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American Journal of Dermatology 
and Genito-urinary Diseases 




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VOL. VII. w| 



JANUARY, 1903. 



No. 1. 



vustogen 

bi the Treatm^it of Gonorrheat 

both acute and chronic, the advantage of thorough disinfection of the 
entire urinary tract is apparent. 

Cystogen is eliminated through the urine and gives to that fluid 
antiseptic properties. It makes the urine sweet and bland. 

This bland and antiseptic urine bathing in its downward course the 
tubules of the kidneys, the ureters, the bladder and the urethra, prevents 
the extension of the disease and assists in its abatement. 

The practice of continuing the use of Cystogen for some weeks after 
all symptoms have disappeared, establishes the cure as no other treat- 
ment will. Dose: 5 grains, dissolved in water 3 to 4 times daily. 

Procurable of all wholesale druggists. 

Powdered, per ounce $1.00, per 8 ounce package (Ho^ipital 5ize), $4.00. 
5 ffcaln tablets, per ounce, $1.10. per 8 ounce package (Hospital Size), $5.00. 
5 grain tablets In paper boxes of as tablets each, per dozen boxes $4.00. 
Cystogen Aperient, (Granular Effervescent Salt of Cystogen with Sodium 
Phosphate), per dozen bottles $8.00. 



Samples 
on request. 



C-JJ. 



Cif^toaen 
Chemical Co.[ 

'^T. LOU/S, Mo. i/jSA. 



Write for 
Literature. 



Kntcrcd at the Foit-Officc at St, Louis. Mo., as second-class mail matter. 



eSPINAL DEFLECTIONS ARE CONQUERED@ 

perfected system and appliances of 

The banning 
O. & M.-T. CO. 



ONLY AWARD AT CHICAGO, 1893. 

ONLY AWARD AT PARIS, 1900. 
FORTY-EIGHT HEDALH AND DIPLOMAS. 



Pig. S8. Botary Ourvature 



Flf. SI. Antero-Poaterlor 
Ourvature, Inor«aiiiic. 



Fiff. Sa. Ant«ro- Posterior 
Ourvatur*. Decreasing. 



Fig. 94. Botary Curvature 
Deoreaslng. 



F iff 8. 23 and 94. In Bilateral or Rotary Curvature, to reverse the force of the body's weight to the 
opposite side at each point of curvature, i» tne true philosophy of cure.— Uanming. 

Figs. 31, 22 and 27. In Simple Drooping, iJpinal Irritation and Antero- 
posterior Curvature, to lift the weight of head and shoulders from the 
tender spinal points, and by pushing forward the dorso-lumbar curve transfer 
pressure to central portions of bodies of vertebrse, is the aheet- anchor of hope. 
— Uannino. 

Nothing in nature has the inherent physical power to correct iu own im- 
proper relation to gravity. ''As the twig 18 bent the tree is inclined'* is as true 
of the child as of the twig. Why, then, the absurd prognosis of "The child will 
outgrow it?"- Banning. 

Spinal curvatures are created and perpetuated by a deflected spinal center 
not by an unequal muscular antngonisni. The latter is purely adaptive. Hence 
the failure of^ exercise, massage, electricity and muscle-cutting to remedy.— 
• Hanmno. 

And whatever we may do in these spinal cases, nothing must compromise o 
put in jeopardy the very largest liberty and power of the Spinal, Abdominal and 
Pectoral Muscles.— Banning. 

SPINAL IRRITATION. 

(From Dr. E. P. Banning's essay, "The Uuman Spine." Mailed Free.) 
* * * However obscure and unsatisfactory the various pa- 
thologies of irritation of the spinal tissues are, and however un- 
successful the counter-irritating treatments may be, one thing is 
nearly infallibly certain, if you place your hands under each 
axilla and gently lift for h\e minutes— or if you at the same time 
support the abdomen and the small of the back— the greatest 
sufferers universally speak of a sense of rest from uneasiuess 
and pain. Now whilst this cannot prove the existence of any 
particular condition of the spine, it must clearly show that weight 
and friction on the vertebrae aggravate the local and radiated 
sufferings, and most forcibly suggests that a par^ of the remedy, 
at least, is to elevate the abdominal viscera from the irritable 
uterus and ovaries, and at the same time a part of the weight 
from the irritable cartilages, ligaments and nerves, and also to 
preserve the privileges of air, exercise and the diversions of society. 



Fig. S7. Spinal Prop for Spinal 
Irritation without Curvature. 
SappertinsT the abdomen, ex- 
pandiDe the waist and che8t,and 
supporting the weak spine; also 
reflevine spinal irritation, by 
taking the weight of the body 
from tender spinal points, and 
protecting tbe latter in the case 
of jolting and twisting the body 



Send for Deseriptlve Price List. Measuring Blank and Dr. Bannlng's Bssay, "The Human Spine." Address. 



BANNING 0.&M.-T.C0.,81 Berry St., Ft. Wayne,lnd. 



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A BI*MONTHLY MAQAZINC DCVOTCD TO ▼HC «ON9IOCIIAT|ON OF CUTANEOUS MCDICINC 
VCN4IICAL DISCASCB ANQ aCNITO-URINAIIY SUWaSIIY. 



S. C. MARTIN. M. 0. 

P W Or «— on or OffRMATOLOOV IN THC BAHNU MCOIOAL OOLUat 



EDITORS 

G. M. PHILLIPS. M. 0. 
PNorusoii or acMrro>uiimAfiv diokams tr. LO«fis o mj ua m or 

PNVIICIANO AND •UNQCONO. 

MANAGING BDITOR 
S. C. MARTIN. Jr.. M. 0. 



SUBSCRIPTIONS AND ADVERTISING. 

The subscription price of this Journal Is $x.oo per year, in advance, postage prepaid* for the United States, Canada and 
' Mexico; $i jo per year for all foreign couairles Included in the postal union. Slnpc copies, as cents. 
Advertising rates will be furnished upon application. 

Address all communications, correspondence, books, matter refardlag advertising, and make all checks, drafts and post- 
office orders payable to 

AMERICAN JOURNAL OF DERMATOLOGY 
PjdeHty Building St. Louis. Mo . U S. A 



Vol,, vn. 



JANUARY, 1908 



No. 1. 



iN THE PRESENT STATUS OF BACTERh 
OLOQY CAN ITS RELATION TO CUTA^ 
NBOUS PATHOLOGY BE ACCU- 
RATELY DEFINED? 

The relation of micro-organisms to 
both contagious and non-contagious 
diseases of the skin is so indefinite and 
confusing to the mind of the practical 
physician, that, in order to promote 
uniformity in methods of practice, the 
American Journal of Dermatology has 
instituted an inquiry among prominent 
specialists and scientists, to determine 
as far as possible the limitations of 
this new factor in the etiology and pa- 
thology of cutaneous disease. 

Many thoroughly educated and ex- 
perienced clinicians claim that in most 
diseases of the skin micro-organisms 
are incidental or secondary factors, 
while others affirm, with Unna, that 
they stand in close causal relation to 
nearly all skin diseases. The follow- 
ing statements will shed considerable 



light on this interesting and trouble- 
some subject: 

J. Abbott Camtbxll, M. D., late Professor of Diseases 
of the Skin, Philadelphia Polydinie, Pittabnii^, 
Pennsylvania. 

Answering your question in a per- 
sonal manner, I desire to say that I 
am not so confidently imbued with the 
thoroughness with which my co-work- 
ers in the field of dermatology have 
ascribed the bacterial origin of disease. 
I believe that after all good, conscien- 
tious workers have labored with the 
microscope in this branch, that they 
will soon equalize matters and find that 
many of the so-called bacteria have no 
effect upon the production of certain 
conditions. This time may be far dis- 
tant or nearer than we can now fore- 
see. 

Thubston O. Lusk, M. D., Instructor of Dermatology in 
tne New York Post-Oraduate Medical School and 
Hospital, New York City. 

To answer your question, defining 
the limitations of bacteria in dermatol- 



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ogy, will require years of study and 
research. We are only beginning to 
make headway in that direction , and 
the progress is necessarily slow. Any 
of the recent text-books on the subject, 
however, will give all we know at the 
present time, and it will be found suf- 
ficient for practical purpose?. 

If you should publish all the answers 
received to your question there would 
undoubtedly be among them quite a 
number of conflicting opinions, and in 
this age of science it is not opinions 
but facts that we want and expect. 

Henry Gc. -Phtabd, M. D., Professor of Dermatologyt 
QalTersitT and Bellevue Hospital Medical College* 
WSw York aty. 

The subject of bacteriology in con- 
nection with dermatology is too large 
a one to tackle at present. When the 
bacteriologists ai*e all through I may 
have something to say from a prac- 
tical standpoint. Until then you must 
excuse me. 

William Allen Pusky, M. D., Professor of Dermatology 
and Clinieal Dermatology, College of Physicians and 
Surgeons of Chicago, Chicago, Illinois. 

An expression of opinion as to the 
extent of the role that bacteria play 
in dermatology would require consid- 
erable labor and time, and I am at 
present so crowded with work that I am 
not able to undertake it. 

ISADOBB Dyer. M. D., Professor of Dermatology in the 
New Orleans Polyclinic, New Orleans, Louisiana. 

At the present time it seems rather 
hard for me to be able to cover the 
ground in the matter of bacterial etiol- 
ogy in skin diseases, especially with 
Unna leading the school of those argu- 
ing the parasitic origin of eczema and 
its cogeners. 

I am so much a clinician in my work 
and teaching that I have inclined rather 
to an indifference to the point of shai'p 
definition in this class of skin diseases. 
I believe that we are far from classify- 
ing skin affections, and that the field 
is too young to make positive distinc- 
tion of etiology based on micro-organ- 
isms as the causal factor. This does 
not mean that there are not some dis- 



eases of distinct bacterial origin, but 
the borderland is so elastic that to-day 
\% depends muojli on the view-point of 
the individuid observer as to whether 
certain diseases are primarily or sec- 
ondarily microbic. It would require 
much time to be exhaustive on this 
subject, and just now I am only able to 
give you this cursory opinion. 

Herman G. Klotz, New York City. 

There can be little doubt that bac- 
teria play an important part in the eti- 
ology of cutaneous diseases. How- 
ever, our exact knowledge of the 
micro-organisms and of their biology 
is by no means commensurate with the 
enormous amount of what is said and 
written about bacteria, their toxines or 
products, etc. With dermatology itself 
to a certain extent in a more or less 
chaotic state of revolution, and bacte- 
riology still in one of evolution, it 
seems that the time has not yet ap- 
peared for setting up definite limita- 
tions of the new factor. 

Granville MacGowan, M. D., Professor of Diseases of 
the Skin, College of Medicine, University of Southern 
California, Lios Angeles, California. 

I am not one of those who believe 
that the ultimate cause of all diseases 
of the skin may be traced to the growth 
of molds or to the poisonous materials 
resulting from such growths. 

This theory is certainly an attractive 
one, and has caused much valuable re- 
search by a few who possess a prac- 
tical working knowledge of dermatol- 
ogy, with the skill and experience nec- 
essary for culture work and the apti- 
tude to draw approximately correct 
conclusions therefrom. At the same 
time it has given rise to a mountain of 
nearly worthlese bacteriological literary 
lore, put forth by a multitude of in- 
competent workers, to further confuse 
the literature of dermatology, which 
already needs much simplifying to be 
understood by the ordinary man of 
medicine. 

Yet, out of all this useful and use- 
less research some good comes some- 



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times — a million eggs so that one fish 
may grow to maturity. 

Diagnosis of diseases of the skin is 
certainly not greatly helped, as a yule, 
by the assistance rendered by the lab- 
oratory. As a guide to practice we 
need to have before us continually the 
imprints upon the skin, the clinical im- 
pressions or pictures of disease which 
the etiology, bacterial or otherwise, 
stamps there. 

Once familiar with the pictui'e, in 
crossing a bit of gfass land or chap- 
paral, it is very easy to tell where 
sheep have passed, by the close crop- 
ping of the grass and the trampling of 
the soil by the myriads of hoofs. A 
sheepman will tell you the kind of 
iifliaq|j in the band, how long it is since 
they wiirt hf^ 11m character of the 
shepherd, and hemay gonlo a Innwd 
dissertation upon the sheep. 

Sabourand will do the same thing in 
relation to tinea. This but few of us 
will ever learn, but it is well that some 
should know it and explain it, for the 
knowledge may some time prove useful. 
For the many it is sufficient that hav- 
ing found a sheep or tricophyton it 
may be killed for the good of human- 
ity. But we should have protection 
from the individual who, not being fa- 
miliar with the general characteristics 
of sheep, finding one should kill him 
and claim a reward for his body, on the 
suspicion that he had robbed a bee-hive, 
because his meat was sweet. 

Let the bacillus introduced into der- 
matology as an etiologist bring with 
him from his sponsor such a descrip- 
tion of birth, childhood, youth, ma- 
turity and progeny that anyone sup- 
plied with proper apparatus for cult- 
ure work and of reasonable experience 
may isolate it from a given case of dis- 
ease. Without these qualifications no 
recognition should be extended by 
those who write books or orally in- 
struct others, to the claims of observ- 
ers who would seek to trace the origin 
of any of the diseased conditions of 



the skin that are not already fully dem- 
onstrated in a new bacillus or coccus. 

Hbnry W. Stelwaqon, M. D., CHnical Professor of Der- 
matology in the Jeflfenon Medical College, Philadel- 
phia, Pennsylvania. 

*<'At the present day one need 
scarcely enlarge upon the etiologic as- 
pects of this cause ; nor is it necessary 
to enumerate the large number of dis- 
eases that, in a broad sense, might be 
placed under this etiologic heading. 
Pediculosis, scabies, the irritation pro- 
duced by bedbugs, fleas and mosquitos, 
may be mentioned among the animal 
parasitic affections, and tinea versico- 
lor, favus, ringworm, among the veg- 
etable parasitic diseases, to which could 
be added numerous others due to the 
lower micro-organisms, such as im- 
petigo, furuncle, tuberculosis cutis,^ 
IqiofMy, etc. Afaiifthitp sbA uuadl iisive 
proof as to the alleged cause and effect 
is still wanting in connection with the 
by far larger number of the diseases 
presumably due to micro-organisms,, 
but no one can deny their growing im- 
portance in the etiology of disease, 
and the great value of original investi- 
gation in this direction. 

''With the advent of this etiologic 
element the subject of contagion has 
naturally been pushed into the fore- 
ground, and an expression of opinion 
on this point in a particular disease is 
often hedged about with difficulties. 
While admitting the probable parasitic 
origin of many diseases, and the infer- 
ential deduction of communicability 
that naturally follows, still observation 
shows that in many instances, more 
especially in those in which the dis- 
ease is presumably due to the lower 
organisms, contagiousness does not 
seem to be even suggestively demon- 
strated in practice— at least not with 
any degree of certainty. In many dis- 
eases, therefore, for which we even 
now accept a parasitic factor, we must 
assume that favoring conditions of the- 

* Taken from "Treatise on Diseases of the Skin." Bjr 
H. W. Stelwagon, M. D . page 84, 1902. Published hy 
W. B. Saunders & Ck>., Philadelphia, Pennsylvania. 



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ORIGINAL Articles, 



systemic state or the local tissues ex- 
ist, and without which the successful 
invasion or pathogenic multiplication 
of the micro-organism fails or remains 
harmless. In short, I am fully in accord 
with Professor Duhring^s opinion that 
Hhese parasites usually require a pe- 
culiar condition of the skin or soil for 
their growth and development.' Even 
prolonged exposure, unless conditions 
are favorable, is in many such dis- 
eases without result; this is fre- 
quently demonstrated with such ordi- 
narily actively contagious maladies as 
ringworm ; and the vegetable parasitic 
affection, tinea versicolor, judged by 
clinical experience, is only in the rarest 
instances communicated from husband 
to wife or the reverse, and yet the 
fungus exists in abundance and is 
readily demonstrable. Nor, appar- 
ently, is every person to the same ex- 
tent a pei^sona gi*ata to even the more 
active animal parasites — bedbugs, fleas 
and even the louse and itch-mite, al- 
though the last two are the least fas- 
tidious as to the character of their 
prey. Apparently some inherent pe- 
culiarity of the skin or the odor of its 
secretions measureably protects some 
individuals against successful parasitic 
invasion." 

JAMK8 Kkyins Htdc, M. D., PfofoMor of Skin. Genito- 
urinary and Venereal Diseases, Rush Medical Col- 
lege, Chleago. niinois. 

* Parasitic Diseases. — * 'Under this 
title were once included solely the 
dermatoses induced by the presence of 
the animal and vegetable parasites. 
Among the former may be named 
scabies and pediculosis; among the 
latter, ringworm of the scalp and of 
the beard. But the term parasite has 
■acquired a much wider scope since the 
recognition of the micro-organisms 
which have been demonstrated to be 
efficient in the production of a long list 
of cutaneous affections. Among these 
may be named the bacilli productive of 
cutaneous tuberculosis and of lepra; 

*From "A Praetieal Treatise on Diseases of the 
Skin." Fifth edition. By James N.Hyde, M. D. 1900 
Published by Lea Bros. & Co., Philadelphia. 



the pus cocci, responsible for the sev- 
eral forms of impetigo and pustular 
eczema; and the streptpcocci. recog- 
nized in several forms of dermatitis. 
In most of the dermatoses which are 
recorded to-day as parasitic, germs 
have been recognizcNl, which either 
singly or in co-operation with others, 
have been proved to be effective in the 
production of these disorders, or have 
been demonstrated to play an active 
part either in their extension or ex- 
acerbation.*' 



John V. Shoimakkb, M. D., Professor of Skin Mid Vene- 
real Diseases in the Medieo^AiroxEieal OoUege and 
Hospital, Philadelphia, PennsylvanU. 

***The development of bacteriolog- 
ical research has inevitably modifi^ 
and enlarged our conceptions of the 
etiology and pathogenesis of diseases 
of the skin. It has been already 
clearly demonstrated that many are, 
either directly or indirectly, the re- 
sults of infectious processes. It is 
reasonable to assume that the list of 
infectious dermat- 'ses will be extended 
considerably from the investigations 
constantly being earned on by numer- 
ous and independent observers. Clin- 
ical facts had already assured us that 
cutaneous manifestations were in many 
instances excited by the presence in 
the blood of products of tissue change. 
Being retained within the organism, 
these substances have the power of 
exciting diseases in the integument as 
well as in other tissues. The eruption, 
consequently, is but a part of a general 
disorder, such as gout, rheumatism, 
diabetes, syphilis, scrofula, or tubercu- 
losis. These diseases are enirendered 
by chemical compounds elaborated 
within the body, and not necessarily 
or always of microphytic origin. In 
another class of cases the cutaneous 
malady seems to depend upon the di- 
rect action of micro-organisms which 
have lodged upon the skin, and there 
found a fitting soil for development. 
It is probable that here, as elsewhere, 

*Froto "A Praetieal Treatise on Diseases of the 
Skin." By John V. Shoemaker, M. D. Fourth edition. 
Published by D. Appleton & Co., New York. 1901. 



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the two causes are often conjoined, 
and that, as a rule, the skin onlj 
proves a fitting soil when its vitality 
has been previously impaired bj causes 
acting from within the organism. Ex* 
temal agencies, also, such as heat, 
cold, clothing, etc., have their share of 
influence in preparing a field upon 
which parasitic organisms may flour- 
ish." 

NoBMAN WAiJCKft> M. D.» f>BUow of Ihe Boyal OoUece of 
Phytieiant of Edinburgh; Assistant PhysicUa for 
DiseMM of th« Skin to tiio Royal Edinburgh In- 
firmary, Edinburgh, Scotland. 

***Infar too many diseases we are yet 
ignorant of the actual infectious cause. 
In others the probable causal relation of 
some germ to the disease is widely ad- 
mitted, while there are others which it 
f , is only by analogy that we can consider 
I infectious at all. It is not necessary 
I that the cause of a disease shall be 
present at the actual place where signs 
I at irritation are observed microscop- 
ically. Pai^sites of all kinds have the 
power of exerting their influence at a 
distance, and be the parasite gross, as 
in the case of scabies, or minute, as in 
the case of impetigo, the effects pro- 
duced by its presence may be found in 
localities remote from where the actual 
parasite can be detects. This is what 
is called chemiotaxis, the poison pro- 
duced attracting the mobile elements of 
the tissues. Thus, in certain pustular 
affections of the skin, which are clearly 
inoculable, the cause of the disease 
will be found in a small colony of 
gtftms situated only at the apex of a 
considerable pustule, while the vessels 
for some distance around show evident 
signs of disturbance." 

WtLHAU S. QoTTHViL. M. D., Physidan to the City Hos- 
^tal; Dermatologist to Lebanon and Beth-Israel 
Hotpitals, etc.. New York City. 

Among all the momentous changes 
of modem medicine, none has been 
more radical and farther reaching in 
its effects than the alterations of our 
ideas as regards the etiology of dis- 

•Prom "An Intvodnction to Dermatology." By Nor- 
man Walker, M. D. 1899. Published by William Wood 
A Co., New York. 



ease. Dermatology has not escaped 
this influence, and comparatively little 
is now heard of the action of diatheses, 
changes in the tissue fluids, psychic 
effects, and other general and indefi- 
nite causes in the etiology of derma- 
toses. To a certain extent the change 
is justifiable; in a considerable number 
of ca^es we are now in a position 
to point out the definite causative factor 
of the disease in question. But in the 
majority, including some of the very 
commonest affections with which we 
have to deal, we are still as much in 
the dark as ever. We now, however, 
usually have the courage to proclaim 
our ignorance and say o)>enly that we 
do not know, leather than to ascribe 
these maladies to agencies of indefinite 
and unprovable nature. 

Light, heat, cold, mechanical and 
chemical influences are the acknowl- 
edged causes of a variety of skin 
affections, including erythema solare, 
erythema photo-electricum, lentigo, 
xeroderma, hydroa, chillblains, burns, 
corns, callosities, occupation derma- 
toses, drug eruptions and others. In 
another series of diseases an organic 
factor of a fungoid or bacterial nature 
has been found, and it is to these that 
the present brief inquiry is to be di- 
rected. 

A number of dermatoses have long 
been known to be caused by the pres- 
ence of living organisms on or within 
the skin. Epizoa like the pulex irri- 
tans, pediculus and leptus auctumnalis 
cause pediculosis. Dermatozoa, as aca- 
rus scabei demodex folliculorum and 
filaria medinensis, cause scabies, acne 
and Madura foot. Hematozoa like the 
filaria sanguinis hominis cause elephan- 
tiasis and lymph-scrotum. Epiphyta 
like the achorion Schoenleinii, tricho- 
phyton, microsporonminutissimum and 
microsporon Audouinii cause favus, 
ringworm, eczema marginatum and 
ptyriasis versicolor. Endophyta are 
the actinomyces that occasionally affect 
the skin, and the blast omyces that have 
been recently proved to be the cause 



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of various granulomatos and ulcerative 
affections. 

Turning now to the purely bacterial 
affections of the skin, we are con- 
fronted with conditions which are un- 
doubtedly unsatisfactory, but which 
are inevitably in a department of our- 
science which is undergoing its first 
development. In a certain few cases 
a bacterial cause for the affection in 
question has been found, and has been 
definitely proven to be the causative 
agent. In others, again, though the final 
proofs obtainable from inoculation are 
still wanting, the parasitic agent has 
been found with a constancy that ren- 
ders its relationship to the disease cer- 
tain. In a large number, however, the 
results are as yet conflicting; some 
observers find an organism, and others 
do not; and different structures are 
described by different investigators. 
And in some affections that are un- 
doubtedly bacterial, as shown by every 
fact of their history, we are still en- 
tirely wanting in anything like reliable 
data as regards the organic agent that 
causes them. 

Among the external microbic causes 
of skin diseases the staphylococcus is 
probably the most important. A whole 
series of dermatoses, clearly differen- 
tiable clinically by variations of site, 
depth of tissue affected and course, is 
caused by it. All the pus affections of 
the skin and its appendages, as well as 
many varieties of disease from other 
cause, are due to its primary inocula- 
tion upon the skin, or its secondary 
implantation upon already existent le- 
sions. Impetigo, echthyma, furuncle, 
carbuncle and panaritium are examples 
of the first, as are impetiginous eczema, 
ulcerating syphiloderm, and ulcerating 
lupus of the second method of inocula- 
tion. The staphylococcus causes ery- 
sipelas, the Ducrey-Unna bacillus soft 
chancre. The tubercle bacillus is the 
etiological agent in a number of derma- 
toses, including lupus vulgaris, tuber- 
culosis cutis verrucosa, tubercular ul- 
ceration and post-mortem tubercle. 



Hansen's bacillus is recognized as the 
etiological agent in leprosy, and the 
rhinoscleroma bacillus is the cause of 
the disease from which it takes its 
name. Malignant pustule is caused by 
the bacillus anthracis, and glanders 
and farcy are due to the organism that 
is so well known in veterinary medi- 
cine. 

Turning now to the maladies that 
are probably microbic, but in which 
the active agent has not yet been abso- 
lutely demonstrated, we recognize 
syphilis as probably the most import- 
ant of the class. No reasonable man 
can doubt the existence of a microbic 
cause for this disease; I taught its 
probability twenty years ago, when 
bacteriological science was still in 
its infancy. Yet of all the various 
discoveries of the syphilitic organism 
that have been proclaimed, not one, 
from that of Lustgarten years ago to 
that of Niessen in 1900, has been defi- 
nitely confirmed. Other examples are 
the eruptive fevers, for which the evi- 
dence of microbic origin is almost as 
strong as for syphilis. Variola, scar- 
latina and measles have skin eruptions 
of undoubtedly microbic origin, though 
the etiological agent has not so far 
been found. Diphtheria and typhoid 
are in a class by themselves, for the 
etiological factors have been found; 
but their exact relationship to the 
exanthems that sometimes accompany 
these diseases have not been deter- 
mined. 

The list of possibly microbic skin 
diseases a long one, and it seems prob- 
able that many of them will be trans- 
ferred to the proven class before very 
long. The impression is gaining ground 
that the "symptom-complex" which we 
call eczema is, at all events for certain 
members of the group of diseases, of 
bacterial origin. The pathogenicity of 
Unna's morococcus is, however, still 
unproven ; but there seems good reason 
to place much reliance upon the experi- 
ments of Becker, Boeckbardt and Ger- 
lach last year, who investigated the 



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relationship of the staphylococcus and 
its cultures to the disease. They found 
that cultures containing the organisms, 
but none of the toxins, caused impet- 
igo, furuncle or abscess when inocu- 
lated upon the irritated skin, but not 
eczema. Cultures containing cocci and 
toxins, and filtered cultures containing 
the toxins alone, invariably produced 
typical acute papular or vesicular ec- 
zema. As stated in my recently pub- 
lished review of the year's work in 
dermatology in Progressive Medicine^ 
these findings are of great importance, 
and, if confirmed, will undoubtedly 
have a marked effect upon both classi- 
fication and treatment of these diseases. 
Of other possibly microbic skin diseases 
I shall mention only lupus erythemato- 
sus. There is some evidence that it is 
caused by the tubercle bacillus, or its 
toxines, like lupus vulgaris ; but it is 
still entirely inconclusive. 

144 West Forty-eighth street. 

A. Ravooli, M. Dm Professor of Dennatology and Syphil- 
ographr, Medical Department Cincinnati Univer- 
sity, Cincinnati, Ohio. 

These eruptions belong to a large 
<5lass of affections of inflammatory 
nature, acute or subacute in character, 
easily relapsing. . 

The skin is affected by a large num- 
ber of micro-organisms, of which some 
are specific and some non-specific, and 
they can be divided in two groups : one 
of the micrococci and another of the 
bacilli. 

The micrococci of non-specific nat- 
ure are the most important; they are 
the staphylococci and the streptococci. 

1. Staphylococcus (Rosenbach), the 
most prevalent of all, is represented by 
small rounded elements, sometimes 
isolated, oftener united. It develop- 
readily upon the various culture media. 
From the different color the staphys 
lococci have been divided in three 
varieties: Staphylococcus aureus, S. 
citreus and S. albus. 

It is still unsettled whether these 
three staphylococci represent distinct 
species, or if they are varieties of the 



same species. From the fact that they 
are often found together in the same 
foci, and that from some culture ex- 
periments staphylococcus aureus has 
lost its chromogenic power and has 
been transformed in white, has pre- 
vailed the opinion that the three 
staphylococci are only varieties of the 
same species. 

The staphylococci are found as 
saprophytes in soil, water, ice, air, 
dust, cloths, etc. When they attain 
the rank of pathogenic agents they 
produce suppuration. The chromo- 
genic varieties are in general more 
virulent than the white. The skin 
offers a large field to the staphylococci 
for their development. According to 
the seat and to the activity of the 
germs, the morbid results are of dif- 
ferent intensity. 

The diseases of the skin caused by 
staphylococci can be grouped in ec- 
zema, impetigo, folliculitis (sycosis 
coccogenica), acne, furuncles. 

In some cases, on account of the 
virulence of the staphylococci and of 
the liability of the skin, they are capa- 
able of producing bullaa of the skin, 
which we usually call ''dermatitis bul- 
losa." 

2. Streptococci observed by Coze 
and Felz were isolated from erysipelas 
by Felheisen are much smaller micro- 
cocci, and they have tendency to 
group themselves in chain. They are 
easily cultivated in serum, either pure 
to mixed with boullion, and in this me- 
dium attain a high degree of virulence* 
The streptococcus, like the staphylo- 
coccus, is widely spread in nature: it is 
found in the air, in water and in the 
soil. It invades putrescible matters, 
and is easily found on the skin and 
constantly in the buccal cavity. 

This microbe is much more virulent, 
and produces edema, suppuration, 
pseudo-membranes and gangrene. 

The diseases of the skin resulting 
from the streptococcus can be grouped 
as follows: Erysipelas, folliculitis ma- 
ligna (decalvans), carbuncle. 



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ORIGINAL ARTICLES. 



It is possible that other acute malig- 
oant diseases of the skin with tend- 
ency to gangrene are also caused by 
the streptococci, but it has not yet been 
proved. The streptococci are also of 
different varieties, and show modifica- 
tions in their biological characteristics 
sufficiently marked. To these varieties 
has to be attributed the difference of 
intensity of the named affections. 

Diseases of the Skin Due to Bacilli. 
— Some are produced by the tubercle 
bacillus (Kob B., which appears as a 
non-motile rod possessing a strong 
tinctorial reaction. It seems that the 
tubercle bacillus in certain conditions 
undergoes morphological modifications, 
showing projections and ramifications 
terminating in club-shaped swellings. 
But so far it has no practical conclu- 
sions. The tubercle bacillus is very 
resistant and only with difficulty is de- 
stroyed. It is widely spread among 
the human race and animals, which 
are, like the man, affected by this 
dreaded bacillus. 

Like any other tissue the skin is 
frequently affected, and according to 
the different anatomical structures pf 
the skin, where the bacillus finds its 
place, the affection has a different ap- 
pearance. In the same time the skin 
may be affected by the bacilli, and be 
also affected by the toxinee, which are 
the production of the bacilli hidden in 
more deeper parts of the organism. 
To the presence of the tubercle bacillus 
we can refer the following skin affec- 
tions: Lupus erythematosus, lupus 
vulgaris, tuberculosis lui>oides, lichen 
scrofulosorum, some cases of folli- 
culitis, acne cachecticorum, ulerythema 
sycosif orme, tuberculosis miliaris cutis, 
tuberculosis verrucosa, erythema in- 
duratum, tubercular ulcers. 
Another specific bacillus is the bacillus 
leprae, discovered by Hansen, which 
causes leprosy, with its cutaneous 
manifestations, which we know as 
leprides and leproma. 

Bacillus anthracis and bacillus mallei 
attack also the skin, producing their 



deleterious effects. In severe cases of 
diphtheria the diphtheritic bacillus 
causes ulcerations of the skin sur- 
rounding the mucous membranes of 
the nose, mouth and of the genitals. 

Septic vibrio (Pasteur) or bacillus of 
gaseous gangrene, which is also fre- 
quently found in the soil, dung and in 
the mud. When it is introduced in a 
wound, produces a gangrenous spot, 
which widely spreads on account of 
the evolution of gas, which infiltrates 
the surrounding tissues. The microbe 
remains limited, but its deleterious 
toxines produce general infection with 
fatal end. 

Next to the bacilli there are other 
parasites of a higher order capable of 
producing infectious diseases which 
find their entrance in the skin. These 
forms belong already to the fungi, and 
are so-called phycomyces. The most 
important is the streptotrix bovis, or 
actinomyces, which is the cause of 
actinomycosis in man and animals. 
This fungus produces two different 
appearances of the disease, one in form 
of sarcomatous growths and another 
in form of suppurating foci. In both 
cases the characteristic yellow granules 
are easily found, representing sub- 
limated sulphur. Under the microscope 
the mycilial filaments irradiating like 
the spokes of a wheel are soon to be 
found. 

It is a facultative anerobic vegetable, 
which lives as saprophytes upon the 
graminaceas. For this reason the cat- 
ties are frequently affected with this 
disease. 

Streptotrix Maduree is another fun- 
gus, which produces the Madura foot, 
a disease frequently observed in India, 
Algeria and South America. 

Recently have been described some 
kind of fungi, which have been referred 
to the blastomyceta, and to them Gil- 
christ and Busse have attributed a 
peculiar malignant form of dermatitis, 
which they have called blastomycetic 
dermatitis. 

Coccidia and sporozoa have also been 



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described as the factors of cancerous 
growths, but so far no positive ob- 
servations give us any right to call them 
the true producers of carcinomatosis. 

Gio. G. Mblvin, M. Dm St. John, N. B., Canada. 

Having been requested by the editor 
of the American Journal of Derma- 
tology for a statement regarding the 
above subject, it seemed well in com- 
plying with his request to make that 
statement as practical and, therefore, 
as short and concise as possible. 

It will be observed that this article, 
in many respects, is very elementary. 
This is unavoidable. In treating any 
subject in its entirety many facts must 
be recited which are elementary in 
character, and this will be no excep- 
tion, especially to those versed in derma- 
tology. But, indeed, the writer makes 
no claim to originality, his aim being 
simply to gather together in as plain 
a manner as possible the well-known 
and acknowledged truths respecting 
the subject in question. 

Nothing herein noted will have ref- 
erence to the obscure, ill-defined and 
not-yet-sufficiently-observed lesions pe- 
culiar to tropical climates, nor to that 
multitudinous class of parasites pres- 
ent in all lesions, whether upon the 
skin or elsewhere, which have not been 
proven to have an etiological relation 
to the diseases in which they are found. 
There is, also, another limit which we 
will set ourselves. It is not proposed 
to say anything of those parasites of 
an animal nature and beyond micro- 
scopical size, such as are the prime 
factors in scabies or pediculosis. These 
do not, properly, come under the head 
of bacteria; that is to say, while bac- 
teria are parasites, all parasites are not 
bacteria. 

So bounded, it will be found that 
our subject is not nearly so extensive 
as might, at first sight, be imagined. 
In these days germs occupy a large 
amount of the doctor's time and 
thought. One or two very important 



diseases, such as pulmonary consump- 
tion, having been found, indubitably, 
to be caused by living organisms, it is 
quite natural that the suspicion of bac- 
terial origin should attach itself to 
nearly everything with which we come 
into contact. Concerning the impoi't- 
ance of deciding the origin of a dis- 
ease, whether it be produced by germs 
or not, there can be no question. In 
the first place, all diseases, as a matter 
of course, parasitical in their origin, 
are by reason of such causation conta- 
gious. This is very apparent. If a 
certain germ cause a disease in one 
person, then it is very plain such germ, 
transplanted, may cause a like disease 
in another, and the possibility of the 
transplantation is always compara- 
tively easy. Thus it was that phthisis 
pulmonalis was removed from the list 
of non-contagious to that of conta- 
gious affections. Again, bacterial ori- 
gin or otherwise is highly important as 
regards treatment and prognosis. 
Nothing is easier than to destroy life, 
especially such low life as we usually 
find in germs, if we can come into 
actual contact with the parasite, and, 
therefore, for this very reason, other 
things being equal, a parasitic disease 
has a better prognosis than a non- 
parasitic one. Every one knows the 
improvement in prognosis of phthisis 
pulmonalis since Koch's discovery be- 
came known. If, then, the etiology 
as regards bacteria be so important in 
constitutional diseases, where the germ 
is generally hidden away in the depths 
of the organism, it is very evident that 
it becomes almost all-important in dis- 
eases of the skin, which are, in general, 
local and easily accessible. 

In order to be as concise as possible, 
and also for the sake of plainness, we 
will tabulate in alphabetical sequence 
those bacteria which, with the forego- 
ing limitations, may be called specif- 
ically pathogenic, and opposite to 
them the names of the diseases for 
which they are held responsible: 



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Parasite. Disease. 

Achorion Schonleinii Tinea favosa (favus). 

Bacillus anthrocosis Malignant pustule, anthrax, etc. 

** lepra (Hansen) Leprosy. 

^' tuberculosis Lupus vul^is. 

Microsporon furfur Tinea versicolor. 

^^ minutissimum Erythrasma. 

Staphylococcus aureus et al bus. .Impetigo contagiosas. 

C Tinea capitis vel tonsurans. 

Tricophytina < Tinea barbae vel sycosis. 

( Tinea circinata vel corporis. 



I am well aware that in formulating 
the above table I am treading upon ex- 
ceedingly debatable ground. A host of 
authorities, more or less reliable, are 
ready to question it, chiefly in the way 
of addition, but scarcely any two of 
them would agree as to the exact num- 
ber to be added. The above repre- 
sents, therefore, all those micro-organ- 
isms universally acknowledged patho- 
genic in a dermatological sense. Some 
of them, such as the staphylococci, are 
responsible, probably, for more dis- 
eases than they are credited with in 
the table, such as furunculosis, etc., 
but these exceptions are neither nu- 
merous or important. 

It will be observed that they are not 
all local in their effect. Leprosy is es- 
sentially a constitutional disease, the 
importance and certainty of its terrible 
skin manifestations alone being respon- 
sible for its bein^ classed as a skin dis- 
ease. It will also be noted that the 
range of germ diseases is compara- 
tively limited, not only in number, but 
to a far greater degree in importance. 
Of the ten or a dozen diseases men- 
tioned, only a few of them are of re- 
ally practical interest. Compared with 
these not yet, at least, proved bacterial 
in origin, they sink almost into insignifi- 
cance. Leprosy, fortunately, is a dis- 
ease almost never seen in Anglo-Saxon 
communities. Its bacillus was discov- 
ered by Hansen, towards the middle of 
the last century, and under the micro- 
scope is scarcely to be distinguished 
from that of pulmonary consumption. 



except in its slightly smaller size. It 
may also be added that the manner of 
staining is identical. Its most likely 
habitat is, especially in the earlier 
stages, the discharge from the nose. 

The bacillus of tubercule is too well- 
known to need any extended reference. 
Its importance, however, in lupus, is 
very much less, diagnostically, than 
in the lung disease. It is a matter of 
some difficulty to differentiate it in the 
lupoid tissue, but, fortunately, the 
clinical features of this disease are so 
pronounced that no one, if versed at 
all in dermatology, may be excused in 
overlooking it. In another place* I 
have discussed the remarkable immu- 
nity from phthisis pulmonalis enjoyed 
by those suffering from L. vulgaris, 
even when the latter is situated at the 
very entrance to the respiratory tract. 
It would project this article beyond a 
reasonable length to attempt to de- 
scribe in full the mechanism of pre- 
paring the bacillus for examination, 
nor would it be profitable, seeing that 
such work is so much better performed 
in text-books for that purpose, than 
the writer could do it. As its name 
denotes, it is a rod-shaped germ, six 
or eight times longer than wide, and 
usually, though not invariably, found 
in clumps of half-a-dozen or so. The 
bacillus of anthrax^ or malignant pus- 
tule, was almost, or quite, the first 
pathogenic micro-organism discovered. 
It is consequently more than half a cent- 

* See my article on skin muiifestatioiis in general 
disease, in September 1902 issue, AUBBIoak joubkai. 

OF DXBMATOLOOY. 



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11 



ury old. It is among the longest of path- 
ogenic germs, being found in straight 
or broken rodis many times longer than 
wide. It can, nearly always, be dem- 
onstrated in any collection of pus re- 
moved from the lesion, and under quite 
a low power. The fungus of tinea 
favosa is still more easily found. A 
scraping from the affected scalp, con- 
taining any infected crusts, softened 
by and immersed in liquor potassse, 
will distinctly show it with a No. 6 ob- 
jective. Once seen, it can never be 
mistaken for anything else, even for 
that of the tricophyton, which it most 
resembles. By its distinctly larger 
size than the latter it is quite easily 
known. Beside that, the clinical dif- 
ference between favus and tinea ton- 
surans is so pronounced that a mistake 
would be inexcusable. Between the 
fungus of favus and that of tinea ton- 
su7'ans^ the chief difference, in appear- 
ance, as already noted, is the greater 
size of the former both in the diameter 
of the spores and in the breadth of the 
mycelium . Indeed, between the fungus 
of favus, ringworm and erythrasma 
there is no radical distinction except 
size, but this is so pronounced, the 
microsporon minutissimum being so 
very small, that there should be no 
difficulty in differentiating, especially 
with the clinical cases before us. The 
remaining fungus, that of tinea veri- 
cdlor^ is essentially different in its dis- 
tribution upon the microscopical field 
from either of the other three. The 
spores hang in clusters almost exactly 
as grapes do on the vine, and for this 
reason are very distinguishable, indeed. 
All four are plainly seen in liquor 
polassee, without any staining what- 
ever. The staphylococcus aureits and 
albus are simply pus-producing germs, 
and although I have included them in 
my list of pathogenic organisms, yet 
their standing, as such, is still doubt- 
ful. They are easily stained, as found 
in pus, by most of the aniline dyes, 
and are quite easily seen by a No. 6 
lens. Having passed, in rapid review. 



those germs which alone, with fore- 
going limitations, are of importance in 
dermatology, it is periiaps proper that 
a few reasons be given for being thus 
dogmatic in our assertions. 

The chief disease which the derma- 
tologist has to treat is eczema. Now, if 
eczema were proved to be a germ dis- 
ease, it would, by reason of its enor- 
mous frequency, be a very important 
fact. Indeed, such a germ would 
easily outweigh, in importance, all the 
others put together. But eczema is 
not a bacterial disease, notwithstand- 
ing frequent assertions to that end. 
There is, indeed, a form of disease 
called **parasitic eczetoa," which, in 
its clinical characteristics, is appar- 
ently germ-produced, even though its 
specific cause has not been demon- 
strated. But such disease is not ec- 
zema. To call it such is a misnomer. 
It is, until a definite name, consequent 
upon its cause, be given it, a parasitic 
dermatitis. A germ-produced disease 
is contagious, as has already been 
shown. Eczema is not. The former 
is of gradual onset. Eczema, as I 
have repeatedly seen, often envelops 
the whole body in a few hours. Ec- 
zema almost always is symmetrical, 
while there is no possible reason for a 
bacterial disease to be so. Eczema, 
again, is often limited in particular per- 
sons to asmall localized space, and, after 
being cured, will recur exactly upon 
the same spot, a coincidence which there 
are a million of chances to one against 
its happening if produced by a germ. 
Time and again, also, has eczema been 
investigated for pathogenic germs; 
innumerable have been found, but 
none, that when introduced into the 
system, ever even simulates the orig- 
inal disease. There are a few proofs 
of its non-bacterial origin. Yet this 
disease constitutes thirty per cent, of 
all dermatological lesions. 

Again, one of the most important, 
and, unfortunately, frequent diseases 
met with by the skin expert is syphilis. 
Now, while there is no question as to 



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Original Articles. 



the contagiousness of this disease, yet 
this contagiousness is not due to a 
germ. The exhibition of iodide of 
potassium will often produce an erup- 
tion of the skin. But no one will 
pretend to believe that pot. iodid con- 
tains **germs." Again, the contents 
of the poison glands of the cobra de 
capella of India, will, when injected 
into the system, produce inflammation 
and death within a very few minutes. 
The suddenness of its onset effectually 
precludes the supposition that its fatal 
effect is due to any micro-organism. 
Almost innumerable instances might 
be adduced in this connection. In a 
word, there are other disease-produc- 
ing elements residing without the body 
other than germs, to the chief of 
which, for want of a better, the name 
virtis has been affixed. Nothing can 
be more important than to keep in the 
mind a clear distinction between them. 
Yet nothing is easier, or more com- 
mon, than to get them confused. It 
must be admitted, however, that, al- 
though we possess considerable knowl- 
edge of the life-history and mode of 
toxic procedure in the matter of germs, 
we are yet in almost complete igno- 
rance of the nature and method of ac- 
tion of virus. Yet, in all probability, 
it is to this subtle and powerful ele- 
ment we owe the origin of syphilis. 
The strongest argument against the 
bacterial origin of syphilis is the un- 
doubted and peculiar hereditary nature 
of this complaint. Volumes have been 
written to disprove this trait of syph- 
ilis, but without conclusive effect. If, 
then, to syphilis we add psoriasis, all 
the so-called ' 'childish exanthemata," 
as measles, scarlet fever, etc., etc., 
pemphigus, nearly all the various ab- 
normal growths and tumors, in none 
of which, a specific etiological germ 
has been differentiated, we shall come 
to see, after all, the limited scope the 
path(^enic, germ has in dermatology. 
StilU as .hinted at the outset, this is 
hardly a subject for congratulation. 



It must be confessed, taking psoriasis 
as an example, that the greater num- 
ber of these non-bacterial lesions are 
still sealed books to us, so far as 
their origin is concerned, and the 
not knowing the true genesis of a dis- 
ease is a decided handicap to its treat- 
metit and progress. However, there 
is an advantage, and a great one, in 
recognizing that in all probability it is 
futile to look for germs or the true 
etiological factor in many of these 
complaints. The germ business, to 
speak in a slangy way, has been, and 
is being, greatly overdone. The old, 
plodding, patient, painstaking pursuit 
of original causes, other than material- 
istic, has almost faded from earth. 
The influence of that subtle and ob- 
scure entity, which, for want of a 
better name, we call the mind over the 
body, and its power to cause diseased 
conditions, has been relegated to the 
limits of exploded superstitions, very 
unwarrantably, in the opinion of the 
writer. While undoubtedly disease is 
not an entity in itself, just as undoubt- 
edly it is not always caused by an entity. 
I am not going to quote the hackneyed 
extract from Shakespeare about *'more 
things in heaven and earth," but it is 
true, nevertheless. Let us hope that 
a few of our great original thinkers 
will leave the everlasting and sordid 
chase after "bugs," and again take 
up the more elevated and almost di- 
vine contemplation of the influence of 
"mind over matter." 



o:*?o 



*'In the application of therapeutics 
to eczema, more is to be accomplished 
by a careful study of the patient in 
every aspect, and the application of 
remedies suitable to the condition 
found, than by the employment of any 
special prescription which is supposed 
to be of value in the disease." 

L. Duncan Bulkley, 

New York. 



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Diverticula of the Male Bladder— Schmidt, 



18 



NOTES ON DBVBRTICULA OP THE MALE 
BLADDER. 

By Louis E. Sohmidt, M. So., M. D., 

Associate Prof esBor of Gtonito-Urixkftry Diseases, Chicago 
Policlinic; Clinical Professor of Genito-Urinair Sur- 
gery, School of Medicine, Northwestern Univer- 
sii^j Attending Genito-Urinary Surgeon and 
Dermatologist, Alexian Brothers'^Hos- 
pital, Chicago. 

Since this condition occurs so fre- 
quently, is so often not diagnosed, or 
is misinterpreted, and as it gives rise 
to so many symptoms, I have thought 
it justifiable to discuss this condition 
before a general meeting. 

While there is no absolute uniform- 
ity of opinion in respect to the exact 
nomenclature, it seems to be right to 
distinguish between a diverticulum 
proper and the so-called false divertic- 
ula. 

A true diverticulum is a cavity com- 
municating with the viscus whose wall 
consists of all or of a part of the con- 
stituent layers of the bladder wall. It 
is true, however, that in large divertic- 
ula the wall is formed by the mucosa 
and submucosa only. If this condition 
affects a part of the bladder covered 
by the peritoneum, the latter may 
make a third layer. 

Shallow recesses of the bladder wall 
which are not attached to the bladder 
as distinct and separate cavities may, 
according to English, be called bladder 
cells. 

A false diverticulum is a sac which 
originally had nothing to do with the 
bladder wall, but is a pathological cav- 
ity which by some cause or other came 
into communication with the viscus. 
For instance, perforation of a neigh- 
boring abscess into the bladder, or the 
establishing of a communication be- 
tween the bladder and a tumor cavity 
by ulceration. 

Although it is true that occasionally 
congenital diverticula are to be found, 
the overwhelming majority of cases 
are acquired conditions, and the state- 
ment seems to be borne out by expe- 
rience that cells and true diverticula are 
practically only different stages of the 



same process whose beginning depends 
upon the same pathologic changes. 

The first step for the formation of a 
diverticulum is always a partial hyper- 
trophy of the bladder wall ; and then 
a consecutive weakening of a part of 
the wall which is enclosed by hyper- 
trophied muscular bundles; in other 
words, the first stage of formation of 
a diverticulum is trabeculization of the 
bladder. It becomes quite apparent 
how the causes for trabeculization 
produce in the long run the bulging 
out of circumscribed areas pf the blad- 
der wall. The trabeculization of the 
bladder, a partial work hypertrophy of 
the muscular coat is always the result 
of the overtaxing of the functional 
capacity of the bladder. That is, 
some obstruction in the urethra forces 
the bladder to permanent, extraor- 
dinary exertion for expelliAg the urine. 
The usually concomitant conditions 
of such an obstruction give impulse to 
frequent urinary calls, so that not 
only the force of contraction but also 
the number of these exertions of the 
bladder are increased. It is easily un- 
derstood how the bladder wall in those 
areas which are encircled by the hyper- 
trophied muscle bundles will give way 
under the pressure, when the bladder 
contracts around its contents. But 
even if this should not have been the 
case the progressive hypertrophy of 
the bundles which protrude into the 
viscus will give the impression that a 
sac with an open communication is 
attached to the bladder wall. The en- 
trance to these recesses will, of course, 
be wide open, and as long as the mus- 
cular coat does not give way, the depth 
of these recesses will never be great* 

The muscular coats will very easily 
give way under two conditions. First, 
if by inflammatory infiltration the mus- 
cular coats in certain locations are 
teased apart. Or if by an old inter- 
stitial cystitis the larger part of the 
muscular fibres in a certain spot have 
been lost. In such a case the mucosa 
and submucosa will protrude in and 



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through thifi defeotive spot and into 
the abdominal cavity like a hernia. A 
pre-existing pericystitis by involving 
circumscribed areas of the bladder wall 
may also lead to the same condition. 

It is to be observed that in the 
course of time the size of the sac gets 
out of proportion with its entrance, so 
that a very small opening may lead 
into a large diverticidum and there is 
no limit to the growing size of the sac 
but the elasticity and resistance of the 
tissues. The shape of the opening 
changes with the progress in the devel- 
opment of the diverticulum. While at 
first the opening is rhomboidal, outlined 
by the sharp edges of the muscular bun- 
dles, in time it acquires a more rounded 
shape. The history of a diverticulum 
accounts at the same time for the fact 
that diverticula are almost never found 
in the trigonal part of the bladder. 
Here the bladder wall is supported by 
underlying organs and the pelvic floor, 
and strengthened by accessory muscle 
bundles from the pelvic musculature. 
The intimate attachment between the 
different layers of the bladder wall in 
this region is another factor which 
militates against the formation of di- 
verticula in this region. Different ob- 
. servations convinced me, furthermore, 
of the fact that the trigonum, on ac- 
count of its topographic relations, is 
possessed of a very limited contracti- 
bility only, so that trabeculization of 
this part of the bladder is never to be 
found. 

The cystoscopic view of divertic- 
ula will, of course, vary according to 
the stages of development. But one 
thing is always characteristic. While 
it is^easy to illuminate the fundus of a 
shallow recess, and while its opening is 
always of the same size as its bottom, 
a true diverticulum, on account of its 
bottle-shaped form, will, in most cases, 
appear as a dark hole, because only un- 
der certain circuraatances will it be pos- 
sible to throw the light of the cyst- 
oscopic lamp into the sac. 



The symptoms caused by diverthAflft 
are in quite a number of cases covered 
by the symptoms which are the conse- 
quence of the pre- and co-existing dis- 
turbances in the urethra and bladder. 
But there area few points which always 
lead to the suspicion of the existence 
of diverticula, and consequently force 
upon us the necessity of a cystoscopic 
examination. If it occurs repeatedly 
that in flushing out the bladder sud- 
denly, after the fluid had returned 
quite clear, a big drop of yellowish 
mucus appears ; if the patient reports 
that the last drops of uriBe always 
smell rather offensively; if a patient is 
the bearer of a dull pain in the hypo- 
gastric region without showing any defi- 
nite symptoms accounting for it, the 
presence of one or more diverticula 
may be suspected. In some cases of 
old chronic cystitis, in which silver 
nitrate was applied for some length of 
time, a quite characteristic occurrence 
is frequently observed . Either the pa- 
tient reports that once in a while after 
he has finished urinating a blackish 
fluid was voided, or, if it occurs during 
a treatment, that the returning fluid is 
of a blackish tinge, we may safely as- 
sume that this originates in the fact that 
some of the silver nitrate solution re- 
mained retained in a bottle-shaped 
diverticulum . A chemical test for this 
emptied fluid will reveal the presence of 
silver. Similar phenomena may occur 
after the use of iodoform emulsions. 

A quite characteristic complex of 
symptoms arises if the formation of a 
diverticulum is combined with the ex- 
istence of peri-cystitis, while uncom- 
plicated peri-cystitis causes a permanent 
dull pain outside of the usual region 
of bladder pain. This pain becomes 
very sharp in the last-mentioned com- 
plication . The patients call it a piecing 
one, and this excessive pain is confined 
to a distinct spot. The location of this 
pain tallies with the location of a diver- 
ticulum. The pain is always started by 
micturition — that is, a sharp pain arises 



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Diverticula of the Male Bladder—Schmidt. 



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every time when the contracting blad- 
der makes the diverticulum pull with 
its top at the peri-cystitis focus. 

The dignity of diverticula becomes 
yetj apparent if we consider the con- 
ditions in chronic cystitis which, as a 
rule, accompanies the presence of 
diverticula, the cystitis being produced 
by the same infection which gave rise 
to the development of strictures in the 
urethra, or developed later on in con- 
sequence of chronic retention and sub- 
sequent infection. The diverticulum 
will be a receptacle in which the prod- 
ucts of the cystitis will always be re- 
tained for some length of time, so that 
they will adhere to its wall, thus giving 
rise to decomposition. 

Larger diverticula become very im- 
portant, if such a sacculation becomes 
attached to an inguinal or femoral 
hernia. The descending hernia, by 
and by, drags the diverticulum into the 
hernial canal, and then quite serious 
phenomena of incarceration might 
take place, even if the prolapsed intes- 
tine proper does not become impacted. 
In such a case a diverticulum is very 
apt to become gangrenous, and urinary 
infiltration and fatal infection quickly 
take place. 

The diagnosis in such cases may be 
a very difficult one. While, if a part 
of a bladder which carries no diverticu- 
lum becomes entangled into a hernia, 
we have decided and leading symptoms, 
this is not necessarily the case if a 
diverticulum descends with a hernia. 
If symptoms of incarceration take 
place, the attention misht be drawti 
to the possibility of the impaction of a 
diverticulum through the following 
facts: The urinary calls become fre- 
quent, the contraction of the bladder 
eictremely painful, and blood may ap- 
pear in the urine. 

Quite important conditions might 
arise if the formation of a calculus 
should take place inside of the diver- 
ticulum. 

The chronic retention in a diverticu- 
lum leads quite easily to precipitation 



of the urinary solids, while the organic 
skeleton for the formation of a calcu- 
lus is furnished through the existing 
cystitis. If once the nucleus of a cal- 
culus is deposited in the diverticulum, 
the further deposition of urinary salts 
will be a rather rapid one on account 
of the already mentioned chronic re- 
tention. The same holds good if a 
renal calculus, after its descent from 
the kidney, gets caught in the diver- 
ticulum. This is proven by the fact 
that cuts through stones taken out of 
diverticula show quite frequently that 
the nucleus is formed from substan- 
ces which are only precipitated in 
the kidney. These diverticula stones 
remain quite often permanently im- 
bedded, at least with the bulk in 
the diverticulum, and by and by, 
through permanent deposition, grow 
out of the sac into the bladder viscus. 
The attachment of mucus and pus 
covers the free surface of such a 
stone quite often so completely that 
this condition gives rise to all kinds of 
fallacies in diagnosis. All these cir- 
cumstances explain why a stone in the 
diverticula may, for some time, not 
furnish at all the characteristic symp- 
toms of a vesical calculus. The classic 
symptoms of stone appear only after 
it surpasses the level of the diverticula 
entrance, or in case it becomes dis- 
lodged by some sudden force. 

The diagnosis of a stone in a divertic- 
ulum faces the peculiar difficulty due 
to the above explained conditions. The 
stone searcher may not reach the stone 
at all, or gliding over the free surface, 
which is covered with pus and mucus, 
it does not communicate to the ex- 
amining hand the sensation character- 
istic of the contact with a calculus. 
The greatest aid in diagnosing such 
stones is furnished by the cystoscope. 
If a certain spot in the field of view 
should not be quite free from all doubt- 
ful appearances, the operative cysto- 
scope can be resorted to. With an 
introduced sound the questionable 
prominence may be touched. With a 



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curette the covering may be removed. 
With the forceps the prominence can 
be grasped, and it is thus possible to 
find out whether a part of it is sunk 
down deep into the bladder wall and 
whether it is possible to dislodge the 
stone. 

The therapy so far as diverticula and 
the conditions of the mucosa inside of 
them is concerned, faces very difficult 
propositions. As has been mentioned, 
it is extremely difficult, if not impossi- 
ble, to clean out deep diverticula by 
flushing out, so that it is very hard to 
bring the disinfectant or astringent 
fluid in contact with the diseased 
mucosa. We can overcome this diffi- 
culty if diverticula are not too nu- 
merous by direct local applications 
through the operative cystoscope. It 
is a matter for further experience and 
tests whether the pumping apparatus 
devised by Eraus will prove itself ex- 
pedient for cleaning out diverticula. 
It has been repeatedly suggested, espe- 
cially by French authors, that exten- 
sive diverticula be resected by lap- 
arotomy, following the resection by im- 
mediate suturing of the excision wound. 
I personally have no experience in 
this direction. The combination of a 
diverticulum and an inguinal or femoral 
intestinal hernia points quite strongly 
to the resection of the prolapsed 
diverticulum. Its excision and com- 
plete suture will recommend itself 
in non-inflamed cases. Gangrenous 
diverticula will call for drainage after 
the necrotic parts have been removed. 
I would like to mention, that we must 
always think of the possibility that 
part of the bladder may be involved in 
a hernia if the conditions, after expos- 
ing the sac, are not quite clear, if a 
great amount of preperitoneal fat ap- 
pears, and if large veins en masse ap- 
pear at the median aspect of the hernia. 
This possibility will become a certainty 
if the characteristic muscle bundles of 
the bladder come in sight. After a 
stone in a diverticulum is diagnosed 
the therapy will be indicated by the 



possibility of dislodging the stone, 
either by bimanual manipulations or 
through the aid of the operative 
cystoscope. It will be best to proceed 
with litholapaxy provided that no other 
contra-indication exists, if it can be dis- 
lodged. In case it should be impossi- 
ble to dislodge a stone the only indi- 
cated operation will be a cystotomy. 



CLINICAL REMARKS ON SOME ADVANCED 

FORMS OP URETHRAL STRICTURE 

TREATED BY A COMBINED 

URETHROTOM YAND 

PERINEALSEC' 

TION. 

Bt Reginald Habrison, F. R. C. S., England, 
Surgeon to St. Peter's Hospit*], London, England. 

In some clinical remarks I recently 
offered* on the commoner forms of 
urethral stricture, I reserved for sep- 
arate consideration certain instances 
where the methods of treatment then 
referred to were unlikely to prove of 
much benefit for the reasons that 
either the obstmctions were too "burn- 
soar"-like and contractile to dilate or 
too tough or extensive to divide from 
within the urethra. In addition to 
such characteristics the strictures are 
not unfrequently complicated with 
fistulee or tortuous routes in the per- 
ineum and scrotum through which both 
urine and pus escape. Hence the dis- 
comfort of the patient is often greaUy 
added to. Cases answering to this de- 
scription are generally regarded as 
being best treated by some form of 
perineal section or, as it is sometimes 
called, external urethrotomy, and it isto 
this point I desire nowtoconfinemyself . 
As a contribution to this subject I 
published a series of casesf where the 
usual operation of perineal section as 
undertaken for stricture in the deep 
urethra had been greatly simplified 
and its safety and efficiency increased 
by combining with it internal urethrot- 

•The Lancet, April 23, 1898. 
t Brit. Med. Jour., July 18. 1885. 



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Urethral Stricture—Harrison. 



17 



omy. Strictures of the class now 
under notice are but rarely impassable 
to some form of instrument, and as by 
reason of the urinary fistulae which so 
often complicate them they are seldom 
urgent in their nature, time is allowed 
not only for effecting an entrance into 
the bladder by the natural way, but 
also for ascertaining what may be the 
outcome of some kind of dilatation. 
Assuming that the former is accom- 
plished, though dilatation proves fut- 
ile, the combined operation probably 
offers the best solution of the difficulty. 
In describing it, together with such 
modifications as I have adopted since 
the publication of my first paper on 
this subject, I will take in illustration 
two typical instances in which it was 
employed. 

Case 1. — ^A man, aged fifty-one 
years, whom I saw and operated upon 
in 1890 had been the subject of a 
stricture with a strong tendency to 
contract for some years and had un- 
dergone no less than six operations 
for it, including a divulsion by Holt's 
method and five internal urethrotomies 
at various intervals and places. For 
some months before I saw him the 
stricture had been contracting and 
closing in spite of the patient's well- 
directed efforts with suitable bougies 
to keep it open. Straining to urinate 
was constant and prevented continuous 
sleep, and there was some cystitis with 
probably pyelitis. It was clear that a 
free relief must be afforded as struct- 
ural kidney complications appeared 
imminent. I performed an internal 
urethrotomy with Teevan's modifica- 
tion of Maisonneuve's instrument, as 
I thought that the latter might not 
stand the strain put upon it by the 
cartilaginous character of the tissues 
which had to be divided. This being 
done I passed a full-sized grooved staff 
^No. 12 English) into the bladder. 
As the latter was evidently gripped in 
the deep urethra I had the patient 
placed in the lithotomy position, and I 
divided in the median line from with- 



out inwards such contracted tissues as 
remained. I thus opened the urethra, 
and found by passing my finger first 
into the bladder and then hooking it 
forwards. along the urethra in the di- 
rection of the penile orifice that the 
walls of the canal had now been ren- 
dered free and unresisting. A full- 
sized gum-elastic drainage-tube (such 
as I have elsewhere described and fig- 
ured$ in connection with the larger 
subject of bladder drainage) was passed 
into the bladder through the wound 
and retained. The parts were well 
washed out with a solution of per- 
chloride of mercury (1 in 6000). The 
drainage-tube was finally withdrawn 
on the sixth day and the wound soon 
closed. Eight years have now elapsed 
since this operation was practiced. 
The patient remains in good health, 
and suffers no further inconvenience 
from his urinary organs than having 
occasionally to pass a full-sized bougie 
for himself. I frequently meet him. 

Case 2. — This patient, aged forty- 
. five years, had a tough contractile 
stricture which had resisted dilatation, 
and was complicated with several uri- 
nary fistulse of two years' standing. I 
operated upon him in 1892. He was 
treated in the same way as the preced- 
ing patient, and in addition the various 
fistulae were opened up and scraped. 
The result was equally satisfactory 
and is so far permanent. 

Perineal section carried out on these 
lines has been found to present many 
advantages. In the first place it is 
easier to effect a division of the hard 
and condensed tissues of the perienum, 
such as generally surround strictures 
of this kind, upon a fairly large staff 
than upon a small one or even upon 
the shouldered staff which Syme used 
for marking the commencement of 
the contracted portion of the canal. 
The freedom or otherwise with which 
the large-sized instruments move in 
the canal is sufficient to determine 

t Surgical Dlsorderi of the Urinary Organs, 4th edi- 
tion. 



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the necessity for proceeding at once 
with the external section, as well as 
the precise locality and d^ree of the 
contraction which remains. It may 
seem at first sight in combining these 
two operations that the magnitude of 
an ordinary perineal section is in- 
creased. This, however, is not the 
case, as the division of more or less of 
the obstruction from within the canal 
has not infrequently proved sufficient 
to completely clear the urethra, whilst 
it invariabfy tends to lmit:cansiderably 
the extent of any extern^ seetion 
which may still be required. Further, 
it must be rmtmwbaeed that there is 
no kind of wound involving the deep 
urethra which heals so kindly or is so 
free from those constitutional symp- 
toms which occasionally follow opera- 
tions on this canal than that where a 
temporary drain is established for the 
urine. Again, this point is import- 
antly supported by the results follow- 
ing rupture of the deep urethra from 
external violence. Cases of this kind 
where a perineal section is performed 
and a temporary drain established 
compare most favorably, both imme- 
diately and remotely, with those where 
the treatment consists in the retention 
of a catheter, when this can be passed, 
the points of distinction being in the 
former class of cases the absence of 
septic symptoms of a serious nature 
and the more favorable character of 
the scar which results. There is no 
worse kind of stricture to manage than 
that following an extensive rupture of 
the deep urethra and its treatment by 
what may be described as the closed 
method. It is on grounds such as 
these that I believe the combined op- 
eration proves of much benefit in the 
treatment of some of the most serious 
and complicated forms of urethral 
stricture. 

Before concluding these remarks I 
will briefly refer to a class of strictures 
which I have only incidently noticed. 
This is the structurally impassable 
stricture— impassable alike to instru- 



ments and urine, and associated invari- 
ably with an extraneous route for the 
urine, probably through the perineum. 
The latter condition is the result either 
of nature's effort to provide escape f pr 
the urine by abscess and fistula or of 
the surgeon's, more promptly and di- 
rectly, by incision. In endeavoring to 
restore a urethra Oi this kind and to 
close a well-worn fistula tke surgeon 
will fully recognize the mechanical and 
physiological difiiculties before him 
not only in reproducing a portion^of the 
canal which to all intents and purpose^ 
is obliterated, hut in subsequently fit- 
ting it to take up the functions coQ'- 
nected wttii the process of . natural, or 
even aided, mieturitioci. It requires 
no great amount of surgical ingemrity 
to establish the continuity of the 
urethra so far as instrumentation is 
concerned, but to secure a reasonable 
degree of control or influence over th^ 
restored portion of the canal is by no 
means certain. On the other hand, 
experience and trial have not infre- 
quently shown that a good urinary 
fistula has proved an excellent substi- 
stute for a bad urethra. 
Lower Berkeley street, W. 



BSDOVBSICAL SURQBRY WITH SPECIAL 

REFERENCE TO CYSTOSCOPY AND 

URETER CATHETERISM.* 

Bt F. Kriissl, M. D., Chicago, DlinoiB, 

Professor of Genito-Urinary Surgery, Chicago Clinical 
School. 

It is but natural that with the earlier 
progi*es8 made in the surgery of the 
kidney and bladder the necessity of 
rendering the diagnostic means more 
exact and therapeutic procedures less 
complicated and risky became more ur- 
gent. As the first step in this direc- 
tion — notwithstanding previous at- 
tempts — may be considered the explo- 
ration of the female bladder and the 
removal of foreign bodies, stones and 
tumors from the viscus after rapid di- 

* From a paper on the program of the meeting of the 
niinois State Medical Society. 



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Cystoscopy— KREIS3L. 



19 



latation of the urethra practiced by 
^moD. But this forcible distensiouis 
not a^^Hnld, insignificant procedure, as 
it requires general anesthesia, fre- 
ouently produces deep lacerations of 
iveilafisues, and from there quite pro- 
fuse hMMMi^ges and ocoasionaliy re- 
sults in irrepMM^wpontinence. The 
desire to explore the^tMlies and the 
renal pelvis, and the necessity it^ym 
tect the former in abdominal and vi^ 
inal sections, led to epicystotomy and 
colpocystotomy as a preliminary step 
for the subsequent catheterization of 
the ureter. 

Pawlik, in Vienna, accomplished the 
same result per vias naturales, using 
the outlines of the ligamentum inter- 
uretericum in the vaginal wall as a 
guide to the vesical opening of the 
ureter and afterwards constructed his 
cystoscope, which permitted the in- 
spection of the illuminated bladder and 
the catheterization of the ureter without 
difSculty. He was soon followed by 
Kelly in this country with a similar in- 
strument, the publication of the. latter 
causing a bitter fight for the priority 
in the invention carried on in med- 
ical journals here and abroad for a 
time. However, Howard Kelly has 
done so much for the development of 
intravesical surgery in America since 
then that any unintended trespassing 
on Pawlik' s invention may be par- 
doned. 

Simultaneously with the remarkable 
progress in renal surgery in the last 
decade, the surgeons felt the import- 
ance and necessity of much exacter 
methods of diagnosing surgical dis- 
orders of the kidney and of informa- 
tion regarding the presence, situation, 
condition and functional capacity of 
the other mate. The result furnished 
by palpation and urinalysis proved fre- 
quently unsatisfactory or unreliable 
and misleading, necessitating as here- 
tofore explorative operations. To ob- 
viate the latter various apparatus have 
been constructed, aiming to collect the 
urine of both kidneys separately as it 



enters the bladder. Among many I 
may only mention the segregators de- 
vised by Neuman (Deutsche Medioin' 
ische WochenschHft^ 1897), and by 
Harris {Journal AmericanMedical A$- 
sociation^ 1898), and A. J. Downes^ 
in Philadelphia. The underlying prin- 
ciple is the establishing of two separate 
sections in the lower bladder wall by 
means of an artificial septum. Each 
iSiMiMi is supposed to contain the vesi- 
cal openta|^itf4li»^K)rresponding ureter, 
and from each one tbe " wimu ifr taken 
by suction and collected in septtr^te 
receptacles for further tests. The ad^ 
vocates of this method claim in its 
favor that it does not require any spe- 
cial skill, nor illumination of tbe blad- 
der or searching for the ureteral open- 
ing, the absence of any danger of 
ureteral lesions or infection, and t^at 
it allows simultaneous observations and 
comparisons of the quantity of the se- 
cretion of both kidneys in a certain 
period. Objections are also not lack- 
ing, and it is a fact that misleading 
conclusions arrived at by this method 
have been followed by grave conse- 
quences. It is difficult to establish 
with absolute certainty the watershed 
in the male bladder, impossible in hy- 
pertrophy of the prostate and in a 
bladder whose shape is rendered irreg-- 
ular by any pathologic condition out- 
side, but close to its wall ; for instance, 
tumors and pericystitis. Errors and 
doubts in tracing symptoms to the 
bladder, instead of to the kidney, and 
vice vei'sa^ are also possible and have 
occurred. Rose's procedure for the 
same purpose (C,f. Gyn.^ 1897), in- 
tends to eliminate such errors. The 
patient, female, is placed in the knee- 
chest posture, a speculum 6 ctr. long 
and 1 ctr. wide, introduced into the 
bladder, and having found the ureteral 
opening by using reflected light, the 
vesical end of the tube is pressed 
against the surrounding bladder wall, 
and the urine accumulating in the tube 
removed by suction. There is no doubt 
that all these procedures are accompa- 



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nied by more or less inconvenience and 
pain to the patient, that the pressure 
exerted on the urethra, bladder and 
surrounding organs is not without eon- 
sequence and their efficiency a rather 
limited one. The claim that the inex- 
perienced is able to perform them is a 
rather weak excuse for practicing them 
in a period in which cystoscopy has 
become a well-developed branch of 
urinary surgery. Catheterization of the 
ureters through the cystoscope, appli- 
cable alike in both sexes, is in the 
hands of the experienced ones a com- 
paratively mild, painless and harmless 
act, it often permits not only an exact 
diagnosis of the diseased kidney, but 
furnishes valuable information con- 
cerning the presence, condition and 
functional capacity of the mate. 

The condition of a kidney still hav- 
ing secretory tissue might make its 
removal urgent, and yet its mate not 
being essentially diseased, might have 
such a low functional capacity as to 
render it incapable of assuming the 
work for both, and the surgeon will 
refrain from a radical operation. 

In another case the findings may be 
such as to indicate that both kidneys 
are similarly afflicted; that one has 
none, or hardly any, secretory tissue, 
while the functional capacity of the 
other is still intact. Here the surgeon 
will perform the radical operation with 
a good prognosis, and to the relief of 
the patient. Instructive is a case re- 
ported b}' Casper, in which a tumor of 
the right kidney was present, but the 
urine furnished by this kidney was 
perfectly clear, containing traces of 
albumin, while very bloody urine came 
from the left kidney. Such conditions 
are found in tumors and tuberculosis 
of the kidney. 

Among the instruments for ureter 
catheterization I mention the cysto- 
scopes of Nitze, Casper, Albarran, 
Kelly, Brenner and B. Lewis. 

Our knowledge along the line of 
functional diagnosis was materially in- 
creased of late by the methods known 



as kryoscopy, the Phloridzin test and 
the determination of the quantity of 
secreted urea, aided by the ureter- 
catheterism. Credit for these innova- 
tions must be given to Koranyi, Kuemel 
and Casper. The latter ascertained 
that the values for the quantity of 
sugar and N, and the freezing point of 
the urine of a healthy person when 
collected from both kidneys simulta- 
neously and separately are invariably 
equal, but that all values in unilateral 
kidney disease fall below the values of 
the healthy one. This difference is so 
pronounced that errors are nearly pos- 
itively excluded, so that the determi- 
nation of these values, taken together 
with all the other methods of investi- 
gation, lend a formidable support to 
the diagnosis, prognosis and surgical 
intervention in various kidney diseases. 
With the possibility of a much earlier 
diagnosis, we may now hope that the 
mortality after kidney operations, 
which has been materially lowered by 
the wonderful strides in surgery, will 
be still considerably reduced by the 
combination of uretercatheterism, ra- 
diography and the new methods of 
functional diagnosis. 

But the catheterization of the ureters 
was not only the stepping stone to a 
more solid basis in diagnosing kidney 
diseases, it has also contributed to en- 
large our therapeutic possibilities in 
pathologic conditions of the ureter and 
the renal pelvis through the cystoscope, 
opening still brighter prospects for the 
future. 

Few as the records in this respect 
are, yet the results obtained are very 
encoui*aging, and they demonstrate the 
feasibility of successful, bloodless, in- 
travesical intervention for the relief 
from an obstruction in the ureter by 
concrements, valves or structures, and 
the treatment of an infectious process 
in the renal pelvis. All this, of course, 
under especially favorable conditions. 
The bulk of these cases will, as here- 
tofore, be subject to cutting operations, 
although catheterization does in many 



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Cystoscop y—Kreissl. 



21 



cases aid the surgeon by indiciiting 
where an incision has to be made, and 
in a few others facilitate and simplify 
the subsequent operation. We succeed 
in temporarily emptying a hydrone- 
phrosis or pyonephrosis by uretercathe- 
terization, but the direct cause of these 
conditions are such as to require a cut- 
ting operation for their permanent re- 
moval. We may dilate a stricture of 
the ureter, but the character of these 
coarctations frequently demands a 
bloody division for a radical cure. 

Two cases are on record in which an 
intractable fistula remaining after ne- 
phrotomy was finally closed by leaving 
the catheter in the ureter and renal 
pelvis for weeks without injury to the 
tissues. 

With the ureteral bougie we can oc- 
casionally loosen a stone of small size, 
replace it into the renal pelvis, or 
facilitate its passing into the bladder 
cavum, and in this way simplify the 
subsequent operation — nephrotomy, 
lithotripsy, etc. — for its final removal. 

Very promising is the combined em- 
ployment of the uretercatheter and the 
radiography devised by A, B. Johnson, 
in New York, a year ago, and by Felix 
Loewenhard, in May, 1901. A flexi- 
ble lead stiletto, inclosed in the ureter- 
catheter is passed into the upper urinary 
ways, and its exact location brought 
into plain view by a subsequent x-ray 
exposure. The advantages of this 
method are obvious 'at once. We are 
enabled to see the anatomical route of 
the normal ureter or any deviations, 
deflections and inflections, we also can 
graphically locate the point of an 
eventual obstruction and decide upon 
the choice for the subsequent opera- 
tion. The diagnosis of the unilateral 
double kidney and of the horseshoe 
kidney is also facilitated. 

This method, indorsed by Tilden 
Brown at the meeting of the American 
Associat. of Gen.-Urin. Surg., April 
30, 1901, has also met with the sym- 
pathy of the West, judging by a hasty 
•♦preliminary" notice to the prof ession 



l)y two Chicago physicians at the meet- 
ing of the Am. Med. Assoc, June, A. 
C, and in Casper's Monatsbeinchte 
fuer Urology^ in August, A. C. 

I call the ureter catheterization endo- 
vesical surgery in a broader sense, be- 
cause the starting point for its appli- 
cation is the bladder, and the latter is 
the only route through which bloodless 
surgical manipulations pass in the up- 
per urinary ways. The endovesical 
surgery of the bladder proper is as 
old as the lithotripsy and the removal 
of foreign bodies from the bladder 
cavum ; they are procedures represent- 
ing the typical bloodless, or nearly 
bloodless, operations whereby the in- 
tegrity of the bladder wall and sur- 
rounding tissues remain undisturbed. 
The great advancements in this partic- 
ular branch of surgery are of a more 
recent date, inaugurated by the cysto- 
scope, and in particular by the opera- 
tion cystoscopy, notwithstanding the 
older and inadequate straight endo- 
scopic tubes. As an auxiliary diagnostic 
means in surgical diseases of the blad- 
der, the cystoscope is of incalculable 
value, a fact so generally - recognized 
to-day that it would be an insult to the 
practitioner to more than mention it. 
Less appreciated by many, yet, on the 
other hand, overestimated by some, is 
the efficiency of the operation cysto- 
scope, whose best representatives are 
the instruments of Nitze and Casper. 
Another one is Latzkos' instrument, in 
which the various appliances like cu- 
rets, scissors, forceps, snare and cau- 
terizer are entirely separated from the 
cystoscope, are consequently of larger 
dimensions at the vesical end and in- 
troduced in the bladder before the 
former. This arrangement allows more 
freedom in handlingthemintheviscus. 
It has the disadvantage of all similar de- 
vices which, exclusively designed for 
the female bladder, are a copy of Bren- 
ner's uretercystoscope, andNitze's op- 
erating instruments, it is, according to 
my experience, too short for the male 
urethra. 



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The employment of Casper's instru- 
ment permits the crushing of smaller 
concrements, while with the snare of 
Nitze's instrument pediculated tumors 
can be removed, and the base cauter- 
ized, sessile neoplasms can be burned 
down, ligatures and other small foreign 
material are easily removed without a 
cutting operation. Ulcerations of the 
bladder- walls of various origin stub- 
bornly resisting local medicinal treat- 
ment can be brought to rapid epithelia- 
lization by curetting and cauterizing. 
All these procedures are carried out 
under local anesthesia in an illuminated 
organ, controlled by the eye; in most 
of them the loss of blood is nil or in- 
significant, and rest in bed not required. 
Larger tumors and extended ulcera- 
tions will, as heretofore, be subjected 
to cystotomy, notwithstanding the few 
cases on record in which Nitze, for in- 
stance, succeeded in removing a large 
tumor piece wise in fifteen and more 
**sitting8." Such procedures cannot 
be practiced without damaging results, 
especially in men, by biiiising the 
prostate and vesical neck and the re- 
flex action upon the kidney. Cystotomy 
has to be considered as the more radi- 
cal and milder intervention in these 
cases. 

Last, but not least, among the endo- 
vesical surgical procedures, I wish to 
place the galvanocaustic radical treat- 
ment of prostatic hypertrophy, com- 
monly known as Bottini's operation. 
As it was originally and still is per- 
formed quite frequently, it cannot 
strictly be called an intravesical opera- 
tion, the cauterizing blade being drawn 
from the bladder cavura downwards 
into the prostate. But the new cysto- 
scopic prostate incisor designed by 
Freudenberg and Bierhoff puts the 
operation on the same level as the cyst- 
oscopic manipulations in the ureters, 
and means a progress in this method 
of dealing with the hypertrophied 
gland. While previously we had to 



rely upon the sometimes deceiving 
sense of touch alone, we are at present 
in a position to place the cautery blade 
exactly to the point desired, and the 
objections raised against this method 
as being unsafe and dangerous because 
of working in the dark are now without 
foundation. Those who^ like myself, 
have performed a great many of these 
operations with the old instrument, and 
had occasion to use the new cystoscopic 
incisor, will readily appreciate its supe- 
riority in appropriate oases. Trouble- 
some, to be sure, is the hemorrhage 
following the introduction of the some- 
what voluminous instrument, which 
interferes with a good view of the pro- 
trusions. 

In enumerating the methods and ap- 
pliances employed in intravesical sur- 
gery, I have given consideration to 
most of the best known. I am fully 
aware I could have mentioned various 
others, but did not do so partly because 
this would have gone beyond the limits 
of the subject of my article, partly be- 
cause many of those not mentioned 
have to be classified as more or less 
ingenious imitations or as mere play- 
things. Summing up what has been 
accomplished in endovesical surgery, 
we can readily see that cystoscopy had 
a great influence upon increasing our 
diagnostic and therapeutic faculties in 
bladder and renal surgery, and that, 
vice versa ^ the demands of the steadily 
advancing surgery of the bladder and 
kidney acted as a stimulus for the im- 
provement in cystoscopic technic and 
diagnosis. It cannot be expected that 
the endovesical surgery will displace 
all other surgical procedures, but it 
certainly has somewhat narrowed the 
limits of cystotomy already, it has 
gained a broader field for itself in the 
bladder by simplifying the therapy 
therein, and it has to be wished that it 
might show itself just as successful in 
renal and ureter surgery. 

92 State Street. 



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Epicarin as an Antipruritic— Reichmann. 



28 



BPICARIS AS AN ANTiPRURtTIC. 

Bt Max ReiohmaNN, M. D.» Chleago, 111. 

'^The most striking feature of ep- 
icarin is its property of causing su- 
perficial exfoliation of the epidermis, 
which is often, although not always, 
accompanied by a slight exudation 
from the cutaneous vessels. The use 
of the drug is, therefore, indicated in all 
cases in which such an effect is desirable. 
This effect, in connection with its anti- 
parasitic influence, renders the drug of 
service in dermato-mycosis and in 
scabies."^ 

With these words Professor Kaposi 
recommended epicarin, a condensation 
product of creatinic acid and beta- 
naphthol, which, aside from its com- 
plete odorlessness, has the advantage 
of being absolutely nontoxic, and what 
is of great practical importance, of be- 
ing stainless in its application. Kaposi 
employed the remedy especially in 
cases of scabies and regarded it as 
preferable to hetanaphthol (which he 
also was the fir^t to introduce into the 
therapeutics of this affection), more 
particularly on account of its nontoxici ty 
and cleanliness. Other observers have 
tested the drug and have reported 
satisfactory results. Thus, for in- 
stance, Pfeiffenberger* has used ep- 
icarin in scabies ; Kraus^ in cutaneous 
affections in children attended with 
itching ; Rille* ^nd Siebert* in scabies, 
while Winkler^ extended his experi- 
ments to prurigo and seborrhea capitis. 

During the past two years I have 
resorted to epicarin in all itching af- 
fections of the skin which came under 
my observation, and in the following 
will briefly describe various cases in 
which its antipruritic effect was dis- 
tinctly manifested. 

Case I, Scabies. — The family of H. 
L., consisting of three adults and five 
children. In the fall of 1901 the 
father and his eldest son presented 
themselves with a cutaneous affection 
which had attacked the son about four 
months previously and ^adually had 
spread to the other members of the 



family. The son showed marked 
eczematous lesions on the hands, legs, 
and gluteal region, besides distinct itch 
burrows. The latter were particularly 
well developed in the father, who had 
been the last to acquire the disease. 
In the other members of the family 
the diagnosis of scabies €ould also be 
readily made, and I prescribed three 
applications of a 10 to 15 per cent, 
epicarin ointment, to be followed by a 
warm bath. Immediately after the 
first inunction the itching subsided. 
Only the youngest child, about five 
years old, presented slight dermatitis, 
which, however, disappeared after the 
application of oxide of zinc ointment. 
The eczema of the oldest son was cured 
in a short time by means of Lassar's 
paste, with the addition of salicylic 
acid. 

Case II, Lichen ruber plantis. — Mrs. 
H. W. had suffered since three years 
with a constantly recurring cutaneous 
affection, which lately had been partic- 
ularly disagreeable on account of the 
marked itching. Over the right 
shoulder blade there were present two 
adjacent oval plaques which seemed to 
be made up of waxy, shining nodules 
of a bright red color, slightly depressed 
in the center. Besides the adminis- 
tration of arsenic, a 10 per cent, alco- 
holic-epicarin solution was ordered to 
be applied to the affected skin. Ac- 
cording to the patient's statement the 
itching subsided even after the first 
application. The disease itself only 
partially disappeared, three months 
having elapsed since the beginning of 
the arsenical treatment. 

Case III, Urticaria. — W. S., twen- 
ty-one years old, was attacked after 
eating raw oysters for the first time, 
with an extensive urticarial eruption. 
The existing pruritus was promptly re- 
lieved by the application of a 10 per 
cent, alcoholic solution of epicarin. 

Case IV, JUingworm. — P. O. M., 
eight years old, has suffered since a 
week with a cutaneous eruption on the 
backs^ofboth hands as well as the left 



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Original Articles. 



cheek. The ring-shaped lesions were 
very characteristic, while the scraped 
off scales, after staining according to 
the method of Waelsch, showed the 
distinct presence of the trichophyton 
tonsurans. The treatment consisted 
of a 10 per cent, alcoholic solution of 
epicarin, applied morning and night to 
the affected parts with a brush. A 
cure resulted in five days without re- 
action. 

A sister of this patient who came 
under observation in the early stages 
of the disease presented slightly raised 
red patches without any central heal- 
ing. In this case two applications of 
the solution were sufficient to produce 
a cure. 

Case V, Eczema IneMrtgo. — T. P., 
twenty-eight years old, pharmacist, 
had suffered since a number of years 
from an obstinate intertrigo. His last 
attack appeared in July of this year 
and was particularly characterized by 
violent itching. The application of a 
15 per cent, alcoholic solution of epi- 
carin, however, rapidly removed this 
distressing symptom. 

This comprises my personal experi- 
ence with epicarin, and I have no doubt 
that further observations will show this 
new drug to be an antipruritic par ex- 
cellence. 

LiTKRATURB. 

1. M. Kaposi: Epicarin, a New Remedy (Wiener Med. 
Woclienschrift, No. 6. 1900). 

2. G. Pfeiffenberger: On the Use of Epicarin in Der- 
matology (Klin. Tlierap. Wochenschrift, No. 19, 1900). 

Idem: Farther Observations on Epicarin (Klin. Therap. 
Wochenschrift. No. 29, 1901) . 

3. E. Kraus: On the Use of Epicarin in Certain Cuta- 
neous Affections in Children (Wiener Med. Zeitung, No. 
24, 1900). 

4. I. H. Bille: On the Application of Epicarin in Cuta- 
neous Diseases (Die Heilkunde, September, 1900) . 

5. F. Siebert: Experiments witn Epicarin in Scabies 
(Munchner Med. Wochenschrift, No. 43, 1900). 

6. F. Winkler: A Contribution to the Therapeutics of 
Epicarin (Monatsh. f. Pract. Dermat., Bd. 33, No. 8). 



In sycosis, Fox recommends the use 
of the following ointment after epilat- 



R 



Zinc oxide 
Zinc carbonate . 
Rose ointment .... 



....aa 3 j 
....ad S j 



KOILONYCHU AND ITS SUCCESSFUL 

TREATMENT; WITH THE REPORT 

OF SOME CASES.* 

Bt A. H. Ohmann-Dumssnil, St. Loais. 

