some weeks, renewed twice daily.

If the prepuce can not be retracted, its cul-de-sac should be thoroughly washed out with tepid water, by means of a syringe with a flat nozzle, if possible, every two or three hours, according to the rapidity