must be strictly observed in the performance of internal urethrotomy:

I. The urethra must be thoroughly irrigated immediately after the operation, after the first urination and after the first passage of sounds subsequent to the operation. The bladder should also be emptied and irrigated at the end of the operation.

2. The meatus must be cut to a size of 4 mm. larger than the normal caliber of the urethra.

3. The strictured part of the canal must be cut to the full size of the normal caliber of the urethra in each individual

case.

4. The normal caliber should in each case be determined beforehand in accordance with the standard of measurements laid down by Otis.

5. The operation will fail if the urethra is acutely or subacutely inflamed at the time of its performance, or if such inflammation arises during the healing of the incision subsequently. The tying of a catheter into the urethra after the operation is objectionable, because of the inflammatory reaction which it so frequently excites. When this occurs a greater amount of connective tissue is formed in the cicatrix, and recontraction results.

6. The normal caliber of the urethra must be maintained during the healing of the incision, and this is secured by the passage of a sound of the size of the normal caliber of the urethra every second day after the operation until the wound is healed.

This requires on an average 14 days. The absence of bleeding following the use of the sound is a reliable guide for determining when the incision has healed.

Summarizing what has been said, it may be put thus:

are

1. Electrolysis and divulsion methods of treatment which should both be abandoned.

2. Internal urethrotomy is the only method of treatment by which an important number of cures can be obtained. It is an operation involving but little danger. Its application should be restricted to strictures within the first five inches of the canal unless external perineal urethrotomy is done in combination with it. 3. For strictures of the deeper part of the canal gradual dilatation is the best form of treatment if constitutional disturbance does not rise in connection with its employment, and if the urethra for a reasonable length of time maintains the caliber to which it has been expanded by the instruments.

4. For the cases in which the strictures of the deep urethra recontract rapidly after dilatation, or those in which constitutional disturbances arise in the course of its employment, also for the resistant or impassable strictures of the deep urethra, in all of which conditions gradual dilatation is useless, external perineal urethrotomy, or internal urethrotomy combined with the external incision in the perineum, is the safest and most efficient method of treatment.

5. External perineal urethrotomy is the only operation that should be applied. in cases of stricture accompanied by urinary extravasation.

6. Resection of the strictural part of the canal should be selected in cases of intractable, very dense strictures of the perineal part of the canal.

Internal urethrotomy done under the conditions and in accordance with the rules I have stated above will yield from 50 per cent. to 60 per cent. of radical cures, and at an operative risk of death of about 1.5 per cent.

into the retina at birth, that the defective vision has an anatomic basis. At this stage, if the squinting eye is forced into use, it will speedily regain the vision which it has begun to lose. If, however, the child is neglected, the vision of the squinting eye grows progressively worse, and may become in time so blind that the child is hardly able to count fingers when held a foot in front of the eye. When this stage has been reached, it is usually too late to force the eye to take up its function again, and it has become blind or amblyopic from disuse. It may safely be affirmed that only in those cases in which the educative treatment of the squinting eye is begun very shortly after the onset of the squint will it be possible to bring about a complete restoration of vision. From this point of view alone it is absolutely essential that there be no delay in instituting treatment. Furthermore, the sooner the training to develop the sense of fusion is begun the better chance will the child have of acquiring full binocular vision.

There are five therapeutic indications: (1) To correct as accurately as possible any refractive error; (2) to occlude the fixing eye, thereby forcing into use the deviating eye; (3) (for the same purpose) to instill atropin into the fixing eye only; (4) to train the fusion sense, and (5) operation. A very widely-held belief is that a child under four or five years cannot wear glasses. This is entirely erroneous. Worth records instances of infants under 12 months wearing correcting lenses with great satisfaction. present the author has under observation an 18-month-old child who came with a constant monolateral squint, and who is wearing strong plus spherical lenses with apparent entire satisfaction.

At

I.

To secure the enactment of laws in each State or Federal territory placing the supervisory control and licensure of midwives with the boards of health, re

quiring that these unqualified practitioners be examined and registered in each county, and that they required to immediately report each case of ophthalmia occurring in their practice, under penalty, if found guilty, of forfeiture of their license and a fine.

Distribution by health boards of circulars of advice to midwives and mothers, giving instruction as to the dangers, method of infection and prophylaxis of ophthalmia neonatorum.

3. The preparation and distribution by health boards of ampoules or tubes containing the chosen prophylactic. For midwives I per cent. solution of nitrate of silver is almost universally recommended by obstetricians and opthalmologists. For physicians the Credé solution should consist of a 2 per cent solution of chemically pure fused nitrate of silver. If used as directed by Credé, one drop from a glass rod one-eighth of an inch in diameter, it is free from excessive irritation and absolutely safe. To insure purity of the drug and accuracy of dosage the Credé solution should be given freely to physicians who make applications therefor. This, however, should be merely advisory. The health department should be free to use such prophylactic as it may deem best.

the number of cases of ophthalmia neonatorum that has occurred in their practice; whether or not a prophylactic was used; if so, what-together with the result.

5. The accomplishment of these measures by the appointment of committees through the various State and county societies, whose co-operation would make concerted action possible.

6. To secure these ends the requested co-operation of the American Association. of Obstetricians and Gynaecologists, the Academy of Ophthalmology and Oto Laryngology, the American Ophthalmological Society, the American Public Health Association and such other organizations as may appoint committees on ophthalmia neonatorum.

George M. Gould Vision and Senility. (Interstate Medical Journal) believes there is a most intimate and causal relation between vision and old age. The habit and fact of overprolonged senility, a too early beginning of old age, he suggests is almost wholly due to ocular defects and failures. Good vision being the sine qua non of health, activity and youthful feeling, the onset of presbyopia, when uncorrected by glasses, necessitates that renunciation of labor and social functions which we call old age. Where visual ability has for years been crippled by refractive error and eyestrain choroiditis, there is a needlessly early assumption of the consequences of old age. Gould suggests that the habit of giving up energizing work and useful activity soon after 45 years was largely established in countless ages when spectacle lenses were unknown. To maintain the perfection of the ocular mechanism and functions beyond the age of 45 will be to limit senility to the last year or two of

life and to prolong useful activity for many up to 70 or 80.

Blindness Due to Phleg- Seggel (Klin. Momonous Tonsillitis. natsbl. f. Augenheilk, XLV, 1907). The patient, a man 20 years of age, suffering from a febrile phlegmonous inflammation of the right tonsil, presented right-sided exophthalmos, with swelling of the lids and conjunctive, and almost simultaneously the eye of the affected side became blind, with a rigid pupil. Subsequently there was loss of sight in the other eye as well. Two days after the appearance of the right-sided exophthalmos a hard strand corresponding to the internal jugular vein became palpable upon the same side of the neck. The patient recovered under symptomatic treatment of the angina and injections of mercurial ointment into the neck. The left eye was again enabled to count fingers at one metre's distance, in the upper nasal quadrant, whereas the blindness persisted in the right eye. The ophthalmoscope showed the picture of atrophy in both optic nerves.

The clinical picture is interpreted by the author in such a way that, subsequent to the inflammation of the right tonsil, there was thrombophlebitis of the palatine vein, transmitted from here to the internal jugular vein, then through the inferior petrosal sinus to the right cavernous sinus and the ophthalmic vein. The thrombosis passed to the left cavernous sinus through the circular sinus Ridleyi. In this particular instance the blindness in thrombosis of the cavernous sinuses presumably was not referable to compression of the nerve fibres or to optic neuritis, but rather to the sudden shutting off of the blood supply corresponding to the rapid evolution of the amaurosis.

F. R.