The diseases of the nails are of more 
than ordinary interest to him who can 
interpret them properly. Each one con - 
stitutes a symptom or a complex of 
symptoms which point to a condition 
at times limited to the onychial tissues, 
and at others indicative of a general 
condition of the organism of a more or 
less pathologic nature. Every one 
is acquainted with the appearance 
of the clawed nails in tuberculo- 
sis of the lungs, more especially 
when associated with the charac- 
teristic clubbed fingers. The distal 
phalanx is thickened, ** clubbed," and 
bears a nail with a certain amount of 
curvature, and bluish, as well as ac- 
companied by a generally unhealthy 
appearance. Every constitutional dis- 
ease is associated with a characteristic 
appearance of or change in the nails, 
each one of which is an index of suffi- 
cient importance to lead to more thor- 
ough examination if it is to be cor- 
rectly interpreted by the examiner. 
Whilst all this will be readily acknowl- 
edged by any one who has devoted 
some attention to the subject, it will 
also be conceded that the literature of 
diseases of the nails is apparently 
sparse, and that not much has been 
written upon them. In reality quite 
an amount has found its way in peri- 
odical literature, but scattered to such 
a degree and in different languages 
which have acted as a greater or less 
deterrent to him who desires to acquire 
a knowledge of the subject. With 
such difficulties to overcome it is easily 
understood that the general practi- 
tioner is unable to acquire even a 
superficial knowledge of that which 
should certainly be to him a most im- 
portant part of his post-graduate med- 
ical education, were he but sufficiently 
enlightened in regard to it. His re- 
course to text-books on skin diseases 

* Rea 1 before the Missouri State Medical Association. 



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Koilonychia—Ohmann-Dumesnil, 



26 



only leads to failure and disappoint- 
ment, as these appendages of the skin 
receive but scant courtesy. 

The greater portion of the ex- 
ceedingly short notices written on 
diseases of the nails are almost en- 
tirely confined to onychogryphosis 
and onychomyocosis described in such 
a summary and perfunctory manner 
that but little of real worth can be ex- 
tracted from them. The atrophic 
troubles of the nails are either omitted, 
so far as a consideration of them is 
concerned, or they are entirely omitted. 
In fact, the whole subject is so en- 
shrouded in darkness that the nails 
would seem to have been relegated to 
the limbo of those subjects which 
constitute an opprobrmm medicince. 
Whether this is due to a certain idea that 
they are not deserving of more atten- 
tion, or to a lack of study concerning 
their defects and troubles, or a self- 
acknowledged weakness to properly 
combat the diseases of nails, the writer 
will not undertake to determine. The 
fact remains, however, that there is 
not sufficient attention paid to these 
diseases in text-books and, as a natural 
consequence, a rather deplorable lack 
of knowledge respecting them. That 
this should exist can be easily under- 
stood when some authors have but one 
term for diseases of the nails, which 
really means nothing. It is a general 
one, whose meaning lacks in specificity^ 
and means nothing to him who may 
even be conversant with the diseases 
of the nails. What is referred to is 
the name onychia. This simply im- 
plies an affection of the nail or nails 
and means nothing beyond what any 
layman might say and does say when 
he applies for treatment. The meaning 
of the term is a very general one, and 
on account of this lack of specificity it 
is practically worthless. We will not 
further discuss this phase of the sub- 
. ject, but rather enter into a considera- 
tion of that concerning wfiich we de- 
sire to say a few words and give some 
definite ideas concerning the recogni- 



tion and successful treatment of a con- 
dition which is by no means rare, but 
which, up to this time, has not received 
the recognition which it deserves. 

The disease concerning which I de- 
sire making a few remarks is an inter- 
esting one in several respects. It is 
known technically as koilonychia and 
ordinarily as "spoon" nails. It is by 
no means a rare condition, but one 
which, unfortunately, has attracted 
but little attention from those who 
practice general medicine, from the fact 
that very little importance has been 
attached to it, and patients afflicted 
with the trouble have paid but very 
little attention to it. Outside of any 
medical interest attaching to it, it is of 
a sufficiently marked character in 
many cases to attract attention to it, 
and jt becomes, after a certain time, an 
object of more or less solicitude to the 
patient. 

Koilonychia may be observed in one 
or more of the nails of the fingers of one 
or of both hands, although the latter 
is not so frequently observed as iti^ 
presence in a few fingers. The appear- 
ance presented by the nails w^hich are 
involved differ in different stages of 
the disease. It may be stated in gen- 
eral terms that the beginning is char- 
acterized by a flattening and thinning 
of the nails. This is very slow but 
progressive, and this very slowness 
makes it unperceived by the subject of 
the trouble until it is well marked, and 
it suddenly dawns upon his mind that 
the nails are not normal. In addition 
to this there is a curving of the nail 
from side to side, which gives the 
characteristic shape that has given the 
name of "spoon" nail. This condition 
has been so marked, in certain cases^ 
as to give rise to alarm, although it 
merely pointed to a deeper condition 
which was really of a serious nature. 
The thinning of the nails acts as a 
drawback in the performance of certain 
work, and not alone this, but there is 
also considerable pain experienced in 
the performance of many ordinary acts> 



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26 



Original Articles. 



such as writing, sawing, and other 
work requiring a certain amount of 
pressure to be exerted upon the pulps 
or sides of the distal phalanx. The 
nails themselves are not normal in 
color, and are very apt to be fissured 
longitudinally through any slight 
trauma. Another accident to which 
they are liable is that of breaking trans- 
versely and more generally at the line 
of juncture of the nail and nail-bed, or 
at that point where the nail becomes 
free. These are some of the symp- 
toms which patients will abserve and 
to which they will call particular at- 
tention. One point which requires 
particular attention is the dryness of 
the nail, which is so great in many as 
to amount to positive brittleness; 
whereas, in others the nails are elastic 
and susceptible of being doubled up 
without producing even a crack in the 
surface. 

A peculiarity in this disease, and it 
is one which occurs quite often com- 
paratively, is the involvement of only 
the distal half of the nail, the proxi- 
mal or attached half presenting a nor- 
mal appearance. In these cases we 
have the added peculiarity of the ex- 
treme thinness of the free extremity 
of the nail and its Assuring, with the 
presence of V-shaped areas of small 
portions of the nail, the small fissure 
extending upwards from the apex of 
the V. Unna has reported a case of 
complete leukonychia, in which some 
of the nails present the appearance of 
koilonychia. Heller, in his monograph 
on the '* Diseases of the Nails," pre- 
sents the picture of one of his cases, 
as well as that of one of Rille, in which 
the characteristic appearance of the 
disease is well represented. In fact, 
it may be stated that koilonychia is a 
disease which, from the paucity of the 
literature devoted to it, can hardly be 
regarded as being so rare. lie who 
will but observe the nails on all the 
hands which he has occasion to exam- 
ine will find that it is a comparatively 
common condition. With these few 



preliminary remarks I will now proceed 
to give the histories of a few cases 
which are typical, after which I shall 
proceed to a consideration of the eti- 
ology, pathology and treatment of the 
trouble. But a very few cases have 
been chosen out of a large number ob- 
served by me in the past few years. 

Case I. — Miss X., eighteen years 
old, applied for treatment for a condi- 
tion which she considered most pe- 
culiar and which she was fearful was 
an indication of a very serious general 
condition. An examination demon- 
strated the fact that the nails of both 
hands were affected and presented a 
classic picture of **spoon" nails. They 
were unusually thin, so much so that a 
slight pressure upon any one caused a 
sinking of the nail, which persisted for 
about fifteen seconds and evoked a 
rather sharp pain. In addition to the 
concave condition there existed other 
evidenced of an atrophic process. The 
nails of the little fingers, of the right 
ring-finger, of the index fingers and of 
the thumbs showed small circular pits 
or depressions a little larger than a 
pin-point, and shallow, narrow, longi- 
tudinal furrows which could be de- 
termined more exactly by the touch 
than by ordinary inspection without a 
glass. 

The patient stated that the thinning of 
the nails had begun about three years 
f>reviously , when she began to menstru- 
ate. The establishment of this function 
had acted upon the nervous system, and 
probably with more effect, from the 
fact that she was of that nervo-lym- 
phatic temperament so often observed 
in blondes, of which she was one. 
Her nervous condition had been much 
aggravated by worry over her nails 
and the fact that all her attempts to 
be treated had been discouraged 
by those medical men to whom she 
had applied and who merely gave 
her the consolation that the matter 
amounted to nothing. Careful ques- 
tioning brought out the fact that she 
wa^ suffering from nerve starvation, 



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KoilonychA—Ohmann-Dumesnil. 



27 



and, in fact, was rapidly approaching 
that deplorable state known as neuras- 
thenia, led me to prescribe internally 
sl phosphorus pill of one-fiftieth of a 
grain, gradually increased to one- 
twenty-tifth, to be taken three times 
daily during meals. Locally she was 
ordered to rub into each nail thor- 
oughly and carefully, twice daily, the 
following ointment: 

R Stansi oleat „ 5j. 

Lsnolioi poriss, 

Uug. aqu8B rosae ^ „.a«Ss8. 

M. 

Sig. Bub into nails twi«e daily. 

At the end of five weeks I had the 
satisfaction of seeing the case practi- 
cally cured. I had the patient call later 
when the nails had been completely 
renewed in growth, and they were nor- 
mal in every respect. They were once 
more well formed, showed no atrophic 
-changes, were of normal thickness and 
were once more what she called 
strong. 

Case II. — Mrs Y., aged thirty -two, 
with one child, was sent to me with an 
aggravated case of syphilis, which she 
acquired from her husband after the 
birtJi of her child. When I saw her 
she was divorced and forced to earn a 
living as a seamstress. Her syphilis 
had had a very depressing effect upon 
her for two reasons. In the first place, 
she desired to keep her malady a 
secret, no one outside of her family 
physician being aware of the true nat- 
ure of the case. In addition to this, 
her being sent away from home for 
treatment on account of the severity 
of her case worried her. Her syphilis 
presented the lesions of a disseminated 
squamous syphilide attacking the en- 
tire body with the exception of the 
face. Both the dorsal and palmar 
surfaces of the hands were affected in a 
marked manner, and this eruption had 
proven quite refractory to the treat- 
n^nt administered. The nails of some 
of the fingers presented the typical 
appearance of koilonychia. The nail 
of the right index, the ring and little 



fingers offered the same changes. On 
the left hand, the nail of the thumb, 
of the middle and of the ring finger 
also presented this appearance. Atro- 
phic circular depressions could be 
found in all of them, but no furrows 
that were at all marked. No particu- 
lar medication was ordered for the 
nails beyond rubbing them with the 
same ointment used on the eruption. 
Internally, a rather radical mercurial 
treatment was given. As the syphilis 
improved the koilonychia did, and this 
latter has disappeared, although the 
luetic condition is far from being com- 
pletely healed. The entire result has 
been a most satisfactory one, the pa- 
tient being particularly gratified at once 
more having normal naUs which are 
strong and free from all pain on pres- 
sure. The color, which was cyanotic^ 
is now pink, and the improvement is 
plainly discernible. In fact, the nails 
are as nearly normal as they could be 
found in a syphilitic who is progres- 
sively improving. 

Case Hi. — Z., a young man of 
twenty-six, applied to me on account 
of his nails, which troubled him chiefly 
on account of their appearance. They 
presented the typical appearance of 
the disease, although not in a very 
marked degree. It was sufficiently so, 
however, to have aroused his solici- 
tude, and made him apprehensive that 
it possibly presaged some very serious 
condition. He stated that he was in 
charge of a rather important depart- 
ment of a railroad, and had much work 
of a mental nature to do and many 
cares upon his mind. It could be eas- 
ily seen that he was troubled in mind 
and restless in spirit. He did not rest 
easily on account of his many duties, 
and the added trouble which he had 
on account of his local condition did 
anything but conduce to his physical 
or mental well-being. He was in such 
a state that he was rapidly bordering 
on a general breakdown. All of his 
nails were affected, more especially 
the distal half of each one, and his 



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28 



Original 



constant care in keeping bis nails pared 
down had led to the small fissures so 
often observed in cases of this sort. 
His endeavor to prevent a further ex- 
tension of the fissures by paring had 
led to the production of a number of 
triangular notches, producing a saw- 
like condition of the nails. These were 
thin, and their beds appeared anemic, 
as evidenced by their pale bluish color. 
The treatment in this case consisted in 
both management and medicines. 
Strict injunctions were given not to 
pare or in any other way disturb the 
nails mechanically. In the next place, 
hygienic rules were given and such ex- 
ercise advised as would tend to increase 
vigor and muscular tone. Locally was 
ordered the ointment to be applied to 
the nails as given in the history of 
Case I. Internally, the patient was 
ordered to begin with a one-fiftieth 
grain phosphorus pill during meals, 
this being gradually increased to one- 
twenty-fifth grain. In addition to this 
the following Asiatic pill was ordered 
to be taken after each meal : 

R Acidi arseniosi gr. iij. ™ 

Pulv. piperis nigris 3"J- 

Ext. gentian q s. 

M. ft. caps. (No. 5) No. 60. , _^ 

Sig. One capsule after each meal. 

Under this treatment the patient im- 
proved steadily in all respects, but the 
most marked change for the better 
took place in his nails. During all this 
period it was not necessary for the pa- 
tient to quit his occupation or modify 
it in the least degree, his improvement 
progressing with the treatment. 

Case IV. — W., a young unmarried 
man of twenty-eight, came to me for 
the treatment of erythematous skin 
disease of the face. He stated that he 
was an accountant, and was also en- 
gaged in the occupation of soliciting 
sales for the firm of which he was a 
partner. As he detailed his history, 
his nails attracted my attention and a 
closer examination showed them to be 
rather larger than normal so far as 
their width was concerned. In addi- 



Articles. 

tion to this, they were quite thin and 
inclined to be concave. The case was 
one of koilonychia, although not a very 
marked one. The nails did not show 
any tendency to fissure, and yet their 
thinness was quite marked. An oral 
examination showed that the young 
man was worried and his strength 
overtaxed, he himself remarking that 
his nervous system was run down. 
Although he presented what would be 
regarded as a good physical condition, 
his nervous organization was evidently 
below par. He was fidgety, restless, 
. and presented the evidence of one who 
was dissatisfied with matters. Whilst 
he had never done any manual labor to 
amount to anything, he bitterly com- 
plained of the appearance of his nails. 
He deplored the fact that his nails no 
longer presented the normal appear- 
ance which they formerly did, and he 
acknowledged that he felt very sensi- 
tive on the matter of the change in his 
nails. As his cutaneous trouble de- 
pended upon the same cause as the 
original affection, a simple soothing 
lotion was ordered for his face and the 
same treatment as in Case III., for his 
nails. Progressive improvement took 
place, and his nails, whilst not yet re- 
stored to the normal, bid fair to be so 
at no very distant future. 

Many more cases could be cited, but 
those given are sufficient to give an 
idea of the trouble, the conditions 
present, and of the treatment which 
has proven successful. The examples 
which have been mentioned are not 
selected cases, but rather a few taken 
at random, to illustrate some different 
forms of the disease. It may have 
been noticed that in these cases no 
mention has been made of the toe- 
nails. This has been done advisedly 
as in none has there been any involve- 
ment of the latter. As a matter of 
fact, I have found that there is no im- 
plication of these, and but a very few 
are mentioned by those authors who 
have contributed anything on the sub- 
ject. So that until more are seen in 



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Koilonychia—Ohmann-Dumesnil. 



29 



this location, it would appear rather 
premature to make any extended re- 
marks upon this particular phase of 
the subject. 

An interesting question connected 
with the disease under consideration 
is its etiology. All those who have 
written on koilonychia, dismiss the en- 
tire matter in a very few words and 
have very little or nothing to say on 
its etiology. It will, perhaps, be bet- 
ter to sum up their views, and then 
draw those conclusions which seem to 
be legitimate in view of the appear- 
ance, treatment, and other facts con- 
nected with cases which have been ob- 
served, including the changes which 
have been noted. As has already been 
stated, the available literature on the 
subject is sparse, and in no instance, 
has any extended consideration of the 
subject been made by any author. 

H.Radcliffe Crocker says*: '*Spoon 
nails, in which the nail is thinned and 
€oncave from side to side with the 
edges everted, and with hollowing to a 
less degree, sometimes antero-posteri- 
orly, have been observed id some 
wasting diseases, but also there are a 
few cases on record where the etiology 
is obscure." This will certainly ap- 
pear very short and unsatisfactory to 
any one desirous of beinff informed on 
the etiology of this disease, and it cer- 
tainly shows a certain amount of want 
of interest in the matter. 

We are treated to more on the sub- 
ject by Dr. Julius Heller ;t who states 
that in a case observed by him in a 
servant girl of twenty-five, nothing was 
observable beyond the fact that she 
was chlorotic. He quotes Professor 
Rille, of Innsbrueck, who reported a 
<5ase to him in a peasant's daughter of 
thirty-five, who was anemic and in 
whom the disease had existed since 
childhood. At a meeting of the Berlin 
Dermatological Society, Max Joseph 
presented a case of koilonychia com- 
plicated by total leuconychia. He re- 

* Digeages of the Skin. Philadelphia, 1893, paee 834. 
t Die Krankheiten der NaBgel. Berlin, 1900, page 134. 



garded the leuconychia as being due to 
the general anemia of the patient, al- 
though others who were present, con- 
tended that it could only be explained 
through the action of the subungual 
hyperkeratosis which was present. 
Heller states that in Joseph's case it 
existed only in the most slight degree 
and was completely absent in his case. 

Professor A. Jarisch,* after quoting 
Heller and a few other authors in which 
he rejects Unna's theory, because it 
might appear plausible were the same 
conditions always observed and in every 
case, concludes that a definite and con- 
clusive explanation cannot be given 
until microscopic examinations of a 
satisfactory nature are made, in which 
opinion a number of authors share. 

Joseph Zeislert in speaking of fur- 
rows in nails and their causation by 
systemic diseases says: "More rarely 
observed, yet somewhat related to the 
foregoing, is an anomaly consisting in 
a sort of excavation or central depres- 
sion of the nail plate, due in all proba- 
bility to a process of shrinking in the 
nail bed. This condition has been de- 
scribed by Crocker as spoon nails, and 
elsewhere as koilonychia." 

From the opinions which have been 
quoted above there can remain no doubt 
that the subject of the etiology of 
koilonychia is involved in a great deal 
of obscurity. Any one who will exam- 
ine into the histories of the cases ob- 
served and of those detailed by writers 
cannot fail to notice that one underly- 
ing fact is apparent in all, and this 
points to the inevitable conclusion that 
the disease before us is a trophoneuro- 
sis manifested by an atrophy of the 
nail plate as well as of the nail bed. 
The coincident presence of leuconychia 
is merely confirmatory of the cause, 
and the general state of the organism 
in the patients is of such a form as 
would encourage neuratrophic changes 
in the different anatomical parts of the 
skin as well as in its appendages. We 

* Die Hautkrankheiten. Vienna, 1901, page 1032. 
t Trophic Affections of the Nails.. Jour. Cut. and Genito 
Urln. Diseases. 1901, page 511. 



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are here brought face to face with a 
condition which has factors which 
make the entire matter a most pozzling 
one and correspondingly difficult of 
solution. Whilst we may understand 
thai all the nails of the hands are not 
affected it is rather difficult to explain 
the fact that the toe-nails are exempt 
from the process. These questions are 
still sub judice ; but there can be no 
doubt that confirmatory proof of the 
fact that koilonychia is a trophoneuro- 
sis is furnished by the success which 
attends a treatment directed to an 
amelioration of the nutrition and gen- 
eral toning up of the nerves, more 
especially the sympathetic system, 
which is generally understood as being 
instrumental in bringing about trophic 
changes. The whole subject is a most 
interesting one, and worthy of serious 
study at the hands of sound investi- 
gators, If an interest is awakened in 
the nail disease we have no doubt that 
there will be many who will devote 
time to its further elucidation. 

Equally as unknown and of as much 
interest is the pathology of this trouble. 
Whilst post-mortem examinations will 
show some changes, any thorough 
pathologic examination will have to 
depend upon the examination of biopsic 
specimens. There is no doubt that 
there exists a shrinkage ( schrumpf ung) 
of the nail bed, and this, by diminish- 
ing the nutrition of the nail, brings 
about a consequent atrophy. The nail 
itself becomes thin and its attachment 
to its bed weaker and weaker, leading 
gradually to a curving of the sides which 
are not so tightly attached. Hence 
the development of the concavity which 
is observed This question of pathol- 
ogy is one which requires a great deal 
of research, and it is only a lack of ma- 
terial which has prevented examination 
of a satisfactory nature. No one will 
consent to sacrifice a distal phalanx for 
this purpose, and in no other way can 
satisfaction be obtained. 

What is perhaps of more interest to 
the practitioner is the successful treat- 



ment of the condition. It may be wel 
to premise that the nails are very slow 
to respond to any therapeutic meas* 
ures, as they are endowed with no sen- 
sation and derive all their nourishment 
from the nail bed, there being no circu- 
lation in the nail itself. It is by a 
slow process of absorption that nutri- 
tion is established, this determining the 
reason for such marked changes fol- 
lowing a slight disturbance of circula- 
tion such as will follow a failure in the 
trophic nerves in affording the normal 
stimulation necessary to establish a 
proper circulation. It will also serve 
to explain the fact that quite some 
amount of time is necessary to obtain 
any result ; and the reason why females 
are benefited more than males is that 
the former are more patient as well as 
persistent in carrying out a treatment. 
In order to obtain permanent good re- 
sults a long period of time is often 
necessary, but such result can be at- 
tained. It should always be impressed 
upon patients that this is a conditio 
sine qua non^ and those who are not 
ready to stand a long siege might as 
well not undertake the cure of koilo- 
nychia. We have seen patients who 
refused a long course of treatment 
come back for dehiscence of the nails 
and cheerfully submit for any length 
of time. It is well to tell of the possi- 
bility of this and warn them of it. In 
those cases in which the cause is Ray- 
naud's disease too much must not be 
promised. It is pretty well established 
that the cause of symmetrical asphyxia 
of the extremities is trophoneurotic in 
nature, and unless the course of the 
process can be arrested little hope can 
be offered for a complete cure of either 
one or the other of the diseases. So 
that much depends upon the proper 
selection of a case. That is to say, a 
patient who will not be willing to carry 
out the treatment for a long time had 
better not be encouraged to begin with 
it, as he will be doomed to disappoint- 
ment and his physician to failure. 
This is not the only point to observe. 



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KOILONYCHIA-OHMANN'DUMESNIL. 



31 



Much care should be exercised in the 
proper choice of remedies, as well as 
the methods to be used in their appli- 
cation. As in all questions of thera- 
peutics, DO haphazard or guesswork 
can be indulged in or continual changes 
Qiade. For the purpose of local med- 
ication, I have found the diluted oleate 
of tin to be the best. It is a true nail 
tonic, and it is a consistent one. Some 
German writers have used the oxide of 
tin, but they have not repoi-ted particu- 
larly brilliant results from its use. In 
fact, the oleate of tin must be very 
properly made or it will fail of its pur- 
port and I desire to say that the make 
of Parke, Davis & Co., of Detroit, is 
that which has best served my purpose 
in all cases. The method of applica- 
tion should be with a nail polisher, as 
this will insure its penetration into the 
nail substance. But little of the oint- 
ment need be placed upon the nail be- 
foi*e it is rubbed in, but it must be very 
thoroughly applied. So far as the 
general treatment to be followed in 
koilonychia, as much or even more 
care must be exercised in the choice of 
the remedies used. The remote cause 
of the trophoneurosis must be de- 
termined and the treatment directed to 
that. Thus, in Case II, reported in 
this paper, the cause was syphilis and 
the treatment was directed exclusively 
to that, although it would have com- 
pletely failed in a non- luetic patient. 
Of course, it is necessary that the phy- 
sician possess a good knowledge of 
general medicine and of the remedies 
particularly adapted to the neurotic 
conditions observed in the patient un- 
der treatment. This it is which per- 
haps makes the treatment of nail dis- 
eases so difficult and demands so much 
more at the hands of the medical prac- 
titioner. Too many of the latter class 
look upon affections of this nature as 
of very secondary importance, when 



really the whole fault lies in their un- 
willingness to acknowledge their ina- 
bility to successfully treat a case. The 
very paucity of monographs and arti- 
cles on diseases of the nails is 
evidence of the fact that little attention 
is paid to them, and a corresponding 
lack of knowledge in regard to them 
exists. Koilonychia in particular is 
worthy of extended study at the hands 
of medical men, as it is a trouble which 
is rich in its indications of general 
neurotic trouble in some cases. So 
little has been written upon it and so 
few cases have been thoroughly exam- 
ined that a most fertile field is opened 
to those who will devote time to its 
further study. The pathology of the 
disease is still unworked, and a thor- 
ough study of this particular portion 
is certainly destined to yield rich and 
useful results. 

It must not be forgotten that this 
particular deformity of the nails, like 
all others, forms a most useful indica- 
tion to various systemic troubles, and 
is worthy of ijiore consideration than 
has been heretofore accorded to it. 
Those books which speak of it, incom- 
plete as the subject-matter devoted to 
it may be, are deserving of serious 
study on account of the suggestions 
which are made and which would lead 
to a further developmant of the mat- 
ter. A closer study of the disease will 
inevitably lead to suggestions of treat- 
ment for many cases which are looked 
upon as incurable, and some real prog- 
ress, as well as useful information on 
a large class of obscure diseases, will 
be made. One need not specialize his 
practice to do this, and a thorough con- 
sideration of the various points in- 
volved will, beyond all doubt, benefit 
the medical profession by affording to 
it something real and useful, as well as 
tangible. 



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URTICARIA, ITS VAQARIBS AND 
TREATMENT. 

By S. C. Mabtin, M. D., St. Louis. 

This cutaneous eruption in its dif- 
ferent forms is so often an accompani- 
ment of other diseases and morbid 
conditions of the system, that it would 
be more properly designated as a 
symptom than as a separate disease. 
We find it generally described as a 
non-contagious inflammation of the 
skin attended by the development of 
ephemeral round or oval wheals, either 
red or whitish in the center with a 
surrounding red areola. These eleva- 
tions range in size from a small papule 
to nodules of an inch or more in diam- 
eter, and even sometimes running into 
edematous infiltrations of considerable 
extent. The prominent subjective 
symptoms are itching, burning and 
tingling sensations. This eruption is 
sometimes attended by a high febrile 
movement and serious constitutional 
disturbances; at other times the gen- 
eral organism seems to be in a fairly 
normal condition. During the course 
of many contagious and visceral dis- 
eases, urticaria is an incidental feature 
which often embarrasses the diagnos- 
tician. 

The antitoxins, new drugs and nu- 
merous pharmaceutical preparations 
which are being constantly prescribed 
by physicians, make these uticarial 
eruptions much more common than 
they formerly were. The extravagant 
habits and luxurious indulgences of 
modern life, with their resulting dys- 
peptic and neurotic disorders, have 
also contributed much to the increas- 
ing prevalence of urticarial eruptions. 
Imperfect transformation of tissues and 
retention in the system of toxic mate- 
rial which should be excreted, add 
their influence to the Ipnglist of causes 
w^hich provoke these cutaneous disor- 
ders. But all these things alone would 
not be sufficient to produce urticarial 
eruptions without the existence of a 
predisposition to the occurrence of se- 
rious exudation of the cutaneous tis- 



sues, from the fact innumerable in- 
ternal and external causes which are 
constantly operating upon a large class 
of people do not in very many cases 
provoke urticaria. A peculiar condi- 
tion of the skin has been revealed in 
certain susceptible persons by what is 
called dermographism. With a pencil 
names or figures may be written on 
their backs ; these names or figures are 
simply linear infiltrations produced by 
the movement of the pencil on the 
person's skin. Urticaria is undoubt- 
edly the expression of a vaso-motor 
disturbance of the skin tissues in per- 
sons of irritable neurotic proclivities. 
The poison of small-pox will some- 
times produce a prodromal rash in the 
form of an urticaria a day or two be- 
fore the development of the- typical 
small-pox eruption. This happens only 
in that class who have urticarial sus- 
ceptibilities. The toxic products of 
undigested food absorbed and thrown 
into the circulation, act as irritating 
substances ^nd provoke urticaria in 
those predisposed to such lesions of 
• the skin. The mucous membranes, or 
the internal skin, may also develop 
these lesions ; and possibly in the seri- 
ous febrile cases, where there are 
gastric and intestinal complications, 
these internal lesions are responsible. 
When the urine shows a marked de- 
crease in urea and uric acid, often the 
most stubborn cases of urticaria result. 
I have known these cases to be 
promptly relieved by the adminifi*tra- 
tion of colchicum or salicylate of soda 
when all other remedies had failed. In 
all chronic and apparently incurable 
cases the urine should be tested, when 
it will often be found that there is a 
deficiency of organic salts, with their 
probable retention in the system. 

In some persons with peculiar idio- 
syncrasies, urticaria results from in- 
gestion of certain kinds of food. Cer- 
tain kinds of fish, meat, vegetables and 
fruit will provoke an attack. In many 
of these cases it is very likely these 
articles of food have undergone some 



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Pathogenesis and Treatment of Diabetes Mellitus. ss 



putrefactive changes before they were 
-eaten, evolving toxic products which 
■excited the trouble. Most people know 
little and care less about the quality of 
their food as long as it is palatable. 
The same is true of the beverages they 
iise, and for this very reason the phy- 
sician should give such matters his 
especial attention. The success in 
treatment of all skin diseases is 
achieved more signally along dietary 
than medicinal lines. This is often 
-demonstrated in patients who, after 
having been, for months drugged with- 
out any benefit by one physician, are 
cured by another who prescribes hy- 
giene and diet instead of drugs. 

In most cases of urticaria, saline 
■aperients, diuretics and intestinal anti- 
septics with rational hygienic and die- 
tary management will soon effect a 
-cure. When these means fail, a 
searching effort must be made to ascer- 
tain and remove the cause. Let atten- 
tion be directed to the correction of 
those inherited or acquired nervous 
susceptibilities which operate as pre- 
•disposing causes. Build up crippled 
organs and restore functional activi- 
ties. Cleanse the stomach and intesti- 
nal canal, and keep them free from 
ptomaines and other toxins. See that 
the stomach and intestines furnish the 
proper secretions for the purposes of 
digestion, and that the liver and pan- 
■creas supply the proper digestive fer- 
ments to prepare the food for absorp- 
tion and utilization. See that the kid- 
neys, liver, lungs,. skin arud bowels re- 
move from the system all waste mate- 
rial and noxious matter. Attention to 
nil these details in some cases is abso- 
lutely necessary to insure successful 
' results. 

During convalescence, if the vital 
powers have been reduced, tonics with 
•alkalies or acids, according to the re- 
•quirements of the case, may be pre- 
scribed. In some cases of an intermit- 
tent form, quinine should be given, 
and when rheumatism is associated 
with urticaria, a combination of iodide 



of potassium, bromide of potassium 
and chloral hydrate, each in ten-grain 
doses, may be prescribed three or four 
times a day. Atropine in doses of one 
one-hundred and twentieth of a grain 
three times a day will sometimes be 
serviceable. Salicylate of soda in fif- 
teen grain doses in obstinate cases, 
three times a day, will often give prompt 
relief, but smaller doses will rarely be of 
any service. Iron, arsenic and strych- 
nine, in connection with saline aperi- 
ents, in some chronic cases have a ben- 
eficial effect. Warm and cold baths 
^ alternated, may at times be used to 
good effect. The excessive itching will 
often yield best to the following lotion : 
Bichloride of mercury grs. x, spirits of 
rosemary and alcohol each Si, emul- 
sion of bitter almond gvi. M. Sig. — 
Sponge the parts two or three times 
a day. 



<fi^o 



PATHOQENBSIS AND TREATMENT OF 
DIABETES MELLITUS. 

The clinical phenomena of this dis- 
ease have been elaborately studied for 
a century or more by the best 
equipped minds of the medical profes- 
sion without shedding much additional 
light on its etiology, pathology or 
treatment. The laboratory has also 
been appealed to, with equally barren 
results. While definite knowledge has 
not increased its boundary to any con- 
siderable extent, theoretical teachings 
in multiplicity and variety have as- 
sumed such proportions as to bewilder 
and confuse the medical mind. 

The most prominent clinical revela- 
tion of this pathological condition is 
pronounced glycosuria. This is not 
the disease, but is simply a finding 
which furnishes the starting point for 
investigation of the disease. The pres- 
ence * of sugar in the urine does not 
cause the trouble, but its diversion 
from the channels of nutrition is a 
matter of deep concern. It is natural, 
in the absence of any known organic 
disease which we can assign as a cause 



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of augar in the urine, that our atten- 
tion should be directed to suapeoted 
organic lesions, neuroses or disordered 
functions of the digestive apparatus. 
We have either excessive sugar pro- 
duction in the organism or diminished 
sugar destruction, and in some cases 
probably both. In the milder types of 
the disease the sugar is undoubtedly 
derived from the carbohydrates of the 
food, for by withdrawing this kind of 
food, sugar in the urine disappears. 
In the severer forms of the disease 
sugar continues in the urine after the 
withdrawal of the carbohydrates. In 
these oases it must be produced from 
the proteids of the body. 

In our efforts to ascertain why sugar 
is formed in excess or why, when thus 
formed, it is not oxidized, certain facts 
repeatedly confirmed by scientific in- 
vestigation should be carefully con- 
sidered. For example,a variety of nerve 
lesions may induce glycosuria. Irrita- 
tion or puncture of a circumscribed 
area in the floor oi the fourth ventricle 
in the medulla is followed by the ap- 
pearance of sugar in the urine., If the 
vagus nerve is divided in the neck, or 
if the spinal cord be divided above the 
origin of the great sympathetic nerve, 
diabetes may result. This shows that 
nerves exert a powerful influence on 
the functions of organs. 

Nutritional changes are also depend- 
ent upon digestive ferments, especially 
those of the liver and pancreas. Any 
organic or functional disorder of these 
glands will alter or diminish their 
secretions and to that extent impair 
the processes of nutrition. There is 
probably something supplied by the 
normal pancreas besides amylopsin 
which promotes certain changes in the 
carbohydrates and prepares them for 
the uses of nutrition. When sugar is 
properly prepared for absorption and 
appropriation by the blood it passes to 
the liver for further changes, under- 
goes combustion in the lungs, gen- 
erates heat, and thus aids in saving de- 
struction of the albuminoid constitu- 



ents of the body. In certain d^bili* 
tated conditions of the system tJbie^ 
inhalation of oxygen is restricted^- 
oxidation of si^r is lessened, and 
much of it passes through the kidaeyja- 
to the bladder, producing jglycosuria.. 

Dr. George Alexander uibaon re- 
ports twenty-four cases of diabetes- 
mellitus in which sixteen showed 
changes of the pancreas^ possibly in 
some of the other eight cases there 
may have been functional disturbancea 
of this gland which escaped attention..* 
Many observers during the past cent- 
ury have recognized a close relation 
between diseases of the pancreas and 
diabetes mellitus. A. W. Mayo Rob- 
son and B. G. A. Moynihan in their 
work on ''Diseases of the Pancreas," 
in speaking of the relations of the- 
pancreas to diabetes, state: 1. Extir- 
pation of the whole pancreas produces 
diabetes. Extirpation of nearly the 
whole pancreas gradually induces dia- 
betes. Extirpation of a limited part 
of the pancreas does not produce dia- 
betes. 2. Diabetes in a large number 
of cases is associated with or accom- 
panied by diseases of the pancreas^ 
the most f reqent of which is a chronie 
interstitial inflammation and sclerosis.. 
There are, however, eases of diabetes 
in which tjiere is no demonstrable af- 
fection of the pancreas and cases of 
chronic interstitial inflammation with- 
out diabetes. The authors however do- 
not deny that in the cases of diabetes- 
disconnected with discovered pan- 
creatic disease there may have b^n 
some obscure undiscovered organic or 
f unctional disease of the gland. 

Hansemann quotes from the post>- 
mortem records of the Berlin hospitals 
in the period of ten years, forty oases 
of diabetes with disease of the pan- 
creas, eight cases of diabetes without 
disease of the pancreas, six cases of 
diabetes without any note of the con- 
dition of the pancreas, and nineteen 
cases of disease of the pancreas with- 
out diabetes. The forty cases men- 
tioned include thirty-six oases of 



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Pathogenesis and Treatment of Diabetes Mellitus 85 



simple atrophy, three of sclerosis and 
atrophy, and one of complex change. 

R. T. Williamson famishes a table 
which shows the condition of the pan- 
creas in twenty-three consecutive cases 
of diabetes, viz.: 1. (Extensive 
changes) two cases of marked cirrho- 
sis, one case of cancer. 2. (Fairly 
well-marked changes) two cases of 
cirrhosis, one case of lipomatosis, one 
case of atrophy, fatty degeneration 
and inflammation, one case of very ad- 
vanced atrophy. 3. (Slight changes) 
one case of atrophy with slight fatty 
degeneration, two of atrophy without 
other changes. 4. Four cases of 
atrophy, but only in proportion to 
other wasting. 5. Eight cases of pan- 
creas normal macroscopically and mi- 
croscopically. In twelve of the above 
eases the pancreas was either normal 
or only atrophied in proportion to the 
general wasting. 

According to available statistics at 
least one-half of all cases of diabetes 
are associated with recognized disease 
of the pancreas, but how many are 
accompanied by functional derange- 
ments of this gland, we have no means 
of knowing. Certain groups of cells 
lying in the interalveolartissue of the 
pancreas are made up of small, irregu- 
larly polygonal cells with a round nu- 
cleus and homogeneous refractive cell 
body. These structures are known 
as the ''islands of Langerhaus," and 
are supposed to be the main source of 
the glandular secretion. It is now 
supposed that in partial extirpation of 
the pancreas from which glycosuria 
did not result, these islands were not 
destroyed, and where glycosuria did 
result, they were destroyed. 

In forming an opinion of the etiol- 
ogy and pathogenesis of this disease, 
we must recognize certain facts: 
1. That nutritional changes character- 
ize all cases of diabetes. 2. That the 
nervous system is deeply implicated in 
a large number of cases. 3. That dis- 
ease of the pancreas is more constantly 
associated with diabetes than that of 



all other organs combined. This con- 
stancy of association must possess 
^ome etiological significance, especially 
in the almost invariable absence of 
other organic lesions. We realize the 
importance of the pancreatic ferments 
in intestinal digestion. They take the 
lead in preparing the carbohydrates, 
the hydrocarbons and proteids for util- 
ization in nutrition. When the nutri- 
tive processes are disordered it is nat- 
ural that we look in this direction for 
the cause of such disturbances. There 
is very just ground for the presump- 
tion that in the pancreas and the cen- 
tral nervous system, glycosuria often 
finds its starting point. 

The difficulty, from a therapeutic 
standpoint, lies in recognizing patho- 
logical conditions of the pancreas. Its 
pathology has not been sufficiently 
studied. We do not even thoroughly 
understand all the functions of thi& 
gland. We know it secretes nmy lop- 
sin, tripsin and steapsin, and that these 
ferments act on the starches, the pro- 
teids and the fats, but we do not know 
the full scope of their action. We 
have every reason to believe that the 
pancreas does other work outside of 
its action on these three classes of 
food, but what that is we can only con- 
jecture. When we shall have mastered 
these secrets we will probably know 
much more about diabetes mellitus. 

In the present status of our knowl- 
edge the treatment is more hygienic 
and dietetic than medicinal, although 
the three methods must be intelli- 
gently combined. Where the patient 
is not too much reduced in strength, 
judicious exercise in the open air is 
beneficial, for the reason that it pro- 
motes the inhalation of oxygen and 
thereby increases the combustion of 
sugar in the lungs. Great care must 
be taken in the withdrawal of the car- 
bohydrates from the food. Very often 
a too sudden withdrawal of this class 
of food, and an oversupply of proteids 
without fats, will result in diabetic 
coma from poisoning by oxybutyric 



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acid. The urine should be tested 
•every two or three days, and if it is 
found to contain acetone and diacetic 
acid, the proteids should be reduced 
and the starches moderately increased 
in the diet. Whenever a complete 
withdrawal of the starches frees the 
urine from sugar without increasing 



the waste of tissues and loss of 
strength, it is safe policy. The pro- 
teids should not be used for any con- 
siderable period of time without the 
accompaniment of the fats. For me- 
dicinal agents arsenic, iron and strych- 
nine, with the alkaline salts, are among 
the most useful aids. 



NENA/^ PUBLICATIONS. 



A Pbaotical TRKATI6E ON Small-Pox. niustrated by 
Colored Photoffraphs From Ldfe. By Geoboe Hrnrf 
Fox. A. M., M. £>.. Consulting Dermatologist to the 
Health Department of New York City, with the 
Collaboration of S. D. Hubbard. M. D., S. Pollitzbb, 
M. D., and J. H. Hdddleston, M. D. Parts I and II. 
Published by J. B. Lippincott Company, Philadelphia, 

The above treatise on small-pox, 
with the beautiful and life-like colored 
photographs representing the different 
stages and types of the disease, will 
prove a boon to the medical profession. 
With this treatise in the hands of every 
physician, a mistake in diagnosis would 
seldom occur. Part I takes up the 
symptoms, cause of the disease and 
<liagnosis, with eight colored plates 
illustrating the stages of the disease 
up to the ninth day. Part II discusses 
treatment and vaccination, and con- 
tains seven colored photographs illus- 
trating the different stages of the 
disease from the ninth- day to the 
twentieth, and also one plate represent-^ 
ing the different phases of vaccination. 

Anatomical Researches on the So-Called "Pros- 
tatic Hypertrophy" and Allied Processes in 
the Bladder and Kidneys. By Stanislaus Cie- 
CHANOWSKi. Edited by R. H. Greene, A. M., M. D, 
Published by E. R. Pelton, New York City. 1903. 

The interesting feature of the above 
anatomical researches is the elaborate 
pi-esentation of current theories on the 
etiology of prostatic hypertrophy, and 
the author's careful analysis of the 
same, with the conclusions he has 
reached clearly stated. The author 
asserts that the functional disturbances 
of the bladder in old people are gen- 



erally due to bladder insufficiency and 
not to enlargement of the prostate, as 
generally believed. He thinks that 
atheromatous changes play an insig- 
nificant role in this disease, and that 
the prostatic hypertrophy, as a rule, 
results from inflammatory processes 
which are latent for years, unobserved 
by the patient in consequence of the 
insignificant symptoms. To what ex- 
tent this inflammation is due to gonor- 
rhceal processes and their sequences, he 
is unable to decide. He says this is a 
question for the future to determine. 

A Guide to the Practical Examination or Urine. By 
James Tyson, M. D. Tenth edition. Revised and 
Corrected, with a colored plate and wood engravings. 
Price, $1.50, net Published by P. Biakiston's Son 
& Co.. 1012 Walnut street, Philadelphia, Pa. 1902. 

The necessity for accurate diagnosis 
in the practice of medicine is so appar- 
ent to every intelligent physician that 
no channel from which knowledge can 
be gleaned is now overlooked. The 
examination of the urine as a means of 
el ucidating pathological phenomena 
is now recognized as one of the phy- 
sician's most useful aidb. The object 
of the above book is to popularize this 
line of investigation by simplifying the 
methods of examination. As a practi- 
cal guide to the student and physician 
in this branch of science this little 
book stands without a rival. 



The Plague op Lust, Being a History of Venereal 
Disease in Classical Antiquity. By Dr. Julius 
ROSENBAUM. In two volumes. Published by Charles 



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CaningtoD, Esq., 13 Faubourg Montanartre, Paxis, 
France. 

To lawyers, physicians, students and 
specialists in sexual diseases this book 
wfll prove of the highest value and is 
worthy of a special place in their 
library. Whilst the discussion of this 
subject should only be permitted under 
the most rigid restrictions, the study 
of anthropology is an indispensable 
part of a professional education. The 
value of such knowledge must be meas- 
ured by the use made of it. If the 
lawyer or judge can more intelligently 
and justly interpret and administer the 
law* by possessing a thorough knowl- 
edgeof sexual perversions and vagaries, 
society is benefited. If physicians are 
rendered more capable of treating dis- 
ease by a thorough knowledge of the 
unspeakable sexual abominations prac- 
ticed by the different races of people, 
suffering humanity is the beneficiary. 
The author, in faithfully and truth- 
fully portraying the foulness and sin- 
fulness of lust, has performed a cred- 
itable task. It remains for those who 
read this book to make a proper use of 
the information thus acquired. 

Cakckb ot the Utkrcs, a Clinical Monograph on 
ITS Diagnosis and Treatment. By Arthur H. N. 
Lbwers, M. D., Lond., F. E. C. P., <Liond. Price, 
$3.00. net. Published by P. Blakiston's Son & Co., 
1012 Walnut street, Philadelphia, Pa. 1902. 

The above clinical monograph will be 
read with morethan usual interestby the 
general practitioner as well as specialist 
in female diseases. The author deals 
with this diflScult subject from a prac- 
tical and conservative standpoint. He 
makes no extravagant claims for sur- 
gical methods of treatment, but main- 
tains that encouraging results can be 
attained in no other way. He urges 
early diagnosis and prompt removal of 
diseased tissues. He insists upon the 
necessity of radical operative pro- 
cedure as soon as the nature of the 



disease is recognized, and cites cases 
in which operation produced both tem- 
porary and permanent relief. Formerly 
cancer was so uniformly fatal in its re- 
sults that an accurate diagnosis was not 
considered important, and its an- 
nouncement to the patient amounted 
to a death sentence which was not ad- 
visable, but now with this known re- 
sults of early operative measures, con- 
ditions have changed. 

Hand-Book of Medical and Orthopedic Gymnastics. 
By Anders Wide, M. D. Second revised edition. 
Published by Fonk & Wagnalls Co., New York City. 
1902. 

This most excellent volume will 
prove helpful to the medical practi- 
tioner in many of the trying diseases 
which confront him. Many of the 
diseases of the circulative and nervous 
system yield reluctantly to medicine 
alone. In such cases gymnastics and 
massage are valuable supplements to 
medicinal treatment. It seems strange 
in this era of research and discovery 
that this branch of science has been so 
generally slighted by the medical pro- 
fession. The circulation of this book 
among progressive members of the 
medical profession will not only facili- 
tate their work, but will result in a 
benefit to suffering humanity. Price, 
$3.00. 

The Pocket Reference Book and VisiriNa List, Per- 
petual. Published by J. H. Chambers & Co., St. 
Louis. 1903. 

Two Hundred and Fifty Thousand Miles of Travel* 
IN Many Lands. 

You cannot afford to miss this op- 
portunity to accompany Mr. Burton 
Holmes on his personally conducted 
Easy Chair journeys in ten volumes, 
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38 Therapeutic Suggestions. 

THERAPEUTIC SUGGESTIONS. 



TREATMENT OP ECZEMA. 

With proper attention to diet, a total 
abstinence from the use of water on 
the affected parts of the skin, by bath- 
ing or otherwise, a proper combination 
of arsenic with other reconstructives, 
in anemia or debilitated states of the 
system, and suitable topical applica- 
tions, we may look for speedy and sat- 
isfactory results. A very excellent 
local treatment consists of the free use 
of Glycobenphene (Heil). It allays 
pruritus, relieves inflammation and 
gradually removes the infiltrated prod- 
ucts of inflammatory action. 

Glycobenphene possesses qualities 
which render it efficient as a topical 
application in all forms and stages of 
cutaneous irritation or inflammation. 



ANASARCIN IN THE TREATMENT OF 
MERCURIAL DROPSY. 

As dropsy results from many causes, 
but is seldom attributed to mercurial 
poisoning, the following clinical case 
may be of some interest to the profes- 
sion: 

H. M., age twenty-five, before con- 
sulting the writer had undergone a 
mercurial course of two months for a 
syphilitic infection. Towards the close 
of the mercurial treatment he became 
suddenly anasarcous. He was weak 
and anemic, but free from any symp- 
toms of venereal disease. The urine 
was scanty and high colored, deposit- 
ing a lateritious sediment. It was also 
charge<l with serum. He complained 
of a cough and pain in the side. He 
was placed under the following treat- 
ment: Anasarcin tablets — one three 
times a day; fifteen drops of tincture 
of iron three times a day, alternately 
with the tablets. He was also given a 
small dose of Rochelle salts every sec- 
ond day. Treatment continued thirty 
days, with complete recovery and dis- 
charge. 



TREATMENT OP ULCERS. 

IrriUiting applications should not be 
applied as a dressing under any circum- 
stances, nor should undue . pressure of 
a bandage be exerted on the iiTitable 
surface when it is used as a support to 
the weakened tissues. Offensive dis- 
charges should never be imprisoned by 
improperly devised dressings, as their 
septic influence would materially re- 
tard the healing process. Before cura- 
tive treatment is instituted thorough 
disinfection of the ulcer and surround- 
ing parts is indispensable. To accom- 
plish this a considerable area of skin 
surrounding the ulcer should first be 
disinfected by shaving the part and 
thoroughly scrubbing it with soap mini 
warm water, previously sterilized by 
boiling. If the granulations are ex- 
uberant, soft and oedematous, they 
shotild be scraped with a sharp spoon. 
Now pack the ulcer with lint dipped in 
a solution of Tyree's antiseptic pow- 
der (two teaspoonfuls of the powder 
to sixteen ounces of distilled water). 
This dressing should be changed twice 
or three times a day for two cr three 
days, or until satisfactory results are 
obtained. 



OBSERVATIONS ON AN/BSTffBSK OP 
THE DRUM MEMBRANE.* 

By Geo. B. McAuliffe. A. B., M. D. 

The majority of clinicians do not be- 
lieve in trying to obtain local an«s- 
thesia of the membrana tympana. 
Their deductions have been drawn io 
the main from the futility of using co- 
caine for this purpose in the external 
auditory meatus. It is but rational to 
believe that nature protects the tym- 
panic cavity from the effects of fluids 
dropped by chance or design into the- 
external canal. This protection is 
given by the dermal layer of the drum 

* Abstract of a paper read before American Otological 
Society at New London, Conn., July 7, 1902. 



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Women's Diseases. O p e n Sores.— Pundent Diseases 

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HYDROZONE is put up only in extra small, small, medium and large size bottles 
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40 



Therapeutic Suggestions. 



membrane — a skin without glandular 
action or hair, acting only as a shield 
fdr the layers beneath, 

Jacques, by utilizing the selective 
action of methylene blue, mapped out 
the nerve plexus in the middle layer of 
the drum membrane. The nerves 
spread out in radical meshes from the 
periphery — mostly from above. In the 
deeper portion of the dermal layer de- 
tached bundles run in different direc- 
tions and end in apparently sensory 
end tips. 

The mucous membrane of the Eu- 
stachian tube and of the tympanic cav,- 
ity get their main nervous supply from 
the same source — the glosso-pharyn- 
geal. 

From a consideration of these facts 
we see that the external dermal layer 
has very little to do with the sensitivity 
of the drum membrane, and that most 
of the medicines dropped into the ear 
or applied to the drum, membrane have 
little effect until they nullify the shield- 
like action of the skin covering. 

The fact that refrigeration does not 
extend deeply enough to desensitize 
the membrane demonstrates the truth 
of the former of the above mentioned 
conclusions. Furthermore, it cannot 
be localized to the track of the in- 
tended incision. The refrigerating 
sprays need a space of a few inches to 
secure evaporation. This would bring 
under its action the whole membrane 
and canal. I tried to get a tip devised 
for spraying ethyl chloride on the re- 
gion of the membrane selected for 
operation, but was not successful. The 
application of the spray to the sensi- 
tive canal and the subsequent thawing 
are very painful. I have thought that 
if liquid air could be applied, as it is 
claimed, by a cotton applicator, it 
would be the ideal refrigerant knife 
for the membrana tympani. Unfor- 
tunately, too, refrigerants interfere 
with healing and may cause slough.- 
ing. 

Various preparations like Bonain's — 
menthol, carbolic acid and cocain — 



depending for their action principally 
on the carbolic acid, have been used. 
More or less success has been re- 
ported. I do not believe that the an- 
aesthesia obtained by this class of 
cauterants is ever complete, for rea- 
sons given above. 

Fluids which disturb the osmotic 
equilibrium of the drum membrane and 
produce minute solutions of continuity 
in the dermal layer, thereby allowing 
cocain or its succedanea to reach the 
nerve filaments, are the best we have 
at present for use in the external 
canal. 

The conditions favoring this applica- 
tion of cocain are : ( 1 ) The removal of 
foreign substances and loose scales- 
from the drum membrane and canaL 
(2) Dehydration of the outer layers of 
the membrane — a desiccation which 
causes molecular contraction and inter- 
stices through which the ansesthetic 
can reach the deeper parts and nerve 
terminations. (3) The induction of 
endosmosis. The first condition is met 
by the use of hydrozone, which is 
stronger and better than any other 
kind of H202 preparation'in softening 
and boiling oi^t the debris of the canal 
and in lessening the resistance of the 
dermal layer. The hydrozone is sub- 
sequently mopped out by cotton appli- 
cators or syringed from the canal. 
The second and third conditions are 
met by the use of alcohol and aniline 
oil. The latter is absorbed more slowly 
and its effects last longer than the 
former. The solutions used are five 
to twenty per cent of cocain in equal 
parts of absolute alcohol and aniline 
oil. Anaesthesia is gained in ten to 
fifteen minutes. The disadvantage of 
the solution is that the aniline oil is 
toxic and obscures the field. The ex- 
ternal canal is generally filled to en- 
sure osmotic instability and certainty 
of penetration. The toxicity can in a 
great measure be prevented by not 
filling the canal, but by applying to 
the drum membrane a small wad sat- 
urated with the solution and by mak- 



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Pil. 


Pil. 


Antiseptic Comp. 


Chalybeate Comp. 


WARNER 


WARNER 


FORMULA 


FORMULA 


Sodium Sulphite, 1 gr. 
SalicyHc Acid, 1 gr. 
Pv. Capsicum, 1-10 gr. 
Pepsin Conc't, 1 gr. 
Ext. Nuc. Vom. 1-8 gr. 


Mass Cha'vbeafe, 2>^ grs. 

Ext. Nuc. Vol. 1-8 gr. 

m Ft. Pl\. No. j. 

SUGAR-COATED ONLY PINK TINT 


Very efficacious in Dyspepsia 


The best method for the adminis- 


and Intestinal Indigrestion, and 


tration of iron in an assimilable 


especially valuable in caaes of 


form to which is added the tonic 


mal-aesimilation of food. 


effect of the Nux Vomica." 


Specify "Warner & Co." when prescribing 


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42 



Therapeutic Suggestions. 



ing only one application. The obscur- 
ation of the field by the dark oil will 
then be less, and the solution can be 
more easily raopped away. 



ACTION OF lODIPIN ON THE VASCULAR 
SYSTEM. 

The influence of iodine on absorption 
and its specific action on the vascular 
system have been frequently discussed. 
Iodine causes a dilatation of the pe- 
ripheral vessels. The utility of the driig 
is unfortunately hampered by nuraer- 
rous injurious collateral effects. This 
drawback often compels us to avoid 
iodine even in the face of urgent in- 
dications. Recently, iodipin (iodized 
sesame oil) has been shown to be a 
most efficient substitute for iodine, 
equally potent and free from toxicity. 
Dr. Richard Thaussig* has inaugurated 
clinical experiments with iodipin, se- 
lecting affections which make a vascular 
dirug-action desirable, such as asthma, 
arterio-sclerosis, syphilitic endarteritis 
and chronic lead-poisoning. 

The remedy was administered in- 
ternally and hypodermically. The oily 
taste often interferes with inhibition by 
the mouth, and, when large doses are 
taken some manifestations of iodism 
are apt to occur, probably as a result 
of rapid absorption. This absorption 
takes place in the small intestines, 
where iodipin is split into its compo- 
nents, iodine and sesame oil. Iodipin 
may be given per rectum, but the ab- 
sorption is very slow and the thera- 
peutic action often inadequate. 

By far the best route is the hypo- 
dermic. For this purpose the 25-per- 
cent preparation is employed. Injected 
with aseptic precautions, the drug pro- 
duces no local reaction of any signifi- 
cance. The usual single dose in the 
author's cases was five drams on the 
average, one injection being made 
every fourth day. The therapeutic 
results were similar to those obtained 

• Wiener Med. Woch., 1902, No. 29. 



by giving the alkaline iodides. Toxic 
manifestations were occasionally no- 
ticed, but they were mild and followed 
very large doses. 

A most agreeable feature of the new 
drug is its influence on the nutrition. 
Many patients gain in weight while 
taking iodipin. This may be due to its 
fatty component, and contrasts favor- 
ably with the usual cachectic conse- 
quences of prolonged iodide medica- 
tion. 

The author finally emphasizes the 
beneficial action of iodipin In lead-in- 
toxication. Probably this effect is due 
to the influence on the abdominal vas- 
cular system. 

Iodipin, concludes the author, pos- 
sesses considerable value, since it ena- 
bles us to supply iodine to the diseased 
tissues for a long time, without pro- 
voking a specific intoxication. 



CLINICAL LECTURES ON DISEASES OF 
THE SKIN. 

The Governors of theNew York Skin 
and Cancer Hospital announce that Dr. 
L. Duncan Bulkley will give a fifth se- 
ries of clinical lectures on diseases of 
the skin in the out-patient hall of the 
hospital on Wednesday afternoons, 
commencing January 7, 1903, at 4:15 
o'clock. The course will be free to the 
medical profession. 



FOR SEBORRHOBA OF THE SCALP. 

B^ Sulphuris „ ..... 5 iss 

Vaseline g j 

M. ft. ungt. Rub on scalp at night. 

Every morning sponge the scalp with 
the following lotion : 

gt Tr. canth gss 

Spts. ammon. arom g ss 

Lig. pot. arsen.* g as 

Glycerine 3 ij 

Alcohol 5 ij 

Aqua rose q. s, to make gviij 

M. Big. — Sponge the scalp well every morning. 



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Is Antiphlogistic, Analgesic, Antispasmodic, Non-Poisonous, Non-Irri- 
tating, and possesses all the healing qualities of Balsamics. 

Different Forms of Tinex and Other Parasitoses: 

Paint with 10 to 20 per cent alcoholic solution of Sander^ s Eucalyptol, 

Eczema^ Acne, Dermatitis, Pruritus, etc.: 

20 mtn. {in acute) to 60 min. {in chronic) of Sander^ s Eucalyptol to the ounce of 
Ung, Zinci, 

Ctiancroids, Ulcerating Ctiancres, Ulcers and Septic Wounds: 

Add 10 drops of Sander's Eucalyptol to a pint of warm water and wash parts: 
then paint the ulcer with Sander's Eucalyptol, full strength, and apply occlusive 
dressing. 

To avoid the irritation so frequently following the application of the common products of 
Eucalyptus found in the market, and to assure certain therapeutic results, we respectfully re- 
quest to always specify ** Sander's Eucalyptol** when prescribing, or to obtain it in the originate 
package from meyer Bros, Drug Co., St, Louis, Mo. 

Sample and literature of Sander and Sons' Eucalyptol, gratis, through Dr. San- 
der, 88 Lincoln Aventie, Chicago, 111. Meyer Bros. Drug Co. , St. Louis, Mo. , Agents. 

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44 



Selections. 



SELECTIONS. 



URiNB PROM BACH KIDNEY. 

Valentine {Medical Record ^ October 
25, 1902). — Ureteral catheterism, in- 
disputably the best, has its limitations, 
and also a goodly number of oppo- 
nents. For it the bladder must have a 
capacity of at least 50 c. c, must not 
be a bleeding bladder into which one 
or the other kidney is pouring blood 
too rapidly for the irrigating cysto- 
scope to wash away, the bladder walls 
must not be desquamating large shreds, 
and the ureters must be large enough 
to admit the smallest catheter, besides 
other conditions evident upon a mo- 
ment's thought. 

Ureteral catheterization demands 
continual practice, greatest possible 
skill, acute vision and most delicate 
manipulative tact. For this reason 
segregation occupies a distinct place in 
urology. Harris' and Downes' instru- 
ments for segregation are founded on 
the principle of the water-shed, and 
present distinct inconveniences when 
used upon the male. Cathelin's method 
which is here fully described by Val- 
entine is considered by him to possess 
decided merits. [Cathelin printed a 
description of his instrument in the 
Presse Medicale (No. 48, June 14, 
1902), and has given the details of his 
technique and his principal results in 
the Ann. des MaL des Org. Genito- 
Urin. (July, 1902)]. 

The principle of the instrument is 
based upon pushing into the bladder a 
soft rubber membrane which adapts 
itself to the wall, and which is grasped 
by the bladder, thus dividing the vis- 
cus into two halves. 



useful remedy to render the urine 
9LC\A.^ Exchange. 

ORCHITIS. 

Lutaud (JkTedecine) combats the p^in 
of orchitis by the administration of 
cachets containing seven and one-half 
grains of sulphate of quinine. In the' 
majority of cases pain is arrested after 
the first dose, and it is unnecessary to 
give an injection of morphine. At the 
same time the following is applied lo- 
cally : 

It Methyl salicylatis.. ^ Jyj 

Guaiacol 3J 

Vaselini Jj 

M. Sig. — Apply locally once or twice a 
day. — Ex. 

Dr. William P. Loth reports three 
cases of tinea circinata in adults, 
treated at the Dermatological Clinic of 
Professor Hardaway, St. Louis Poly- 
clinic. One patient, presenting on the 
right arm small, nodular masses and a 
number of follicular pustules, was 
cured by the application of a five per 
cent, xeroform ointment; the second, 
in which the extensor surfaces of both 
hands were covered with vesicles and 
vesico-pustules, yielded to an ointment 
containing four per cent, each of sul- 
phur and balsam of peru, and the third 
having on the outer and extensor as- 
pect of the left wrist a thick group of 
acuminate pustules, was treated with 
equal parts of trikresol and alcohol 
three times weekly, a three per cent 
xeroform salve being applied in the 
interim, and only a slight scarring re- 
mained to mark the site of the lesion. 



In chronic catarrh of the bladder, 
when the urine is loaded whith phos- 
phates, benzoate of ammonium, in 
doses of ten to thirty grains, is a 



THE TREATMENT OF NEVUS, OR 
BIRTHMARKS. 

A simple and safe method of treat- 
ing nevi and port-wine marks consists in 
exerting pressure around the nevus by 



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ANASARCIN 



i 



i 



(Oxydendron-Sanibucu5-5cilla Compound.) 

A SPECIFIC FOR DROPSIES 



Doctor:— 

If you know a thing to be a fact, it is not wrong or 
unethical to say so. Neither does it smack of quackery or 
Charlatanism and should not shock the sensibilities of any, 
however refined, cultured or zealous of medical ethics for us 
to claim that ANASARCIN is a specific in dropsies, when 
clinical experience has demonstrated such to be a fact. If 
quinine is a specific in malaria, much more is ANASARCIN 
in dropsies resulting from disease of the heart, liver or 
kidneys, because that a trial of it in hundreds, yea, thousands 
of cases has not resulted in a failure known to us where 
directions have been followed. 

Besides being a specific for dropsies, it is a permanent 
cure in the conditions mentioned when begun early and 
continued a sufficient length of time, i, e., until the diseased 
organs regain normal function. ANASARCIN is composed of 
the active principles of Oxydendron Arboreum, Sambucus and 
Urginea Scilla, and is sold exclusively to physicians or 
druggists for physicians. Trial box free with literature and 
testimonials furnished physicians on application. 



I 



I 



ADDRESS 



The Anasarcin Chemical Company 

WINCHESTER, TENN,, U, S. A. 



=^-^LONDON AQBNTS- 



1%%^ 



Tbos. Christy A Co., 4-10 '12 Old Swan Lane, Upper Thames St., B. C. 



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46 



Selections. 



an encircling ring in order to arrest the 
circulation to and from the part and 
then slowly inject five to seven minims 
of rectified spirits of wine with an ordi- 
nary hypodermic syringe. The result 
is to harden the tissue and to cause the 
nevus to shrink and disappear. In 
treating nevi of large dimensions more 
than one injection could be given at 
the same sitting, or at short intervals 
of time in different parts of it ; the ab- 
sorption in one part could be taking 
place while another part was being 
prepared, bearing in mind the effect of 
alcohol upon the system. This method 
has the advantage of being easy of ap- 
plication, and there are few practi- 
tioners who are not possessed of all 
the material needed ; if not it is read- 
ily procurable, and with ordinary care 
it will not, I think, prove dangerous. 
Care must be used that the syringe is 
perfectly void of air before injecting 
the agent. — Dr. T. M. Holgate in 
Pediatrics. 



ECZEMA iN iNPA^TS. 

In certain cases of eczema in infants 
the effect produced by a thorough 
and continuous use of a zinc ointment 
containing twenty grains of ichthyol 
and fifteen or twenty of salicylic acid 
is certainly remarkable and undoubt- 
edly much greater than from either 
the zinc or ointment alone, or when 
combined only with the salicylic acid. 
— Dr, Bulkley. 



TREATMENT OP PRURiTUS VULV^, 

Siebourg (quoted in the American 
Journal of Obstetrics y October, 1901) 
has had good results in the treatment 
of some cases of pruritus vulvae by sub- 
cutaneous local injections of weak solu- 
tions of cocaine and carbolic acid. He 
then attempted to accomplish the same 
purpose by simple injections of salt so- 
lution. He believes that local anes- 
thesia is caused by the pressure of the 
injected fluid. — Therapeutic Gazette. 



INDEX 



Original Articles. page. 
In the Present Status of Bacteriology Can 
its Relation to Cutaneous Pathology be 
Accurately Defined? 1 

Notes on Diverticula of the Male Bladder. 
By Louis E. Schmidt, M. Sc, M. D 13 

Clinical Remarks on Some Advanced Forms 
of Urethral Stricture Treated by a Com- 
bined Urethrotomy and Perineal Section. 
By Reginald Harrison, F. R. C. S., Eng- 
land „ 16 

Endovesical Surgery with Special Refer- 
ence to Cystoscopy and Ureter Catheter- 
ism. By F. Kreissl, M. D , Chicago, 
Illinois 18 



Original Articles. page. 

Epicarin as an Antipruritic. By Max 

Reichmann, M. D., Chicago, Illinois 23 

Koilonychia and its Successful Treatment; 

with the Report of Some Cases. By A. H. 

Ohmann-Dumesnil, St. Louis 24 

Urticaria, its Vagaries and Treatment. By 

S. C. Martin, M. D., St. Louis 32 

Pathogenesis and Treatment of Diabetes 

Mellitus 33 

New Pubucations 36 

Therapeutic Suggestions 38 

Selections 42 



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A BI-MONTHLY MAGAZINE DEVOTED TO THE CONSIDERATION OF CUTANEOUS MEDICINE 
VENEREAL DISEASES AND QENITO-URINARY SURGERY. 

EDITORS 

S. C. MARTIN, M. D. G. M. PHILLIPS, M. 0. 

P*tOrinOR or OrRMATOLOOV in THC BARNCS MIOIOAI. OOLLIOI PROriMOR OP OCNITO'URmARY DISIAMS ST. LOUIS OOtUOl OP 

rr. LOUIS. PHYSICIANS AND SURQIONS. 

MANAGING EDITOR 
S. C. MARTIN. Jr., M. D. 

SUBSCRIPTIONS AND ADVERTISING. 

The subscription price of this Journal is $x.oo per year, in advance, postage prepaid, for the United States, Canada and 
Mexico; $1.50 per year for all fortign countries Included in the postal union. Single copies. 35 cents. 

Advertising: rates will be furnished upon application. 

Address all communications, correspondence, books, matter regarding advertising, and make all checks, drafts and post- 
office orders payable to 

AMERICAN JOURNAL OF DERMATOLOGY 



fidelity Buiidtng. St Louis. Mo . U. S. A 



Vol,. VII. 



MARCH, 1903. 



No. 2. 



ACTINOMYCOSIS AND X-RAY THERAPY.* 

By M. L. Hkidingsfbld, Ph. D., M. D., 

Prof. Dermatology, Laura Memorial College; Clinical 

Lecturer Dermatology, Miami Medical College; 

Dermatologist to Presbyterian Hospital. 

The following case of actinomycosis 
is of particular interest, not only be- 
cause of its well-defined type and char- 
acteristic appearance and history, but 
also because it demonstrates the ineffi- 
cacy of x-ray therapy in this class of 
affection and the excesses to which, on 
occasion, it can improperly be carried. 
Mr. J. H., aged sixty-two years, a 
farmer by occupation, but for the past 
six years a dairyman, and the present 
owner of twenty-three cows. In De- 
cember, 1900, he consulted a dentist 
relative to a small, painful nodule sit- 
uated on the buccal mucous membrane, 
in proximity to the right lower molars, 
and whose surgical removal was fol- 
lowed by brief temporary improve- 
ment. The nodule retained its pain- 

*ReT>orted Cincinnati Academy Medicine, January 
26, 190d. 



ful and inflamed character, and soon 
assumed such proportions and charac- 
ter that the dentist advised a consulta- 
tion with one of our most pro.minent 
homeopathic surgeons, in June, 1901. 
The surgeon advised the extraction of 
all the lower teeth in proximity to the 
affected area, and which were at that 
time the seat of considerable neuralgic 
pain. The extraction was not fol- 
lowed by any marked improvement, 
and the patient sought his family phy- 
sician, who, in January, 1902, advised 
a consultation with one of Cincinnati's 
most prominent regular surgeons ; thi& 
surgeon promptly pronounced the con- 
dition malignant disease of the jaw, 
and urged the removal of the right 
half of the lower jaw, stating that thiif 
would be the only means of prolong- 
ing his life longer than a year, and 
possibly not longer than six months, 
even with an operation. Patient was 
greatly depressed by the unfavorable 
character of the prognosis, and su- 



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preme resignation to his fate deterred 
him from undergoing the operation. 
In March, 1902, patient came under 
the care of an x-ray specialist, who, 
■during a period of almost three 
months, made twenty-five prolonged 
And rather intense exposures. This pro- 
longed treatment, other than inducing 
XI rather severe and annoying derma- 
titis, did not seem to exert any marked 
influence, either towards checking its 
progress, inducing retrogres s i v e 
changes or alleviating the subjective 
pain and distress. After an interval 
of three months, during which time 
the patient did not receive special at- 
tention, patient consulted a second 
x-ray specialist, who proceeded to give 
him another course of x-ray therapy, 
of twenty exposures, covering a period 
of eight or nine weeks, and which was 
followed by the same negative results, 
AS far as two additional months of ob- 
servation (during which time the pa- 
tient was again without special atten- 
tion) permit us to judge. 

The now thoroughly disheartened 
And discouraged patient once more 
sought the care and attention of his 
family physician. Dr. J. G. Walton, of 
Home City, with whom I saw the case 
in consultation for the first time, De- 
<5ember 17, 1902; at this time the skin 
covering the lower maxilla on the right 
side for a distance of several inches 
upward on the cheek, and downward 
on the neck from the chin to the an- 
terior border of the ear, was diffusely 
infiltrated, semi-fluctuating, somewhat 
doughy in character and deep brownish 
red in color. Above the right lower 
maxilla, at about the junction of the 
anterior two-thirds with the posterior 
two-thirds, was a large ulcerating fun- 
gating ulcer, size of a silver one-half 
dollar, with thick indurated borders 
and base, and filled with masses of dense 
granulations. Beneath the jaw were 
four or five long, slender sinuses, from 
which there constantly oozed, in in- 
creased amount on pressure or on mo- 
tion of the jaws, a considerable quan- 



tity of thin, sero-purulent discharge, 
which contained a number of sulphur- 
yellow colored flakes, which, when 
macerated, stained and placed under 
the microscope, revealed characteristic 
central body and radically disturbed 
mycelia of the ray fungus. In addi- 
tion to the diffused character of the in- 
filtration, foci of softening and sinus 
formation, characteristic discharge, in- 
sidious onset, mucous membrane ori- 
gin, maxillary involvement, predis- 
posed occupation, readily detected fun- 
gus, remained the fact that the patient 
two years previously was the possessor 
of a lumpy jawed cow, all of which 
evidence, overwhelming and conclusive 
in character, rendered the diagnosis 
such a simple and easy matter that it 
scarcely seems probable that it could 
be overlooked. A portion of the bor- 
der of the ulcer, which was removed 
for histological examination, revealed 
itself to be almost a pure type of epi- 
dermal tissue, extensively hypeitro- 
phied and proliferating, from pro- 
longed character of the irritation and 
inflammation. 

Patient was placed on potassium 
iodide, internally, on date of his first 
visit, December 17, 1902, and iodipin 
injections were instituted December 
22d. On the date of the last consul- 
tation, January 8, 1903, although his 
general condition has been very se- 
riously impaired by the excessive 
drain, prolonged and painful char- 
acter of his affection, the local im- 
provement has been very marked, to 
such an extent that the diagnosis is 
not only confirmed, but sincere hope is 
now also entertained that his recovery 
will be both complete and permanent 
in character. 

The overlooking of the diagnosis in 
such an apparent case is attributable 
solely, I believe, to the excess to 
which x-rav therapy is at present car- 
ried. Man^ of the men who interest 
themselves in this work believe it to 
be such an unfailing remedy for almost 
any form of inflammatory change. 



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Ureter to the Bladder— Robinson. 



49 



that a careful consideration of the nat- 
ure and causes of the affection, and 
therapy in its older, though possibly 
antiquated garb, is of little or of sec- 
ondary importance. So supreme is 
their faith in the x-ray that at the 
shrine of therapy, at which they wor- 
ship, it is fast becoming the only god 
which they invoke to their aid. Fort- 
unately for medicine, though unfort- 
unate for man and the ills to which 
he is heir to, it is not the cure-all that 
some imagine, and as the foregoing 
case demonstrates. My experience 
may be somewhat unique, but I am 
strongly impressed that, though it is a 
valuable agent, and though it occupies 
an important, almost indispensable, 
place in dermatologic therapy, it does 
not possess the unfailing reliability 
and efficacious power, even in the 
treatment of lupus and epithelioma, 
which it is commonly reputed to pos- 
sess. I believe its aid is often invoked 
when it is not required, and that its 
action is at times decidedly delete- 
rious. 

Instances like the preceding case 
will serve not only to bring x-ray 
therapy into moderate disrepute, but, 
oft repeated, will effect a harmful re- 
action, from which, no doubt, it will 
be a long time recovering. No one 
can question, even at the present time, 
but that it holds and is destined to 
hold a very important, permanent and 
indispensable place in dermatological 
therapy, but at the same time it does 
not possess the unfailing reliability 
and efficacy which many of its most 
ardent admirers claim for it. Itn 
proper employment entails the careful 
consideration of definite principles 
which are being slowly elaborated, and 
are not, as yet, fully established; 
fundamental, and by no means the 
least important of which, is the estab- 
lishment of a correct diagnosis and 
full consideration of, and not reckless 
disregard for, the older and equally 
efficacious and reliable methods of 
treatment. It is fortunate for med- 



ical science that definite principles are 
involved, otherwise its employment 
would be so simple and mechanical 



Dr. Heidingsf eld's case of actinomyoosis. 

that skill, knowledge, experience, 
judgment and learning, and all the 
gifted attributes and attainments 
which contribute so much worth to- 
wards making the study and practice 
of medicine the most enlightened and 
inspiring of all professions, could mean 
little or nothing, and its practice could 
be relegated to the merest tyro, quack 
or mechanician, who, irrespective of 
cause and nature of disease, could cure 
ailment and restore health by the 
mere turning of a switch. 
22 West Seventh street. 



RELATION OF TUB URETER TO THE 
BLADDER. 

Bt Btron Robinson, B. S., M. D., Chicago. 

The relation of the ureter to the 
bladder should be considered in two 
segments — (a) extramuralis, and 
(6) intramuralis. Both extra- and 
intramural segments are of extreme 
importance in obstetrics and gynecol- 
ogy, especially in the large field of 
vaginal hysterectomy. 

(a) Extramural Segment, — This 



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It is located nearly one inch 
distal to the external os. It 
courses obliquely distalward one- 
fa a 1 f to three-quarter inch 
through the vesical wall, whence 
it ends at the distal ureteral ori- 
fice, forming one of the angles 
of the vesical trigone. The 
course of the ureters through 
the vesical muscularis and fibrosa 
is not far from parallel, but on 
arriving at the vesical mucosa 
they rapidly converge medially 
between vesical muscularis and 
mucosa — i. e., there is a slight 
angle of the intramural ureter* 
at the junction of vesical, mu- 
cosa and muscularis. Accord- 
ing to my dissections, the vesi- 

FiQ. 1.— Illustration of the relation of the ureter to bladder, vaffina ^,,i fihrrkno anr\ miifi/^nlaritt fnnir>Q 
and cervix uteri. 1, Arteria uterina arisinR from the internal iliac. Cai UOrOUS aUQ mUSCUiariS lUUlCS 
2, Distid arteriouretera][^croB8ing. 3, Cervical loop. 11 is placed on and UrctCr do UOt blcud Or COal- 

esce. The ureter is separated 



the trigonum vesiciP. The 
tween bladder and vagina. 



extramural segment of ureter lies be- 



corresponds in general to the vaginal 
ureteral segments. 

The extramural segment is the one 
which is the more liable to trauma^ 
account of its intimate relation 
cervical arterial loop or the 
portion of the pelvic floor se; 
the utero-ovarian artery. T& 
mural portion is also the seg] 
the ureter which is so intimate 
lated to the vagina. The extramura 
segment possesses a strong fibro-muri- 
cular ureteral sheath which accompa- 
nies the ureter through the bladder 
wall. It bends medial ward before it 
ends in the bladder. 

The extramural portion is applied 
practically to the dorsal, lateral and 
distal surface of the bladder (base). 
One inch distal to the os uteri externum 
the ureter penetrates the bladder wall. 
It lies in an extensive bed of areolar 
tissue and veins. 

(b) The Vesical Intramural Por- 
tion. 

The intramural, intravesical or intra- 
parietal portion is so named by reason 
of its location in the bladder wall. It 
is the terminal portion of the ureter. 




from the bladder wall by a visible 
zone of connective tissue, which insures 
independent function of bladder and 
ureter — i. e., the bladder can contract 
^whilethe ureter continues to 
tents in the bladder. In 
worCThrNjc ureter can pour itscon- 
padder, but the function 
sralve in the bladder wall 
10 urine to regurgitate 
'ureter in any state of the 
/systole or diastole. The lo- 
cation of the intramural portion of the 
ureter corresponds to the junction of 
the proximal one-third with the dis- 
tal two-thirds of the ventral, vaginal 
wall. In some cases the junction is 
practically in the middle of the vaginal 
wall. Indication of folds on the vag- 
inal wall, as noted by Powlick, pre- 
sent a triangular outline correspond- 
ing to the vesical trigone. The ure- 
ters project the folds vaginalward. 
The summit of the vesical trigone, 
which is situated at the level of the 
orificium urethrse internum, will be 
separated from the distal ureteral ori- 
fice by about one inch (resting), or 
one and one-half inches (distended) 
bladder. At the entrance of the ure- 



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Ureter to the Bladder— Robinson. 



61 



ter8 into the external bladder wall 
they are separated about one and one- 
half inches (resting), and at their en- 
trance into the internal bladder wall 
they are separated about one inch 
(resting). The ureter courses for con- 
siderable distance beneath the vesical 
mucosa. 

The pars intramuralis is the one-half 
inch of the fixed distal end of the ure- 
ter. It lies within the vesical wall. 
The ureteral sheath lessens as the ure- 
ter passes with it obliquely through 
the bladder wall, almost disappearing 
at the mucosa. The distal ends of 
the two ureters and the proximal end 
of the urethra together form the tri- 
gonum vesicae ( Lieut audii) an isos- 
celes triangle, one inch in area of fold- 
less mucosa, containing the chief ves- 
ical sensory nerves and rich vascular 
supply. 

The intramural portion opens into 
the bladder one-half inch ventral to 
the portio vaginalis., It is short, 
oblique, narrow (the second most con- 
stricted part of the ureter), having a 
length of one-third to one-half inch. 

The portio intramuralis ureteric 
passes for nearly three^fourths of an, 
inch through the vesical wall, and in- 
dependent of it, insuring- separate i^nd 
independent action of both ureter and 
bladder wall. The vesical segment of 
the ureter, consisting of the intra- 
mural and extramural portions, must 
always be of the highest importance 
with regard to the surgical interven- 
tions on the pelvic viscera. In hys- 
terectomy, especially per vaginam, the 
cervix uteri being drawn distal ward by 
traction forceps, alters the normal 
ureteral and cervical relations. Draw- 
ing the uterus distalward applies the 
ureter more closely to its lateral cer- 
vical borders as well as to the sides of 
the bladder. 

The ureteral fistula in the intramu- 
ral segments is difficult to heal. I 
have observed one in practice that 
lasted three years, in spite of numer- 
ous operations. The extramural seg- 



ments in the resting bladder are sepa- 
rated about one and one-half inches, 
but in a well-filled bladder may be sep- 
arated over two inches. Under favor- 
able circumstances the vesical segment 
of the ureter can be palpated per va- 
ginam. The intramural segment is 
important, as it is the second narrow- 
est sphincter of the ureter, and calculi 
are liable to lodge in it. It is also the 
point to effect ureteral catheterization. 

The Distal Ureteral Orifice. 

The distal ureteral orifice is visible to 
the naked eye, generally located on a 
mammilliform process at the proximal 
lateral angle of the trigonum vesicse. 
Sometimes it does not present any 
elevation, but, on the contrary, a de- 
pression in the vesical mucosa. 

Its form is generally an obliquely lat- 



Fig. 2. — A, B, D, E, F, represents the distal end of the 
ureter as it appears in the bladder with various shapes 
and distance from each other. 1 and 2 are the distal ure- 
teral orifices, and 3 is the oriflcium ure three internum. C 
is an illustration to show how the ureter penetrates the 
vesical tunics. 1, Tunica fibrosa vesicie. 2, Tunica mus* 
cularis vesicoB 3, Tunica mucosa vesicie. 4 to 5 repre- 
sents the ureter piercing the coats of the bladder. The 
end of the ureter at 5 is made to bend too sharply, as it 
should course for considerable distance under the vesical 
mucosa. From 4 to 5 is about three-fourths of ^n inch. 

eralward-directed oval slit cne-eighth of 
an inch in diameter, with the sharpest 
point of the oval pointing distalward. 



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The thickened linear mucous 
ridge connecting the ureteral 
orifices at the base of the tri- 
gone is slightly convex distal- 
ward, which again facilitates the 
use of the catheter. 

The trigone is a mobile or- 
gan, and the distance of separa- 
tion between the distal ureteral 
orifices so vary in the distend- 
ing (diastole) and contracting 
(systole) bladder that the figures 
given by different authors, to fix 
the relation of the distal ureteral 
orifices to the trigone, vary so 
much as to lose their value. 

If one takes a half dozen 
authors, the distance given be- 
tween the distal ureteral orifices 
by one author will be one-half 
or double that of the other. 
Thus, one author will give the 
distance between the ureteral 
orifices as two-thirds of an inch, 

Fio. 3. --Six illustrations of the various appearances of the distal _-^j M>rx^4-U^w» av«^ r.«^ ^r%t% fki«.^ 
end of the ureter in the bladder. 1 and 2, i3istal ureteral orifices. ^^^ anOtUCr, OUQ aUQ One-inira 
3, Oriflciumurethne internum. The various appearances of the vesi- Jn/thAQ T found that the di*^- 

tance between the distal ureteral 
orifices varied remarkably in several 
hundred autopsies, owing to the thinned 
or thickened vesical wall, to the quan- 
tity of the vessel contents, the ex- 
tremes being two-thirds to two inches. 
In general, the trigonum vesicae was 
an isosceles triangle of one inch (rest- 
ing) or nearly two inches (distended). 
The distal ureteral orifices are reached 
with facility by the finger in woman 
subsequent to dilatation of the urethra. 
To catheterize the ureter it may facili- 
tate by following the oblique dorso- 
lateral ridge of the trigone, when the 
point of the catheter may fall in the 
orifice. 

The pars extramural! s vesicae is the 
portion of the ureter that lies between 
vaginal and bladder walls, in contact 
with both, but can be freed from each. 
The vaginal portion of the ureter is of 
supreme importance, as it can be at- 
tacked per vaginam for surgical inter- 
vention, as the removal of ureteral 



cal is here illustrated. 

The orifice may, howevcF, be rounded, 
punctiform or like the beak of a flute. 
In this last condition the ureteral ori- 
fice is limited proximally and distally 
by a curvilinear mucous fold in the 
form of a valve, constituted by the con- 
tact of the borders of the mucous folds. 
An extreme illustration of this valve 
in the form of a bridle rein is noted in 
the upper left-hand figure (illustra- 
tion No. 3) surrounding an oblique 
ureteral orifice. One can easily see 
the advantages offered by this mechan- 
ical arrangement to facilitate catheter- 
ization. The elevated ridge produced 
by the muscle of Jurie, the interure- 
teral muscle connecting the ureteral 
orifices, aids catheterization. 

The ureteral orifices occupy the 
proximal lateral extremities of the 
base of the trigonum vesicae, and a 
slight lateral mucous ridge exists which 
facilitates the introduction of the 
catheter. 



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calculi, removal of stricture or repair 
of ureteral fistula. 

With the distention of the bladder 
the extramural portion lies more in 
contact with the bladder and is forced 
lateral ward. 

The proximal ends of the intramural 
segments are separated about one and 
three-quarter inches, the distal ends a 
little over one inch. In empty blad- 
der the distal ureteral orifices are 
about one inch sepai*ated by filled blad- 
der, they are from one and one-half 
to two inches separated. 

In empty bladder the portio extra- 
muralis lies more dorso-ventrally ex- 
tended, which makes the distal arterio- 
ureteral crossing more distant from 
the ureteral penetration of the blad- 
der. If the bladder be filled the ar- 
terio-ureteral crossing approaches the 
bladder. 

I found by injecting numerous ure- 
ters from the bladder with canula that 
most ureters entered the bladder in 
^ sagital or dorso-ventral direction, 
and that the transverse traversing of 
the bladder by the ureter is an excep- 
tion. Practically the transverse direc- 
tion of the portio intramuralis ureteris 
begins in the submucosa vesicalis, or, 
perhaps, in the vesical muscularis. 

To avoid trauma to the ureters in 
vaginal hysterectomy, the bladder 
should be forced proximalward and 
the ureter proximalward and lateral- 
ward. When the ureters leave the 
lateral pelvic wall to pass to the blad- 
der, they course adjacent to the pelvic 
floor between the peritoneum and the 
reflected parietal layer of the pelvic 
fascia, which glides into the visceral 
pelvic fascia. The ureters enter the 
base of the bladder dorso-ventralward 
surrounded by plexus venous. 

Conclusions as Regards the Vesi- 
cal Segment of the Ureter. 
1. It penetrates the vesical wall 
obliquely, especially the mucosa, for a 
half inch. 2. It forms a perfect non- 
regurgitating parietal valve. Urine can 



enter a distended bladder, but not & 
di'op can re-escape through the ureter. 
3. The distal orifice is located at the 
proximal external angle of the vesical 
trigone. 4. The orifice is an obliquely- 
directed, oval, mucous slit one-eighth 
inch in diameter. 6. The oval mucous 
slit is generally situated in a depres- 
sion or in a mammillated elevation, oc- 
casionally surrounded by a mucal fold 
constructed in such an an-angement 
that it facilitates uretheral catheteri- 
zation. 6. The ureteral orifices make 
their exit on a foldless mucosa contain- 
ing the chief vesical sensory nerves — 
the trigone. 7. The intramural vesi- 
cal ureter penetrates the tunica fibrosa 
and tunica muscularis of the bladder 
wall independently, surrounded by its 
fibrous muscular ureteral sheath. The 
tunica fibrosa and tunica muscularis of 
the vesical parietas are separated from 
the intramural ureteral segment by 
the ureteral sheath, a fibro-muscular 
structure constituting a distinct macro- 
scopic tissue zone between ureter and 
bladder wall. Perhaps the space be- 
tween the ureter and fibro-muscular 
ureteral sheath is a lymph space facili- 
tating mobility. 8. The fibro-muscu- 
lar ureteral sheath accompanying the 
intramural segment of the ureter, es- 
pecially that penetrating the tunica 
fibrosa and tunica muscularis vesicae, in- 
sures separate and independent action, 
function of ureter and bladder — e. g.<, 
while the vesica urinaria executes its 
diastole and systole the intramural ure- 
teral segment independently acts or 
functionates as usual. In other words, 
the rhythm of bladder and ureters are 
separate and independent in function, 
even in the vesical segments. 9. The 
distal ureteral orifices and the proxi- 
mal end of the orificium urethra-inter- 
num practically make an isosceles tri- 
angle of one inch on a side. 10. The 
distal end of the ureter, like the prox- 
imal end, is mobile ; however, the dis- 
tal end moves with the vesical trigone, 
while the proximal end (calyces) 
moves with the kidney. 11. Though 



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the oblique valve arrangement of the 
ureter in the bladder wall would not 
absolutely prevent ascending bacterial 
<iisease, yet when the ureter be trans- 
planted in the tractus intestinalis, 
when possible, the distal orifice of the 
ureter should accompany it. 



