will generally attend steady efforts repeated day by day to draw back the prepuce. Acquired Phimosis must be treated according to the indications of each case. Generally rest in bed, cleanliness and patience suffice in an acute case; but occasionally it is absolutely necessary to either circumcise, slit up, or forcibly dilate the prepuce. If the prepuce be itself inflamed, it is best to merely slit it up in the dorsal middle line.

PARAPHIMOSIS. The prepuce behind the glans strangles it, and cannot be pulled forward by the patient. Treatment.-Invariable success, except in old cases, may be expected from Mr. Furneoux Jordan's plan of compressing the penis gently and patiently in the cavity formed by hollowing slightly the palms of the two hands and then opposing them. Soon the oedema yields, and then the paraphimosis is reduced by the fingers and thumbs. The preliminary compression, if gently and patiently done, makes bearable an otherwise intolerably painful procedure. 2. In case of need, the following operation may be done: draw the glans forward, then, passing the point of a narrow-bladed scalpel into the sulcus on the dorsum of the penis, make a perpendicular incision about one-third of an inch in length through the integuments at the bottom of the groove directly across it '-Erichsen. Thus the constricting band is divided.

HERPES PREPUTII may be mistaken for chancre. Distinguishable by its extremely superficial character, by the number of vesicles at first, and afterwards by there being nothing to see except excoriation and pus. Lasts a few days. Readily cured by washing once a day with hot water and dressing with zinc ointment. Patients subject to it should never use soap to the part, but wash daily with water only and dry thoroughly.

PENIS, WARTS ON.-For pathology, &c., vide CONDYLOMATA, and SYPHILIS. Treatment.-Snip off with scissors. Dress with cupri sulph. pulv. and zinci oxid. Or keep constantly applied lint soaked in R acid. nitric. dil. 3ij, aquæ Oj. In obstinately recurrent cases, the prepuce should be worn back and the glans kept exposed.

PENIS, CANCER of.

EPITHELIOMA. (Scirrhus is extremely rare.) Usually commences after middle life, on the glans, as a firm warty growth, with a broad base. Its progress resembles

that of cancer elsewhere, but it is usually slow, and it seldom infects other organs. Treatment.-Thorough excision. Amputation not necessary where a clean sweep can be effected without so radical a measure. When there is sufficient doubt about the diagnosis, give a fair trial to antisyphilitic remedies.

PENIS, GANGRENE OF.--Besides the ordinary simple and specific inflammations to which the organ is liable, Humphry instances the following as recorded causes of gangrene: typhus and paraplegia. Spontaneous gangrene has been observed (Partridge).

PRIAPISM is rather a symptom than a disease, and points to one of two classes of causes: (1) reflex irritation, e.g., from gonorrhœa, prostatic disease, and injuries to penis; (2) paralyses, e.g., from injuries to spinal cord.

The penis is liable to many other affections common to the ordinary tissues, and these are frequently mistaken for specific affections; e.g., I have known one of the most able specialists in London to diagnose an inflamed lymphatic as a hard chancre. Phlebitis occurs occasionally, producing the ordinary symptoms.

PENIS, INJURIES OF.-Chief points in connection with these are that (1) extensive contusion produces priapism, lasting for days; (2) wounds should be carefully adjusted, and united by sutures; (3) bleeding is easily arrested by cold and pressure; (4) swelling of the penis in children should suggest the possibility of a string tied round the organ having been hidden by the swelling.

Perinæum.-Chief affections are abscess and fistula. Hernia and a misplaced testicle in the perinæum occur very rarely.

PERINEUM, ABSCESS IN THE.-Commonly caused by a slight urinary extravasation behind a stricture. Symptoms.-At first attention is attracted by fever, perhaps rigors, and pain in the region of the bulb. A hard lump is felt; this increases and softens. Treatment.-Open early; incise in the middle line. If a stricture co-exist, it is good practice to divide it at the same time (external urethrotomy). At all events the stricture, being the cause of the abscess, must be treated.

PERINEAL FISTULA.-A result of perineal abscess. Generally closes when the original stricture of the urethra is cured. Perinæal fistulæ occasionally have their origin in comparatively remote affections, e.g., cancer within the pelvis. In order to cure

a perinæal fistula it may be necessary to (1) teach the patient to catheterise himself four times a day, or (2) to incise the fistula freely, or (3) to cauterise it; (4) it is to be remembered that the presence of a small calculus may prevent healing.-(Thompson.)

