and many nervous symptoms. Later on in this paper I shall say more about the nervous symptoms.

Sometimes the degree of phimosis is so great that there is no preputial opening at all. In fact, this is the kind of case I met with in my first experience in circumcision. It was while I was serving my interneship at the Capital City Hospital of Augusta, when I had a patient, an adult, who had been suffering untold agonies as the result of a phimosis with no preputial opening. In other cases the opening is so small that they can not see any part of the glans even though you attempt to pull the prepuce back. But in most cases I find that a small portion of the glans can be brought into view by a certain amount of manipulation. Sometimes, and often it is the case, you may find a complication of phimosis in the way of an elongated prepuce, which is called hypertrophic phimosis. Where you have phimosis it is impossible in many cases to keep the organ clean and in a sanitary condition, and the want or lack of cleanliness leads to infection of different forms, and to inflammation of the glans.

Balanitis is very frequently found in infants as the result of phimosis. There are so many complications from phimosis that I can only touch upon a few in this paper. I have already referred to some.

It may be the cause of urethritis and lead to cystitis, and that to uritis, and it may seriously impair the function of the kidneys.

In consequence of the straining induced by phimosis hernia is apt to be a complication, either umbilical or inguinal. Straining also may lead to hydrocele as a result of the pressure upon the spermatic cord.

These are some of the mechanical results of phimosis, but more important than any of these are the reflex conditions coming as the result from the irritation. Many

times we find such nervous symptoms as a result simply of preputial adhesions.

The pruritus, as a result of the hyperesthetic condition, causes priapism, and hence we have masturbation, which is one of the worst habits the young can be guilty of. It saps the young life and causes many a strong mind to become weak. Early circumcision, from no other cause than this, should be done without thinking of it as being such a delicate thing to do, nor letting timidity upon the part of the physician overcome the duty to your fellow man and to your country.

Insomnia, night terrors and many other nervous symptoms may be produced.

Phimosis is a common cause of frequent micturition, one of the mechanical complications, and a great many of the symptoms of stone in the bladder. Nocturnal incontinence is a symptom with which we are all familiar, and I dare say most of us have had experience on this line of a personal nature. You will excuse me if I say that if I should ask you for your own personal experience with reference to wetting of the bed when you were a child, I should be most confident that your answer would be in the affirmative. Why is this true? Simply because of an existing phimosis or an adherent prepuce. Why is this, then, not an important subject, if all this is true?

Reflex phenomena: We come now to the reflex phenomena which may be brought about by the neglect of early circumcision. The reflex phenomena attributed to phimosis, rather to neglect of early circumcision, are not a few. My sympathy goes out to the little fellow who has been neglected so long that these nervous symptoms are brought on.

In cases where it is necessary to circumcise, do your duty, and when the little fellow becomes a man he will

thank you and his father for thus having treated him. But I was about to diverge from the reflex phenomena, which are caused by phimosis or adherent prepuce.

Foremost among these are epilepsy, convulsions, neurasthenia, pseudo-paralysis, chorea, muscle spasms, strabismus and amaurosis.

These nervous diseases are included in the functional nervous troubles of childhood. Sometimes we fail, however, to make the proper diagnosis in patients suffering from some nervous disease by saying it is due to phimosis. Not all nervous diseases can be attributed to this malformation of the penis. But I say, gentlemen, when you are called to see a patient, and if you see it is nervous and irritable find out if it is a male. If so, look for an adherent prepuce or phimosis. It will be well for us all to remember that one point in trying to come to a conclusion as to what is the real source of the disease. It is a serious thing to neglect a weak, anemic child who shows symptoms of a nervous temperament by letting the phimosis exist. Circumcise! Circumcise!!

Some children have an elongated prepuce and a phimosis without giving them any unpleasantness. This is only true with reference to very healthy children, but later in life it is apt to give them trouble, trouble of a very serious nature, as was the case with my first patient whom I circumcised in the city hospital here in this city, some years ago.

Operation: My method of operation is to first prepare the field by asepticizing after anesthetizing; either a local anesthetic or a general anesthetic may be used. This depends upon the concomitant circumstances. With a couple of hemostatic forceps grasp the foreskin above and below and make a slight traction. Catch the prepuce where it is desired to be cut with another forceps horizon

tally, and cut off the redundant prepuce. Now I trim away another small amount of the mucous membrane, say one-half to three-fourths of an inch from the corona glandis, then stitch the mucous membrane to the skin with catgut and dress with sterile gauze.