PRVRiaO AND PRURITUS, 

By S. C. Martin. M. D., St. Louis, Mo. 

The above diseases are still often 
-confounded, although essentially dif- 
ferent in every feature except that of 
itching. Prurigo is a papular disease, 
beginning usually in infancy and con- 
tinuing indefinitely in its typical form, 
while pruritus is a neurosis usually of 
middle and advanced age, in which 
there is no structural change of the 
skin except such lesions as are sec- 
ondarily developed from scratching to 
relieve the excessive itching. Prurigo 
is met with on the extensor surfaces 
<5hiefly, while pruritus is mostly local- 
ized or limited to some special part of 
the body. 

It seems strange that prurigo should 
be so generally associated with pruri- 
tus, which it does not resemble, and 
never confounded with papular ec- 
zema, which it so frequently imitates 
in nearly every particular, especially 
those forms which persistently defy 
all plans of treatment. This is prob- 
ably due to the fact that nearly all 
text-books speak of it as an Austrian 
disease and attribute its discovery to 
Hebra. Hebra deserves the credit of 
elaborating its clinical history, more 
especially the worst form, known as 
prurigo ferox, but I think it is going 
too far to claim that Austria or siuy 
other country enjoys a monopoly in 
this type of skin disease. Any spe- 
cialist of large experience in skin dis- 
eases must know that it is not rare, 
especially in large cities, to meet with 
a persistently itching papular eruption 
which in its clinical and anatomical 
history furnishes an almost exact 



picture of the disease described by 
Hebra as prurigo. 

The treatment of this disease is 
more or less empirical. Attention to 
hygiene, diet and improved nutrition 
is paramount. The daily use of the 
hot bath and free applications of tar 
soap will give great relief. Wilkin- 
son's ointment should be applied at 
night for a week or ten days, the pa- 
tient sleeping between blankets, and 
at the end of this time a warm bath 
should be taken. Antipyrin in doses 
of two to three grains at short inter- 
vals will diminish the itching. Crocker 
advises full doses of cannabis indica 
(tincture) for this purpose. Kaposi 
recommends a 5 per cent, ointment of 
napthol combined with oxide of zinc. 
This is spread upon pieces of muslin 
and applied to the limbs under a roller 
bandage. Constipation should be 
guarded against by the free use of 
saline laxatives. Arsenic, iron and 
strychnine in some cases may be em- 
ployed with benefit. Cod-liver oil, 
malt extract and bitter tonics, in con- 
nection with the betterment of hygi- 
enic environment, will enhance the 
effect of local remedies. 

Itching is a prominent symptom of 
many cutaneous diseases, but it is sub- 
stantially the whole of the disease 
known as pruritus. It may occur at 
any age, but is most common and 
troublesome late in life. The nostrils, 
anus, scrotum and vulva are the re- 
gions most liable to be affected. It 
may occur at any season of the year, 
but the winter months are the favorite 
time for its appearance. 

The causes of pruritus are not always 
easily ascertained. Gout, diabetes, 
neurasthenia, jaundice, malaria and 
dyspepsia frequently are the funda- 
mental factors claimmg our therapeutic 
recognition. The indulgence in alco- 
hol, coffee, tobacco and improper food 
is often injected into the current his- 
tory of this disease as a contributing 
agency. In old age the skin degener- 
ates, wears out, and its innervation be- 



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Third Act in the Drama of Syphilis— Robbins. 65 



comes correspondingly impaired and 
perverted. These changed conditions 
provoke neuroses, and in most of such 
cases radical cure is out of the ques- 
tion. Palliation is all that can be 
hoped for. The treatment must be 
along rational lines. Narcotics' should 
be seldom employed, and when neces- 
sary, they should be used with great 
care. Where a patient is prevented 
from sleeping by the itching of this 
disease, do not give opium. The 
bromides will do better without pro- 
ducing the injurious effects of opium. 
Bulkely recommends cannabis indica 
and gelsemium. A hot bath at night 
with a free addition of salt will induce 
rest. External applications are very 
important helps. Fox recommends 
chloroform liniment to allay the itch- 
ing. He also advises the employ- 
ment of carbolic acid for local anes- 
thesia. One of his favorite prescrip- 
tions is: 

Ul Acid carbolic 20 parts 

Glycerine 20 parts 

Aquae ...^....ad 100 parts 

This he cautiously applies as a lo- 
tion, sometimes diluted to suit the 
case. 

My only objection to carbolic acid 
is, it must be used in great strength to 
secure anesthetic effects, and in this 
form it is liable to be absorbed with 
poisonous results. Chloral and cam- 
phor mixed in equal parts will in some 
cases give prompt relief. We also 
have menthol, cocaine, salicylic acid, 
corrosive sublimate and cyanide of po- 
tassium, all valuable remedies to select 
from, as occasion may require. Elec- 
tricity is also an effective remedy well 
worthy of trial. At best this disease 
is equally troublesome to the patient 
and the physician. It often exhausts 
the patience of the former and baffles 
the skill of the latter, and in some 
cases takes its leave without the help 
of either. 



THIRD ACT IN THE DRAMA OF SYPHILIS. 

By Hxnby Alfbxd Robbims, M. D., 

Professor of Dermatology and STphiloloiry In the Medical 

Department of Howard University; Dermatologist 

to the Washington Hospital for Foundlings. 

Alfred Fournier, in his ''Lesons eur 
la Syphilis,'* Paris, 1873, gives the 
following striking analysis of the 
''drama" of the apparition and de- 
velopment of syphilis: 

I^irst Act, — Contamination. — The 
virus peneti*ates the organism by one 
mode or another. 

Second Act. — Production at the 
point where the virus has penetrated, 
and only here, of a lesion, known as 
initial, which, for the time, constitutes 
the only expression of the disease. 

Second Interval. — Another period of 
repose of the organism ; the initial le- 
sion continues to be the only symptom 
by which the disease is expressed. 

Third Act. — Explosion of multiple 
and disseminated lesions beyond and 
outside of the seat of contamination.^^ 

This is the period of visible gen- 
eralization of the disease. 

The Apostle James says: * 'Behold 
how great a matter, a little fire kin- 
dleth." This text occurs to me when- 
ever I look at the innocent-looking 
chancre. When you first see it, it has 
passed through the hatching stage — 
the stage pf incubation. It has suc- 
cessfully performed that role in the 
first act of the drama of syphilis. 

Experimentation proves to us that 
the chancre — the initial lesion of 
syphilis — is only dangerous when it is 
allowed to play its part alone. Para- 
doxical as it may appear, when it is 
irritated and aggravated, and, as it 
were, weep's tears of pus, then its 
venom is gone, and it gives rise only 
to a little sore, which soon passes 
away. 

Really, the evolution of syphilis be- 
gins at the moment the germ (or what- 
ever it may be) is imbibed, whether 
it be through an abrasion, or through 
the soft and moist and delicate tissues 



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where they are generally located. 
There you see it, and you can count 
upon twenty-one days or more since it 
was conceived. It has played its role ; 
it has matured and given birth to the 
tragedians, who exclaim: '*All the 
world is a stage" for us. 

As we approach the third act of the 
drama of syphilis, memory takes me 
back to the scene at Hell Gate some 
years ago. For years General Newton 
had, silently and almost unbeknown, 
an army of laborers below the bed of 
the river, working like beavers, drill- 
ing through solid rock in every direc- 
tion, making innumerable passage- 
ways, which were filled with dynamite, 
and through them all, wires were laid. 
When all was ready, a child pressed a 
knob connecting the electric wires, and 
that mighty explosion took place, rais- 
ing mountains high, acres of water, 
and the terrible roar shook the earth 
for miles. Then the work was over, 
and Hell Gate was shorn of its hor- 
rors. The explosion which takes place 
in the third act of the drama of syphi- 
lis is far different. Demons that have 
been maturing are then let loose, and 
verily! hell itself cannot be more 
horrible than is this vindictive disease 
to many who are in its grasp. 

The first demon set free in the third 
act of the drama, is one called Hypo- 
chondria — a melancholy actor, who 
throws the victim into a state of great 
mental and physical depression. 

Then the second actor, known as the 
demon Anemia, puts in an appearance, 
and attacks the vital fluid — feeding on 
the red, disdaining the white cor- 
puscles. Thus, the heart's action is 
involved, the pump works less vigor- 
ously and intermits and palpitates. 
The oxygenation of the fluid is inter- 
fered with, and consequently the vic- 
tim gasps for breath, and respiration 
becomes laborious. 

Then appears another misanthropic 
actor with sallow visage, known as the 
demon Indigestion. It would be safe 
to place before the victim the choicest 



viands, for, like Tantalus, he cannot 
tQUch them. 

In women the demon Amenorrhea 
appears and adds to her woes ; some- 
times it gives way to one called Menor- 
rhagia, but too often, during this act 
of the drama, she conceives, and the 
poor offspring, cursed by the sins of 
its progenitors, will have all the char- 
acteristics of the third act of the drama 
of syphilis. 

The demon Fever plays a varied role, 
being often mistaken for the quotidian 
type of malarial fever, with nocturnal 
exacerbations. 

Cephalalgia is the name of a vindict- 
ive demon, who places the victim on 
the rack, and, as it were, bores holes 
into his brain, and makes him yell with 
anguish. It will sometimes vanish 
during the day, but it is sure to return 
at night. 

The little demon, Sternalgia, grasps 
the victim by the throat and calls to its 
aid — the actor. Asthma. 

Vertigo makes the victim reel to and 
fro like a drunken man, and makes it 
appear to him as if he were a pivot, 
with all sorts of fantastic objects 
circling his head. This demon is gen- 
erally accompanied by one called 
Nausea. 

Strabismus cocks the eye and gives 
the victim a comical or sinister aspect. 

Arthralgia loves to toy with the 
larger joints, such as the shoulder, el- 
bow and knee joints. 

Rheumatism is booked for a long 
role, but, like all actors, loves to play 
at night. 

Alopecia now puts in an appearance, 
and if the victim has any personal 
beauty, it deprives him of it. Very 
often it gives him a pie-bald appear- 
ance. The hair emcircling the bald spots 
standing up in every direction. It also 
takes away his eyebrows, giving him a 
ludicrous appearance, and also a sure 
sign to all the world of the nature of 
the disease. Sometimes it removes 
every hair from his body — from the 
crown of his head to the sole of his foot. 



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Third Act in the Drama of Syphilis—Robbins, 57 



Demons come and go over the prom- 
inent parts of the skeleton, called 
Osteocopii, forming nodes sometimes 
and giving rise to pains terrific. 

Sometimes, and not infrequently, 
the drama is tame and uninteresting, 
and the third act is only ushered in by 
the appearance of Erythema, whose 
presence on the stage is a sure indica- 
tion of constitutional syphilis. 

I will now call your attention to pa- 
tient's illustrative of the third act of 
the drama of syphilis. 

Not long ago I presented to you two 
patients, which gave you a better idea 
of the evolution of syphilis than you 
could have attained by years of read- 
ing and studying of venereal atlases. 
One patient was a young pure-blooded 
African. The jnitial lesion was located 
on a long prepuce, just at the mucous 
fold. It was of the papular variety of 
Fournier, being on a sort of **raised 
plateau." There were cord-like lym- 
phatics extending to the bubo, and he 
was covered with a papular syphiloderm 
with a serpaiginous circle on his fore- 
head and mucous patches in his mouth. 

The other patient was a young white 
man of light hair and blonde complex- 
ion. The initial lesion was supposed 
to be on the mucous surface of the 
prepuce, which was long and edematous. 
A V-shaped-piece had been cut out, 
but no chancre or chancroid could be 
found, but the bloody serous discharge 
from the meatus .was indicative and 
diagnostic of urethral chancre. As 
with our other patient, there was the 
**ribbon" of lymphatic vessels leading 
to a bubo. This patient had a bubo 
in each groin, which as in the preced- 
ing case did not suppurate. From 
head to foot he was covered with 
roseola. With the white patient the 
demons Cephalalgia and Rheumatism 
were most persistent. He also had 
double iritis. 

Several years ago I was summoned 
in the greatest haste to a man who 
had suddenly fallen. A physician, 
who had also been called, had pro- 



nounced the case to be one of apo- 
plexy. I had attended the man, how- 
ever, who had chancroids that were 
phagedenic, and there was a suspicious 
discharge, similar to that found in 
urethral chancroids. I was awaiting 
the development of roseola before 
placing the patient on constitutional 
treatment. The man's habits were 
those of a **bon-vivant," and he was 
constantly under the effects of alco- 
holic stimulant. Here, then, was the 
stage of ''general explosion" of the 
third act of the drama of syphilis that 
I had to deal with. The patient be- 
came maniacal, and delusions, at times 
ludicrous, and pathetic at others, fol- 
lowed each other. It became neces- 
sary to send him to friends who re- 
sided two days distant by rail. He was 
placed in charge of a gentleman who, 
fortunately, was a man of great phys- 
ical strength, and who had been for- 
merly a sailor by occupation. At night 
when the train was speeding along at 
forty miles an hour, the patient darted 
out of the car, followed instantly by 
his attendant. The patient attempted 
to jump off the car, and had partially 
succeeded, when he was grabbed by 
the collar and dragged back, and then 
began the struggle on the platform of 
the rapidly moving and swaying car. 
The description given by the gentle- 
man who succeeded in conquering the 
maniac and dragging him back into the 
car was the most blood-curdling one 
that I ever listened to. After this 
episode, several knockdown arguments 
had to bo used before they arrived at 
the end of their journey. This pa- 
tient gradually improved, but it was 
fully three months before he was re- 
stored to his customary mental equi- 
librium. The history of his paramour 
was very similar. She was sent to the 
Hot Springs of Arkansas, the Mecca of 
those who *'live not wisely, but too 
well." Then she became an inmate of 
a mad house, and finally death put an 
end to a checkered career. 

In these cases, the demons that were 



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68 



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set free were aggravated by the arch 
demon Drink, which, sooner or later, 
brings most of its victims to the grave 
or asylum. 

You will remember that in a large 
per cent, of cases the disease is ac- 
quired in an innocent way. 

ELEPHANTIASIS IN JAPAN. 

By Albsbt S. ASHif bad, M. D., New York. 

Note. — I recently published a com- 
munication in the New York Herald^ 
February 8, 1903, relative to the in- 
creasing occurrence of cases of ele- 
phantiasis in different parts of the 
United States. I pointed out the con- 
nection between culex fatigans and 
elephantiasis. I suggested the advis- 
ability of our health authorities com- 
pelling elephantiac patients to be kept 
isolated under mosquito nets during 
the night to prevent contamination of 
our own breeds of mosquitoes, or 
propagation by the imported West In- 
dian breed. I sent a copy of this pub- 
lication to Prof. L. O. Howard, of 
Washington, and received a letter in 
reply as follows : 



..I 



*'U. S. Dept. of Agriculture, 

DIVISION OF entomology. 

Washington, D. C, 
February 10, 1903. 
My Dear Dr. Ashmead: — I have 
your letter of the 9th inst. Culex fat- 
igans is known in the U. S. and has 
been recorded from Massachusetts, 
Maryland, District of Columbia, New 
York, Illinois, Minnesota, Nebraska, 
Kentucky, Texas, Virginia, New Jer- 
sey, Connecticut, and is well known 
in the West Indies as well as in India, 
Australia, South America, East and 
West Africa. I am much interested 
in your newspaper article. The dis- 
tribution of culex fatigans is so gen- 
eral that I should think that elephan- 
tiasis might spread almost anywhere 
in the United States. 

Yours very truly, 

L. O. Howard.'' 



Culex fatigans is the mosquito which 
is infected with the filariasic and ele- 
phantiasic germ in Barbadoes, West 
Indies. And from the peculiarity of 
distribution of the species in the 
United States, it would appear that it 
has been imported to our Atlantic 
coasts, and to the Mississippi and Mis- 
souri rivers by way of New Orleans. 
If such is the case it is reasonable to 
assume that some of these importa- 
tions contained the germs of filariasis 
and elephantiasis of infected Barba- 
does. Hence it is of utmost impor- 
tance that in those states where culex 
fatigans is recorded, elephantiac pa- 
tients when found should be protect* d 
at night from mosquitoes to prevent 
continued spread of this disease. 

Besides this, there is another danger 
from these mosquitoes, which evidently 
have been imported from Barbadoes, 
as will be seen from the following let- 
ter published in the Hoboken, New 
Jersey, Observer^ February 16, 1903: 

Danger of Leprosy From 
Mosquitoes. 

Sir: — In your allusion in the Ob- 
server^ February 9th, to my communi- 
cation on the question of elephantiasis 
and mosquitoes, in the New York 
Herald^ you congratulate the people 
of your state on the fact that culex 
fatigans, the host of the germ of this 
disease, is not a native of New Jersey. 
I beg to inform you that you are mis- 
taken. Professor Howard, of Wash- 
ington, writes me that the insect is re- 
corded from New Jersey. 

Allow me the further observation 
that this germ, in my opinion, is the 
cogener, so to speak, of the germ of 
leprosy. And it is also the belief of 
a good many eminent leprologists that 
leprosy, too, is transmitted by some 
mosquitoes of leper countries. 

My own opinion for a number of 
years has been that leprosy has two 
intermediary hosts, which operate to- 
gether: fish and mosquitoes. The mos- 
quito having sucked the blood of a 



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Elephantiasis in Japan— Ash mead. 



09 



leper carries the spore ( not the bacil- 
lus) to the water, where he finally 
dies. His dead body, or the larvae, 
are eaten by the fish, which in turn is 
eaten by human beings, who in this 
way may become inoculated with the 
spores of leprosy. Of the spore life 
of the leper bacillus, outside the hu- 
man body, there is hardly anything 
known. But many leprological schol- 
ars are at present at work on the prob- 
lem. That there is a period of spore 
life to the bacillus after inoculation in 
the human being is suspected because 
of the long, latent period of incubation 
of the disease, and because the leper 
bacillus is not found in human blood. 
We have no means of recognizing the 
spore, which might occupy the blood 
current, but our microscope and stain- 
ing process tell us that the bacillus is 
not there. At all events there is great 
probability of leprosy also being trans- 
mitted by the * 'Jersey'* mosquito if 
once he should become inoculated with 
the spore of the lepra bacillus. 
Very sincerely yours, 

Albert S. Ashmead, M. D. 
New York, February 14, 1903. 

1 . Some General Considerations. — 
Man, indeed, being omnivorous, can of- 
fer a place of habitation to the para- 
sites, both of herbivorous and of car- 
nivorous animals. It must be observed 
that an immense majority of these 
parasites is furnished to man by the 
domestic animals, which is accounted 
for by the frequency of our relations 
with these animals, and their impor- 
tance in our alimentation. Concern- 
ing the manner of attack and of evolu- 
tion of the parasites, the following 
classification may be made: First of 
all, they are naturally divided into two 
large sections: internal parasites, or 
endoparasites, and external parasites, 
or ectoparasites. The latter are again 
grouped according to the degree of 
their pai'asitism. Some are free or 
temporary parasites, that is,living upon 
their host only when they come to 



feed at his expense, and leaving him 
again, or at least being susceptible of 
leaving him, in order to live freely : such 
are the tabanidse (gadflies), the mus- 
cides (flies), the hyppoboscides, the 
simuliides (biting gnats), etc., among 
the insects; the dermanysses (derma- 
tozoa) and the argas (ticks) among the 
acarians. They attack men under the 
same conditions as animals do, and, 
consequently, do not deserve to be 
classified as parasites. There is no 
other means of avoiding them, but 
keeping clear of the localities which 
they prefer, or of the animals to whom 
they are partial, even of the places 
where these latter dwell. 

The other external parasites, called 
stationary, remain permanently on the 
host, as soon as they have established 
themselves. There are those among 
them who live in freedom during a cer- 
tain period of their existence, whose 
parasitism is a periodical one — oestridee 
(bot flies), chiques, inodes, strambidi- 
ons, etc. To these the same indications 
apply as the preceding; for if they 
show themselves always in greater 
abundance in the places frequented or 
inhabited by their habitual hosts, it 
happens seldom that they pass from 
the animals to man. 

There are also external stationary 
parasites, which are subjected to the 
parasitic condition from their hatching 
to their death, and thus present a 
permanent parasite. This is the case 
with the sarcoptes scabiei, sarcoptes 
minor and the demonden. With these 
parasites, direct, immediate transmis- 
sion predominates by far. 

Regarding too the internal parasites, 
the habitual mode of transmission 
is mediately through aliments and 
beverages. Among these are the coc- 
cidae, the balantidium, divers tenias, 
the distomata, the ascarides, the 
stronggles, thefilaria^ thelinguatules, 
etc. In most cases it is evidently 
water that serves as vehicle, so that, 
for the common parasites, as well as 
for the microbes, the question of pot- 



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able waters is of essential importance. 
The distomata, however, may be in- 
troduced into the human system with 
vegetable aliments, when the latter are 
ingested raw. Some internal para- 
sites, too, are directly transmitted by 
the animals themselves, with whom 
man lives too intimately; the echin- 
ococci transmitted by the dog, for in- 
stance. 

Immediate transmission also takes 
place between the animal and man, in 
the case of taenia solium, tasnia sagi- 
nata, bothriocephalus latus, trichina 
spiralis, ete. In elephantiasic or fil- 
arial diseases of man the connection of 
the mosquito as an intermediary host, 
in the full life development of the 
hematozoon, filaria sanguinis hominis 
has been fully and conclusively made 
out by Dr. Patrick Manson, of Amoy, 
China, in the Customs Medical Re- 
ports, published in Shanghai by order 
of the Inspector-General of Customs. 
Dr. Manson discovered the parent 
filaria in the mosquito in 1878, and 
has since published several admirable 
articles, giving the results of his ex- 
periments, which in the main were in- 
dependently confirmed by Dr. Mac- 
Kenzie, of the London Pathological 
Society ; Lewis, of India ; Myers, Cob- 
bold, Wucherer, Bancroft, Araujo 
and others. These facts having an 
entomological bearing and being of 
great scientific interest and practical 
importance, were classified by Dr. 
C. V. Riley, entomologist of the U. S. 
Agricultural Department, Washington. 
As they were given to me in 1886 by 
Prof. Riley, and as I take them briefly 
from my notes which I made at that 
time, they are as follows: In 18^^ 
Lewis announced the discovery of im- 
mature or larval hematozoon in the 
blood and urine of persons afflicted 
with chyluria, and he named it filaria 
sanguinis hominis. The mature form 
was first described by Cobbold as 
filaria Bancrofti in 1877. As found 
in the lymph, the parent filaria emits 
its young in the lymph stream. The 



young makes its way from the lympb 
to the blood, where it undergoes no 
growth or development. In this its 
newborn state it is enclosed in a deli- 
cate, transparent, rather loose tunic or 
cyst, and is found in the blood of pa- 
tients affected with elephantiasis, but 
only during the night. This disease is 
manifested in a thick, tuberculated and 
insensible condition of the skin akin to 
leprosy. It is endemic over the more 
thickly populated and tropical portions 
of the globe, and in its various forms 
is very painful, resulting in deformity 
and not infrequently in death. The 
best authorities now believe that vari- 
ous diseases of the lymphatic vessels 
and glands, as varicose groin glands, 
lymph scrotum, elephantiasis and 
chyluria are pathologically one and 
the same disease, and are due to the 
presence of this filaria, which has, 
in fact, been recorded from South 
Europe, Asia, Australia and Brazil. 
Dr. Araujo has verified at Bahia its oc- 
currence in the mosquito and otherwise 
confirmed the observations of Manson 
and others in different parts of the 
world. Before the young filaria can 
undergo their full development, they 
must first enter the body of the female 
mosquito (culex fatigans), which sucks 
them up in her nocturnal attacks; 
within the mosquito they develop in 
from five to six days, and upon the 
death of their host or before passing 
into water frequented by the mosquito 
for purposes of oviposition and are 
thus returned by drinking to the hu- 
man stomach, from which they make 
their way into some lymphatic vessel, 
where the sexes meeting, the female 
remains perhaps for years, giving birth 
to active young. Dr. Manson, in the 
Customs Medical Reports, March 31, 
1882, gives the results of some later 
observations which are full of interest. 
It seems that the periodicity in the 
filarial disease has no connection, either 
with temperatures, atmospheric press- 
ure, or light, but must be looked upon 
as an adaptation of the habits of the 



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Elephantiasis in Japan—Ash mead. 



61 



parasite to those of the mosquito. 
The conditions for the ingress of the 
filarise into the circulation appear to 
be developed ordinarily during the last 
few hours of the waking state, and 
the parasites are eliminated during the 
last few hours of sleep. Under ordi- 
nary conditions of sleeping or waking, 
the embryoes enter the circulation every 
evening, increase until midnight and 
diminish as morning approaches, until 
they entirely disappear, and are not 
found from 9 a. m. to 6 p. m. This 
periodicity of the parasite is independ- 
ent of parturition in the parent, as re- 
production is continued during the 
twenty-four hours. The importance 
of thus tracing to their true source 
diseases whose origin has long been 
involved in mystery cannot be over- 
estimated ; and these facts would seem 
to give additional reasons for the 
filtering of drinking water, and the 
use of mosquito-nets in all tropical 
climates. Dr. Manson suggested that 
the facts ascertained in this connection 
may lead to a possible future explana- 
tion of the diurnal intermission and 
remission of fevers of the ague class. 
The most interesting conclusions that 
have been forced upon Dr. Manson 
are that the presence of the parasite 
in the human body does not always or 
necessarily produce disease, and that 
when disease is produced, it is by ex- 
ceptional oviparous reproduction, in- 
stead of the ordinary viviparous mode. 
His conclusions were as follows: 
In the instance in which the parent 
worm has been discovered, she was 
found in lymphatic vessels on the dis- 
tal side of the glands. This has been 
shown to be in many,if not in all, cases 
her normal habitat. Her progeny, 
therefore, must travel along the af- 
ferent vessels, through the glands, 
and so on to the thoracic duct, and 
thence into the blood. The lang, sin- 
uous and powerful body of the em- 
bryo is well adapted to perform this 
journey. But suppose instead of this 
mature embryo an ovum is launched 



into the lymph stream prematurely, 
and before the contained embryo has 
sufficiently extended its chorion, then 
this passive ovum must certainly be 
arrested at the first lymphatic of the 
lymph current. It measures 1-750" 
and 1-500", whereas the outstretched 
embryo is only about 1-3000" in di- 
ameter. It is much too large to pass 
the glands, and the embryo rolled up 
in its chorional envelope cannot aid 
itself. It becomes in fact an embolus. 
Now, filarisB are prodigiously prolific; 
myriads of young are expelled in a 
very short time. Professor Riley has 
watched the process of parturition in 
the minute corvi torquati. Every few 
seconds a peristaltic contraction, be- 
ginning low down in the interior horns 
and extending to the vagina, expels 
some twenty or thirty embryoes. If 
this process of parturition occurs pre- 
maturely, or peristalsis is too vigorous 
and extends to a point high up in the 
uterine horns where the embryo has 
not yet completely stretched its 
chorional envelope, then ova are ex- 
pelled. These, as they reach the 
glands, where the afferent lymphatic 
breaks up into fine capillary vessels, 
act as emboli, and plug up the lymph 
channels, one after another. In this 
way the gland or glands directly con- 
nected with the lymphatic in which 
the aborting female is lodged are thor- 
oughly obstructed. Anastomosis for 
a time will aid the passage of lymph, 
but the anastomosing vessels will carry 
the embolic ova as well as the lymph. 
The corresponding glands will then in 
their turn be invaded, and so on until 
the entire lymphatic system, directly 
or indirectly with the vessel in which 
the parent worm is lodged, becomes ob- 
structed. This is the true pathology 
of the elephantoid diseases: First, 
parent filarise in a distal lymphatic; 
second, premature expulsion of ova; 
third, embolism of lymphatic glands 
by ova; fourth, stasis of lymph; fifth, 
regurgitation of lymph and partial 
compensation by anastomosis; sixth, 



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renewed or continued premature ex- 
pulsion of ova; further embolism of 
glands. This process, according to 
the part of the lymphatic system it 
occurs in, the frequency of its recur- 
rence and its completeness, explains 
every variety of elephantoid disease. 

2. Elephantiasis in Japan, — Ele- 
phantiasis in Japan is characterized as 
a local disease of tropical or semi- 
tropical regions. It is known to be 
caused by filariasis, either chyluric or 
hematic, and by obstruction of the 
lymph passages. The Japanese phy- 
sicians know that it existed in Egypt 
since very remote times, and that it is 
found to-day in the West Indies, South 
America, East Indies, West Africa, 
Arabia, Samoa and the Fiji Islands, 
as well as in Japan and China. *'Bar- 
badoes foot" it is sometimes called, 
because Barbadoes, West Indies, was 
the original seat of the disease. The 
disease is most prevalent in Japan in 
the localities where are found the most 
lepers. This is in keeping with what 
is known of its occurrence in other 
situations. For instance, according to 
Rev. Mr. Turner, a missionary in the 
West Indies, fully fifty per cent, of 
Ihe inhabitants of those islands suffer 
from elephantiasis. There are, be- 
sides, many other places where about 
ten per cent, of the population are at- 
tacked by it. In Japan it is leprous 
Kiushiu, and especially Sai-Nan dis- 
trict of Kumamoto prefecture, the 
most leprous province of Japan, that 
has the most elephantiasis. There 
lire, according to Kitasoto's statistics, 
2473 known lepers in Kumamoto. 
Elephantiasis prevails in leprous Abe, 
Kaseda region, Kumake district; on 
Yaneko island, of Kagoshtma prov- 
ince, where there are recorded 691 
lepers; and in Minami, Matsubara 
district of Nagasaki province, where 
there are registered 769 lepers. Wher- 
ever lepers are congregated there are 
the most elephantiacs to be found. 
Outside of Kiushiu it is also met with, 
but in less numbers. For instance, in 



Banta district of Doshu; in Oki island, 
of Shimane prefecture, where there 
are known to be 313 lepers ; in Shu- 
sami village of Kishu ; in Oshiraa, of 
Zushu; in Misaki, city of Soshu, 
where there are 900 lepers; in Eiu- 
kiu and Formosa islands — all situa- 
tions scourged by leprdsy. There are 
also seen more or less cases of ele- 
phantiasis in other localities of Japan, 
but the causes are thought to be dif- 
ferent in these than, in those above 
mentioned. 

Elephantiasis in Japan is commonly 
called '*oashi" (large foot), or **koe- 
ashi'* (fat foot). In Kumamoto 
province the appearance of the '*tan- 
doku" (copper-colored poisoning) is 
called **kusa-furu" (literally: shak- 
ing of grass). 

In Kagoshima prefecture, elephan- 
tiasis of the lower limb is called '*shune- 
buto" (leg fat), and that of the 
scrotum '*ogintama" (large testicle); 
and the appearance of the copper-col- 
ored poisoning is called, from its sim- 
ilarity, '*buku-kusa-furu" or simply 
**kusa-furu" (shaking of grass). 

The disease attacks more readily 
peasants and fishermen who live near 
the sea-shore, than the inhabitants 
living further inland. Persons who 
live in the interior are very liable, 
while traveling through the regions 
where the disease mostly prevails, to 
be attacked by it. There are no 
statistics ascertainable as to the exact 
ratio of inhabitants attacked. But 
the best authorities do not agree with 
Dr. Larrey's statement, that ten per 
cent, of Japanese are afllicted with 
elephantiasis. Where investigations 
have been made, persons suffering 
with the disease were found to be 
almost exclusively peasants and fisher- 
men, or of poor people who were 
forced to live near the sea-coast. 
From information obtained from local 
physicians and from other reliable 
sources, more males are liable to be 
attacked than females and children. 

The part of the body most generally 



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4ittacked is the lower limb, one or 
both. Next to this in frequency is the 
scrotum or penis. It rarely develops 
on the upper limbs or breast, and most 
rarely on face, head, fingers, or shoul- 
der and arm. Sometimes it attacks 
only a limited part of the skin, which 
becomes pendulous, like a sack. Local 
developments may appear simultane- 
ously on a lower limb and the scrotum^ 
or on a lower limb and the breast. 
When it develops on a lower limb, 
scrotum or penis, considerable lym- 
phatic glandular engorgement is seen. 
This is usually of a hard consistency, 
but sometimes a softened one presents 
itself. Development of elephantiasis 
on upper limbs or breast is invariably 
accompanied by axillary engorge- 
ment; on the face and head, by cer- 
vical engorgement. The proportion 
of elephantiasis development on the 
lower limb, according to Japanese 
statistics, is ninety-five per cent. 

The symptoms of elephantiasis in 
-Japan are similar to those of the trop- 
ics. It begins with chilliness or shiv- 
ering, followed by fever. The parts 
affected are markedly red and swollen, 
and the neighboring lymphatics show 
inflammatory dilatation. The fever 
subsides in two or three days, leaving 
on the skin an inflammation which, 
during the subsidence of the fever, 
vanishes more or less, but not entirely. 
The fever repeats itself three or four 
times a month, but usually the returns 
occur three or four times a year. As 
the fever is repeated the affected parts 
increase in inflammation, and the 
lower limbs gradually **get fat,'* as 
the Japanese call it, thus showing a 
hard, «*elephant-foot-like" tumor. 

The scrotum increases in bulk, reach- 
ing to several <'tens of pounds'* in 
weight, and not infrequently to such 
an extent that its lower portion touches 
the ground. Violent exercise or in- 
jury of the affected parts brings back 
the fever. The skin of the affected 
parts sometimes appear smooth, at 
other times rough, or milky looking 



inflammation. In general, it is of hard 
consistence. But on the scrotum it is 
usually soft, which is due, perhaps, to 
the fact that here the elephantiasic 
process occurs by lines and roots in a 
portion already pendulous. The scro- 
tum development is frequently accom- 
panied by hydrocele. This was noted 
by one doctor three times out of forty- 
three cases. The secretion of water 
did not differ from ordinary hydrocele, 
and microscopic examination of the 
contents revealed no filarial germ. The 
elephantiasic portions in these cases 
did not present the tense sensation, or 
feeling of pressure, nor the character- 
istic ''fattening." In one patient, an 
old woman, who had already ''fatten- 
ing" apparent of the labia and lower 
limb, on closer examination showed that 
the growth had not developed on one 
side of the leg as much as on the other. 
The cause of this was found to be that 
she had habitually sat in the Japanese 
fashion, squarely and closely, so that 
the inner sides of the limbs had pre- 
vented the growth, while the outside 
alone showed characteristic "fatten- 
ing." 

Elephantiasis in Japan is not caused, 
in the opinion of Japanese physicians, 
by an obstacle to the lymph pass- 
age. But it is thought that it is proba- 
ble that the copper poisoning-like in- 
flammation of elephantiasis is due to 
the development of elephantiasis in the 
obstructed passage of the gland, where 
the lymph accumulates. 

The cases of chyluric disease in con- 
nection with elephantiasis in Japan are 
very rare. Only one such case was 
met with in forty-three elephanti- 
acs, and in not one case was the filarial 
germ found in the blood of patients 
suffering with pure elephantiasis. The 
duration of the disease in acute cases 
consumes several decades, but death 
directly from the disease hardly ever 
occurs. 

3. The Connection Between Filaria- 
sis and Elephantiasis. — The cause of 
chyluria, the usual effect of filariasis. 



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was discovered by Deraarquay in 186&, 
by a scrotum inflamed and filled with 
water of chyluric character. It was 
the filarial germ. This germ was first 
seen by Wuchurer, in Bahia, Brazil, 
in 186G, in the urine excreted by a 
chyluric patient. Subsequently, in 
1870, it was found by Lewis, of Cal- 
cutta, India, in the lymphatic glandd 
of an elephantiasic patient afilicted in 
the foot and scrotum, and also in the 
blood of a hemato-chyluric patient. In 
1872 Lewis thought that the usual 
abode of this germ was in the blood, 
and gave it the name of fiiaria san- 
guinis hominis. Subsequently Patrick 
Mansonmadean investigation on fiiaria 
Bancrofti, the mother germ, and con- 
cluded that its abode was in the lym- 
phatic vessels. Further, he explained 
that the medial host of this germ was 
the male mosquito, which sucks the 
blood infected with the germ, and then, 
in six or seven days, causes metamor- 
phosis, resulting in a body one-six- 
teenth inch long. If we suppose that 
the human blood filariasic germ, like 
other parasitic organisms, requires a 
medial abode, it is to be inferred that 
the disease was contracted by man 
through drinking or bathing in water 
which conveys the germ developed in 
the body of the mosquito or louse; or 
it might be that the germ escapes with 
the excretions of the patient, soaks in 
the ground, and then, in the presence 
of moisture or water, effected a cer- 
tain metamorphosis and finally entered 
the human body through some medium. 
In Japan the urine of every place is 
saved, collected in barrels and allowed 
to stagnate, decompose, for the pur- 
pose of manuring rice fields. Nothing 
in Japan is thought to be so valuable 
as a manure as rotten urine. It could 
very well become the source of con- 
tagion or intermediary transmitter of 
a host of diseases. And in the case of 
chyluria is probably a frequent means 
of infecting other insects than the 
mosquito with the germ of elephan- 
tiasis. 



Later Patrick Manson reported that 
the blood germ of filariasis, whick 
took up its abode in human blood, wfis- 
not the only kind to which Lewis had 
given a name, but that there were sev- 
eral kinds, four or five, and probably 
more. Thereupon, he gave the new 
name fiiaria nocturna to what had been 
known before as the filariasic germ» 
To the other five kinds of germs he 
gave the names fiiaria diurna, fiiaria. 
perstans, fiiaria Demarquaii, fiiaria Oz- 
zardi and fiiaria Magalhaes. 

Fiiaria nocturna, as is well known, 
appears, according to the condition of 
the host's body, in the arterial blood 
vessels only during the night. Fiiaria 
diurna exists in Western Africa, and 
appears in the blood vessels during^ 
the day and vanishes in the night. 
These two germs are almost of the^ 
same size, and are similar to each 
other, 

Fiiaria perstans exists to a large ex-^ 
tent in Western Africa, and has no 
covering membrane. Its size is about 
one-half of that of the former two, 
and appears in the blood current dur- 
ing both night and day. 

Fiiaria Demarquaii is found in the 
West Indies and New Guinea, and is 
almost the same size as that of fiiaria 
perstans. Its posterior part, however, 
ends in a sharp point, giving a tail-like 
appendage, and appears to be destitute 
of covering membrane. This germ 
appears also in the blood during both 
day and night. 

Fiiaria Ozzardi was discovered in the 
blood of natives of British Guiana, 
South America, and is nearly the same 
size as that of the last two. It has 
no covering membrane, and exists^ 
in the blood vessels during both day 
and night. This germ is of two kinds, 
the one sharp-tailed, the other blunt- 
tailed. Whether these two kinds may 
be considered as belonging to the same 
species or not, is a question. 

Again, the opinion that the sharp- 
tailed one is the Demarquaii germ, and 
that the blunt-tailed one, f . perstans^ 



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is not yet ascertained. The other 
opinions, that filaria Magalhaesi is 
the germ having sexual distinction, 
discovered by the Rio Janeirian Ma- 
galhaes in the left ventricle of the heart 
of a dead child, and that it is wholly 
distinct from Bancroft's filaria; and 
that, since its discovery in human blood 
of the western hemisphere, filaria De- 
marquaii is the grown germ of filaria 
Ozzardi, have not been proved. 

Of all the germs above mentioned 
filaria nocturna is the one most ex- 
tensively found. Its probable mother 
germ, or Bancroft's filaria, was dis- 
covered for the first time in the sub- 
dermic layer of the armpit. After- 
wards it was found by Lewis in 
coagulated blood of an elephantiac 
patient who had the characteristic 
dilatation of the lyniphatic vessels. 
Its length is about 38 mm. and thick- 
ness that of a hair. C. W. Daniels 
ascribes the diflSculty of distinguishing 
the grown germ to the uncertainty of 
its abode, the minuteness of its size 
and similarity of its appearance to that 
of the oth,er germ. Mansop holds the 
opinion that although the grown germ 
may exist in the blood, it does not 
invariably produce the disease. This 
seems to be true from the fact that 
when he examined the blood of eighty- 
eight healthy natives of Cochin China, 
for Surgeon Elcum, he found twenty 
specimens out of seventy-four of 
healthy blood to be infected with filaria 
nocturna. The other fourteen speci- 
mens of blood were found to be those 
of elephantiacs, and in these there was 
only one that was free of the germ, 
from which he inferred that the pres- 
ence of filaria in the blood was not 
always proof of filariasis, nor absence of 
it freedom from the disease. However, 
it may be explained by supposing that 
the filariasis is caused by obstruction 
to the lymphatic passage and grown 
germs often die without leaving off- 
spring. 

In Japan the diseases which are 



classed as filariasis are, inflammation of 
lymphatic glands, tumor of glands, 
tumor of armpit, lymph scrotum, dila- 
tation of dermic and subdermic lymph- 
atic vessels, hydrocele, chyluria, dis- 
charge of chyle by the bowels, and 
hemato-chyluria. 

Local elephantiasis, in accordance 
with the views of Magalhaes,Wucherer 
and Manson, is also called filariasis. 
Turner's view, that elephantiasis is 
caused by the malarial germ, is not be- 
lieved in. The reason that Manson 
classed elephantiasis as filariasis is not 
only that the grown germ is found in 
the blood of elephantiacs, but because: 
1. Filarial infected localities are also 
infected by elephantiasis; wherever 
there are most filariacs, there are found 
also the most elephantiacs. 2. The 
dilatation of lymphatic vessels, char- 
acterizing filariasis, is also seen in 
elephantiasis, and frequently appear 
simultaneously . 3 . Lymph-scrotum , 
undoubtedly filariasic, is often accom- 
panied by scrotal elephantiasis. 4. Bar- 
badoes leg sometimes follows an oper- 
ation on lymph-scrotum. 5. Elephan- 
tiasis and dilatation of lymph-vessels 
both belong to disease of the same 
system, the lymphatics. 6. Character- 
istic filariasis, dilatation of lymphatic 
vessels and true elephantiasis both 
show symptoms that accompany the 
repeated occurrence of inflammation of 
lymphatic vessels. 7. The cause of 
the characteristic dilatation of lymph- 
atic vessels of filariasis has been traced 
to the filarial germ, and elephantiasis 
often simultaneously appears with it 
and must have a close connection with 
that germ. Hence it is fit to ascribe 
the same cause for both diseases. 

Manson gave as reason for not find- 
ing filaria in the blood of a majority of 
elephantiacs, that the lymphatic vessels 
which convey lymph from the affected 
part of the' body were obstructed. 
Thus further infection was prevented. 
It has since been shown that the imma- 
ture germ produced the obstruction. 



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Dr. Honda, of Japan, believes that both 
the mature mother germ and the ova 
play a part in the obstruction. 

The cause of elephantiasis in Japan, 
as in other tropical countries, is be- 
lieved to be filariasis. But some phy- 
sicians doubt that the local elephan- 
tiasis is characteristic of that disease. 
There are several opinions held in 
Japan as to the cause of this type of 
elephantiasis, such as heredity, syph- 
ilis, the independent germ theory and 
filaria. But none was proved nor was 
it ascertained by examination of the 
affected skin, or by the discovery of 
filaria in the lymphatic vessels. Thus 
far, discoveries worthy to be referred 
to have been made by Doctor Otani, 
of the Nagasaki Hospital, who found 
filaria in the biood of two patients, 
one of whom was affected simulta- 
neously by elephantiasis and filariasis 
of the scrotum, the other by elephan- 
tiasis alone. Another case of reference 
relates to investigations made by Doc- 
tor Wayuchi on three patients who had 
both diseases simultaneously on Oki 
Island. 

The hereditary theory as the cause 
of the disease is based on the fact that 
members of the same family are par- 
ticularly liable to contract the disease, 
which indicated to the Japanese that 
the primary cause might be trans- 
mitted and received by blood relation. 
They did not take into account the 
probability of local mosquitoes becom- 
ing affected by the sick member of the 
family and the community afterwards 
through drinking water. 

Moncorvo, of Rio Janeiro, has re- 
ported three cases of congenital ele- 
phantiasis. Scheube expressed doubt 
as to the possibility of congenital 
transmission of filaria characterizing 
elephantiasis. Doctor Honda exam- 
ined some cases but saw nothing that 
would indicate the possibility of hered- 
itary transmission of the disease. Nor 
did he meet with an instance of one 
member of the family affected after 



the other. In Japan, however, there 
are on record two cases where mar- 
riage of daughters of elephantiac 
parents had been followed by develop- 
ment of the disease. But this is not 
thought to be due, necessarily, to he- 
redity, for it is well known that trav- 
elers who pass through infected local- 
ities are contaminated with the dis- 
ease. The theory of syphilis as a 
cause of elephantiasis is dismissed 
from the medical mind of Japan, 
without argument. Its support is of 
the weakest kind. The germ theory 
as a cause is said to have been held by 
the late Doctor Yashuo. 

In an article, * 'Investigation of Fila- 
riasis,'* by Doctor Jamura, of Japan, 
who studied elephantiasis in Kiushiu, 
he describes its cause as filariasis. 
But, generally, the opinion is held that 
the exact nature of elephantiasis there 
is yet unknown. 

Dr. Honda, of the Japanese navy, 
has investigated elephantiasis along 
the sea-coasts of his country in many 
localities. He studied first filariasis, 
to fiod out the relationship between 
it and elephantiasis. In Amakusa 
island, he had twenty doubtful cases, 
of which sixteen proved subsequently 
to be elephantiasis. In Kagoshima 
prefecture, he had twenty-seven cases, 
in all forty-three cases. Among them 
about four-fifths were over forty years 
of age. He explained this fact by the 
plea, that the young men and women, 
from fear of exposure of their infirm- 
ity, would not come to his dispensary 
where they might meet strangers. 
Hence age could not be taken into ac- 
count in his investigation. Of these 
forty-three patients, there were thirty 
men and thirteen women. Their oc- 
cupation was peasants, next in frequen- 
cy fisherman, and only one merchant. 
Three of them had scrotal elephantia- 
sis. The character of the fluid of the 
scrotum did not differ from that of 
ordinary hydrocele. Microscopic ex- 
amination showed no filaria in the 



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Elephantiasis in Japan—Ash mead; 



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water. Twelve cases were without 
pain from the engorgement. The con- 
sistency was very hard. 

For the pm'pose of determining a 
relationship between elephantiasis and 
filar iasis, he "studied especially the 
disease which most surely is manifested 
in filariasis, that is chyluria. In the 
warm region of Kmshiu coasts, both 
elephantiasis and chyluria show them- 
selves predominant, which he thought 
confirmed Manson's opinion, that the 
two diseases are locally connected. 
But later observations dispelled this 
notion. For according to the physi- 
cians of Amakusa island (Kiushiu) 
one disease is almost exclusively con- 
fined to the upper part of the island, 
while the other one is found most 
abundantly in the lower part. Dr. 
Honda found several cases of filariasis 
in the lower part of the island, but 
scarcely any elephantiacs in that same 
spot. In other places there were many 
elephantiacs but not one of filariasis. 
He found out also that chyluria af- 
fected both wealthy and poor people, 
while elephantiasis, mostly the latter. 
He could not understand this, if both 
diseases had the same cause. In 
Kagoshima there were several towns 
where twenty or thirty elephantiacs 
were produced, but the local physicians 
said there was no case of filariasis. 
This he thought was due to the fact 
that poor people who are mostly af- 
fected by filariasis could not afford to 
employ physicians, and because it did 
not appear to their minds as serious an 
affection as elephantiasis ; thus it was 
hidden from the doctors. He does 
not deny, therefore, the simultaneous 
manifestation of the two diseases, un- 
til he has observed it by permanent 
residence there. He spent four days 
there and saw the filarial germ in only 
one case out of sixteen. This was a 
patient with both diseases. In an- 
other case he could obtain no lymph, 
because the affected parts were so hard 
that no knife or pin could be inserted. 
In Kaseda, Kagoshima, he found no 



filaria in the blood of twenty-seven 
cases examined. If, therefore, he 
says the cause of elephantiasis in Japan 
is due to the filaria, it is strange that 
no one has found the gerpi in a pa- 
tient's blood. He thought that he 
might detect the germ by examining 
the blood and other contents of the 
affected parts during the period of 
* 'copper poisoning" rash, so he made 
a microscopical preparation of the 
blood from the foot of a woman twen- 
ty-two years old, who was in the last 
period of kusa-f uru (sha^Ling of grass) . 
The result was negative. But he did 
not take the blood, after repose, or 
while she was sleeping. 

Case 1, — A native of Fukami vil- 
lage ; age, sixty-eight ; occupation, fish- 
erman. Diagnosis, elephantiasis of both 
lower limbs and simultaneous chyluria. 
Healthy since birth, no remarkable dis- 
ease. At the age of thirty-five at- 
tacked by '«kusa-furu." At the be- 
ginning the appearance recurred five 
or six times a year, but at present 
only once or twice a year. For sev- 
eral years he suffered from '*gonor- 
rhoea," excreting whitish, or reddish 
white, turbid urine, and not infre- 
quently he felt pain from obstruction 
to the passage of urine. This gradu- 
ally subsided, but not entirely. Ex- 
amination of the blood showed filaria. 

Case 2. — A native of Otari village; 
occupation, peasant; age forty-five. 
Diagnosis, lower limb elephantiasis. 
He was healthy from birth, but waer 
attacked by "kusa-furu" when thirty- 
four years old. At every appearance 
of this fever and rash the **fattening" 
of the lower limbs was increased ; the 
lymphatic vessels may be seen to be 
inflamed and much dilated. From one 
of the affected parts, where the skin 
was soft and undulating, a drop of 
fluid was withdrawn and examined. A 
worm very similar in shape and struct- 
ure to filaria nocturna was found. 
The movement of this worm was slow, 
due, perhaps, to the low temperature,. 
40 degrees F. 



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--v5^J 



JR a E B' 


^ 


»^ A 


•fe 5Ji * ^^ 


^ 


^ Jfe -'^ 


/" «: ^ T 


4 


9 * m 


^>«J*M 




*R ^ T 


«t 3 Bm 




msLm 


A ;' «^ 




^m% 


^ Si 1^ 




^ U Si 




A. Germ taken from a dilated lymphatic vessel of lower 

limb elephantiasis. B. Germ taken from soft part 

of inflamed lymphatic gland. 

H Case 3, — A native of Otari village; 
occupation, peasant; age, forty-three. 
Diagnosis, lower limb elephantiasis. 
Since five years of age has been af- 
flicted with elephantiasis. As the ap- 
pearances of fever repeated themselves 
the lower limb increased in bulk; the 
lymphatic vessels were also seen to di- 
late and inflame. In the beginning 
the outbreaks of fever were frequent, 
but now only twice or thrice a year. 
When it now occurs it lasts only three 
to six days. The upper part of lower 
limb is generally hardened and stiff. 
Its front part has two soft, elastic de- 
velopments on it of the size of the tip 
of the small finger. The skin of these 
two portions appears as a very thin 
layer, showing the contents beneath 
it. A pin prick is not followed by a 
flow of blood. Instead, a transparent, 
thick liquid oozes out of the hole. 
Microscopic examination revealed a kind 
of thread worms, whose movements 
were slow. Their size was larger than 
filaria nocturna's, and apparently 



measured 1.25 mm., with covering 
membrane very rare. Both extremi- 
ties were of the same size. One ex- 
tremity, which appeared to be the 
head, if it had been slightly broader, 
had two or three elevated rings, which 
might be due to its death. 

Case 4. --A native of Akangi vil- 
lage ; occupation, peasant ; age, twenty- 
two. Diagnosis, lower limb elephan- 
tiasis. There was no inflammation of 
lymphatic vessels in this case. She 
had been healthy since birth, but had 
not yet menstruated. At the age of 
sixteen was affected with '*ku8a-furu." 
They recurred four or five times a 
year, each time continuing three days. 
Her last attack of it was ten days ago. 
The right lower limb, upper part, is 
''fattened" more than usual. Near the 
ankle joint there are several slits at the 
side, from which oozes a transparent 
liquid. Examination of this gave neg- 
ative results. There was no worm. A 
sofl line ran obliquely over the inner 
side of limb. An aspiration needle 
was inserted deeply here and a small 
quantity of fluid drawn out. Examina- 
tion of this showed worms identical 
with those of case 3. 

Case 5. — A native of Otari village ; 
a peasant woman ; age, fifty-five. Diag- 
nosis, lower limb elephantiasis. Healthy 
from birth ; since eight years ago is 
affected with **kusa-furu," which re- 
peats itself once or twice a year. Grad- 
ually both limbs increased in bulk. In 
late years the appearance of "kusa- 
furu" is accompanied by red inflam- 
matory development on the affected 
parts. Before the subsidence of the 
rash, violent exercise always prolongs 
its period, The aspirating needle drew 
from a soft part a sanguineous fluid, 
which on examination revealed thread 
worms, like in cases 3 and 4. They 
were very small, and net so plentiful; 
a microscopic slide showed only one or 
two. 

In these five cases there was only 
one of simultaneous occurrence of ele- 
phantiasis and filariasis. Yet this one 



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Elephantiasis in Japan— Ashmead. 



60 



•case is sufficient to confirm the belief 
that they are the same diseases in Ja- 
pan as well as elsewhere. The filaria 
obtained in the second case proves 
this, and it is probable that the worms 
of the third, fourth and fifth cases 
were metamorphoses of filaria noc- 
turna, occurring m the lymphatics. 
Dr.Iyijima thought these thread worms 
differed anatomically from Lewis' fila- 
ria, as it occurs in the blood, and that 
the difference might be due to their 
lymphatic habitat. Dr. Honda classi- 
fied his worm as a distinct kind. Ac- 
cording to Mueller, there are two hun- 
dred and twelve different kinds of 
filaria. 

Here are Manson's germs: 




Pig. 3ft.— («) Filaria nocturna X 300; 
(h) t dinnia, Africa X 300 ; ,(c) f. 
Deuiarquaii, St. Vincent X 300; (d) 
f. Ozzardi. British Guiana X 3X)-, (<r) 
f. perstans. Airic:i X 3j{). 



Dr. Honda's conclusions on his in- 
vestigation of the subject in Japan, 
which he made to his government, are 
that Manson's view that elephantiasis 
and filariasis are locally connected is 
not proved by Japanese facts. Yet he 
admits that his view has been geograph- 
ically too narrow, and that it is pos- 
sible in a broader locality; regions 



where elephantiasis prevails ma^ also 
be always the regions where filariasis 
prevails. He thinks that when eJapa- 
nese physicians have said that they have 
not seen filariasic cases, but only ele- 
phantiasis, it is because they were not 
able to distinguish between them. 
Conclusions may be drawn as follows: 

1. Elephantiasis is endemic in Kiu- 
shiu and other parts of Japan and is 
identical in its symptoms with that of 
other tropical regions of the world. 

2. Simultaneous manifestations of 
elephantiasis and filariasis are identified 
with Amakusa and Kagoshima. 

3. Elephantiasis affects principally 
poor people, especially peasants and 
fishermen living near coasts. 

4. Elephantiasis and chyluria occur 
together, biit rarely. 

5. The existence of the Lewis filaria 
in the blood of pure elephantiacs is 
very rare. Elephantiasis, when accom- 
panied with chyluria, shows filaria in 
the blood. Hence, in Japan, too, 
elephantiasis is traceable to filariasis, 
and the disease therefore belongs to 
the filarial diseases. 

6. Thread worms, although differing 
from the filaria of Lewis, must be rec- 
ognized as connections with the cause 
of elephantiasis. The thread worms of 
Japan, even if they are distinct worms 
from those of Lewis, are filariasic 
worms; therefore Japan's elephan- 
tiasis must be regarded as filariasis. 
Filariasis is not caused by one and the 
same worm in different parts of the 
world, any more than they are carried 
everywhere by the same breed of mos- 
quito. 

7. The difficulty of finding filaria in 
the blood of elephantiacs in Japan may 
be attributed to the fact that the 
lymphatics are obstructed and to the 
Japanese system of hot baths. The 
habitat in the human body may be dif- 
ferent there. It may be also due to 
the fault of the Japanese physician's 
technique. 

8. The germ of elephantiasis and 
filariasis gets into the Japanese human 



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J 



Health of Women— Elsner. 



73 



proper clothing. From the age of 
live to thirteen you find our little girls 
attending public schools, where their 
little minds are crowded beyond their 
capacity and at the expense of phys- 
ical development. If physical culture 
is practiced, it is too meager and 
almost entirely misdirected. It is in 
these schools where we allow children 
to needlessly contract disease, and 
often carry with them through life 
some effect of its ravages. The poorer 
classes must, after going to their 
homes, look after a younger member 
of the family or do housework, so 
that the entire waking hours are given 
up to toil. Among the well-to-do no 
better conditions exist. It is French, 
German, music teacher or dressmaker 
that requires their time. 

At the age of puberty we find our 
girls divided; the one class continue 
with their mental work at high school, 
the others are sent into the world to 
make their own way. During this 
stage of development we meet with 
the most prolific causes for future 
trouble. No attention is paid to the 
change in the girl's nature — her nerv- 
ous tension as she approaches her first 
menstruation. Instead of being kept 
quiet in mind and body, she is hustled 
with recitations and study periods on 
the one hand, with hard work in 
poorly ventilated shops or stores on 
the other. With acutely congested 
pelvic orgfans she starts her period, 
and for lack of advice she continues 
and soon builds the nidus for an ever- 
lasting defect of some sort. Chloro- 
sis, gastric disturbances, constipation, 
hysteria as well as organic nervous 
troubles appear. Menorrhagia, metror- 
rhagia, dysmenorrhoea and amenor- 
rhoea, together with altered position of 
the pelvic organs, now abound. She 
is making a most excellent start to 
ripen into ''womanhood of the age." 

After school days are over the 
young woman is face to face with the 
social problem. The one class does 
society, and the other is done by so- 



ciety after a hard day's work in shop 
or store. Why is it that todaj' a good 
house servant is a treasure? Simply 
because the girl refuses to put up with 
a healthful home, good food and moral 
restraint, and prefers short hours with 
cold meals and bad ventilation, in 
order that at six at night, and every 
night, she is free to dance, to skate, 
and indulge (if she chooses) in all 
forms of improper social relations. It 
is often said ''appendicitis was not 
heard of years ago." True. It ex- 
isted, but was not diagnosed. How- 
ever, pus tubes, ovarian and uterine 
diseases were not common in our 
grandmothers. It is not physical de- 
generation that underlies all these 
troubles, but immorality, and mostly 
among the men, that should be looked 
to for the causes of these unhealthy 
states in women. I tell you, gentle- 
men, small-pox is not in it when, in 
one week's experience of a general 
practitioner, he sees a child of five, a 
mother of fifty, seven males with 
gonoiThcea and two fresh cases of 
syphilis, one of them with the initial 
lesion on the tonsil. What hope is 
there for the future generation ? 

As for the married woman of today. 
Well, her aim is to lead society, avoid 
conception and, if unsuccessful, at- 
tempts to relieve herself or gets the 
abortionist to assist her. If she bears 
children she most often refuses to 
nurse them, and only when it is too late 
does she see her mistakes. 

Diseases and conditions due directly 
to occupation, such as lead, mercury 
and arsenical poisoning, writers' cramp, 
house-maids' knee and many others do 
not interest us just here. We are only 
concerned in the work that produces 
pelvic and genital congestions, as we 
get in the tailoress, seamstress, clerk, 
cook, etc., when their physical and 
moral education has failed to prepare 
the body to endure these hardships 
with immunity. How different is the 
picture of the girl you meet with 
bright, sparkling eyes, full, ruddy 



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cheeks and a graceful, elastic gait. 
Such have profited by good physical 
and moral training; you can send her 
behind a desk or counter with plenty 
of endurance to meet all demands of 
her work; even then she is not too 
fatigued to enjoy a dancing or a theater 
party. She has a clear, cheerful spirit 
because she enjoys perfect health. She 
is the woman who fills the house with 
contentment and happiness. She is 
never wearisome or fretful and makes 
the ideal mother. 

It is self-evident from some of the 
foregoing statements what should be 
done to remedy this great evil. I prefer, 
however, to incorporate anything fur- 
ther that may suggest itself to eliviate 
the distress to my summing up. 

In the first place we, as physicians, 
must make a bold stand to inculcate in 
the young as well as the old, the rich or 
poor, such habits of life that will form 
the basis for physical and moral 
strength. We should discourage mar- 
riage for those that are unfit physically, 
mentally or morally. 

We must insist on fresh air in and 
out of the homes; protect against any- 
thing that breathes the air of nervous- 
ness to the child, see to it that the 
ignorant mother be instructed how to 
bathe, dress and care for her infant. 
Mothers should be shown the advantage 
of making companions and comrades 
of their young daughters so that at the 
time of their growing into womanhood 
all matters therewith connected can be 
freely discussed. 

Plead with our educational boards 
not to crowd our children ; and create 
in school life a demand for a competent 
physical trainer. Encourage public 
games and parks where children should 
be compeljed to attend after school 
hours. Start public school inspection 
even if we must volunteer our services. 
Seek legislation to control by medical 
inspection shopworks and so reject such 
as are unfit for certain work and desig- 
nate such labor as may suit their work* 
ing capacity. Such inspectors should 



have the power to make suggestions 
for better light and ventilation of shops 
and stores. It should be made a mis- 
demeanor for a girl under eighteen 
years of age to attend a dance and like 
places of amusement at night unless 
accompanied by a guardian or parent. 
Preach and preach to the young mar- 
ried woman about her duty to the world 
and her offspring. Show her the beauty 
of a good home with children that will 
be an everlasting monument of health, 
happiness and prosperity. 

SPINAL ANESTHESIA WITH TROPA-CO- 

CAISE IN QENITO'URINARV 

SURQERV.'' 

Bt M. Kbotoszyneb, M. D., San Francisco. 

As early as 1885 in the first publi- 
cation upon spinal anesthesia that ap- 
peared in medical literature. Corning 
(1) says: "Whether the method will 
ever fijad an application as a substitute 
for etherization in genito-urinary or 
other branches of surgery, further ex- 
perience alone can show." Since 
August Bier's first experiment with 
spinal anesthesia he emphasized the fact 
that operations in the pelvis, perineum, 
and the anus are fitted for this mode 
of anesthetizing, as complete analgesia 
may be obtained for these regions 
through small and comparatively un- 
dangerous doses of the anesthetizing 
drugs. 

My own experience with spinal an- 
esthesia dates back about two years. 
At that time I witnessed several oper- 
ations under spinal anesthesia by Dr. 
Tait, who, with Dr. Caglieri, wrote a 
remarkable treatise (2) upon the sub- 
ject. I soon afterwards proceeded to 
experiment with spinal cocainization 
in some of my old prostatic patients, 
where a general anesthetic appeared to 
be dangerous on account of heart and 
kidney complications. My experience 
with the method was not very satis- 
factory on account of the very dis- 

•Read before the Medical Society of the State of CaU- 
fomia. 



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GenitO' Urinary Surcery—Krotoszyner 



76 



tressing and often dangerous symp- 
toms which most of my patients ex- 
hibited daring and after spinal cocaini- 
zation, and at the last meeting of the 
California State Medical Society, held 
in Sacramento, I said, discussing Dr. 
A. W. Morton's (3) paper on spinal 
cocainization: "I have used this 
method . . . and have noticed such 
violent and distressing symptoms . . . 
that I would not wish to repeat this 
method of anesthetizing unless I am 
compelled to." 

Such and similar objections to spinal 
cocainization are voiced by various au- 
thors. Mikulicz (4) for instance, re- 
ports among thirty-five cases of spinal 
cocainization, ten times distressing 
symptoms during and eight times after 
the operation. The horrible picture 
of intoxication so often observed after 
spinal cocainization is best described 
by Kam merer: 

''Suddenly the patient becomes pale, 
the pulse becomes rapid and small ; the 
patient yawns and makes deep and 
difficult inspirations until dyspnea sets 
in, pulse thready, not palpable; profuse 
perspiration, nausea and vomiting, 
spastic contractures of lower extremi- 
ties; pulse-rate, that had increased to 
140-160, sinks to 55-70; collapse at 
different periods. These symptoms 
may last a very few or even fifteen or 
twenty minutes." 

I had, therefore, almost decided to 
abandon spinal anesthesia entirely 
when my attention was shortly after- 
wards called to an article of Willy 
Meyer of New York (6) who had op- 
erated on three cases under spinal an- 
esthesia with tropa-cocaine, and at the 
same time Schwartz's (7) publication 
upon the use of tropa-cocaine in place 
of cocaine fell into my hands. Schwartz 
arrived, through carefully conducted 
experiments, at the result that 0.05 
tropa-cocaine injected into the sub- 
arachnoid space produced as perfect an 
analgesia as the ordinary cocaine, 
while none of the disagreeable and 
dangerous symptoms experienced with 



the ordinary cocaine w«re noticeable. 
Tait (e. c), who had experimented 
with several other drugs in order to 
avoid the toxic influence of cocaine, 
began at the same time to use the 
tropa-cocaine and called my attention 
to its advantages over the cocaine, es- 
pecially in its not being accompanied 
and followed by the above-mentioned 
distressing and dangerous symptoms. 
I had at that time under my care an 
extremely sensitive patient of seventy- 
five years, with a supra-pubic fistula of 
four years' standing as a result of su- 
pra-pubic lithotomy, from which the 
urine continually flowed down along- 
side the supra-pubic tube over the pa- 
tient's thighs, causing a very annoying 
eczema. Rectal examination revealed 
a very large prostate, the middle lobe 
of which obstructed the entrance of 
the bladder. On account of the pa- 
tient's advanced age and his faulty 
kidneys, an operation under local an- 
esthesia in the hypersensitive patient 
seemed to be impracticable. I there- 
fore decided to perform a Bottini op- 
eration under spinal anesthesia with 
tropa-cocaine. I injected 0.05 or 5-«» 
of a grain of tropa-cocaine and start- 
ed five minutes after injecting to 
operate. In rapid succession I intro- 
duced steel sounds of increasing size 
in order to dilate the urethra, that had 
not been used for several years as a 
urinary channel; then I introduced the 
Bottini instrument and made three very 
extensive incisions to the three lobes 
respectively, leaving a catheter in the 
bladder afterwards. During the opera- 
tion the patient was occupied in conver- 
sation with a friend, his pulse did not 
increase in rate nor deteriorate in vol- 
ume, no nausea, no vomiting, respira- 
tion normal, not the least sign of pain 
during cauterization of the gland. 
The patient did not show any disa- 
greeable after-effects from the anes- 
thesia (no rise in temperature, no 
headache). I repeated in this patient 
twice the same same method of anes- 
thesia, the first time about six weeks 



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after the first Bottini operation, in or- 
der to close the supra-pubic fistula, the 
second time, two months after the 
second operation, in order to perform 
a second Bottini operation for the re- 
establishraent of the spontaneous 
micturition through the natural pas- 
sages after closure of the supra-pubic 
fistula. 

Such a result could never have been 
obtained without the aid of this method 
of anesthetizing, because I don't think 
the patient could have survived three 
general narcoses, neither would a care- 
ful surgeon have attempted these op- 
erative procedures on account of the 
dangers connected with general anes-.. 
thesia in old and decrepit individuals. 

Since this experience I have done 
almost all my genito-urinary surgery 
under spinal anesthesia with tropa- 
cocaine and can recommend it highly. 
I have operated so far in over one 
hundred and twenty cases. Most of 
my work was done on the bladder, 
scrotum, penis, etc. 

Tropa-cocaine is chemically benzol- 
pseudotropin hydrochlorate, and has 
the formula C« H,, No (C« H,-CO) 
HCL. This alkaloid occurs with co- 
caine and other bases in the small Java 
Coca leaves, prepared synthetically by 
Liebermann. It forms white needles, 
melting at 271 degrees C, or 519.8 
degrees F., and is readily soluble in 
HjO. In solutions of 2 per cent, to 5 
per cent, it produces a rapid anes- 
thesia, is less toxic and more reliable 
than cocaine (Ferdinando and Chad- 
bourne). 

I have always used for my work the 
glass tubes as prepared by Dr. Tait. 
Each tube contains 1 cc. of a 4 per 
cent, solution of tropa-cocaine, both 
ends of the tube are sealed, then 
placed in a bath of water and glycer- 
ine for one an<l one-quarter hours at 
a temperature of 120 degrees F. and 
cooled off. The glass is filed off at a 
convenient place so that it may be 
broken when the contents are needed 
for injection. I shall not describe here 



the instrumentarium and technique of 
lumbar puncture, as those points are 
repeatedly dwelt upon by various au- 
thors in former publications. I gen- 
erally obtained complete analgesia for 
my field of operation by the above- 
mentioned dose of tropa-cocaine, and 
generally started the operation ten 
minutes after the injection. In some 
cases where I injected less than 1 cc. 
of the 4 per cent, solution, or even 
only half the dose, I had to wait fif- 
teen, twenty or twenty-five minutes 
until analgesia was obtained. In two 
cases of my whole material no anal- 
gesia occurred, and the operation had 
to be done under general anesthesia. 
In both instances the escaping of sev- 
eral drops of cerebro-spinal fluid made 
it sure that the point of the needle had 
punctured the subarachnoid space, and 
in the case of a very nervous woman 
with vesical spasms certain symptoms 
(slight icterus with rise of tempera- 
ture until eight days after spinal 
puncture) were observed that I was 
inclined to ascribe to the lumbar 
puncture. 

In nervous and excitable patients, 
occasionally, the operation was some- 
what impeded by great restlessness of 
the patient, which sometimes could be 
arrested by placing a mask over the 
patient's face, simulating chloroform 
anesthesia. Whenever those patients, 
after the operation, were asked if they 
had felt any pain they invariably de- 
nied it. We never used of late a 
stimulant hypodermatically or per 
OS before or during the operation, 
as generally no shock or other dis- 
tressing symptom caused by the punc- 
ture or the injected drug were notice- 
able. One assistant is placed at the 
head of the patient to carefully watch 
respiration, pulse, pupils, etc. A 
nurse is detailed in some instances to 
engage a nervous patient in pleasant 
conversation and to distract notes upon 
one interesting observation. 

An important point that so far has 
not been brought out is that this 



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Genito- Urinary Surgery—Krotoszyner. 



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method of anesthesia permits us to ob- 
tain the patient's consent for removal 
of an organ daring the operation, 
where in general anesthesia a second 
operation would be necessary because 
the patient's consent for a more radi- 
cal procedure could not be obtained. 
To illustrate this point I may be per- 
mitted to give brief notes upon one in- 
teresting observation. 

A man of thirty-three consulted me 
for a subacute anterior urethritis ( with 
gonococci) and epididymitis on the 
right side. Upon taking the history 
of the case I ascertained that the right 
testicle had been swollen for several 
months previous to the present attack 
of gonorrhea, which at that time lasted 
for about three weeks. As no benefit 
could be effected by ambulatory treat- 
ment, the patient was persuaded to 
enter the hospital, where, in spite of 
rest and careful treatment, the swell- 
ing of the right epididymis increased ; 
a few. days later an effusion into the 
tunica was noticeable, which rapidly 
increased ; puncture was made for di- 
agnostic purposes and 1 cc. of a sero- 
purulent fluid obtained, that contained 
pus cells, tubercle bacilli, streptococci, 
but no gonococci. The operation un- 
der spinal anesthesia revealed an epi- 
didymis and testicle that were entirely 
riddled by tubercular abscesses, miliary 
tubercles covered the cord and sur- 
rounding tissues up to 4 or 5 cm. from 
the epididymis. I informed the pa- 
tient of the condition of the organs 
mentioned, and obtained permission 
for castration, which I did, following 
up the vas deferens to the internal in- 
guinal ring. 

I am certain from my experience 
that spinal anesthesia with tropa-co- 
caine will prove to be a useful and re- 
liable method in our field of surgery, 
though I will admit that disagreeable 
symptoms will occasionally be notice- 
able from its use. Repeatedly in my 
cases a slight dyspnea was observed ; 
the pulse-rate increased to 100, in two 
cases to 120; involuntary defecation 



occurred in three cases, and in the 
case of the above-mentioned woman, 
where no analgesia was effected, pro^ 
fuse vomiting followed the injection of 
the drug. But all those disagreeable 
sequels were the exception ; as a rule 
the analgesia was complete, and the 
operation could be finished without 
any interruption caused by the intra- 
spinal injection. The same favorable 
results were obtained as regards after- 
effects. I have never observed the ex- 
cruciating headache so often noticeable 
after spinal cocainization, and I am in- 
clined to believe with Bier (8) that 
neither the difference in pressure of 
the cerebro-spinal fluid nor circulatory 
disturbances, but the toxic effect of 
the cocaine is the real cause of this 
distressing symptom. In regard to 
increase of temperature as a sequel of 
spinal anesthesia with tropa-cocaine, 
I cannot express a decided opinion. In 
the few of my cases where it occurred 
I was not certain whether the condi- 
tion of the wound was not the cause 
of this symptom. 

The majority of my operations lasted 
less than an hour. Only in one case 
(an external urethrotomy with total 
obliteration of the urethral canal) we 
worked one hour and forty minutes 
with complete analgesia after injection 
of 0.05 tropa-cocaine. 

The only real danger, to my mind, 
connected with this method of anes- 
thesia lies in the possibility of sepsis 
to the spinal canal. Therefore, I 
would not attempt spinal anesthesia in 
a private dwelling. In the hospital I 
have the patients in whom spinal anes- 
thesia is to be made prepared as for a 
laparotomy. The day before the oper- 
ation the patient gets a full bath, his 
back is shaved and a sublimate-pad ap- 
plied upon it. On the operating table 
the field of the puncture is sterilized 
as carefully as the site of an abdominal 
section. 

I hope you will test this method un- 
biasedly in your genito-urinary sur- 
gical work, so that well-established indi- 



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cations for this method of anesthetiz- 
ing may be drawn from for future 
experience. My work teaches me that 
the method seems to be impracticable 
in very nervous and excitable patients. 
I can highly recommend it, though, 
for old and decrepit individuals, where 
a weak heart or unreliable kidneys 
would contra-indicate a general anes- 
thesia. I have not had a mishap in 
my spinal anesthesia with tropa-co- 
caine so far, and I consider this method 
not to be more dangerous than any 
other form of anesthetizing, while its 
advantages over general anesthesia for 
the patient are unquestionable. 



REFERENCES. 

1.— J. L. Coming: New York Medical Jour- 
nal, October 31, 1886. 

2.— Dudley Tait and Guido Caglieri: Trans- 
actions of the Medical Society of the State of 
California, 1901, p. 266. 

3.— A. W. Morton: Transactions of the Med- 
ical Society of the State of California, 1901, p. 
228. 

4.— I. V. Mikulicz: Arch. f. Klin. Chir.„ 
Vol. LXIV, p. 767. 

6.— F. Kammerer: N. Y. Med. Monatsschr.,. 
1901, p 1. 

6.— W. Meyer: Med. News, Vol. LXXVIII, 
p. 669. 

7.— Karl Schwartz: Centralbl. f. Chir.,1901,. 
No. 1. 

8.— Aug. Bier: Arch. f. Klin. Chir., Vol. 
XLIV, p. 236. 



ABSTRACTS. 



THE IMPORTANCE OF DtAONOSIS !N 
SKIN DISEASE. 

Dyer, in The Medical News^ gives 
the following important points in the 
diagnosis of skin diseases: (1) The 
location of the disease; (2) the dis- 
tribution on the particular region on 
which it occurs; (3) the arrangement 
of the component parts or lesions. 
The lesions themselves must be studied 
in detail so as to classify the disease. 
Eruptions which are bilaterally sym- 
metrical are either constitutional in 
origin or are exposed to the identical 
local cause on both sides of the body. 
Parasitic diseases are found on the 
flexors preferably, or on the exposed 
parts of the body. The more chronic 
diseases of the skin become, the deeper 
the color; on the other hand, the 
brighter and more vivid the color, the 
more acute the disease. Scales, ulcers 
and scars are the evidences of chron- 
icity. Fluid lesions seldom itch. 
Papular eruptions almost always itch. 
Single ulcers are almost always syph- 
ilitic, trophic, traumatic or malignant. 
On the face ulcers are seldom due to 
other causes than cancer, syphilis or 



tuberculosis. The color of eruption 
on the Caucasian is always important 
in diagnosis. Syphilis is pigmented 
brown or buff as its eruptions fade. 
Leprosy is shaded brown or purple. 
Lichen rubor is violaceous or white. 
Psoriasis is always pale red, covered 
with white scales. Seborrheic eczema 
is always yellow red, with greasy 
scales. Syphilis, when ulcerating, 
smells rancid; favus has a mousy 
odor; varicose ulcers smell sweet; 
neurotic ulcers or those of leprosy 
are nauseous and foul, while rodent 
ulcer has the smell of rotting meat. 



SUPRAPUBIC PROSTATECTOMY. 

Taylor, in the Dublin Journal of 
Medical Science^ makes the following 
statements: (1) It is an operation 
from which good results may be ex- 
pected in suitable cases; (2) it is 
doubtful if the operation should, as a 
rule, be attempted in very old men if 
their vital powers have reached a low 
ebb, and in whom it is probable that 
there is grave organic renal disease 
associated with chronic cystitis of long 
standing; (3) in absence of severe 



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cystitis, provided the patient's general 
health is fairly good, the suprapubic 
operation which the author describes 
raay be employed without obvious 
risk; (4) in prostatectomy, as in 
other operations of an extensive char- 
acter, it is desirable that the various 
steps of the procedure be carried out 
in as expeditious a manner as possible, 
consistent, of course, with safety and 
efficiency ; ( 5 ) suprapubic prostatect- 
omy, as practiced at the present day, 
aims at enucleation of encapsulated 
growths, and meets all the require- 
ments of the case. 



INPANTILB SYPHILIS. 

Martin reports (Munch. Med. Woch- 
enschrift) the statistics of the medical 
clinic of Jena, from the years 1860 to 
1890, regarding infantile syphilis. Al- 
together there were fifty-six cases, of 
which thirteen were acquired and for- 
ty-three heriditary. Of the thirteen 
acquired cases, the source of infection 
could be determined in six. Of these 
thirteen, two died in the clinic, one of 
pneumonia and the other of diphtheria. 
Seven patients lived to adult life ; four 
passed from observation. In one case 
the patient had tertiary symptoms at 
the age of eleven. The others, with 
the exception of an occasional infec- 
tious disease, remained well. Of these 
seven cases two were men, both mar- 
ried, had large families, and all the 
children were healthy. Of the five 
women three are married and have no 
children. One had one child that died 
at the age of two years. A fourth 
has had eight children, of whom six 
are still alive. All the children were 
fairly intelligent, and showed no moral 
or physical defect. Of the forty-two 
eases with hereditary syphilis, twenty 
males and twenty-two females, thir- 
teen showed symptoms of the disease 
very early and thirty not until the fifth 
year. Of the thirteen cases of pre- 
cocious hereditary syphilis three passed 
from observation. Of the remaining 
ten, seven died in early childhood, and 



one at the age of eighteen, of pulmon- 
ary tuberculosis. The patient was ap- 
parently quite intelligent. Of the re- 
maining two cases one is probably 
still alive. One of them was morally 
defective, and his parents were the 
same. The other was fairly intelligent,, 
married, and has two living children. 
Of the thirty cases of late hereditary 
syphilis, three males died at the age& 
of nine, eleven and fifteen years. One 
of these was remarkably intelligent; 
another was morally defective. Two 
patients died at the ages of seventeen 
and nineteen years. The causes of 
death in all cases may have been 
syphilis. As for the other patients, 
it appears that, as far as was known, 
they are all married, and have children 
that are fairly healthy. Among the 
women there can be no doubt that 
there wa? some delay in the appear- 
ance of puberty. Of the thirty-three 
children born up to 1900, five had 
died. There were also numerous mis- 
carriages. — Philadelphia Med. Jour^ 
nal. 



VITILIGO OP SYPHILITIC ORIGIN. 

At a meeting of the Society of Der- 
matology and Syphilography MM. 
Pierre Marie and Crouzon exhibited a 
patient whohadavery extensive vitiligo 
which had been progressively develop- 
ing for about twenty years. He had 
also a very pronounced buccal leuco- 
plakia. The patient denied having had 
syphilis, and presented no sign of that 
disease, except a double papillary 
atrophy and a modification of the pu- 
pillary reflexes. The authors never- 
theless believed that the vitiligo and the 
leucoplakia had a common origin, and 
insisted upon the relationship between 
vitiligo and syphilis. They referred to 
cases of the kind reported by du Castel 
and Tenneson, among others, and to 
the occurrence of vitiligo in certain 
nervous diseases, the relations of which 
to syphilis are without doubt. 

M. Darier said that the syphilitic 
origin of vitiligo, impossible to admit 



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in certain cases, in others appears very 
probable. He had observed a case in 
a lady, thirty-five years of age, who, 
indeed, herself showed no signs of 
syphilis, but who had been married for 
seventeen years to an undoubted syph- 
ilitic. She exhibited at the same time 
not only the purely epithelial lesions 
of leucoplakia, but also superficial 
sclerosis of the tongue. She had like- 
wise had vitiligo for two years. 

Therefore, in establishing a funda- 
mental difference between congenital 
and acquired progressive vitiligo it is 
necessary, in the latter cases, to look 
for syphilis. 

M. Brocq said that in such cases we 
should mistrust coincidences and adopt 
the view of an etiological relationship. 
He had at the time under his care a 
patient who had an old vitiligo, acquired 
and progressive, of the genital organs, 
and who also had syphilis. — La Tribune 
Medicale. 



BULLOUS (EDEMA OF THE BLADDER. 

Of this very rare affection Dr. Lin- 
•denthal has observed one case in con- 
sequence of the application of apessary. 

A woman, fifty-two years of age, was 
attacked by cystocele, with uterine pro- 
lapse, and it was judged well that she 
should wear an annular pessary. It had 
been in position but a few days when 
she was assailed by symptoms of cys- 
titis with tenesmus. A cystoscopic 
examination showed the existence of a 
bullous ofidema in the region of the 
trigone. The pessary having been 
withdrawn, the vesical symptoms, ob- 
jective and functional, subsided almost 
at once. Upon the mucous membrane 
of the bladder nothing was to be seen 
but a small, hsemorrhagic spot. The 
pessary was replaced, but immediately 
the vesical tenesmus and osdema reap- 
peared. The pessary being removed 
a second time, the oedema was absorbed, 
but at its site were seen small spots of 
haemorrhage and partial necrosis of the 
mucous membrane. The last accidents, 
except the oedema, being reproduced 



each time that the pessary was reap- 
plied, the patient consented to an opera- 
tion for the relief of the uterine pro- 
lapse. Care was taken in performing 
vaginofixation to make attachment at 
some distance from the bladder, for 
fear of favoring increased necrosis of 
the mucous membrane and perforation 
of the bladder. 

It is to be supposed that in this par- 
ticular case the bullous oedema and 
necrosis consecutive to compression by 
the pessary found some adjuvant con- 
dition in a rather special distribution 
of the vessels. — La Tribune Medicale, 



RADIOTHERAPY AND PHOTOTHERAPY IN 
CARCINOMA, TUBERCULOSIS AND 
OTHER DISEASES OF THE SKIN. 

Hyde, Montgomery and Ormsby 
(Journal of the American Medical 
Association, January 3, 1903) present 
an interesting paper on the use of the 
X-rays and the actinic solar rays in the 
treatment of carcinoma, tuberculosis, 
psoriasis and various other skin dis- 
eases. They report twenty-one cases, 
and from these and from a considera- 
tion of the literature believe that they 
are justified in drawing the following 
conclusions : 

While it is too early to form definite 
and sweeping conclusions regarding the 
value of radiotherapy and phototherapy 
in all the affections in which they have 
been employed, our experience leads 
us to believe that in tuberculosis of the 
skin these methods of treatment are 
superior to any others now known to 
us. In lupus erythematosus, photo- 
therapy has in our hands given very 
satisfactory results, far better than 
those we have obtained by any other 
method. 

In superficial carcinoma involving 
considerable areas, radiotherapy is 
undoubtedly preferable to all other 
known methods of treatment. Super- 
ficial lesions more circumscribed are 
equally amenable to treatment with 
the X-rays, though in many instances 
small tumors can be removed more 



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81 



promptly by complete erasion or ex- 
cision. For many of these circum- 
scribed growths we are now inclined to 
advocate removal either with the knife 
or curette, followed by a series of 
treatments with the X-rays. In oper- 
able carcinoma of the skin which in- 
cludes deeper tissues we advocate com- 
plete extirpation, followed by X-ray 
treatments. Where the growths are 
inoperable radiotherapy offers a possi- 
ble chance of recovery, or of lessening 
the discomfort of the patient. As a 
result, however, of our observation of 
our own and other cases, we believe 
that in exciting an inflammation in car- 
cinoma one is, to some extent at least, 
encouraging an extension of the growth 
through a dissemination of the cancer- 
cells to normal (or inflamed) tissue. 
We believe this possibility constitutes 
s, danger in the treatment of carcinoma 
by the X-rays that has not been suffi- 
<;iently recognized. 

The value of radiotherapy in exten- 
sive cases of hypertrichosis has been 
fairly well established by other ob- 
servers. It has given us excellent re- 
sults in the majorty of cases of psori- 
asis treated. It has unquestionably 
been used successfully in many of the 
chronic inflammatory diseases of the 
skin, especially in acne, rosacea, fol- 
liculitis, and suppurating wounds, but 
until this agent can be employed with 
greater accuracy we believe it should 
be reserved chiefly for those cases in 
which better known and better con- 
trolled methods are not successful. 

It is not yet possible to draw definite 
conclusions with reference to the com- 
parative values of radiotherapy and 
phototherapy. The former is, for the 
most part, readier of application, and 
apparently has a wider field of useful- 
ness than the latter. In lupus ery- 
thematosus, however, phototherapy 
has repeatedly given us excellent re- 
sults where the X-rays have failed al- 
together or aggravated the condition. 
Judging from our experience and from 
the larger experience of Finsen and 



others in the treatment of tuberculosis 
of the skin, we believe that in this dis- 
ease phototherapy gives in the end re- 
sults as rapid as those obtained with 
the X-rays, with better cosmetic ef- 
fects, and without danger of deep burns 
There is no doubt that phototherapy 
and radiotherapy are valuable addi- 
tions to our methods of treating cer- 
tain diseases. There is also no doubt 
that their field of usefulness eventually 
will be proven much more restricted 
than that in which they are employed 
at present. Unfortunately, there can 
be no doubt also that harm is doing 
and will be done by the action of 
X-rays in the hands of the unskilled or 
the unscrupulous. No one should at- 
tempt to employ radiotherapy who has 
not first carefully studied the subject 
and followed the work of some expert. 
Even with such preparation great cau- 
tion is needed in acquiring experience 
with this new therapeutic agent, its 
accurate control and the character of 
results obtained being still subjects of 
discussion. 



ACIDS INTERNALLY tN PRURITUS. 