PERINEUM, INJURIES TO.-Causes.-Blows received in climbing over railings, &c., or by being thrown on the pommel of the saddle. Pressure of child's head in parturition. The injuries vary in seriousness from slight bruises to injuries involving such important structures as the urethra, rectum, and bladder. Parturition may result in

Ruptured Perinæum.-Varies much in extent. The more extensive ruptures often allow the walls of the vagina, rectum, or bladder, as well as the uterus, to prolapse. The utmost annoyance may be caused by inability to hold the fæces. Treatment. Sutures should be put in at the time when the injury occurs. Otherwise it is, except in trifling cases, advisable to postpone the operation until the child can be weaned and the mother restored to the best attainable health. Operation.-Scalpels with short and with long handles, forceps, long and short, strongly curved needles with handles (e.g., Baker Browne's needle), sutures of silk, whip-cord and silver or catgut. Ligature, artery forceps, etc. Handled sponges. Duck-bill speculum; retractors. Lithotomy position. Assistant holds duck-bill speculum against anterior wall of vagina. Perinæum, etc. is shaved. Square flaps of skin and mucous membrane are marked out on either side of rupture, involving part of the vaginal surface of the recto-vaginal septum, and widening somewhat towards the surface of the perinæum. The flaps to be reflected thoroughly, not the slightest bit of mucous membrane to be left. But the flaps need not be removed altogether, should rather be left and sewn together over the vaginal edge of the wound. Pass posterior suture first. It should go through recto-vaginal septum, i.e., should never appear in the rupture at all. Suture to enter and leave skin at one inch from edge of wound. Fasten on two pieces of elastic catheter, or else use button suture. When deep sutures are tightened, wound gapes superficially. To remedy this add a few small silver sutures. Before sutures are tightened, stop all hæmor

rhage. Iced water usually recommended for this. I think hot water will be found to answer better (120° to 130° Fahr.). The hæmorrhage will be less if the mucous membrane only, without any of the subjacent erectile tissue, be shaved off (T. Smith). To lessen tension, the superficial fibres of the sphincter ani may be divided laterally; or lateral incisions may be made a short distance outside the external ends of the sutures. Bowels should have been well opened before, and should, after the operation, be kept closed by liq. opii m x bis die, for a fortnight. For ten days draw off urine thrice a day with a catheter; and, for a week or two afterwards, patient should urinate on her hands and knees. Pay attention to the diet. Keep the wound and vagina clean. After washing with any antiseptic lotion, dry carefully and gently.

Periostitis. Vide BONE.

Phagedæna. Vide ULCERS and SYPHILIS.

Pharynx. Its chief affections are inflammation, abscess, tumours, epithelioma, syphilitic disease, ulceration, wounds, and presence of foreign bodies.

CONGENITAL DISCONTINUITY OF PHARYNX AND ESOPHAGUS, A complete monograph on this, by Ilott of Bromley, is in Path, Transact. for 1876.

ACUTE DIFFUSE PHARYNGITIS.-Highly dangerous. Usually spreads from fauces. Dyspnoea, dysphagia. Great swelling, internal (and often also external). Progress rapid. Termination. Usually death, in a few days, either suddenly or with signs of sinking. Pathology.-Inflammation of cellular tissue of pharynx and of oesophagus; great oedema; often suppuration. Treatment.-Supporting, stimulating. Enemata. Quinine. Laryngotomy to avert danger of suffocation.

POST-PHARYNGEAL ABSCESS.-Cause. Often caries of cervi cal vertebræ. Most dangerous in children: because then may not be diagnosed till it has produced suffocation. May open externally in neck. Treatment.-Puncture with an abscess knife having its blade, except near the point, protected by lint. Finger may be used as a director.

ULCERS OF PHARYNX, usually syphilitic in adults and some

S

Treatment.-See Treatment of

times strumous in children.

SYPHILIS and SCROFULA.

DILATATIONS AND POUCHES OF PHARYNX Occur. Food is apt to lodge in them. Diagnose by the history given by the patient. Regurgitation sometimes occurs, or patient may be able to empty the pouch by external pressure. Secondary laryngitis may occur.

PHARYNX, FOREIGN BODIES IN.-Vide ESOPHAGUS.

Phimosis. Vide PENIS.

Prostate.-Chief Affections. - Inflammation, acute and chronic; abscess, periprostatic abscess; hypertrophy; simple tumours; atrophy; tubercle; cysts; malignant disease.

PROSTATE, ACUTE INFLAMMATION OF. Causes. Gonorrhoea, cystitis, strong injections, cauterisation, mechanical injuries, e.g., from sounds. Catching cold, alcoholic excesses, and sexual excitement will determine an attack if some other influence pre-exist, such as gonorrhoea, gout, or rheumatism. Symptoms.-Local pain extending into loins and back, weight, and fulness. Frequent and painful micturition, especially painful at the close of the act. Pain becomes shooting and throbbing. Anal and perineal tenderness and fulness. Defæcation painful. Micturition often difficult or impossible.

Fever. Pus in urine when abscess bursts. Per anum the prostate can be felt enlarged. Piles may be induced. Treatment.-Rest in bed. An aperient to commence with. Antimony. Acetate of potash in full doses. Ten to twenty leeches to perinæum and round anus. Hot hip-bath. Poultices to perinæum. Retention usually relieved by hot baths and liq. opii. Or a soft catheter may be passed. Prostate remains for a long time afterwards enlarged and hard, obstructing flow of urine.

PROSTATE, CHRONIC INFLAMMATION OF.-Usually a sequel of acute. Generally, but not always, enlargement of the gland. Obstruction to passage of urine. Anal and perinæal pain. Gleety discharge. Sometimes nocturnal emissions. Pain in sexual intercourse. Irritable bladder. Treatment.-Rest. Regular and unstimulating diet. Tonics and stomachics. Iron, with a mild aperient. Counter-irritation to perinæum. For the nocturnal emissions, make three or four applications of a