or infidelity could be traced to a lack of sexual affinity as a basis. If sexual hygiene were better understood, the etiology of "wifely frigidity" would be stated as "a long and redundant prepuce in the husband, with accompanying hypersensitiveness of the glans penis," and the treatment "circumcision."

Still another advantage of circumcision remains to be stated, though it seems hardly necessary to do so, as it is usually recognized by the profession at large. I refer to the lessened liability to masturbation. A long foreskin is irritating per se, as it necessitates more manipulation of the parts in bathing, etc., and it most surely becomes more so when not kept clean of the normal secretions of the parts. This irritation leads the child to handle the parts, and, as a rule, pleasureable sensations are elicited from the extremely sensitive mucous membrane, with resultant manipulation and masturbation. The exposure of the glans penis following circumcision does not admit of an accumulation of secretions and consequent irritations, and at the same time lessens the sensitiveness of the organ. The results are obvious.

The operation of circumcision is too well known to require much comment here. However, when the operator aims to secure good cosmetic effects it is not as simple as is generally taught. The line of union between the skin and pseudo-mucous membrane lining the prepuce following circumcision is sometimes-very often, in fact-marked by nodules somewhat resembling the corunculæ myrtiformes. With some attention to the more perfect apposition of the two parts, and a few more sutures, this can be avoided. The frenum should be carefully apposited with the skin on the under surface of the penis first, and then the skin and the pseudo-mucous membrane on the dorsum approximated equally as carefully, the sutures on the sides being placed last, care being taken that there is no eversion of either surface. Sterilized No. 2 catgut forms an efficient suture material. The operation in which the redundant tissue is removed by cutting over the phimosis forceps is in every way preferable; it is quicker, and there is absolutely no danger of injury to the glans penis.

There is rarely if ever any indication calling for circumcision in an infant under three years of age, and the operation is best performed then. The usual method in infants of performing the "dog ear" operation is to be condemned. Local anesthesia under cocain or eucain is to be preferred unless absolutely contra-indicated. The untoward symptoms attributed to cocain by its enemies I have failed to observe,

and, in my opinion, it approaches the ideal in minor surgical work.

There is one addition to the operation which I have employed of late, and for which I had hoped to lay claim to priority, but find that I can not do so. In the ordinary operation the folds which exist on each side of the frenum still remain after the operation has been performed. The removal of a wedge-shaped piece from the frenum obliterates these folds, thus doing away with another lurking-place for infectious organisms. An operation performed as outlined above is complete in every respect, and fulfills all the requirements to its performance.

Recognizing, as we do, the benefits of circumcision, and having heard but one objection to its performance-the declaration of the old Baptist preacher, that "the Lord A'might put it there, and he reckoned he knew his business"-we should use every effort to obtain for it an universal recognition. With the present status of religious dogma, and the eternal war of creed on creed, we can not expect the church to take cognizance of it other than to oppose it. If therefore lies with the physician, the family adviser in affairs hygienic and medical, to urge its acceptance.

KANSAS CITY, MO.

A FEW NOTES ON NASO-PHARYNGEAL DISEASES COMMON TO THE ADULT.*

BY S. G. DABNEY, M. D.

Clinical Lecturer on Diseases of the Eye, Ear, Nose, and Throat in Hospital College of Medicine, Louisville, Ky.

Among the symptoms which are common to the ordinary affections of the naso-pharynx, and which may exist either singly or in various combinations, are the following:

1. Oversecretion of Mucus. This is not only a cause of frequent hawking and expectoration, but, trickling down the throat, it may give rise to cough, and when swallowed may disturb the stomach. It is often caused by a shrunken adenoid growth, the sequel of this disease of childhood which has either been neglected or imperfectly removed. In such cases treatment is most satisfactory. The same symptoms may be due to obstruction within the nasal cavities, and may be relieved by the operation appropriate to this condition. Most obstinate, in my

137.

*Read before the Louisville Medico-Chirurgical Society, January 4, 1901. For discussion see page

experience, are the cases in which a general hyperemia of the nasopharynx is the only cause to be detected.

2. Interference with Deglutition. This may exist either as a slight discomfort or as acute pain. As illustrating the former and at the same time showing how entirely misleading the history as given by the patient often is, I may relate the following case: A very intelligent lady from Somerset, Ky., consulted me for a discomfort in swallowing, resembling the sensation of a foreign body moving up and down. She observed it first after eating watermelon, and was confident that a seed had caught in her throat and slipped up and down. The examination showed a post-nasal soft polyp about the size of a chestnut growing from the nose and resting on the upper surface of the soft palate. Its removal gave her entire relief, and then for the first time she realized to what extent her nose had been obstructed. Acute pain in swallowing may be due to ulceration on the upper surface of the soft palate, generally syphilitic. It is characteristic of specific ulceration that when at rest its pain is far less than that of tuberculosis or carcinoma.