Prof. H. Leo, of Bonn (Semaine 
Medicale, xxii. No. 51), recommends a 
trial of hydrochloric or sulphuric acid 
in all cases of generalized pruritus of 
obscure origin, whether there bealka- 
linuria or not. Sometime ago he was 
called to a man suffering for more than 
a year from very intense generalized 
pruritus. Nothing abnormal could be 
discovered save an alkalinity of the 
urine due to an increased elimination 
of phosphates ; so the doctor ascribed 
the pruritus to hyperalkalinity of the 
blood. Accordingly he prescribed a 
50 per cent, solution of hydrochloric 
acid in doses of ten drops every two 
hours. As a result, the pruritus di- 
minished in intensity, and the urine 
became clearer. After several days a 
li per cent, solution of sulphuric acid 
was given, a tablespoonful every two 
hours, and still later the strength was 
increased to 2^ per cent. The pruritus 



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Abstracts. 



soon disappeared completely. Dr. Leo 
has applied the same treatment with 
success in another case of generalized 
pruritus and in a case of vulvar pruritus. 
In these three cases the urine was 
alkaline; but in three other cases it 
was of normal reaction before institut- 
ing the treatment, and yet the results 
were very satisfactory. Of course, 
there were some instances in which no 
success was had. — Phila. Med. Jour. 



TREATMENT OF SYPHILIS WITH INTRA- 
VENOUS INJECTIONS OP MERCURY 
CYANIDE. 

Renault {Oaz. Hehdom., 1902, No. 
55 ; abstract from Derm. Centralblatt^ 
September, 1902) has obtained good 
results with injections of mercury cy- 
anide into the veins of the arm. He 
uses a 1 per cent, solution and gives 1 
c. c. every day or every other day. 
The injections are painless, and the 
action is rapid and sure, particularly 
in affections of the nervous system. 
The author treated fourteen cases of 
syphilis ; three of these patients had 
secondary syphilis with severe head- 
aches, three hadgummata of the tongue 
arid gums, two had medullary disease, 
four had severe tertiary headaches, and 
one had Jacksonian epilepsy. In all 
of these the improvement was rapid, 
the headaches disappeared, as a rule, 
after the first injection, as likewise did 
the epileptiform seizures. In the dis- 
cussion the following objections to the 
treatment were made: The injections 
are difficult to carry out in fat persons ; 
it has been shown that even weak so- 
lutions of mercury bichloride are capa- 
ble of producing phlebitis and throm- 
bosis ; it has not been proved that this 
method is superior to the treatment 
with the unctions and potassium iodide. 
— Phila. Med. Jour. 



CUTANEOUS ANQIOMATA. 

Symmers {Med. News^ Dec. 27, 
1902) found that in comparatively 
young persons, who exhibit the above 
mentioned skin changes, there was 



present high arterial tension. Evei> 
further signs of precocious arterial 
sclerosis were commonly observed. In 
individuals between forty and fifty 
years of age, actual arterial hardening 
went hand in hand with cutaneous an- 
giomata. He considered that the skin 
affections bore no relation to malignant 
disease, and that their existence, even 
in large numbers, is not to be viewed 
with any degree of alarm as far as 
cancer is concerned. 



RECURRENT BULLOUS ERUPTION. 

Gottheil (Jour. Amer. Med. Assoc. y, 
Dec. 27, 1902) observed a recurrent 
bullous eruption, in a child five and 
one-half years old, coming on in the 
fall of four successive years, which ran 
a definite course and was unaccom- 
panied by the other symptoms usually 
met with in lesions of this nature. It 
was not related to an injury, and there 
was no hereditary history. It was not 
a bullous urticaria, for there was no 
itching, nor were there any other urti- 
carial lesions ; and the same argument 
holds for bullous erythema. Dermatitis 
herpetiformis is grouped and inflam- 
matory; this eruption had neither of 
these characteristics. A cantharidal 
eruption could be excluded. He con- 
sidered the disease probably benign 
pemphigus on account of its periodicity 
and the absence of an inflammatory 
areola around the bullae. 



HERNIA OF THE BLADDER. 

Lossen {Beitrage zur hlin. Chirur^ 
gie, Band 35, p. 140) reports three- 
cases of hernia of the bladder and an- 
alyzes the literature. The condition 
has been estimated by different observ- 
ers as occurring in from 1 to 6 per cent^ 
of all herniee. In 3,000 hernia opera- 
tions, in 1.6 per cent, a portion of the 
bladder was found. Hernia of the- 
bladder occurs more frequently through 
the inguinal canal than through the- 
femoral canal. The protruding por- 
tion of the bladder may or may not be- 
covered by peritoneum. In the ma- 



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88 



jority of cases there is an accorapany- 
ing enterocele. As a rule, there are no 
special symptoms in this variety of 
hernia, the diagnosis being made only 
after the incision has been made. Of 
twenty-nine cases in which strangula- 
tion occurred the diagnosis was made 
before operation in five only. Even 
during operation a hernia of the bladder 
js apt to be unrecognized, and in a 
number of cases it has been opened be- 
fore the condition has been diagnosti- 
<5ated. A large amount of subperi- 
toneal fat or a distinct lipoma should 
put one on guard for a bladder pro- 
trusion. If the bladder wall itself be 
seen or its lateral ligament be made 
out, a mistake would be less likely to 
happen. Treatment consists in reduc- 
ing the herniated bladder and closing 
the canal in the usual way. In some 
<3ases, in which there is a pouch-like 
formation of the bladder, resection is 
the proper procedure. — Phila. Med. 
Jour. 



A CENTURY OF ARM-TO-ARM VACCINA- 
TION. 

Eduardo Liceaga {Indiana Medi- 
<;(7Ze7owrn</7) describes the method of 
arm-to-arm vaccination which has been 
practiced for one hundred years in 
Mexico, the greatest care having been 
exercised as to the choice of candidates 
for propagating the virus. As to the 
results, it has been observed, in the 
first place, that persons vaccinated in 
this way remain immune during their 
whole lives. When there is a wide- 
spread epidemic it is stopped in no 
time by at once vaccinating all persons 
who have not been previously so 
treated. The immunity which vacci- 
nation confers on infants is preserved 
during the whole of their lives. No 
Mexican physician has ever died of 
smallpox, even if has been in practice 
for forty years. The same immunity 



has been observed in male and female 
nurses who attended smallpox patients. 
Experiments undertaken by order of 
the supreme board of health of the 
City of Mexico, show that vaccinations 
succeeded exceptionally well. Of 
1,307 revaccinations only twenty-three 
were successful. — Exchange. 



THE TREATMENT OF SCARLET FEVER. 

Adolf Baginsky (Berl. klin. Woch., 
December 8, 1902) believes that scarlet 
fever is caused by streptococci. He 
used first the old Aronson antistrepto- 
coccus serum, with a mortality of 11 
per cent. At the same time the mor- 
tality in cases treated without this 
serum was 14 per cent. The new 
Aronson serum, on the other hand, re- 
sulted in marked diminution of all 
symptoms almost at once. This serum 
together with the new Moser serum 
seems to Baginsky to give a brighter 
outlook for the treatment of scarlet 
fever. — Phila. Med. Jour. 



VULVITIS IMPETIOINOSA IN YOUNQ 
CHILDREN. 

In the Bulletin Medical (December 
27, 1902), Carriere reports the detailed 
case-histories of three little girls with 
impetiginous vulvitis. These children 
were disposed to attacks of impetigo 
of the skin, which, like the vulvitis, 
also began with slight fever. The vul- 
vitis in its course resembled impetigo, 
even containing the same staphylococci 
in the fluid of the vesicles. Impetigo 
of the skin complicated one case, and 
in another it followed inoculation of the 
arm with fluid from the vulva. The 
inguinal glands were swollen in all 
cases. In the treatment he used hydro- 
gen peroxide locally and iron protiodide 
and cod-liver oil internally. [M. O.] 
—Ex. 



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New Publications 



NEW PUBLICATIONS, 



D18EA8SS 07 THE Skin. Their Description, Pathology, 
Diagnosis and Treatment, with special reference to 
the skin eruptions of children, and an analysis of fif- 
teen thousand cases of skin disease. By H. Rad- 
cliitb-Crocker, M. D., P. R. C P., Physician for 
Diseases of the Skin in University College Hospital; 
Honorary Member of the American Dermatological 
Society, etc. Third edition, revised and enlarged, 
vfith four plates and one hundred and twelve illus- 
trations. Philadelphia: P. Blakiston's Son & Co., 
1012 Walnut street. 1903. 

This standard work has been very 
much improved in many respects. It 
has been enlarged by the addition of 
new matter to the extent of covering 
over 1400 pages, and much of the text 
has been rewritten in order to bring it 
up to date. The classification is the 
best that could be devised for the use 
of students. Each disease in the clas- 
sification is also accompanied by a de- 
scription of the most prominent pri- 
mary lesion, as well as presumed etiol- 
ogy and pathogeny. The greatest 
trouble with the young practitioner is 
encountered in dealing with skin erup- 
tions of children, and the author rec- 
ognizing that fact has given special 
attention to this class of cases. For a 
thorough mastery of skin diseases the 
student or physician can find no better 
guide than the above elaborate treatise. 

BiooRAPHio Clinics. The Origin of the Ill-Health of 
De Quincey, Carlyle, Darwin, Huxley and Browning. 
By Georoe M. Gould, M. D., Editor of American 
Medicine, author of "An Illustrated Dictionary of 
Medicine, Biology," etc., "Borderland Studies," '^The 
Meaning and Method of Life/' etc. Philadelphia: P. 
Blakiston's Son & Co., 1012 Walnut street. 1903. 

The above little volume will be read 
with more than usual interest by mem- 
bers of the medical profession, not 
alone on account of its bearing on pro- 
fessional subjects, hut from a histor- 
ical standpoint. In studying the his- 
tory of great men we seldom know 
anything of the physical infirmities 
under which they performed their 
wonderful tasks. We see the revela- 
tion of genius in the lines of the poet, 
and in the eloquence of the orator, but 
we know nothing of the bodily ail- 
ments which hampered their intellect- 
ual efforts. The author selects five 
great historical characters, and holds 
up the mirror to their inner lives, and 
in this mirror we see images of their 



daily lives, which have escaped biog- 
rapher and historian. 

The American Yeab-Book of Medicine and Surqebt 
FOR 1903. A Yearly Digest of Scientific Pro^ss and 
Authoritative Opinions in all Branches of Medicine 
and Surgery, drawn from Journals, monographs and 
text-books of the leading American and foreign au- 
thors and investigators. Arranged, with critical edi- 
torial comments, by eminent American specialists^ 
under the editorial charge of Gkobqe M Gould, A. 
M., M. D. In two volumes— Volume II, General Sur- 

Sery. Octavo. 670 pages, fully illustrated. Phila- 
elphia. New York, London: W. B. Saunders ft Co. 
1903. Per volume: Cloth; ^.00 net; Half Morocco, 
^75 net. 

We do not know of any similar pub- 
lication, either American or foreign, 
that can compete in any way with thi& 
excellent Year-Book, published by 
W. B. Saunders & Company. It is not 
an indiscriminate collection of extracts 
clipped from any and every journal ; 
the matter is carefully selected, edited, 
and in numerous cases commented upon 
by the eminent authorities whom Dr. 
Gould has enlisted as his assistants. 
Every new theory and scientific discov- 
ery worthy of the consideration of the 
professoin has found a place in this 
unusually complete Year-Book; and 
the names of the several editors are 
suflScient guarantee of a proper dis- 
crimination. As usual, the illustrative 
feature is well taken care of, there 
being eleven full-page inserts, besides 
many excellent text-cuts. We strongly 
recommend Saunders' American Year- 
Book as the best work of its kind on 
the market. 

Clinical Tbbatisks on the Patholoot and Therapy 
OP D1SORDEE8 OP Metabolism and Nutrition. By 
Prof. Dr. Carl von Noorden, of Frankfort, Germany. 
Authorized American edition translated under the 
direction of Boardman Reed, M. D., Philadelphia. Part 
I, Obesity. Part II, Nephritis. E. B. Treat & Co., 
New York, Publishers. 1903. 

The above are two very interesting 
and instructive little volumes. The 
author takes very broad and comprehen- 
sive views of the diseases discussed. He 
elaborates their pathology along the 
lines of metabolism and nutrition. He 
shows that the reduction method in 
obesity must be properly selected and 
directed in accordance with the age and 
general physical condition of the pa- 
tient. His dietetic, hygienic of ther- 



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Therapeutic Suggestions. 



apeutic procedures are not so rigid or 
restrictive as to prescribe the same 
rules for the management of all cases, 
but are broad and elastic enough to 
meet the requirements of individual 
conditions. In obesity he is opposed 
to prolonged and excessive efforts to 



reduce corpulence, and advises inter- 
mittent reduction with intervals of 
muscular and physical training. In ne- 
phritis, his aim is to increase the func- 
tions of the skin and relieve the kid- 
neys as much as possible of the 
burdens of excretion. 



THERAPEUTIC SUGGESTIONS. 



Tinea circinata — especially in 
that very troublesome form of the dis- 
ease which affects the scrotum and 
inner side of the thigh— yields promptly 
to the application of borobenphene 
(Heil) used three or four times a day. 



In calculous affections lithiated 
hydrangea is of unquestionable utility. 
Its administration promotes the re- 
moval of gravel from the bladder and 
relieves pain during the passage of 
renal concretions through the ureters. 



Anasarcin has been employed with 
marked benefit in renal dropsy, and in 
various diseases of the kidneys accom- 
panied by edema. Skim milk diet with 
the above treatment is advised. 



The condition of debility and faulty 
assimilation which results from the 
prolonged treatment of syphilis with 
mercury and iodine is remarkably im- 
proved by Gray's glycerine tonic 
compound. The syphilodermata, when 
occurring in cachectic subjects, are 
benefited by a persistent use of the 
same remedy. 



In cases in which there exists a con- 
dition of faulty assimilation of fats, 
cod-liver oil, by reason of the fact that 
it contains in intimate association the 
bile elements, is especially adapted to 
form the molecular basis of the chyle. 
In scrofula, and other disorders of the 
nutritive functions belonging to this 
group, cordial cod-liver oil compound 



(Hagee)is the best agent foi\ promot- 
ing constructive metamorphosis. 

EcTHOL is very serviceable in chil- 
dren with soft and red tubercular 
eruptions on the skin which ulcerate 
and furnish a large quantity of un- 
healthy pus. The steady use of ecthol, 
combined with suitable hygienic means, 
will accomplish important relief in such 
cases. 



Resinol is an excellent remedy for 
allaying irritation in pruritus and urti- 
caria. In eczema with pruritus, resi- 
nol is one of the most effective appli- 
cations for that very troublesome dis- 
order. 



Absolute accuracy of dosage is not 
obtainable in capsules containing 
merely a mechanical mixture of oils 
and solids. 

Tabsules and tabsoids overcome this 
defect. They are attractive, neat and 
clean, and appeal at once to the careful 
physician. 

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in tabsules (Merz). No more expen- 
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Company, Detroit, Michigan. 



Various Uses of Iodipin. — Dr. E. 
J. Feibes, in charge of a sanatorium 
at Aachen, Prussia, reports on his 
extensive experience with iodipin 
(iodized sesame oil) during the past 
few years. He used the 25 per cent, 
strength exclusively; usually hypo- 



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Therapeutic Suggestions. 



dermically, sometimes per os in cap- 
sules or with beer. The iodipin was 
readily assimilated, as shown by the 
prompt presence of iodipin in the sa- 
liva and urine. In sixteen cases of 
malignant early syphilis iodipin ren- 
dered most excellent service ; in every 
instance the symptoms disappeared 
within a relatively short time. In one 
patient in whom mercury was not tol- 
erated and potassium had no effect, 
daily injections of 50 gm. (12 dr.) 
iodipin, 25 per cent., were well borne, 
and in four days brought about a com- 

Elete change m the symptoms which 
ad for eight months previously re- 
sisted subcutaneous mercurial injec- 
tions. Of three cases of rectal syph- 
ilis, in two cure followed the daily 
inunction with 6 gm. (1^ dr.) of mer- 
curial ointment and the injection of 
25^ gm. (6 dr.) of iodipin, 25 per 
cent. ; while in the third case, in which 
mercurial inunctions and potassium 
iodide were ill borne, the hypodermic 
use of iodipin alone promptly resulted 
in recovery. In sixty-three further 
cases of general syphilis speedy recov- 
ery was effected by the combined use 
of mercurial inunctions and iodipin 
injection ; and there were no relapses, 
as had previously occurred in a num- 
ber of the cases after the customary 
treatment with mercury and potas- 
sium iodide. In nasal syphilis iodipin 
rendered good service, and is preferred 
by the author to potassium iodide ex- 
cept in acute cases. He has treated a 
large number of necrosed nasal bones, 
and always achieved excellent results. 
The putrid masses adhering to the 
ulcerated surfaces are very quickly de- 
tached, and no coryza is produced. 
Dr. F. has used iodipin, 25 per cent., 
in quite a series of cases of syphilis of 
the nervous system — hemiplegia, cere- 
bral syphilis, spastic spinal paralysis, 
and locomotor ataxia. ^ ThermaJ baths, 
inunctions and iodipin injections con- 
stituted the treatment which proved of 
more than usual efficacy. In cases of 
obstinate specific adenitis and perios- 



titis, the author injected 1 gm. (15 
min.) of iodipin, 25 per cent., in the 
region of the diseased part. A com- 
pressive dressing of cotton was applied 
in the periostitis cases, so as to pre- 
vent diffusion of the iodipin. The in- 
jection was repeated as a rule but 
once, general treatment usually suf- 
ficing to complete the cure. The ben- 
eficial results manifested themselves 
very promptly in a few days. 

Finally, Dr. F. has treated psoriasis 
and sciatica with iodipin. In five cases 
of the latter he injected 5 gm. (75 
min.) along the course of the nerve. 
In three the result was striking ; the 
pains rapidly subsided, and the free 
use of the limb was speedily restored. 
Sometimes four injections were given 
at one seance. In the three psoriasis 
cases, some of years' standing, warm 
baths containing some creolin, inunc- 
tions with green soap, and injections 
of iodipin 25 per cent., soon brought 
about a marked improvement, so that 
the cure could be readily completed by 
an ointment of white precipitate, green 
soap and vaselin. 

Where the patient I'efuses injec- 
tions, Dr. F. gives the iodipin per os, 
up to 30 gm. (1 oz.) per day. Rectal 
administration is considered superflu- 
ous. — Dermal. Ztschr.y 1902, No. 9. 



Prevention of Cystitis. — In cases 
where frequent catheterization of the 
bladder is necessary there is always 
danger of producing a cystitis even 
with the most constant attention to pre- 
ventive measures. With such patients 
it is not wise to wait until the bladder 
has become distended, but to catheter- 
ize at short intervals (from three to 
four hours), of course giving proper 
care to the instruments. 

As an auxiliary prophylactic measure 
cystogen, grs. v twice daily, should be 
given. This inhibits the growth of 
bacteria in the urine and prevents irrita- 
tion of the neck of the bladder, so fre- 
quent and annoying in these cases. 
This precaution is also advisable before 



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Paint with 10 to 20 per cent alcoholic solution of Sander* s EucalyptoL 

Eczema^ Acne, Dermatitis, Pruritus, etc.: 

20 min. (in acute) to 60 min. {in chronic) of Sander's Eucalyptol to the ounce of 
Ung, Zinci, 

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Add 10 drops of Sander's Eucalyptol to a pint of warm water and wash parts: 
then paint the ulcer with Sander's Eucalyptol, full strengths and apply occlusive 
dressing. 

To avoid the irritation so frequently following the application of the common products of 
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Therapeutic Sucgestiqhs. 



and after prostatectomy, cystotomy, 
the passing of sounds, and in all surgical 
interference of the urinary tract, also 
during the course and following re- 
covery from typhoid fever. 

When a cystitis has become estab- 
lished, cystogen will be found effective 
in rendering the urine clear and non- 
irritating and an importi^nt adjunct in 
restoring the organ to a normal condi- 
tion. The dose in these cases should 
be increased to grs. v, four times daily. 



The Vegetable Kingdom has yield- 
ed another valuable drug to our arma- 
mentarium which has proven itself of 
value to dermatologists in the treatment 
of the various forms of eczema, tinea 
and kindred obstinate skin affections. 
It is best adapted for office practice, 
lending itself to various modifications 
and admixtures with diluents such as 
alcohol, glycerine and the like. Prompt 
results are obtained in the minor skin 
affections of the genitals and scalp. 

Chaparrin, the active principle of the 
shrub known as chaparro amargosa, is 
the preparation referred to and is of- 
fered the profession by the Matthewson 
Laboratory of Marshall, Texas. 



Typhoid Fever — In the treatment 
of this disease it is necessary to con- 
trol the patient's temperature and to 
keep the alimentary canal in as nearly 
aseptic condition as possible. The ef- 
fort of the physician must, however, 
be directed toward preventing intesti- 
nal perforation. No other remedy will 
accomplish this end more readily or 
more satisfactorily than Daniel's cone, 
tine, passiflora incarnata. ThQ ex- 
perience of the medical profession 
justifies the confidence which it has so 
often expressed. In the whole intes- 
tinal tract this remedy acts as a seda- 
tive and hypnotic. It does not lessen 
the supply of blood to any organ of 
the body, but gives natural and con- 
sistent nerve rest. Daniel's passiflora 
does not impair the heart action or 
produce constipation, but as a mild 



laxative and diuretic acts pleasantly as 
an eliminant and nervine. 

Daniel's cone. tine, passiflora in- 
carnata not only relieves * 'after 
pains" speedily, but it acts as a mild 
laxative and diuretic and it is therefore 
an ideal remedy in this condition. 
When once a physician has given this 
remedy a thorough trial he will never 
revert again to morphine, camphor, or 
any of the old-time injurious drugs. — 
William A. Donovan, M. D. 



A Report of Two Cases of Septi- 
c-s:mia Successfully Treated with 
Hg Oj Medicinal. (By E. J. Melville, 
M. D., Bakersfield, Vt.)— (7a«e 1.— 
February 6, 1894, was called to see 
Homer B., aged fourteen, who had 
been ill with a swelling in right groin 
for three weeks. Had been treated 
with hot applications, etc., but during 
that time abscess continued to grow, 
and at the time that I first saw him 
fluctuation could easily be made out. 
Temperature 102.5° F. Pulse 120. 
.Great emaciation. Constant vomit- 
ing. Daily chills followed by copious 
sweating, denoting pus absorption. 
Diagnosed appendicular abscess and 
advised operation. This was done same 
day under local anesthesia. 

Much pus escaped, and several small 
portions of fecal matter, denoting an 
opening into the gut. 

Temperature remained high, and 
sweats continued for three days fol- 
lowing operation, indicating the pres- 
ence of pus. I then began the use of 
Marchand's H^ Oj medicinal (15 vol.), 
so as to destroy the pus and morbid 
element which were still there. I in- 
jected four ounces of Hj Oj with a glass 
syringe slowly, while patient was in 
the Trendelenberg position, and al- 
lowed it to remain about fifteen min- 
utei. The boy was then lowered and 
laid upon his right side, when large 
quantities of pus, broken down tissue 
and gas flowed from wound. By gentle 
compression and massage of abdomen, 
much more was obtained. Large quan- 



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Charlatanism and should not shock the sensibilities of any, 
however refined, cultured or zealous of medical ethics for us 
to claim that ANASARCIN is a specific in dropsies, when 
clinical experience has demonstrated such to be a fact. If 
quinine is a specific in malaria, much more is ANASARCIN 
in dropsies resulting from disease of the heart, liver or 
kidneys, because that a trial of it in hundreds, yea, thousands 
of cases has not resulted in a failure known to us where 
directions have been followed. 

Besides being a specific for dropsies, it is a permanent 
cure in the conditions mentioned when begun early and 
continued a sufficient length of time, i, e.^ until the diseased 
organs regain normal function. ANASARCIN is composed of 
the active principles of Ozydendron Arboreum, Sambucus and 
Urginea Scilla, and is sold exclusively to physicians or 
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Therapeutic Suggestions. 



titles of sterilized gauze were packed 
over the opening in right side. 

The flushing out with Hj O^, etc., 
was repeated every twelve hours. 

Theimprovement was prompt. Tem- 
perature reached normal, and remained 
so after forty-eight hours. 

Wound was now washed out with the 
Hj O2 daily for four weeks, after which 
time the abdominal wound and faecal 
flstula were entirely healed. Patient 
has since developed into a full-grown 
laboring man, and has had no hernia 
nor any outward symptoms of his 
severe illness. 

Case 2. — March 2, 1897, was called 
to see George T., a farmer, aged 
thirty-eight years, who had been in the 
care of a Christian scientist for four 
weeks for a large swelling in right 
side. The treatment consisted in en- 
deavoring to persuade the man that he 
was not ill, and insisting that he take 
active exercise. Found patient in re- 
cumbent position with knees flexed 
upon abdomen, and suffering intense 
pain over right side of abdomen, which 
was filled with a soft fluctuating mass. 
Temperature 103.8° F. Pulse 130. 
Opened abdomen under local anes- 
thesia and evacuated three quarts of 
foul-smelling pus. 

Used four ounces H^ O^ full strength, 
slightly warmed, after pus had ceased 
to flow, and repeated procedure every 
twelve hours. 



This caused cessation of all untoward 
symptoms for eight days, when chills 
and fever returned. 

Another swelling was then noticed 
in right lumbar region, which, upon 
opening, gave one quart of pus. 

Flushed this second abscess in same 
way. The temperature soon reached 
normal, and patient made an unevent- 
ful recovery with exception of swell- 
ing of inguinal glands in left groin, 
which yielded in three days to hot 
fomentations. 

For conclusion I might say that in 
the above cases I used no medicines 
internally, and nothing externally but 
clean linen, plain gauze and H, O, 
(Marchand's). 

The operations performed were sim- 
ply opening abscesses, no drainage 
tubes, no flushing with salt solution or 
water, and no packing of abscesses. 

Though I used the Hj Oj in large 
quantities, and made no especial effort 
to see that all the solution returned, 
and though it was used over a period 
of several weeks, no untoward symp- 
toms developed from its use. 

The above gratifying results induced 
me to use hydrozone (which yields 
thirty times its own volume of nascent 
oxygen, instead of fifteen volumes) in 
other cases where a large amount of 
pus was present, with such good re- 
sults thafe^I am now giving the prefer- 
ence to this very strong solution. 



INDEX 



Original Articles. Paok. 

Actinomycosis and Xray Therapy. By M. L. Heid- 
ingsfeld, Ph. D., M. D. 47 

Relation of the Ureter to the Bladder. By Byron 
Robinson, B. S., M. D 49 

Prurigo and Pruritus. By S. C. Martin, M . D. 54 

Third Act in the Drama of Syphilis. By Henry Al- 
fred Robbins, M. D.. 55 

Elephantiasis in Japan. By Albert S. Ashmead, 
M. D 58 



Original Articles. Paox 

A Sexual Pervert. By W. B. Parson, M. D 71 

Social Position and Occupation as Etelated to the 

Health of Women. By S. L.Eisner, M.D 72 

Spinal Anesthesia With Tropa-Cooaine in Oenito- 

Urinary Surgery. By M. Krotoszyner, M, D 74 

Abstracts 78 

New Publications _ 84 

Therapeutic Suggestions 86 



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A BI-MONTHLY MAQAZINK DKVOTEO TO THK CONSIDKRATION OF CUTANEOUS 
VKNERKAL DISEASES AND QENITO-UfllNAflY SURQBflY. 



MEDICINE 



S. C. MARtiN, M. D. 

or DERMATOLOOY IN THI BAflNCS MIOIOAI. OOLLtM 
ST. LOUtS. 



EDITORS 

G. M. PHILLIPS. M. 0. 

PWOriSSOR or aENITO-UmNARY OltCAMt ST. I.OU« < 
PNVaiCIANS AND MIHaCONt. 



MANAGING EDITOR 
C. MARTIN. Jr.. M. 0. 



SUBSCRIPTIONS AND ADVERTISING. . 

The subscription price of this Toumal is |1.00 per ^ear, in advance, postage prepaid, for the United States, Canada 
and Mexico; |1 SO per year for all foreign countries included in the postal union. Single copies, 25 cents. 

Advertising rates will be furnished upon application. 

Address all communications, correstMndehce, books, matter regarding advertising, and make all checks, drafts 
and post-office orders payable to 

AMERICAN JOURNAL OF DERMATOLOGY, 

Fidelity Building. St. Louis, Mo., U. S. A. 



Vol,, vn. 



MAY, 1903. 



No. 3. 



PROSTATIC HYPERTROPHY PROM EVERY 
SURGICAL STANDPOINT. 

Arranged by Osobob M. PHiiiUPS, M. D., 

Editor*in-Chief Gtonito-Urinary Department American 

Journal cf BemuUology and Genito-XTrinary Diteases, 

and Professor of uenito-Urinary Surgery, St. 

Louis College of Physicians and Surgeons. 

The subject of hypertrophy of the 
prostate is not new, but, on the con- 
trary, is one that has engaged the at- 
tention of medical men from the ear- 
liest record. It is not a condition con- 
fined to a given locality, nor is it one 
appearing at particular seasons, but 
one that selects for its victims men 
who have passed the meridian of life 
without regard to habit, former health 
or activity. It is a condition not un- 
usually considered a disease, yet, as 
we will soon see, is a condition the 
complications of which very often 
strips the declining years of man of 
the usefulness and pleasure for which 
he has so long labored, and commits 



to the grave yearly many who were 
otherwise entitled to live. One is often 
impressed with the idea that discov- 
eries, inventions, improvements and 
truly great advances travel in cycles 
or waves, and this seems to hold true 
with reference to the above subject. 
Prostatic manipulation and considera- 
tion within the past few years has been 
very general. From every quarter 
evidence has come of scientific work. 
Men who for years have been silent 
upon this subject have become awak- 
ened. Surgeons in general have con- 
sented, specialists in this department 
have forged forward and blazed the 
way, which has been taken up by all 
who are interested in the betterment 
of mankind. This issue of this jour- 
nal is here devoted and, I might say, 
dedicated to this class of workers. 
The time devoted to the collection 
and compilation of the views and ex- 



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94 



Original Contributions. 



periencee of this talent and the space 
given is our best acknowledgment of 
appreciation. 

Every one solicited to participate in 
this matter has been asked for an an- 
swer to the fourteen questions here 
enumerated : 

Question No. 1. 

To what extent does occupation tend 

to prostatic h^pei'tropbyf Answer 

with especial rejbnsmx to w^ive indoor j 

active outdoor and sedentary pursuits. 

Question No. 2. 
Which suffer oftenest^ the phlegmatic 
or nervous? The lean or obese? 

Question No. 3. 
In brief J what is the etiology of 
prostatic hypertrophy? 

Question No. 4. 
To what extent has the cystoscope 
been of service in diagnosis^ and 
what instrument is prefen'ed? 

Question No. 5. 
To lahat extent is habit responsible 
for prostatic hypertrophy? Answer 
tvith especial reference to the use of 
alcohol and constipation. 

Question No. 6. 
Wfiai cases do you advise palliation ^ 
and of what does this consist? 

Question No. 7. 
Have you practiced ligation of the 
vasa deferentia? How many cases j 
and with what results? 

Question No. 8. 
Have you castrated for prostatic 
hypertrophy? How often^ and with 
what success? 

Question No. 9. 

Have yoic made the Bottini^ or some 
modification of this operation? How 
often and loith what success? Answer 
with reference to complications^ perma- 
nency of reliefs etc. 



Question No. 10. 
How often have you practiced supra- 
pubic drainage^ and what is your esti- 
mate of results? 

Question No. 11. 
How often have you made supra- 
pubic pi'ostatectomy^ and what have 
been the results obtained? 

Question No. 12. 
Bow often have you made a perineal 
prostatectomy^ and with what success? 
What incision in the perineum affords 
you greatest room? 

Question No. 13. 
Which is the operation of your 
choice J and why? 

Question No. 14. 
What unexpected complications have 
arisen during the operation for pros- 
tatic hypertrophy^ and what during 
the post-operative conduct of the case? 

A. 
Give binef i*esume of your prostatic 
work. 

And their several responses collected 
are here submitted. 

Before entering upon the analysis of 
these answers, however, it might be 
well to briefly consider in a general 
way some features of the prostate. 
The author in so doing will be par- 
doned for omissions, and any theory 
or view that may be at variance 
with those of others ; as far as possi- 
ble he will offer such as he personally 
believes, and which, for the most, are 
those that are generally accepted. He 
will be pardoned also for reference to 
the anatomy and physioloffy of this 
organ, for it might appear that the in- 
telligence of the reader would in this 
way be insulted. That this issue is to 
be broadly circulated, and will fall 
into the hands of many less versed 
upon this subject than those contrib- 
uting, it has been considered well to 
have it convenient. 



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PROSTATIC Hypertrophy. 



96 



Anatomy of Prostate. — The pros- 
tele is a muscalo-glandular body, quite 
three^foortJis being muscular of the 
unstriped wmtiety and one^fourth 
glandular tissue (fmeoam). In size 
and shape it is likened 'io n iiorse 
chestnut. More scientific, it is in shape 
a truncated cone measuring in length 
30 to 45 mm. ; width of base 35 to 50 
mm.; thickness 15 to 25 mm., and 
weighing about 15 to 20 grammes. 
Its position is 5 to 15 mm. below the 
symphysis pubis, 25 to 40 mm. from 
the anus; it surrounds the posterior 
urethra and bladder neck. 

It is held in place by the pubo- 
prostatic ligaments and anterior fibers 
of the levator ani muscles. Be- 
tween the prostate and rectunii is a 
quantity of loose fascia and the pros- 
tatic plexus of veins. Normally the 
prostate is in two lateral lobes, sepa- 
rated by a depression or fissure which 
is readily detected with the examining 
finger; additional lobes, bars or irregu- 
larities are the result of changes com- 
ing through age, disease or injury. 

The prostate is enveloped in a dense 
fibrous capsule, reflections of which are 
diverted into the substance of the organ 

The vacuum glands found here 
present columnar epithelium. They 
are surrounded by muscular tissue and 
empty into the prostatic urethra 
through a prostatic duct. 

About the office of the prostate 
there has been much conjecture, 
though today it is generally conceded 
to be purely a sexual organ, and that 
any other function it may possess is 
secondary. Many claim that the pros- 
tate by encircling the bladder neck acts 
as a sphincter muscle, but later re- 
search does not bear out such a view. 
The prostatic urethra extends the en- 
tire length of the organ ; it is roomy, 
and within it is much that is interest- 
ing; here we find the ducts of the 
glands that enter into its make-up, 
here the opening of the ejaculatory 
ducts, the verumontanum and sinus 
pecularis. 



Physiology of the Prostate. — 
Through its muscular endowment the 
prostate controls the ejaculatory ducts, 
and in this way the seminal fluid is 
taken from the vesicles into the pros- 
tatic urethra, where it is mixed with 
the prostatic secretion. Through its 
muscuko^ natm^ this fluid is com- 
pressed sufficiently to Bend it with tell- 
ing effect into the vagina and i^imst 
the cervix to develop at the critical 
moment in the female sexual satis- 
faction. 

Within the mucous membrane of 
the prostate are found a systens of 
nerves, the behavior of which is an 
unsolved problem; disturbances here 
often give rise to that mysterious and 
puzzling condition recognized as 
sexual neurasthenia, the remedy of 
which is making peace with this part. 

The glandular feature of the prostate 
performs a distinct and important 
function. The secretion is a thin 
opaque, alkaline material, with strong 
spermatic odor. The recognized use 
of which, is a diluent and antiseptic 
for the sp^matic fluid that offers food 
and protection to the spermatoza. 
Thus it will be seen that the prostate 
is not only a sexual organ, but one 
that is absolutely indispensable, that 
without it the race would end and 
without it the pleasure of sexual con- 
tact would be wanting. 

Pathology of Prostatic Hypertrophy. 
— There is so little known of the 
pathogenesis of this condition that this 
part of the subject might well be 
passed, and we are by no means of one 
accord upon what little that is known. 
That it is a chronic non-inflammatory 
hyperplasia, affecting both its glandu- 
lar and muscular composition, most of 
us are ready to admit. Arterio- 
sclerosis has been advanced and de- 
fended by Guyon and Lannois, and as 
ably denied and disputed by Casper, 
Motz and others. The analogy be- 
tween the uterus and the prostate and 
the fibromyoma theory of Thompson 
and Velpeau has faded under the light 



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Original Contributions. 



irch, for pathologists 
deno-fibroma. 
congestion theory is 
ot be supported by 

White and Martin has 
sorters, and the author 
impressed with it, but 
that neither this nor 
lus far taken adds 
imited knowledge or 
on the subject gen- 

prostatic hypertrophy 
riations in size, shape 
this body. All parts 
take on this hyper- 
ime time and in the , 
imining macroscopic- 
lien it is removed, we 
al conclusions. Many 
inequal size and shape 
;he gland is incised. 
Ft and hard. In fact, 
such an arrangement, 
ere a trace of normal-. 
Very often the re- 
pears even more com- 
microscopic examina- 
iderable that is patho- 
lust bear in mind that 
n subject to long and 
r to its removal ; that 
static hypertrophy be- 
y conditions in neigh- 
ich often are reflected 
concretions are fre- 
ind ulcerations follow, 
ell the necessity for 
md how reckless and 
ions usually are that 
ion. 

w of all the facts at- 
ondition, we may be 
present at least, with 
ing, and that our lim- 
upon certain features 
ertrophy should only 
iterest in the more 

practical directions. 

Prostatic hypertrophy is at all times 

easy of diagnosis. The means and 



instruments for this alone are ever at 
hand. To accurately measure the^ 
overgrowth or to determine its precise 
configuration, while interesting from a. 
scientific standpoint, requires special 
instruments and skill, but not always 
at the command of the general phy- 
sician. 

The damage being done by an en- 
larged prostate is by no means deter- 
mined by its size. The author has- 
very often seen enormous glands that 
were producing but little disturbance, 
and the other extreme as well. This- 
condition is often best estimated by 
its consequence rather than by its size- 
or shape. 

The advice that we are called upon 
to render in this situation carries with 
it weighty responsibility. We must 
call to our rescue here our character 
and professional strength, and remem- 
ber all the conditions, under which we 
are to proceed. 

The answers to the questions that I 
now invite your attention fully cover 
the subject in its entirety, and I am 
safe in here promising you satisfactory 
returns for your pains. 

JOHN A. WTETH; M. D.. 

or NEW YORK. 

( 1 ) Sedentary pursuits tend to pros- 
tatic hypertrophy. Active out-of-door 
life promotes normal secretion and ex- 
cretion and assures nourishment of the- 
tissues in general. 

(2) The phlegmatic and nervous- 
suffer about equally if they follow 
sedentary pursuits and are troubled 
from indigestion and uric and oxalic 
acid diathesis. 

( 3 ) Prolonged irritation of the blad* 
der from any cause, together with irri- 
tation of the vascular system which is 
produced by a chronic uric acid and ox- 
alic acid diatheses, and excessive use of 
the prostatic muscle are the chief 
causes of prostatic hypertrophy. 

(4) Have never needed the cysto- 
scope in diagnosis, nor is any instru- 



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Prostatic Hypertrophy, 



Q7 



ment necessary. The symptoms, to- 
gether with a digital examination, 
make the diagnosis easy. 

(5) Alcohol in any form is a factor 
in arterial irritation, and is also a fac- 
tor in prostatic hypertrophy. Consti- 
pation is also a factor. 

(6) In cases where operation for 
^ny reason is more than ordinarily 
•dangerous the catheter life may be ad- 
vised. Especially true in the very aged, 
seventy and over. 

(7) Have not practiced ligation of 
the vasa deferentia, and do not see any 
indication for this operation. 

(8) Have practiced this operation 
{castration) once with regret. Pa- 
tient recovered but was not improved. 

(9) Do not believe in Bottini's op- 
eration and have never practiced it. 

(10) No answer. 

(11, 12 and 13) Have practiced su- 
pra-pubic prostatectomy and perineal 
prostatectomy, but was not satisfied 
with either procedure as compared to 
a combination of both of these opera- 
tions, which, in my opinion, is far pref- 
erable to the one or the other for 
these reasons : Supra-pubic • incision 
into the bladder is a simple operation 
and does not add materially to the 
risk of a perineal incision. With the 
two incisions a dissection can be made 
rapidly and intelligently between the 
index finger of each hand. The drain- 
age through the perineal wound secures 
a quick closure of the upper wound. 
The supra-pubic wound gives a better 
exploration and command of the blad- 
der than the lower incision. No com- 
plications have arisen during or after 
any of my cases. I have had no 
deaths following prostatectomy, but 
have operated only in comparatively 
few cases. My opinion is that the op- 
eration is a valuable one. It should 
be performed early in the history of a 
case of prostatic hypertrophy. If the 
bladder becomes greatly overdistended 
or loses the power of emptying itself, 
and if it is nursed into helplessness by 
the use of the catheter, it is difficult to 



overcome this even after the obstruc- 
tion has been removed. 

(14) None. 

(A) No answer. 

♦ ♦ 

* 

AUaUBTUS 0HARLB8 BEBNAT8. X. D.. 

OF «T. LOUIS. 

(1) The statistics I have seen do 
not decide this question. I have an 
idea that these factors play but a very 
insignificant part. See next answer. 

(2) Do not think these are pertinent 
questions ; do not go much on home- 
opathic or temperamental pathology. 

(3) Etiology. — This is a short sum- 
mary of what is known at present about 
etiology. The question of how much 
clap and stricture contribute to the 
cause of prostatic hypertrophy is not 
yet solved. 

Up to the present time the etiology 
of prostatic hypertrophy has not been 
cleared up. A completely satisfactory 
explanation of the process has not been 
found. Sir Henry Thompson defined 
it as an ^'idioplastic tumor" in his 
lectures, which I had the great pleas- 
ure of hearing. Enlargements of or- 
gans during the early and middle life 
partake largely of an inflammatory 
nature or are found to be small cell in- 
filtrations. Knowing that old age 
somewhat inclines toward or favors the 
development of tumors, we are not 
surprised to find that a part of the sex- 
ual system may show a non-inflamma- 
tory enlargement at a time when this 
system, in all its other organs and in 
its functions, is undergoing a retro- 
grade metamorphosis and is being more 
or less put to rest. However, let us 
remember that Sir Henry's definition 
is not explanatory in any sense and 
leaves the etiology of our subject in 
the dark. 

Reginald Harrison seems to think 
that the hypertrophy is caused by 
overexertion or overwork of the organ 
the function of which he conceives to 
be that of aiding the bladder in the 
evacuation of its contents. He thinks 



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08 Original Contributions. 

that the main purpose of the prostate (7) No. I consider it a practice 

is to furnish a muscular support ^*pri- based on false premises. I do not 

marily to th« bladder and its contents know of a case that was cured. Have 

and secondarily to the adjacent parts," treated a dozen or more which were 

and thus seems to regard enlarged Castrated by others and were not per- 

prostate as a form of compensatory manently benefited, 

similar in its etiology to (8^ No. 

erstood hypertrophies of (9)1 was called to make a perineal 

walls of the heart. Guy- section in one case where infiltration 

3 opposed to this view, he of urine and sloughing of the scrotum 

e hypertrophy as due to followed a Bottini operation. Have 

lis of the urogenital tract, never done Bottini myself. 

568 with Velpeau that in (10) The following table gives the 

re have an analogue of the results of my supra-pubic drainage 

)us uterus. Sir Henry work and the fate of the patients so 

30 favors this view, and I far as known to me: 

at the myoma of the pros- Cm-ed 1 

:ou8 to myoma uteri, and Leading a catheter life, as "before 

It may be referred to de- drainage ........ 8 

or congenital cell-nests Operated on after Bottini and im- 

mant in early life and are proved 2 

to late enlargement by Operated on* after *Bo'ttini and "not 

accompanying the func- benefited 1 

gemto-urinary. organs m Operated on after Bottini and died 

disease. ^^ ^l^e third day after the cau- 

lust admit that the etiol- ^ ^f ^^ ^j^ pyelonephritis . 1 

;atic enlargement is not Operated on by perineal prostatec- 

id that the speculations tomy ... . . . 2 

ve before mentioned are of thes"e one died of 'pyelonephril 

more respectable than tis on the fourth day after op- 

itions which bring diet, eration, the other seems to be 

lodes of living, abstinence cured. 

ce, sexual habits, gout, One patient is now being drained 

)r gonorrhea into direct supra-pubically for the second 

lological relation with the ^j^^ ... 1 

. V. , , Died of pyelonephritis, senile gan- 

the diseases in which the g^ene or pneumonia .... 6 

)t cleared up the patho - Disappeared and condition unknown 4 

3omplete. 

few cases where I have Total 26 

an expert use the cysto- 

lot add materially to our All of those whom I drained supra- 

' the intravesical condi- pubically were eloquent in their praises 

of the relief afforded to them. The 
swer to question 1. The patient who died of embolus was en- 
)od here. tirely relieved of his usual trouble and 
vast majority of cases suffering before he died, and I am not 
*' will have to answer for sure that this death ought to count for 
easure until a radical op- much against the supra-pubic opera- 
perfected that its dangers tion. I regard the supra-pubic drain- 
to a figure much lower age as the best method of giving tern- 
t. porary relief to those patients who are 



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not willing or not in condition to 
undergo prostatectomy* The cystitis 
can be cnred by drainage and will not 
always return after the drain-hole is 
closed. 

(11) Once, in an old man (eighty- 
one years) at St. Mary's Hospital, died 
the next day — think he bled to death. 

(12) Twice. Both cases were bene- 
fited ; one seems almost cured of his 
troubles, if I mfty use this expression. 

(13) Ferguson's or Bryson's opera- 
tion, which are really very similar to 
each other in actual practice. 

(14) If you mean prostatectomy, I 
can say that I had no trouble in my 
two cases. 

(A) See above. 

BUaBNB FUUjBR. X. D., 

OF NEW YORK CITY. 

( 1 ) I do not feel convinced that any 
occupation in particular predisposes to 
prostatic senile hypertrophy. Those 
who have led very active lives, as far 
as I can clinically observe, suffer about 
equally with those of sedentary habits. 
Neither do I think that an antecedent 
history of gonorrhoea can be reckoned 
as an etiological factor. We do not as 
yet know the etiology of this disease. 

(2) I do not think that any of the 
above enumerated conditions exercise 
any causative effect. I have observed 
many clinical cases under each of 
these subdivisions. 

(3) I do not know further than that 
certain races seem to be exempt, as for 
instance Chinese and Japanese. I have 
seen one case, and only one, in a full- 
blooded negro. 

(4) The cystoscope in this connec- 
tion is only of secondary importance. 
If there are projecting intravesical 
h3rpertrophies they can be seen through 
its employment. Digital feel per 
rectum and instrumental examinations 
per urethra of the prostatic portion of 
the canal by searcher and by silk- 
woven catheter, constitute the usual 
instrument means of diagnosis. 



(5) I do not know that habit is re- 
sponsible. Prostatic hypertrophy in 
many instances is of itself a sufficient 
cause for constipation. If one has 
prostatic obstruction, that obstruction 
may be increased by the taking of al- 
coholics. 

(6) I advise palliative treatment as 
a poor substitute for radical treatment, 
chiefly in cases where the individuals 
are so frightened at the suggestion of 
operative relief that I feel that there 
is no use discussing the matter until, 
perhaps, the suffering due to the ad- 
vancement of the disease has made the 
patient amenable to argument. Palli- 
ative treatment practically consists of 
resort to the catheter. 

(7) No, but have watched results in 
the cases of others. Saw one case 
wherein some relief in symptoms re- 
sulted. 

(8) Yes, once. Patient died five 
weeks after of acute mania, the pros- 
tatic obstructive symptoms persisting 
up to death. 

(9) No, I consider the operation 
unsurgical. It is more dangerous 
than prostatectomy at my hands ; it is 
uncertain in its results; many of the 
cases wherein cures have been claimed 
for it have relapsed after a year or so 
from the date of operation. In any 
event it is only applicable to a few se- 
lected cases out of many. 

(10) Supra-pubic drainage, the pros- 
tatic condition being left in ^^statu 
quoj^' I consider very inefficient and 
half-way surgery. When I open the 
bladder supra-pubically I always re- 
move the prostatic obstruction except 
in case of cancer. 

(11) Considerably over 100 times 
my results are radical, permanent and 
excellent. My mortality, formerly 
larger, has for the last year been be- 
low five per cent. 

(12) Somewhat under 100 times my 
results are radical, permanent and ex- 
cellent. My mortality has for the last 
year by this operation been under five 
per cent. I use the median incision. 



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(13)1 study each individual case and 
make' my choice of operation depend 
on the condition of the vesical walls 
and on the size and extent and con- 
sistency of the prostatic hypertrophy. 
I choose perineal prostatectomy instead 
of supra-pubic, where nothing special 
exists to contraindicate that form of 
operation. 

(14) There are numerous complica- 
tions to guard against in these old sub- 
jects. The more accustomed the sur- 
geon is to this form of surgery, and 
the more alert he is, the fewer com- 
plications he will have in his practice. 

(A) In my book on ''Diseases of 
the Genito-Urinary System," and in 
the numerous articles I have written 
on the subject, one will be able, if xle- 
sirous, of getting familiar with my 
ideas in the subject. 

* » 

* 

BDWABD KABTIN. M. D.. 

OF PUILADKLPHIA, PA. 

( 1 ) To no extent. 

(2) Obese, but it often makes them 
lean. 

(3) Probably chronic tubercular 
prostatitis. But I don't know. 

(4) 'Very little. Leiter Nitze. 

(5) None. 

(6) Frequency with residuum, with 
or without infection. Symptoms non- 
crippling, non-progressive; purely lo- 
cal. Forced dilatation of internal ves- 
ical sphincter under nitrous oxide ; in- 
termittent catheterization. 

(7) Yes. Four. Cure, one; bet- 
terment, one; negative, two. 

(8) Yes, once. Cure. 

(i») Four. Negative in all; no com- 
plications. 

(10) About half a dozen cures; ex- 
cellent palliative at times. 

(11) N'o answer. 

(12) Six times; good results in all. 
Inverted U with base in perineum. 

(13) Perineal, as a rule. After- 
treatment simpler and safer. 

(14) Severe bleeding, tearing of 
rectum; great difficulty in removing 



prostate ; friable and adherent capsule^ 
anuria and uraemia. 

(A) Palliative, except when ob- 
structive. Symptoms are progressive. 
Continuous catheterization for acute 
vesical infection; overstretching for 
obstruction associated with small pros- 
tate; galvano-cautery for the same 
condition should overstretching fail. 
X-ray and cystoscope for stone in all 
cases characterized by great pain and 
obstinate cystitis. Prostatectomy by 
perineal route as a rule. 

* * 

» 

B&AN8FO&D LBWI8. X. D.. 

OF ST. I4OUI8. 

(1) Sedentary life favors it. 

(2) The obese. 

(3) Subacute chronic congestion or 
inflammation. 

(4) Is of considerable service in de- 
termining the conformation of pros- 
tatic outgrowth. The Bransford Lewis 
cystoscope, with prism-telescope, en- 
abling the observer to look slightly 
backward as well as at right-angle. 

(6) All influences contributing to 
prostatic congestion or inflammation 
favor development of prostatic hyper- 
trophy ; hence alcohol and constipation 
contribute their quota. 

(6) Cases in which not much resid- 
ual urine, and infection absent; in 
which an operative treatment would be 
dangerous on account of accompanying 
conditions or diseases. Regular cath- 
eterism and vesical irrigation ; internal 
antiseptics. 

( 7 ) Yes, three cases ; no permanent 
benefit. 

(8) Yes, twice; no benefit. 

(9) Yes, about eighteen times ; suc- 
cess in some cases, failure in others, 
intermediate results in others; the re- 
sults dependent mainly on the confor- 
mation of prostatic obstruction pres- 
ent. 

To illustrate my position, I wish to 
call attention to a few points in the 
histories of several cases with which I 
have been personally acquainted. 



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101 



V. S., eet. sixty-five years, came to 
my clinic in October, 1901, suffering 
from various effects of prostatic ob- 
struction, chief among which was com- 
plete and absolute inability to urinate 
voluntarily, and this, notwithstanding 
the fact that perineal prostatectomy 
had been done on him six months be- 
fore (on June G, 1901) by an acknowl- 
edged authority in this mode of oper- 
ating. The complete retention, re- 
lieved only by the regular passage of 
the catheter, had existed, the patient 
said, from the time of the withdrawal 
of the perineal drainage tube, seven 
days after the operation. A perineal 
fistula still existed, from the same pro- 
cedure. 

Here was a case of complete failure 
of relief after removal of the prostate 
by an opei'ator whose ability and ex- 
perience cannot be put into question. 

My cystoscopic examination seemed 
to reveal a projection from the poste- 
rior commissure, hanging somewhat 
into the bladder. With a doubt in my 
mind as to its probable efficacy in the 
case, which doubt I expressed to the 
class before whom I operated, on No- 
vember 20, 1901, 1 made one posterior 
incision, three centimeters in length, 
with the Freudenberg incisor. Be- 
cause of the absence of prostatic tis- 
sue, on account of the previous oper- 
ation, it was evident that care must be 
observed not to bum into perineal 
structures. No hemorrhage resulted ; 
cocaine anesthesia, secured with my 
urethral tablet-depositor, was so com- 
plete that the patient declared that 
there was no more pain than there was 
from an ordinary catheterism. He re- 
mained in the hospital three or four 
days, and was then about, as usual. 
Besult, possibility of voluntary urina- 
tion, and reduction of the complete re- 
tention to seven ounces of residual 
urine* One month later, the same op- 
eration was repeated, with no more 
trouble to the patient ; and the net re- 
salt was a further reduction of the re- 
sidual urine to about four ounces, to- 

2 



gether with increased freedom in vol- 
untary urination. This not being sat- 
isfactory to me — although a marked 
improvement over his condition for the 
previous five or six years— it seemed 
advisable to open supra-pubically, 
which I did before the class on Janu- 
ary 8, 1902. A collarette of fibro- 
mucoid tissue completely surrounded 
the urethral orifice, and in just the po- 
sition to fall together in a valvular 
manner and shut off the egress of urine 
when attempts at voluntary urination 
were made. The more marked the 
contraction, the tighter would the valve 
be closed. My posterior cautery incis- 
ion was there, as shown in the model, 
but it had only bisected the posterior 
segment of the collar, the flaps of 
which could still fall together and in- 
terfere markedly with the outflow of 
urine — although the groove thus made 
would probably allow of the leakage 
through it of a part of the urine. This 
accounted for the improvement noted 
after each of the electro-incisions (re- 
duction in the residual urine at first to 
seven, then to four ounces); and also 
for the failure of the incision to give 
complete relief to the case. 

Through the supra-pubic opening, 
with a Paquelin cautery I burned off 
the whole of the projecting mass, ac- 
centuating the cauterization on the 
posterior aspect, to secure as low a 
level as possible; nevertheless a con- 
siderable depression was still left in 
the bas fond, as I did not wish to open 
the prostatic urethra to secure an abso- 
lutely '*low level," flush with the bot- 
tom of the bas fond. My chief object 
was to remove (he obstruction^ which 
was done in the manner described. 
Nothing was done bearing directly on 
the perineal fistula. It was considered 
that, with clearing up of the outlet, 
this would take care of itself. The 
bladder was drained supra-pubically 
for eight days. After the removal of 
the tube, and even before the supra- 
pubic wound was closed, the bladder 
was able to expel in a good stream 



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Original Contributions. 



through the urethra a part of the urine 
or the irrigation fluid. Since the clos- 
ure of the wound, he has urinated 
properly and regularly, in what he es- 
teems a very delightful stream. He 
can irrigate his bladder without the aid 
of the catheter; in fact, the catheter 
is now never used except for the pur- 
pose of testing the amount of residual 
urine, which has been reduced to one- 
half or three-fourths of an ounce. The 
frequency of urination is about normal 
(six or seven times in twenty-four 
hours). The patient has been able to 
resume his occupation of carpentering 
after an interruption of one year. He 
relates that previous to the prostatect- 
omy, he had been forced to use the 
catheter regularly for nearly eight 
years, carrying it in his pocket for that 
purpose (from March, 1894, to Novem- 
ber, 1901). 

Case 2. — W. D. set. sixty-five years, 
was turned over to my care at the City 
Hospital, by my friend, Dr. Nietert, 
who, with his internes at that time, is 
familiar with the subsequent develop- 
ments. 

The patient had suffered from trou- 
bles connected with urination for four 
or five years previously. His general 
health and strength were markedly re- 
duced, so that he was very feeble, 
looking much older than he really was. 
He was passing urine about thirty-five 
times in twenty-four hours, as often at 
night as in the day time, harassing 
him with loss of sleep as well as much 
actual suffering. His urine was of 
light straw color, low specific gravity 
(1.010), and contained albumin and 
casts, indicative of involvement of the 
kidneys. Cystitis was present. Re- 
sidual urine was about twenty-eight 
ounces. A metal catheter of ordinary 
curve was obstructed, while one of 
long prostatic curve went in easily. 
Because of the enfeebled condition of 
the patient, and the renal complication 
mentioned, a more radical operation 
than the Bottini was deemed danger- 
ous; and it was considered necessary 



to undertake even that with the utmost 
caution. The Bottini was done on 
January 27, 1898, under cocaine anes- 
thesia, onlv one (posterior) incision 
being made in order to avoid severity 
as much as possible. It was ten days 
afterwards before noticeable improve- 
ment began, but it was progressive 
thereafter, so that in a month he was 
urinating freely and in a good stream ; 
and instead of thirty-five times in the 
twenty-four hours, it was only seven 
or eight times. The residuum had 
been reduced to about two ounces. 
The patient's general and renal condi- 
tions had both improved materially. 
I was desirous of showing him at the 
medical society, to which he consented, 
with the request, however, that we wait 
until he could be operated on for a 
large inguinal hernia, of which he was 
the bearer. We waited. He was 
turned over to another consulting sur- 
geon who operated for the hernia. 
The wound became infected, resulting 
in gangrene there and also in the intes- 
tines and lungs. His death soon after 
enabled me to get a good specimen. 

As is usual after maceration in alco- 
hol, the tissues have shrunk some- 
what, so that they do not appear ex- 
actly as they did when fresh ; but the 
moderate enlargement of the prostate 
is evident, likewise the groove posteri- 
orly and tq the right, made by tho in- 
cisor. 

The depth of this groove is only ev- 
ident when we oppose the parts as they 
were seen before the incision was 
made, when the narrowing of the out- 
let is seen to be marked. 

Dr. Willard Bartlett, who made the 
post-mortem examination, made the 
following annotation regarding it: 
"The prostate shows both lateral lobes 
hypertrophied. The wound left by 
what the clinical history terms 'Bot- 
tini's operation,' is completely healed, 
leaving an orifice to the right of the 
median line which will easily admit an 
ordinary lead pencil into the prostatic 
urethra, and evidently furnished a free 



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outlet for the urine." The obstruct- 
ive condition in this case was a bar 
formation at the posterior commissure ; 
the incision had severed it and opened 
a groove through which the urine 
could pass with only slight impediment. 

(10) Practiced it only for the tem- 
porary benefit it affords, which is often 
very valuable, permitting recuperation 
for a raore.effective operation. 

(11) Three times; good result in 
each case. 

(12) Eight times; excellent success. 
The inverted Y incision is preferable. 

(13) Each operation, in selected 
cases; but with other things favora- 
ble, the perineal prostatectomy gives 
most secure results. 

(14) In one case, in which linear 
perineal incision did not give sufficient 
space, a small tear was made through 
the anal margin, and a constipated 
movement of the bowels two days later 
enlarged it for an inch into the anterior 
rectal wall. The perineal wound heal- 
ing, left a urethro-rectal fistula, which 
I healed by an extensive plastic opera- 
tion. 

(A) Summing up the points favor- 
able to the three operative procedures 
especially considerea in this discussion, 
we have ; 

Favorable for the Supra-Pubic 
Route. — (a) General enlargement of 
the prostate, with extreme intra-vesi- 
cal projection of the median or lateral 
lobes, diminishing their accessibility 
from the perineum. (6) Marked ped- 
unculation of the intra-vesical tumors, 
with absence of obstruction from other 
sources. 

Favorable for the Perineal Route. — 
(a) General hypertrophy, involving 
the median and lateral lobes, without 
■extreme intra-vesical projection. (6) 
Large or very thick bar formation; 
marked compression of the urethra be- 
tween the enlarged lateral lobes, (c) 
Excessive development of the prostate 
in the direction of the rectum, (rf) 
In most cases, where the patient is in 
good general condition and there is not 



a special indication favoring one of the 
other procedures. 

Favorable for the Bottini. — (a) 
Cases of extreme debility, unable to 
stand one of the severer operations. 
(6) Cases of bar or medium sessile ob- 
struction, of not too great dimensions. 
(c) Incomplete collar formation, (d) 
Horwitz says it should be employed as 
a prophylatic against further obstruct- 
ive hypertrophy, at the beginning of 
catheter-life. 



J. B. MUBPHT. M. D. 

or CHIOAQO. 



(I) I have not been able to discern 
that occupation plays any part what- 
ever in the production of prostatic hy- 
pertrophy. 

(2^ About equal. 

(3) I am unable to determine, from 
my experience, any etiologic factor in 
the production of prostatic hypertro- 
phy. I believe those given in the text- 
books are erroneous and the result of 
imagination rather than the close ob- 
servance of facts. 

(4) The cystoscope has been of no 
service. 

(b) None. 

(6) I advise palliation in cases of 
temporary obstruction for urinary re- 
tention. Consists of use of hot baths, 
large quantities of distilled water, 
opium and belladonna suppositories, 
avoidance of catheter or bladder irri- 
gation. 

(7) No. 

(8) Yes. With pronounced effect 
in two cases and no effect in the re- 
maining. 

(9) No. I have not performed the 
Bottini. 

(10) I practiced supra-pubic drain- 
age for ten years, in a large number of 
cases, at the Alexian Brothers' Hos- 
pital. The results were very unsatis- 
factory, for two reasons: first, they 
were not resorted to until the cases 
were extreme; second, I believe it is 
not an efficient treatment. 

(II) Probably fifteen or twenty 



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Original Contributions. 



times, with very unsatisfactory re- 
sults. My Alexian Brothers* Hospital 
records are not at my disposal at the 
present time, and, therefore, I cannot 
give the exact number. 

(12) Twenty-nine times, with per- 
fect success. The crescent or "A" 
shaped incision gives the best space. 

(13) The perineal operation, as de- 
scribed in the Jouimal of the Ameri- 
can Medical Association about one 
year ago. 

(14) None during operation. I 
have been impressed by the care that 
must be exercised to avoid the rectum, 
with very large prostates. 

Post-operative complications. — One 
case, apoplexy two weeks after opera- 
tion ; patient was sitting up reading 
newspaper. In another there occurred 
a peri- and endo-carditis, rheumatic, 
five weeks after operation, when the 
patient was practically well and about 
to go home. 

(A^ I believe that the operation of 
the future will be prostatectomy by 
the perineal route, **A" shaped incis- 
ion, removal of prostate from the 
bladder wall from above downward, 
with remov^al of the floor of prostatic 
urethra ; that it should be resorted to 
early, before the manifestations of 
sepsis ; that prostates of any size may 
be removed through the perineum; 
that drainage of the bladder is not 
necessary for longer than two weeks ; 
that with experience and care the 
operation can be performed safely 
within thirty minutes ; that the ''A" 
shaped incision allows as much space 
for the removal of the prostate as the 
vagina for the removal of the uterus ; 
that the result is a practical restora- 
tion of the normal conditions of the 
bladder; that there is permanent disa- 
bility for intercourse. 

* 

OBVILLB HOBWITZ. M. D.. 

OF PHILAOSLPHIA, FINN. 

(1) So far as I have been enabled 
to ascertain — none. 



(2) There seems to be little or no 
difference. The condition is rarely 
found in the negro. 

(3) Not ascertained. 

(4) The cystoscope is of much value 
in portraying the condition of the 
bladder and greatly aids the surgeon 
in determining the expediency of per- 
forming a Bottini operation, or a pros- 
tatectomy. 

The condition of the bladder enables 
the operator to decide whether or not 
a radical operation will be followed by 
relief of the annoying vesical symp- 
toms. 

The most satisfactory instruments 
that have been employed by the writer 
for diagnostic purposes is the posterior 
urethroscope of Swinburn and the 
Bransford Lewis cystoscope. 

(5) The habits of individuals do not 
appear in any way to tend to the 
formation of hypertrophy of the pros- 
tate gland. Constipation is frequently 
an annoying accompaniment associated 
with it; it seems to be caused by the 
enlargement of the gland, as the radi- 
cal operation is often followed by its 
disappearance. This has been espe- 
cially noticed to take place after the 
Bottini operation. 

(6) Palliative treatment is reserved 
for those cases who are advanced in 
years in whom the obstruction has ex- 
isted for a long period of time and ex- 
hausted from pain, suffering and 
loss of sleep. In old men whose re- 
sisting power is at a low ebb, where 
the bladder is hopelessly damaged, and 
in those who show marked signs of 
general sclerosis; as rigid . vessels, 
arcus senilis, polyuria, hyaline casts or 
pyelitis. 

The treatment advocated in this class 
of cases depends on the physical con- 
dition of the patient, the character of 
the prostatic overgrowth, the state of 
the bladder and kidneys. It may be 
summarized as medical; hygienic; 
systematic catheterism; rest in bed 
for several weeks, the bladder drained 
by means of continuous catheterism ; 



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irrigation of the bladder with appro- 
priate sulutions, or instillations of 
various remedies; rectal injections; 
permanent drainage by means of a 
supra-pubic cystotomy; in some in- 
stances a Bottini operation in con- 
junction with periodical catheterism. 
In patients who suffer from recurring 
attacks of orchitis from the passage of 
a catheter, vasectomy is performed. 

(7) Twenty-eight individuals were 
submitted to this operation, all of 
whom, with the exception of six, were 
over sixty-three years of age, and the 
sexual functions of all but six were in 
abeyance. Vasectomy was performed 
whether the enlargement of the pros- 
tate was glandular or fibrous in char- 
acter. No deaths resulted from the 
operation. . The results obtained lead 
me to the following conclusions: 

(a) As a curative measure vasectomy 
is of little value, and is not to be 
recommended. 

( b ) The operation appears to be most 
effective when performed on patients 
between fifty and sixty years of age, 
in whom the prostatic enlargement is 
of the soft glandular variety. The 
genitnl organs of patients of this age 
are usually in a healthy condition, and 
the individuals usually object to any 
operation that is liable to interfere 
with their sexual functions. 

(c) The operation is serviceable in 
those cases where the physical condi- 
tion of the individual renders him unfit 
to undergo surgical procedure, who 
will not submit to a more serious pro- 
ceeding, who has to depend upon the 
frequent use of the catheter or who 
suffers from periodical attacks of 
orchitis. 

(d) Sexual vigor is not diminished 
by the division of the vasa deferentia. 

(e) Atrophy of the testicle does not 
result from the operation. 

(8) In forty-four cases bilateral 
orchidectomy was performed, irre- 
spective of the character of the en- 
largement of the prostate gland. All 
the patients were men in advanced 



years, whose sexual powers had dis- 
appeared; in the majority the heart 
was feeble, the arteries atheromatous, 
and they all suffered from general de- 
bility, the result of the wear and tear 
of prblonged misery. In a few, a far- 
advanced diseased condition of the 
bladder and kidney existed. Several 
had suffered from frequent attacks of 
retention of urine; catheterism was 
necessary in all ; the insertion of the 
instrument was difficult and painful. 
In this class of patients prolonged 
anesthesia, with any seribus operation 
in addition, would in all probability 
prove immediately fatal. 

(a) In selected cases, bilateral cas- 
tration will always hold a place in 
genito-urinary surgery as a means of 
removing the obstruction caused by 
prostatic hypertrophy. 

(6) The operation is indicated in men 
of advanced years, whose sexual pow- 
ers are lost, the overgrowth of the 
prostate being purely glandular in 
character; or who have reached that 
period of life where the passage of a 
catheter becomes difficult and reten- 
tion of urine not an uncommon occur- 
rence; or an advanced diseased condi- 
tion of the bladder and kidneys does 
not preclude a serious operation. 

(c) When the prostatic enlargement 
is fibrous in character no benefit is de- 
rived from the operation, and its em- 
ployment under these circumstances is 
not to be recommended. 

(d) The primary effect of castration 
on the glandular prostatic hypertrophy 
is first to relieve congestion, and 
secondarily to cause atrophy. 

(e) When the prostatic enlargement 
is fibrous in character no benefit is de- 
rived from the operation and its em- 
ployment under these circumstances is 
not to be recommended. 

( /) Orchidectomy in very old sub- 
jects with extensive disease of the 
bladder and kidney is attended by a 
large mortality, and is a very serious 
operation. 

(9) Seventy-nine patients, between 



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the ages of forty-nine and eighty-one 
years, were operated on by me by the 
**Bottini method." One death re- 
sulted. According to Dr. Fredenberg 
(Berlin), the most recent statistics 
show that good results can be looked 
for in 86.63 per cent, of cases; failure 
in 7.6 per cent.; mortality in 4.5 per 
cent. 

For convenience of description the 
cases that I have treated may be di- 
vided into three groups : 

First. — Comprising individuals who 
were commencing to suffer from the 
effects of prostatic obstruction, and 
who required the daily use of the 
catheter. These were between the 
ages of forty-nine and sixty-one. 
Heretofore this class of patients would 
have been placed upon what is known 
as the ''Palliative Method of Treat- 
ment." Of sixteen who submitted to 
the operation before the secondary 
pathological changes that follow pros- 
tatic hypertrophy had taken place, all 
made prompt recovery ; the period of 
convalescence varied from four to 
eighteen days. When operating on 
patients at the beginning of prostatic 
hypertrophy, the gland as a general 
rule being but slightly enlarged, a pros- 
tatic incision with a smaller blade 
should be employed than that which is 
used in more advanced cases. The 
Bottini operation performed early may 
be regarded as a radical method of 
treatment resulting most favorably. 
It would seem as though the time had 
passed when the physician is satisfied 
to advise his patient to use the catheter 
daily and patiently wait until the ob- 
struction becomes so great and the 
complications so grave that some rad- 
ical surgical procedure is necessary to 
give relief. 

Second. — The second group of cases 
comprises those where the obstructive 
symptoms have existed for a length- 
ened time, where the bladder is begin- 
ning to be involved, and is in the proc- 
essof undergoing pathological changes. 
Catheterism is daily requisite, the 



physique of the individual being still 
in good condition. This group is 
portrayed by eight operations, the in- 
dividuals being between fifty-nine and 
sixty-three years of age ; the period of 
convalescence, including necessary 
after-treatment, was from two weeks 
to four months. Of the number op- 
erated upon five were cured, two were 
improved, and one was benefited, so 
far as residual urine was concerned, 
which was owing to the bladder being 
atonied and paralyzed; the catheter 
was readily inserted, the prostatic 
spasm having been entirely relieved by 
the operation. A slight amount of 
cystitis continued with a persistence of 
residual urine, rendering the use of 
the catheter necessary. 

To the third group belonged men 
more advanced in years, their ages 
ranging between sixty-five and eighty- 
one years, in whom prostatic hyper- 
trophy had existed for a lengthened 
period, who had reached what is known 
as the *'Break-diOwn of Catheter Life," 
whose general health was below par, 
with atheromatous degeneration of the 
blood vessels, and polyuria, together 
with damaged bladder and kidneys, 
and who had suffered from repeated 
attacl^s of retention of urine. A large 
amount of residual urine existed in 
each instance. All were in too poor a 
condition to withstand a capital opera- 
tion, and before the introduction of 
Bottini 's method would have had to rest 
satisfied with some. palliative procedure. 

Out of the number of patients op- 
erated upon, in three there was a slight 
tendency to the recurrence of the ob- 
structive symptoms at the end of six 
months, making a second operation 
necessary. Two had occasional attacks 
of congestion of the prostate gland, 
associated with temporary retention of 
urine, following prolonged dissipation 
and exposure. From the results ob- 
tained by the experience that I have 
here recorded, I feel that I am war- 
ranted in forming the conclusions here 
set forth : 



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(a) Success following the Bottini op- 
eration depends on having perfect in- 
struments, a good battery, the neces- 
sary skill, and the employment of a 
proper technique. 

(6) In suitable cases the Bottini is 
the safest and best radical operation 
thus far advised for the relief of pros- 
tatic hypertrophy. 

(c) It is often very efficacious in ad- 
vanced cases of obstruction as a palli- 
ative measure, rendering catheterism 
easy and painless, relieving spasm, 
lessening the tendency to constipation, 
and improving the general health. 

(d) It is of especial service in the be- 
ginning of obstructive symptoms due 
to hypertrophy of the prostate gland, 
and may be regarded as a means of 
preventing catheter life. 

(e) It is indicated in all forms of 
hypertrophy except where there is a 
valvular formation, or where there is 
an enormous overgrowth of the three 
lobes associated with tumor formation 
giving rise to a pouch, both above and 
below the prostate gland, in cases of 
a massive enlargement of the lateral 
lobes or when intra-urethral growths 
exist. 

(/) Where the bladder is hopelessly 
damaged, together wilh a general 
atheromatous condition of the blood 
vessels, associated with polyuria, re- 
sults are negative. 

{g) Pyelitis is not a contra-indication 
to a resort to the operation. 

(10) Have practiced suprapubic 
drainage in seventy-six cases. It is 
doubtless the most satisfactory pallia- 
tive operation that can be resorted to. 
Mortality about 2 per cent. 

(11) Have practiced suprapubic 
prostatectomy in fifteen cases; three 
deaths. Results excellent. 

(12) Have performed perineal pros- 
tatectomy in thirty-one cases. Results : 
Fourteen cured ; seven much improved ; 
four slight benefit; one unimproved ; 
five deaths. Used median incision. 
Bryson's technique ; perineal prostatec- 



tomy gives lower mortality, less hem- 
orrhage, with better drainage; no in- 
jury to the neck of the bladder. A 
shorter time is required to perform the 
operation. Ninety-five per cent, of 
hypertrophy of the prostate gland can 
be removed by means of a perineal in- 
cision. The writer recently removed a 
gland weighing an half a pound by 
means of the median cut. 

(13) A suprapubic prostatectomy 
is a chosen operation in cases of ob- 
struction, due to valve formation, with 
along-standing cystitis; as it is like- 
wise where obstruction is due to a col- 
larette, when a partial resection of the 
gland may be performed. 

Prostatectomy should be performed 
only in cases that have been carefully 
selected. Many are fit only for pallia- 
tive operations. In many instances it 
is wise to perform a preliminary supra- 
pubic cystotomy, drain the bladder 
for some time until the patient's con- 
dition will warrant a pro8tatectom3\ 

(14) No unexpected coniplications 
have ever arisen in the practice of the 
writer during, or following, the oper- 
ation for prostatic hypertrophy. In 
two instances recto-urethral fistula 
formed on or about the twelfth day ; 
owing probably to the employment of 
metal drainage ; drainage is now main- 
tained by means of a soft rubber rectal 
tube, caliber 40 m., after perineal pros- 
tatectomy. In one instance secondary 
hemorrhage supervened on the second 
day. One patient died of secondary 
shock twenty-four hours after opera- 
tion. A perineal operation fistula re- 
sulted in one case, requiring a second 
operation. 

In several cases dribbling of urine 
has followed a perineal prostatectomy, 
which condition has lasted from six 
months to a year. In one case a tend- 
ency to the formation of a urinary 
stricture was developed at the neck of 
the bladder necessitating the use of 
bougies. 

(A) xVo ansvjer. 



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WILLIAM K. OTIS. M. D.. 

OF NBW YORK CITY. 

(1) As far as I am aware occupa- 
tion has no effect in the production of 
prostatic hypertrophy. 

(2) It occurs without reference to 
these conditions. 

(3) I do not know. 

(4) The cystoscope is of considera- 
ble value in the diagnosis, in showing 
the amount of internal overgrowth 
present. The * 'retrospective" cysto- 
scope, made for me by Wappler & Co., 
gives a good view of the internal ure- 
thral orifice which is of great service 
when prostatic hypertrophy is present. 
The same is accomplished by Prof. 
Young's cystoscope for this purpose. 
The ordinary cystoscope is of much 
less value. 

(5) Not responsible at all. 

(6) Prevention of urinary infection, 
use of catheter, avoidance of exposure 
to cold and wet, care of general health 
— avoidance of constipation — uro- 
tropin. 

(7) Three cases without result. 

(8) One case; patient died two 
months after operation without im- 
provement. 

( 9 ) I do not approve of the Bottini 
operation. Consider it dangerous in 
comparison with results obtained, and 
have never performed it. 

(10) Four cases; this being only a 
palliative operation the annoyance of 
the supra-pubic wound, irritation of 
the skin and odor are always present 
though the patient may be compara- 
tively comfortable otherwise. 

(11) iV^o answer, 

(12) iVb answer. 

(13) The perineal operation with 
supra-pubic opening down to but not 
opening the bladder. The enuclea- 
tion taking place through the perineal 
opening, the prostate being pushed 
down with the hand in the supra-pubic 
wound. Gives better drainage and 
quicker recovery than any other 
method. Most serviceable on thin 
subjects. 



(14) No answer. 
(A) No answer. 



ALEXANDBB HUGH FSBaUSON. 

OF CHICAGO, ILL. 



D.. 



( 1 ) Nearly all my cases were robust 
and led active outdoor life, riding, etc., 
but soon lost flesh and became nervous. 
More were physicians than any other 
class. 

(2) Temperament plays no part. 

(3) Infection engrafted on hyper- 
emia or traumatism. In all my cases 
the tissue changes were inflammatory 
in character. 

(4) Can make diagnosis without 
cystoscope. It punishes a patient to 
use it, and the majority of cases cannot 
stand it. The clinical history alone is 
sufficient on which to base a diagnosis 
in the vast majority. The sound and 
finger are the instruments most used 
by me. 

(5) Constipation in 75 per cent. 
Alcoholism caused congestion and re- 
tention; exposure to cold was often 
followed by retention. 

(6) (a) Catheterization for reten- 
tion. 

(6) Aspiration for retention if 
catheter cannot be passed. 

(c) Perineal section and drainage in 
desperate cases too bad for a radical 
operation. 

(cZ) I have used bougieing to advan- 
tage, but it is dangerous. 

(e) All these means are only pallia- 
tive to prostatectomy. I do not prac- 
tice palliation very much. 

(7) Yes. About twelve cases. All 
but two temporarily benefited. None 
cured. I have discarded the procedure. 

(8) Yes. Three times. No benefit 
permanently ; no result at all in two. 

(9) Yes. Three times; one death 
(septic). No permanent relief. I 
know now that they were not suitable 
for Bottini. 

(10) Never practiced it. Have re- 
moved the pro.state via perineum to 
cure supra-pubic fistulse. 



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(11) About twenty-four with six 
deaths. I have abandoned this opera- 
tion. 

N. B.— Thought I had about fifty 
cases until I began to count them up. 

(12) Twenty-nine times ; one death, 
the rest cured. The j^ shape gives 
most rooip , but greatest traumatism . I 
find so much room unnecessary. 

(13) Median perineal, (a) It af- 
fords ample room', (b) The traumatism 
is minimized, (c) Drainage is perfect. 
{d) Never applied a ligature on a 
vessel. 

(14) Opened the peritoneal cavity in 
one case between the rectum and blad- 
der, with no ill result. Post-operative 
i^omplications: (a) Epididymitis in 
five cases, mild in character, (b) 
Rectal fistulae in two cases, both caused 
by careless dressing over a week after 
the operation by the man in charge. 
One of these cured since by operation. 
The other has vesical control. 

(A) Supra-pubic prostatectomy, 25 
per cent mortality. 

Perineal prostatectomy, 3.4 per cent, 
mortality. 

Bottini prostatectomy, 33J per cent, 
mortality. . • 

(One out of three). 

♦ ♦ ^• 
BOBBBT TUTTLB MOBBIS. M. D.. 

OP NEW YORK CITY. 

( 1 ) No definite testimony. 

(2) In my particular set of cases 
the men have belonged to the lean 
and nervous type chiefly. 

(3) Presumably a simple degenera- 
tive change, similar to that which 
occurs in the uterus. 

(4) Of service in determining the 
nature of some of. the complications 
that involve the bladder. I use the 
Rochester S. A. cystoscope at present. 

(5)1 rather doubt if they have any 
bearing. 

(6) Palliative treatment for cases 
without serious complications, and for 
cases with such serious complications 
that the comparative danger between 



operation and no operation is too great. 
Standard methods. 

(7) Yes, one case. No result of 
consequence. 

(8) No. 

(9) No. 

(10) Several cases in former years. 
Now prefer prostatectomy when feas- 
ible. 

(11) Three cases. Combined op- 
eration; satisfactory result. 

(12) Three cases; semilunar. All 
the patients benefited. 

(13) Must depend upon the case. 
In cases requiring special draini^e, 
combined operation. In others, the 
simple perineal operation. 

(14) None. 

(A) It has been chiefly palliative 
until recently. 

* 

B. XBBBILL BIOXBTTS. M. D.. 

OP CINCINNATI, OHIO. 

(1) Cause unknown. More fre- 
quent among civilized races. Occupa- 
tion and sedentary habits are probably 
the greatest factors in its production. 

(2) Have not noticed any differ- 
ence. 

(3) Don't know. 

(4) A great aid where neoplasm is 
intravesical. 

(5) Have no evidence that they are 
a cause, but believe them to be of 
more or less influence in its produc- 
tion. 

(6) Inoperable cases; those who 
could not withstand prostatectomy. 

(7) Once. No benefit. . 

(8) Twelve times. Double orchi- 
dectomy. Excellent results in major- 
ity of cases. Cure in one seventy- 
three years old at end of five years. 
See ''Cincinnati Lancet-Clinic," pages 
396-688, 1902. 

(9) Never approved of the cautery ; 
never did it. 

(10) Never did it. 

(11) Never made one. 

(12) Five times. Perfect drainage ; 
later median incision. 

(13) Perineal prostatectomy. 



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(14) None. 

(A) Have made three prostatec- 
tomies, two complete, one. partial. 
The two were emergencies in which 
vesico-rectal fistula was accomplished. 
Patients utilize rectum for urinary 
receptacle. See Lancet'CUnic, Octo- 
ber 1, 1902, to February 14, 1903. 



HOWABD LUiIENTHAL. m. d.. 

or NEW YORK CITY. 

(1) Most of my cases active in- 
door, but do not believe that any occu- 
pation can be shown to have caused 
the trouble, judging from my cases 
alone. 

(2) The lean and nervous, though 
some of my cases were obese and a 
number were phlegmatic. 

(3) Fibroma and fibromyoma within 
the capsule. 

(4) In my cases of very little ser- 
vice. The observation cystoscope, 
with the prism within the angle so as 
to look around a corner, has been 
used. 

(5) But one of my patients used 
alcohol to excess; nearly all drank 
very moderately. Constipation not a 
marked factor. 

(6) In diabetics, careful catheteri- 
zation with the administration of 
urinary antiseptics is advised, unless 
there is active and alarming hemor- 
rhage, when suprapubic cystotomy is 
advised. No prostatic operation. 

(7) In only one case, the patient 
being very weak. Death from urinary 
sepsis, which was already present be- 
fore result could be observed. Op- 
eration apparently did not hasten fatal 
outcome. 

(8) Three cases; all with temporary 
relief only. One remained well, but 
with some ounces of residual urine, 
for about six months, when catheter 
cystitis supervened. He was not in 
New York at the time, and I lost sight 
of him. One case developed ptyalism. 
(Note connection between parotids 
and testes.) 



(9) Never. 

(10) Temporary im pro vem en t. 
Have practiced it many times before 
the days of prostatectomy. 

*(11) Thirteen times. One death, 
from uremia, within twenty-four 
hours, patient having been uremic at 
time of operation, which was an im- 
perative one. All others were cured 
so that there was no residual urine. 

(12) Never, except partial in one 
case in which it became necessary to- 
abandon perineal route and attack 
from above, because, of large size of 
prostate. 

(13) Suprapubic without perineal 
drainage; better exploration of blad- 
der; obliteration of the trigonal pouch 
on healing. Traumatism to im- 
portant structures less than by peri- 
neal. Quicker. My own very satis- 
factory results will probably induce 
me, in most cases, to continue as I 
have done in the past. 

(14) None during the operation. 
Suppurative epididymitis in one case 
after operation; non-suppurative epi- 
didymitis in one case after operation. 

(A) Operation takes frorii twelve 
to thirty minutes. Shock is very 
moderate; often absent. Severe post« 
operative hemorrhage in two cases, 
both recovering. Sexual power — i. e., 
potentia cceundi — retained in all of 
the younger and some of the older 
patients. 

* 

HOWABD CBUTOHBB. M. D.. 

OF CHICAQO, ILL. 

(1) The sedentary are, so far as I 
am able to see, more disposed to this- 
condition than the active. 

(2) Fleshy men almost invariably. 

(3) I know of no satisfactory ex- 
planation. 

(4) Of decided value in certain 
cases, but not indispensable. 

(5) So far as I have been able to- 
judge, it occurs as often in the ab- 
stainers as in the alcoholics. 

(6) I advise palliation in casea 

* Another successful case since last communication. 



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where operdiion does not seem advis- 
able. By palliation I mean internal 
treatment addressed to the urine, rec- 
tal suppositories, and occasionally 
local flushings with mild antiseptics. 

( 7 ) In no case have I tried the vasa 
deferentia for this condition. I doubt 
whether this procedure has secured an 
abiding place in modern surgery. 

(8) In one case, complicated with 
tuberculosis of both testicles, for which 
latter condition the operation was per- 
formed. The result was excellent on 
the prostate. 

(9) Never performed this opera- 
tion. 

(10) Many times and with fair re- 
sults. Often it is the only procedure 
that we can practice with hope of sav- 
ing the life of the patient. I have 
just operated with success upon a man 
of eighty-six years with entire success, 
who would have died under a tedious 
operation of any sort. 

(11) Ten times, with fair results; 
no death from operative causes. The 
results have been all I had any reason 
to expect. 

(12) Three times. I like a modified 
Kocher incision. While my success 
by this route has not been so good as 
with the other, I believe it to be the 
rational route to the prostate, and 
blame my lack of skill with my poorer 
results. 

(13) The perineal route, for the 
reason stated. 

(14) My most serious trouble has 
been bleeding, which has often been 
troublesome and sometimes dangerous, 
never fatal. 

(A) To give a brief resume of my 
prostatic work, I may say that the re- 
sults have been all that one has reason 
to expect from surgical work in per- 
sons of advanced age. Pain being ab- 
sent, patients do not present themselves 
for treatment until life itself is threat- 
ened, when it is frequently too late 
for operative treatment to be of any 
avail. 



HILARY M. CHBISTIi! 

OF PHILADBLPHIA, 

(1) I have never beei 
that occupation had an 
producing hypertrophy c 

(2) I cannot say. 

(3) I am inclined at f 
lieve that the overgrow 
glandular and muscular 
the prostate gland, coi 
hypertrophy is first of a 
secondarily, inflammator 

(4) The cystoscope is 
in making a diagnosis, 
determining the extent c 
into the bladder and the 
volved. Nitze or Albarri 

(5) I do not think tha 
sponsible directly for ph 
trophy, but each has a vi 
upon the growth after it 1 

(6) In nearly all cas 
life, irrigation of bladdei 
ministration of genito- 
septic drugs. Dilatatior 
urethra with Kollman. 
lator. 

(7) Yes; three time 
relief only. 

(8) Yes; six times; j 
two cases ; fair result in 
improvement in three csa 

(9) Yes; four times; 
lief up to present time 
complications. 

(10) Six cases of bi 
bladders with urinary fe\ 
afford patients considers 
of course did not cure. 

(11) Twice; one appa 

(12) Have not perf on 
ation. 

(13) TheBottlni in a 
with infected bladder 
kidneys, because it is saf 
subjects supra-pubic p 
because it is more thoroi 

(14) None. 

(A) I am a firm be 
palliative treatment of 
phied prostate. In casei 
cystitis I am in the habit 



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tinuous catheterization. (See ad Thera- 
peutic Gazette, February 15, 1901.) 
I believe that 80 per cent, or even 90 
per cent, of cases can live comfortable 
lives with the use of aseptic catheteriz- 
ation. 

* 

OHABLBS CHASSAIGNAO. M. D.. 

or NEW ORLEANS, LA. 

(1) All else equal, sedentary purr 
suits seem to predispose, but it may 
be because those following them are 
apt to be more in the class of those 
who apply for relief. 

(2) The nervous, I believe. I have 
had more patients among the lean. 
May it not be in part because it is a 
disease of old age, and that the obese 
are less likely to live old? In other 
words, a coincidence rather than a rela- 
tion of cause and effect? 

(3) I am an agnostic on this point. 

(4) Comparatively small. It assists, 
but I rely more on rectal touch, meas- 
urement of prostatic urethra, resist- 
ance to metallic sound and manner of 
entrance of same, etc., as well as pa- 
tient's history and symptoms. 

I have become accustomed to the 
Nitze cystoscope and generally use that. 

(5)1 have had patients among total 
abstainers as often as among those 
who use a good deal of alcohol, per- 
haps more. 

Constipation, in my opinion, is a re- 
sult rather than a cause. 

(()) Briefly, in cases that have only 
intervals of trouble or ''attacks;" in 
oases accustomed to catheter life, who 
have learned aseptic precautions, and 
are very old ; in those whose general 
condition, especially as regards kidney 
troubles, would preclude safety in 
operation. 

(7) No. 

(8) Yes. Three. One death;* one 
improvement; one unimproved. 

(9) Yes. Seventeen recorded cases ; 
two recently operated upon and not 
yet discharged. 

* Death was not immediate, and was preceded by 
•cerebral derangement. 



One death, apparently from septi- 
cemia and uremia. Kidneys were bad, 
bladder was infected ; would now pre- 
fer supra-pubic drainage or even pros- 
tatectomy in such a case, though not 
promising for any procedure. One 
unimproved except as to easy entrance 
of catheter. All others improved. Nine 
apparently perfectly well, of whom 
five yet under observation ; one of the 
cases was in a man, eighty-five years 
old, who had had to use catheter with 
increasing frequency for many months, 
and had not voided urine without it for 
several weeks. He remained well for 
four years, up to time of his death, at 
eighty-nine years of age, from senility 
and chronic diarrhea. 

In one case had a urinary scrotal 
fistula from excessive cauterization 
posteriorly; it healed in two weeks 
and patient made a good recovery. 

(10) Many times. Previously as a 
selected treatment, cases not recorded 
properly. Within last five years, only 
as an emergency operation in cases of 
retention with impossibility of cathe- 
terization. One last year, with num- 
erous false passages caused by awk- 
ward attempts at catheterization and 
weak from loss of blood. Recovered, 
and after closure of fistula was able to 
fairly empty bladder; like result in 
several . 

(11) Twice. One recovery with 
good results. One death. 

(12) Never yet, but am waiting for 
an opportunity. Believe it is perhaps 
the best in comparatively young and 
strong subjects, as not only they can 
stand it better, but, having longer to 
live, thoroughness of removal is im- 
portant. 

(13) Bottini is yet my preference, 
chiefly owing to smaller mortality, and 
as I have had good results in the ma- 
jority of cases. 

(14) Can recall only one; in a Bot- 
tini case, some extravasation of irri- 
gating fluid, boracic solution, subse- 
quent to operation, due no doubt to 
excessive length of posterior section ; 



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scrotum was slightly incised for drain- 
age and no harm resulted, as catheter 
was kept en demeure during healing. 
( A ) Data not just at hand to arrai^ge 

systematically. 

* «> 
* 

OHA&LBS H. KAYO. M. D.. 

OP B0CHE8TSB, MINN. 

(1) We have noticed but little dif- 
ference. 

(2) The nervous and lean. 

(3) No answer. 

(4) It has been useful in differen- 
tial diagnosis of prostatic bar and me- 
dian lobe hypertrophy ; also in finding 
a small stone, once, and an ulcer of 
the base of the bladder the real cause 
of the discomfort. 

(5) While probably not responsible 
for the hypertrophy, they act later as 
a cause of acute obstruction. 

(6) In patients with other physical 
infirmities which are more severe than 
the prostatic trouble. In extreme de- 
bility. In severe cystitis with debility. 
Rest, tonics, bladder irrigation or tem- 
porary supra-pubic drainage to cleanse 
the bladder and induce tolerance for 
interference. 

(7) Once. Partial relief. 

(8) Six times, some with pai'tial, 
others complete, relief. Most of these 
cases relapsed within two years. 

(9) No. 

(10) Forty-three times. Improved 
condition in all. Many relapsed, some 
remained improved, not well. 

(11) Thirteen supra-pubic prosta- 
tectomies. Good result in twelve. Two 
combined supra-pubic and perineal, 
with success in one. 

(12) Ten perineal prostatectomies. 
Good success in nine. Inverted incis- 
ion gives most room. Straight me- 
dian is usually sufficient. 

ri3) At present supra-pubic for 
peaunculated middle lobe. Perineal 
for most cases. 

(14) Found enlarged prostate to be 
sarcoma, very bloody. General and 
kidney failure. 

(A) iVb answer. 



HEKB7 H. MOBTON. M. D.. 

OF BBOOKLYN. N. Y. 

(1) iVb an8wei\ 

(2) iVb anstvet'. 

(3) No answer, 

(4) The cystosi^ope I find very val- 
uable in outlining the size and shape 
of the intravesical growths. In several 
cases it was only possible to make a 
diagnosis of prostatic hypertrophy by 
its use, as rectal examination showed 
no enlargement at all. In each case, 
however, there was an enlarged middle 
lobe which acted as an obstruction and 
was plainly visible by the cystoscope. 

It is always desirable to exclude the 
presence of calculus, and this can be 
best accomplished by the cystoscope. 

The instrument which I use entirely 
for this purpose is the Nitze observa- 
tion cystoscope. 

(5) No answer. 

(6) The present high rate of mor- 
tality in prostatic operations induces 
mQ to advise patients to use palliative 
measures so long as they can be made 
reasonably comfortable in that way. 

Palliative measures consist of regu- 
lar catheterization and bladder wash- 
ing, and if there is much spasm of the 
cut-off muscle and irritability of the 
post urethra, the passage of large 
sized sounds has seemed at times to be 
of use. 

^7) No ansiver. 

(8) No answer. 

(9)1 can give only my general im- 
pressions of the Bottini operation, 
which I have done in perhaps a dozen 
cases. 

Its applicability seems to be limited 
to the small, hard, fibrous prostates, 
which form a distinct bar across the 
vesical outlet. Bottini' s operation 
seems to me distinctly contra-indicated 
in the large adenomatous growths. 

With regard to the permanency of 
the relief I cannot state, as my cases 
all drifted out of sight (they were, 
with one exception, all hospital cases), 
with two exceptions. 

One of these, I understand, relapsed 



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after the operation, and the other 
would have temporary attacks of re- 
tention from a swelling and closing up 
of the incisions made by the Bottini 
knife. 

The incisions were clearly visible, 
however, with the cystoscope a year 
after the operation. 

His prostate was subsequently re- 
moved by Dr. Alexander in Bellevue 
Hospital, and six months afterwards he 
reported to me that he had been free 
from trouble since the prostatectomy. 

(10) iVb answer. 

(11) iVb answer. * 

(12) I have done prostatectomy five 
times. 

In three cases I made a supra-pubic 
incision for the purpose of depressing 
the prostate, and enucleated the pros- 
tate through a perineal incision. 

In the other two cases I simply made 
the perineal incision and enucleated 
through that. 

The incision which I made in the 
perineum was the ordinary one for ex- 
ternal urethrotomy, and I found that 
form of incision gave ample room for 
enucleating with the finger. The re- 
sults were as follows : 

One death from shock forty-eight 
hours after the operation. 

One death from infection of the 
supra-pubic wound one week after op- 
eration. 

Three recoveries. 

(13) I have no operation of choice. 
The operations which I consider at 

present are: Prostatectomy perineal, 
supra-pubic, or a combination of both, 
and Bottini' s operation. 

The choice of operation, I believe, 
depends entirely upon the 

a. Form of the enlargement, /. e., 
whether of the adenomatous or fibroid 
type. 

6. The direction of growth, i. e., 
whether it is chiefly intra-vesical or 
towards the rectum, and, 

c. The age and general condition of 
the patient. 

I think that for men who are in fair 



health, even though they may be old, 
with large adenomatous prostates, per- 
ineal prostatectomy, without a supra- 
pubic incision, is a suitable operation. 

If the prostatic growth is chiefly 
intravesical, the supra-pubic operation 
may be required. 

If the growth is of the mixed type, 
I. 6., adenomatous and fibroid, and if 
the fibroid elements largely predom- 
inate, it may be necessary to make a 
supra-pubic opening in order to hold 
the prostate steadily while it is being 
enucleated from below. 

If a large vesical calculus is pres- 
ent, a supra-pubic incision may be de- 
manded for its removal. 

A supra-pubic incision does not seem 
to be required merely because the 
growth is of large size and extends 
high up towards the bladder, since it 
is not difficult to enucleate these pros- 
tates from below. 

With the above exceptions, my 
strong preference, based, to be sure, 
upon a limited number of cases, is for 
the perineal route Without supra-pubic 
incision and making only a longitud- 
inal incision into the urethra, as in ex- 
ternal urethrotomy. 

(14) iVb aiiswer. 
B(A) iVb answer. 

* 
STUABT MoGUIBB. M. D.. 

OF BICHMOND, VA. 

(1) I have observed no difference 
with regard to occupation of patients 
with prostatic hypertrophy. Cases 
come to me as frequently from the farm 
as from the counting house. 

(2) I have observed no difference 
with regard to recurrence of the dis- 
ease in the phlegmatic or the nervous, 
the lean or the obese. 

(3) I have no theory or explanation 
of the etiology of the disease. Lyds- 
ton's theory of sexual overstrain is 
controverted by the fact that the dis- 
ease is rarely if ever seen in the negro. 
Guyon's explanation of the changed 
relation of the base of the bladder to 



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the vesical neck is more logical. Ail 
that can be said at this time is that 
prostatic enlargement is an attendant 
of old age. 

(4) The cystoscope has been of lit- 
tle service to me in diagnosis. I rely 
almost entirely upon information de- 
rived from the finger inserted in the 
rectum and a sound inserted in the 
bladder. 

(5)1 have never seen the use of al- 
cohol or a constipated habit act as a 
causative factor in prostatic enlarge- 
ment, although they aggravate the 
condition when it exists. 

(6) I advise palliation in all cases 
until symptoms are unbearable, treat- 
ment consisting in regulation of the 
habits of life, the use of the catheter, 
irrigation of the bladder and the ad- 
ministration of urinary antiseptics. 

(7) No. 

(8) No. 

(9) No. 

(10) Yes, in over ninety cases. Re- 
sults are indefinite prolongation of life, 
cure of cystitis, relief of pain, but dis- 
comfort from unavoidable leakage 
from the supra-pubic artificial urethra. 

(11) No. 

(12) No. 

(13) I have not yet decided which 
of the •several operations proposed is 
best. I believe that prostatic surgery 
is in a stage of evolution and propose 
to wait and let other men make exper- 
iments and then profit by their results. 

(14) None. 
(A) iVb answer. 



W. FBANK GLENK. M. D.. 

OF NASHVILLE. TENN. 

(1)1 have never observed closely, 
but upon reflection I find all of my pa- 
tients have led active lives. 

(2) I have noticed no difference as 
to temperament or flesh. 

(3) It is unknown to me, but I be- 
lieve masturbation in youth, and ex- 
cessive sexual indulgence in later years, 
to be the chief cause. 



(4) I do not get much aid from 
cystoscope. I like the Bransford Lewis 
instrument. 

(5) I believe habitual use of alcohol 
and constipation have an influence, but 
sexual excess to be the chief cause. 

(6) The cases that are well, except 
for inability to completely empty the 
bladder, I usually advise regular use of 
catheter and washing out bladder. 

(7) Never did it. 

(8) Once, in a man eighty-two years 
old. He died. 

(9) Never made it. Always per- 
form prostatectomy. 

(10) Never used it. Prefer perineal. 

(11) Never. 

(12) Seven times; two deaths, one 
from a heart complication ten days 
after operation, the other septic peri- 
tonitis four days afterwards; oth- 
ers recovered. 

(13) Perineal prostatectomy. Drain- 
age better, 

(14) None. Septic peritonize peri- 
tonitis once. Stenosis mitral valve. 

(A) In the large majority of cases 
the result has been all that could be 
desired, the patients afterward com- 
pletely emptying bladder normally. 



N. PENDLETON DAKDBIDGE. M. D.. 

OF CINCINNATI, OHIO. 

(1) The etiology of hypertrophy is, 
I consider, entirely unknown. I can- 
not trace any connection to any habits 
of life. 

(2) The condition of body or ele- 
ments of character have no influence. 

(3) Quien sabe — who knows. 

(4) Personally it has been of no 
use. The harm it has done probably 
fully balances the occasional good. 

(5) Have not been able to trace any 
connection. 

(6) The rule should be proper hy- 
giene with the use of the catheter when 
it becomes needed under the strictest 
aseptic conditions. 

(7) No. 



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(8) Have castrated two cases with 
no benefit. 

(9) No. 

(10) Supra-pubic drainage is infe- 
rior to perineal drainage. 

(11) Never. 

(12) Once complete with complete 
success ; incision, inverted Y. 

(13) Perineal — for drainage and 
prostatectomy. 

(14) N'o answer. 
(A) N^o answer. 

* 

JOSEPH BILUS EASTMAN. M. D.. 

OF INDIANAPOLIS, IND. 

(1) I have observed prostatic hy- 
pertrophy with about equal frequency 
in men of laborious, active, outdoor 
pursuits and those whose occupations 
are sedentary. I have, therefore, not 
formulated any opinion as to whether 
occupation should be regarded as an 
etiologic factor. 

(2) So far as my limited experience 
is concerned, the phlegmatic and obese. 

(3) In the course of microscopical 
studies of the prostate prosecuted 
for the purpose of determining the 
origin of * 'corpora amylacea,'' I 
have repeatedly noted in glands only 
very slightly hypertrophied the clas- 
sical tissue changes of inflammation as 
described by Green and Cienchan- 
owski. I am of the opinion that in- 
flammation bears an important causa- 
tive relation to prostatic hypertrophy. 

(4) The cyetoscope is of slight 
value in the diagnosis of this particular 
condition. Complications like cal- 
culus and cystitis may be more clearly 
defined, and with a lens instrument like 
the modified Casper, a third lobe may 
under favorable conditions be imper- 
fectly seen. 

(5)1 have not been able to assure 
myself that habitual indulgence in al- 
coholics predisposes to prostatic hy- 
pertrophy. No one of my cases con- 
cerned a hard drinker. Whether con- 
stipation bears a purely causative rela- 
tion I do not know. 



(6) Palliation in no case unless op- 
eration cannot be borne because of ex- 
treme debility. Continuous or inter- 
mittent catheterization, bladder irriga- 
tion,, neutralization of the urine, stim- 
ulation and sedation, emptying of blad- 
der in knee-chest position, application 
of silver nitrate to prostate per rectum, 
sounding, dieting, catharsis, diuresis, 
etc., pro re nata. 

(7) One case; negative result. 
(8)1 have made five castrations for 

prostatic hypertrophy with slight tem- 
porary relief in two cases. One death 
from acute mania. 

(^) I have cauterized the prostatic 
collar through a perineal incision with 
the instruments and after the precepts 
of Dr. W. N. Wishard, with satisfac- 
tory results. Have secured excellent 
bladder drainage by this method. 

(10) In one case; I am opposed to 
the practice of attempting to coax 
water to run up hill, unless for definite 
reasons perineal drainage or continuous 
catheterization cannot be employed. 

(11) One case; pedunculated me- 
dian lobe hypertrophy ; good result. 

(12) Twice, with favorable results; 
the inverted Y incision. 

( 13 ) Perineal prostatectomy ; easier 
of execution, better control of hem- 
orrhage, better drainage. 

(14) Acute mania after castration. 
(A) My observation and work have 

impressed me with the importance of 
early operating in prostatic hypertro- 
phy. Prostatic hypertrophy is a purely 
surgical disease, and all or part of the 
prostate, according to the nature of 
the enlargement, should be removed 
before serious changes in bladder 
and kidneys appear as complications. 

If we may take the history of other 
surgical procedures as our guide, we 
may with fairness assume that with 
education of the laity and the profes- 
sion regarding the importance of early 
and thorough operating, the mortality 
from this disease may be steadily low- 
ered. The operation selected must be 
one which will meet the exigencies of 



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the peculiarities of the prostatic de- 
formity and stage of the disease in the 

individual case. 

* ♦ 

FEBD C. VALENTINE. M. D.. 

OP NEW YORK CITY. 

(1) Most of the patients with pros- 
tatic hypertrophy whom I have treated 
were and are in sedentary occupations. 
I would not, however, conclude here- 
from, except in general way, that 
sedentary pursuits are essential factors 
in this condition. 

(2) In my experience the lean old 
men and the obese young men. 

(3) I have not formed an opinion 
on thjs question. 

(4) The cystoscope has been and is 
of invaluable service to me, especially 
in the diagnosis of prostatism, where 
the enlargement bladderward is more 
marked than rectumward. 

I use the Nitze, Casper, Albarran and 
Kollmann cystoscopes; often succeed- 
ing with one when I fail with another. 

(5) a. I do not know, except as 
answered to question No. 1. 

b. Alcohol and constipation, or either 
alone, certainly aggravate the sufferings 
from prostatism . 

(6) a. When the residual urine is 
aseptic and does not exceed 120 c. c. 

(f. Siv). 

b. Methodical, careful aseptic cathe- 
terism, as detailed in ** Surgical Asepsis 
of the Urethra and Bladder" (Journal 
of the Am. Med. Assn., January 12, 
1901). 

(7) Yes. Eight. None. 
(8^ No. 

?9) I have not performed the Bottini 
incision for fear of operating in the 
dark. 

(10) I turn over all capital opera- 
tions to operators. 

(11) 2^0 answer. 

(12) No answer. 

(13) No answer. 

(14) No answer. 

(A) Deeming with Guyon that pros- 
tatism is **an infirmity, not a disease" 
while the patient can be kept comfort- 

8 



able and free from danger, ray pros- 
tatic work has been and is palliative. 
I have no reason to regret this or to 
change from the conservative methods. 



PAOLA. DE VECOHI. M. D.. 

OF SAN FRANCISCO, GAL. 

(1)1 could not find in my cases any 
special reference to the methods of 
living; 

(2) All my cases were dark in com- 
plexion, rather nervous and lean, but I 
think this condition was consequence 
of the disease. 

(3) All my cases were connected 
with previous inflammation of the 
urethra and bladder due to some in- 
fectious diseases and to abuse of coi- 
tion. 

(4) Cystoscopy has been of a very 
little, and unsatisfactory use, in the 
diagnosis ; first, on account of the dif- 
ficulty of using the instrument on ac- 
count of the enlarged prostate^ sec- 
ond, on. account of the difficulty of 
keeping the water in the bladder clean, 
long enough for a good inspection. 

(5) The abuse of alcoholics and 
constipation were only an aggravating 
contribution in two of the cases which 
came under my care. 

(6) In advanced tuberculosis, in 
nephritis, in diseases of the heart 
which could not stand anesthetics, in 
diseases of the liver with dropsy. Such 
cases came under my observation, and 
I thought it best not to operate. In 
fact, two were operated with fatal re- 
sult. In these cat*es palliative treat- 
ment must be according to the compli- 
cation, and in most cases rest has been 
beneficial combined with the treatment 
suggested by the special disease. 

(7)1 have never practiced it, and I 
do not think it rational. 

(8) Only once and without success. 

(9) The Bottini operation requires a 
perfect knowledge of the technic of 
the operation, a special skill in han. 
dling the instrument which is only f^c. 
quired by assisting some skillful oper. 



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ator and by trying it on the cadaver. 
I have used the Bottini twice with good 
results and permanent relief, and h^ve 
used the Bottini modified three times ; 
once with good and permanent result, 
and twice with only temporary re- 
lief. 

These same patients were operated 
after with other methods without re- 
lief. 

(10) I have never had an oppor- 
tunity. 

(11) Only once and with good re- 
sults, but found the operation very 
bloody and diflScult. 

(12) Seven, five with good success; 
two are recent and cannot report the 
success, although apparently good. 

I always made the central linear in- 
cision, as described by Dr. Good- 
fellow. 

(13) The operation described by 
Dr. Goodfellow, because it affords a 
clear idea of what a surgeon is doing, 
and with ordinary skill and patience the 
enucleation can be completed even In 
the most difiicult cases, and the trauma 
is certainly not so severe as in the other 
methods. 

(14) The only complication during 
the operation has been the hemor- 
rhage, which was quite formidable in 
the supra-pubic. And the complica- 
tion which at times gives some trouble 
in the perineal operation of Dr. Good- 
fellow, is the fistula. However, it 
always closed without trouble in my 
cases. 

(A) (a) Prostatic hypertrophy is a 
frequent disease, especially in men 
over fifty years of age, 

(6) In my cases the causes were al- 
ways remote abuse of coition, pro- 
tracted urethritis and cystitis. 

(c) Ninety per cent, of my cases 
could be controlled by palliatives, 
gradual dilatation of the urethra, some 
times combined with rectal massage. 

(d) My choice of operation is the one 
described by Dr. Goodfellow, .which 
can be called prostatic digital enuclea- 
tion through central perineal cut. 



WALTBB a. 8PEK0EB. F. B. O. 8.. M. 8.» 
M. B., 

OF LONDON, ENGLAND. 

(1) mi. 

(2) mi. 

(3) mi. 

(4) Useful as an aid or in confirma- 
tion. 

(5) N'o answer. • 

(6) N^o answer. 

(7) iVb answer. 

(8) N'o ansioer. 

(9) iVb answer. 

(10) Many times. Poor, on account 
of nervous troubles. 

(11) Often. Very good. 

(12) Many times with very satisfac- 
tory results. 

(13) (a) Supra-pubic for large, 
soft, mobile, with dilated bladder. 

(6) Perineal for hard, fixed with 
small bladder, also **collar-like" ob- 
struction. 

(14) Complications, because case 
too late. General and kidney troubles. 

(A) I have never done vasectomy 
or castration. 

Prostatectomy has the advantage of 
being a radical method when the pa- 
tient is relatively young and strong 
enough. If successful the patient may 
return to his occupation, and espe- 
cially among the poor there are great 
difliculties in carrying out treatment 
depending upon catheterism or involv- 
ing continuous medical attendance, and 
many patients, therefore, become pau- 
pers. 

Supra-pubic prostatectomy is best 
done when there is a large bladder 
and a pedunculated middle lobe. A 
contracted bladder anii a post-pros- 
tatic pouch with enlargement of the 
lateral lobes are not so favorable con- 
ditions. I have operated by the supra- 
pubic method when the bladder wa^ 
contracted with the prostatic obstruc- 
tion mainly like a collar, and although 
the patient did well, yet the operation 
was diflicult, no good view could be 
obtained, and, therefore,^ recurrent 
hemorrhage might well have taken 
place. As regards other ways of per- 



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forming perineal prostatectomy, there 
is not such good eicposure of the pros- 
tate, and the cauterization by Bottini's 
and other methods is done in the dark, 
which, if the cautery is too hot, may 
lead to hemorrhage and sloughing. If 
performed as described there is no 
danger of a perineal fistula, although 
this would be a trivial matter as com- 
pared with a supra-pubic one. Castra- 
tion and vasectomy appear to be very 
uncertain in their results, and leave a 
post-prostatic pouch undrained, with 
possibly a calculus in it, so that renal 
complications progress. 

Conclusion. — The cases quoted in- 
dicate that this operation is especially 
applicable to certain instances of com- 
plicated strictur.e, bladder calculi, and 
prostatic obstruction. The unsuccess- 
ful cases have shown too advanced 
disease of the kidneys. When this 
complication had not set in the results 
were good. 

* 

EDKTJND ANDBEWS. M. D., 

OP CHICAGO, ILL. 

(1)1 have not observed any effect 
of occupation. . 

(2)1 have not been able to observe 
any difference except that long and 
severe suffering seems to promote 
leanness. 

(3) It is only conjectural. It seems 
to me that vigorous men are the most 
frequent victims, but I have no scien- 
tific proof that sexual excess is an 
actual cause. 

(4) The cystoscope is of some val- 
ue, but not absolutely necessary. I 
am not certain which instrument is 
best. 

(5) The relations of alcoholism as a 
cause are not established. Total ab- 
stainers are not exempt, and I have 
not observed that constipated men are 
specially liable. 

(6) When the patient can preserve 
his health and comfort by the velvet 
eye catheter and boric acid injections, 
I advise not to operate. 

(7) Have ligated the vasa deferen- 



tia in a few cases only. Some are 
greatly benefited, but not all. 

(8) I have castrated a few cases. 
Most of them were be — ^^^-^ — ^ ~^ 
lieved of pain, but som< 
had to continue the cal 
examined years later sh 
prostate had become cc 
phied, and yet some of 
quired the catheter. 

(9)1 have observed t 
not practiced it. Some ai 
cured or benefited; som 
lieved; some few had 
continence after it. 

(10) Only for tempo 
For permanent purposes 
operations. 

(11) Have not tried i 

(12) Have not perse 

(13) This question h 
settled . At present my ] 
cline in the following or 

(a) Bottini's operatic 

(6)Prof.E.WyllysA 
pubic operation, whicl 
highly. 

(c) Perineal operatio 

(d) Supra-pubic opei 
cases only. Bottini's o 
est (except vasectomy 
Andrews' operation tal 
the front of the prostate 
next to Bottini's in poin 
more eflScient. Total p 
tectomy is the most dai 
three. Total supra-pu 
to my is dangerous. 

(14) Cannot sufficie 
my cases. 

(A) iVb answer. 

ALBBBT. J. OOH8N] 

OP CHICAOO, ILl 

(1) I have not been a 
cause in the occupation 

(2) In my experience 

(3) Age, recurrent i 
stipation, habitual negh 
ing the bladder, habitua 
for a long period, seem 
corresponding points in 



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(4) I have not used it in these cases. 

(5) I could not determine any rela- 
tion between the use of alcohol and 
hypertrophy of the prostate, but al- 
most all of these patients have been 
habitually constipated. . 

(6) In cases suffering from acute 
infections, and in those suffering from 
advanced nephritis. Rest, a great 
abundance of pure, preferably dis- 
tilled, water, and taken at regular in- 
tervals, not at meal time. Lavage of 
bladder night and morning, with mild 
antiseptic. Uriseptin, 5j, in 08s hot 
water four times a day. 

(7) Yes, eight cases; three cured, 
three improved, two not improved. 

(8) Yes, seven cases; four cured, 
one improved, two died. 

(9) No. 

(10) I have made this operation 
many times in cases in which both 
stone of the bladder and hypertrophy 
of the prostate were present, but eight 
times in cases of hypertrophy alone. 
Results: Cured, three; improved, 
four; died, one. 

(11) Cannot determine number, but 
results were so unsatisfactory that I 
abandoned the method some years 
ago. 

(12) Twice the combined supra- 
pubic and perineal with one death; 
nineteen times the perineal with one 
death and eighteen recoveries. 

I prefer the Zucker-Kandl incision — 
horseshoe— with convexity upwards 
from OS pubis to os pubis. 

(13) The perineal prostatectomy 
through the Zucker-Kandl incision, 
because the gland is perfectly exposed 
to view, the hemorrhage can be com- 
pletely controlled so that almost no 
blood is lost. The operation has a 
very small mortality. 

(14) Laceration of the anterior wall 
of rectum one case during operation. 
Slight hemorrhage after operation. 
Urinary fistula persisting for several 
months in two cases. 

(A) Surgery of the prostate was 
extremely unsatisfactory until the sim- 



ple perineal operation was introduced, 
I adopted this method fifteen months 
ago after seeing it demonstrated by 
Dr. J. B. Murphy and Dr. N. H. Fer- 
guson, and have used it in nineteen 
cases since then with very great satis- 
faction and benefit. 



JACOB GEIGBB, M. D.. 

OF ST. JOSEPH, MO. 

(1) Occupation and pursuits no in- 
fluence. 

(2) Nervous and lean. 

(3) Gonorrhea and sexual excesses. 

(4) Have not used it. 

(5) Alcoholic and constipation pre- 
dispose. 

(6) In the very old and feeble and 
those with septic bladder. 

( 7 ) Two cases with much benefit. 

(8) Three cases; two greatly bene- 
fited, one no result. 

(9) Have not used. 

(10) Four cases; good results. 

(11) Three cases; good result ia 
two cases, third case no improvement. 

(12) Have not performed this op- 
eration. 

(l^) No answer. 
(14) No answer, 
(A) No answer. 

* 

OBANVIIiliE MAO GK>WAK. M. D.. 

OF LOS ANQSLKS, CAL. 

(1) None whatever. The people I 
have treated for prostatic hypertrophy 
came from all walks of life. They have 
been farmers, artisans, merchants, 
bankers, stockraisers, mechanics, sol- 
diers, miners, tailors, sailors, day la- 
borers, preachers, physicians and rail- 
road men. 

(2) To the best of my recollection, 
there have been more individuals who 
might be classed as nervous and fewer 
classed as obese. 

(3) All prostates that I have re- 
moved, upon examination present mac- 
roscopical and microscopical evidences 
of inflammation. But whether inflam- 



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mation has been the cause of the hy- 
pertrophy or an accident arising out 
of the strains and injuries to the dis- 
tended and dilated blood vessels by 
foecal accumulations, catheters, or sex- 
ual excitement, it is impossible to say. 

I confess that I have not been able 
to evolve an explanation, satisfactory 
to myself, as to why certain men who 
are in, or have passed, the sixth decade 
of life, develop prostatic hypertrophy 
while others escape entirely. If this 
were the fate of all old men, it might 
be easy to understand it. Or if it fol- 
lowed the transgression of certain hy- 
gienic laws, one might comprehend it. 
But careful inquiry into every case that 
has presented itself, numbering now 
many hundreds, has failed to give any 
definite reason for the occurrence of 
the trouble either in the habits or the 
occupation of the individuals. 

(4) The cystoscope has frequently 
been of great service to me in deter- 
mining the advisability of doing a supra- 
pubic or combined prostatectomy in 
place of the less dangerous and more 
simple perineal operation, which I 
prefer. If there are obstructive tumors 
within the bladder, outgrowths from 
the prostate projecting into the lateral 
or superior quadrants of the bladder 
neck, their presence can only be de- 
termined by the cystoscope. In such 
cases the perineal operation is only a 
waste of time. But if there are no 
such tumors present, it is foolish and 
unnecessary to do a suprapubic or com- 
bined operation. 

Cystoscopic evidence is also sought 
by me to determine the probable value 
of theBottini operation in a given case. 
If the obstruction is posterior and cen- 
tral, a so-called middle lobe growth, 
in most instances a prostatotomy by 
this method is much less dangerous 
and quite as satisfactory in its results, 
at least for a long time, as a prostatec- 
tomy would be. If the growth is 
fibroid or myomatous, or these elements 
predominate in the hypertrophy to an 
extent that precludes a successful enu- 



cleation, the Bottini is the method of 
choice. I use a Nitze-Albarran, or 
Nitze, or Casper cystoscope for these 
examinations. 

. (5) I do not believe that the use of 
alcohol, or its abuse, is responsible for 
prostatic hypertrophy. Many of my 
clients have been mildly moderate 
drinkers or total abstainers, if any one 
can be considered a total abstainer in 
America, where the majority of people 
who do not drink at their homes, in 
saloons or clubs, get their alcohol in 
patent medicines without their being 
aware that they are drinking. My ex- 
perience is that constipation is more to 
be considered a result of the hyper- 
trophy of the prostate and the conse- 
quent rectal obstruction, than it is to 
be the cause of it, though, unquestion- 
ably, in many instances the presence 
of constipation induces attacks of acute 
inflammatory edema of the prostate 
with retention. 

(6) (a) In all cases at the com- 
mencement of the trouble and up to 
the advent of catheter life. My rea- 
sons for this are: 1. That all sur- 
gical operations about the neck of the 
bladder are serious ones, the outcome 
of which cannot be positively predi- 
cated. 2. Thereis always a possibility 
that the man may lose his life from the 
operation. 3. The object may not be 
attained, or a fistula may form after it. 
4. It is not right to submit a man, 
who still has sexual potency, to one of 
the mutilating oj>erations simply be- 
cause he is certain at some indefinite 
time in the future to be no longer able 
to pass water. 

(6) In the case of individuals who 
are well advanced in the disease, but 
who are easily catheterized, intelligent 
and tractable, the use of the catheter 
may be pursued so long as such indi- 
viduals are comfortable. 

(c) In people who suffer from hem- 
ophilia. 

(d^ In those who have serious valv- 
ular lesions of the heart, accompanied 
by great muscular weakness. 



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. (e) And, most important, in those 
who are unable to secrete a reasonable 
quantity of urea in each twenty-four 
hours — and what I consider a reasona- 
ble daily quantity of urea is from 15 
to 25 grams. 

(/) When the hypertrophy is can- 
cerous or complicated by tuberculosis. 

In the years of commencing prostat- 
ism, the palliative measures I resort to 
are those in common use, consisting 
principally of massage and the careful 
use of the Benique or Guyon sounds or 
the Kollman curved dilator, with hy- 
gienic measures, and the interdiction 
of horseback riding or prolonged sex- 
ual excitement. After the advent of 
catheter life, prolonged drainage, ac- 
cording to the principles taught by 
Sir Everard Home and Felix Guyon, I 
have very frequently found sufficient, 
giving better results than vasectomy, 
and quite as good, as a rule, as castra- 
tion. 

In classes c, d and e, regular cath- 
eterization, following the excellent 
rules laid down by Edward Martin, is 
the best method of procedure. 

If the condition becomes intolera- 
ble, it is better to resort to the Bot- 
tini operation than attempt a prosta- 
tectomy. In classy^ a Bottini prosta- 
tectomy or suprapubic drainage by the 
Senn or Depezzer tubes I have found 
very satisfactory. 

(7) Yes. I cannot say how many, 
but certainly more than twelve, with 
no permanent results of any kind at 
any time, and with no more temporary 
benefit than I have derived many 
times from prolonged urethral drain- 
age accompanied by instillations or 
vesical lavage by solutions of silver 
nitrate. 

(8^ Yes. Twenty times. In three 
instances with apparently perfect suc- 
cess. In nine cases with varying de- 
grees of benefit. Eight times without 
relief of any kind. Upon one of these 
cases I did a prostatectomy three years 
afterwards. I did not notice any 
diminution in the prostate in the in- 



terval. I had one of the original cases 
operated by Dr. Haynes, under my 
care and observation for several years* 
For a year following the castration he 
seemed to be greatly benefited, then 
the prostate increased in size, vesical 
catarrh became marked and calculi 
formed, requiring lithotrypsis twice 
in two years. The obstruction in- 
creased to^a point where it was neces- 
sary to use the catheter every fifteen 
or twenty minutes, and the individual 
finally died from his disease. Out of 
the twenty there were four deaths di- 
rectly attributable to the operation. I 
regard castration as more dangerous, 
and not to be compared as in beneficial 
results with perineal prostatectomy. 

(9) Yes. Twenty-nine times. Very 
good. Many practical cures. I mean 
by that, the ability to empty the blad- 
der either entirely or with a resid- 
ual not to exceed 30 c.c. Four of 
my earlier cases died, but one of these 
was due to carelessness upon the part 
of an assistant in controlling the cur- 
rent, and another directly to my own 
ignorance and inexperience at that 
period. 

One was a paralytic and leaked con- 
tinuously, and wore a urinal from the 
time of the operation until his deaths 
three years afterwards ; but, as he said, 
he was much better off in this condi- 
tion than he had been with his reten- 
tion, when he had been obliged to be 
painfully catheterized every half hour. 
The others were all greatly benefited 
or permanently cured. Three subse- 
quently, when their general health had 
improved through the palliation of the 
Bottini drainage, submitted to pros- 
tatectomy. One of these was cancer- 
ous and died from secondary hemor- 
rhage incident to the prostatectomy. 
I did not find the Bottini scars inter- 
fered in any marked way with these 
enucleations. 

One, a man of seventy-four years 
who was so weak and ursemic that I did 
not dare to do a prostatectomy on him, 
had an apparently perfect result for 



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eighteen months subsequent to the 
Bottini. Then, the obstruction re- 
turning, I did a perineal prostatectomy 
upon him without relief, and three 
months afterwards was compelled to 
cut him suprapubically, and removed 
a fibrous outgrowth, which hung down 
from the left upper segment of the 
prostate into the bladder neck, with 
difficulty by the Fuller rongeur. He 
is now perfectly well, has control over 
his bladder and has restored sexual 
power. 

The complications I have noticed 
have been epididymo orchitis in five 
cases, perineal abscess in two cases, 
peri vesiculitis in another from a per- 
foration of the bladder wall by an an- 
terior burn, and once fatal primary 
hemorrhage, due to an overheated 
cautery in a hemophile. 

(10) Eight times. Twice for cancer- 
ous hypertrophy, using the Senn drain- 
age tube with very good results, the 
individuals obtaining perfect relief from 
pain and living comfortably for nearly 
two years. Three times by the Hunter 
McGuire method with some relief and 
comfort. But these persons did not 
remain long under my observation. 
Three times by the Depezzer supra- 
pubic retention catheters. These lat- 
ter were cases in which catheterization 
was impossible or not feasible, and 
drainage was required to avoid suffer- 
ing, and to prepare, if possible, for 
subsequent prostatic operations. They 
were all feeble old men, who could not 
stand the shock of any radical opera- 
tive measures. They all subsequently 
died within less than six months after 
such drainage was instituted, but were 
quite comfortable while they were alive. 

(11) Twenty-onetimes. Deaths 5, 
cures 14, relief 2. 

(12) Twenty-eight times. Deaths 4, 
cures 21, relief 3, including two which 
may later be classed as cured. 

The Chicago incision or inverted j^^. 

(13) Median perineal prostatectomy, 
the incision is made directly into the 
membranous and prostatic urethra, the 



capsule of the prostate opened by a 
blunt capsule knife from the urethra, 
first on one side and then on the 
other, the tumors enucleated usually 
by the fingers alone. The patient is 
placed in the position of eirtreme flex- 
ion of the lower limbs upon the pelvis, 
the table being slightly in the Trendel- 
enberg position. This position was first 
suggested and practiced by Dr. George 
Goodfellow, of Tucson, and San Fran- 
cisco, and adds greatly to the ease of 
the operative procedure. 

In the greater number of instances 
prostatic obstructions can be removed 
by this method more speedily, with 
less damage to the structures of the 
bladder neck, with less hemorrhage 
and consequent shock, and with less 
space for subsequent infection than by 
any other operation. Further, there 
is less prolonged confinement to the 
bed and the house, and less wetting of 
the patient. If all of the obstructions 
cannot be removed satisfactorily, espe- 
cially in intravesical ones situated in the 
floor of the bladder, more room can be 
obtained by a section of the floor of the 
prostatic urethra and the neck of the 
bladder and the bar, if there be one 
beyond it, by careful work with a Bliz- 
zard in the median line. This will give 
all the room one desires, and through 
it one can feel almost the entire floor 
of the bladder and dig out the isolated, 
tumors in the intravesical walls. It 
will not retard the recovery of the case, 
and does away with the necessity of 
the tube drainage. 

(14) (a) Irregular rupture or tear 
of the bulbous urethra by the careless 
handling of the staff on the part of as- 
sistants. This was followed in one 
case by a fistula, which is not yet en- 
tirely closed after seven months. 

(b) Excessive primary hemorrhage. 
1. Secondary hemorrhage, requiring 
in one case suprapubic cystotomy and 
followed by sloughing of the rectal 
wall from the very tight packing re- 
quired of the perineal wound with 
gauze soaked in adrenaline chloride 



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Original Contributions. 



solution. 2. Rapid formation of cal- 
culous deposits upon the eschars where 
the urine was alkaline, requiring intra- 
vesical or intraurethral curettage for 
their removal. 

(c) Sloughing of cellular tissues of 
abdominal wall and, once, separation 
of pubic symphyses. 

(A) In my hospital, dispensary 
and private practice during the past 
seventeen years I have treated more 
than five hundred cases of men for 
chronic prostatic hypertrophy, and 
had watched most of them go help- 
lessly to ground under the old palliative 
methods. Faulty as these old meth- 
ods are, I am not yet ready to uncon- 
ditionally abandon them. I have 
given what I regard as a fair trial to 
the sexual operations for the relief of 
this condition in at least thirty-two 
cases, and have followed the experience 
of my colleagues in fully as many 
more. I see no reason for continuing 
to do them. I have used the Freuden- 
berg-Bottini or the instrument of 
Hugh Young in twenty -^nine cases. It 
has its limits of usefulness, but any 
general surgeon or urologist who seeks 
to give to his prostatic patients the best 
care and best advice under all circum- 
stances cannot afford to ignore it or 
entertain foolish prejudice against it. 
His time will be well spent in learning 
how to use it. I have employed per- 
manent suprapubic drainage eight 
times for prostatic obstructions ; when 
other measures would be useless or 
inadvisable, it is a valuable resource. 
As a radical procedure, I have done 
twenty-one suprapubic or combined 
prostatectomies, and will probably, 
unless ray experience rises into hun- 
dreds of cases, never do so many 
again. I am, however, glad of my 
experience, for there are cases that 
cannot be dealt with successfully by 
any other method. Out of the twen- 
ty-eight perineal prostatectomies I 
have done, I have met very few that I 
would call easy, and but one that did 
not give me many uneasy moments. 



The general outcome of the prosta- 
totomies and the prostatectomies has 
been good ; best of all has been that 
of perineal prostatectomy. But deaths 
occur, and the results are not always 
faultless, even in the most skillful 
hands. 



BOBEBT HOLMES OBEENE. M. D.. 

OF NEW YORK CITY. 

(1) Sedentary pursuits cause con- 
gestion and increased discomfort from 
an hypertrophied prostate. 

(2) The extent, character and nat- 
ure of the disease modify the suffering 
more than the temperament. Other 
things being equal, the nervous. 

( 3 ) It is the result of chronic inflam- 
mation, causing the formation of con- 
nective tissue which plugs up the 
mouths of the acini, causing them to 
dilate (pseudo adenoma) ; or the in- 
crease in the connective tissue takes 
place between the acini, causing atro- 
phy of the prostate by compressing 
them, or if considerable in quantity 
causing a fibrous prostate. It gener- 
ally commences as a chronic posterior 
urethritis from whatever [cause. (See 
**Nature of Prostatic Hypertrophy," 
Greene and Brooke.-— Journal Amer- 
ican Med. Assso.y April 26, 1902.) 

(4) Great service, not necessarily for 
diagnosis but for prognosis as well, 
showing condition of bladder walls. 
Prostatectomy of any kind cannot be 
expected to completely cure when 
bladder walls much changed in chai'- 
acter. 

( 5 ) Alcohol and constipation in- 
crease urgency of symptoms by caus- 
ing congestion. 

(6) Stimulate reaction by tonics. 
Irrigation of weak solutions of silver 
nitrate, etc., when it causes little 
trouble. Take on catheter life if nec- 
essary. 

(7) No. 

(8) No. 

(9) No. 

(10) Danger of infection of supra- 



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pubic wound and diflSculty of proper 
drainage. 

(11) No. 

(12) Whenever I have had the op- 
portunity, if I could conscientiously 
advise it. 

(13) Operation as reported by Dr. 
J. P. Bryson of St. Louis, Annals of 
Surgery, 1902. 

(14) Possibility of urethro-rectal 
fistula. Of losing a piece of the prostate 
in bladder, and of causing impotence. 

(A) Given above. 

♦ » 

* 

WILLIAM K. WISHABD. M. D.. 

OF INDIANAPOLIS, IND. 

(1) I have observed no influence 
tending to produce hypertrophy from 
this cause. 

(2) I have noticed no difference. 

(3) 1 do not know. 

(4) Yes. Occasionally an instru- 
ment with a lens system aids in defin- 
ing intra-vesical growths, but a direct 
view obtained with an air dilation cyst- 
oscope in inspecting small growths 
about the visical orifice is sometimes 
better. 

(5) I do not think alcohol has any- 
thing to do with it, but constipation 
may. 

(6) I advise palliative trfeatment 
when the symptoms are mild, and when 
for any reason an operation is inadvis- 
able or declined by the patient. 

(7) No. 
(i) No. 

(9) Yes, I have through an instru- 
ment especially devised for the pur- 
pose and which I used through a peri- 
neal opening (see Journal Uutaneous 
and Geni to- Urinary Diseases, June, 
1902). Have also used a cautery 
through an air-dilated cystoscope. I 
use an extra long cautery introduced 
directly through the cystoscope. In 
one case now under observation the 
patient was almost wholly dependent 
on the catheter and had some growth 
near the vesical orifice on the posterior 
wall of the urethra and had been cau- 



terized three times at intervals of about 
two weeks. The patient is now able to 
empty all but one ounce of urine, and 
sometimes less has been found with the 
catheter, after voluntary efforts at uri- 
nation. Five cases where the cautery 
has been used through a perineal open- 
ing with my instrunient within the 
past two years still rei ' ^ 

well. The cautery wai i 

perineal tube in some I 

by the writer in the J 
neous and Genito- Urinary Diseases in 
March, 1892. A small tube was em- 
ployed and reflected light from a head 
mirror used. The results were appar- 
ently permanent and satisfactory, but 
no attempt was made to incise large 
growths. 

(10) Perhaps one-half dozen times, 
but I do not regard simple drainage by 
this method as of very great value. 

(11) Perhaps twenty-five or thirty 
times. The results have been more 
satisfactory when this method has 
been accompanied by a perineal incis- 
ion. 

(12) Probably sixty-five or seventy 
times. I have used a median perineal 
incision. 

(13) I have no operation of special 
choice but try as far as possible to de- 
termine what method best suits the 
individual case. 

(14) I have no especial complica- 
tions excepting occasional hemorrhage. 

(A) N'o answer, 

* 

A. E. HALSTEAD. M. D.. 

OF CHIOAQO, ILL. 

(1) My experience tends to show 
that indoor pursuits seem to favor 
prostatic hypertrophy. 

(2) My cases have been nearly 
equally divided between fat and thin 
individuals. I have no data as to in- 
fluence of temperament. 

(3) I can formulate no rule regard- 
ing the etiology. In a few compara- 
tively young men in whom I have seen 
hypertrophy, I have reason to believe 



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that chronic prostatitis was of etiologic 
moment. I do not believe that vene- 
real excess nor venereal disease as a 
rule have much influence in producing 
this condition. The etiology, I con- 
sider, is that of new growths, the 
cause of which is yet unknown. 

(4) None. 

(5)1 believe constipation and rectal 
diseases, particularly hemorrhoids, 
may have some etiologic significance. 
Alcohol ciinnot be considered. 

(6) Only when patient is progress- 
ing favorably; that is, when catheter- 
ization is successful and there is no 
great distress nor cystitis resulting 
from the catheter life. 

(7)1 have divided the vas (vasec- 
tomy) in Uoo cases without any appre- 
ciable results. 

(8) I have performed orchidectomy 
in four cases. One recovered; was 
well for six months, lost sight of after 
that. One died from ether nephritis. 
Two were improved — one considerably, 
and one slightly. 

(9) No answer, 

(10) I have operated a number of 
times, when I made a supra-pubic fis- 
tula. The exact number of cases I do 
not know; probably ten (10) at least. 
1 believe the operation has a distinct 
place in surgery, particularly in cases 
where prostatectomy is regarded as 
being contraindicated because of the 
low condition of the patient. 

(11) I have operated by the supra- 
pubic route alone but once. I do not 
consider it a good operation. In my 
case it simply resulted in a supra-pubic 
fistula, which relieved the patient for 
about one and one-half years, when 
he died. 

( 12 ) I have done four perineal pros- 
tatectomies. In one I did a combined 
supra-pubic and perineal because of the 
size and position of the tumor. A 
curved transverse incision has been 
my choice. 

(13) The perineal, with a curved 
incision above the anus. Where the 
prostate is high, and if the tumor was 



very large and projected well into the 
l^ladder, I would make a supra-pubic 
opening to facilitate its removal 
through the perineal incision. 

(14) The only complrcation that I 
have encountered in the operation was 
having a large prostate slip into the 
bladder, and with difficulty removed 
after it had been freed from its at- 
tachments. 

(A) (a) Vasectomy two cases; na 
improvement. 

(b) Orchidectomy four cases; one 
well for six months ; one death from 
operation ; two improved, one consider- 
ably, one slightly. 

(c) Bottini operations two; evacua- 
tion free after operation ; in one im- 
provement in cystitis ; in one cystitis 
probably increased, no improvement,^ 
at least; first operated one year, sec- 
ond about nine months; in both gen- 
eral health improved. 

(d) Five prostatectomies, three per- 
ineal, one combined, one supra-pubic 
Three perineals ^ all living, one six 
months, one four months and one 
three months after operation; all 
greatly improved in general health; 
bladder condition in all greatly im- 
proved. One combined, two years after 
operation, has no supra-pubic fistula, 
and can be considered cured. The one 
supra-pubic operation lived one and 
one-half years, and with supra-pubie 
fistula; died of infection of the kid- 
neys. 

* 

BOS WELL PARK, M. D.. 

OF BUFFALO, N. Y. 

(1) No answer. 

(2) No answer. 

(3) No answer. 

(4) Very little. 

(5) In my opinion constipation fig-^ 
ures largely, alcohol but slightly. 

(6) So long as patient has no- 
troublesome residual urine and no de- 
composition attending, nor great diffi- 
culty in voiding. 

(7) Three cases. Not followed for 
final results; temporary improvement... 



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(8) Ten or a dozen cases, five with 
excellent results^. 

(9) Several times. Hospital cases 
can't be followed. 

(10) Several times, bad results. 
Abandoned the method in all save can- 
cer cases. 

(11) N'o answer. 

(12) Eight times, one death. Peri- 
neal semilunar flap. 

(13) Perineal prostatectomy. Ease 
of performance, advantage of perineal 
drainage. 

(14) N'o answer, 
(A) N'o answer. 



ANDREW O. SMITH. M. D., 

OF PORTLAND , OBE. 

( 1 ) No answer. 

(2) No answer. 

(3) No answer. 

(4) No answer. 

(5) I do not believe that alcohol 
tends to prostatic hypertrophy. 

(6) No answer. 

(7) Two. Indifferent results. 

(8) Once. Partial relief . 

(9) No. 

(10) Twice. 

(11) Twice. Good results but more 
shock and much longer convalescence. 

(12) Five times. Best of success, 
minimum amount of shock, rapid con- 
valescence. Median perineorraphy, as in 
urethrotomy, has afforded ^suflBcient 
room. 

(13) Perineal. Less shock, better 
drainage, more rapid convalescence, 
simpler, easier, better. 

(14) Some sepsis in supra-pubic 
cases. 

(A) No answer. 



OABIi BEOK. M. D.. 

OF NEW TOEK CITY. 

(1) Sedentary tends to it mostly. 

(2) The nervous and lean suffer 
most. 

(3) This is too hard a question for 
the busy practitioner. It is probably 



a general tendency to sclerosis induced 
by rich and sedentary habits. 

(4) The cystoscope is of much less 
service than thorough palpation. I use 
Albarran's lately and Casper's. 

(5) The two latter items increase 
the tendency considerably. 

(6) If the extent be small and the 
disturbance accordingly so. 

(7) Yes. Twice, and with fairly 
good results. 

(8) Yes. See Separat-Abdruck aus : 
**Monatsberichte ueber die Gesamt- 
leistungen auf dem Gebiete der Krank- 
heiten derHarn-u. Sexual-Apparate," 
Bd. II, No. 6 u. 7, 1897. 

(9) I am opposed to the Bottini, 
although I know that in a few instances 
relief has been obtained. 

(10) Five times. The result was 
temporarily good. 

ai) Twice. With bad results. 

(12) Nine times. Only one fatal case. 

(13) Perineal prostatectomy. 

(14) Urosepsis after supra-pubic 
prostatectomy. 

(A) See Separat-Abdruck aus: 
**Monatsberichte ueber die Gesarat- 
leistungen auf dem Gebiete der Krank- 
heiten der Harn-u. Sexual-Apparate,'^ 
Bd. II, No. (> u. 7, 1897. 

♦ 

BBNEST 0. MABK. M. D.. 

OF KANSAS CITY, MO. 

(1) My cases have been among men 
who have, as a rule, led active lives, 
though theoretically considered I am 
inclined to the belief that a sedentary 
life would predispose to hypertrophy 
through favoring congestion. 

(2) Do not think that these charac- 
teristics have any special predisposing 
tendencies. 

(3) My study in this field has led me 
to the belief that prostatic hypertrophy 
is the result of a chronic inflammatory 
process producing new connective tis- 
sue formation. The etiologic agent is 
usually the gonococcus. 

(4) Cystoscopy has been of great 
benefit in determining the character of 



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Original Contributions. 



the hypertrophy, i. e., as to the direc- 
tion and extent of the encroachment. 
I use Bransford Lewis' instrument 
preferably. 

(5) Constipation may play a part 
in producing congestion. 

(6) I advise palliation only in those 
cases where a radical procedure is not 
to be considered on account of the 
physical condition of the patient. Pal- 
liation consists of regular aseptic cathe- 
terization and irrigations. 

(7) Have not done this procedure. 

(8) Have not done this procedure. 

(9) Have done Bottini's operation 
once, in December, 1902, in a patient 
seventy-seven years of age. Perfect 
success. It is too" early in this case to 
make any statement as to permanency. 
I am inclined to the belief that the 
Bottini does not afford a permanent 
cure except in exceptional cases. 

(10) Have never practiced supra-pu- 
bic drainage for this condition, nor do 
I consider it a procedure to be thought 
of except as an emergency procedure. 

(11) Have never done this proced- 
ure, having never found a case suitable 
for it. 

(12) Have done two perineal pros- 
tatectomies with perfect results. The 
curvilinear incision between the tuber- 
osities of the ischium affords ample 
room. 

( 13 ) Have no choice and believe that 
the operation should be made to apply 
to the individual case, the character of 
the enlargement being taken into con- 
sideration. 

(14) Have had no unexpected com- 
plications. 

(A) Have done two perineal enu- 
cleations and one Bottini, all three 
cases being successful. 

* 

0BOBOB O. MAO DONAIiD. M. D.. 

OF SAN FBANCI8C0. OAL. 

( 1 ) My experience leads me to be- 
lieve that sedentary occupations favor 
prostatic hypertrophy. 

(2) Phlegmatic and lean. 



N. B.--Probably their leanness is in- 
duced by the toxaemia. 

(3) Alcohol, gonorrhoeal cystitis 
and inflammation of prostate in mid- 
dle life, the prostate never having 
properly recovered; or, any condition 
which causes congestion of the vesico- 
prostatic plexus of veins, as excessive 
masturbation, toying with females 
without proper emission, and liver 
conditions which cause the hcemor- 
rhoidal veins to become varicosed. 

N. B. — All this depends on how the 
haemorrhoid plexus is formed; if the 
connection via the middle and inferior 
haemorrhoidal veins with the internal 
iliac is free, or if the blood is carried 
back from the plexus mainly by the 
superior heemorrhoidal and thus the 
portal system; the arrangement 
varies in different individuals. 

(4) I do not consider the cystoscope 
to be of any material service. Any 
cystoscope that carries the light at the 
distal extremity (bladder) and the 
bladder inflated with air. 

(5) Alcohol, overfeeding, constipa- 
tion and hepatic congestion are factors 
in hypertrophy. 

(6) This is a hard question to an- 
swer. The condition of the patient, 
his arteries, heart, lungs, kidnej's, age, 
and the size and consistency of the 
prostate are all factors which must be 
left to the judgment and experience 
of the surgeon. 

It consists in simply keeping the 
bladder clean, regular habits, diet and 
catheterization by soft rubber instru- 
ment surgically clean. When drawing 
off urine have patient on knees and 
hands, being most particular that the 
end of the catheter is pushed close so 
no air enters. bladder. 

( 7 ) Have never done this operation, 
considering it useless. 

(8) Same as answer No, 7. 

( 9 ) Have never used this procedure. 
Consider it unsurgical. 

(10) Do not do this. 

(11) Ten times. Four deaths; ex- 



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Prostatic Hypertrophy. 



129 



haustion due to shock and hemorrhage. 
Six living cases eminently satisfactory. 

(12) Once; fatal. Favor the semi- 
circular. 

(13) Decidedly supra-pubic, be- 
cause it is less dangerous, quick, sure, 
and all the gland is removed in one or 
two pieces. 

(14) Supra-pubic: contracted and 
hypertrophied bladder, considerable 
hemorrhage from the prostatic plexus 
of veins, shock, anuria and continuous 
hemorrhage of a passive character. 

(A) Palliative treatment is generally 
unsatisfactory, insomuch as sooner or 
later infection appears, with the usual 
kidney complications; it is very hard 
lo make a patient understand the im- 
portance of keeping to the instructions 
and living in surgical righteousness. 
The kind of instrument, which should 
always be soft rubber, and the 
difficulty sometimes experienced in 
getting even this in when the gland 
becomes congested, as it often does 
from many and various causes, is ex- 
treme. The position on the hands 
and knees, so as to draw the paunch 
behind the prostate. Uncertainty that 
the lubricant used is aseptic, soft and 
non-irritating, so that the treatment as 
a rule ends up disastrously, and should 
not be followed if there be any 
chance of a successful surgical intei^- 
ference. 

The supra-pubic, in my opinion, is 
the only one to be followed, that is in 
the majority of cases. The chief feat- 
ure in the operation is to suture the 
bladder to the fascia and skin by an 
interrupted catgut stitch, so that the 
viscus is well held tip to the abdominal 
wall, there is very little trouble in 
shelling out the gland, and we are not 
working in the dark (notwithstanding 
Mayo Robson to the contrary). I 
have never had any trouble in getting 
the abdominal wound to close within 
twenty-one days. Very often in the 
perineal method the whole of the 
gland is not removed, or only in 



pieces, at other times it is loose in its 
capsule; in such conditions the peri- 
neal makes the better operation so far 
as the length of the convalescence is* 
concerned, but if the gland is not very 
large (and it need not be to cause a 
great deal of trouble), hard and very 
adherent to its capsule, then there is 
danger to slipping into the rectum 
with the finger Just in front of the 
prostatic urethra, especially if the rec- 
tum be thin and atrophic, as it often 
is in thin old men. Hemorrhage in 
the supra-pubic operation can usually 
be controlled by packing, and, in ob- 
stinate cases, using gauze wetted with 
a saturated solution of alum in the 
woundy the balance being sterilized 
gauze. 

Although I have done a great many 
perineal sections for various bladder 
and urethral conditions, the only one I 
attempted for the removal of the pros- 
tate proved fatal, for the reason I 
punctured the rectum by my finger. 
It was a prostate that would not 
readily shell. I had to use my cut- 
ting forceps (which I had made on my 
own pattern, and found out afterwards 
another man had been ahead of me), 
while trying to free some of the ad- 
herent gland the tip of my forefinger 
slipped. Then, of course, I had to 
lay the whole business open, sphincter 
and all. The patient lived about ten 
days, but gradually sank. My four 
deaths following the supra-pubic oper- 
ation were from exhaustion, caused 
by loss of blood due to degenerated 
vessels, and because I did not give 
them' sufficient individual care. A 
surgeon who removes a prostate must 
rely on no one until all danger is 
passed. 

In perineal incisions there is danger 
of injuring the rectum while shelling 
out the prostate, especially if the rec- 
tum be atrophic and the anal sphinc- 
ters well marked. If the rectum is rupt- 
ured, it is, of course, fatal in old and 
debilitated men. 



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180 



Original Contributions. 



J. HBNBT DOWD, M. D.. 

OF BUFFALO, N. Y. 

(1) Excepting those sedentary in- 
clined, pursuits (indoor or outdoor) 
have but very little bearing upon 
hypertrophy of the prostate. In my 
experience, men living under either 
condition have been equal sufferers. 

(2) The large majority of cases oc- 
cur in the obese, especially where 
there has always been mental activity. 

(3) The first seed of prostatic hy- 
pertrophy is sown in youth, develop- 
ing insidiously as different causes 
arise, until a true pathologic condition 
is reached: 

Youth — Ungratified sexual desire, 
masturbation, onanism. 

Adult— Abuse of the sexual appe- 
tite, follicular prostatitis, gonorrheal 
in nature, stricture, unnatural sexual 
life and trying to accomplish impossi- 
bilities. 

(4) Regarding the lateral lobes, the 
finger is far superior to any cystoscope 
as a diagnostic agent. This instru- 
ment may be of value where there is 
involvement of the middle lobe. 

(5) A sedentary life tends towards 
hypertrophy. Alcohol is important 
as a predisposing cause. Constipa- 
tion must be considered a very impor- 
tant factor; it tends to continue, if 
not aggravate, the already congested 
or inflammatory condition. 

(6) Palliation should be practiced 
in all cases where no relief, even of a 
temporary character, can be obtained 
from radical measures. Excepting 
in cases where the bladder may be 
looked upon almost as a suppurating 
cavity, this viscus plays but little part 
as a contraindicating agent against rad- 
ical measures. On the other hand, 
damaged kidneys, even trivial in nat- 
ure, but which have existed for a long 
time, offer a serious barrier to even a 
temporary alleviation of the symp- 
toms. Palliative procedures depend 
entirely upon the existing condition ; 
in some supra-pubic, in others peri- 



neal drainage should be the operation 
of choice. 

(7.) I have tied and taken sections 
from thevas several times, but in only 
one was there much relief, and this 
temporary. It is my opinion that 
ligature or section of the vas deferens 
for hypertrophy of the prostate gland 
is of value, and should be used in cases 
where there still remains sexual activ- 
ity. Such was the case where tempo- 
rary improvement resulted. 

(8) In a few cases of castration the 
result was practically nil. When any 
improvement has resulted, the condi- 
tion was similar to that described in 
No. 7. 

(9) Never performed Bottini's op- 
eration. 

(10) Supra-pubic drainage should 
be considered a procedure of last re- 
sort and only palliative. There is no 
doubt it gives relief from the urgent 
urinary symptoms, but it is always 
followed by aggravated bladder com- 
plications which make life almost as 
miserable as when the urine was com- 
ing from below. One patient lived 
two years, and for awhile was in fair 
shape, but soon the bladder became con- 
tracted, stone formed and morphine 
as a regular diet had to be resorted 
to. In my cases I am not proud of the 
results that followed this operation. 

(11) I have removed the prostate 
supra-pubically but once,, the patient 
dying in four days. 

(12) Have never removed the gland 
from below. From repeated opera- 
tions for stone, abscess, etc., I am 
convinced that the inverted **Y" in- 
cision affords the greatest amount of 
room. In using this incision the rec- 
tum can be dissected backwards for an 
inch or so, thus bringing the gland 
clearly into the field, 

(13) There is no doubt but that the 
prostate attacked in the way described 
above can be removed much easier than 
by any other method. Using the in- 
verted *'Y" incision, with slight turn- 
ing backwards of the rectum, transfers 



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Prostatic Hypertrophy, 



181 



the cutting and dissecting process from 
darkness to light. 

(14) Hemorrhage is occasionally a 
distressing complication. Even in the 
hands of the most experienced, tearing 
or almost complete destruction of the 
posterior urethra may complicate mat- 
ters. The rectum has been lacerated, 
thus handicapping the reparative pro- 
cess. Uremia is the most serious 
drawback during post-operative con- 
duct of these cases. 

Second. — Hypostatic congestion of 
the different important organs, as the 
kidneys or lungs, due to the recumbent 
position at an age when the blood ves- 
sels have more or less lost their tone. 

(A) Prostatectomy is still in its in- 
fancy. High mortality can only be 
lowered by attacking the gland early 
and before the upper urinary struct- 
ures have taken on pathological 
changes. 

» 

WILLIAM JONES. M. D.. 

OF PORTLAND, OREGON. 

(1) I have met with it most fre- 
quently among farmers. 

(2) Have noted no difference in 
these different classes. 

(3) Any conditions favoring chronic 
congestion. 

(4) Have not used it. 

(5) Not influenced by habit, accord- 
ing to my observation. 

(6) Cases where there is but little 
residual urine and only moderate cys- 
titis. Then irrigations, and urinary 
antiseptics internally. In very old and 
infirm, regular catheterization and irri- 
gation in presence of considerable re- 
sidual urine and where operation would 
not be well borne. 

(7) No. 

(8) Once. Disappearance of hyper- 
trophy, but amount of residual urine 
(oz.x) not diminished. 

(9) No. 

10) Only a few times. Not more 
than six. Results unsatisfactory. 

( 11 ) Once* After supra-pubic drain- 
age for several weeks and in presence 



of suppurative orchitis, induced by vio- 
lent and unsuccessful efforts at cath- 
eterism. Death on second day. 

(12) Four times. All lived. All 
were made comfortable by the opera- 
tion and still are so. Transverse 
semi-elliptical. 

(13) Perineal. It is done under di- 
rect vision. Bleeding vessels can be 
secured, shock is less, drainage is more 
perfect and the after-treatment is 
simpler, neater and shorter. It seems 
to me a more accurate and surgical 
procedure, less dangerous primarily 
and there is less danger from sepsis. 

(14) iVo atiswer. 

(A) Five cases. One supra-pubic, 
septic at time of operation. Old man 
died on second day. 

Four perineal. One with severe cys- 
titis. All recovered and are leading 
comfortable lives. 



OEOBOE M. PHILLIPS. M. D.. 

OF ST. LOUIS, MO. 

(1) I have not been able to decide 
that occupation influences the develop- 
ment of strict prostatic hypertrophy. 

(2) The greater number of my cases 
have been lean and of a nervous tem- 
perament. 

(3) Undecided. 

(4) Rarely have I been able to use 
the cystoscope in this situation with 
much satisfaction. Usually hemor- 
rhage attends the application of the 
instrument and renders the parts unfit 
for inspection. I think Di^ Brans- 
ford Lewis' the best instrument. 

(5) The twenty-eight cases that I 
have followed and preserved my rec- 
ords of, eleven only were addicted to 
the use of alcohol in any form. 

(6) (a) Extreme age and the debili- 
tated. 

(6) Hygiene in all that the term im- 
plies, rest to the bladder and urinary 
tract as far as it is possible to obtain, 
all done with a view of developing a 
favorable condition for operation. 

(7) Yes; in twenty to twenty-five 



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182 



New Publications, 



instances; a small percentage were 
really benefited. All for a time ad- 
mitted improvement. All in all am of 
the opinion that but little real good 
was accomplished. 

(8) Yes, nine times. I believed at 
the time the conditions were improved 
in all. Subsequently it developed that 
in only three instances were the pa- 
tients satisfied. It became necessary to 
operate on four, doing a perineal pros- 
tatectomy. 

(9) Yes, twenty times. I have been 
able to follow only eight cases longer 
than a month or two ; four of these 
were greatly benefited, four improved. 
I have had many complications follow- 
ing this operation. Excessive and pro- 
longed hemorrhage, orchitis and epi- 
didymitis in several instances. 

(10) Five times. It is a trouble- 
some means of palliation, to be resorted 
to only when other means fail. 

(11) Ten times. The cases that I 



have been able to observe as a rule 
have fared well. Twice have I had in- 
filtration of urine and abscess of the 
abdominal wall to contend with ; both 
cases recovered. 

(12) Sixteen times; the median in- 
cision nine times, the curved incision 
from tuberosity to tuberosity three 
times and the left lateral four times. 
The transverse. 

(13) Perineal prostatectomy. 

(14) (a) Suppression of urine. (6) 
Abscesses. Incontinence of urine and 
feces. 

(A) Not having as correct record of 
my work as some, in a general way I 
wijl say that all work done here aside 
from the removal of the organ is un- 
certain. It is my custom to-day to ad- 
vise a prostatectomy, either supra- 
pubic, perineal, or the two, in all cases 
where surgery is positively indicated 
and the condition of the patient will 
permit. 



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Therapeutic Suggestions. 



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THERAPEUTIC SUGGESTIONS. 



BNLARQBD PROSTATE COMPLICATED 
WITH CHRONIC CYSTITIS. 

By R. Pabbies, M. D., New York City, 

Member of Medical Association of •Greater City of New 

York; Physician Mutual Aid Association and Society 

for Relief of Widows and Orphans of Medical 

Men; Late Visiting Physician .to New 

York Magdalene Asylum. 

It would be difficult to conceive of a 
non-treated enlarged prostate of long 
standing withput chronic cystitis as a 
conlplicatioii, the latter being an al- 
most invariable companion of prostatic 
enlargement of the senile type. This 
is especially so since it is usually the 
symptoms of cystitis which finally call 
the attention of the patient to the 
changed conditipn of affairs. The 
proBtate may have been undergoing 
enlargement for a long time, possibly 
years^ but the patient continues on his 
way in .entire ignorance. Could the 
physiciau have been called in during 
this period, cystitis would possibly be 
unknown as the almost infallible comr 
plication. Nor would surgery have an 
excuse for playing the prominent part 
it does in the treatment of prostatic 
enlargement, for, without cystitis, I 
question whether the enlargement 
would very frequently reach the stage 
of a urinary obstruction. The aseptic 
catheterization of the patient and 
withdrawal of the residual urine before 



it has time to becbme ammbniacal 
would 80 postpone the day of urinary 
interference that the patient would 
probably die of old age before this day 
would arrive without suffering any 
greater inconvenience than an occa- 
sional visit to the physician. But, 
under no circumstances shpuld the pa- 
tient be allowed to catheterize himself, 
because, sooner or later, familiarity 
will breed contempt, and he will neglect 
the. necessary precaution of asepsis,, 
with the result of bringing about the 
very condition he is attempting to 
avoid — cystitis. 

The seriousness of this complication 
is at once apparent to the physician. 
The ammoniacal urine not only in- 
flames the walls of the bladder, but the 
prostate as well. The enlargement of 
the prostate is increased out of propor- 
tion to its growth under ordinary con- 
ditions. This in turn results in in- 
creasing the amount of ammoniacal 
residual urine, which, in turn, has 
greater powers of damage to the blad- 
der wall and prostate. The residual 
urine increased, the bladder capacity 
is lessened, and the patient voids his 
urine more frequently fmd his frequent 
straining efforts to empty the diseased 
bladder brings a greater flow of blood 



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\ • / 

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Literature on request. 

>VM. R. WARNER & CO. Philadelphia 

nUNCHES: NEW YORK, CHICAQO, NEW ORLEANS, LONDON. 



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180 



Therapeutic Suggestions. 



to the affected parts, resulting in in- 
creased congestion, etc. Deplorable 
as the condition of the patient now is, 
it is generally at this stage that the 
doctor first sees his patient. Prognosis, 
from a medical standpoint, is naturally 
not optimistic, and one at first is led 
to accept Sir Henry Thompson's view, 
that medicine has practically no place 
in the treatment of prostatic hyper- 
trophy. Yet, if one were inclined to 
be skeptical as to the value of surgery, 
the host of operations, from the Fried- 
enburg-Bottini and supra-pubic pros- 
tatectomy, to castration and ligation 
of the cord, would probably suggest 
the unsatisfactory field which surgery 
has found the enlarged prostate. One 
then again turns to medicine with the 
hope, at least, of making the patient 
**comfortably sick." 

A great many remedies are used for 
ameliorating the distressing and an- 
noying conditions, the most prominent 
of which are a dull pain behind the 
pubis and frequent urination, especially 
during the night, in some cases every 
hour or oftener. The two symptoms 
alone are sufficient to bring the patient 
to a deplorable condition mentally and 
physically. The pain can be relieved 
by belladonna and opium suppositories, 
and the vesical irritability by the in- 
ternal administration of sanmetto in 
teaspoonful doses before meals and at 
bed-time. Tr. of nux vomica in five 
to ten minim doses is also of great 
value for its general tonic effect. 
Locally, when the urine is distinctly 
ammoniacal in character, two or three 
ounces of an aqueous solution of nitric 
acid, one minim to the ounce, should 
be injected into the bladder daily, fol- 
lowed by sterilized water. At times 
several ounces of a solution of nitrate 
of silver, one to one thousand ( 1-1000) 
once or twice a week will prove of 
greater value. Finally a solution of 
borax, a teaspoonful to the pint, should 
be substituted for the more drastic 
nitric acjd and nitrate of silver. The 
sanmetto internally, and the washing 



out of the bladder with borax solution , 
should be continued after the patient 
is well on the way to recovery. While 
I am not prepared to state that absorp- 
tion of hypertrophied tissue takes 
place under this treatment, yet there 
is a decided reduction in the size of 
the prostate, owing to the fact that 
all irritating influences are removed, 
and a better condition of nutrition is 
established. Hot sitz baths and rectal 
enemata are of great assistance in the 
treatment, and, I would suppose, mas- 
sage of the prostate, although I have 
never had to resort to the latter pro- 
cedure. 



As A SCALP WASH in the treatment of 
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6 oz. Apply to scalp daily. 

One application of chaparrin, when 
applied in sufficient strength, will allay 
itching for twelve hours. 



Acute Catarrhal Cystitis. — In 
this condition, with thick, ropy, tena- 
cious mucus secreted in immense quan- 
tities by the bladder cells, it usually 
becomes purulent and the Urine is 
loaded with great masses of muco- 
pus. Prompt relief follows the use of 
uriseptin, given in dessertspoonful 
doses four times a day, in hot water. 



For the relief of dropsical condi- 
tions, especially in renal dropsy from 
acute desquamative nephritis, anasar- 
cin tablets, one four times a day> will 
give astonishing results. 



Ecthyma. — The first thing to be 
done in these cases is to obtain clean- 
liness, proper hygienic surroundings, 
and complete abstinence from alcohol- 
ics. If there is a general debility, 
tonics must be given and the dietary 
improved. Locally, all crusts should 
be removed with soap and water, the 
lesione dressed two or three times a 
day with glycobenphene (Heil), and 
the parts properly bandag^. 



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FIRST OF ALL 

insist on rest and freedom 
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GRAY'S- -TONIC 



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No. 15 Murray Street, New York 



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Enough to make two gallons of standard antiseptic solution will be sent with clinical 
reports for 10c. This would make about seven dollars' worth of the usual bottled anti- 
septic solution. From THE IOUR»IAL OF THE AHERICAN MEDICAL ASSOCIATION: 

"At the Forty-fourth Annual Meeting of the American Medical Association. Llewellyn Eliot. A.M., M.D., Surgeon 
to Providence Hospital and Eastern Dispensary, and President of the Medical Association of the District of Colum- 
bia, etc.. Washington. D. C. in an article read before the Section of Obstetrics, said: 

'In irrigating the cases, we may use the solution of bichloride of mercury, carbolic acid, or any other medica- 
tion which individual preference may suggest; for my part, I employ a solution of Tyree's Anti.'ieptlc Powder, which 
consists of: parts sod. bor. 50. alumen 50. ac. carbol. 5, glycerin 5. the cryst. prin. of thyme 5, eucalyptus 5. gaultheria 
.5 and mentha 5.' " 

J. 5. TTREE, CHEniST. WflSniNQTON, D. C. 

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Ir88 



Therapeutic Suggestions. 



fHB RATIONAL TREATMENT OF DROP" 
SICAL CONDITIONS. 

By a. B. Welbuen, M. D. 

In order to elucidate the principles 
jind details of treatment in the above 
disease, it would be better first to 
mention some of its peculiar etiolog- 
ical and pathological characteristics. 
Dropsy signifies the presence of a 
Serous fluid (which has escaped from 
the blood vessels) in the subcutaneous 
5r submucous celjular tissue, in serous 
cavities, or in the cellular tissue of 
certain organs. When the subcu- 
taneous cellular tissue is extensively 
involved it is called anasarca; when 
restricted to a limited area it is called 
oedema. When this serous fluid ac- 
cumulates in the peritoneum it is 
ascites. If we have both the sub- 
cutaneous cellular tissue and serous 
cavities implicated we have what is 
called general dropsy. Dropsy results 
from a loss of balance between ex- 
halation and absorption. It may be 
•due to an obstruction in the circula- 
tion, to a debilitated state of the ves- 
sels and tissues, or an abnormal con- 
dition of the blood. A variety of or- 
' ganic and functional disturbances will 
create all of these conditions. 

Success in treatment will be meas- 
ured by the ability of the physician to 
locate and remove the predisposing 
and existing causes. The starting 
point of this disease, in the great 
majority of cases, is in the heart, liver 
or kidneys. Heart dropsy begins in 
the feet and ankles, and extends up- 
wards. Ascites, in the peritoneum, 
from obstruction in the portal circula- 
tion. Renal dropsy starts with a 
puflSness in the eyelids, face .and 
hands. It may finally involve the 
whole body as well as serous cavities. 
By bearing the above facts in mind, 
search for the cause of the disease is 
facilitated. After ascertaining the 
source of this trouble and addressing 
attention to its removal, the next step 
is to promote absorption of the fluid. 
This is done by the use of diaphoret- 



ics, diuretics, purgative^ and general 
restoratives. Our aim should be to 
deplete overfilled vessels, relieve local 
stasis, and promote an uninterrupted 
blood current through all the organs 
and tissues of the body. How can we 
best accomplish this object? Shall we 
ply our patient with innumerable drugs 
to meet the different indications, or 
shall we endeavor to find some agree- 
able tnedicinal combination possessing 
the specific therapeutic properties to 
fulfill these indications, without dis- 
comfort or detriment to the patient? 

If successful results from the use of 
a remedy in disease furnish a guide to 
practice, the writer has the strongest 
grounds for recommending anasarcin 
to the profession, as a most valuable 
and reliable remedial agent in dropsy. 
The ingredients, as published by the 
manufacturer, indicate that it stimu- 
lates the heart, equalizes the circula- 
tion, is a safe diuretic, ef&cient di- 
aphoretic, and promotes the absorp- 
tion of accumulated serous fluids. The 
writer has carefully tested anasarcin 
in a large number of dropsical patients 
with the most complete confirmation of 
the above claims. A few of the clinical 
cases in which anasarcin was chiefly 
employed are herewith reported : 

Case I. — Anna M., age forty-two; 
symptoms as follows: A weak and in- 
termittent pulse, palpitations, face 
bloated and purple, anxious counte- 
nance, dyspnoea, legs oedematous and 
painful, urine scanty, foul and charged 
with lateritious sediment, serous ac- 
cumulations in thorax and peritoneum, 
bowels constipated, with some dis- 
tention and flatulency. Diagnosis: 
Dropsy, from valvular incompetency 
and portal obstruction. Treatment: 
Mercurial purgation, followed with 
two small doses of Epsom salts and 
cream of tartar. The patient was then 
given anasarcin tablets, one three times 
a day, with a small dose of Epsom 
salts every second or third day. This 
treatment was continued three weeks, 
in connection with an upbuilding diet, 



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ANASARCIN 

(Oxydendron-Sambucus-Scilla Compound.) 

A SPECIFIC FOR DROPSIES 



Doctor:— 

If you know a thing to be a fact, it is not wrong or 
unethical to say so. Neither does it smack of quackery or 
Charlatanism and should not shock the sensibilities of any, 
however refined, cultured or zealous of medical ethics for us 
to claim that ANASARCIN is a specific in dropsies, when 
clinical experience has demonstrated such to be a fact. If 
quinine is a specific in malaria, much more is ANASARCIN 
in dropsies resulting from disease of the heart, liver or 
kidneys, because that a trial of it in hundreds, yea, thousands 
of cases has not resulted in a failure known to us where 
directions have been followed. 

Besides being a specific for dropsies, it is a permanent 
core in the conditions mentioned when begun early and 
continued a sufficient length of time, i. e., until the diseased 
organs regain normal function. ANASARCIN is composed of 
the active principles of Oxydendron Arboreum, Sambucus and 
Urginea Scilla» and is sold exclusively to physicians or 
druggists for physicians. Trial box free with literature and 
testimonials furnished physicians on application. 



A DORESS = 



The Anasarcin Chemical Company 

1 1 WINCHESTER, TENN., U. S. A. 



LONDON AQBNTSr^ 



Thos. Christy A Co., 4'10-12 Old Swan Lane, Upper Thames St, B. C. 



i^%/%/%^%^%%/%/%^%^%/%^%/%%/%^^%^^%'%/^^^%^%^%^%'^%^%^%^'%^/^%^%^%^^^%^%%^ 



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140 



Therapeutic Suggestions. 



when the patient, being entir,ely re* 
lieved, was discharged. 

Case II. — ^Mary B,, ag© sixteen; 
Symptoms: Pain in right side, feces 
clay-colored, urine high-colored,scanty, 
depositing lateritious sediment, not 
coagulable, tongue coated, bowels con- 
stipated, abdomen distended by serous 
accumulations, legs cedematous. Diag- 
nosis : Ascites and anasarca, from ob- 
struction of liver and portal system. 
Treatment: Small dose of calomel, 
followed by saline purgation, and then 
anasarcin tablets, one three times a 
day ; small doses of Epsom salts and 
cream of tartar were given on alter- 
nate days. Under this treatment pa- 
tient was relieved and discharged at 
the end of eighteen days. 

Case III. — Female, age thirty-five, 
of intemperate habits; symptoms: 
Was confined to her bed with a tense, 
swollen and enlarged abdomen, legs 
(edematous, pitting on pressure; op- 
pressed with suffocation, the urine 
scanty, dark-colored and lateritious, 
hot coagulable by heat ; violent bilious 
vomiting; bowels constipated. Diag- 
nosis: Anasarca and ascites, caused by 
liver and portal obstruction from in- 
temperance and exposure. Prescribed 
five grains each of calomel and bicarb, 
soda, followed by Epsom salts and 
cream of tartar; then gave anasarcin 
tablets, one three times a day, a saline 
aperient on alternate days, diet nutri- 



tious. Treatment continued sixteen 
days, with recovery and discharge of 
patient. 

Case IV. — John W., aged thirty; 
symptoms: Pale and anemic, spleen 
enlarged, abdomen tense and hard, 
with evidence of serous accumula- 
tions, extremities oedematous, urine 
scanty, high-colored and containing 
lateritious sediment; no coagulatioa 
on application of heat. Diagnosis: 
Ascites and anasarca, from prolonged 
attack of malarial fever. Treatment: 
Small dose of calomel, followed by 
Epsom salts and cream of tartar; 
anasarcin tablets, one three times a- 
day; tine, of iron, ten drops three 
times a day ; Epsom salts and cream of 
tartar, small dose every other day; 
nutritious diet. Treatment continued 
thirty days; recovery and discharge. 

Case V. — James M., aged sixteen $ 
symptoms: Slightly anasarcous in the 
extremities, urine scanty and pale,, 
slight coagulum by testing with nitrous 
acid, shortness of breathing. Diag- 
nosis: Anasarca, from mild attack of 
scarlatina. Treatment: Hot sponge 
bath daily, fifteen drops spts. of nitre 
three times a day, small dose of 
Kochelle salts every second day, an- 
asarcin tablets, one three times daily, 
nutritious diet. Treatment continued 
twenty-one days, with complete recov- 
ery and discharge of patient. 

St. Louis, Mo. 



INDEX. 



Original Conteibutions. paos. 

Prostatic Hypertrophy from Every Sargiciil Stand- 

Joint by Numerous Authorities— 
ohn A. Wyeth, M. D 96 

Aufirnstus Charles Bemays, M. D 97 

Eugene Fuller, M. D , :... 99 

Edward Martin, M. D 100 

Branaford Lewis, M. D 100 

J. B. Murphy, M. D 103 

Orville Horwlt2,.M. D 104 

WUliam K Otis, M. D 108 

Alexander Hugh Ferguson. M. D 108 

Robert Tuttle Morris. M. D 109 

B. Mertill Ricketts. M. D 109 

Howard Lilienthal. M. D 110 

Howard Crutcher, M. D 110 

HUary M. Christian. M. D Ill 

Charles Chassaignac, M. D 112 

Charles H. Mayo, M. D 113 

Henry H. Morton, M . D 113 

Stuart McGuire, M. D 114 

W. Frank Glenn, M. D 115 

N. Pendleton Dandridge, M. D 115 



Original Contributions. page. 

Joseph Rilus Eastman. M. D — 116 

Ferd C.Valentine, M.D 117 

PaolaDeVecchi, M. D 117 

Walter G. Spencer, F. R. C. S.. M. S.. M. B 118 

Edmund Andrews, M. D 11^ 

Albert J. Ochsner.M. D 119 

JacobGeiger, M. D ... 120 

Granville Mac Gowan. M. D 120 

Robert Holmes Greene, M.D 124 

William N.Wishard. M.D 125- 

A. E. Halstead. M. D 125 

Roswell Park, M.D 126 

Andrew C. Smith, M. D. 127 

Carl Beck. M.D 127 

Ernest G.Mark. M.D 12T 

George C. MacDonald, M. D 128 

J. Henry Dowd, M. D 130 

William Jones. M. D 131 

George M. Phillips, M.D.... 131 

New Publicvtions 132 

Therapeutic Suggestions 134 



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Is the true nuclein derived from the lymphoid glands of 
healthy animals without the use of chemicals, and con- 
tains the unaltered vital principles which cannot be made 
artificially from plants nor extracted from chemicals. 

Indicated in all infectious and toxic conditions, debil- 
ity and tissue waste, and locally in the treatment of Ulcers 
and Surface Lesions. In fact, in any case where a true 
physiological leucocytosis is required. 



SAMPLES AND LITERATURE ON REQUEST. 



Send for Illustrated Booklet and Fee-Table of our 

PATHOLOGICAL, CHEMICAL AND BACTERIOLOGICAL LABORATORIES. 



REED St CMRNRICK 

42-46 OERMANIA AVE. JERSEY CITY, N. J. 



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149 



Therapeutic Suggestions, 



INDOLENT ULCBRS. 

Cases of indolent ulceration that are 
so annoying to the general practitioner 
may be much benefited by the use of 
protonuclein (special). 

The form of treatment may be 
classed as strictly routine, because a 
certain procedure in all cases gives 
parallel results. The ulcer surface 
should be thoroughly cleansed by the 
curette or continuous poulticing. The 
use of the curette is more or less pain- 
ful and at the same time much tissue 
may be destroyed. By poulticing the 
necrotic masses will separate and a 
general stimulation follow the applica- 
tion of moist heat. In old indolent 
ulcerous surface it is recommended 
that the first four dressings be made 
by covering the ulcer with protonu- 
clein (special) and then bandaging m 
ptace a thick covering of hot wet 
absorbent cotton, changing twice 
daily. These dressings should finally 
be followed by dry dressings of pro- 
tonuclein (special). This form of. 
treatment will give the best results. 



THE TREATMENT OP CARBUNCLE. 

The treatment of carbuncle must be 
-constitutional and local. At first active 
saline purgation is our sheet-anchor, 
followed by light stimulation and a 
highly nourishing diet. Opiates should 
be freely administered when necessary 
to reUeve pain and procure rest. 
Protonuclein tablets, three at a dose, 
frequently repeated, will be of great 
service. Sulphate of magnesia, in full 
doses with ten drops of dilute sulphuric 
acid added to each dissolved dose, will 
produce excellent results. Trophonine 
later on will prove beneficial. The 
local treatment should begin with the 
constitutional, and be equally as 
thorough. All of the suppurating 
outlets should be syringed out with 
pure zymocide and a 5 to 10 per cent. 



solution of. carbolic acid injected in 
various parts of the tumor. Ice bags 
should be kept applied from the be- 
ginning and continued until the periph- 
eral extension is arrested; necrosed 
tissue should be removed, but incisions 
are of doubtful utility, and are seldom 
advisable. Complications may modify 
this treatment in some of its details, 
but in the main the measures suggested 
will arrest the progress of the disease 
and prevent septic poisoning. 



IMPAIRMENT OP THE DIGESTIVE ORGANS 

FOLLOWING THE ADMINISTRATION 

OP IODIDES. 

During the extensive exhibition of 
potassii iodidi, where there is a gen- 
eral impairment of the digestive or- 
gans, trophonine will be found to be 
of the greatest possible benefit— being 
a highly palatable and nutritious food, 
and at the same time containing the 
nuclei-albumen which gives it a most 
forcible place during the prolonged 
necessary anti-syphilitic treatment.- 
Observation has demonstrated that the 
lymphoidal structures are greatly stim- 
ulated by judicious feeding, so where 
we administer a food readily assim- 
ilated and at the same time containing 
a substance as one of its component 
parts which bring about a result pre- 
cisely to be desired, such a food im- 
mediately becomes a therapeutic agent 
and powerful adjunct to other lines 
of treatment. 



LOCAL TREATMENT OP ACNE. 