3. Nasal Obstruction, with its Long Train of Consequences. When this develops in the adult, the nose itself being clear, it is often due to a post-nasal polypus, or perhaps several such growths. Their usual origin is the posterior portion of the middle turbinated bone. The size they attain is often remarkable, sometimes as large as an English walnut. The youngest patient in whom I have seen this disease was a boy, eleven years old, both nostrils being completely occluded. The most remarkable case of the kind in my experience was in a young negro man about thirty years old. His general appearance was that of extreme exhaustion and malnutrition. He declared that he had vomited every thing he had swallowed for six months or more, and that a few hours before his visit to me he had vomited up the growth, which was to be seen lying on his tongue. This growth was about the size of my thumb, firm in consistence, dark red in color, smooth in outline, and several inches in length. It grew from the posterior nares. It was removed by slipping a galvano-cautery loop over it, carrying well up toward its origin, and burning it off. The microscopist reported that it was a mucous polyp which had undergone fibro-cystic degeneration. Hanging down in the pharynx, it had caused almost constant nausea. There is not the same tendency to recur in these growths as in the multiple polypi within the nose, the latter being often symptomatic of a disease of the ethnoid. Few operations in minor

surgery give more brilliant or complete relief than the removal of one of these large post-nasal polypi.

4. Symptoms Referable to the Ears. Among these we find deafness. in greater or less degree, tinnitus, occasionally pain and an overresonance of the patient's own voice. Naturally, the causes of these affections most amenable to treatment are such as can be removed by surgical means, adenoid tissue, posterior hypertrophies, and polypi.

5. The Voice. This may be impaired either by growths which lessen resonance by removing the "sounding-board" function of the naso-pharynx, or by affections which cause an oversecretion of mucus and frequent clearing the throat. The latter condition I have treated quite frequently in singers. Often the training of the throat muscles they have undergone is of the greatest assistance in the operative treatment of the naso-pharynx.

Method of Examination. The ease with which the naso-pharynx may be examined by post-rhinoscopy varies very greatly in different individuals. The varying distance between the soft palate and the post-pharyngeal wall is one cause of this variation, but even more important is the control of different individuals over their throat. This is largely a matter of patience and tact on the part of doctor and subject. I have often found White's palate retractor of the greatest assistance both in examination and treatment. I can not but think that some of my friends who fail to get any advantage from it are deficient in the method of its use. Having cleansed the naso-pharynx with post-nasal syringe or spray, a five to ten-per-cent solution of cocaine is applied to the posterior and upper surface of the soft palate, soaked in a little cotton on a probe bent at right angles. After a few minutes' delay the retractor is pushed around the palate and the patient directed to take a deep breath with the lips (not the teeth) closed. In so doing the soft palate is relaxed and brought forward, and the retractor may be fixed on the upper lip. The patient should be directed to continue to breathe naturally as the tongue is depressed. Posterior rhinoscopy with or without this assistance will quickly reveal the presence of new growths, hyperemia or ulceration. In a few cases tying the palate forward with a catheter carried through the nose and brought out through the mouth has been more satisfactory than White's retractor; but generally the latter has been less uncomfortable to the patient and more efficient in drawing forward the palate.

Treatment. For the removal of the post-nasal soft polypi Jarvis' snare has been most useful to me. I generally use No. 5 piano wire. The snare being arranged, and the wire drawn somewhat back, is introduced through the nose and its adjustment over the polyp accomplished with the aid of the rhinoscopic mirror; the surgeon holding the mirror in his left hand, the snare in his right, while the patient holds down his tongue with the depressor. Though this may sometimes be accomplished without fixing the palate, still this is often necessary, and by the methods described is usually easy. As a rule there is no difficulty in operating at the first sitting; occasionally a few visits are necessary to train the patient's throat. In soft polypi the snare may be rapidly closed, but in posterior hypertrophies, and, of course, in harder growths, to avoid hemorrhage, considerable time should be spent in cutting.

In adenoid tissue in adults the indications for its removal are, in my experience, more often oversecretion of mucus and disease of the ears. than well-marked nasal obstruction. A complete removal is therefore all the more necessary. The ideal way to accomplish this is to observe the application of our instruments with the rhinoscopic mirror. By the devices already described this can almost always be accomplished. Both curette and forceps are, in my mind, often called for. The curette is quicker, and with a few good sweeps may often remove nearly the whole growth, but quite frequently the roof of the nasopharynx runs up to an acute angle, and the curette not fitting in this will leave an adenoid mass to keep up hyperemia and oversecretion. Around the mouth of the eustachian tube, too, the forceps are often more efficient. As an application to syphilitic ulcers in this locality, nothing has been better in my hands than nitrate of silver applied on a mop in thirty to sixty grains to the ounce solution, after cleansing with syringe. It should be applied directly, and only to the ulcerated surface.

LOUISVILLE.

THE DANGERS OF GLASSWARE.

BY J. S. HOSKINS, M. D.

In several shapes we use glassware to hold preserves, jelly, salt, milk, etc. By these I mean the new fruit jars that have popular devices, such as rubber bands and glass lids, and wire appliances to hold down the lid; also those which have screw or spiral necks, upon which the zinc top turns. The danger of their use is purely from the