The skin is first subjected to the 
disinfected needle and comedo ex- 
tractor until all pustules and sub-epi- 
dermic foci are evacuated and the 
conspicuous comedones removed. The 
surface is then rendered aseptic with 
zymocide (pure), which should be ap- 
plied several times a day. 



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VKNKflKAL OI8KA8K8 AND QKNITO-UfllNARY SUROKRY. 



HKDICINC 



EDITORS 

S. C. MARTIN. M. D. G. M. PHILLIPS. M. D. 

^norctsoR op oiiimatolo«v in tm« barncs mcomal oollkoc Miopcnoii or •cnito-urinanv oikams rr, louis ooluoc op= 

■T. LOUIS. PMVSIOIANS AND SURaCONS. 

MANAGING EDITOR 
S. C. MARTIN. Jr., M. 0. 



SUBSCRIPTIONS AND ADVERTISING. 

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Address all communications, correspondence, books, matter regarding advertising, and make all checks, drafts 
and post-office orders payable to 

AMERICAN JOURNAL OF DERMATOLOGY, 

Fidelity Building. St Louis, Mo., U. S. A. 



Vol.. VII. 



JULY, 1903. 



No. 4. 



MEDIAN PERINEAL URETHROTOMY AND 

CYSTOTOMY THROUGH A SUPER- 

PICIAL TRANSVERSE INCISION, 

APTBR CELSUS. 

By Waltbb G. Spencer, P. R. C. 8., M. 8., M. B., 
Surgeon to the Westminster Hospital, London, England. 

In some special cases I have found 
it advantageous to reach the neck of 
the bladder by first making a superficial 
semilunar incision across the perineum, 
and then a second deep one exactly 
along the middle line, so as to lay open 
the hinder part of the urethra and the 
neck of the bladder. 

* Celsus, baying described the holding of the 
patient in the lithotomy position by assistants, 
and the bringing down of the stone to the neck 
of the bladder by the index and middle finger 
of the left hand in the rectum, whilst the fin- 

gers of the right hand made pressure on the 
ypogastrium, says: "Over the neck of the 
bladder near tiie anus a lunate incision, the 
horns of which point a little towards the hips, 
is cut throogh-the skin as far as the cervix of 
the bladder; then, below the skin, a second 
incimflris to be made, crossing the first where 



I do not regard the method as sup- 
planting the well-known suprapubic 
and perineal operations, except lateral 
lithotomy, which has rightly lapsed 
into disuse, but as applicable to certain 
special cases, such as are detailed be- 
low. 

There is nothing novel in the pro- 
cedure ; on the contrary, it is the ear- 
liest of all systematically described 
lithotomy operation8,viz. , that given by 
Celsus,* book vii, chap. xxvi. It has 
been used for perineal prostatectomy, 
and is described and figured by Kocher 

it is convex, which lays open the cervix until 
the urethra is exposed; and so that the wound 
is a little larger than the calculus.'' The cal- 
culus then comes into view, and may be pushed 
out or extracted bjr the fingers or by a special 
scoop, against which, if too large, the stone 
may be broken by a chisel. Celsus continues: 
**Por those who, for fear of a fistula, which in 
this position the Greeks call koruada, make 
too small an opening, are afterwards brought 
tothis very result with still greater danger; 
for the calculus makes a way for itself, when 



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142 



Original Articles, 



*(*«Text-book of Operative Surgery/' 
by Dr. Theodor Kocher, translated 
from the second German edition by 
Mr. H. J. gtiles, pp. 163 — IbS, figs. 
74 and 75), where it is said to have 
been practiced by Dittel and Zucker- 
kandl. I am fully aware that this 
operation described by Celsus has not 
been largely followed, and that by 
suggested emendations of the text and 
strained commentaries it has been 
sought to explain the passage as an 
-obscure description of left lateral 
lithotomy. I am only concerned to 
show that, taking the description of 
•Celsus as it stands, his operation agrees 
essentially with that which I have car- 
ried out. The anus was held out of the 
way by the fingers of the left hand, 
which drew the stone towards the 
perineum; a free superficial incision 
was made, and then by a deep median 
incision the neck of the bladder was 
^divided, not ruptured, sufficiently to 
allow of the removal of the stone 
without the production of complications 
^lUd of a urinary fistula. 

The operation, as I have performed 
it, is as follows: — ^The patient, pre- 
pared by shaving and cleaning, is placed 
in the lithotomy position with the 
pelvis raised by a sandbag. The cen- 
tral point of the perineum is then made 
the middle of a horseshoe-shaped in- 
cision of the skin, the ends of which 
terminate on either side of the anus 
Just internal to the ischial tuberosities. 
By deepening the lateral portions of 
this incision the ischio-rectal fossae are 
exposed, and in the middle the ex- 
ternal sphincter ani is detached from 
its connection with the central point of 

forced out, unless it find one. It is even more 
dangerous still when the shape of the stone or 
its rough surface contributes to this effect, 
from which both haemorrhage and over-stretch- 
ing of nerves may be produced, which if any 
one escapes, yet he will have a larger fistula 
by the cervix being torn than he will if it be 

"Cum jam eo venit, incidi super vesicae cer- 
vicem juxta anum cutis plaga Innata usque ad 
cervicem vesicae debet, comibus ad coxas spec- 
tantibus paulum: deinde ea parte, qua resima 
-plaga est, etiamnnm subcute altera transversa 



the perineum, care being taken not to 
cut into the bulb or the urethra at this 
stage. The anus and the lower, portion 
of the rectum are now pushed back- 
wards with the fingers and held there 
by a flat retractor, the knife not being 
used lest the gut be injured. By re- 
tracting the anus and drawing the bulb 
forwards there is exposed the prostate, 
the prostatic and membranous urethra 
surrounded by the constrictor urethr® 
muscle, the bulb covered by the bulbo- 
cavernosus muscle, and the transverse 
perineal muscles inserted into the cen- 
tral point. Whilst thus retracting the 
wound the transverse perineal and the 
bulbar arteries or their branches, if 
cut, are clamped or tied. The urethra 
is next opened by an exactly median 
incision, commencing along the median 
raphe of the bulbo-cavernosus muscle, 
and extending backwards through the 
membranous urethra to the prostate. 
It is of the greatest importance^ in 
order to insure rapid healing, to keep 
exactly in the middle line, and there is 
no difficulty in doing this without the 
aid of a staff, although a median staff » 
accurately held, is of assistance where 
the urethra is permeable. But there is 
no difficulty in making this median in- 
cision without any guide when the 
urethra and prostate have been first of 
all exposed, as described. The urethral 
incision must be of sufficient length 
from the prostate forwards to allow of 
subsequent manipulation without any 
tearing. 

Having opened the urethra along the 
middle line a probe-pointed gorget can 
be passed into the bladder, followed by 
the finger, which can now fully examine 

plaga facienda est, c^ua cervix aperiatur, donee 
urinae iter pateat sic, ut plaga paulo major, 
qnam calculus sit. — Nam, qui metu fistulse 
(quam illo loco Ropvada Graeci vocant) parum 
patefaciunt, cum majore periculo eodem revol- 
vuntur: quia calculus iter, cum vi promitur 
facit, nisi accipit: idque etiam perniciosus est, 
si figura quoque calculi, vel aspritudo aliquid 
eo sontulit. Ex quo et sanguinis profusio, et 
distentio nervorum fieri potest: quae si qnis 
evasit, multo tamen patentiomm fistulam 
habiturns est mpta cervice, quam habuisset, 
incisa.*' 



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Median perineal Urethrotomy— Spencer, 



143 



the bladder, aided by the counter- 
pressure of the left hand on the hypo- 
gastrium. Owing to the larger super- 
ficial wound and the free opening of 
the urethra, there is not required that 
thrusting to get the tip of the finger 
beyond the neck of the bladder char- 
acterizing the ordinary median cyst- 
otomy, whilst lateral lithotomy opens 
the bladder partly by cutting, partly 
by tearing the left of the neck. A small 
speculum can be passed into the blad- 
der and the wall viewed directly by the 
aid of a small electric lamp. A rectal 
speculum with a slit is of service in ex- 
amining an enlarged middle lobe of the 
prostate, which will partly project into 
the slit. Such an enlargement can be 
pinched off or burnt down by the cau- 
tery in full view, whilst the speculum 
protects the sphincter vesicae from in- 
jury. A firm enlargement of the pros- 
tate can be drawn downwards into fuller 
view by a volsella, and burnt or cut 
away whilst the bleeding is completely 
controlled. A groove can be burnt in 
the middle of the enlarged prostate un- 
til the level of the floor of the post- 
prostatic pouch is reached, which is 
thereby effectually drained, whilst all 
injury to the rectum is avoided by the 
preliminary retraction. Portions of an 
enlarged lateral lobe may be shelled 
out or punctured with the cautery point 
to promote absorption, and beyond lie 
the vesiculse seminales, which are easily 
reached by a little further retraction 
of the rectum. There is ample room 
to U80 lithotomy forceps or a scoop, 
and to extract small or medium-sized 
stones from bladder pouches, or indeed 
to use one of the large perineal litho- 
trites. In cases of complicated stricture 
with fistulae traveling back towards the 
rectum, the urethra is reached by a 
median incision behind the stricture, 
which can then be traced forwards, 
and fistulous tracks outside the urethra 
are either excised or slit up. 

After the necessary manipulations 
are completed the bladder can be 
washed out; all bleeding points are in 



view and may be tied, or if in the 
prostate touched with the cautery. 
It is hardly necessary to insert any 
plug or tube ; in any case it should be 
removed the next day. 

When the legs of the patient are 
brought down from the lithotomy po- 
sition not only do the edges of the 
urethra come well into apposition along 
the middle line, but the transverse 
skin incision does so also in the folds 
between the anus, scrotum and but- 
tock. This can be clearly demon- 
strated by turning the patient on his 
side after extending the legs; the 
edges of the curved skin incision will 
be found to have come naturally into 
place. There is therefore no need for 
any sutures. 

The after history of the cases will 
show that the leakage of urine through 
the perineum is surprisingly small, 
urine being quickly passed through the 
penis, whilst the flow through the 
perineum ceases in a week or ten days, 
owing , to the union of the urethra 
along the median line. Following 
upon this the skin wound completely 
unites, leaving a scar which forms a 
slight ridge across the perineum in 
front of the anus. 

The classical complications, recur- 
rent hemorrhage and septic absorp- 
tion, are absent owing to the methods 
of operating, the free skin incision, 
the deliberation of the manipulations, 
the exactly median incision avoiding 
all rupture and lateral deviations and 
pockets, the complete arrest of hemor- 
rhage, the free escape of urine after- 
wards. 

The following cases illustrate the 
advantages of this operation. 

(a) Urethral Stricture. 

Case 1. — ^A tailor, aged forty-nine, 
was seen with cystitis and incontinence. 
His stricture had followed on several 
attacks of gonorrhea, the first twenty 
years before. It commenced in the 
penile urethra, and was completely 



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1^4 



Original Articles. 



impermeable even under an anesthetic. 
The membranous urethra was opened 
behind the stricture, which was di- 
vided forwards to one inch in front of 
the posterior fold of the scrotum ; an- 
terior to this it was simply dilated. A 
false passage leading backwards to- 
wards the rectum was slit up com- 
pletely. The patient was soundly 
healed two months after the opera- 
tion, the urethra readily admitting a 
No. 16 bougie, which he was ordered 
to pass regularly at intervals. 

Case 2. — A ropemaker, aged thir- 
ty-seven, developed a stricture follow- 
ing gonorrhea twelve years before. 
Dilatation by bougies was attempted, 
but this caused great pain, with rigors, 
fever and collapse, also epididymitis, 
and these symptoms recurred when 
dilatation was again attempted. Fol- 
lowing the operatian with the complete 
division of the stricture exactly along 
the middle line, a No. 16 bougie passed 
without any pain or other symptoms. 
The perineal wound soon healed, and 
the patient was dismissed with a No. 
16 bougie. 

Case 3. — A draper, aged thirty- 
eight, suffered from a stricture which 
had followed several attacks of 
gonorrhea, the last more than ten 
years before. Four years previously 
internal urethrotomy was done, and he 
learnt to pass a No. 9 to 12 metal 
bougie. This he could do easily at 
first, then with increasing difficulty, 
although he tried regularly, until he 
could no longer pass the bougie at all. 
Increasing frequency of micturition 
and straining set in until he had to 
pass one ounce or so every hour, night 
and day, after much straining. Inter- 
nal urethrotomy was again attempted, 
and as this failed external urethrotomy 
by the Wheelhouse method was per- 
formed, and a perineal tube tied into 
the bladder to give the front part of 
the urethra rest. After draining for 
some time nothing could be satisfac- 



torily passed. When I first saw the 
man, whilst urine was escaping from 
the perineum, no bougie could be 
passed unless under an anesthetic, 
when, after considerable difficulty in 
avoiding false passages, I passed a 
full-sized bougie. Still no improve- 
ment followed, nothing could be 
passed except under an anesthetic on 
account of the false passages. I 
therefore operated as I have de- 
scribed, and after dividing the strict- 
ure throughout its whole length, ex- 
actly along the median line, I found 
the tracks of three very indurated 
sinuses leading backwards towards the 
rectum. Having partly excised and 
partly slit them up completely, I tied 
a catheter in the bladder through the 
penis, and conducted the urine off to 
a vessel under the bed. Continuous 
drainage and daily irrigation of the 
bladder was kept up for five weeks, 
when his No. 12 silver catheter could 
be easily passed and he was dismissed, 
passing this catheter for himself, with 
the perineal wound quite healed. 

With regard to alternative measures 
Cock's operation is valuable when 
there is retention with the urethra 
dilated behind the stricture or when 
there is threatened or actual extravasa- 
tion of urine, but it leaves the stricture 
in front and any false passages un- 
treated. Wheelhouse's operation is 
sometimes very difficult, takes a long 
time, and unless the stricture is com- 
pletely divided is apt to be unsatis- 
factory. Moreover, false passages are 
left untreated, and hence there is often 
a difficulty, especially when the pa- 
tient tries to pass his own instrument. 
It will be noted that the three patients 
were comparatively young, two under 
forty and one under fifty, and that the 
strictures were complicated. The 
method provided a satisfactory cure, 
the perineal wound healing soundly, 
and the patients being able to pass for 
themselves the largest sized bougies.. 



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(6) Removal of Calculi. 

Case 4. — A cabdriver, aged fifty- 
seven, presented the following surgical 
history : Six years before he had been 
operated upon for stricture; three 
jears before a stone had been crushed, 
but the removal .was incomplete, and 
shortly afterwards supra-pubic lith- 
otomy was done. It was a very diffi- 
cult operation owing to the very con- 
tracted and sacculated bladder. One 
year before he underwent lateral lith- 
otomy, after which there was severe 
recurrent hemorrhage for a week, 
which had to be controlled by firmly 
plugging the wound. Four months 
before being seen by me his stricture 
had again been dilated and his bladder 
sounded without a stone being found. 
I thus had to deal with a patient in 
whom a stone had formed for the 
fourth time in a very contracted and 
sacculated bladder with a partially 
strictured urethra. The cicatrix of 
the supra-pubic lithotomy wound was 
very depressed, and. I learnt that the 
operation had been difficult enough at 
first; to have attempted a repetition 
would inevitably have led to the open- 
ing of the peritoneal cavity, and its in- 
fection by alkaline urine. Lithotrity 
had previously failed, and lateral lith- 
otomy had been attended by dangerous 
hemorrhage. 

The operation therefore was carried 
out as has been described ; a large bul- 
bar artery was tied on each side, the 
neck of the bladder reached, and a 
stone the size of a pullet's egg easily 
removed from a pouch on the left side 
of the trigone. Some phosphatic con- 
cretions were also scooped and washed 
out. At the same time the opportunity 
of fully dividing the imperfectly 
cured stricture was taken. No tube 
was inserted. There was no further 
bleeding, he began to pass urine 
through the penis on the third day, by 
the end of the week hardly any urine 
escaped by the perineum, and in three 
weeks the wound had completely 



healed. After the previous lateral 
lithotomy there had been firm plug- 
ging of the wound for a week, no 
urine passed through the penis for 
three weeks, and the perineal wound 
leaked for a long time. 

The man continued to wash out his 
bladder for two years, and so remained 
free from any re-formation of stone. 
Then he began to neglect the washing 
out, and gradually symptoms of stone 
came on agam, with pain in the pros- 
tate and orchitis, which went on to 
suppuration. I therefore repeated the 
operation about two and a half years 
later; there was not only a stone in 
the same pouch, as before, but also a 
number of small calculi in the sub- 
stance of the prostate, all of which 
were easily retooved from the fully 
exposed organ. He likewise recovered 
rapidly from this repetition of the 
operation. Most of the urine passed 
through the penis within the first week, 
and the external wound healed in about 
a month ; the testis also healed. When 
last seen the patient was in good 
health, and may continue so if he at- 
tends to the daily irrigation of the 
bladder. 

Oase 5. — A greengrocer, aged forty, 
gave the history that about a year ago 
burning pain had commenced in the 
urethra before and after micturition. 
Gradually the pain increased with fre- 
quent micturition and occasionally 
hsematuria, so that he had to give up 
work. During the last two months 
the frequent micturition had changed 
to complete incontinence, with great 
and constant pain in the perineum and 
tip of the penis. When seen the pa- 
tient was very pale, thin, haggard. 
From the urethra was escaping thick 
pus, as in acute gonorrhoea, but the 
pus was mixed with alkaline urine, for 
there was complete incontinence. 
Faeces were also being passed involun- 
tarily, and he had superficial sores on 
his back and buttocks. At first sight 
I thought the patient had an abscess 
of the prostate, but on examining per 



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rectam a large stone could be felt oc- 
cupying the neck of the bladder and the 
prostatic urethra. A sound easily struck 
this stone, but could not be passed 
beyond it. By passing the finger fur- 
ther into the rectum and examining 
bimanually, with the other hand on 
the hypogastrium, another stone could 
be felt above the first, but held firmly 
by a contracted bladder. During these 
manipulations thick pus spurted out 
from the meatus urinarius. 

As the patient was in such pain, and 
pus seemed to be retained, I operated 
at once by the method described. The 
first stone reached, oval in shape and 
two ounces in weight, was fixed in the 
dilated prostatic urethra and the neck 
of the bladder, having its long axis 
corresponding to that of the urethra. 
It was easily extracted. The second 
stone, also oval in shape ^nd weighing 
two and one-fourth ounces, was lying 
transversely, with the bladder most 
firmly contracted over it, and articu- 
lating with the first where there is a 
facet, so as to form a T. This stone 
was manipulated bimanually so as to 
turn its long axis into the vertical, and 
was then extracted by forceps, aided 
by a hand on the hypogastrium. 

Both stones are exhibited ; one has 
been cut and analyzed; it Is mainly 
composed of urates, and shows two 
nuclei fused together. After the oper- 
ation the patient did not present any 
special symptoms; the temperature 
gradually became subnormal. Diar- 
rhoea set in, and he died on the fifth 
day after the operation. 

Post'Tnortem. — Both kidneys were 
found equally distended with non- 
odorous pus, the remaining cortex was 
riddled with small abscesses, and sev- 
eral abscesses existed between the cor- 
tex and the capsule. The bladder was 
very contracted and thickened, but not 
sacculated ; there was a superficial ul- 
ceration of the mucous membrane, 
with a few submucous hemorrhages. 
The prostate was small and thin, but 
not excavated by an abscess. The pus. 



therefore, which flowed from the 
meatus mostly, came, apparently, from 
the kidney. The operation wound was 
limited to the cut edges of the prostatic 
and membranous urethra. There was 
no bruising nor sloughitig nor inflam- 
matory infiltration of any kind around 
the neck of the bladder. 

Case 6. — A tailor, aged forty-one, 
had served in the Zulu war of 1879, 
where he was attacked with acute in- 
flammation of the kidneys, and con- 
tinued to pass blood for three month» 
(? endemic hsematuria). This left a 
"weakness in the loins" until eight 
moixths previously, when he began to 
suffer from nocturnal incontinence and 
passed pieces of stone. Shivering 
fits used to come on at night, 
and a week before he became rapidly 
worse wjth great pain and frequency 
of micturition, straining and inconti- 
nence. The patient looked very ill, his 
urine was alkaline and contained pus 
but not blood. On examination per 
rectum the prostate was found enlarged 
and very tender, and a stone was 
struck immediately behind it. His. 
bladder could not be washed out owing 
to the pain, but it seemed very con- 
tracted. Two days before operation 
the patient had severe rigors, tempera- 
ture rising to 104.6** F., a pulse of 
108, with abdominal tenderness and 
rigidity. He was in such pain that he 
used to sit up in bed and hold his penis. 
Some fragments of small calculi were 
passed. At the operation a norma) 
prostate was reached, but behind it was 
a pouch containing many small stones,, 
some faceted, some fractured, alto- 
gether a handful, 244 grains in weight,, 
and composed mainly of urate of 
ammonia. The bladder was hyper- 
trophied and contracted. The patient 
lost his pain and the abdominal rigidity 
disappeared, but on the second day he 
collapsed and died. 

Post-mortem both pleural eavitiea 
contained fluid; the lungs ^were 
cedematous and bronchitic. There was 
a single horseshoe kidney which 



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showed marked septic changes ; there 
were several small faceted calculi in 
the single pelvis and passing down the 
two dilated ureters, and two or three 
had reached the bladder subsequent to 
the operation ; at least the bladder was 
fully explored with the finger before 
terminating the operation. The blad- 
der was intensely congested, with some 
hemorrhages. The operation wound 
was of the strictly limited character 
described in the former case; it had 
been a very satisfactory means of 
reaching the pouch behind the pros- 
tate and in affording free drainage. 

It is unnecessary to say much on 
such a well-worn topic, yet I think 
that these three rather exceptional 
cases indicate that occasionally the 
operation on the lines described by 
Celsus is definitely of advantage. The 
two latter cases came under treatment 
too late, yet the opportunity of making 
a post-mortem examination showed 
that the operative interference was 
strictly limited to the middle line of 
the prostatic and membranous urethra. 
At the discussion of the removal of 
large stones at the Ipswich meeting of 
the British Medical Association much 
stress was laid upon perineal lithotrity 
for large calculi. The wound I have 
made would readily admit the large 
lithotrites shown at that meeting. 

(c) Prostatic Obstruction. 

Oase 7. — A healthy-looking man 
aged seventy-two, employed as a mes- 
senger, had had increasing pain and 
frequency of micturition for two years, 
until finally he passed one to two 
ounces of urine every hour, day and 
night. A sound entered a contracted 
bladder and so pushed back a middle 
lobe of the prostate that it could be 
felt per rectum. All instrumentation 
caused much pain, and the bladder 
would not allow of more than one and 
one-half ounce of water being injected. 
A fortnight of treatment in bed with 
drugs in no way improved the patient, 



and micturition occurred every half- 
hour to one hour, day and night. The 
prostate was easily reached at the op- 
eration, and tt soft pedunculated mid- 
dle lobe was found, with a collar sur- 
rounding the orifice of the contracted 
bladder. Pieces were plucked away 
by punch forceps and the rest burnt 
down with the cautery, guarded by a 
rectal speculum with a longitudinal 
slit. A phosphatic concretion the size 
of a field pea was removed. The 
patient passed three ounces of fluid 
through the penis on the third day. 
As he was quite relieved he slept well 
and rapidly recovered. Fourteen days 
after the operation the perineal wound 
had quite healed. He returned to his 
work as a messenger, and when seen 
subsequently had no further trouble. 

Cases 8 and 9, — I have had two 
other successful cases in patients about 
sixty, the obstruction being mainly a 
collar-like projection with a small 
bladder. They returned to work with- 
out need of further instrumental or 
other treatment. 

The fourth case was unsuccessful. 

Case 10. — An Italian wire-worker,, 
aged 58, had had difficult micturition 
for two years, and had lately very 
much pain, pa^^sing a few drops of 
urine only at a time. He had an earthy, 
wasted look,. and was very weak. The 
urine was of low specific gravity, and 
contained some albumen. No catheter 
could be passed except a silver one, 
and that with difficulty. On reaching 
the prostate two very vascular lateral 
lobes were found joined by a high 
ridge which projected into the blad- 
der, having behind it a deep bladder 
pouch. Through the slit of a rectal 
speculum the ridge was burnt away 
until a deep channel was made between 
the lateral lobes, affording a complete 
drain for the pouch. The patient at 
first improved, and a fortnight after 
the operation got up. He passed 
water through the penis ; the bladder 
was emptied, and the urine lost its 
albumen. However, his pulse never 



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^ank below 100, nocturnal deliriam 
■and then a typhoid condition super- 
vened, and he died a month after the 
operation. The perineal wound, al- 
though healthy, had not completely 
healed. Unfortunately a post-mortem 
examination was not allowed, but he 
apparently died from chronic 
nephritis. 

Prostatectomy has the advantage of 
being a radical method when the pa- 
tient is relatively young and strong 
enough. If successful the patient 
may return to his occupation, and es- 
pecially among the poor there are 
great difficulties in carrying out treat- 
ment depending upon catheterism or 
involving continuous medical attend- 
ance, and many patients therefore be- 
come paupers. 

Supra-pubic prostatectomy is best 
done when there is a large bladder and 
a pedunculated middle lobe. A con- 
tracted bladder and a post-prostatic 
pouch with enlargement of the lateral 
lobes are not so favorable conditions. 
1 have operated by the supra-pubic 
method when the bladder was con- 
tracted with the prostatic obstruction 
mainly like a collar, and, although the 
patient did well, yet the operation was 
difficult, no good view could be ob- 
tained, and therefore recurrent hemor- 
rhage might well have taken place. 
As regards other ways of performing 
perineal prostatectomy, there is not 
such good exposure of the prostate, 
and the cauterization by Bottini's and 
other methods is done in the dark, 
which, if the cautery is too hot, may 
lead to hemon*hage and sloughing. 
If performed as described there is no 
danger of a perineal fistula, although 
this would be a trivial matter as com- 
pared with a supra-pubic one. Castra- 
tion and vasectomy appear to be very 
uncertain in their results, and leave a 
post-prostatic pouch undrained, with 
possibly a calculus in it, so that renal 
complications progress. 

Conclusion. — The cases quoted in- 
dicate that this operation is especially 



applicable to certain instances of com- 
plicated stricture, bladder calculi 
and prostatic obstruction. The un- 
successful cases have shown too ad- 
vanced disease of the kidneys. When 
this complication had not set in the re- 
sults were good. 



PBMPHiaUS VBQBTANS. 

Bt L. p. Hambubokb, M. D., 
Instnictor in Medicine, Johns Hopking Unirenitj, and 

Maubiob Bubsl, M. D., 
Resident Medical Officer, Johns Hopkins Hospital, Balti- 
more. Md. 

The conception of pemphigus has 
undergone a marked change since the 
beginning of the century just past. At 
that time any condition of the skin 
characterized by a bullous eruption was 
included in the class of pemphigus. 
There was a leprotic pemphigus, a 
syphilitic pemphigus, a pemphigus the 
result of burns, a neurotic form, a 
form following the use of drugs, and 
so on. To such an extent did physi- 
cians "torture one poor word*' that 
Martins (1) could enumerate, in 1829, 
ninety-six varieties of the * 'disease." 
Gradually, however, the use of the 
word was discontinued in referring to 
cutaneous conditions where the etiology 
of the bullous eruption was known or 
seemed probable. Instead of describ- 
ing leprotic and syphilitic pemphigus, 
it seemed more approprite to speak of 
these eruptions as the bullous exan- 
thems of leprosy and syphilis. The 
neurotic form came to find its place 
under the nervous maladies of the skin 
and in a similar manner a number of 
other varieties was classified. A con- 
tribution to this process of exclusion 
was added when Hebra defined ery- 
thema multiforme, and thus eliminated 
a great group of cases from this cha- 
otic collection. It is to this master, 
too, that we are indebted for the cri- 
teria which determine, even at the 
present time, the classification of a 
bullous eruption under the caption of 
''pemphigus." (2) 



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Essentially a chronic disease of the 
skin and mucous membranes of un- 
known etiology^ pemphigus is charac- 
terized by successive eruptions of bullae 
with subjective symptoms, either ab- 
sent or present, in varying degree, and 
offering a prognosis dependent upon 
the particular variety of the disease 
under consideration. 

At present four varieties of the dis- 
ease are distinguished. The common 
form, pemphigus vulgaris, has been 
long recognized. Its firm bullae, its 
tendency to recurrence and its doubt- 
ful prognosis are well known. The 
differentiation of the other three has 
been accomplished by the publication 
of a series of three papers which will 
be briefly mentioned. 

In 1844, Cazenave (3) separated the 
variety which has since been repeat- 
edly recognized and described under 
the title of pemphigus foliaceous. The 
flaccid blebs soon rupturing, the sur- 
rounding epithelium becomes detached. 
The epithelial exfoliation continuing, 
great areas of skin are denuded until, 
it may be, the whole body is flayed. 
The mucous membranes, hair and nails 
are in the meanwhile involved, and the 
patient, exhausted by sleejplessness, 
pain, fever and digestive disturbances, 
succumbs. 

In the years following Cazenave' s 
publication, many obscure examples of 
bullous eruptions were described. Each 
observer did not hesitate to suggest a 
name for the affection he reported, 
and so there accumulated a confusing 
mass of material. In this group cer- 
tain differences were apparent. One 
set was characterized by a bullous erup- 
tion, frequent involvement of the mu- 
cous membranes and slight disturb- 
ance of the cutaneous sensibility. 
These disorders ran a malignant course, 
and were in some instances regarded 
as anomalous forms of syphilis. 

A second group declared itself by 
the multiformity of its manifestations, 
for, in addition to the characteristic 
bullous and vesicular efllorescences. 



other elementary lesions were repre- 
sented. These cases showed remis- 
sions and recurrences, and did not, as 
a rule, attack the mucous membranes. 
They were benign and accompanied by 
pruritus and parsesthesia. Recognizing 
these differences, Duhring (4), in 
1884, separated this second group and 
created the dermatosis which bears his 
name. 

No cutaneous disease has given rise 
to more lively debate than has Duhr- 
ing's dermatitis herpetiformis. Its 
very right to a separate existence has 
been assailed by no less an authority 
than Kaposi (5), and its nosologic po- 
sition has not yet been thoroughly set- 
tled. It may, however be assumed 
that it is entitled to be regarded for 
the present as a clinical entity. The 
question is bound up in a consideration 
of the relation of the disease to other 
inflammatory conditions of the skin. 
Kaposi would have us regard derma- 
titis herpetiformis as a refuge in classi- 
fying atypical cases of erythema mul- 
tiforme and pemphigus. So long as 
etiological, pathological and bacterio- 
logical criteria are wanting, the differ- 
ential diagnosis must depend upon the 
clinical picture and the evolution of 
the disease. These are sufficient to 
differentiate 'dermatitis herpetiformis 
from erythema multiforme in a major- 
ity of instances. In the one the irreg- 
ular distribution of the lesions and the 
striking subjective symptoms contrast 
strongly with the preference of ery- 
thema multiforme to attack the dor- 
sum of the hands and feet and with 
the usual absence or mildness of itch- 
ing and burning. 

The relation of Duhring' s dermato- 
sis to pemphigus, however, is much 
more intimate. Indeed, Duhring him- 
self states that '*The semblance in 
some, but by no means all, cases to 
pemphigus naturally suggests a close 
relationship of the two diseases, and 
that such exists in these cases there 
can be no doubt." (6) He reports a 
case in which the condition at one 



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time would have been diagnosed pem- 
phigus, and which he subsequently 
classified as dermatitis herpetiformis 
because of the presence of peculiar 
vesicles, blebs and pustules in combi- 
nation. Though it is unquestionable 
that the polymorphism, the herpeti- 
form arrangement of the lesions and 
the subjective symptoms create a spe- 
cial place for Duhring's dermatosis, the 



grouped and subjective symptoms are 
at times prominent, so that there are 
well recognized and generally accepted 
examples of chronic pemphigus, which 
form connecting links between the 
commdn varieties and dermatitis her- 
petiformis. The modifying terms ser- 
piginous, pruriginous and gyrate illus- 
trate this transition. The future may 
provide an etiological basis for a more 



Pig. 1. — The prominent vegetations in the groin are here depicted. 

crusts are seen on the abdomen. 



Two of the impetigo-like 



intimate relation to pemphigus should, 
for the time being, be emphasized by 
considering it as a variety of this dis- 
ease. The commoner types of pem- 
phigus itself do not always present 
uniform pictures, and, though the 
characteristic lesion is a bulla, the bleb 
may rise from an erythematous base, 
and wheals and pustules may be pres- 
ent. The eruption is occasionally 



satisfactory classification, but until 
then it seems advisable to group with 
pemphigus vulgaris and pemphigus 
foliaceous, Duhring's dermatitis her- 
petiformis. 

The fourth variety of chronic pem- 
phigus was defined by Neumann in 
1886. It is from this form of the dis- 
ease, pemphigus vegetans, that the 
patient, whose history and condition 



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will subsequently be recounted, suf- 
fered. The early history of this disease 
was referred to in sketching the ori- 
gin of dermatitis herpetiformis. There 
a certain class of bullous eruptions 
pursuing a malignant course was con- 
trasted with a ffroup of benign affec- 
tions which Dunring embraced in the 
description of his dermatosis. It was 
also stated that they were sometimes 
regarded as varieties of syphilis, and 
it may be added that this view contin- 
ued to be held until Neumann recog- 
nized their connection with chronic 
pemphigus, and published his opinion 
in the Vierteljahschrift fuer Derma" 
tologie und Syphilis in 1886. (7) 

Pteviously, under the title of herpes 
vegetans, Auspitz (8) described what 
Neumann viewed as the affection under 
consideration. Moreover, a syphilis 
cutanea papillomaformis (vegetans) or 
framboesia syphilitica, Kaposi (9) re- 
ported a case likewise supposed to be 
of a similar nature. In none of these 
instances is the condition of the mu- 
cous membranes indicated. Besides, 
in the patients of Auspitz the occur- 
rence of pregnancy and the presence 
of syphilis in one of them complicated 
the diagnosis. At the present moment 
the inclusion of both Auspitz and 
Kaposi's cases with pemphigus veg- 
etans might be questioned. But there 
can be no doubt that Neumann had 
seen this form of pemphigus and had 
fallen into error. The patient whose 
condition he, as well as Hebra, re- 
garded as luetic, and whose case was 
published as such in 1876, was, he 
subsequently determined, a victim of 
pemphigus vegetans. 

This patient was a lady thirty-one 
years old whom Politzer asked Neu- 
mann to see in January, 1875. She ' 
was then complaining of great discom- 
fort on swallowing. Her illness dated 
from the previous November, when 
blebs appeared in the right axilla. 
Bursting, they left a raw, moist sur- 
face on which granulations appeared. 
The mucous membrane of the lower 



lip, mouth and fauces became affected 
so that the patient could take only 
liquid nourishment. The condyloma- 
like axiUary vegetations led to a diag- 
nosis of syphilis. Subsequently the 
vegetations appeared on the abdomen, 
in the groins, and over the labia ma- 
jora. The various orificial mucosae 
became affected. 

The disease progressed steadily, 
other blebs, isolated and confluent, 
developing in the axillary region, on 
the chest, abdomen and back. The 
exfoliation of the epidermis left raw 
surfaces like a burn of the second de- 
gree. There was considerable pain 
and the eruption exhaled a foul, al- 
most unbearable odor. Uninfluenced 
by the remedies administered, the pa- 
tient died, emaciated and exhausted, 
after an illness of four months' dura- 
tion. The only comfort afforded the 
sufferer was the use of the full con- 
tinued bath. 

Before the patient died it became 
evident that the condition was an in- 
dependent affection, uninfluenced by 
antisyphilitic treatment, and, in truth, 
bore relation to the group of chronic 
pemphigus. Then Neumann recalled 
two previous instances in which the 
erroneous diagnosis of lues had been 
made, and, together with six other ex- 
amples subsequently recognized and 
correctly interpreted, published his 
paper on the basis of these nine cases. 

Almost simultaneously and inde- 
pendently Mr. Jonathan Hutchinson 
called attention to "A Form of Chronic 
Inflammation of the Lips and Mouth 
which Sometimes Ends Fatally, and 
is Usually Attended by Disease of the 
Skin and Nails." (10) With his char- 
acteristic accuracy of observation and 
recording he gives an account of sev- 
eral cases of ulcerative stomatitis, with 
and without cutaneous eruptions, to 
which his attention had been directed 
during the previous ten years. He 
points out that a question might arise 
as to whether all of them are of the 
same nature, and from our present 



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knowledge it seems more probable that 
they are not similar. Yet, in the first 
group he recites the histories of two 
cases of pemphigus vegetans without 
assigning, however, a name to the 
affection. But in a few words he 
shows clearly its distinguishing feat- 
ures and makes a surmise as to its re- 
lation to pemphigus. *'The cases are 
important," he writes, *'on account of 
their severity and from their close re- 
semblance in some instances to syph- 
ilis;'* and again, in portraying the 
eruption, he describes '^bullee like 
those of pemphigus." He adds: 
**When the buUse broke, papillary ex- 
crescences sprouted up from .their 
base." Though Mr. Hutchinson gives 
such a clear representation of the dis- 
ease, nevertheless it is Neumann's pa- 
per that has led to a general recogni- 
tion of pemphigus vegetans. The 
French give him due credit by^ calling 
the affection "Maladie de Neumann." 
The subsequent history of the disease 
is contained in the publication and dis- 
cussion of about fifty cases, from 
which a survey of its features may be 
made. 

Pemphigus vegetans is not a com- 
mon disorder. In this country, J. 
Nevins Hyde is the only observer to 
report a case. (11) It is a disease of 
adult life, and spares neither sex. The 
patient is in good health until attacked, 
and neither the family history nor the 
occurrence of a previous illness throws 
light on the etiology. Mr. Hutchin- 
son comments on the fact that his 
patients were residents of the country. 
Statistics drawn from the recorded 
cases regarding the occupations and 
residences of sufferers from pemphi- 
gus vegetans cannot be compiled, for 
the published details are too meager, 
but it is rather interesting to note that 
our patient, as well as Danlos and 
Hudelo's, (12) were both farmers. 
In the discussion of the latter case, 
Brocq mentioned that he had seen the 
disease in a peasant, and that there 
were "aphthous cows" on the farm. 



The interpretation of these facts must, 
for the present, be left undecided. 

The disease usually commences with 
soreness in the throat and mouth. In 
the present instance tiny pinhead- 
stzed vesicles could be detected on the 
dorsum of the tongue, but owing to 
local conditions of beat and moisture 
the blebs here do not long retain their 
form. Therefore, an examination usu- 
ally reveals the mucous membranes of 
the mouth and fauces more or less 
eroded and partially covered with a 
yellowish pellicle of macerated epi- 
thelium. Hoarseness^ pointing to an 
involvement of the laryngeal mucosae, 
was the earliest symptom in our pa- 
tient. In Ludwig's patient the pre- 
putial sac and urethra were first af- 
fected. (13) The conjunctiva may 
suffer, and it is said that even the 
vaginal portion of the uterus and the 
rectum have been attacked. The af- 
fection of the mouth and throat is 
usually misinterpreted, and it is only 
when the characteristic bullous erup- 
tion makes its appearance that the true 
nature of the condition becomes mani- 
fest. Occasionally this eruption marks 
the inception of the disease, followed 
later by involvement of the mucous 
membranes. 

The interval between the onset of 
the stomatitis and the appearance of 
the bullae is usually one of days or 
weeks, but exceptionally (as in one of 
Koebner's oases) two years passed be- 
tween the oral affection and the ap- 
pearance of condyloma-like growths 
in the groins. (14) 

The evolution of the eruption could 
be readily traced in the present case. 
Here the earliest lesion was a vesicle, 
the smallest being about 2 mm. in di- 
ameter. Enlarging, a bulla somewhat 
lax and pendulous, and attaining a 
diameter of 1.5 to 2 cm., was formed. 
On opening the bleb a clear, transpar- 
ent, straw-colored serum exuded. In 
from two to three days the bulla be- 
gan to exhibit yellowish points at its 
most dependent portion. The area of 



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opacity having increased, the serous 
contents of the bleb finally became 
purulent. At this .stage there devel- 
oped a red areola about the lesion. 
Soon the thin layer of epidermis en- 
closing the pus ruptured and there was 
thus disclosed a red, raw, weeping sur- 
face, partially covered by the col- 
lapsed epidermal wall. The adjacent 
patches now became confluent, and the 
epidermis of the surrounding skin was 
lifted up so that the process spread in 
all directions, forming large areas 
many centimeters in diameter, at the 



last vestige of the dead epidermis dis- 
appeared, and from the denuded sur- 
face there sprang a gray papillary out- 
growth to a height varying with the 
location. On the arms and abdomen, 
where there was little mechanical irri- 
tation, it was not prominent; but in 
the axillse and groins and over the 
back, regions exposed to friction, the 
papillary vegetating, condyloma-like 
character of the lesion was strikingly 
illustrated. 

The cutaneous lesions may attack 
any portion of the body surface, but 



Fig. 2.— The illustration shows lesions on the back. Most of them are excoriations, about the 

borders of many the remains of the vesicle can be seen. One of the large crusts 

can be seen in the infrascapular region on the left side. 



periphery of which a ledge of epi- 
dermis, 2 to 5 mms. in width, re- 
mained adherent. In other places the 
true skin was not exposed, but came 
to be protected by the formation of a 
thick, yellowish brown crust, which, 
too, was fringed by the attached edge 
of the remains of the original bulla. 
Here, as in the previous condition, an 
inflammatory halo encircled the lesion, 
giving the whole an ecthymatous ap- 
pearance. Whether this crust formed 
or the tender surface became exposed, 
the end process proved the same. The 



the perigenital, axillary, umbilical 
areas and the regions bordering on the 
orificial mucosae are seats of predilec- 
tion. Except in the groins, pemphi- 
gus vegetans does not tend to show a 
symmetrical distribution. 

In three of Neumann's cases the 
nails were affected, blebs appeared at 
their roots, the nails were discolored 
and lifted from their base by granula- 
tion tissue and pus. In a fourth case, 
recently reported, all the nails were 
the seat of such changes. (15) 

In the present instance a small bulla 



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as well as the vegetations was exam- 
ined microscopically. The early le- 
sions exhibited the signs of inflamma- 
tion without any specific characters. 
With the exception of the layer of 
columnar epithelium, the entire epi- 
dermis took part in the formation of 
the bleb's wall. The corium was the 
seat of around-celled infiltration. The 
vegetations consisted of hypertrophied 
papillae with their covers of stratified 
epithelium and their dilated blood ves- 
sels. Leredde and likewise Gastou 
have found eosinophiles in great 
abundance in the cellular infiltration of 
the epidermis. Such was not the con- 
dition in the present case. 

Our bacteriological studies have 
been of interest. Cultures from the 
bullae showed only the staphylococcus 
pyogenes aureus ; but from the mouth 
and, it may be added, from the blood 
after death, a bacillus belonging to the 
pseudo-diphtheria group was grown in 
pure culture. This organism pre- 
sented a similarity to the pseudo-diph- 
theria bacillus which Waelsch has 
twice isolated from recent blebs and 
from the blood of two patients suffer- 
ing from pemphigus vegetans. (16) 
Both our organism and Waelsch 's ex- 
hibited irregular staining properties 
and polymorphism, and both were 
pathogenic for guinea-pigs. There are 
these differences, however: our bacil- 
lus did not stain by Gram's method, 
while Waelsch's did retain its coloring. 
We could rediscover the organism in 
the blood of the dead guinea-pigs, but 
in Waelsch's animals the blood was 
sterile. In neither series of observa- 
tions were changes resembling those 
of pemphigus vegetans found. 

Aside from the condition of the mu- 
cous membranes and skin, pemphigus 
vegetans has no characteristic symp- 
toms or signs. Itching is not a prom- 
inent feature, but the excoriation 
causes much pain and burning. 

Irregular attacks of fever may usher 
in fresh eruptions or may occur inde- 
pendently. 



Albuminuria and gastro-intestinal 
disturbances are not infrequent. 

Leredde (17) lays great stress on 
the occurrence of an eosinophilia. In 
his own cases, as well as in one of 
Neumann's and Danlos and Hudelo's, 
the eosinophilic cells were augmented ; 
in the latter to six per cent. We 
noted particularly that in our own 
cases no such increase in eosinophiles 
occurred. The absence of eosinophilia 
in the present instance is significant in 
view of Coe's obervations on its prog- 
nostic import in pemphigus, (18) his 
suggestion being that the presence of 
eosinophilia may betoken a more fa- 
vorable outlook. 

Symptoms referable to the nervous 
system have been occasionally de- 
scribed. In three of Neumann's pa- 
tients the tendon reflexes were exag- 
gerated, and two of them suffer^ 
from muscular contractures in the ex- 
tremities. In the third there was, in 
addition, ptosis of the right eyelid. A 
muscular tremor has also been noted 
by Herxheimer. (19) The patient in 
our care exhibited a certain mental 
sluggishness. While under observa- 
tion he was somewhat stuporous, re- 
sponding to questions slowly and only 
after the lapse of a noticeable interval 
of time. 

The course of pemphigus vegetans 
is marked by a steadily progressing 
cachexia in spite of periods of marked 
amelioration in, the condition of the 
mucous membranes and skin. Indeed, 
the integument may assume an almost 
normal appearance and yet the sufferer 
may be separated from death by only 
a few days. Pneumonia, nephritis 
and intractable diarrhoea are the usual 
terminal events. The duration of the 
disease varies from a few weeks to 
fourteen months, usually less than a 
year. There are two reported excep- 
tions to this statement. In both the pa- 
tients lived ten years after the inception 
of the infection. The first is the one 
seen by Neumann in Hebra's clinic, 
and whose condition is- briefly de- 



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Pemphigus Vegetans— Hamburger—Rubel. 



105 



scribed and illustrated in Kaposi's 
(20) Atlas. The other was reported 
by Koebner. (21) 

It is the case of a man thirty-two 
years of age, who suffered in 1886 
from blebs and ulcers over the mu- 
cous membranes of the cheeks and 
tongue. In 1888, condyloma-like 
gro?rths uninfluenced by mercurial 
treatment were present in the gluteal 
region. For the next several years 
the lesions in the mouth recurred. 
In 1890, the bullous eruptions with pap- 
illary excrescences appeared in the 
groins. Treatment by curetting 
brought relief and he was said to 
be in good health in 18i^3. Two years 
later the malady returned and death 
ensued after an illness of a year. 

Thus it will be seen that the appar- 
ent recovery is only a respite, death 
is the ultimate result. 

Post-mortem, no changes in the in- 
ternal organs have thrown light on the 
nature of pemphigus vegetans. In 
one of Mr. Hutchinson's cases a lai^e 
lympho-sarcomatous tumor was found 
in front of the spine, imbedding the 
pancreas and large vessels. In our 
patient a similar neoplasm was situated 
in the anterior mediastinum, presum- 
ably having its origin in the thymus. 
In none of the other published autop- 
sies were such tumors disclosed. The 
causal relation is, therefore, not evi- 
dent, but it is proper that this coinci- 
dence between Mr. Hutchinson's case 
and the present one should be indi- 
cated. 

The nervous structures have been 
repeatedly studied in the hope of throw- 
ing light on the origin and nature of 
the disease. Unfortunately, examina- 
tion of the brain and cord of our pa- 
tient was not permitted. The first, 
second and third dorsal spinal ganglia 
were excised, however. They exhib- 
ited no gross alterations. Microscop- 
ically, the ganglion cells showed inter- 
esting changes, the chief of which 
consisted in a marked increase of pig- 
ment. Some cells were three-fourths 



occupied by the pigmented granules 
while many showed one-half the cyto- 
plasm thus replaced. Others pre- 
sented signs of degeneration in that 
the outline of the nucleus was wanting 
and the nucleolus had l^ecome indis- 
tinct. Marianelli ^22) has also ob- 
served this hyperpigmentation in the 
cells of the upper cervical ganglia of 
the sympathetic, and degenerative 
changes similar to those just described 
but having their seat in the cells of the 
anterior comua and Clarke's columns 
have been noted in a case of pemphi- 
gus vulgaris by Brochieri.(23) These 
alterations have probably no bearing 
on the causation of pemphigus vege- 
tans; indeed, they are, doubtless, as 
Koebner points out, secondarily de- 
pendent on the toxaemia of the disease. 

It follows then that neither bacte- 
riological nor pathological studies (24) 
have furnished means of identification 
and the diagnosis of the disease must 
rest on its clinical aspect and course. 
Fully developed, the affection has 
been most frequently mistaken for 
syphilis. *'Though the patient's mor- 
als," writes Neumann, Vwere thus in- 
dicted, on the other hand, the hope 
of recovery was held out to him." (25) 
To be saved from such an error the 
diagnosis becomes a matter of impor- 
tance. 

The elementary bullous eruption 
should, when present, lead to a recog- 
nition of the pemphigoid nature of 
both the vegetations and the lesions of 
the mouth. If the blebs have been 
effaced, subsequent efiiorescences alone 
or together with the stomatitis, should 
make the diagnosis clear. Aside from 
the bullae, the superficial nature of the 
excoriations and certain characteris- 
tics of the vegetations serve to differ- 
entitate pemphigus vegetans from 
syphilis. The former grow rapidly 
and the remains of the bleb may be 
detected at the periphery of the vege- 
tations ; the border of a condyloma is 
firm and indurated. Neumann also 
calls attention to the stippled appear- 



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ance of the vegetations as opposed to 
the uniform deposit which may cover 
a condyloma. Finally, the absence of 
a history of lues, the ' fact that other 
evidences of syphilis are wanting, and 
the injurious effect of antisyphilitic 
treatment, which was noted in our pa- 
tient as well as in other of the recorded 
cases, these data contribute to estab- 
lish the correct diagnosis of pemphi- 
gus. 

Little need be added to what has 
already been said regarding the differ- 



disorders from Neumann's disease. 
Here they do not present the asym- 
metry of pemphigus vegetans. Neither 
does a single bulla, as in the latter 
disorder, by its eccentric extension, 
come to involve a considerable area of 
skin. Lastly, they point out the fa- 
vorable influence of local treatment on 
the cutaneous manifestations of pem- 
phigus vegetans as contrasted with its 
usual failure in dermatitis herpeti- 
formis and pemphigus vulgaris. 

There are a number of other der- 



FiG. 3. — Represents the earliest lesion described, the vesicle. It will be seen that serum 
hks accumnlated in the stratum mncosum and has lifted np the greater part of that layer, 
leaving the columnar cell layer still attached to the corium. Here and there groups of poly- 
gonal cells have also remained adherent to the true skin. 

The portion of the epidermis forming the walls of the vesicle is thinnest at the summit of 
the bleb, where it is made up of but two layers of flattened cells; from this point toward the 
margin the layers become more numerous until the entire normal thickness is reached. 

Great numbers of leucocytes, especially the polymorphonuclear, are seen both within the 
vesicle and upon its surface. The contents of the bleb consist mostly of serum, leucocytes and 
epithelial cells in various stages of degeneration. 

In the framework of the corium, especially about the blood vessels, there is marked round- 
cell infiltration, but here and there are groups of neutrophiles. In almost every papilla two 
or three dilated capillaries are found distended with blood. 



entiation of the other members of the 
pemphigus group from pemphigus 
vegetans itself. It is well known that 
they may exhibit, at rare intervals, 
vegetating lesions. Indeed, in Grou- 
ven's case of pemphigus vegetans the 
lesions at the onset were those of the 
common and exfoliating types and only 
the subsequent course led to the diag- 
nosis of pemphigus vegetans. (26) 
Hallopeau and Leredde (27) believe 
that the mode of development of 
pemphigusvulgari6,aswell as of derma- 
titis herpetiformis, differentiates these 



matoses complicated by disease of the 
mucous membranes and vegetating le- 
sions which have led to confusion with 
pemphigus vegetans. .The disorder 
which Hallopeau regards as the pustular 
variety of Neumann's diseaae should, 
in all probability, be set aside as a dis- 
tinct condition. Its pustular character, 
the grouping of the lesions and its 
more benign nature (only two of the 
five patients died) contrast with the 
essentially bullous character and the 
hopeless outlook of Neumann's dis- 
ease. Tommasolli (28) has persist- 



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ently iDsisted that the term ^'peniphi- 
gU8 vegetans" has been used to cover 
a multitude of conditions some of 
which have no evident relation to 
pemphigus. He has proposed to des- 
ignate them all as condylomatosis 
pemphigoides maligna^ thus abandon- 
ing the title of pemphigus vegetans. 
This procedure is not justifiable. On 
the other hand, there can be no doubt 
that as pemphigus vegetans at least two 
conditions have been on several occa- 
sions described and confused ; the dis- 
ease which Neumann distinguished 
and another to which Hallopeau's der- 
matosis belongs^ a condition character- 
ized by vegetations but where the bul- 
lous or vesicular lesion is absent or 
plays such an insignificant role that 
for the present it may be excluded 
from the pemphigus group. 

The pustular character of impetigo 
herpetiformis, too, should differenti- 
ate it from pemphigus vegetans. The 
frequent association with pregnancy is 
an assistance in the diagnosis of im- 
petigo herpetiformis as well as in the 
recognition of other cutaneous dis- 
orders pccurring in this state. 

Finally, the rare examples of drug 
eruptions, such as Hallopeau (29) de- 
scribes as following the use of iodide 
of potassium, though combining dis- 
ease of the mucous membranes with 
cutaneous vegetations, may be distin- 
guished by the attendant circumstan- 
ces and the subsequent course. 

We hate now discussed the diagno- 
sis of pemphigus vegetans when the 
disease is presented in its entirety. 
The superficial resemblance to syphilis 
has been emphasized. At the onset, 
with the lesions localized in the mouth 
and throat, a confusion with lues is 
likewise possible and the failure of 
antisyphilitic treatment or the appear- 
ance of the cutaneous efilorescence 
may first indicate the error in diagno- 
sis. Seldom, however, does one see 
mucous patches so extensive as the in- 
itial stomatitis of this variety of 
pemphigus, while occasionally, as in 



our patient, the occuiTence of intact 
vesicles on the mucous membranes, 
raises a suspicion of the true nature of 
the disorder. 

The usual "epidemic stomatitis*' or 
'*foot and mouth disease," communi- 
cated by cattle, is also accompanied by 
a vesicular eruption in the mouth and 
fauces, but the demonstration of the 
source of infection, the hemorrhagic 
tendency of the disease and its usually 
favorable course are guides to its recog- 
nition. 

At rare intervals there are encoun- 
tered in adults examples of severe 
stomatitis of unknown origin, such as 
Mr. Hutchinson has described in the 
paper to which we have referred. 
These bear, in all probability, no rela- 
tion to pemphigus. The possibility of 
Neumann's disease should ever be held 
in mind and a careful and repeated 
search for the ill-omened bulla be 
made. Mr. Hutchinson's patients re- 
covered under a treatment to be pres- 
ently mentioned. 

It may be gathered from the fore- 
going statements as to the grave nat- 
ure of the disease that treatment is 
limited to assuaging the suffering of 
the patient. General medication is 
without effect. Arsenic is valueless, 
mercury and iodide of potassium are 
harmful. The efforts of Waelsch to 
develop a treatment based on a pos- 
sible etiological factor are worthy of 
note. After isolating the pseudodiph- 
theria bacillus from his two cases 
and finding that diphtheria antitoxin 
apparently immunized animals, he 
was led to use the antitoxin on 
his second patient as a therapeutic 
measure. While the patient was re- 
ceiving this treatment, the animals 
having survived forty to forty-four 
days died, and it became clear that the 
protection was temporary or apparent. 
The attempt to obtain an antitoxin for 
the particular organism under consid- 
eration was now made, but the patient 
succumbed before the necessary mate- 
rial could be gathered. 



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Another therapeutic saggestion has 
come from Mr. Hutchinson. In those 
cases of severe stomatitis which bore 
a resemblance to the buccal disorder of 
Neumann's disease opium was admin- 
istered , and under its use the lesions 
healed. But, in no case of undoubted 
pemphigus vegetans has opium been 
fairly tried at the beginning of the 
malady. One is therefore justified in 
exhibiting opium in any unusual case 
of stomatitis, even before a definite 
diagnosis is established. 

Although nothing alters the fatal 
tendency of the disease, the cutaneous 
lesions are favorably influenced and 
the discomfort of the sufferer is greatly 
diminished by the continuous use of 
the full bath. Under this treatment, 
the excoriations over the back, neck 
and arms of our patient healed and 
there was obtained a degree of comfort 
which the previous applications of lo- 
tions, ointments and powders failed to 
give. 

The state of the mouth necessitated 
the use of liquid and soft food while 
rinsing with a hydrogen peroxide wash 
was continued. 

After all has been said, the nature 
of this malady remains obscure. The 
prevalent view is that the immediate 
cause is some infection or intoxication. 
Perhaps subsequent investigation may 
prove a causal relation between the 
pseudodiphtheria bacilli which Waelsch 
and we have isolated and place pemphi- 
gus vegetans in the category of infec- 
tious diseases. But the disease is not 
contagious and in addition to a specific 
organism some predisposing factor 
must be assumed. With the presence 
of an eosinophilia in some cases as a 
basis, Leredde. has suggested that a 
latent alteration in the hsemopoietic 
apparatus predisposes certain individ- 
uals to the immediate cause, whatever 
it may be. Such an hypothesis is ex- 
travagant. Analogy like that offered by 
the eosinophilia of trichinosis teaches 
that an increase in these cells is the re- 
sult of an intoxication or infection and 



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offers no evidence as to the previous 
state of the blood-forming organs. 

History. . 

Mr. E. M., farmer, married, age 
fifty- two years, was admitted to the 
Johns Hopkins Hospital, rn the service 
of Dr. Osier, February 6, 1901. He 
complained of a skin eruption and sore 
mouth. 

Family History. — Mother died of 
'^consumption." Father died of ''stom- 
ach trouble." A sister died of "con- 
sumption." A sister is living and 
suffers from asthma. Four maternal 
aunts have died of "consumption." 
There is no history of new growths, 
nor is there an account of a trouble 
similar to the present in the family. 

Past History. — Measles and whoop- 
ing-cough as a child. At the age of 
twenty to twenty-five, he had a skin 
eruption which was said to be due to 
"poison oak." Subsequently he had 
several attacks. 

At twenty-seven years he was over- 
come by the heat; since then he has 
been susceptible to the sun's rays, hav- 
ing on several occasions suffered from 
vertigo after exposure. 

Ten or twelve years ago he had an 
eruption on the wrist ; it itched and was 
pronounced eczema. 

About five years ago he became 
nervous and weak and since then has 
not been able to do hard work. 

He suffered from shaking chills two 
years ago. 

Until four years ago he chewed 
tobacco a great deal. He has never 
smoked to excess. He seldom drinks 
beer or whiskey. 

He denies all venereal diseases. 

Present illness began in January, 
1900, with hoarseness. At about this 
time he suffered from a sore mouth. 
Little ulcers appeared on the lips, 
tongue and on the inner surface of the 
cheeks. They originated, he asserts, 
in little "blisters." Just before the 
onset of the sore mouth he had a scabby 



eruption on the legs which he attrib- 
uted to "red bug bites." 

In less than a nionth after the be- 
ginning of his illness an eruption com- 
menced in the left groin. It was diag- 
nosed eczema and under treatn;ient ap- 
parently disappeared. Then a similar 
eruption appeared in the right groin ; 
it itched a little. The same treatment 
was used, but it was of no avail and 
the disorder reappeared in the left 
groin. It gradually grew worse and 
spread. It became so bad that the 
patient could not move about. The 
mouth and throat continued sore at 
intervals. In June, he commenced to 
expectorate a clear saliva which ran 
from the mouth night and day. In 
September the disease was called syphi- 
lis, and he was given the appropriate 
treatment by mouth and by inunctions. 
After this treatment the condition of 
the mouth gi-ew worse, that of the 
groins seemed better. Two weeks ago* 
yellow blisters appeared on the arms, 
and the condition of the skin over the 
back grew worse. This eruption, the 
patient states, is entirely different from 
the "red bug bites" which were origi- 
nally on the legs. 

His general condition has become 
gradually worse. He has difficulty in 
chewing and swallowing. Bowels are 
regular. He has lost seventy-five to 
eighty pounds in the past twelve 
months. 

Physical Examination. — The pa- 
tient is a sparely nourished man. Mu- 
cous membranes are of fairly good 
color. 

The patient is constantly expectorat- 
ing a turbid, foul-smelling, tenacious 
sputum. The mouth presents a re- 
markable appearance. The vermilion 
of the lips is excoriated and irregularly 
covered by a whitish pellicle of 
macerated epithelium suggesting the 
mucous patches of syphilis. The 
tongue is covered with a yellowish 
white coating. Its dorsum is cracked 
and excoriated. Here and there on 
careful inspection tiny pin-head sized 



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Pemphigus Vegetans— Hamburger-Rubel. 



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vesiclea can be discovered. The mu- 
cous membranes of the lips, cheeks 
and fauces present the same white 
macerated and excoriated appearance 
just described. 

With the exception of the palms, 
soles and scalp, no part of the body 
surface is entirely free from lesions. 
At the outer canthus of the right eye 
there is an excoriation about one cm. 
in diameter, the edges of which are 
formed by overhanging epidermis 
suggesting the remains of a bulla. The 
surface is bathed with a purulent fluid. 
A dirty brown crust is situated over 
the lobule of the right ear and a foul- 
smelling purulent discharge exudes 
from this external auditory meatus. 
The lips are covered with yellow 
honeycomb-like crusts. The right 
nostril is partly plugged by hard brown 
crusts and a discharge of pus comes 
from it. 

Scattered over the neck, arms, 
axillro, flexures of the elbows, fore- 
arms, back, abdomen, legs, and groins 
the lesions are distributed in various 
stages of evolution. The earliest 
change is evidently the formation of a 
vesicle or bulla. These lesions are 
present in the lumbar region, in the 
right axilla and flexure of the elbow 
and in the right groin. There are 
about one-half dozen of them. They 
vary in size from that of a lentil to 
that of a thumb-nail, are flaccid, dis- 
crete and the skin about them is un- 
changed. Here and there are bullae of 
about the same size which have in 
their dependent portions a turbid 
yellow fluid. 

The greater number of lesions are 
excoriations varying in size from about 
i to 8 cm. in diameter. They are dis- 
crete and confluent. Over the lumbar 
region they have come to form a large 
irregular patch about 20 by 10 cm. in 
size.. The base of these excoriations 
is bright red and weeping ; the border 
is formed by a ledge of epidermis. 
These characteristics are particularly 
well marked over the back. Some of 



the excoriations, as over the abdomen, 
are covered with large yellowish brown 
impetigo-like crusts and are surrounded 
by a red halo. Scattered among these 
lesions are tiny papulo-pustules evi- 
dently due to secondary infection. 

The inguinal and perigenital regions 
are the seat of unusual changes. The 



Fig. 6. — This represents one of the papillae 
magnified. Here the loose structure of the 
stroma is clearly seen. Here and there scat- 
tered in the connective tissue are white blood 
corpuscles, for the most part polymorpho- 
nuclears. 

An enlarged capillary filled with blood ex- 
tends the whole length of the papilla, and oc- 
cupies about one-fourth of its entire width. 
One or two layers of columnar cells nre seen 
on the surface. 



groins are occupied by elevated green- 
ish brown, foul-smellmg excrescences 
about 10 by 20 cm. in diameter. The 
surface is crusted and cracked ; closer 
inspection reveals its papillary char- 
acter. The same lesion extends along 
the lateral aspect of the scrotum and 
posteriorly as far as the anus. Iri^eg- 
ular patches of pigment are seen on 
the shins. 



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The nails of the left hand show deep 
transverse ridges about their centers. 

The lungs exhibit the physical signs 
of emphysema; examination of the 
heart is negative. The abdominal 'ex- 
amination is negative. The sputum 
does not contain the tubercle bacillus. 
The urine varies in specific gravity 
from 1010 to 1020, is acid, contains 
neither albumen nor sugar and does 
not give the diazo reaction. Micro- 
scopically, the sediment shows large 
sheets of epithelium. 

Examination of the faeces yielded 
no noteworthy results. 

The blood: hcemoglobin, 85 per 
cent. Red blood corpuscles, 4,212,000. 
White blood corpuscles, 13,500. 

Treatment and Progress of the 
Condition. 

The patient was given soft and 
liquid food and Fowler's solution 
m. vi, was administered three times a 
day. About two weeks after admis- 
sion to the hospital, he was placed in a 
tub bath. While under this treatment 
the condition of the skin showed an 
improvement although fresh lesions 
appeared from time to time. Thus, 
the left eyelid became involved, there 
was a profuse purulent conjunctivitis 
but eventually these signs disappeared. 
From practically all the excoriations 
pigmented papillary excrescences de- 
veloped as the healing process took 
place. About the neck and over the 
upper half of the sternal region, parts 
not covered by the water, the excoria- 
tions failed to heal. The papillary 
growths in the groins were not so 
prominent. 

The condition of the mouth and 
throat varied from time to time, but on 
the whole became more and more in- 
volved so that even the swallowing of 
liquids caused great pain. 

The temperature was elevated and 
irregular, ranging, as a rule, from 99° 
to 97.7°, only on two occasions going 
above 102°. 



The patient lost weight continually, 
became very much emaciated, his mind 
wandered, the signs of a broncho- 
pneumonia developed on March 10, 
1901, and he passed away the follow- 
ing day after an illness of about f oi|r- 
teen months. 

Autopsy. 

The privilege of investigating the 
brain and spinal cord was withheld. 
The autopsy confirmed the diagnosis of 
broncho-pneumonia and emphysema. 
The condition of the spinal ganglia has 
already been noted. 

In the anterior mediastinum there 
was a firm nodular yellowish white 
mass firmly adherent to the peri- 
cardium. It measured 18.5 by 7 cm^ 
On section, the tumor was firm and 
gritty. It was found to be lobulated 
and composed of a translucent pale 
pink tissue striated with fine white 
lines. Microscopically, it consisted of 
irregular masses of tissue containing- 
nuclei closely packed together and 
separated by compact strands, often 
rounded columns of dense fibrous 
tissue relatively poor in fibroblasts.. 
The former tissue cells possessed nuclei 
either of the lymphoid or fibrous tissue 
type. 

With the exception of the skin and 
lungs all other organs were normal. 
There was no ulceration in the gastro- 
intestinal tract or in the bladder. 

Bacteriology. 

Cultures taken from the blebs are 
either negative or show the presence of 
the staphylococcus aureus. Cultures 
from the mouth reveal the presence of 
a small bacillus in almost pure culture. 
In bouillon media it occurs in chains 
and groups of two. It is not motile, 
stains irregularly, particularly with 
Neisser's reagent. There are a num- 
ber of irregular forms. It does not 
stain by Gram's method. 

On agar it forms a moist, greyish 



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PEMPHIGUS Vegbtans— Hamburger— RuBEL. 



108 



white film with abrupt finely serrated 
edges. 

Gelatine is not liquefied. 

No gas is formed in glucose agar. 

On potato the growth has a faint 
yellowish hue and is moist. 

In bouillon there is a heavy floccu- 
lent sediment with white particles in 
suspension. 

Litmus milk shows iio change at the 
end of twenty-four hours but in forty- 
eight hours it is paler but not coagu- 
lated. 

The indol reaction is not given. 

On October 8, 1901, both a guinea- 
pig and a rabbit were inoculated sub- 
cutaneously with a sixteen-hour bouil- 
lon culture of the organism. The 
former received fifteen minims, the 
latter twenty-five minims. 

The rabbit at the time of inoculation 
weighed 850 grms. It steadily lost 
flesh after the injection ; on October 
26, eighteen days after its inoculation, 
it died, weighing 620 grms. At autopsy 
nothing abnormal was found except 
slight congestion ofthe kidneys, spleen 
and liver. Cultures were taken from 
the heart's blood and a pure culture of 
the organism injected previously was 
obtained. 

The guinea-pig weighed 230 grms. 
on October 8 ; it too, lost flesh steadily 
and succumbed on November 1, twen- 
ty-four days after inoculation, having 
lost eighty grms. On section nothing 
abnormal was found. Cultures were 
taken from all the organs. From the 
heart's blood the original organism 
was isolated in pure culture. 

The organs of these animals were 
carefully examined microscopically 
but no lesions were demonstrable. 

The organism we were dealing with, 
no doubt belongs to the pseudodiphthe- 
ria group. 

After the death of our patient, the 
micrococcus lanceolatus was isolated 
from the lungs; a pseudodiphtheria 
bacillus from the blood. 



REFERENCES. 

1. Ueber d. Blasenausschlag oder Pemph , 
Berlin. '^ 

2. Virchow, Handb. d. Spec. Path, u 
Therap., 1S74, 2te Auflage, Bd. III. 

8. Ann. des Maladies de la Pean et de la 
Syphilis, tome 1, p. 208. 

4. N. Y. Med. Jour., 1884, Vol. 39, p. 562. 

5. Path, et Trait, d. Malad. d. la Peau (Tra- 
duction par Besnier et Doyon), 1891, tome 1, 

p. OOlF. 

6. Cutaneous Medicine, 1898, Part II, p. 
447. 

7. Bd. xiii, S 167. 

8. Arch. f. Derm. u. Syph., 1869, Bd. 1, 
S. 246. 

9. Ibid., S. 403. 

10. Med. Chir. Trans., 1887, Vol. Ixx, p. 421. 

11. Jour, of Cutan. and Genito-Urin. Dis., 
1891. p. 412. 

12. Ann. de Derm, et de Syph., 1900, tome 

1, p. 1166. 

13. Dent. Med. Wochenschr., 1897, S. 267, 

14. Deut. Arch. f. Kl. Med., 1894, Bd. 53, 
S. 61. 

16. Ann. de Derm, et de Syph., 1901, tome 

2. p. 869. 

16. Arch. f. Derm. u. Syph., 1889, Bd. 1, 
S. 71 and 78-100. 

17. Ann. de Derm, et de Syph., 1900, tome 
1, p. 1161. 

18. American Medicine, June 28, 1902, p. 
1092. ' » F 

19. Arch. f. Derm. u. Syph., 1896, Bd. 36, 
S. 141. 

20. Die Syphilis d. Haut u. der angren- 
zenden Schleimhaeute, 1875, III Lieferung, 
Tafel Ixiii u. Ixiv. 

21. Loc. cit. 

22. Giorn. ital. delle Malat. vener. e della 
Pella, 1889. 

83. Giorn. ital. delle Malat. vener. e della 
Pella, 1898, anno 33, p. 371. 

24. For studies on the metabolism see 
Stueve, Arch. f. Derm. u. Syph., 1896, Bd. 36, 
S. 191, and Giovanni, Gior. ital. delle Malat. 
vener. e della Pella, anno 33, 1898, p. 364. 

26. Loc. cit. 

26. Arch. f. Derm. u. Syph., 1901, Bd. 66, 
S. 423. 

27. Traite pratique de Dermatologie, 1900, 
p. 734. 

28. Arch. £. Derm. u. Syph., 1898, Bd. 44, 
S. 323. 

29. Op. cit., p. 636. 



For the treatment of obstinate 
cases of ringworm of the general sur- 
face, Stelwagon recommends the plan 
of painting with a saturated solution 
of chrysarobin in chloroform, and cov- 
ering with a coating of collodion. 



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Original Articles. 



SPBRMATORRH(EA AS A DISEASE SUI 
QBNBRtS. 

By J. A. De Ab^ond, M. D., Davenport, Iowa. 

When Josh Billings said that he 
would rather see a man who did not 
know so much than to see one who 
knew so many things that were not so, 
he voiced a great truth, and its breadth 
is such as to include whole sections 
and whole societies. The truth of 
Josh's philosophy is brough to mind 
again by the perusal of an address by 
Dr. Sturgis, of New York, delivered 
before the Mississippi Valley Medical 
Association last year. The doctor 
took for his text ''Diagnostic Points 
of Difference Between Spermatorrhoea 
and Seminal Pollutions." The ad- 
dress entire was published in the Amer- 
ican Journal of Dermatology for No- 
vember. The reader will find the argu- 
ment good reading, but for present 
consideration the points made em- 
phatic by the speaker will do for us. 
They were these : 

1. Spermatorrhoea is a disease sui 
generis. 

2. Spermatorrhoea has nothing in 
common with pollutions. 

3. Spermatorrhoea does not usually 
lead to impotence. 

4. Pollutions may or may not be 
associated with spermatorrhoea. 

5. Pollutions are liable to lead to 
impotence. 

Proposition number one being the 
weakest and hardest to swallow, may 
as well be considered first. Sper- 
matorrhoea has long been a large bear 
because nobody would go into the cane- 
brake and drive the little runt out. 
Irregulars and colicky writers gen- 
erally have held the boards, and a bit 
of deviation from the normal, unsup- 
ported by one single suspicious germ 
of bad habits or canying with it a bit 
of morbid anatomy worthy of the 
name, has gotten the reputation of 
being a very bad, dangerous disease. 
When you assume that spermatorrhoea 
is a disease sui generis^ you give it 
a rank and a station which the facts do 



not warrant, and by so doing you give 
to an airy nothing a local habitation 
and a name, and this at the expense of 
the truth and in defiance of good judg- 
ment. Primarily and as a basic fact 
spermaton*hoea is not a disease at all, 
and to so class it is to lend aid to a 
very disreputable enemy. That it is a 
disease sui generis is absurd. Any 
disease is a disease sui generis simply 
because it has some peculiar character- 
istics. The newer and safer nosology 
will eliminate a large section of so- 
called diseases that hold a place be- 
cause they are a little on the sui gen- 
eHs order. The sooner we get away 
from the idea that spermatorrhoea is a 
disease at all, the sooner will we be 
prepared to treat and benefit that 
large class of the young of both sexes 
who have inherited sexual propensities 
out of proportion to the ability to con- 
trol them. Children born during the 
observation and continuance of the 
sexual abandon, which legal authority 
gives but which wisdom does not en- 
dorse, are powerless to control the 
sexual fire which is early lighted and 
which time alone seems able to quench. 
These are the multitudes who furnish 
the great army who have the doubtful 
distinction of having a disease sui 
generis. 

Let us for a moment go back to 
first principles and see what spermator- 
rhoea is, anyway. Gould says it is 
** involuntary discharge of semen." 
That looks like a very mild sort of sui 
generis business to start with, "invol- 
untary discharge of semen." Semen 
is a complex material, primarily fabri- 
cated by the testicles, added to by 
glands along the way, and kept in store 
in the seminal vesicles. Nature mani- 
festly intended to supply a reasonable 
demand, and to keep the supply- al- 
ways ready. Between the storing 
power and the emitting mechanism 
there is a very delicate adjustment of 
nervous energy. When reasonable 
demands for semen are made and at 
reasonable intervals, that magnificent 



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Spermatorrhoea as a Disease— De Armond. 



106 



nervous control and adjustment are 
beautifully exhibited. When, how- 
ever, inordinate demands are made — 
inordinate as to time, amount or occa- 
sion — ^this fine nervous control is inter- 
fered with and the victim of his own 
passion secures irregular and unsolic- 
ited emissions, and these are sperma- 
torrhoea. That does not look like a 
very severe form of malady, does it? 
In truth, does it look like a malady at 
all? If a schoolboy persists in looking 
cross-eyed to secure applause, he in 
time comes to look cross-eyed when 
he has no idea of playing clown ; but 
he is miles off from a disease sui gen- 
eris. 

The victim of his own abuse is 
greatly alarmed at the unsolicited 
escape during sleep of seminal fluid 
and he at once gets busy with the 
book which tells him that he has some- 
thing sui generis. Sometimes the 
alarm is sufficient to cause a cessation 
of the abuse, and in that case the pa- 
tient at once starts out to find some- 
thing which will stop those emissions. 
Sometimes the patient is unable to dis- 
continue the habit and to his grief is 
added the guilty knowledge that if he 
does not kill himself nature will make 
him impotent, and between the con- 
templation of the two possibilities, he 
is not in what you would call a satisfied 
mind. Here then you have all that 
there is to a disease which we are asked 
. to consider to be one that is sui generis. 
True fear of consequences has driven 
countless thousands to drink, to crime, 
to suicide, but nowhere do you find 
spermatorrhoea recorded as one of the 
diseases which is crowding the great 
white plague as a destroyer of human 
life. It, as a matter of fact, is a fear 
and not a disease at all. True, it is 
not well to let such conditions go un- 
remedied, but life is not threatened by 
letting it go. Happiness is sacrificed 
by ignoring these patients, but like 
that attendant phantom, varicocele, 
nature will eventually cure it well 
enough to let the victim die of old age 



if not of piety. In time these losses 
become few and far between, so that 
the warning that patients will become' 
impotent will rarely materialize if the 
patient will let up on his abuse and 
take care of himself. Nature may for 
a long time continue a habit once thor- 
oughly established, but rarely to the 
extent of destroying a secreting func- 
tion. 

So much for spermatorrhoea. Now 
comes that bug-bear seminal pollu- 
tions. The very name is disgusting as 
it means "defilement,** but it really 
should be restricted to that condition 
wherein masturbation is persisted in 
beyond the ability of nature to supply 
material for waste. At best it is a rare 
state, and many students of sexual 
pathology never see a case. It abounds 
in asylums, and is found among the 
non compos mentis citizenship. It rep- 
resents almost complete destruction of 
the nervous mechanism controlling the 
storing and emitting powers of the 
body. Even then it is a mental dis- 
ease rather than a physical one in the 
sense of a disease. It leads to impo- 
tence because it leads to the incapacity 
to secure or maintain an erection. 
Furthermore such abuse is inimical to 
the fabrication of spermatozoa of vital 
parts. 

Spermatorrhoea has nothing about it 
that calls for a sign of impo.tence, ex- 
cept in so far as it relates to fear and 
the failure, to allow nature time to 
fabricate perfect sperm. Spermator- 
rhoeics often become impotent because 
they let the fear become the fact. 

Spermatorrhoea is very far from be- 
ing a trivial affair. Its consideration 
means much just as its successful treat- 
ment means everything to the patients, 
but the matter will never be cleared up 
any by making a bear out of a bush. 
Writers and authors never fail to urge 
great effort on the part of the patient, 
when, in fact, in thousands of cases 
the patient might as well be advised to 
stand on his head for a steady job as 
to quit a habit which was stamped into 



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his being as surely and as cruelly as 
ever the drink habit was fastened onto 
the boy to show .him paradise, and 
then lure him to the bottomless pit. 

I would not assume that because 
spermatorrhoea lacks the essentials of 
a disease that therefore it is not a fit 
subject for our best study and most 
careful attention. But let us put some 
of the blame where it all belongs, and 
instead of looking for the doubtful 
ending of abuse let us raise our pro- 
tests against that sanctified abuse 
which flourishes so well under the sanc- 
tion of law, but which produces a 
progeny of helplessness just the same. 
It is not only a mistake, but it places 
these patients in a wrong light to re- 
gard their weakness as depravity, 
when as a matter of fact it is depravity 
removed a generation or two. This 
view of the matter brings to the fore 
that other question, which relates to 
the treatment of self-abusers before 
they have reached the stage of im- 
pending or feared impotence. Bight 
here is where the treatment means 
something, since it gives hope, and 
hope is what is ever on the wavering 
line with the victims of their own pas- 
sion. 

Treatment of spermatorrhoea is 
always difficult because few patients 
can be made to understand that after 
abuse it is the rare exception for all 
losses to cease. So persistent are the 
nocturnal losses, especially, that many 
students of sexual pathology have 
come to believe that seminal losses 
during the adolescent period are nor- 
mal. Be this as it may, he who as- 
sumes to stop seminal emissions lacks 
only the broom to attack the Atlantic 
ocean. I am of the opinion that it 
were far better to tell a patient that 
losses are normal and can no more be 
stopped than can the growth of the 
hair, and that any treatment looking 
toward that end must be useless and 
disappointing. Nor is it essential. A 
careful scrutiny of the drugs ordinarily 
used to control a loss which should be 



viewed as a safety valve, will satisfy 
most any one that the elements are 
offered for greater harm than the 
omission of any treatment at all could 
possibly do. 

At best spermatorrhoea, if honored 
by a position in the nosology, is a dis- 
ease that does its greatest damage to 
the mind. Few bodies are invalided 
by it. True, it makes weak men and 
unfits them for begetting a race of 
athletes, but worse than all it acts as 
a barrier to best mental effort, and in 
that it robs many a man of the stamp 
of genius. 

A quarter of a century hence the 
literature of sexual matters of our age 
will be read as a curiosity, so great 
will be the advance in the treatment of 
what now is treated by a ready-made 
method wholly devoid of reason, sys- 
tem or satisfactory results. This, 
however, cannot be otherwise until the 
haze and glamour and mystery that 
have been supposed to envelop the 
subject is removed and rational 
methods are given a show. When the 
reader contemplates that when men 
high in the authority on such subjects 
present as the result of their labors 
the ultimatum scheduled at the begin- 
ning of this paper, there is left only 
the plain statement that the sperma- 
torrhoeic is up against a proposition 
which is most unpromising. All these 
years the regular profession has been 
denouncing the vampires for their 
scare methods. Can it be that we 
have failed to recognize the actual 
facts, or worse still, have we been at 
sea without compass or pole star? Or 
are we lost and back-tracking it? 

We may differ as to some details 
and the order of their importance, but 
upon one ground we can meet, and that 
relates to the place to locate the blame 
for a large preponderance of sexual 
weakness. Instead of viewing the 
hapless victim of an uncontrollable 
passion as depraved, let us pity him 
as the luckless victim of a load con^^ 
signed to him by those who kepi 



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within the legal lines, bat gave promi- 
nence to a dangerous passion just the 



49ame. 



PROSTITUTION IN JAPAN. 

Bt Albsbt S. Asbmkad, M. D., New York City, 
Formerly Physician to the Yoshiwara of Toklo. 

The word Yoshiwara means literally 
**The Plain of Reeds.'' In the reign 
of the Shogun lyemetzu, about 1659, 
it was the favorite seat of residence of 
the prostitutes. The word Yeddo, the 
old name of Tokio (east gate), is 
Aino, and means *'Plain." In 1867, 
the beginning of the present Meiji era, 
the government suppressed the gen- 
eral houses, and confined the women 
of this class to one quarter of the city. 
•** Yoshiwara*' to-day is applied to the 
prostitutes' quarter of Tokio. The 
gateway of the quarter is shaded by 
a high willow tree, the willow of wel- 
oome. The licensed houses, Eashiz- 
ashiki, are all under regular medical 
attendance. The examinations are en- 
forced once a week, and are controlled 
by a special policeman. 

A girl applying for license) as a pros- 
titute is severely questioned by a chief 
of the Yoshiwara police. ' She is 
usually accompanied by a parent or 
other guardian. When a girl is 
forced by her parents, or of her own 
free will desires to become a **lady of 
pleasure," a sum of money usually 
passes in the way of contract, say 
<10 to $50^ sometimes even more. 
No Yoshiwara woman is allowed to go 
out of the district without a special 
pass, and accompanied by her maid or 
a relative. Physical examination of 
the girl takes place once in ^^itchi- 
roku" (a Japanese week), usually the 
•day following the holiday, or, as we 
would say, Sunday. Those who are 
found to be diseased are sent to the 
special city hospital, which was mine 
while I lived in Tokio. The inmates 
of the prrtstitute bouses are doubly 
taxed, by the government and by the 
bawdy house keeper. The govern- 



ment taxes the owner of the property 
$5 a month and each prostitute $2 
a month. The restaurant keeper is 
charged $3. The terms applied 
to the girls engaged in this oc- 
cupation are: Orian, politest term; 
shogi, common; joro, opprobrious and 
severe; and yujo, **fille de joie," the 
tenderest or prettiest. Some of the 
rooms (each one has her own) are 
charmingly decorated and adorned 
with screens, carvings, chinaware and 
lacquer. Sometimes the wall exhibits 
some Kakemono, with appropriate 
poetry, as Matsu kiku, nao, sonsu, 
literally, **pine chrysanthenjums still 
are," that is the pine and chrysanthe- 
mums always preserve their charm, 
even in winter, when other flowers 
die, and by implication, *'My charms 
are everlasting, like the pine and the 
chrysanthemum ." 

Prostitution in Japan is considered 
to be an ineffaceable stain on the indi- 
vidual and an irremediable lowering of 
dignity; and yet they believe that 
there are some cases in which it leaves 
the moral character untouched. For 
were not the noble women of the Taira 
family once captured and forced to be 
prostitutes, and did not men who 
were not noble seek wives from the 
Yoshiwara, on this account, ever 
afterward, to put noble blopd in their 
offspring's veins ? Of the famous and 
beaiitiful harlot, Murasaki it was 
said, **She defiled her body, but not 
her heart." And she was described 
as **a lotus in the mud." Hence 
many prostitutes look forward to re- 
spectable marriage as a possibility of 
escape from their shame. But these 
cases are rare. The female footprints 
in the Yoshiwara nearly all point one 
way. When once one becomes an in- 
mate she remains till disability or death. 
Poverty and natural inclination are the 
determining causes that recruit the 
ranks of the joro. A Japanese 
proverb says: **Once get into dirty 
water and you will never be washed 
clean again as long as you live." 



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(Ichido doro midsu nihai&ra, issho 
mi wo arayenai.) This applies to 
these women of the Yoshiwara. Some 
few get married. Occasionally one 
will commit suicide. Others desoend^ 
through becoming ugly or old, to the 
position of servants in the house where 
formerly they were ornaments. 

Among the '♦lotuses of the mud** 
there is a great deal of romance. 
Novels by the hundreds tell the 
stories of the denizens of the Yoshi- 
wara, of their beauty, their misfor- 
tunes, goodness, triumphs, happiness, 
or despair and suicide. As was said 
in Palestine long ago, there are often 
more virtues to be found in the harlot 
class than among the ♦ 'highly respect- 
able." This is as true of Japan as 
it was of Jerusalem. 
^* 

PROSTATIC SURQERY^HiSTORiCAL 

AND EXPERIMENTAL* 

Bt BXNJAMlK Merbill Rickbtts, Ph. B., M. D., 
Cincinnati. Ohio. 

Anatomy. — Two lateral and a mid- 
dle lobe constitute the prostate, which 
was first described by Hume, 1806. 

The gland is not constant and is of 
many variations. 

Normally it is about one and one- 
half to two inches in its transverse di- 
ameter; one inch antero-posterior di- 
ameter, and one inch in depth. 

It is composed of Cowper's glands 
(each the size of a pea); numerous 
follicles and muscular tissue arranged 
to form about twenty channels lined 
with columnar epithelium (excretory 
ducts) through which a milky, slightly 
acid fluid passes to dilute the semen. 
All vertebrates fecundate in the same 
way. 

Blood supply is from the internal 
pudic artery. 

The venous blood enters the internal 
iliac vein through the dorsal vein. 

Nerve supply is from the hypogas- 
tric plexus and the filaments of the 
sympathetic. 

* Abstract. Bead before Ohio State Med. Socy., Jane 
5, 1903, Dayton, Ohio. 



Etiology. — Man is the only animal 
that has hypertrophy of prostate. No 
definite cause yet assigned; habits,, 
disease and evolutionary changes from 
quadrupedal to bipedal state, probably 
the most important factor. 

"Prostatic hypertrophy not found in 
Japan, India or China." (Otis.) 

Surgery of Prostate. — Ammonium 
Lithotomus, B. C, 460-357; John- 
nesde Romanes, 1555 ; Ran of Leydon 
and Frere Jean, 1700, in operating for 
stone no doubt contributed much ta 
advance the various subsequent opera- 
tions for prostatic hypertrophy. 

Cystotomy may be said to have been 
inaugurated when the bladder was first 
opened for any purpose. Both peri- 
neal and suprapubic drainage have been 
successfully accomplished with more 
or less benefit in hypertrophy of the 
prostate. 

Massage was first employed by Est- 
lander, 1878; Hogge claimed priority 
in the use of electrical massage. 

Lewis, 1899, employed the finger 
and condemned instruments for this 
purpose. 

Neiswanger, 1900, employed cata- 
phoric applications of iodine in hyper- 
trophy of prostate. 

Injection of various solutions, argentt 
nitras, iodine and cocaine, into the 
prostate was done by Hall, 1887; no 
special effect. 

Heurate, 1896, injected testicular 
extracts into the prostate. 
' Ligation of cord was done by Mears, 
1894, without effect. 

Ligation of iliac arteries was done 
by Bier, 1893, and Meyer, 1894, while 
Loze, 1898, removed the venus plexus 
(veico). 

Vasectomy was employed by Lou- 
mean, 1895, since which time there 
have been several hundred such op- 
erations. 

Sleinach, 1896, showed by experi- 
ments on rats that the removal of the 
seminal vesicles and prostate gland 
does not lessen the sexual passion or 
ability to perform the sexual act, with 



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« discharge of spermatozoon, but that 
fertilization is prevented. 

The ability of the semen to fertilize 
is lessened by the removal of their vesi- 
•cles. 

The operation of vasectomy has be- 
come obsolete. 

Castration was first performed for 
prostatic hypertrophy by Mercier, 
1857, but was pot again performed 
until White, Ramm and Cobat, 1893, 
did it. 

Removal of one testicle is supposed 
to cause its corresponding prostatic 
lobe to undergo atrophic changes, 
while the removal of both testicles 
will cause atrophy of all the lobes. 

The operation was based upon the 
fact that eunuchs do not have prostatic 
hypertrophy. 

Several hundred cases of prostatic 
hypertrophy have been subjected to 
emasculation with more or less benefit. 

It should be done in but a few se- 
lected cases, such as extreme age or 
lessening of vitality, or before more 
radical measures. 

The operation is seldom considered 
since the inauguration of prostatect- 
omy. 

Prostatotomy coni^\st8 in incising the 
prostate by knife, cautery or other- 
wise, for abscess, cysts, foreign bod- 
ies, injuries or pathologic conditions. 

Tenotomj/ of Levator prostate was 
first done by Wyman, I880, and again 
by Andrews, 1902, with much benefi- 
cial result. 

Urethral Prostatotomy. — Incising 
the prostate through the urethra by 
knife, catheter and various other de- 
vices dates from Home, 1817, since 
which time many such operations have 
been done by as many different de- 
vices. Much benefit has been obtained 
from this method, but it is no longer 
considered rational. 

GffJvanO' Cautery has been employed 
since 1875, when Rabitsch and Bottini 
reported the result of their work. 

The cautery was very seductive and 



attended by much mortality and un-;- 
certainty in its results. 

It is applicable (if at all) in but a 
few cases of a selected type. 

It cannot be considered a rational 
procedure, as the cautery cannot be 
seen. 

Perineal Prostatectomy is the re- 
moval of a part or all of the prostate 
gland through a median, transverse or 
lateral perineal incision. 

Gibb's question, 1857, was, ''Can- 
not enlargement of the middle lobe of 
the prostate gland be removed by the 
lateral operation* for lithotomy?" 
This is one of the earliest suggestions 
for the removal of the prostate gland 
through a perineal incision. 

Since this time many such opera- 
tions have been made for this purpose, 
and there can now be no question as 
to this route and method being the 
most acceptable and beneficial opera- 
tion for hypertrophied prostate. 

Rectum for Urinary Receptacle. — 
Ricketts, 1902, in removing the pros- 
tate gland in two cases of emergency 
succeeded in diverting the urine into 
the rectum. 

During the last century there have 
been several cases reported in which 
the vagina was closed by an operation, 
that the urine might escape into the 
rectum for the relief of vesico-vaginal 
fistula. 

Prostatectomy ( Suprapubic) . — Only 
a part of one or more prostatic lobes 
can be removed by this method. 
Usually complete removal of the lobe 
is confined to the ^ middle lobe, for 
which it was first intended. 

Roonhysen, in cutting on the gripe 
or with grooved sound and gorget, 
found it impracticable, and the supra- 
pubic operation for stone, which was 
probably one of the first suprapubic 
operations, was resorted to. 

Lisrink, 1882, was one of the first to 
remove the prostate gland suprapubic- 
ally, since which time many such 
operations have been made for pros- 



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tatic hypertrophy with great success. 

Of all operations for hypertrophied 
prostate the perineal and suprapubic 
operations remain supreme in their re- 
spective order. 

Prostatectomy (Perineal and Su- 
prapubic Combined). — The combined 
operation has many advantages in a 
certain class of cases of prostatic hy- 
pertrophy. However, since the many 
prostatic retractors have been de- 
vised there is not the necessity for 
entering the bladder suprapubically. 

Fuller, 1895, removed the prostate 
gland and drained through the perineum 
and suprapubically. 

Abscess of prostate is common and 
more frequently due to cysts, gonor- 
rhea and trauma, usually gonorrhea. 

Most frequent way of escape is into 
the rectum. 

Tuberculosis seldom originates in the 
glandular tissue, primary disease be- 
ing rare in the prostate. 

It is usually secondary and may in- 
volve a part or all of one or more 
lobes. It was first described by 
Louis. 

Complete removal of the disease can 
be made and should be done. 

Echinococci, most common parasite 
found in the prostate gland, usually of 
primary origin. 

The cyst usually ruptures into the 
bladder or rectum, in which case spon- 
taneous recovery will ensue. If into 
the peritoneal cavity death may result 
or the parasites may become encysted 
and remain harmless indefinitely. 

Calculi form in the prostatic ducts, 
and may be discharged into the urethra 
or remain in the prostate to become 
encysted. 

Fuller, 1900, reports such a stone 
weighing three ounces. 

Carcinoma of the prostate is more 
frequent in childhood, and beyond the 
age of 50, primary or secondary, 
usually the latter. Often in the civ- 
ilized races, and originates, as a rule, 
in the mucosa of the prostatic urethra. 



No treatment, surgical or otherwise^ 
is at present of any avail. 

Beling, 1822, records an interesting 
case of prostatic carcinoma. 

Sarcoma of the prostate is usually 
hard and of slow growth, originating^ 
in the cortical substance. 

More frequently found in the young. 
No hemorrhage except in advanced 
growths. May be primary or secondary,, 
usually primary. 

London Lancet ^ 1853, i, 473, men- 
tions a case of sarcoma of the prostate. 

Early removal should be done, as it 
is the only hope. 

if 

SYPHILIS OP THE NERVOUS SYSTEM. 

Bt Fbank £. Coulter. M. D., Omaha. Nebraska. 

No portion of the nervous system 
can be considered entirely exempt 
from the ravages of syphilis. Hen- 
schen quotes figures from which we 
are safe in concluding that one at 
least in every seven infected by syph- 
ilis, develops some lesion of his nerv- 
ous organization. The preceding 
statements afford all the apology we 
have to offer for the present paper* 
Syphilis too often remains unrecog- 
nized until the period for relief is 
passed. In this disease especially^ 
even more than in many others, if we 
would be successful in the treatment^ 
an early recognition of the condition 
is absolutely essential. On this point 
we think all will unite. 

Upon careful reflection the conclu- 
sion is reached that syphilis, as an 
etiological factor of disease in this 
country, is not recognized as fre- 
quently as it should be; we in this 
western portion especially have too 
exalted a conception of our own virtue. 
This false modesty frequently ham- 
pers us in obtaining a true history of 
infection from this disease. As a re- 
sult of investigations, both remote and 
recent, it seems most probable that 
this disease is due to a micro-organ- 
ism ; if definitely isolated at the pres- 



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Syphilis of the Nervous System— Coulter. 



171 



ent time or not, there still seems to 
be some question. 

Let us, then, consider the earliest 
etiological factor of the trouble — the 
question of, or subjection to, or liabil- 
ity of infection. All will agree that 
outside of a few rare cases, that are 
mostly conGned to the medical pro- 
fession, there is but one method by 
which the disease is propagated. Sir 
Wm. Gowers has most aptly stated 
that no patient should be considered 
absolutely free from syphilis unless he 
has never been exposed. This, how- 
ever, does not apply to the members 
of the medical profession. Some may 
consider his statement entirely too 
broad, but when you come to ponder 
it carefully you will conclude, we 
think, that it is true. The point of 
infection is readily concealed or over- 
looked, so that many of these patients 
do state the truth so far as they know 
it when they tell us that, to the best 
of their knowledge, they never were 
infected. 

Let us ever remember there is no 
word in the English language descrip- 
tive of the virtuous man, the counter- 
part, of "virgin" as applied to the 
female. Many cases of an undoubted 
syphilitic nature have developed in the 
nervous system, as well as in other 
locations, when the patient has posi- 
tively and honestly, as he believes, 
never suffered from the initial lesion 
of syphilis. If such cases are prop- 
erly questioned many will admit gon- 
orrhoea, many others will say they had 
a *'8oft chancre'* or some other so- 
called unimportant lesion, a few will 
say they had the ''classical Hunteriati 
sore," while but very few will tell you 
they never were exposed. 

A very few men and some women 
run the gauntlet for a time when vis- 
iting the shrine of Venus and are never 
entrapped; others, and it is no small 
per cent., make the journey and are 
entrapped, but do not truly recognize 
this fact; still another class, and they 
are not the majority, have been 



"unfortunate" and realize as well as 
acknowledge their condition. 

While we believe our patients do 
not as often try to deceive us in these 
matters as we sometimes think, yet it 
is our duty to drive these questions 
home when soliciting the history, for 
the benefit of all concerned. There 
are recognized a number of contrib- 
uting factors that serve to bring to the 
surface, as it were, syphilitic manifes- 
tations. A few may be mentioned — as 
trauma, mental or physical overexer- 
tion, sexual excess, ^strong emotions, 
alcoholism and exposure; these only 
serve, however, to bring out the re- 
sults of the infection already so well 
inaugurated. Alcoholism seems to be 
one of the most, if not the most potent 
of these factors. Because of another 
paper prepared for this society, in- 
herited syphilis and its relations to the 
nervous system will not be considered. 

Morbid Anatomy and Pathology. — 
For the sake of convenience the old 
familiar terms, primary, secondary 
and tertiary, will not be adhered to, 
but instead the entire manifestations 
of this disease as found involving the 
nervous system will be divided into 
the early and late changes, and some- 
times are designated as specific and 
parasyphilitic. 

The terms early and late, of course, 
are only relative at best; so are pri- 
mary, secondary and tertiary, for that 
matter, as are many terms used in 
medicine. It would seem that after a 
period of ten or twelve years in the 
majority of cases the results of the 
specific infection of syphilis undergo 
an alteration. Why this is the case 
we are at a loss to understand, unless 
the active force of the disease is ex- 
pended by that time; anyhow, it does 
not yet seem to have been satisfacto- 
rily explained, but the clinical picture 
observed after the period just men- 
tioned is much changed from what is 
seen before that time; this is not an 
infallible rule, but a frequent fact. 
In this connection it may be of inter- 



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est to know that about forty-four per 
cent, of all syphilitic intracranial le- 
sions develop within the first three 
years of infection, that about fifty-nine 
per cent, develop within the first five 
years, and in rare* instances a definite 
syphilitic cerebral lesion has developed 
while the initial hard chancre was still 
in existence. Many of the cord lesions 
of an acute nature also become mani- 
fest during this early period. This is 
food for thought for those who do not 
believe that results follow the infec- 
tion swift and definite. 

Under the head of the early or spe- 
cific manifestations may be mentioned 
the vascular lesions, endarteritis, 
thrombosis, gummatous formations, 
meningo-encephalic inflammations, 
etc., then we have a rare form of waxy 
degeneration of the middle coat of the 
arteries occurring in syphilis. Athe- 
roma may be of a syphilitic nature, but 
more frequently is simply degenera- 
tive. The later changes are those 
which usually become manifest after 
ten or twelve years from the date of 
infection and are the degenerations 
and sclerosis, the principal representa- 
tive in the encephalon being general 
paralysis of the insane, the so-called 
softening or paresis, and while paresis 
occurs in other than syphilitic patients, 
yet there is no doubt that syphilis is 
one of the most prominent etiological 
factors of this disease; in the cord, 
posterior sclerosis is the representative. 
To return to the lesions enumerated as 
occurring in the earlier stage of the 
disease, they may be classed according 
to structures involved: 1st, those of 
the blood vessels; 2d, those of the 
brain cord and its membranes; 3d, 
the formation of new growths known 
as gummata. 

The chief vascular alteration is oblit- 
erating endarteritis, yet this is not now 
considered as strictly pathognomonic 
of syphilis, as it once was; it results in 
thrombosis and softening, or if only a 
partial obliteration obtains, sclerosis or 
hardening may be found in either the 



encephalon or cord. Any of the cord 
or intra-cram'al arteries may be the 
seat of these alterations, but the verte- 
brals, the basilar and mid-cerebrals are 
most likely to suffer, hence symptoms 
must vary according to the particular 
artery involved. The cerebral corte"i 
and membranes, one or both, are not 
infrequently the seat cff inflammatory 
action, and if the vertex be involved 
the symptoms will differ from those 
present when the base is the seat of 
operations. Gummata may be found 
either on the vertex or the base, or 
both, these bein^ the most usual loca- 
tions, very seldom in the interior. 
Sometimes these may be very diffuse in 
character, in others they are circum- 
scribed. They vary in size from a 
millet seed to a walnut, and often are 
multiple. Some writers believe that 
acute simple inflammation of the cord 
seldom if ever exists, but that the con- 
ditions described as such are those of 
multiple thrombosis of the capillaries, 
and certainly t;he anatomical arrange- 
ment of these vessels would support 
the theory. 

Symptoms. — The symptoms pro- 
duced by a specific vascular lesion in 
the encephalon, or cord, are not essen- 
tially different from those produced by 
any other like lesion ; that is, a throm- 
bosis due to syphilis is not essentially 
different from a thrombosis due to 
some other cause, granted that in both 
instances it is complete; and the same 
may be said of hemorrhage or em- 
bolism; this refers to the early clin- 
ical phenomena only, remember. The 
same statement may be made and holds 
good regarding inflammations and 
gummata, but not to quite the same 
extent. You naturally ask the ques- 
tion, if the statements just made be 
true, how are we to make a diagnosis 
of syphilis, how may we be positive we 
are dealing with a syphilitic manifesta- 
tion at all? The following rules, if 
observed, will direct you in the diag- 
nosis. You will observe in these cases: 
1st, a peculiar association or succession 



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Syphilis of the Nervous System— Coulter. 



178 



of symptoms that indicate a double or 
multiple lesion; 2d, a most unusual 
tendency to remissions and relapses; 
^d, the onset of the case is usually 
sudden rather than acute, and the 
•course is sub-acute or sub-chronic 
rather than chronic; 4th, symptoms 
as a rule resolve rapidly under appro- 
priate treatment, but not always. You 
will thus observe that there is a pecu- 
liar grouping of symptoms that is not 
found in any other disease and is char- 
-acteristic only of syphilis. 

The most frequent vascular lesion 
found in syphilis of the nervous sys- 
tem is thrombosis, and you will at 
-once understand, as has been stated, 
the symptoms vary depending upon 
the particular vessel affected, and it 
would be interesting in this connection 
to follow these out in the case of each 
•of the vessels named had we sufficient 
time. As has already been indicated, 
i:he pathological changes are often 
incomplete, hence the symptoms are 
in such cases more or less transient 
and indefinite in character. This ex- 
plains a hemiplegia that often makes 
apparently a good recovery, also an 
^aphasia that is transient, verbal am- 
nesia, parasthesia, lapses of conscious- 
ness that are fleeting, temporary men- 
tal confusions, etc., which accompany 
the condition. Usually the patient ex- 
periences a warning, such as headache, 
vertigo, transient numbness, or loss of 
power before the full force of the at- 
tack is experienced. Just here if you 
zare able to diagnose the condition your' 
skill will be of the utmost value. 

Within a few months a lady was 
•brought to my office having rapidly 
and within a few hours experienced a 
loss of power in the left forearm, hand 
^nd fingers, the member being limp 
-and flaccid to such an extent that she 
-could not use it only to a limited de- 
-gree. There was also experienced a 
sensation of fullness and burning in 
the member, as if it would burst. This 
•condition had been preceded several 
liours by headache ; but no nausea, no 



unconsciousness, no convulsions, local 
or general. She was twenty-five years 
of age, and having positive evidence of 
syphilitic infection four years before, 
we were able to at once diagnose the 
situation as a commencing thrombosis 
of the second branch of the right mid- 
cerebral. Nitroglycerine and strych- 
nine were prescribed every three 
hours, and potassium iodide three times 
a day, and the results were that within 
three days all symptoms of the im- 
pending paralysis had disappeared, the 
strength also returning. This case is 
only one out of many of a like charac- 
ter that could be related. 

Hemorrhage and embolism do not 
frequently occur as the result of syphi- 
lis; hence, we will not take the time 
to consider them here; but if they 
should occur,the same diagnostic points 
should be observed as would differ- 
entiate these conditions were the cause 
other than syphilis, remembering that 
hemorrhage and thrombosis are very 
different conditions, and require en- 
tirely different management. As to 
gummata, these productions are often 
multiple, they may be circumscribed 
or diffuse, and as stated are found 
most frequently on convex (external 
surface) or on the base. Headache is 
a common symptom, worse at night 
usually; then again convulsive attacks, 
general or localized, often appear. 
Vertigo and vomiting may be present. 
Weakness manifest in some group of 
muscles is often found. Optic neuritis 
is present in a large number of cases. 
If the gumma is located at the base, 
some of the twelve pairs of cranial 
nerves are most likely to suffer in com- 
plication from the third down; the 
sixth because of its length and location 
is found most frequently involved, but 
it is of poor diagnostic value as a 
localizing sign (Russell). Memory is 
often bad and mental confusions usu- 
ally exist. Aphasia in some of its 
various forms often is present. Under 
certain conditions the gumma is more 
or less diffuse, then the localizing signs 



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are less definite. The membranes may 
become involved as well as the cortex, 
when more or less of an inflammatory 
condition will be found present. In 
such a case much depends upon loca- 
tion and the general evidence of men- 
ingitis in combination with an enceph- 
alitis, the symptoms may be more or 
less acute, hence the picture you will 
study may vary. Polyuria and poly- 
dipsia may be present. Ptosis, di- 
plopiaor someform of external ophthal- 
moplegia or bilateral heminopia or an 
internal ophthalmoplegia may be en- 
countered. These eye symptoms are 
peculiarly charact^stic in that they 
are often fugitive, present today and 
absent tomorrow, or at most lasting 
but a few weeks. The ophthalmoscope 
shows changes in the fundus in about 
40 per cent, of the cases. It may be 
an optic atrophy, chocked disc, or a 
retinitis. Hereditary syphilis may 
often be demonstrated by some of the 
above signs, and in these congenital 
cases a partial inhibition of mental de- 
velopment is prominent. 

Diagnosis. — It would seem almost 
useless to say anything more on the 
question of diagnosis, other than what 
has just been mentioned in the symp- 
toms, but that particular part of the 
subject is so important that perhaps a 
few more words may not be entirely 
useless. One of the most important 
questions is, first, the history of ex- 
posure, but this is not absolutely es- 
sential, as we have seen, for the dis- 
ease will tell its own story generally ; 
second, if your patient is suffering 
from intra-cranial syphilis, he will 
most likely show some other evidence 
of the disease, yet this is not absolutely 
certain. Always look for the sore 
throat, mucous patches, glandular 
enlargement, patches of characteristic 
discoloration of the integument, etc. 
If the patient be married, note care- 
fully the history of any miscarriages. 
See if the pupils are equal in size and 
regular in contour; this is a most im- 



portant point. Also note the Argyle- 
Robertson reaction, if present . 

Of the early syphilitic manifesta- 
tions in the cord, a so-called trans- 
verse myelitis is most frequently en- 
countered, or the myelitis may be dis- 
semitiated ; another most frequent cord 
condition is a meningitis that may be 
localized or general, and subacute or 
chronic in character. Tabes is con- 
sidered by most authors one of the 
parasyphilitic manifestations usually,, 
the per cent, varying according to the 
experience of each observer. 

Patrick has given the following 
points between general paresis and 
cerebral syphilis. He says: "When 
the symptoms appear at a remote 
period, say ten years after infection, 
the disease is probably paresis, cere- 
bral syphilis usually appearing before 
ten years, In paresis usually the higher 
mental faculties and operations are 
first attacked ; those of a purely routine 
nature are last to suffer. In cerebral 
syphilis these symptoms are usually 
somatic, as paralysis in various situa- 
tions, usually focal, sensory disturb-- 
ances, etc. ; therefore in cerebral 
syphilis there are apt to be symptoms 
added to the clinical picture that are 
not usual in paresis. " 

Severe headache is generally pres- 
ent in syphilis, but absent in paresis. 
Pains in other parts of the body, worse 
at night, stand for syphilis rather than 
paresis. Marked anesthesia or pares- 
thesia would indicate syphilis. Paraly- 
sis of any of the cranial nerves below 
the third will indicate syphilis instead 
of paresis, hence external ophthalmo- 
plegia would mean syphilis, while 
internal may or may not. TheArgyle 
Robertson pupil may mean either 
syphilis or paresis. Physical weak- 
ness and tremor, if general, would in- 
dicate paresis, while if local would be 
more in favor of syphilis. Primary 
optic atrophy would indicate paresis,., 
while optic neuritis or secondary 
atrophy would indicate syphilis." Now,. 



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SyPH!LIS OF THE MERVOUS SYSTEM—COULTER. 



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these differential points are interesting 
when one remembers that some au- 
thorities place syphilis as the etiological 
factor in paresis as high as 75 to 85 
per cent., but from a practical stand- 
point, however, if the statement just 
made be true, it is not of much impor- 
tance in the treatment. 

Prognosis. — There is probably no 
condition where a prognosis is more 
valuable than in the one we have under 
consideration, but at the same time it 
may be most faulty. Two points 
should not be omitted in this con- 
nection : first, it is a mistake to sup- 
pose that all syphilitic lesions of the 
cord or brain will recover under ap- 
propriate treatment. This fallacy has 
permeated the profession pretty thor- 
oughly and should at once be removed. 
An artery that has once been perma- 
nently closed by a syphilitic throm- 
bosis will remain so in spite of all the 
mercury or iodides in the world, just 
the same as if the condition was caused 
by some other disease. The same 
holds true of the other vascular lesions. 
A gumma may be absorbed or become 
stationary, but a cicatrix of a more or 
less irritative character remains. The 
second point well to remember is that 
it is the very nature of this disease to 
have remissions and relapses; patients 
are ''up and down," and these hopes 
are often an ig?iis fatus following 
which a reputation may perish and a 
valuable life be lost. 

Turner makes the statement that 30 
to 35 per cent, of cerebral syphilis re- 
cover, that about 12 per cent, are fatal 
and soon die, while the remainder, 53 
to 58 per cent., over half, you will 
note, are more or less permanently 
maimed. No doubt these cases em- 
brace the most unfavorable of all cases 
and have most probably been taken 
from hospital practice, where those 
who are most likely to be past help 
will appear, for a hospital is not 
usually sought unless something serious 
has transpired. In the early mani- 
festation of the condition, and we 



mean by this when the patient com- 
mences to manifest some of the pre- 
monitory signs, already referred to.^ 
then if recognized a more hopeful 
prognosis may be ventured, other 
things being satisfactory. As to the 
cord troubles, it would seem that the 
figures mentioned are to optimistic. 
In summing up the prognosis one can 
say, if recognized early and appropri- 
ate treatment instituted, much benefit 
may be expected and often an apparent 
cure result ; hence the very great im- 
portance of an early, careful and ac- 
curate diagnosis. If later manifesta- 
tions are encountered, less improve- 
ment is probable, but considerable 
benefit may be derived. If the very 
late manifestations are found the im- . 
provement will be but little, and if the 
progress of \ he disease is stayed it is 
perhaps about all that can be expected in 
many cases. Above all, remember that 
each case demands individual and care- 
ful study and that a prognosis must 
depend upon the mtelligent interpreta- 
tion of the facts thus obtained, based 
upon the conditions present. 

Treatment. — Just a few words on 
the very important question of treat- 
ment. When the evidence is all col- 
lected it will be found that many cases 
of syphilis, of the nervous system, and 
of other organs as well, have been 
allowed to perish and have been taking 
mercury or the iodides much of the 
time. The fault does not reside in the 
remedies, but in the method of admin- 
istration. Many patients are drugged 
to death by these remedies who would 
have been saved by an intelligent ex- 
hibition of the very same remedies. 
As to the remedies themselves, the two 
just mentioned are the only ones 
worthy of consideration in the treat- 
ment of syphilis. How should they 
be given, and when ? are most pertinent 
questions. 

Unfortunately the leaders in neuro- 
logical work of today differ as to the 
size of the dose and the length of the 
time treatment should be continued; 



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Original Articles. 



however, personally, the method of 
<jrowers would seem most satisfactory. 
Perhaps that is because we are the 
more familiar with it. So far as in- 
flammations are concerned, he rather 
believes that they are best controlled 
by mercury, while gummata are pos- 
sibly better controlled by iodides, or 
at least as readily controlled by them 
as by any remedy. In the Lettsomian 
lectures, he makes this statement: ^^I 
am inclined to think that when a lesion 
is distinctly influenced by either drug 
(referring to mercury and the iodides), 
if this is given freely the effect, of one 
is as great as the other." In his hos- 
pital practice, in many instances, it is 
his custom to first give mercury until 
the physiological effects are estab- 
lished; then follow with the iodides. 
He does not sanction, but discourages, 
the large dose and long-continued use 
of the latter drug as given in this 
-country, and fortifies his position by 
pathological findings that would seem 
<3onclusive and incontrovertible. The 
theory advocated is that the tissues be- 
come accustomed eventually to the 
remedy in large doses and that in cer- 
tain eases syphilitic lesions are not 
-controlled as they are when the remedy 
is first administered; hence a moderate 
dose, ten to fifteen grains of the 
iodides, three or four times daily, and 
continued for from six to ten weeks 
only, then an interval is allowed and 
the treatment is resumed later. The 
two remedies are not usually given at 
the same time, unless a very rapid 
action is desired, the reason given be- 
ing that the iodide eliminates the 
mercury before its full effects are ob- 
tained. Many methods of adminis- 
tering mercury have been used, but 
inunctions, and by the mouth have 
proven the best for all-around work. 
In certain cases other methods may be 
tried perhaps with advantage; such as 
the hypodermic, fumigations, etc. 
Baths are not to be forgotten in th e treat- 
ment of this condition, and waters of 
a sulphurous nature are especially ad- 



vantageous in assisting in the elimina- 
tion. 

We purposely because of time limi- 
tation have not discussed the questions, 
**Can syphilis be cured, and is it a 
self-limited disease?" Much can be 
said pro and con upon this subject, and 
it is suflSciently broad of itself to 
furnish material for a paper more 
voluminous than the present one, 
hence we crave your indulgence be- 
cause of our inability to call your at- 
tention to but a very few of the 
important points in connection with 
this most interesting subject. 

REFERENCES. 
Oppenheim. 

Brain. Aatamn number, 1902. 
Allchin, Manual of Medicine, yol. iii. 
J. Rissian Russell, Clinical Lectures, 1901. 
Gowers* Manual of Nervous Diseases. 
Lettsomian Lectures, Gowers. 
Diseases of Nervous System, 3rd Edition, 
Gowers and Taylof . 



A SIMPLE REMEDY FOR THE CURE OF 
VARICOCELE. 

By Frank A. Bbkwer, Sb., M. D., King City, California. 

In my late article relating to this 
subject, written for the Pacific Medical 
Journal^ in which I endeavored to show 
that a more rapid cure of varicocele 
was possible through an improvement 
of the '* Morgan Method," the motive 
sought was to increase an interest upon 
the part of the medical profession at 
large, if possible, in the great crying 
needs of humanity for the relief of 
genito-urinary lesions, which in real- 
ity have assumed an epidemic form! 

There is no mistaking this fact, as 
the late records of the army and navy 
indicate in their examinations of ap- 
plicants for service in the Cuban and 
Philippine wars, where over 68 per 
cent.' of cases were rejected owing to 
the presence of varicocele. 

A specialist in these diseases has 
lately published a statement to the 
effect that he has found that fully 95 
per cent, of the male sex are afflicted 
with this maladv. 



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Cure of Varicocele— Brewer. 



177 



Why? My reader, at that rate it 
will not be loDg before the American 
Nation must call upon some more nor- 
mal foreign human elements to come 
to its rescue, if not sooner relieved. 

Hence, the duty of proffered assist- 
ance in the reduction of this increas- 
ing affliction becomes an imperative 
one upon the part of the medicos in 
general, instead of leaving it to the 
specialist, as is now the case, many of 
which are mere frauds, and others 
charging most exorbitant rates ! 

No doubt many of our medicos dis- 



dulged by spec 
tried, but were 
lieving. 

Becoming lat 
** Morgan Meth< 
with more satisi 

Finding that 
ble of improven 
cure might foil 
vent an outfit tt 
both testes, bi 
unaffected orga 
mal nourishmen 
Morgan Metho< 



/^ (r/ 



•▼r^r-flc^^" 



^»» • x'S^ 







like to add this specialty to their prac- 
tice, owing to an imaginary idea of a 
redundancy of ''gonorrheal taint," but 
several specialists have informed me 
that not over one per cent, are thus 
affected. 

Certainly there can be no objection 
in a remunerative point of view, as 
this disease is no respecter of person, 
affecting both the rich as well as the 
poor alike, and up to date the spe- 
cialist is having it all his own way and 
doing a lucrative business. 

In my late article in the Pacific Med- 
ical Journal I referred to an accident 
happening to myself, that of receiving 
a kick from a brother-in-law at my 
back, while poised in a squatting posi- 
tion upon the floor of my office, the 
blow striking my left testis, ruptur- 
ing some of its vessels and disorganiz- 
ing its entirety, resulting in a true 
varicocele. 

The usual forms of remedies in- 



versible poise, t 
and confinemen 
sacular investm 

A single susp 
Irish linen waf 
with same kinc 
inches in lengtl 
were attached 
with a oorrespo 
lets along its op 

Upon one enc 
were fastened ; 
(Irish linen) v 
ficiently long c 
suspensory at it 
of the penis, > 
pension. 

A body bell 
structed having 
end, and as well 
of about four 
tached to it, th< 
the left of the j 
the body, so as 



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Original Articles. 



the testis within the groin and prevent 
its roUingt towards the median line and 
becoming injured. 

Upon the ends of each tape were 
fastened an eyelet for the support of 
the testis. 

The form of the suspensory and the 
belt are here exhibited, the suspensory 
being flattened out in order to give a 
•better idea of its form. 

This suspensory was sized to em- 
braced the testis and scrotal integu- 
ment more or less tightly, but not suf- 
ficient to inflame the tissue, but enough 
to prevent an escape from the mouth 
of the suspensory orifice ; at the same 
time care was fully observed to avoid 
irritation in the tying process until 
nature became accustomed to the in- 
terference. 

The scrotal tissue was at first en- 
•couraged to a laxity by an ablution of 
quite warm water, then dried with a 
soft towel. 

The left portion of the scrotum, 
including the left testis, was then 
seized with the fingers and thumb of 
the right hand and elevated to a per- 
pendicular poise. 

With the fingers and thumb of the 
left hand embracing both «ides of the 
scrotum and testis a gentle pressure 
was applied, and a sliding motion to- 
wards the body followed, by which the 
overcharged .vessels of the testis were 
relieved of their stagnant fluids, the 
same were forced into the greater cir- 
culation, and a fresh supply of blood 
encouraged in substitution. 

This motion was similar to that of a 
milker when stripping the teat of his 
oow. 

Still holding the tissue at its per- 
pendicular the single suspensory was 
applied, and hooks fastened to the 
eyes, then carried on upward and at- 
tached to the tape eyelets of the body 
belt, previously placed in position, 
und the opposite end was fastened to 
the base of the penis (not too tight at 
the beginning). 

The clamp was then attached to the 



outer third of the scrotal tissue and 
also lip of suspensory, the purpose 
of the latter being to regulate the 
flow of blood into the testis vessels 
(a sufficiency only being allowed to 
nourish them) and to better sustain 
in position the suspensory. 

However, the clamp may be dis- 
pensed with, other lesions being absent 
besides varicocele. 

A sponging of cold water was then 
applied to the imprisoned organ» 
which not only relieved greatly the 
painful bearing-down sensation, but as 
well prevented undue irritation of the 
parts through interference of adjust- 
ments. 

A wrap of a soft linen napkin 
(wrung out of cold water) around 
the penis and testicles at night upon 
retiring, and left till morning, will be 
found not only cool and relieving of 
any and all inflammatory conditions, 
but as well assist in shrinkage of the 
testicle vessels, so necessary in re- 
formation. Keep all instruments 
washed and clean. 

The milking method and sponging 
in cold ablutions were indulged daily 
for three or four days, the adjust- 
ments being detached for that pur- 
pose, lighter pressure being applied in 
each application. 

A cessation of disturbance then fol- 
lowed, and the labor of restoration 
was left entirely to nature; but the 
reversement and attachment of the 
testis to the belt was fully observed 
and continued until reorganization was 
fully accomplished, which required 
but a few days. 

This is absolutely requisite for suc- 
cess, otherwise a failure will surely 
follow or the adjustment must be worn 
for a longer period. 

Upon discarding the single suspen- 
sory a regular suspensory, somewhat 
smaller than the diameter of the 
scrotum, was substituted, in order 
to strengthen the reorganization of the 
testis and prevent its return to its 
defection, and also to disallow an 



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m 





WWch yields thirty limes iU vol- 
lime of •• nascent oxygen " near 
to tlie condition of •*ozone»'* 

is daily proving: to physicians, in 
some new way, its wonderful efficary 
in stubborn cases of Bczema^ Paoriaaia, Sal^ RJEttfum, Iteh. 
Barbaras Itob, Bryaipelaa, Ivy Roiaoning, Riagworm, 
Herpea Zoater or Zotta^ etc Acne, Pimplea on Faoe 
are cleared up and the pores healed by HYOROZONE and 6LYC0Z0NC 
in a way that is 
magical. Try this 



treatment ; results 
will please you. 

Pall method of treat, 
ment In my book. 
•♦ The Thenpeuticml 
Applications of Hy- 
drocone and Glyco- 
aone * ' ; Serenteenth 
Edition, 339 pagvs. 
Sent free to physlc^ns 
00 tequesc. 



Prepared only by 




danist and r.radnate of the ** Ecole Ccntrale det 
Arts et Manu&ctures de Paris " (France) 

07-50 Prince Street, New York 



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180 



Original Articles. 



undue scrotal elongation, so habitu- 
ally inclined by a like condition of the 
vessels of the testis ; hence the substi- 
tution must be observed. 

Upon adoption of the regular sus- 
pensory the administration of the 
Poison extracts was found most excel- 
lent and beneficial to the genito- 
urinary organs and the entire system 
as well. 

Suffice it to say that in a very short 
time indeed nature kindly restored the 
testis to its former condition, and 
furnished an organ as solid as any 
man coxxld possibly desire. 

But right here allow me to warn ad- 
visedly to the effect that in the treat- 
ment throughout of these organs 
great care and gentleness must be ob- 
served at the preliminary, especially 
so in the milking method and tying 
process, or nature will ^^cry out and 
kickj)ack,^^ To discourage an inflam- 
matory condition becomes the first 
requisite, ever remembering that these 
organs are the most sensitory of the 
entire human anatomy. 

In a correspondence with a majority 
of specialists of large experience in 
treating genito-urinary disease, it was 
learned that compression of the scro- 
tum and testis and electrical appli- 
ances were indulged ; also* astringent 
lotions and ointments applied ; but no 
reversion and elevation of the organs 
were resorted to, nor milking method 
followed, hence the failure. 

Now let us return to the duty of the 
physician. 

The family medico is held in as 
much reverence as the family minis- 
ter; in fact, more so, because the very 
life of its members depend wholly 
upon him, in a sanitary point of view; 
hence when that physician observes 
any facial indication of **genital- 
urinary abuse^' upon the part of their 
sons, it becomes his most sacred duty 
not only to so inform the parents 
(particularly the mother), and advise 
medical treatment at once, knowing 
well, as he does, the total ignorance 



of the parents of the abuse; and, as- 
well, warn those sons of the serious- 
consequences as a result. 

With this most damnable deteriora- 
tion of the human race, can we wonder 
that infantile mortality assumes such 
alarming proportions? 

To say the least, the reformation of 
this most serious malady lies within 
the physician's power. Will he do itf 

The adoption of this criminal prac- 
tice upon the part of the younger ele- 
ment is not so much due to voluntary 
option, but is, as a general rule, ini- 
tiated through the teachings of older 
confederates, many being gi'own to 
maturity — a fact indisputable. 

Happy the day for the restoration 
of the mass of the male sex of the 
human family if a two-thirds number 
of medicos now in general practice 
would throw off the yoke of prejudice 
and pursue a special course in genital- 
urinary lesions. 

svblaminb in the treatment of 
syphilis. 

By M. Fkiedlandbb, Berlin, Germany. 

Though the general results of the 
mercurial treatment in syphilis are 
satisfactory enough, the forms in 
which -the drug could hitherto be in- 
troduced into the syst^ii left much to 
be desired. The inunction of the oint- 
ment is unscientific ; we have no means 
of telling how much of the drug is 
absorbed and how much is taken up 
by the underclothing. Indeed, it is 
now a matter of debate whether the 
effects of this method are not ascrib- 
able to the inhalation of volatilized 
mercury during the process. There is 
almost the same uncertainty when the 
mercury is administered internally or 
by baths. 

Subcutaneous or intramuscular in- 
jection is the only scientifically unim- 
peachable method of administration, 
but, unfortunately, all mercurial prep- 
arations hitherto employed in this way- 
have serious drawbacks. Corrosive 
sublimate energetically coagulates the 



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A WISE PRECAUTION 

ON THE PART OF THE 

FRESCRIBINa PHYSICIAN 

When writing a prescription for 

Eux. Salicylic Comp. 

Would be to carefully specify 

Warner & Co. 

The original and wonderfully effective remedy, indicated in 

RHEUMATISM 

and analogous disorders. 

The imitations and substitutes are the cause of failures and 
injure the reputation of the prescriber and the genuine product. 
There is no failure when the ''Warner" product is used. 

Literature on request. 

WM. R. WARNER & CO. Philadelphia 

BRANCHES: NEW YORK, CHICAGO, NEW ORLEANS, LONOON. 



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182 



Therapeutic Suggestions. 



tissue albumin, causing hard infiltra- 
tion and severe pain. The other sol- 
uble mercurial salts either contain too 
small an amount of the metal or are 
not sufficiently soluble. The insoluble 
salts have the advantage of requiring 
less frequent administration, but they 
cause severe pain, and it is not pos- 
sible to remove any portion of the 
drug should the patient unexpectedly 
show signs of mercurial intoxication. 
The occasional deaths due to their 
employment hardly incite to their 
more general use. 

Sublamine, mercurys ulphate ethyl- 
enediamine, however, I found to be 
extremely soluble and not to coagu- 
late albuminous solutions. The suc- 
cess of laboratory experiments made 
in this direction induced me to try it 
clinically. 

Fifteen syphilitica were treated with 
3.4 per cent, sublamine solutions, some 
'280 injections being given altogether. 
Some of the patients had fresh chan- 
cres; others had papular, tubercular 
and ulcerative * secondary syphilo- 
derms, and the rest had syphilitic af- 
fections of the mouth, tongue and 
larynx. The action of sublamine was 



exactly the same as that of sublimate. 
Primary indurations softened and 
healed, papular and tubercular syph- 
ilides retrogressed, and the mucous 
patches and ulcers of the mouth dis- 
appeared. 

But the reaction at the site of in- 
jection was in every case far less 
marked. All the injections were made 
into the gluteal muscles. Indurations 
did indeed occur, but they were smaller 
and softer than those caused by sub- 
limate, and disappeared more quickly* 
It was also evident that the pain was 
very much less. To eliminate the pos- 
sibility of bias on the part of the ex- 
perimenter, two patients were given 
(without their knowledge) sublimate 
injections in the midst of their subla- 
mine treatment, and they both com- 
plained at the next consultation of the 
especial pain of their last injection. 
Unpleasant by-effects were never ob- 
served. 

We therefore possess in sublamine 
an anti-syphilitic that is readily sol- 
uble, does not destroy the injection- 
needle so rapidly, and, while as suf- 
ficient as sublimate, causes less indu- 
ration and pain. 



THERAPEUTIC SUGGESTIONS. 



In the treatment of catarrhal pyeli- 
tis and the almost inevitably conse- 
quent cystitis, Lithiated Hydrangea 
(Lambert) in teaspoonful doses gives 
the most satisfactory results. 

_— —- -^ \ 

In dropsical conditions the first in- 
dication is for the removal of the fluid ; 
the second, removal of the cause. It 
is not always easy to fulfill either of 
these indications. Anasarcin possesses 
the therapeutic properties to fulfill 
both in a greater degree than any other 
combination of drugs. It stimulates 
absorption of the effused fluid, equalizes 
the circulation and restores the phys- 
iological action of the organs. 



Obstinate cases of urticaria, lichen 
and psoriasis associated with the uric 
acid diatheses respond promptly to 
teaspoonful doses of Uriseptin four 
times a day. 

Its good effect in these cases is due 
to its action as a solvent of uric acid, 
as a diuretic, gentle diaphoretic and 
metabolic stimulant. 



TiiYRADEN AND Thyroidin . — Thyra- 
den is a lactose trituration of the dried 
extract of thyroid gland, 1 part of 
which represents 2 parts of the fresh 
gland. The preparation has an agree- 
able odor and taste, is reported to be 
non-poisonous, free from ptomaines, of 



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DO NOT FORGET 

the importance of a remedy 

that pacifies the irritable stomach 

and intestines. This attribute of 

GRAY'S—TONIC 



COMP. 



makes It the most valuable 
Summer Tonic and reconstructive 
in malnutrition, nervous exhaustion 
and general debility. 

THE PURDUE FREDERICK CO. 

No. IS Murray Street, New York 



k , 



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Therapeutic Suggestions. 



uniform action, without untoward by- 
effects ih proper doses, and to repre- 
sent active constituents of the thyroid 
in the least changed, yet permanent 
form. 1 gm. of thyraden represents 
0.7 milligram of iodine. Thyraden 
has been employed with good results 
in myxedema, cachexy, cretinism, thy- 
reopriva, struma, rachitis, adiposity, 
psoriasis, lupus, leprosy, diabetes, etc. 
The dose for adults is 2 to 4 grn. three 
times a day, gradually increased in ex- 
ceptional cases up to 8 grn., best taken 
in tablets ; children receive one-quarter 
to one-half of these quantities. Ex- 
cessive doses produce weakness of the 
limbs, heaviness of the head, palpita- 
. tion and insomnia. 

Thyroidin is the simple dried thyroid 
gland of sheep, 1 part of which repre- 
sents 6 parts of fresh gland ; it is thus 
three times as powerful as thyraden, 
and is accordingly given in one-third 
the doses of the latter. Its indica- 
tions and uses are identical with those 
of thyraden. 

Pain and Its Eemedy. — (By J. D. 
Albright, M. D., Philadelphia, Pa.)— 
. . . Believing that the bar in the way 
of the profession, in the use of opium, 
is its tendency to evil after-effects, and 
the harum-scarum idea that a little opi- 
um will induce the habit, and these 
terrible concomitants (?) I wish to call 
their attention to a preparation that I 
have long been using, and have not yet 
seen one case in which the habit was 
formed, nor ever had any complaint as 
to evil after-effects. This remedy is 
papine, a preparation of opium from 
which the narcotic and convulsive ele- 
ments have been removed, rendering it 
a safe remedy for children, as well as 
for those of mature age. . . Up to a 
year ago I always gave chlorodyne tab- 
lets and viburnum for after-pains. 
Then I came across a case that refused 
to yield to them in the time I was ac- 
customed to have them do so, and I 
concluded to try papine. Its results, 
to make the story short, were such 



that I now never giveanytlung else for 
after-pains, and they yield in aboi^t 
half the time that was required with 
the above named remedies. — Medical 
Summary. 



Weak tissues are a prey to infective 
micro-organisms. By proper nutrition 
the system is enabled to defend itself 
against disease. In incipient tubercu- 
losis three things are necessary : Out- 
of-door life, nutritious diet and Hagee's 
cordial of cod-liver oil comp. The 
latter alone is tonic, nutritive, recon- 
structive, pleasant to take and readily 
assimilated by the weakest stomach. 



Colorado Springs, Col., ) 
July 13, 1900. 5 
MoR. Merz Capsule Co.: 

Dear Sir: — I am glad to say that 
the santal compound furnished me by 
request from your house has proved 
itself excellent in two severe cases of 
gonorrhoea and one of cystitis. I don't 
know of any other preparation so near 
being a specific in prostatic troubles- 
as the Merz santal co« 

Yours truly. Dr. C. B. C. 



Disease and dirt are the demoniac 
twins of ignorance. Cleanliness is in- 
deed godliness. Mucous membranes 
inflamed and throwing forth unclean 
discharges should be flushed with pure 
warm water containing an alkaline, 
soothing, healing germicide. We have 
such in Tyree's antiseptic powder, and 
this can safely be commended to the 
public by physicians. Catarrhal dis- 
turbances, no matter whether located 
in the throat, nose, genito-urinary 
equipment or rectum, can be promptly 
relieved by using the Tyree's anti- 
septic powder as directed on the box. 



Neurilla in Epilepsy. — A case of 
a boy twelve years old, nervous tem- 
perament, who appeared inclined ta 
epileptic attacks. I employed neurilla. 
There was a great improvement from 
the use of this valuable prescription^ 



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il AN AS ARC IN 

(Oxydendron-Sambucus-Scilla Compound.) 

ii A SPECIFIC FOR DROPSIES 



Doctor:— 

If you know a thing to be a fact, it is not wrong or 
unethical to say so. Neither does it smack of quackery or 
Charlatanism and should not shock the sensibilities of any, 
however refined, cultured or zealous of medical ethics for us 
to claim that ANASARCIN is a specific in dropsies, when 
clinical experience has demonstrated such to be a fact. If 
quinine is a specific in malaria, much more is ANASARCIN 
in dropsies resulting from disease of the heart, liver or 
kidneys, because that a trial of it in hundreds, yea, thousands 
of cases has not resulted in a failure known to us where 
directions have been followed. 

Besides being a specific for dropsies, it is a permanent 
cure in the conditions mentioned when begun early and 
continued a sufficient length of time, i, e,^ until the diseased 
organs regain normal function. ANASARCIN is composed of 
the active principles of Oxydendron Arboreum, Sambucns and 
Urginea Scilla, and is sold exclusively to physicians or 
druggists for physicians. Trial box free with literature and 
testimonials furnished physicians on application. 



A D DRESS 



The Anasarcin Chemical Company 

WINCHESTER, TENN.. U. S. A. 



LONDON AQBNTS- 



Tbos. Christy A Co., 4*10 '12 Old Swan Lane, Upper Thames St, B. C. 




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186 



New Publications. 



and X ani now using same in my prac- 
tice regularly. 

William Richardson, M. D. 
North Londonderry, N. H. 



Pneumonia is prevalent throughout 
the United States, especially during 
the summer months. It attacks old 
and young alike, and occurs more fre- 
quently in cities than in the country. 
Confine patients in a dry, sunny, well- 
qtired room, temperature 70°; food 
should be liquid, viz., milk, broth 
and meat juices, and given at stated 
intervals in small quantities. When 
nervous symptoms first appear begin 



the use of Daniel's cone. tr. passiflora 
incarnata, in small doses. It is safer 
and more effective than morphine or 
the bromides. 



Colorado in Summer. — Colorado ia 
summer is the most delightful place in 
the country. The health and pleasure 
resorts of this wonderful state are best 
reached by the Colorado & Soutlverp 
Railway, which issues an elegant book 
"Picturesque Colorado," a copy of 
which may be had by enclosing three 
cents in postage to T. E. Fisher, G. P* 
A., Denver Colo. 



NEW PUBLICATION'S. 



A 8T8TEM OF Phtsioloqic Thibapeutics. By Solo- 
mon SoLis Cohen, A. M., M. D., Senior AsslstaQt 
Professor of ClinicAl Medidne in Jefferson Medical 
College. Volume V. Prophylaxis, Personal Hygiene, 
Civic Hygiene, Care of the Sick. By Joseph McFar- 
land, M.D.; HenryLeffman, M. D.; Albert Ahrams, 
A. M., M. D., and W. Wavne Babcock, M. D. Illus- 
trated. Published by P. Blakiston's Son & Co., 1012 
Walnut street, Philadelphia, Pa. 1903. 

This important volume of the above 
System of Physiologic Therapeutics is 
a valuable contribution to medical 
science. The necessity of a more ex- 
haustive study of prophylaxis and hy- 
giene, and a more general application 
of these auxiliary forces in the subju- 
gation of disease, is recognized by 
every progressive physician. The mere 
recognition of disease and familiarity 
with the therapeutic properties of 
drugs in its treatment are inadequate 



equipments for a successful practi- 
tioner of medicine. He should be 
thoroughly acquainted with the intrin- 
sic and extrinsic causes of disease as 
well as all its channels of transmission. 
He should be prepared to defend the 
human organism against its first ap- 
proaches. The prevention of disease 
is paramount. It simplifies the work 
of the physician and saves him many a 
hard battle. This book in a bi^oad- 
gauged spirit outlines the course he 
should pursue. Part 1st discusses the 
origin and prevention of disease* Part 
2d takes up civic hygiene. Part 3d 
treats of domestic and personal hy- 
giene, nursing and care of the sick 
room. 



INDEX. 



Original Abticucs. • page. 

Median Perineal Urethrotomy and Cystotomy 
Through a Superficial Transverse Incision, After 
Celsus. By Walter G. Spencer, F. R. C. S., M. S., 
M.B 14:1 

Pemphigus Vegetans. By L. P. Hamburger, M. D.148 

Spermatorrhoea as a Disease Sui Generis. By J. A. 
I)eArmond, M. D 164 

Prostitution in Japan. By Albert S. Ashmead, 
M.D 167 



Original Articles. page. 

Prostatic Surgery— Historical and Experimental. 

By Benjamin Merrill Ricketts, Ph. B.. M. D 168^ 

Syphilis of the Nervous System. By Frank E. 

Coulter, M. D 170- 

A Simple Remedy for the Cure of Varicocele. By 

Frank A. Brewer, Sr., M. D... 17ft 

Sublamine in the Treatment of Syphilis. By M. 

Friedlander ISO 

Therapeutic Suggestions 182 

New Publications 18ft 



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A •l-MONTHLV MAQAZINK DCVOTKD TO THK OONSIDKflATION OF CUTANEOUS MKDICINK 
VKMKIIffAL MSffASffS AND OCNITO-URINAIIY •UftOKIIY. 



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AMERICAN JOURNAL OF DERMATOLOGY. 
Fidelity Boildingr. St. Louis, Mo., U. S. A. 



Vol. VII. 



SEPTEMBER, 1903. 



No. 6. 



DBRMATOLOQiCAL TBACMNQ IN 
MADRID. 

Bt a. Rato«li, M. D., Olneinaati, Ohio. 

The International Congress of Med- 
icine in Madrid has showti to the med- 
ical world some interesting work on 
dermatology, with which we English- 
speaking people were not well ac- 
qaainted. It has, furthermore, brought 
us together with colleagues of the 
greatest learning, who are constantly 
working for the advance of our sci- 
ence. 

The city of Madrid has a large hos- 
pital called St. John de Dios, which is 
solely for diseases of the skin. It is 
situated somewhat on the outskirts of 
the city on a magnificent spot, with 
open air and plenty of light. It is the 
pavilion system, and is built in the 
middle of magnificent gardens. I 
must thank Dr. Juan Azua, professor of 
dermatology and syphilology of the 
Facultad de Medicina of Madrid, who 



took Dr. von Duering and myself 
through his wards for a special visit 
to the hospital. The wards are not 
very large ; they contain an average of 
from twenty to twenty-four cots, and 
are clean and well kept. The Sisters 
of Charity take care of the patients, as 
they lack an institution for training 
nurses. The hospital is built in pa- 
vilions, making twenty-five in number, 
surrounded by elegant gardens. 

In every ward were interesting 
cases, but the purpose of Dr. Azua 
was to call our attention to a case of 
multiple cutaneous necrobiosis, re- 
sulting from capillary stasis, which 
had been the subject of his communi- 
cation to the congress. 

His patient was a man twenty-seven 
years of age, the whole surface of 
whose skin was of a bluish brown 
color, giving it a marbled ap- 
pearance, and which was uniformly 
extended from the elbows to the 



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hands and from the knees to the feet, 
giving an intense cyanotic discolora- 
tion. The veins of both extremities 
were greatly turgid and distended. 
The ears and lips of the patient were 
also bluish and somewhat cyanotic. 
The interesting point was that when 
the patient was lying down in a hori- 
zontal position his feet and arms re- 
turned / to a normal color, being 
relieved from the higher pressure of 
the blood. Azua called attentiop to 
the condition of inertness of the veins, 
which loob;ed like tubes, without any 
resistance. 

In the. parts of the skin mostly sub- 
ject to pressure the patient showed a 
great number of necrotic spots. The 
necrosis begins ordinarily on the 
places where the capillary stasis is 
most marked, in the form of a brown- 
ish spot, without any subjective dis- 
turbance, only marked by diminished 
sensibility. The color becomes black 
and the necrotic skin gets dry, and 
the surrounding skin, cyanotic and blu- 
ish from the venous stasis, becomes 
swollen and edematous. The necrotic 
skin in a period of time, varying from 
three to four months, is detached in 
the form of dry eschara, surrounded 
by thick, dry scales, leaving a cicatrix 
the size of the eschara. On the legs, 
however, the stasis being more intense 
and the caudation more abundant, it 
causes the gangrenous spot to be of 
the humid type, and sloughs off sooner, 
leaving an open sore. 

Between the superficial necrotic 
points others are formed of a much 
deeper and severer nature. In this 
case the gangrenous process affects 
the skin and the subcutaneous tissues. 
The spot is dark brown, hard to the 
touch, the epidermis is detached by 
blisters containing brownish serum, 
and soon the whole place is changed 
into a deep ulcer. 

The resulting ulcerations after the 
sloughing of the necrotic tissues are 
of a healthy, red color, the granula- 



tions are readily formed and heal up, 
leaving a superficial scar. 

Azua called our attention to the 
normal temperature of the patient, 
which is between 36.2° and 37° C, 
showing a diminution of nearly one 
degree. Hands and feet are con- 
stantly cold, and the palms and soles, 
are always moist with abundant per- 
spiration. 

The mucous membranes were per- 
fectly normal. 

The examination of the blood showed 
it to be at the normal standard, and 
the urine was in perfect condition. 

The pulse of the patient was some- 
what weak and rapid; when lying 
down in bed it reached from 78 to 90, 
and after a little exercise went to 120 
and 130. The heart seemed somewhat 
dilated in the left auricle. The con- 
dition of the stasis of the skin is 
claimed to have been of congenital or- 
igin, and there has been no acquired 
specific infection in the patient. 

Azua explained the symptoms of 
palpitation and some dyspnea as the 
result of difficult capillary circulation 
rather than the effect of a central cir- 
culatory trouble. 

His conclusion was that the disease 
consists in ^^ primary muitiple necrobi- 
QsiSy from capillary stasis.^ ^ The dis- 
ease is congenital and its cause seems 
to be an embryogenic malformation of 
the tissues forming the walls of the 
blood vessels, especially of the capil- 
laries* 

The accurate description of the dis- 
ease illustrated with numerous plates, 
the exact study of all its symptoms, 
of its etiological factors, etc., made 
such an impression on the members of 
the congress that they decided to call 
this disease by the name of disease 
Azua. 

One of the pavilions of the hospital 
is occupied by the dermatological mu- 
seum. The institution has been in ex- 
istence for nearly thirty years and is 
in connection with the dermatological 



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laboratory. It was beffun by the ef- 
forts of the distinguished dermatolo* 
gists, Jose Eagenio Olavide, Eus^bio 
Castelo y Serra, professors in the 
same hospital. 

Both enriched the museum with a 
large number of moulages, represent- 
ing exactly the most important cases 
during their service. Thi^s work was 
enlarged with the collection of Drs. 
Perez Gallego, Pedro Martinez, 
Mossas San Juan and Manuel Ramos, 
who had been professors in the same 
hospital. 

At present the pathological labora- 
tory and the museum department is in 
the hands of the professors of the hos- 
pital, Manuel Sans Bombin, Francisco 
Cerezo, Fernando Castelo, Matias 
Martin Romero and Juan Azua. 

The hospital is under the direction 
and supervision of the Diputacion 
Provincial^ together with the general 
hospital. They are now building a 
new pavilion for the museum, leaving 
it independent of the laboratory. 

Every pathological piece in the mu- 
seum is accompanied by its clinical 
history, and the doctors of the hos- 
pital give a course of lectures to the 
students, taking advantage of so mag- 
nificent a collection. 

The rooms of the museum have large 
shelves, of which thirty-three are oc- 
cupied by dermatological models. 
There is an interesting collection of 
models representing chancroids of the 
different regions with resulting .bubos. 
Vegetations in the different forms of 
mucous membranes of the genitals. A 
complete collection of models repre- 
sent the syphilitic initial lesion in all 
its varieties in the genitals, and another 
represents cases of extragenital chan- 
cres ; among them is worthy of note a 
hard chancre of the tragus of the 
auricula. 

A very good collection of models 
represents the mucous patches in all 
their varieties, and, in the same way, 
the different eruptions of the second- 
ary and tertiary period of syphilis. 



Case No. 15 is occupied by models 
representing leprosy in all its periods 
and varieties, beginning with cases 
showing simple discoloration, lepra 
alba, to all its varieties of lepra tuber- 
osa and ulcerosa. 

Case No. 16 contains a large collec- 
tion of cases of lupus and other scrof- 
ulous eruptions, mostly from the 
service of Azua and Olavide. This 
collection is continued with many mod- 
els of rhinoscleroma and of tubercu- 
losis verrucosa and of ulcerated jscrof- 
ulodermata. 

There also deserves mention a collec- 
tion of magnificent models represent- 
ing eczema in all its varieties and 
stages, and also a collection of cases of 
ichthyosis.. 

Very interesting and faithful repro- 
ductions of erythema caused by pella- 
gra attracted my attention, as' they 
showed the different stages of this 
disease. One entire case is filled with 
models representing forming of tri- 
cophities and cases of favus of the 
scalp and of the body. Neoplasmata 
of benign and of malignant nature 
have interesting specimens. 

Medical students and physicians are 
allowed to enter and study in the mu- 
seum at certain hours. The work of 
the moulages is done by the artist, 
Henry Zofio, who teaches others the 
way to prepare the composition and 
give the colors to the models. 

The expenses are all charged to the 
Diputacion Provincial^ which encour- 
ages the officers of the hospital in this 
interesting and useful work. 

I must say, not without regret, that 
the teaching of dermatology in Madrid 
is farther advanced, has better oppor- 
tunities and receives much more en- 
couragement than among us. 

W 
In alopecia seborrhoica, where there 
are signs of con(imencing inflammation 
of the scalp, a lotion of glycerini plumbi 
subacetat ji, liq. carb. detergens, 
gss, aqua rosse ad, Jviii, is often one 
of the best applications. 



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HVOROCBLB^ITS CURB BY A SIMPLB 
OPBRATION. 

Bt B. F. liicoBiSH, M. D., Barbados. West Indies. 

The following metbod of operative 
treatment for hydrocele is so easy of 
performance, so simple in explanation 
and so trifling as regards its immedi- 
ate aftei'-effects when done aseptically, 
entaihng no confinement to bed, that 
I place it before the profession, confi- 
dent that the above points in its favor 
will render it worthy of general recog- 
nation and adoption. 

It is thus done : Pass a very narrow- 
bladed knife through both outer and 
inner sacs of the hydrocele and slit the 
inner one — tunica vaginales - for about 
half inch, withdraw the knife, and if 
the hydrocele is a large one, allow about 
half of the fluid to pass out; if the 
hydrocele is small, allow none; then 
close the outer wound. The result is 
that the remaining fluid gradually finds 
itself in the loose connective tissue be- 
tween the sacs, and is gradually ab- 
sorbed. A cure is thus effected. The 
fluid passing slowly over the edges of 
the inner wound prevents its closure ; 
hence, a permanent passage from the 
inner sac to the loose connective tissue 
is left by which all subsequent secre- 
tion is removed. This is also the ex- 
planation of cure where a portion of 
the sac is excised. As this latter is, 
however, a far more formidable opera- 
tion, the points in favor of mine, as 
given above, must turn the scale 
strongly in its favor. This modus 
operandi of cure also explains that of 
iridectomy for glaucoma ; and just as 
my operation is to be preferred to ex- 
cision of the sac in hydrocele, so, I 
believe, a simple incision at the angle 
of the anterior chamber, enlarged in- 
ternally, will take the place of iridec- 
tomy ; for as both diseases are sequels 
of inflammation — Prof. Bossa's recent 
experiments going to prove this as 
regards glaucoma — we must see that 
a like result will follow similar opera- 
tions. Glaucoma then is simply hydro- 



cele of the eye. The idea is to secure 
a permanent exit for the accumulated 
fluid and for subsequent secretions, 
so that there may be a gradual absorp- 
tion of the effusion, the sequence of 
the inflammation. 

PRQSmVTIOS IN JAPAN. 

BT SoLOicoN CulibOSmk MABtiN, Jb., H. D., St. Louis. 

CHAPTER I. 

In order to better understand the 
peculiar features of Japanese prosti- 
tution, it is necessary to get a glimpse 
of the social, religious and gov^n- 
mental influences which have been such 
potent faotors in molding Japanese 
character. All of the vices of a na- 
tion bear more or less the impress of 
national custom, or the label of popu- 
lar fashion. If a certain people are 
noted for cleanliness and gentle be- 
havior, their worst vices will more or 
less partake of these characteristics. 

Society in Japan differs widely from 
that of all western nations. The peo- 
ple are not divided into a large variety 
of classes on the lines of culture, 
wealth, lineage, commercial status or 
religion, as in Europe and America^ 
There is no aristocracy outside of ofli- 
cial circles, and even this somewhat 
exclusive class, apart from the high 
officials of the government, does not re- 
ceive any special recognition from the 
common people. 

The Japanese are essentially demo- 
cratic in all their affiliations, with the 
single exception of their implicit and 
loyal submission to their government 
however arbitrary it may be. To- 
wards foreigners they are courteous, 
frank and obli|ring in their behavior, 
but never confidential in matters that 
pertain to their private affairs. 

Males treat females with a certain 
degree of consideration and kindness, 
but never regard them as equals. The 
women, accustomed to being regarded 
as inferiors, are rarely self-asserting or 
willful, and are not inclined to take 
the initiative in anything outside of 



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their domestic duties. They do not 
receive any special homage from the 
men, and while they seem to be satisfied 
with their condition^ it is not natural 
that they should be inclined to hero* 
worship ; besides, the women are bet- 
ter looking than the men, and this 
may also . have something to do with 
their apparent lack of enthusiasm for 
the opposite sex. 

, The marriage relation is also not 
calculated to make life what it should 
be for the women. Marriage in Japan 
is not a matter which exclusively con- 
cerns the parties to the cgntract. It 
is usually arranged by the two families, 
regardless of the wishes of eith^ 
party most deeply concerned. This 
is especiaUy true with regard to the 
girl, who is regarded as a non-entity. 
While marriage is a legal contract in 
Japan, as long as the man and woman 
live under it, according to Japanese 
law, it can be annulled at any time by 
the will of the married couple. Under 
the existing laws marriage in Japan 
cannot be considered a sacred or stable 
institution, and consequently one of 
the great barriers to immorality is 
greatly weakened. The Japanese are 
not any more immoral than other more 
cultured nations, and perhaps not so 
much so as some of them. This is 
very much to their credit, as their 
religion, if they have any (which 
is doubtful, according to European 
ideals), their laws and social usages 
are not calculated to put a premium 
on virtue. They are naturally a clean, 
temperate and orderly people, and we 
can readily understand as a race they 
would not tolerate any departure from 
these characteristics in the sexual rela- 
tions of any class of their people. 
Whilst the Japanese cannot be called 
a religious or devotional people, they 
are not irreligious. They are so free 
from bigotry that they tolerate in 
their peculiar belief an admixture of 
Shintoism, Buddhism, Confucianism 
and Christianity, Shinto, in a certain 
sense, is their national religion, but 



this does not teach or enforce any 
system of morals; it i? simply a blend- 
iqg of mythology, nature and ancestor- 
worship. It has no moral code, and 
reveals nothing of a future life. Ac- 
cording to this doctrine, there is no 
heaven or hell, but occasional mtima- 
tiuns of a dim, misty hades. Bud- 
dhism is a kind of religious ceremonial 
with altars, candles, incense, rosaries, 
images and processions, with gods and 
goddesses, but no supreme God or Crea- 
tor of the Universe. It stands for 
knowledge and seff-perfectionmept aa 
the means of transference into Nirv- 
ana, which is supposed to be a state of 
S4q)reme beatitude or annihilation. 
Confucianism is a system of philoso- 
phy which teaches ethics, morals and 
unconditional submission to govern- 
ment. There certainly is nothing in 
this doctrine repugnant to the adminis- 
trators of the law, and, therefore, it 
enjoys the official recognition of the 
Mikado and his court. 

In addition to the above doctrines 
which have been so harmoniously ac- 
cepted and blended in Japan, the 
modern spirit of progressiveness has 
adopted some of the more assimilable 
features of Christianity. It is, how- 
ever, a curious fact that while Japan 
has, by the absorption of modern 
ideas, in the last thirty years, trans- 
formed itself from an isolated, insig- 
nificant nation, into a world-power, it 
still clings to many of the absurd 
traditions of prehistoric times. 



CHAPTER II. 

YOSHIWARA. 

Up to 1596 prostitution in Yedo 
(now Tokyo) was an unlicensed and 
unregulated institution. It had no 
fixed place of abode, and as a result as- 
signation houses and brothels were 
distributed in groups or singly to suit 
the convenience of inmates and pa- 
trons. There were, however, three 
quarters in close proximity to eaeh 
other, where about fifty of these 



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houses were established — Eoji-macbi, 
Eamakura-gashi and Yangi-machi. At 
this time Yedo was a small, insignifi- 
cant place, but having been selected 
for the seat of the Takugawa govern- 
ment, it was rapidly increased in popu- 
lation by the influx of adventurers, 
speculators and parasites of the gov- 
ernment from every part of the coun- 
try. Among the immense hordes of 
newcomers, as might be expected, 
were many of that disreputable class 
who either enter the ranks of prosti- 
tution or hover around its outskirts 
for the purpose of appropriating the 
proceeds of the infamous trade. 

The brothel house business was not 
in a languishing state while other lines 
of trade flourished. The number of 
disreputable dens rapidlj^ increased 
until, with the growth of legitimate 
business, there was little room left for 
the shameful industry, and the gov- 
ernment began to adopt restrictive 
measures which finally culminated in 
the segregation of this class and their 
subjection to the dominion of law and 
order. 

The construction of the Castle of 
Yedo, and the extension of municipal 
improvements, soon encroached upon 
the territory occupied by houses of 
ill-fame and their removal to other lo- 
calities followed. The brothel-keep- 
ers, in their trouble, requested the 
government to allow them to establish 
a courtesan quarter. Their petition 
did not receive any attention until 
in 1612 a persevering reformer by the 
name of Shoji Jinyemon, who was an 
interested member of the "profes- 
sion," made such a powerful plea to 
the government for the assignment of 
prostitution to a special quarter of the 
city, that after five years' deliberation 
the petition, with certain qualifica- 
tions, was granted. His plea to the 
government was couched in the follow- 
ing language: 

In Kyota and in Suruga, and also in all 
other thickly populated and busy places (to 
the number of more than twenty) there have 



been established, in accordance with ancient 
custom and precedent, regular licensed K^eisei- 
machi, whereas, in Yedo, which is growing 
busier and more popnlous day by day, there is 
no fixed Yujo-machi. In consequence of this 
state of affairs housea of ill-fame abound in 
every part of the city, being scattered hither 
and thither in all directions. This, for nu- 
merous reasons, is detrimental to public mo- 
rality and ^welfare, etc., etc. 

(1) As matters stand at present, when a 
person visits a brothel he may hire and dis- 
port himself with Yujo (filles de joie) to his 
heart's content, give himself up to pleasure 
and licentiousness to the extent of being un- 
able to discriminate as to his position and 
means and the neglect of his occupation or 
business. He may frequent a brothel for days 
on end, giving himself up to lust and revel, but 
so long as his money holds but the keeper of 
the house will continue to entertain him as a 
guest. As a natural consequence, this leads 
to the neglect of duty towards masters, defal- 
cations, theft, etc., and even then the keepers 
of the brothels will allow the guilty ^ests to 
remain in their<houses as long as their money 
lasts. If brothels were all collected into one 
place a check would be put to these evils, as, 
by means of investigation and inquiry, a 
longer stay than twenty-four hours could be 
prohibited and such prohibition enforced. 

(2) Although it is forbidden by law to kid- 
nap children, yet, even in this city, the prac- 
tice of kidnapping female children and entic- 
ing girls away from their homes under false pre- 
tenses is being resorted to by certain vicious and 
unprincipled rascals. It is a positive fact that 
some evil-minded persons niake it a regular 
profession to take in the daughters of poor 
people under the pretext of adopting them aa 
their own children, but when the girls grow up 
they are sent out to service as concubines or 
prostitutes, and it is in this manner the indi- 
viduals who have adopted them reap a golden 
harvest. Perhaps it is this class of abandoned 
rascals that even dare to kidnap other peo- 
ple's children. It is said to be a fact that there 
are brothel-keepers who engage women, know- 
ing perfectly well that they are the adopted 
chil<£ren of the parties who wish to sell the 
girls into prostitution. If the prostitute 
houses be all collected into one place, strict 
enquiries will be made as to the matter of kid- 
napping, and as to the engagement of adopted 
children, and should any cases occur in which 
such reprehensible acts are attempted, in- 
formation will be immediately given to the 
authorities. 

(3) Although the condition of the country 
is peaceful, yet it is not long since the subju- 
gation of Mino province was accomplished, 
and consequently it may be that there are 
many ronin prowling about seeking for an op- > 
portunity to work mischief. These ruffians 
have, of course, no fixed place of abode and 
simply drift hither and thither, so it is impos- 
sible to ascertain their whereabouts in the ab- 
sence of properly instituted enquiries even 
although they may be staying in houses of ill- 



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fame for a considerable nnmber of days. If 
the authorities p^rant this petition and permit 
the concentration of the existing brothels in 
one regular place, the brothel-keepers will 
paj special attention to this matter and will 
canse searching enquiries to be made about 
persons who maj be found loafing in the pros- 
titute quarters, should they discover any sus- 
picious characters the^ will not fail to report 
the same to the authorities forthwith. 

It will be deemed a great favor if the ausust 
authorities will grant this petition in the full- 
ness of their magnanimous mercy. 

Shogi Jinyemon^ who, it seems, was 
not only a reformer, but ^ood politi- 
cian, succeeded in having himself ap- 
pointed director of the prostitute quar- 
ter, under the pledge of enforcing the 
following regulations : 

(1) The profession of brothel-keeping shall 
not be carried on in any place other than the 
regular prostitute quarter, and in future no 
request for the attendance of a courtesan at a 
place outside the limits of the enclosure shall 
be complied with. 

(2) No guest shall remain in a brothel for 
more than twenty-four hours. 

(Z) Prostitutes are forbidden to wear clothes 
wiui gold and silver embroidery on them; they 
are to wear ordinary dyed stuffs. 

(4) Brothels are not to be built of imposing 
appearance, and the inhabitants of prostitute 

Quarters shall discharge the same duties (as 
remen, etc.) as ordinary residents in other 
parts of Yedo city. 

(0) Proper enquiries shall be instituted into 
the person of any visitor to a brothel, no mat- 
ter whether he be gentleman or commoner, 
and in case any suspicious individual appears 
information shall be given to the Bugyo-sho 
(office of the city governor). 

The above instructions are to be strictly ob- 
served. (Date. ) Thb Bugyo. 

The site at Fukiya-Machi selected 
by the authorities for the founding of 
quarters for prostitutes was a low, 
level plot of ground embracing an area 
of about twelve acres (two square 
cho), which at this time was covered 
with weeds and reeds. The name, 
Yoshiwara, which literally means Plain 
of Reeds, was therefore adopted as a 
designation of the prostitute quarters, 
and afterwards came into general use 
in all the large cities of the empire as 
an appropriate name for this abomina- 
ble institution. The work of prepar- 
ing the ground and building houses 
commenced in 1617, and in less than a 



year ''business" was in full blast, 
although the quarters were not fully 
finished before the year of lt526. Aftei: 
all improvements had been completed 
for the comfort and convenience of 
this sporting community and the 
''business" had gone on smoothly for 
nearly forty years, the denizens re- 
garded this place as their permanent 
home; but in the year 1656 all of 
their calculations were rudely upset 
by an edict from the governor 
(Bugyo), directing the removal of all 
houses to another place, as this quar- 
ter was needed to meet the demands 
of more legitimate industries. Many 
efforts were made by the elders of the 
Yoshiwara to induce the governor to 
rescind his order, but their petitions 
were rejected, and they were com- 
pelled to accept from the authorities 
the grant of a plot of land in the 
neighborhood of the Nihon-dsutsumi, 
which was accompanied with the fol- 
lowing liberal terms ; 

(1) Hitherto the ground to be occupied has 
been limited to two square cho; in the new 
place these limits will be increased by 50 per 
cent., and extended to three cho by two cho 
(8x2). 

(2) Whereas, hitherto, the profession has 
been allowed to be carried on in the day- 
time only, in consideration of the quarter tie- 
ing moved to such a distant place it is, in 
future, permitted both day and night alike. 

(3) More than 200 Furo-ya (bath-houses), 
now existing in the city, shall be abolished. 

(4) In consideration of the Yoshiwara being 
removed to a distant place, its people shall 
hereafter be exempted from the duties of act- 
ing as guards against fire on the occasion of 
the festivals at Sannoand at Kanda, or as fircr 
men in time of conflagration, etc. 

(6 ) The sum of 10,500 ryo will be granted to 
assist the expenses of removal, at the rate of 
14 ryo per small room. 

In accordance with the conditions 
provided by the authorities for the 
new Yoshiwara (Shin- Yoshiwara) it 
will be seen the area of ground is in- 
creased from two square cho (nearly 
twelve acres) to three cho (nearly 
eighteen acres), and the ^'business'* is 
allowed to be carried on day and night, 
instead of the day-time only, as was 
formerly the rule. The bath-houses 



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(Furo-ya) were abolished, as they 
seriously interfered with the regular 
''business." Those bath-houses, like 
nearly all others from time immemo- 
rial, the world over, were merely se- 
cret or unlicensed brothels, conductr 
ing, under the guise of bathing, the 
abominable trade of prostitution. 

The munificent sum of 10,500 ryo 
($5,250) was allowed to assist in d^ 
fraying the expenses of removal. The 
managers of the Yoshiwara obtained 
this sum with also the indulgence of 
four months' time to effect the removal, 
but the great fire, called the ''Furi-sode 
Kwaji,*' on March 2, 1657, swept ov^r 
the city of Yedo before the specified 
time expired, destroying a large part 
of the city, and almost entirely wiping 
out of existence the Yoshiwara. This 
great disaster hastened the work of re- 
moval, and in a few weeks temporary 
shanties were prepared for the use of 
the prostitute class, on the site of the 
New Yoshiwara, until sufficient time 
was allowed for the erection of perma- 
nent buildings. The ••trade" was not 
seriously interrupted by the sudden 
change of locality. On the other hand, 
the circumstances attending the trans- 
ition were such as, in a great measuie, 
to cause a partial suspension of the 
rigid rules governing prostitution, 
which enabled brothel-keepers to mul- 
tiply their methods of robbing their 
patrons. The new Yoshiwara was 
beautifully laid out in a quadrilateral 
figure, or in the form of a parallelo- 
gram, with four streets — one passing 
through the center from the great 
gateway (0-mon), called Naka-nocho, 
and three, intersecting this at right 
angles, called Kyo-machi, Sumi-cho 
and Yedo-cho. The continuation of 
Sumi-cho to the right, on account of its 
large number of assignation houses 
(Ageya), was called Ageya-machi, or 
assignation house street. In 1668 the 
class of Jigoku( unlicensed prostitutes) 
became so numerous in the city of 
Yedo, and were plying their vocation 
so openly, that the authorities found 



it necessary to gather them into the 
Yoshiwara. As there was not room for 
over five hundred newcomers in the 
houses already built, and very little 
room for additional buildings in the 
Yoshiwara, additional ground in the 
rear of the existing brothels was se- 
cured and new quarters prepared for 
their accommodation. In the course 
of time the fashions of this • 'earthly 
paradise" required changes in the name 
and character of some of its establish- 
ments. Ageya, or assignation houses, 
were abolished, and Cha-ya (tea- 
houses) took their places. The name 
of assignation house became distaste- 
ful to both inmates apd patrons, and 
tea-house was substituted, because, 
probably, it was less suggestive of the 
real occupation of its inmates. 

The Japanese are a fastidious and 
orderly people, and this characteristic 
is witnessed in the conduct of the pros- 
titute class. There is a certain amount 
of order and decency even among pros- 
titutes in plying ^heir villainous trade. 
While these unxortimate females may 
really be divided into three classes, the 
Jijoku, or unlicenseavclass ; the Shogi, 
or licensed class, andvthe Geisha, or 
professional singers aM dancers, for 
the sake of an outwarcV. show of de- 
decency, these classes aiV artistically 
subdivided and **christeLVd" with a 
great variety of eupbonious^nd ethical 
titles expressive of the different forms 
in which they exercise their calling. 
As the members of these yifferent 
classes break away from thv\ usages 
which they are supposed to c^serve, 
their names are changed, and tl^y are 
re-classified, or relegated to the lowest 
rounds of the ladder. ProstitutW at 
best is an abominable evil, whicL can- 
not be defended from any stand^loint, 
but leaving out the moral aspect cf the 
question and placing it on grounjia to 
be viewed solely from an ethical, so- 
cial and sanitary standpoint, Japan, in 
dealing with it, in many respects, /is far 
in advance of some of her morel pre- 
tentious neighbors of western ci riliza- 



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tion. Prostitution in Japan has always 
been under rigid police surveillance. 
While the Japanese are the easiest 
people in the world to govern, the au- 
thorities do not neglect to devise stern 
laws for their government, and they 
are not lax in enforcing them. As a 
sample of the government's vigilance, 
I quote the following proclamation is- 
sued by the governor of Tokyo in 
1722: 

Whereas secret prostitution has been pro- 
hibited in the wards of this city, aiid whereas 
it appears that the practice has been car- 
ried on in an audacious manner, it is hereby 
ordered that henceforth secret prostitutes shall 
be treated as follows: 

(1) The person harboring secret prostitutes 
will be ordered to yield up to the government 
his ground lot, furniture, house and godown, 
and the woman offending shall herself have 
her furniture seized, and for the space of 100 
days shall be manacled with irons and com- 
mitted into the custody of the responsible par- 
ties of her ward, an officer being detailed oU 
to visit the house every other day to inspect 
the seal on her manacles. 

^2) The owner of pounds and houses in 
which secret prostitution takes place shall be 
held in the same penalties, even although he 
is not living on the premises, but only repre- 
sented by a care-taker. The care-taker snail 
have all his furniture seized, and shall be 
manacled for a period of 100 days, during 
which period he will be committed into the 
custody of the responsible parties in his ward, 
and every other day the bonds shall be exam- 
ined and the seals inspected. 

Three days after this date the appointed of- 
ficials and Yoshiwara authorities will proceed 
to search for persons carrying on illicit pros- 
titution, and if those persons are apprehended 
they will be dealt with as stnted above. 

Persons harboring: offenders may be pun- 
ished with banishment or death, and, more- 
over, the members of the ward who are re- 
sponsible for the parties may be likewise pun- 
ished, in accordance with the foregoing. Now, 
therefore, take notice, and let this be pub- 
lished throughout the city. 

Again, in 1876, the following order 
was promulgated, dated the 27th of 
January, and numbered 23, as fol- 
lows: 

Persons practicing secret prostitution and 
the keepers of secret houses used for that pur- 
pose, shall be punished as follows: 

Principul or Accessory: 

First offense — Fine not exceeding 10 yen or 
two and one-half months' imprisonment. 

Second offense — Fine not exceeding 20 yen 
or five months' imprisonment. 

Keeper of the house: 



First offense — Fine not exceeding 15 yen or 
three months' imprisonment. 

Second offense— Fine not exceeding 80 yen 
or six months' imprisonment. 



CHAPTER III. 

When ''business" in the Yoshiwara 
begins to fall away the brothel-keepers 
devise new methods of increasing their 
revenue. They invent new procedures 
and change the names of special call- 
ings according to the requirements of 
the situation. If they find that new * 
customers are timid about entering the 
various brothels, they appoint ushers 
to conduct them to such houses as they 
think will suit their tastes. To certain 
houses the duty of introducing guests 
is assigned. These establishments are 
called "Introducing Tea-houses'* (Hi- 
kiti-Jaya). The better class of these 
houses is located within the enclosure 
and is under the direct supervision of 
th^ authorities, but many houses of 
this character, less select and less ac- 
curately disciplined, are situated out- 
side the great Gate. There are in 
each of the better class of "Introduc- 
ing Tea-houses" (Hikiti-Jaya) within 
the Yoshiwara, three or four attract- 
ive girls, who arrange the introduction 
of guests to the inmates, to the satis- 
faction of their employers. One of 
these girls will take charge of the 
guest, ascertain his choice of brothel 
and courtesan, and will then conduct 
him to the desired place, arrange for 
suitable favors, and will wait upon 
him until the sake bottles have been 
several times emptied and replenished. 
When the refreshments are served and 
disposed of, to the satisfaction of the 
guest, the guide shows him his room, 
waits until his female friend arrives 
and then takes her departure. This 
waiting maid sees that all the wants of 
the guest are fully supplied until he is 
ready to leave, when an itemized bill, 
including her services, is presented 
and settled by the guest, who is pain- 
fully surprised to find that the bill al- 
most exactly tallied with the contents 



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of his pocket-book. The correct esti- 
mate of the guest's finances may be 
readily understood when it is known 
that the authorities of the Yoshiwara 
distribute registration books to the va- 
rious tea-houses in which are recorded 
the personal description and all visable 
belongings of visitors. 

At the same time all the brothels 
keep a similar set of books for compar- 
ison with those of the tea-houses. The 
introducing houses assume the grave 
responsibility also of accounting to the 
authorities for the character and con- 
duct of the guests whom they intro- 
duce. Credit is not often extended to 
the guests unless they are known to be 
trustworthy and financially responsible 
for their debts, and the introducing 
houses must know this, for the guests 
pay them for all accommodations and 
they settle at stated times with the 
brothels. Between the introducing- 
houses, their servant maids and the 
brothels, all business is conducted on 
the basis of mutual confidence. 

The Hikiti-Jaya, or introducing- 
houses, derive their income principally 
from commissions on fees paid to 
courtesans, dancing girls, and percent- 
ages on food and sake furnished to 
the guest, as well as tips received from 
visitors who are disposed to be lavish 
with the use of their money. Besides, 
these introducing-houses will have 
nothing to do with visitors who do not 
patronize first or second-class es- 
tablishments. Such visitors gener- 
ally fall into the hands of the emis- 
saries of a low class of tea- 
houses, either inside or outside of the 
enclosure, who fleece them in a less 
artistic style, but in an equally thor- 
ough way. They very often fill them 
up with sake, and when they settle 
their bills their mental condition is 
such that they readily pay for many 
things they never got, as well as ex- 
orbitant sums for what they did get. 

This class of bunco-steerers know 
how to size up their victims as well as 
their more refined co-workers. There 



is now and always was a fastidious 
class of higher-ranked people who were 
ashamed to be seen entering the Yoshi- 
wara. Such people resort to various 
disguises to hide their identity. It 
was formerly the custom of certain 
tea-houses outside of the great Gate, 
called Amigasa-Jaya to furnish them 
with a basket-shaped hat, made of 
rush, which, when placed on the head, 
concealed the face of the wearer. 
These braided hats were supplied for 
the small sum of 10 sen (5 cents), 
part of which was returned when the 
hat was brought back. This device, 
however,has been abandoned and other 
less conspicuous methods adopted. 

With all of the different phases of 
vice witnessed in the Yoshiwara there 
is an outward appearance of decency 
required by visitors, and cheerfully 
complied with by the denizens of this 
quarter. 

Formerly there were very many 
artists, male and female, known as 
Geinin. These artists became too 
familiar with the Geisha or dancing 
girls, and their liasons with this class 
became so open and indecent that an 
office for the management of the 
Geisha and artists was established, 
called Kembansho. The director of 
this office was authorized to exercise a 
rigid control over these classes in the 
performance of all their various pro- 
fessional duties. 

The different classes of prostitutes 
in the Yoshiwara from its earliest days 
seemed to multiply according to the 
demands of the great variety of its 
patrons. Most any kind of taste or 
financial footing of visitors could be 
satisfactorily served within the en- 
closure of this great den of prostitu- 
tion. The guest with 10 sen (5 cents) 
from the lowest strata of the popula- 
tion could get what he wanted, as well 
as the man with 10 yen ($5.00) from 
the upper crust of society. Competi- 
tion and scarcity of money occasioned 
frequent fluctuations in the value of 
the commodity for s^le in this public 



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mart of vice, but strange as it may 
appear, the fees received by prostitutes 
during the first century of the Yoshi- 
wara averaged more than double those 
of the present time. Some of the 
inmates were classed according to the 
size and location of the brothel they 
occupied. Certain brothels with lat- 
tice work in front and located in more 
aristocratic quarters, were much higher 
priced than others less favorably situ- 
ated and equipped. 

Inmates of the middle part of a 
brothel were a grade-higher than those 
of the side apartments. Those oc- 
cupying large and medium-sized houses 
were, of course, better paid than the 
courtesans of the shops and barracks. 
Some of the prostitutes could only be 
exhibited in their cages, while others 
like the «*Yobi-da8hi" and ''Chusan*' 
were permitted to parade the main 
street (Naka-no-cho) at will. In ad- 
dition to favorable environment, per- 
sonal charms and the glamour of costly 
attire were attractions which enhanced 
the price of the courtesan's favors. 

The "Tayu'' for nearly a century 
stood at the head of the prostitute 
class, both in beauty and elegance of 
attire. In 1642 there were 18 Tayu 
in the Yoshiwara, but this class gradu- 
ally died out, and in 1751 was extinct. 
The fee of the Tayu was at first 6 yen 
or about three dollars, but about forty 
years later in was ' increased to 16 
yen or eight dollars. The **Koshi- 
Joro" were next in rank to the 
*'Tayu," and their fee at first was 4 
yen, but later increased to about ten 
yen. A reaction of public opinion 
against these extravagant charges 
brought to the front another class 
called *«3ancha-Joro," who reduced 
the fee to about 2 J yen. 

The superior tact of the class known 
as «*Sancha-Joro," and moderate 
fees required for their favors, rendered 
them popular with guests snd gave 
them a monopoly of the fieM/^^^ a 
long time after the disappearwi^ of 
the ««Tayu'^ and "Koshi-Joro;" but 



the craze for change, something new, 
and the not uncommon belief that 
nothing is good that comes cheaply, 
gave rise to a more pretentious class 
of courtesans who were called "Yobi- 
dashi." The most superior attraction 
of this class consisted in the gorgeous- 
ness of their wearing apparel. Long 
robes of costly silk, with the hair ar- 
tistically arranged and fastened with 
hair-pins made of glittering tortoise- 
shell, added to the dazzling beauty of 
face and form, constituted charms that 
rarely failed to captivate the multi- 
tude. This class had the right of way 
in all the fashionable quarters of the 
famous abode of prostitution. But 
those who dance must pay for the 
music. Splendor of apparel costs 
money, and this class knew how to 
indemnify themselves for their outlay. 
From twelve to sevetiteen yen, or from 
$6.00 to $8.50, was agreed upon as 
about the proper fee for a day and a 
night's entertainment. When it is 
understood that the '«Yobi-dashi" 
maintained apartments elegantly ar- 
ranged in all their appointments, and 
were attended by two female pages, 
two grown-up female servants, a man 
carrying a lantern-box, a footman, and 
an old woman who acts as chaperone, 
the fee does not appear to be unrea- 
sonable. 



CHAPTER IV. 

The higher class of courtesans, in 
pursuance of a long-established custom 
of the Yoshiwara, was entitled to from 
one to three young female attendants, 
called "Kamuro," according to the 
grade they occupied. This honor was 
a distinguishing feature of their rank. 
The «'Tayu" and '*Koshi-Joro" were 
entitled to two and three, while the 
' *Sancha-Joro' ' were alloweJone. The 
keeper of the brothel selected these 
little girls and had them*:trained accord- 
ing to their aptitude for the business. 
If they displayed unusual talent or 
other accomplishments which might be 



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useful to the '* profession,'* they were 
given special training in these lines. 

The Eamuro served the courte- 
sans to whom they were assigned in 
various capacities besides accompany- 
ing them in their promenades. The 
prostitute who commanded the ser- 
vices of the Kamuro was called Ane- 
Joro. She supplied the Kamuro with 
an outfit of clothing and paid all the 
necessary expenses. In all the plans 
of educational training provided for 
the Eamuro, her future usefulness to 
the profession was kept in view. If 
the girl was dull and gave no promise 
of future usefulness, she was neglected 
and became a drudge in the brothel 
service; but if she was bright and 
attractive, with an ambition to advance 
in this disreputable calling, she was 
promoted a step higher, and after the 
age of about fourteen became a 
*'Shinzo" novitiate, who soon learned 
to assume all the functions of the 
prostitute class to which she was ad- 
mitted. 

The introduction of the Shinzo to 
the profession was usually attended 
by considerable ceremony and with the 
exchange of suitable presents and 
mutual congratulations among the 
members of the circle she proposed to 
join. As a general rule the "Ane- 
Joro" whom she had previously served 
gave her a helping hand preparatory to 
her debut as a full-fledged member of 
the profession. When the term of ap- 
prenticeship as Kamuro expired and 
the girl was ready to enter upon the 
vocation of a prostitute, the master or 
brothel-ke.eper who had trained her. as 
a Kamuro and watched over her from, 
perhaps, the age of seven to fourteen 
years, would try to hold her in his 
service by offering her parents or 
guardians a certain sum of money for 
a bill of sale, which was sometimes ac- 
cepted, but at other times refused, in 
consequence of better offers from other 
brothel-keepers. 

To circumvent this sharp practice on 
the part of parents or guardians, the 



brothel-keeper often secured a certifi- 
cate of sale instead of apprenticeship , 
when he engaged the ^irl as a Kamuro. 
This kind of traffic is, however, not 
now tolerated by the government. In 
all first-class brothels of the Yoshiwara, 
and even the smaller houses, it has al- 
ways been the custom to employ super- 
vising matrons who have full charge of 
all the details of their management. 
These women are usually recruits from 
the ranks of old and experienced in- 
mates who themselves were beyond the 
age of properly entertaining guests, 
but know all the outs and ins of the 
business. They were formerly called 
*'Yarite," but now are known as 
^'Obasan," a name answering to 
*< Auntie" in the English language. 
In the higher classed houses these old 
veterans lead luxurious lives. They 
are provided with nicely furnished 
quarters with female lieutenants, al- 
ways ready to execute their orders. 
Of course, in the smaller establish- 
ments the profits of the trade do not 
justify this convenient method of 
supervision, and the female manager is 
not only compelled to give her per- 
sonal attention to the numerous affairs 
of the house, but often finds it neces- 
sary to do a little private entertaining 
in order to bring her revenue up to a 
level with her personal expense ac- 
count. The amount of remuneration 
depended largely upon the orderly and 
satisfactory treatment of guests and 
the volume of business transacted, as 
the income of the "Yarite" was 
largely derived from commissions on 
the money spent by guests and such 
gratuitous offerings as their liberality 
prompted. The management of the 
brothels was not conducted without the 
aid of men servants. In large estab- 
lishments there were inside men and 
outside men, night watchers, bath- 
room men and general utility men. In 
the smaller brothels there was no spe- 
cial division of labor for the male 
employes, nor were as many needed 
to meet the requirements of the broth- 



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100 



els. Besides, these men were not the 
recipients of tips or gifts from guests 
to any g^eat extent, as such marks of 
favor were reserved mostly for the 
courtesans or female attendants of the 
brothel. 

In the more pretentious establish- 
ments, which command a large trade, 
the services of a head clerk are needed 
to successfully conduct the finances of 
the house. This man, who is called a 
*'banto," is an important perl^onage, 
and commands the same respect ac- 
corded the master of the brothel. He 
has his regular office hours, and during 
this time usually appropriates a large 
share of the perquisites which in his 
absence fall to his subordinates. His 
income from all the different sources 
within his reach amounts to a snug 
little sum, which gives him considera- 
ble prestige among the habitues of the 
establishment in which he is employed. 

Among the more conspicuous at- 
taches of the Yoshiwara are the 
clowns, or buffoons, known as *«Ho- 
kan," and the dancing girls, or 
"Geisha." No party or banquet would 
be fully enjoyed without the presence 
of these professional entertainers. 
The more ridiculous their antics, and 
the more all rules of decency are out- 
raged, the more vociferously are their 
performances applauded. 

The **Hokan," or buffoon, was 
formerly a more important person than 
now. He lived mostly outside of the 
Yoshiwara, and was more of an ama- 
teur clown than a professional per- 
former. He had other means of mak-: 
ing a livelihood, but being gifted with 
wit, musical talent and comical genius, 
he was in demand at all places of 
amusement. The better class of Ho- 
kan, known as <<Zamochi,*' were highly 
cultured, and mingled in the best cir- 
cles. They enjoyed the confidence of 
the nobility, and were often invited to 
entertain their guests on social occa- 
sions. The other class, called «*Taiko- 
Mochi,*' like the present *'Hokan" of 
the Yoshiwara, were less talented and 



accomplished in the usages of polite 
society. They were more vulgar than 
witty, and were welcome only among 
classes of similar tastes. When they 
performed at public places of amuse- 
ment their antics were suggestive and 
revolting, often discarding every arti- 
cle of clothing, they demonstrated 
their contempt for decency. 

The better class of **Hokan'* in 
former times received a fee of 10 yen 
($5.00) for a four hours' engagement, 
but to show how this class of profes- 
sionals has degenerated, the present 
day *»Hokan'* does not receive for his 
services more than 50 sen (25 cents) 
to 1 yen (50 cents). The profession, 
since the restoration, has dropped in 
public esteem, even below the level of 
the '* Geisha," or dancing girl. Both 
classes of these professionals have de- 
generated to the point where they 
have to be kept under official surveil- 
lance by the **Kembansho," or office 
for regulating the affairs of the 
"Geisha" and other professionals. 

They cannot exercise their calling 
without a license, and a small commis- 
sion is levied on their fees by the 
"Kembansho" for this privilege. If 
the services of a "Geisha" are needed, 
she is summoned by an official of the 
Eembansho, who keeps a record of 
the hours she is engaged, and calcu- 
lates the amount of commission ac- 
cordingly, on the basis of a fee of 
12i sen per hour. 

The ^'Geish's" functions are of a 
somewhat variable and multiple char- 
acter. She is expected to dance, play 
on the guitar, or sing, as the occasion 
requires, and when she is not profes- 
sionally employed, she is required to 
make herself generally useful in the 
household of the brothel where she 
temporarily resides. They have no 
permanent quarters, as their occupa- 
tion takes them from house to house. 

It is difficult to understand how any 
woman of the least self-respect can 
entangle herself in the mashes of 
brothel-house procurers. But these 



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infamous pimps do a thriving business 
not only in Tokyo, but in all the great 
metropolitan centers of the world. 
Wherever poverty and the promiscu* 
ous mingling of the sexes co-exist, 
there is an inviting field for the vil- 
lainous emissaries of prostitution. 

In former times in Tokyo girls were 
bought and sold for prostitution al- 
most as openly as the buying and sell- 
ing of cattle, but now, this vile busi- 
ness is conducted on a different plan, 
along lines that conceal the violation 
of law. 

The **Zegen** (procurers) late in 
the eighteenth century became so bra- 
zen in their operations that the Toku- 
gaV^a government in 1792 was com- 
pelled to issue the following edict : 

Among those people living in this city who 
make it their business to find positions for 
men and women desiring to obtain employ- 
ment are parties known as ze^en or naka* 
tsugi. The plan of action adopted by these 
individuals is to engage women tor a specified 
number of years at certain fixed wages, 
although at the time, there is in fact no open- 
ing offering. In the written memorandums 
of agreement entered into, it is provided thar 
even should the women thus hired be em- 
ployed in such disgraceful or low positions as 
meshintori (lower class prostitutes kept in 
inns under the guise of servants) menial serv- 
ants,or in anyothercapacities whatsoever, they 
shall have no grounds for raising objections 
or complaints of any kind on that account. 
Under these circumstances it is not usual for 
zegeft to keep women on their hands for long, 
and if no suitable situation be found within a 
short time, they sell and transfer the girls to 
other zegen for a certain sam of money. The 
zegen also prolong the period of service con- 
tracted for with the result that the parents do 
not know when to expect their daughters 
back. In this manner the whereabouts of 
many women are lost, and their parents or 
relatives are compelled to apply to the au- 
thorities to search for and discover them and 
cause their restitution. It is also reported 
that sometimes zegen extort money from 
parties seeking relatives, and from the pro- 
prietors of brothels, and thus matters are 
arranged and compromised privately without 
referring them to the authorities. These prac- 
tices are tantamount to traffic in human be- 
ings and are hiejhly reprehensible, therefore 
the profession of zegen or naka-tsugi i« hereby 
prohibited. This law is to be strictly ob- 
served. 

Four years later the following noti- 
fication was issued : 



(1) When a brothel engages a new courte- 
san through the medium of a professional 
Kuchi'ire no mono (a person who finds situa- 
tions for would-be employers), full inquiries 
shall be privately instituted as to whether the 
woman has been kidnapped or otherwise, her 
birthplace, status, position, etc. Also as to 
whether she is a real or adopted child of her 
reputed parents. Inauiries shall also be made 
as to the status, residence, etc., of her surety. 
These matters must be thoroughly investigated 
previous to entering into a contract of engage- 
ment; the inauiries are to be made through 
the medium of third parties, and not from the 
said middleman himself; and if the woman be 
actuall/engaged, the above-mentioned details 
shall be entered into the nanushi's book. The 
term of engagement arranged must not exceed 
twenty years. 

(2) The profession of zegen and naka-tsugi 
having been prohibited in the fourth month of 
the fourth year of Kwansei (the year of the 
**Ox**) on the application of interested parties, 
the authorities rendered the following decis- 
sion: 

Whereas, heretofore there have been numer- 
ous instances of zegen and naka-lsugi having 
signed and sealed documents as sureties for 
courtesans under the pretense that they were 
relatives of the women, it is hereby decreed 
that, on and after the fifth month of the pres- 
ent year, when the period of service has ex- 
pired (as mentioned in the separate bonds of 
guarantee handed to their masters), the ex- 
courtesans shall not be given over to their 
sureties, but to their own actual blood rela- 
tions, and it is further ordered that the pro- 
prietors of brothels are to assist the time-ex- 
pired women in the matter of placing them in 
the charge of such actual blood relations, as 
aforesaid. 

Should any zegen residing within the pre- 
cincts of the Yoshiwara receive applications 
direct from ^omen seeking employment as 
couitesans, such zegen shall conduct the ap- 
plicants to a brothel for the purpose of intro- 
ducing them to an employer. When engage- 
ments are finally concluded, the zegen shall 
not (as formerly) seal the agreements, inas- 
much that he is only permitted to act as a 
mere introducer between the parties. 

(3) Should the number of middlemen in the 
Yoshiwara be limited, the profession would 
become a monopoly, and to prevent the sell- 
ing and buying of the good-will of the trade, 
as well as to prevent any dishonest practices, 
an agreement was lodged by each middleman 
with the nanushi. The latter has been in the 
habit of reminding the middlemen of the con- 
tents of this contract once in every month, and 
obtaining their signatui'es each time in proof 
of his having done so. Of late, persons ply- 
ing a smilar profession have appeared in the 
vicinity of the Yoshiwara, but have remained 
outside the enclosure. This is contrary to the 
notification, and makes it difficult to exercise 
proper control over them, therefore they shall 
be compelled to move into the Yoshiwara un- 
der pain of having the exercise of their pro- 



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aoi 



fession suspended. Henceforth, all persons 
desirous of carrying on the business of a mid- 
dleman shall only be allowed to do so inside 
the gates of the quarter. 

After the promulgation of. the fore- 
going decrees by the government, the 
infamous traffic in girls was somewhat 
restricted to the Yoshiwara, but the 
zegen (procurers) employed agents 
outside to co-operate with them in 
prosecuting their nefarious trade, who 
adopted such methods as enabled them 
to evade the provisions of the new 
laws. 

Under the new plans of procedure 
the efforts of the government were 
thwarted at every step, and the **busi- 
ness*' of the procurer was equally as 
prosperous as under the old law. 

Finally, in 1872, patience ceased to 
be a virtue, in the opinion of the gov- 
ernment, and a decree was issued 
granting absolute liberty to prostitutes 
throughout the jurisdiction of the em- 
pire. 

It must be said, to the credit of the 
prostitute^ that they were not slow to 
take advantage of their freedom. In 
a few weeks after the issuance of this 
decree thousands of these unfortunate 
women left the places of prostitution 
and reformed their lives. 



A PLAIN TALK ON MATTERS PER- 
TAININQTO OEMTO-URINARY ANAT- 
OMY, PHYSIOLOGY AND 
DISEASES. 

Bt Db. BRANsroBD Lewis, of St. Loxiis, 
Professor of Gonlto-Urinary Surgery, Marion-Sims-Beaa- 
mont Medical College; Consultant in Gteni to-Urinary 
Surgery to the Female Hospital, Bebekah Hos- 
pital, etc.; Member of American Association 
of Qenito-Urinary Surgeons, American 
Medical Association, Etc. 

There is probably no subject more 
far-reaching in interest, or about which 
there is more speculation, than that 
which £ propose to discuss tonight. 
While I haven't the experience to jus- 
tify me in speaking from the stand- 
point of the gentler sex — never having 
been a girl — I have been a boy ; and I 
know 8ome of the things they do and 



say. I know it is a sad and backward 
boy who does not think on sexual sub- 
jects before he is old enough to wield 
much of an influence in this world's 
affairs. And boys talk on the subject; 
and what nonsense they do talk ! And, 
for that matter, what nonsense they 
expound on such subjects, even after 
they get to be men ! Reeling off theo- 
ries that are profound but far-fetched. 

But there are two good reasons why 
this should be: the lack of informa- 
tion that boys get from sources truth- 
ful and reliable; and, on the other 
hand, the abundance of misleading in- 
formatioii that they get from sources 
either questionable or abominable; 
from such sources as other boys or, 
worse than that, the quack literature 
and *• marriage guides," so easily ob- 
tainable by confiding youth. 

In the first place, ostrich-like, we 
bury our heads in prudery, and refuse 
to discuss such subjects with the in- 
quisitive youth ; and we allow him to 
grow up with distoi-ted ideas and worse 
habits. Instead of eirt^nding to him 
the helping hand of advice and com- 
fort, we leave that to be done by the 
most devilish-minded of society — ^the 
harpies of charlatanism, who feed on 
the fears and superstitions of such be- 
nighted individuals. A condition not 
understood by them is interpreted as a 
condition diseased. For instance, nat- 
ure has made provision against the 
squeezing of one testicle against the 
other by hanging the left one lower 
than the right. A nervous boy una- 
ware of this provision, reads in one of 
the advertising circulars that one of 
the sure signs of *'lo8t manhood" is 
the hanging of one testicle lower than 
the other. He looks up the matter 
on himself and finds, alas! that he is 
afflicted in that way. A guilty memory 
of past indiscretions is sufficient ex- 
planation to him why the condition ex- 
ists. Still, to be perfectly certain about 
it and give himself the benefit of the ■ 
doubt, he studies the subject further 
— examines those noble distributors of 



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intelligence, the daily newspapers, and 
finds something like the following, 
which is to be seen in nearly every 
publication of the day : 

*«Te8t Your Kidneys. 

Let some morning urine stand for 
twenty-four hours in a glass or bot- 
tle. If then it is milky or cloudy or 
contains a reddish, brick-dust sedi- 
ment, or if particles or germs float 
about in it, your kidneys are dis- 
eased.'* 

No loop-hole of escape is left for 
him; he is certain, now, that he has 
Bright's disease as well as ''lost man- 
hood.'* For, be it known, every urine, 
healthy or unhealthy, contains mate- 
rials in solution when passed that later, 
when the urine cools, precipitate to 
form a sediment of various sorts — of 
phosphates or urates — things that have 
nothing more to do with Bright' s dis- 
ease than a cat with spectacles. The 
devilish cunning of, the villain who 
writes the, advertisement is apparept ; 
he fixes matters for everybody who" 
urinates; and there are very few of us 
who can get along without attention to 
that detail of life. Is it a wonder that 
we read such additional items of news 
as the .following, which appeared in the 
same issue that contained the ''kidney 
test" alluded to: 

"Suicide Due to Causeless Fear." 

Andrew J. Teggin, an artist, whose 
pictures have been exhibited at the 
Academy of Design, took chloroform 
today, and died soon afterward at the 
New York Hospital. Teggin 's death 
was the end of five years' dread of 
Bright's disease. Though eminent 
specialists had assured him he had no 
symptoms of the disease, he persisted 
in believing that he was doomed to die 
from it, and this so worked on his 
mind that he killed himself rather 
than wait for the end he felt sure 
would come." 

Knowing that these unfortunate con- 



ditions exist, it would seem proper 
that some provision be made to rem- 
edy them. Parents should not only 
have plain and candid conferences with 
their children on these subjects, but 
should send them to the family doctor, 
who could easily put them on the right 
track and help to keep them there by 
subsequent encouraging advice and in- 
struction. It will be my endeavor 
this evening to lightly touch on a num- 
ber of these topics — sufficient, at least, 
to serve in dissipating some of the If; 
fanciful dreams and harmful rubbish (^i 
that hang about them. 

Anatomy and Physiology. 

The genitO'Xirinary system is divis- 
ible into two sets of organs — the gen- 
ital organs and the urinary organs. 
The genital organs serve for the repro- 
duction of the species, carrying on the 
sexual function ; and the urinary or- 
gans serve to make and get rid of the 
urine, acting as one of the sewer sys- 
tems of the body, as it were. 

Urinary Organs, — These consist of 
the kidneys, ureters, bladder and the 
urethra. 

The kidneys are two rounded bodies, 
located in the "small of the back," 
under the ribs. As the blood flows 
through them they extract from it cer- 
tain waste-products, for which the 
system has no longer any use, and 
which would be injurious, indeed, if it 
were retained longer. 

Ureters. — The outlet for the escape 
of the urine is found in the ureters, 
two small tubes running from the kid- 
neys downwards and joining the blad- 
der at its lower portion. By these 
ureters the urine is conducted into the 
bladder. 

Bladder. — The bladder is a reser- 
voir for the temporary retention of the 
urine — for holding the urin^ between 
the times of urination — and a very 
useful organ it is. 

Urethra. — From the lower end, or 
"neck," of the bladder the elastic 



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CenitO' Urinary a 

canal called the urethra leads, passing 
through the prostate, the cut-off 
muscle and the penis. The urethra 
completes the channel for conducting 
the urine from the body; and the 
smaller opening at its outer end per- 
mits of the projection of the urine in 
a good stream that adds to the con- 
venience of the act. But the urethra 
has another office to fulfill. If all 
urethras should become stopped up 
permanently, this fact would shortly 
become apparent in the depopulation 
of the world. That is, the urethra 



Pig. 1. — The kidneys, areters and bladder of 
the male (Morris). 

must also conduct the semen to the 
outer world or into the vagina of the 
woman. 

Genital Organs and Seminal Chan- 
nel. — The semen is a mucilaginous- 
looking tluid that contains the life- 
giving bodies called spei^matozoa, which 
are the fecundating elements of man. 
They resemble ordinary tadpoles in 
both appearance and movements. 
These spermatozoa are manufactured 
in the two bodies called testicles, which 
hang in the bag called the scrotum. 



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climax of intercourse or night-emis- 
sion. '^Normally" is used intention- 



■lu 



Tf 



ir»+ h 



airck m 



far*. 

IS 

f 

e 

iS 



It 

y 

d 
e 
t 



d 

i- 
h 

t 
e 
t 



but as a matter of fact, there are cer- 
tain vastly important features about 
its make-up that are not usually l^nown 
or understood, not only by the frater- 
nity of pharmacy, but often by the 
medical profession, which lack of 
knowledge on the part of both contrib- 
utes very largely to their inability to 
really cure gonorrheas with the numer- 
ous *'sure cures" so much in vogue, 
and also makes them think they have 
cured such cases when they have only 
stopped the discharge, which is no evi- 
dence of cure at all. These features of 
the anatomy of the urethra I am espe- 
cially anxious to make clear to you. 

At a point just in front of the pros- 
tate is a muscle that surrounds the 
urethra like a puckering-string. It 
contracts around the. urethra with a 
tight grip at all times, day and night, 
except when it is relaxed by some 
special influence, such as the act of 
passing water. At all other times it 
is tightly closed, preventing the in- 
voluntary escape of the urine from the 
bladder. It has a very important oflSce 
to fulfill. If it should go on strike, 
wet trousers would be quite the fash- 
ion. It is the main constrictor or 
sphincter for the bladder — that is, it 
is the principal muscle upon which the 
bladder depends for helping to retain 
the urine during the interims between 
urination. It prevents water from 
passing outwards through the urethra, 
although the water may make strong 
pressure against it and endeavor to go 
past it. The same thing is true with 
water going in the opposite direction. 
If, for instance, we apply a small 
syringe against the outer opening of 
the urethra (the meatus) and inject 
water into the urethra, it goes back 
readily until it reaches the muscle, 
where it finds a strong barrier against 
its further progress; it is prevented 
from going further, none of it reach- 
ing the back part of the urethra. This 
muscle is, therefore, a dividing muscle 
for the urethra, dividing it into two 
unequal parts, a long front part and 



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Genito-Urinary Anatomy— Lewis. 



206 



a short back part. It is, therefore, 
called the cut-off muscle of the urethra. 

If it would act in a similar obstruct- 
ive manner to the infectious inflamma- 
tion called gonorrhea, we would be in 
a position to admire its capabilities 
more than we are. But it does not. 
Gonorrhea is an inflammation of the 
urethra caused by a microbe called the 
gonococcus (Fig. 4), that takes root 
at the front end of the urethra and 
shortly thereafter propagates enormous 
numbers of its own kind, at the same 
time causing the inflammation that 
makes it the aggravated disease that 
we recognize under that name. The 
inflammation travels backward; and 
is not at all overawed by the muscle; 
it gets past the muscle in by far the 
large majority of all cases of gonor- 
rhea. 

In order to cure gonorrhea we must 
first kill out the hordes of gonococci 
that infest the urethra, and then allay 
the inflammation. We cannot kill them 
by using internal medicines, such as 
sandal oil or copaiba; gonococci must 
be attacked by direct application of 
remedies that kill them, without at the 
same time injuring the tissues. Sup- 
pose we give injections into the urethra 
of the best of such remedies, using the 
small syringe ordinarily employed for 
this purpose; the fluid passes back- 
ward along the front urethra and medi- 
cates all of that part of the canal, pos- 
sibly killing all of the gonococci lying 
in that part, but does it pass back into 
the rear part of the canal where there 
are also hordes of gonococci and active 
disease? By no means. The cut-off 
muscle prevents that; so that, not- 
withstanding the patient's devoted at- 
tention to the treatment prescribed, 
heroically swallowing the boluses of 
horrid medicines and giving himself 
the injections with energy and fre- 
quency, he reaches only the front part 
of the diseased urethra, failing to ap- 
ply any remedy at all to the back part. 
Perhaps he does much good for the 
front part, killing out the gonococci 



there and stopping the discharge ; but 
on the discontinuance of the medica- 
tion there is renewed infection of the 
same membrane from the organisms 
coming from the back part of the 
urethra, and renewal of discharge as 
active as ever. He may go through 
this sequence time after time, becom- 
ing more discontented all the time, 
because he does not seem to he ''cured 
completely.*' The fact is he has never 
been cu7'ed at all; he has never had 
treatment to the whole involved area. 
The lessening of the discharge was 
only a misleading indication of im- 
provement, not an indication of cure. 
It was as if a man had two broken 
arms and expected to be cured by hav- 
ing a splint placed on only one of 
them. Except, in this instance, it is 
not so favorable, since the arm has a 
natural tendency to get well, while the 
gonorrheal infection has no such benev- 
olent disposition. Gonococci may re- 
main in the back part of the urethra 
for months or years — in fact, indefi- 
nitely — and with the property of be- 



FiG. 4. — Gonococci. 

ing reawakened into activity and either 
causing renewed gonorrhea in the 
individual himself, or of being con- 
veyed to his partner of an intercourse, 
endowing her with gonorrhea, months 
or years after he had supposed him- 
self well. In this way many innocent 
wives are infected, often to the chagrin 
and heart-felt grief of their husbands 
who had supposed themselves free 



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from disease for months or years be- 
fore. They did not know that the 
absence of active discharge was no 
reliable indication of their restoration 
to health. 

These facts, also, throw a flood of 
light on the subject of * 'three-day 
prescriptions'* for the "sure cure*' of 
gonorrhea. In most instances where 
such combinations appear to be suc- 
cessful, it is either a non-gonorrheal 
case (simple urethritis), or the injection 
has simply caused a temporary stoppage 
of the discharge, as previously ex- 
plained. The patient thinks he is ac- 
quiring and curing numerous separate 
cases of gonorrhea, when, as a matter 
of fact, he is simply having revivals of 
the same old case, reducing its activity 
each time and stopping the discharge, 
but never curing it. 

Therefore, you can see that in order 
to get an effective cure for urethral 
gonorrhea it is not so much a matter 
of the selection of the proper remedy, 
as it is the proper application of that 
remedy. All of the parts involved by 
the gonorrheal process must be treated 
before we can expect a cure. We must 
treat the back part of the urethra as 
well as the front part; we must kill 
out the gonococci lying back there, 
and also allay the inflammation there. 
This can be done and is done every 
day, and without harm or pain to the 
patient, by those who study these sub- 
jects; and they establish a cure that 
does away with Noeggerath's doleful 
axiom: **Once a gonorrhea, always a 
gonorrhea." Therefore, my druggist 
friend, I advise you to dispense your 
medicines for killing gonococci as 
ordered or requested by the physician, 
but also to dispense with the endeavor 
to cure cases of real gonorrhea with 
such futile measures as '*sure-cure" 
injections, which, at the best, can only 
be a form of ''absent treatment,*' 
since it never quite reaches the part af- 
fected. These sure cures are beautiful 
theoretically but disappointing prac- 
tically. 



Nor can we stop with even this far- 
reaching claim for the extended possi- 
bilities and the serious nature of gon- 
orrheal infection. We must remem- 
ber that there are other organs than 
the front and the back urethra that are 
subject to the inroads of the gonococ- 
cus. You have observed that the pros- 
tate is in intimate relationship with the 
urethra, surrounding it at its posterior 
end. Gonococci go from the urethra 
into the prostate, infect its glands and 
tissues and make gonorrheal prostatitis. 
They enter the little ejaculatory ducts, 
from which the semen escapes, and 
pass up into the semen bags (ves- 
icles), causing the same gonorrheal 
process there; and when we under- 
stand how isolated and secluded is this 
lodgment for them, we will again be 
impressed with the utter fallacy of 
trying to cure such wide-spread infec- 
tion with three-day injections, It is a 
problem on which many of the best 
men of the world have spent years of 
labor: is it to be expected that our 
nearest friends, those who look on 
gonorrhea as being "nothing worse 
than a l?ad cold," wise as they are on 
the subject of three-day cures ; is it to 
be expected that they have solved the 
problem with the superficial knowledge 
that they have acquired from a few 
personal experiences? They not only 
do not solve it, but they are playing 
with edged tools, the misuse of which 
may have the most disastrous conse- 
quences to the misguided friends who 
take their advice. 'Tis not the patient 
alone who is concerned, but the ques- 
tion involves the future wife, the fam- 
ily, the very foundation on which the 
state is built ! 

Bugbears. 
I wish to give you short explana- 
tions of some of the staple bugbears 
of quack literature — those maladies 
which we learn from circulars are all 
horrible beyond conception, but at the 
same time are all "cured without re- 
sort to the knife," provided we put 



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Genito-Urinary Anatomy— Lewis. 



207 



our trust (and our money) in the keep- 
ing of the noble philanthropist whose 
name appears at the bottom of the ad- 
vertisement. 

Sterility means inability to fecun- 
date or impregnate. Possibly, from 
some reason, spermatozoa are not 
manufactured, or perhaps the chan- 
nels through which they travel from 
the testicles to the urethra are ob- 
structed, preventing the transmission 
of the spermatozoa to the female ; al- 
though intercourse is repeated time 
and again, and apparently successfully 
in every respect, the ejaculated semen 
does not contain the spermatozoa that 
are necessaiy for the fertilization; 
sterility is the result. Either the man 
or the woman may be at fault. 

Impotence. — A condition that is usu- 
ally much more harrowing to the pa- 
tient is that of impotence ; inability to 
carry out the act of sexual intercourse,* 
and without reference to the question 
of impregnation. In order to effect 
satisfactory intercourse on the part of 
the male, there must be erection of 
the penis. This state of erection is 
constituted by the filling of that organ 
by relatively enormous quantities of 
blood, rendering it so tense that rigid- 
ity is the result. This is maintained 
in the intercourse for a varying length 
of time, until the nervous crisis called 
ejaculation is experienced, freeing the 
semen-bags of their contents and also 
the penis of its pent-up blood, after 
which there is subsidence again to the 
normal state of flacidity. 

There are various causes for inabil- 
ity to acquire a sustained erection, 
briefly divided into physical and men- 
tal. Depressing or agitating impres- 
sions are calculated to dispel one's 
amorous inclinations; likewise are 
those of fear or distrust, etc. It is 
for a similar reason that the very be- 
lief itself in one's inability to perform 
the act in a commendable manner often 
intimidates and defeats the candidate 
at the very outset. Here is where the 
mental effect is dominant and disas- 



trous. The candidate is humiliated 
where he would like to be enthralled. 
And he felt all the time that it would 
be so. And that's the very reason that 
it was so. Relief from his foreboding 
will bring about relief from the appar- 
ent defect. But is he likely to be re- 
lieved by sermons on **lost manhood" 
and such distorted imaginings in liter- 
ature? Hardly. 

But there are, as I mentioned, phys- 
ical causes for impotence, to relieve 
which they must be sought out in an 
intelligent manner by a medical attend- 
ant — not by the imaginative brain 
of the uninformed patient. Empiric-^ 
ally prescribing or taking the various 
sexual stimulants, is a very injudicious 
way of getting at the relief. Often 
such remedies act injuriously instead 
of beneficially ; they add to congestion 
of the organs that, may be already con- 
gested or inflamed. The best policy 
in such cases is to hunt out the cause, 
whether physical or mental, and re- 
move it. Often it is unrecognized and 
uncured gonorrhea, possibly of long- 
standing. 

Spermatorrhea and masturbation 
are names that derive their horror 
chiefly from the use that quacks and 
charlatans make of them, scaring the 
unfortunate and misinformed into the 
belief that they are suffering from the 
effects of the one or the other, and 
that they will never'again be able to 
satisfactorily breathe the air of hal- 
lowed society until they have taken a 
course of the charlatan's treatment 
** without Recourse to the knife." It 
is an unfortunate fact that nearly all 
boys are destined to pass through a 
more or less protracted period of im- 
becility and general cussedness, in 
which they turn with unerring cer- 
tainty to tastes and acts that are inju- 
rious and debasing, rather than bene- 
ficial and elevating. They upset cus- 
toms and conventionalities : they break 
furniture; they masturbate, and fi- 
nally get to smoking cigarettes. A 
lawyer-friend of mine gave it as his 



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GenitO'Urinary Anaiomy— Lewis. 



209 



opinion — and he ought to know — that 
all boys ought to be put in a barrel 
and fed through the bung-hole from 
the time they are seven until they are 
twenty. While I do not participate to 
the fullest extent in this belief, I do 
think that something ought to be done 
with our boys. They ought to be in- 
structed, as I intimated before, in the 
elementary truths, at least, of sexual 
matters being inculcated into them 
by the parents or the family phy- 
sician ; and they ought to be circum- 
cised^ — the permanent and tempting 
invitation to masturbation in the form 
of the foreskin being removed in 
their early infancy, before sexual 
feelings are experienced, and the vi- 
cious counsel of other boys is received. 
Moses realized the vast benefits to 
be derived from this procedure and 
displayed his far-sightedness in exact- 
ing it as a religious rite among his 
people, else it would never have been 
80 universally followed by them. The 
Gentile, with the long pendant fore- 
skin (Fig. 5) does not know what it is 
to have a clean penis, dry and hygi- 
enic, even though he wash it every 
day; the natural secretions are held 
under the foreskin become infected 
and decomposed, leading to conditions 
that are anything but healthy and de- 
sirable. One such is shown in the il- 
lustration of venereal warts (Fig. 6); 
a matter purely of long foreskin and 
lack of cleanliness. There is some 
reason, then, and excuse as well, why 
boys should be boys, endowed as they 
are with anatomical conditions, as 
well as traits, calculated to lead them 
astray. But, notwithstanding this. 



Fig. 5.— Abnormally long and tight fore- 
skin. 

Fig. 6. — ^Venereal warts, resulting from snch 
a foreskin 

Fig. 7. - Hydrocele. 

Fig. 8. — Varicocele before operation. 

Fig. 9.— The same after operation. 



there is reason, for retaining some 
faith in the ultimate favorable outcome 
of American boys. If all of them who 
masturbate are destined to permanent 
invalidism and degeneracy, where do 
our governors, our senators and our 
presidents come from? Such boys 
cannot all goto the House of Delegates ! 

As to spermatorrhea, that is merely 
one of the various symptoms of gen- 
ital disorder that when it is present 
should be jrelieved, like the others, by 
the cure of the condition that lies at 
the bottom of it. ** Spermatorrhea" 
means loss of semen ; but, more often 
than not, the supposed loss of semen is 
only an escape of prostatic mucus, in- 
dicative of irritation in the prostate in- 
stead of the generative organs. So 
that while deserving of attention and 
relief, it has none of the horrible as- 
pects dwelt on by some writers on 
these topics. 

Hydrocele means an abnormal col- 
lection of water (serum) in a certain 
part of the scrotum (Fig. 7). It has 
nothing to do with venereal disease, 
and is ordinarily relievable by either 
tapping and injection of certain solu- 
tions, or by open incision methods. 

Varicocele is a dilatation of the 
veins in the scrotum (Fig. 8) that 
surround the cord, often accompanied 
by undue pendancy of the scrotum, 
which hangs down to such a degree 
that no support is given to the testicles ; 
giving a diagreeable, dragging-down 
feeling that is sometimes very uncom- 
fortable or even painful. While it is 
relievable with comparative ease and 
certainty by operation (Fig. 9), it does 
not always require operation or even 
treatment ; if of only mild degree, the 
wearing of a good scrotal suspensory 
may answer all needs. No medicines 
applied either locally or taken inter- 
nally will cure varicocele or hydrocele. 

(to be continued.) 



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AN BTIOLOQIC FACTOR 
SD QENITO'URINARY 
OlSBASBS* 

Frautm ANN, of Munich, Germany. 

of bacteria exist on the 
8 has been demonstrated 
), Bordoni-Uffreduzzi, 
I others. Among them 

diverse kinds of cocci 
r. W. Dammann (1) has 
: kinds which are un- 
, and to which he has 
owing names: B. epi- 
'. luteus liquefaciens; 
flavescens; micrococcus 
xcording to Guenther 
ere can, be found on the 

bacteria which cannot 
pathogenic. 

ref ore, maintain that the 
ally found on the exter- 

no role in the derma- 

mic bacteria, as an etio- 
tack the outer and inner 
m without or within. 
173) has shown that in 
infection by the staphy- 
rule, occurs through the 
dn, and that, therefore, 
ugh the unbroken skin 

ntly, however, infection 
through injuries of the 
hey be only microscopic 
:his way infection may 
rough the blood and 
Is into the innermost or- 



gans. On the other hand, it is a fact 
that through an internal infection or 
internal morbid process of a bacterial 
nature, germs are carried to the skin 
and eliminated in this manner. Ac- 
cording to Guenther (I. c.) a few oases 
of this kind have been observed. 

That these bacteria may produce (as 
a modification of the internal affection) 
new, local morbid changes, can be 
easily conceived. 

The same holds good for bacterial 
metabolism, analogous to the derma- 
toses, which are caused by the stomach 
and intestines. Many diseases, as scar- 
let fever, measles, etc., of which noth- 
ing definite is known, can be explained 
according to the above. 

The attempt to find a specific, etio- 
logic bacterial cause for skin and sex- 
ual diseases — particularly for such the 
contagious nature of which has been 
demonstrated, in spite of the discovery 
of the various micro-organisms — has 
been successful only in comparatively 
few affections. 

The specific germ for one or another 
affection has been found; not so for 
the great majority, although we must 
assume that for entire groups of der- 
matoses there exist either a specific 
micro-organism t)r one producing va- 
rious pathologic pictures. 

I have compiled from the works of 
Baumgarten, Joseph, Kaposi, Lang, 
and from current literature, the fol- 
lowing table, giving the bacteria found 
in the various affections: 



COCCEN. 



3 pyogenes 



Albus. 
Bac. fluoresc. liq- 
uefac. 



Albus. 



Impetigo contagiosa Fox. 

Furunkel. 

Carbunkel. 

Foudroyante Gangraen (Four- 

nier). 
der Genitalhaut (Buergner). 

Impetigo Bockhart. 
Pemphigus infantum. 
Sykosis (simplex) coccogena. 



the original German MS., for American Journal of Dkrmatoloot, by Dr. Gnstavus M. 



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COCCEN— Continued. 





+ Albus. 
Toxine. 


Eccema (Bockhart). 




4- Cereus albus. 
Streptococcus pli- 

catilis. 
Lemaistre. 


Perleche (Pourleche). 
Angulus infectiosus, 

Faulecke. 




+ Streptococcus. 
Pneumonic diplo- 
coccus. 


Erysipel. 




-f- Streptococcus. 
Tetracoccus. 


Variola. 
Varicellen. 


Staphylococcus pyogenes|od. Bac. Unna. 


Acne (Lomry). 




Impetigo Bockhart. 

Sykosis (simplex) coccogena.~ 

Pemphigus 'infantum. 




Eccema (Bockhart). 




Foudroyante Gangraen (Four- 

nier). 
der Genitalhaut. 
(Lang u. Sorgo.) 



Staphylococcus aureus al- 
bus. 



4- Aureus. i 

Streptococcus pi i- Perleche. 

catilis. 
Lemaistre. 



Staphylococcus cutis com-l 
munis Sabourand. 1 


Pityriasis capitis. 
Seborrhcea corporis. 


Staphylococcus hsemor- 
rhagicus. 




bei einer von Schafon ueber- 
tragbaren Blasenkrankheit. 



Pneumonic diplococcen. 



-f- Streptoco ecus, 
staphyloc. aur. 



Erysipel. 



-f Streptococcus. 



Morbilli (Cornil et Babes). 



Mikrococcen. 



ident. ? mit Strepto- 
coccus. 



Orientbeule. 



ident.? mit Staphy- 
loc. aureus. 
+ Albus. 



Scarlatina (E. Klein, Jamieson, 
Edington). 



Pemphigus infantum. 



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BACILLEN. 



Bac. anthracis. 


Haut-Milzbrand. 


Bac. diphtheriee. 


+ Toxine. 


Haatdiphtherie und exantheme 
(serum). 


Bac. typhi. 


+ Toxine. 


typhoese Hautgeschwuere, 
Roseola. 



Bac. rhinosklerom. 



Rhinosklerom. 



Bac. leprae. 



Bac. tuberculosis. 



Milzbrand aehmliche ba- 
cillen. 



Toxine (— ?). 



I Lepra. 

Scr oph ul Oder m a . 
Lupus vulgaris. 
Tuberculosis verrucosa cutis. 
Ulcus tubercul. cut. 
Tuberculoese Tumorcu, der 
Haut. 

^ Lichen scrophulosorum. 

Acne cachectica. 

Lupus erythematodes. 
:S ; Pityriasis rubra Hebra. 

^i 



+ Coccen (Peckel- 
haring u. Wink- 
ler). 



ident. mit Bac. der 
B uttersaeure 
gaehrung (Schat- 
tenfroh) 



Beri-Beri (Ogata). 



Gasphlegmone (E. Fraenkel). 



Bac. pyocyaneus. 






Ekthyma gangraenosum. 


Bac. Matzenauer. 






Hospitalgangraen . 


Elaschen bacillus Uuna. 


lEccema seborrhoicum. 


Bacillus mit duennen En- 
den. 




Elephantiasis erythem. ^gypt. 


Bac. Unnae. 


nach Lomry 
ylococc. 
albus. 


Staph- 

pyog. 


Acne. 



Bac. fluorescens liquefa- 
ciens. 



Strepto. bacillus Unna. 



Foudroyante Gangraen (Four- 
nier). 

Ulcus molle. 



Bac. Ducrey. 



lUlcus molle. 



Bac. von Niessen. 



ILues. 



Bac. Lustgarten. 
Bac 



Justin de Lisle et 
Louis JuUien. 



Lues. 

Lues. 



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Bacteria as an Etiolocic Factor— Trautmann. ais 



BACILLEN— Continued. 



Bac. Paulsen. 



ILaes. 



Bac. M. Joseph u. Pior-{ 
kowski. 



Lues. 



Coccen. 



lErysipeloid (Roaenbach). 
JLues (Aufrecht). 



Dach Ogata Bacillen. Beri-Beri (Pekelharing 
I Winkler). 



Morococcus Unna. 



ISeborrhoische Schuppen. 



Mikrococcus Sabourand. I Toxine. 



jAIopeoia. 



Tetracoccen. 



+ Staphylococc. p, 
aur. 
Streptococcen. 



Variola. 



Streptococcus pyogenes. 



+ Staphylococc. 

pyog. aur. 

Pneumococcen. 



+ Pneumococcen. 



+ Mikrococcen. 



+ Staphylococc. 
pyog. aur. 
Tetracoccen. 



nach Kolisko U4 
Chotzen secun- 
daer. 



Secundaer. 



Erysipel (Fehlelsen). 



Morbilli. 



Scarlatina. 



Variola. 



Lues (Kassowitz u. Hoch- 
singer). 



Mykosis fungoides. 



Impetigo (simplex) vulgaris 
Unna. 



Streptococcus plicatilis, + Staphyloc. pyog. 
Lemaistre. aur. 

Staphyloc. cereus 
alb. 



Perleche. 



Gonococcus Neisser. 



iGonorrhoea. 



If we look first of all at the staphy- 
lococci, we will observe that the va- 
rious kinds occur sometimes alone, 
sometimes several together, and some- 
times in conjunction with other bac- 
teria. 

1. The staphylococcus pyogenes au- 
reus alone is met with in impetigo 
contagiosa Fox, furuncles and car- 
buncles. 

It has also been demonstrated in 



gangrene foudroyante (Fournier) of 
the genital skin by Buergner. 

According to Lomry, the staphylo- 
coccus pyogenes albus is found in acne, 
while Unna advances his acne bacillus. 

E. Klein (4, p. 81) has described 
the staphylococcus hsemorrhagicus, 
which is very closely related to the 
staphylococcus pyogenes aureus and, 
perhaps, an identical coccus with the 
one described by Mocard. 



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Original Articles, 



This organism produces gangrenous 
mastitis of sheep, and has been found 
in a pustular dermatitis of the hand, 
observed in Malton, North England, 
caused by contagion with the hemor- 
rhagic edema of the vulva of sheep. 

2. The staphylococcus pyogenes 
aureus and albus conjointly are found 
in impetigo Bockhart and in pemphi- 
gus infantum (acutus neonatorum con- 
tagiosus). 

Almquist produced with the staphy- 
lococcus pyogenes aureus alone the 
latter disease, and named it micrococ-, 
cus pemphigi neonatorum. 

According to Lang, this coccus is 
apparently different from the ordinary 
staphylococcus pyogenes aureus only 
by a lesser virulence. 

3. Both aureus and albus, further- 
more, occur in sycosis (simplex) 
coceygeus. Both, together with their 
toxins, can produce a typical eczem, 
according to Bockhart, E. Bender and 
V. Gerlach. 

4. In so-called perleche are found 
the staphylococcus pyogenes aureus, 
the cerus albus and the streptococcus 
plicatis Lemaistre. 

5. In contradistinction to the above 
findings, Lang (according to a publi- 
cation by S. Sorgo) demonstrated the 
staphylococcus pyogenes albus and the 
bacillus fluorescens liquef aciens in gan- 
grene foudroyante of the genital skin; 

6. As regards the streptococci, they 
are met with in a series of affections. 
But also with these, one must consider 
whether they are the direct producers 
of a disease or only secondarily car- 
riers of infection. 

For it is very probable that they can 
play their infectious role far easier on 
apart of skin, already diseased, than on 
healthy integument. As they are met 
in various infectious diseases we must 
choose between the following ques- 
tions, viz. : are they the one cause of 
various diseases, or are they possessed 
of but an accidental importance in the 
presence and principal effect of the un- 



known pathogenic germ, not yet dis- 
covered? 

Fehleisen's streptococcus produces 
erysipelas. We know from experience, 
however, that other bacteria also pro- 
duce the same morbid process. 

According to I. Rosenbach, Passet 
and others, in regard to the morpho- 
logic and culture features, no differ- 
ence can be established between the 
ordinary and Fehleisen's streptococ- 
cus. Besides, Jordan (5) has demon- 
strated in two cases of erysipelas the 
staphylococcus pyogenes aureus. Other 
cocci, as for example the pneumococ- 
cus, produce erysipelas. 

One could, perhaps, pronounce such 
cases of erysipelas as are produced by 
other bacteria than Fehleisen's strepto- 
coccus as not genuine, nevertheless 
the sj'mptomatology and course are 
alike, so that clinically the term ery- 
sipelas is justified. 

Lang calls attention to the difference 
which has been claimed to exist be- 
tween Fehleisen's and the ordinary 
streptococcus, consisting in this: that 
the former produces erysipelas, the 
latter suppuration. This difference is 
nullified by experiments which have 
established the fact that the strepto- 
coccus alternately can produce both 
princesses. 

Just as here the same picture is pro- 
duced by different micro-organisms,, 
so we can consider whether, on the other 
hand, the same bacterium depending, 
perhaps, on its degree of virulency, 
may not produce diverse pathologic 
phenomena. The findings in morbilli, 
scarlet fever and variola justify the 
consideration of such a hypothesis. 

According to Baumgarten (6, p» 
385), the cocci which have been dem- 
onstrated to exist in the lungs of those 
suffering from measles, by Cornil and 
Babes (7), may be either the strepto- 
coccus pyogenes or the pneumonia 
diplococcus of Fraenkel-Weiohselbaum . 
According to the same author, who 
bases his opinion on the observations 



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made by Loeffler, Heubner, Bahnd and 
others, the micrococcus found by 
E. Klein (8^, Jamieson and Edington 
{9) to circulate in the blood of men 
Buffering from scarlet fever, may be 
the streptococcus pyogenes. 

Garre has isolated the streptococcus 
pyogenes in variola, while Guttman 
has found in the same disease and 
varicella the staphylococcus pyogenes. 
Other authors have isolated tetracocci, 
which are found on the normal skin. 

The chain cocci found in mycosis . 
fungoides (Rindfleisch, Auspitz), ac- 
oording to Koebner, Ziegler and others, 
are also nothing else but pyogenic 
streptococci. Baumgarten interprets 
them as an accidental colonization. 

Pyogenic streptococci are also seen 
in impetigo vulgaris Unna, in per- 
leche ; in addition to the above-named 
bacteria the streptococcus plicatilis. 

The finding of streptococci in a se- 
ries of diverse affections speaks more 
for a secondary importance. 

Cocci, for which a specific role has 
been claimed, have been found: in 
•erysipeloid, by Rosenbach, a coccus 
with which he could produce this af- 
fection; in beri-beri, by Pekelharing 
and C. Winkler (16), a certain coccus 
which has been prepared by Lacerda 
Ogata (11) with the bacillus of malig- 
nant pustule. In plague, the inocula- 
bility of which has been demonstrated, 
various authors have found micro- 
cocci; in the seborrheic scales Unna 
found morococci. Sabourand (12) 
holds responsible for all forms of 
alopecia the toxins of a micrococcus 
with which he could produce falling 
out of the hair in animals. 

We, therefore, find various bacteria 
in one and the same disease, while ob 
the other hand the same micrococcus 
(often alone) appears in various dis- 
eases. 

A similar condition is observed with 
the bacilli, although several are fixed. 
I need but remind you of the b. an- 
thracis, diphterise, typhus, which ap- 
pear on the skin — the bacilli of rhino- 



scleroma appear to be certainly pathog- 
nomonic. For tuberculosis of the skin 
we have to consider scrophuloderma 
ulcerosum, lupus vulgaris, tuberculosis 
verrucosa cutis, ulcus tuberculosum 
cutis, and the tuberculous skin tumors, 
in which the tubercle bacillus can be 
demonstrated, though in small num- 
bers. 

Bacilli similar to those of malignant 
pustule, as already mentioned above, 
have been found in beri-beri, and by 
E. Fraenkel in gas phlegmon. Schat- 
tenfroh considers Fraenkel's find iden- 
tical with the bacillus of lactic acid 
fermentation. 

The question raised by Schimmel- 
bush (14, p. 23), viz. : whether the ba- 
cilli pyocyanci can penetrate into the 
tissues of the body of man and develop 
pathogenic propeities, and which was 
left unsolved by him, has been an- 
swered in the affirmative by F. Hitsch- 
mann and H. Kreibich (13), who have 
demonstrated the bacilli in the tissues 
of patients afflicted with ecthyma 
gangrenosum. 

Matzenauer (Lang, 15, p. 242) has 
established a bacillus for hospital gan- 
grene, respectively for the related 
gangrenous genital ulcer, the culture 
and inoculation of which yielded in- 
sufficient results. In seborrheic ec- 
zema Unna's bottle bacillus plays a 
role. 

The bacillus fluorescens liquefaciens 
has already been mentioned above in 
connection with foudroyant gangrene 
(Fournier) of the genital skin (Lang).' 

In erysipeloid elephantiasis which 
occurs in Egypt, and which should be 
differentiated from the lymphorrhagic 
form, Ines (16) found bacilli with 
thin ends. 

Even the bacterial products of meta- 
bolism have been considered by au- 
thors. According to Bockhart, E. 
Bender and V.Gerlach, typical eczema 
can be produced with the toxins of 
staphylococci alone or in connection 
with staphylococci. According to the 
French school, the products of raeta 



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holism of the tubercle bacilli are the 
cause of the so-called tuberculides. 
To these belong lichen scrophulosum 
(scrophuloderma papulosum), acne 
cachectica, lupus erythematodes and 
pityriasis rubra Hebra. 

As regards the genital diseases, we 
are positive about the gonococcus of 
Neisfeer. Ducrey has discovered a 
bacillus in ulcus molle, and later Unna 
has found a strepto-bacillus, which 
Krefting has studied in the pus of 
bubo. According to Andry, both are 
identical. 

Bacteriologically syphilis has long 
been of special interest to us, and 
numerous experiments and discoveries 
have been published. 

According to Baumgarten (6, p. 392), 
Aufrecht and others have early de- 
scribed forms of cocci. 

EassowitzandHochsinger (17) have 
found in the blood vessels of children, 
suffering from hereditary syphilis, a 
streptococcus, which has been demon- 
strated by Kolisko (18) and Chotzen 
(19) to originate from a secondary in- 
fection. 

Much more numerous were the find- 
ings of bacilli. After a long series of 
such, which, however, did not stand 
the test, the belief prevailed that Lust- 
garten's bacillus was the true and cor- 
rect one. As is well known, the same 
has also been demonstrated in the 
smegma preeputii. 

Lehmann and Neumann (20, Vol. ii, 
p. 375) say: **No bacteriologist be- 
lieves today in Lustgarten's bacillus, at 
least as regards its relation with 
syphilis;" while Migula (21, ii, p. 497) 
believes that one should not go that 
far. 

The publications of Niessen raised a 
lot of dust, and have been repeatedly 
attacked; this after discoveries of 
bacilli in syphilis have been reported 
by Eve and Lingard, Disse and Tagu- 
chi. They were followed by Justin de 
Lisle and Louis Tullien (22 and 24), 
also by Paulsen (23). 

The findings of tnese micro-organ- 



isms were based on their presence Id 
the blood of syphilitics and in syphil- 
itic products. 

The fact that lues is hereditary has 
long ago suggested the theory of germ 
transmission. 

As regard tuberculosis, Baumgarten 
(6, p. 103) cites lani (26, p. 522^^ 
who has demonstrated tubercle bacilli 
in the sperma of phthisics whose 
genitals were normal. 

Thus we can conceive a hereditary 
tuberculosis. Baumgarten further- 
more calls attention to the so-called 
Flecksucht (Pebrine disease) which 
attacks the silk-worm epiJermically, 
caused by the microbion Pebrine: 
**The Pebrine parasites enter from the 
sick butterfly in the cells of the ova 
and seed, which carry the disease germ 
in the insect now developing from 
them, so that it also becomes attacked 
by the Pebrine disease, the parasite of 
which grows with the growing cell of 
the ovum." 

This fact is positivelj' established, 
and analogous to it we can conceive 
the process of transmission of heredi- 
tary syphilis. Max Joseph and Pior- 
kowski (26) chose for their experi- 
ments the sperma of syphilitics, and 
have succeeded, after inoculating ster- 
ilized human placenta, in cultivating 
colonies of bacilli grouped like fences. 

The same bacilli were also found di- 
rectly in luetic sperma, in the blood of 
syphilitics and in syphilitic products^ 
while the results in healthy men, or 
such who had been infected a long- 
time ago or in whom treatment has 
produced an apparent cure, were all 
negative. 

In comparison with the other dis- 
coveries the last named seem to have 
the best chance of solving the bacteri- 
ologic problem of syphilis. 

A final decision, however, at present,, 
must be withheld until further exami- 
nations and experiments are made. 

Sabourand (27), in regard to the 
importance of streptococci and staphy- 
lococci in theetiology of the derma- 



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tesesy holds responsible three of their 
kiads, viz. : the streptococcus identical 
with that described by Fehleisen, the 
staphylococcus aureus and the staphy- 
lococcuH cutis communis. 

If we survey our arrangement of 
the cocci, we must conclude, that even 
according to the same, these three 
varieties play the chief role. 

There must be, however, a strict 
differentiation between their char- 
acter as an etiologic factor, as for ex- 
ample in impetigo, sycosis coccogena, 
erysipelas, etc., and as a secondary 
find as in morbilli, scarlet fever, etc. 

As regard the other cocci, with the 
exception of the gonococcus, partially 
their exisience are but secondary, par- 
tially their identity with the above 
named must be accepted. 

While we observe one and the same 
species of cocci in various diseases, we 
notice that the Bacilli have the char- 
acteristic property of either produc- 
ing one special disease or to accom- 
pany such an one. 

The proof of their relation to the 
large number of dermatoses as an 
etiologic factor is settled only in a few 
instances, in otherstheir presence justi- 
fies only a supposition of their etiologic 
role, which must be acceptded as un- 
certain at best. 

This especially holds good for the 
Joseph-Piorkowski bacilli, which, ac- 
cording to the latest experiments, 
decidedly oppose the assumption of 
their causal relation to lues. 

Therefore, in spite of untiring re- 
searches, the bacteria as causative 
factors of the affections under discus- 
sion have been established but in a few 
instances. 

The reason for this may be that per- 
haps the largest part of the dermatoses 
are due to mechanic, nervous, patho- 
physiologic, chemic and parasitic 
causes. 

LITERATURE. 

(1) G. W. Damtnann: Vorlaeufige Mitteil- 
ungen ueber einige Mikroorganismen der nor- 



maleo Haut. Brit. Med. Joarn., 16. vil. 1892. 

(2) C. Guenther: Einfuehrnng in das Sta- 
dium der Bakteriologie. Leipzig. 1898. 

(3) Garre: Portocfaritte der Medicin. 1886. 

(4) E. Klein: Ueber einen fuer Mensch 
« und Thier pathogenen Mikrococcus, Stapbylo- 

coccns bsemorrbagicus. Centralblatt fiier 
Bakteriologie. IV. 1897. 

(6) Jordan: Archiv fuer klin. Chirurgie. 
1891, Band 42. 

(6) Baumgarten: Lebrbncb der patbolog. 
Mykologie. Braunschweig. 1890. 

(7) Cornil et Babes: Les Bacterics. 2 ed. 
1886. 

(8) E.Klein: Tbe Etiology of scarlet fever. 
Proceedings of the Royal Society. Vol. xlxx. 

(9) Jamieson and Edingtpn: Brit. Med. 
Jour., 1887, Juni 11, Aug. 6. 

(10) Pekelharing und Winkler: Mitteil. 
ueber die Beri-Beri. Deutsche med. Wochen- 
schr., 1887, No. 39. 

(11) Ogata: Muenchen aerztl. Intelligenz- 
blatt, 1886, No. 47. 

(12) R. Sabourand: Malad. du cuir chev- 
elu. I. Les mal. seborrheigues. Paris. 1902. 

(13) P. Hitschmann und K. Kreibich: Zur 
Patbogenese des Bac. pyocyanens Und zur 
Aetiologie des Ekthyma gangraenosum. Wi- 
ener klin. Wochenschr., 1897, No. 50. 

(14) C. Schioimelbusch: Anieitung zur 
aseptischen Wundbehandlung. Berlin. 1892, 

(16) Ed. Lang: Lehrbuch der Hautkrank- 
heiten. Wiesbaden. 1902. 

(16) Ines: Mikroorganismen bei den Wund- 
infectionskrankheiten des Menschen. Wies- 
baden. 1884. 

(17) Kassowitz und Hochsinger: Wiener 
med. Blaetter, 1886. No. 4. 

(18) Kolisko: Wiener med. Blaetter, 1886, 
Nos. 4 und 6. 

(19) Chotzen: Vierteljahrsschr. f. Derma- 
tol, u. Syph. 1887. I. 

(20) Lehmann und Neumann: Atlas und 
Grundriss der Bakter. 

(21) W. Migula: System der Bakterien. 
Jena. 1900. 

(22) Justin de Lisle et Louis Jullien: 
Deutsche med. Wochenschr., 1901, No. 29. 

(23) Paulsen: Biolog. Abt d. aerztl. Ver- 
eins. Hamburg. Sitz. 14. I. 1902. Muen- 
chen, med. Wochenschr., 1902, No. 9. 

(24) von Niessen: Betracht. ueber de 
Lisle's und Jullien*s Syphilisbacillen. Klin, 
therap. Wochenschr., 1902, No. 14. 

(26) Jani: Ueber das Vorkommen von 
Tuberkelbacillen im gesunden GenJtalapparat 
bei Lnngenschwindsncht, etc. Virchow's 
Archiv, Band ciii, 1886. 

(26) Maxjosephund Piorkowski: Berliner 
klin. Wochenschr.. 1902. Nos. 13 u. 14; 
Deutsche med. Wochenschr., 1902, Ncs. 60-62. 

(27) Sabourand. Paris: Die Rolle der 
Streptococcen und Staphylococcen in der 
Aetiologie der Hautkrankheiten. 69. Jahres- 
vcrs. der Brit. med. Gesellsch. in Ct el ten- 
ham. Brit. J6um. of Dermatology, 1901, Sep- 
tember. 



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rUB TBCHNIQUB OF PROSTATECTOMY. 

Bt Niosolas Ssnn, M. D., Chicago, lUlnois. 

The following is an expression of 
Dr. Nicholas Senn's views on the tech- 
nique of prostatectomy: The ques- 
tion as to the most feasible route by 
ivhich to attack the diseased prostate 
hsLS not been definitely settled. The 
suprapubic method has many weighty 
-advocates, and for a time was deemed 
the easiest, most efficient and safest. 
The perineal route has, however, been 
.given a more extended trial, and a very 
large experience appears to have de- 
•cided in its favor. From an anatomic 
standpoint, the perineal operation is 
•certainly the most rational of the two, 
and will undoubtedlj'^ survive the test 
of time. The removal of the enlarged 
prostate does not always meet all the 
indications in the case operated on. 
Few cases come to the surgeon in 
which the bladder is intact in conse- 
<juence of the mechanical obstruction 
or infection, hence in the majority of 
cases it becomes necessary to estab- 
lish free drainage after the removal of 
Hxe prostate for the purpose of initiat- 
ing a successful treatment for the co- 
•existing complications. Every sur- 
geon who has had an extensive experi- 
-ence in perineal prostatectomy has 
Jearned that not all enlarged prostates 
-can be removed by enucleation. There 
are cases in which the diseased organ 
must be removed by morcellement. It 
is a rule in surgery, which it is always 
well to bear in mind, and that is to op- 
erate as little as possible in the dark 
in important anatomic localities, and 
this rule applies with special force to 
perineal prostatectomy. In obese sub- 
jects and in cases of very large pros- 
tates it is often exceedingly difficult to 
bring the parts to be removed within 
reach of the index finger. It is under 
these trying circumstances that the op- 
erator will appreciate the advantages 
of an incision that will expose the pros- 
tate freely and bring it within easy 
reach of the finger or the instruments 



required for its removal. Very little^ 
is gained by attempts to render the 
prostate more accessible by intraves^ 
ical instrumental pressure, and such: 
efforts are by no means always harm-^ 
less. The danger from hemorrhage 
and accidental wounding of the peri- 
toneum is reduced to a minimum by 
resorting to an incision that will ex- 
pose the prostate in the freest possible 
manner to sight and touch. I have= 
attempted to do this by combining the 
median incision with two lateral in- 
cisions, representing in outline an in- 
verted capital Y. The median incision 
is made in the usual way, laying bare 
the membranous portion of the urethra. 
The lateral incisions are carried from 
the lower angle of the median to a 
point half way between the anal mar- 
gin and the tuberosity of the ischium, 
cutting through about the same struct- 
ures as are involved in the lateral op- 
eration for stone in the bladder. The 
wound is next deepened largely by the 
use of blunt instruments and all hem- 
orrhage arrested as it occurs, main- 
taining throughout the entire opera- 
tion practically a bloodless field. This 
will give the operator an opportunity 
to recognize and identify the tissues as 
he proceeds with the dissection. In 
this comparatively bloodless way the 
rectum is detached until the membran- 
ous portion of the urethra and the 
lower segment of the prostate can be 
distinctly seen and felt in the apex of 
the deep triangular wound. By using 
narrow, flat, deep retractors the rec- 
tum is pushed backward and the" 
wound margins are retracted laterally, 
thus exposing freely the parts con- 
cerned in the next step of the opera- 
tion. I then proceed as follows: On 
a grooved staff, which is now inserted 
into the bladder, the membranous por- 
tion of the urethra is incised and the 
grooved director of Wheellhouse in- 
serted into the bladder. Withdrawing 
the staff and using the director as a 
guide, the prostatic part of the urethra 
is dilated with the left index finger. 



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The Technique of Prostatectomy—Senn. 



210 



which, after it enters the bladder, 
serves as a blunt hook with which the 
prostate is drawn gently downward and 
forward into the wound. The capsule 
of the gland is next incised transversely 
4Uid with the opposite index finger enu- 
cleation of the left lobe is commenced. 
This part of the operation is usually 
•asy, sometimes difficult and not infre- 
quently impossible. Recklessness and 
undue violence are to be carefully 
avoided. Enucleation is often facili- 
tated by grasping the lower part of 
the prostate with my bullet forceps or 
some other grasping instrument on 
which traction is made during the pro- 
cess of enucleation. I seldom attempt 
to remove the prostate in its entirety. 
Occasionally this can be done, but 
usually it will be found much easier to 
remove only one lobe at a time. After 
the removal of the left lobe the right 
index finger is inserted into the blad- 
der and the right lobe enucleated with 
the left. If it is found impracticable 
to remove the prostate by enucleation 
morcellement must be resorted to. 
The finger in the bladder is almost in- 
dispensable in operating by this 
method. With it the parts are brought 
within easier reach, and it serves at 
the same time as a valuable guide for 
the use of the cutting and traction in- 
struments. With grasping forceps 
portions of the gland are seized, when 
the necessary traction is made by an 
assistant, while the surgeon does the 
•cutting with blunt-pointed scissors 
well curved on the flat. Complete 
prostatectomy in such cases is not 
necessary, but enough tissue must be 
removed to insure a free outlet for the 
urine and to guard against a recur- 
rence of obstruction from the same 
cause. I am decidedly in favor of a 
preliminary cystotomy in performing 
perineal prostatectomy, as it greatly 
facilitates the removal of the gland by 



enucleation or morcellement, and in 
the majority of cases it becomes a ne- 
cessity for the treatment of complicat- 
ing affections of the bladder. It is 
preferable to incise the urethra and 
take advantage of such an openins: 
into the bladder during an operation 
than to tear it accidentally, as is so 
often done when operators undertake 
a perineal prostatectomy without a 
perineal cystotomy. I invariably drain 
the bladder by inserting a soft rubber 
drain with two oval fenestra near thd 
vesical end. The drain is fastened in 
the lower angle of one of the lateral 
incisions with a suture which includes 
the outer margin of the wound. The 
perineal wound is drained with a strip 
of iodoform gauze, which is brought 
out on the side of the rubber drain. 
The balance of the incision is sutured. 
The bladder is kept practically empty 
by siphonage by connecting the peri- 
neal drain with another piece of rubber 
tubing, making the connection with a 
glass tube. Throiigh this rubber drain 
the bladder can be washed out daily 
with appropriate antiseptic solutions. 
The iodoform gauze drain should re- 
main for at least five or six days, as its 
presence in the wound is of the great- 
est value in preventing infection by 
leakage of septic urine. The bladder 
drainage must be continued until the 
condition of the urine is sueh as to 
warrant suspension of intravesical 
medication. 



Dropsy is a marked and obstinate 
symptom of chronic parenchymatous 
nephritis. The face is pale and puffy, 
and in the morning the eyelids are 
oedematous. The anasarca is general, 
and there may be involvement of the 
serous sacs. Anasarcin tablets, prop- 
erly administered, will produce aston- 
ishing results. 



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CIRCUMCISION AND FLAOBLLATION 
AMONQ THE FILIPINOS. 

While I was in the Philippines in 
1899 and 1900, and particularly while 
stationed at San Miguel de Mayumo, 
Calumpitand Hagonoy, in the province 
of Bulacan, Luzon, I had exceptionally 
good opportunities, through the assist- 
ance of two educated and liberal na- 
tives who spoke Spanish— one a mes- 
tizo and the other an indio — for learn- 
ing about some of the less generally 
known customs of the Filipinos. 

The indios -- those who have the 
least admixture of non-Malay blood — 
are, as a rule, extremely secretive and 
distrustful of foreigners, whom they 
call ^^Gastila^^' a word derived from 
the Spanish ^'Castellanoj'' which 
means Castillian or Spaniard. This 
term is applied by the Philippine indio 
to all white men. The great body of 
the natives are as secretive toward for- 
eigners as are the Chinese. Priests 
and others who have spent their lives 
among them, say that it is impossible 
for any one to understand their char- 
acter unless he has played with them 
in childhood and lived his life as one 
of them. T^hey have a great many 
ancient pagan rites and superstitious 
customs, of which some are derived 
from the rites of various religious sys- 
tems and some are of secular origin. 
Some of those which had their origin 
in religious observances have long since 
lost all religious association, while 
others which formerly had no connec- 
tion with any system of religion what- 
ever have become embodied in a sort 
of semi-Christian semi-pagan worship. 
Most of the Tagalos, who are nomi- 
nally Christian and Catholic, observe 
not only the rites of the Catholic 
Church, but many pagan rites and cus- 
toms as well. Some of these latter 
are purely tribal in their prevalence, 



while others are observed throughout 
the archipelago and have come to hold 
an almost national meaning and asso- 
ciation for many of the natives. Even 
the fact of the existence of some of 
the most prevalent of their customs is 
unknown to many white men who have 
spent considerable periods of time in 
contact with the native. 

Though I have read, I think, every 
book descriptive of Philippines pub- 
lished previous to 1901 in the English 
language and many of those published 
in Spanish, I do not remember to have 
seen any mention of circumcision in 
any of these books, and the only men- 
tion of flagellation which I recall was 
in Foreman's very comprehensive book 
in which he mentions that a Spanish 
sea captain told him that be had seen 
flagellations in one of the more south- 
ern islands. Extremely few white men 
have seen flagellants in the Philippines^ 
though flagellation is prevalent. I be- 
lieve that the following is the first pub- 
lished description of circumcision and 
flagellation as performed in ihe Phil- 
ippines: 

Circumcision is a very ancient cus- 
tom among the Philippine indiosy and 
so generalized that at least 70 or 80 
per cent, of males in the Tagal coun- 
try have undergone the operation • 
Among them, being uncircumcised is 
looked upon as a defect, so much so 
that children of both sexes cruelly 
taunt those who have reached the age 
of puberty and are still uncircumcised. 
They apply to them with intent to in- 
sult the term ^^supvt^'^ which orig- 
inally meant "constricted*' or "tight, "^ 
but has come to mean "one who can- 
not easily gain entrance in sexual in- 
tercourse." When American troops 
first came to Hagonoy and bathed in 
the river, the fact that they were un- 
circumcised was a subject of great 



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^ssip in the market place. It is not 
known where the natives got the cas- 
tom — possibly from the Mohammedan 
Moros of the southern islands. The 
Moro men are all circumcised by their 
^^panditas^^' or priests, as a religious 
ceremony necessary to make them eli- 
gible for matrimony, but among the 
Tagalos, who are professed Catholics, 
the operation has no religious associa- 
tion. Neither is it among them done 
on account of any idea of cleanliness, 
but from custom and disinclination to 
be ridiculed. The friars were not 
able to root out the custom, as it was 
an ugly subject to treat of from the 
pulpit. Among the Jews the opera- 
tion is done on the tenth day after 
birth, but among the Philippinos — 
both Mohammedan Moros and Chris- 
tian Tagals — it is practiced at the age 
of from eight to twelve years. In the 
Tagal country it is called *'Huli^^' and 
is performed as follows: The opera- 
tor provides a polished piece of wood, 
sufficiently curved and of such length 
that when one end of it is driven into 
the ground the boy to be operated 
upon can '*squat on his hams"- prac- 
tically sit on his calves — and insert the 
free end of the stick, which is pointed, 
between the head of his penis and his 
foreskin. After the foreskin has been 
drawn over the point of the apparatus, 
which is called ^^tamurung^'' the op- 
erator (also in the squatting position) 
picks up a sharp knife and places it so 
that the edge rests lengthwise on the 
foreskin. Then, holding the knife in 
place with one hand, he gives it a sharp 
blow with a stick of wood or a joint of 
cane held in the other. If he does not 
succeed in entirely exposing the head 
of the penis at one blow, he gives a 
second or even a third. Guava leaves, 
which are astringent, are afterward 
applied in the form of a paste made by 
chewing the leaf, or in the form of a 
powder prepared by burning them, 
and the wound is bandaged. The 
dr/dssing is changed daily. While the 
wound is fresh the patient cannot wear 



trousers on account of the pain they 
would cause, and he wears instead 
merely a cloth dropped from his 
middle. 

Flagellation was a custom probably 
taken from the early Spanish friars, 
but it has been so discouraged of late 
years by the church that it is per- 
formed only in smaller villages of the 
interior and in the outlying barrios of 
the larger towns, more or less secretly, 
away from the sight of white men. 
But, notwithstanding the fact that the 
existence of flagellation among the 
Filipinos is practically unknown to 
foreigners, it is extremely prevalent 
during Holy Week. On Holy Thurs- 
day in 1890, while at Hagonoy in Bula- 
can Province, having learned about the 
flagellants from a native, I took 
some pains to see something of them, 
and riding out alone at some risk suc- 
ceeded in seeing a number. 

Although the Philippine flagellants 
are called ^^penitentes*^ the flagellation 
is not done in penance, but as the re- 
sult of a vow or promise made to the 
deity in return for the occurrence of 
some wished-f or event, and the '*peni- 
tentes*' are frequently from the most 
knavish class. A person falls ill, for 
example, and he promises the deity 
that if he gets well he will perform 
penance of such and such kind, during 
such and such days of Holy Week, for 
so many years. Or if he has an enemy 
whom he wishes to get rid of he vows 
that if this enemy dies, he will drag a 
ball and chain, or flagellate himself, 
or perform some other specified pen- 
ance on Holy Thursday every year 
during the rest of his life. Back of 
the small chapel called '*rm7a«," which 
exists in every village, begins his pen- 
ance. With his face covered to prevent 
recognition, stripped to the waist, and 
with no clothing but loose, thin, white 
cotton trousers, one finds him stand- 
ing with his arms folded, his head 
bowed forward and his body bent, 
while an everyday-looking native slaps 
him on the back till the blood comes 



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into the skin. Then he is spatted with 
a piece of wood with little metal points 
in it till his back is macerated and the 
blood runs freely. Then he starts out 
on a long day's journey from viaita to 
visita. He is certainly a w«ird and 
barbaric spectacle as he silently and 
slowly stalks along with covered face, 
swinging from side to side a cord into 
the end of which is braided a bunch of 
sticks about the size of pencils, which 
strike his bare bleeding back a loud 
sound at every step and macerate it so 
the blood oozes down and soaks his 
white trousers. At short intervals he 
prostrates himself in the dust, utters 
some unintelligible jargon, possibly a 
prayer, while the everyday-looking 
citizen spats him on the back and on 
the soles of the feet with a flail as he 
grovels there. At intervals the out- 
landish figure goes through grotesque 
contortions or progresses by hand- 
springs. Whenever he comes to a 
stream or ditch be plunges into it, and 
whenever he reaches a visita he grovels 
before it and spends much time in 
prayer. One may see these flagel- 
lants lying prostrate in the dust for 
long periods at a time. But the chief 
picture one carries in mind is an erect 
native with covered face, bare bloody 
brown back, and blood-stained trou- 
sers, stalking slowly forward alpng 
the bamboo -fringed roads to the 
rhythmic accompaniment of the swing- 
ing scourge, while from every house 
for miles comes a weird monotone lilt 
which represents the chanting of the 
passion. — Lieutenant Charles Norton 
Barney, U. S. A., Medical Depart- 
ment, in Journal of the Association of 
Military Surgeons. 



ACNB SIMPLEX. 

Every general practitioner is ex- 
pected to keep himself informed of the 
latest advances in all the wide range of 
medicine and surgery, including, of 
course, all the special branches. Fort- 
unately he is not expected to be thor- 
oughly conversant with all the refine- 



ments of technique ; nor is he expected 
to be able to apply all the methods of, 
for instance, modern gynecological 
surgery, plastic and abdominal. But 
he is expected to know when they 
should be employed, and it is his prov- 
ince to assist the afflicted patient, or 
her family, in the choice of a compe- 
tent person to employ them. All this 
being demanded of the general practi- 
tioner, is it not just that the specialist, 
for instance, in gynecology and ab- 
dominal surgery, should also be ex« 
pected to keep well informed regard- 
ing the concomitant ills from which 
hi$ patient may suffer? We certainly 
do not wish to encourage the soi disant 
'•universal specialist" who styles him- 
self a specialist in whatever ailment 
any individual patient may exemplify, 
but merely to encourage a broadening 
of the specialist field of observation, if 
not of practice. 

Among the minor concomitant ills 
by which women with pelvic disease, 
especially functional disease, are an- 
noyed, perhaps none is more frequent 
than acne simplex, or, as it is fre- 
quently called, acne vulgaris. And, 
perhaps there is no minor ailment in 
which both the general practitioner 
and the gynecologist fail more abso- 
lutely in aiding the patient. Leaving 
out of consideration the young girls at 
puberty, it is not at all difficult for any 
gynecologist to recall many cases in 
which he has been consulted regarding 
minor functional pelvic disordei^s, not 
because they were themselves so 
troublesome, but in the hope that 
through them the real cause of the an- 
noyance, acne, might be reached. In 
this point of view we'have been con- 
siderably impressed by a symposium 
upon the etiology and treatment of 
acne pmblished in the Transactions of 
the American Dermatological Associa- 
tion, and recently mentioned in the 
Annals. 

Dr. Gilchrist, of Baltimore, after 
most careful and painstaking investi- 
gation, is certain that acne is due to. 



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228 



the presence of a specific bacillus 
which he terms the bacillus acnes. The 
pustular form is apparently due to 
a mixed infection of the bacillus acnes 
and the staphylococcus pyogenes. 

But what most interests the gyne- 
cologist and practitioner is the treat- 
ment of this condition. The paper 
upon thia subject was contributed by 
Dr. Fox, and was abundantly dis- 
cussed by many of the most prominent 
dermatologists in America. 

The most useful method of treat- 
ment in severe cases seems to be the 
curettage of all lesions with a broad, 
sharp curette, thus covering a large 
area at one seance. Of equal import- 
ance is the extraction of all comedones, 
and the opinion is advanced that if 
careful search, with a lens if neces- 
sary, is made for incipient comedones 
their extraction thus early will do much 
toward the prevention of future acne 
lesions. 

Massage, not according to any fixed 
rules of manipulation, but merely by 
gently pinching the skin of the af- 
fected area, is also considered of great 
value, and as a topical application sul- 
phur in some form is acknowledged to 
be the most eflScacious. Many argue 
strongly against the employment of 
unguents in any form, and suggest 
that in massaging the face powdered 
pumice-stone be used to keep the fin- 
gers from slipping. We have recently 
seen very happy results which seem 
more rational from the substitution of 
aarphur for the powdered puniiice. 
Laxative and general hygienic meas- 
ures are of well-known and undoubted 
advantage. Every woman having a 
concomitant pelvic disease and acne 
has a right to expect that both condi- 
tions receive proper treatment, or that 
she at least be aided to the proper 



treatment if the gynecologist or prac- 
titioner do not feel competent to em- 
ploy it, and to this end we wish these 
articles might be read by all. — Annals 
qf Gynecology and Pediatry. 

AN EPIDEMIC OP TRICHOPHYTOSIS OF 
THE SCALP IN SCHOOL CHILDREN 

Werther describes an epidemic of 
ringwonn in school children, seven- 
teen out of thirty being affected. The 
main points of interest being : 

1. The different clinical forms in 
some of the cases. 

2. The identity of the trichophyton 
as shown by cultures. 

3. The botanical peculiarities as 
shown in cultures, especially in the 
method of ''Plaut." 

4. The successful inoculations of 
pure culture in animals and on man. 

The source of infection could not be 
positively established, but the first case 
developed in a boy on his return from 
a vacation. The author mentions cat- 
tle as a possible source of infection, 
although near the end of his article he 
identifies the growth as Sabouraud's 
tricophyton of the cat. He recom- 
mends \he ingenious method of Plaut 
(Muench. Med. Wochensvhr.^ 1902, 
No. 5, S. 208), of placing the suspected 
hairs between a slide and a cover-glass, 
which is placed on moist blotting-paper 
in a Petri-dish. The aerial forms of 
growth from the tricophytic hair give 
a very typical picture in from six to 
eight days. The endogenous spores 
or terminal chlamydospores render 
identification easy. The dry cultiva- 
tion of the tricophytons frees it from 
contamination by bacteria and pus* 
cocci, and affords an admirable method 
in studying the trichophytons.— Wer* 
ther, in monatshft. f. Prkt. Dermt. — 
Exchange. 



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DiSSASES OF MSTABOUSM AND NXTTBITION. ] 

Db. Carp von Noobden. Published by K. 
& Co., New York City. 1903. 

So many diseases and pathological 
conditions spring from disorders of 
metabolism and nutrition that ample 
grounds for elaborate study of these 
processes are apparent to every physi- 
cian. 

The author, in this little volume, 
takes up that troublesome disease de- 
scribed as membranous catarrh of the 
intestine, or colica mucosa, and thor- 
oughly discusses its pathogenesis and 
treatment. His lucid presentation of 
this disease and the rational treatment 
outlined should be carefully studied by 
the general practitioner, who so often 
has to deal with it. 

A System ov Phtsiolooio Thebapeutios. A prmctical 
exposition of the methods, other than dnu giving, 
useful for the prevention of disease and in the treat- 
ment of the siok. Edited bj Solomon Solis Cohen. 
A. M., M. D., Senior Assistant Professor of Clinical 
Medicine in Jefferson Medical College. Volume X, 
Pneumotherapy, including ^rotherapy and Inhala> 
tion Methods and Therapv. By Dr. Paul Louis Tis- 
sier. One-time Interne of the Paris Hospitals, As- 
sistant Consulting Physician to Lamneo and Lari- 
boisiere Hospitals, Chief of Clinic in the Faculty of 
Medicine of the University of Paris. Illustrated. 
Philadelphia: P. Blakiston^s Son Sc Co., 1012 Wal- 
nut street. 1903. 

The above volume contains a philo- 
sophical presentation of a most impor- 
tant branchof physiologic therapeutics, 
which has not been sufficiently recog- 
nized and studied by the practical 
workers in the medical profession. As 
a therapeutic agent, the air cannot be 
ignored. Its relation to health and 
disease is too intimate and constant to 
be overlooked. At this time the open 
air treatment of consumption empha- 
sizes the necessity of investigation 
along the lines of this volume. Part 
1st treats the whole subject of eero- 
therapy exhaustively, whilst Part 2d 
takes up inhalation methods and 
therapy. It must be borne in mind by 
the reader that physiologic therapy 
does nbt antagonize wisely directed 
pharmacotherapy. They are allied 



sciences of equal value to the pro- 
gressive members of the medicalguild. 

Pbaotioal Hand-Book of the Pathology of the Skin. 
An introduction to the histology, pathology and 
bacteriology of the skin, with special reference to 
technique. By J. M. H. Maoleod, M. A., M. D , M. B. 
0. P., Assistant in the Dermatological Department, 
Charing Cross Hospital; Physician to the Skin De- 
partment, Victoria Hospital for Children. With 
eight colored plates and thirty-two black and white 
plates. Philadelphia: P. Blakiston's Son & Co., 
1012 Walnut Street. 1903. 

This most excellent book furnishes 
the groundwork upon which cutaneous 
pathology rests. The author elabo- 
rates all of his views of skin lesions 
from the anatomo-pathological basis. 
In this way he avoids much of the 
present embarrassment connected with 
nomenclature. He discusses the de- 
velopment, general characteristics and 
minute structure of the cutaneous tis- 
sues, and then describes the pathologic 
changes which they are liable to 
undergo. He devotes due attention 
to the various methods for histological 
examination of the different cutaneous 
structures. His views on the causal 
relation of micro-organisms to skin 
diseases are rational and conservativo. 
He maintains that Koch's postulates 
must be accepted in determining this 
question. This book also has the 
merit of being the first and only one 
on the special lines mapped out by 
the author. It is the outcome of pro- 
longed labor and research, and will 
prove a useful guide to students and 
physicians who wish to gain a thorough 
knowledge of thin branch of medicine- 
Price, $5.00 net. 

Human Anatomy. By Samuel O. L Potter, M A., 
M.D. Seventh edition, revised and enlaised. Price, 
80 cents net. P. Blakiston's Son & Co., Philadelphia. 
1903. 

The present edition of the above 
quiz-compend has been rewritten, en- 
larged by the addition of 82 pages, 
and brought completely up to date. 
This expansion of the text allows room 
for a more thorough elaboration of 



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Which yieMs thirty times lU vol- 
ttme of «• nascoot oxygon *' noor 
to the cooditiofi of ••ozone,'* 

is daily proving to physicians, in 

some ne^ way, its wonderful efficacy 

in stubborn cases ol Bozema^ PBoriuaiBf 8mlt Rheum, Itet, 

Barber* a Itob, Bryaipelaa, Iry Poiaoning, Ringworm, 

Herpea Zoater or Zona, afe. Acne, Bimplea on Face 

are cleared up and tlie pores healed by NYIMOZONE and OLYCOZONC 

in a way that is 



mac:ical. Try this 
treatment ; results 
will please you. 

Full method of treat. 
Dient In my book. 
•* The Thenpeuticml 
Applications of H]r> 
drozone and Glyco> 
sone * • ; Seventeenth 
Edition, 339 paRes. 
Sent free to physidaos 
oa fequest. 



Prepsrad only hf 



Cbenlst and Graduate of the *• Ecole Centrale dea 
Arts et Manu&ctures de Paris '» (France) 

57-59 Prince Street, New York 



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essential details without interfering 
with the condensed form of statement 
heretofore adopted. As it now stands, 
it will meet all the wants of the med- 
ical student in preparing for his ex- 
aminations. The total number of 
illustrations has been increased from 
117 to 138, and the tables and plates 
heretofore appearing in an appendix 
are now placed in the text. 

LuoOTHiBAPT. By 0. E. RoOBBS. M. D. Published by 
the Metropolitan Press, Seattle, Wash. 

The above is a very interesting book. 
Its style is clear and forcible. The 
author is very enthusiastic over the 
results he has obtained from light 
treatment in a great variety of dis- 
eases. He employs the combined rays, 
and claims they penetrate deeper and 
are adapted to a wider range of patho- 
logical conditions than the actinic 
rays alone. His views are optimistic, 
but appear to be corroborated by a 
large number of clinical tests. He 
claims that lucotherapy is applicable 
to all forms of inflammation, and exerts 
its therapeutic effects by vibratory 
force; that it is bactericidal, tonic, 
counter-irritant, analgesic and hyp- 
notic in its action. Undoubtedly light 
therapy has a bright future, but it 
will take time and patient investigation 
to estimate its full value. 

DI8BA8B8 OF THB SKIN. By JaT F. SHAMBBBO, A. B., 

M. D. Third edition, revised and enlarged with 106 
illastrations. Philadelphia: P. Blaklston's Son & 
Co. Price, 80 cents net. 1903. 

This little book will serve as a use- 
ful guide to the medical student and 
convenient reference work to the 
busy practitioner. Its teachings, while 
in touch with the latest modern re- 
search, are practical and conservative. 
Especial attention is given to differ- 
ential diagnosis and treatment, and 
the clinical features of skin disease are 
thoroughly elucidated with suitable 
illustrations. More practical knowl- 



edge can be gained from a careful 
perusal of this book than from a pro- 
longed study of some more elaborate 
works. 

A Manual of Spboial Tbbatmbmt. By W. Watsoit 
Ohbtkb, M. B.,F. B. O. S., F. R. S., Professor of 
Snrjgery In King's College, London; Sorgeoii to King's 
College HospltaJ. ete., and F. F Bubohabd, M. D. and 
M. S. (Londl), F. B. 0. S., Teaeher of Practical Sur- 
gery in King's College, London; Snrgeon to King's 
College Hospital, etc. ; Complete work now ready. In 
seven imperial octavo volumes, with illostrationa. 
Volume Vll,595 oages, with 118 illastrations. Cloth. 
90.75 net. Lea Brothers & Go.,' Philadelphia and 
New York. 1003. 

This volume of the above manual 
of surgical treatment brings to com- 
pletion one of the grandest works of 
the age. The cordial reception, by 
the medial profession, of the previous ' 
volumes clearly shows there is an 
urgent demand for tho special informa- 
tion that this work supplies. The 
field of surgery has broadened to such 
an extent that no teit-book of surgery 
can do justice to the important sub- 
ject of special treatment, and the 
practitioner who is thoroughly ac- 
quainted with pathology, symptom- 
atology and diagnosis feels the want 
of this kind of information in the diffi- 
cult cases which he sometimes en- 
counters. The authors of this work 
have had an arduous task to perform,, 
but a brilliant success has crowned 
their laborious undertaking. It is 
eminently a practical work embodying, 
not all, but the best methods of treat- 
ment* As the work is devoted ex- 
clusively to surgical treatment, room 
has been found for elaboration of 
details in operative procedures and 
after-treatment* This will be realized 
better when we see the complete 
work comprises about 3W)0 pages. 
The present volume is devoted to the 
treatment of the surgical affections of 
the rectum, liver, pahcreas and spine, 
the genito-urinary organs, the breast 
and the thorax. No up-to-date practi- 
tioner or surgeon can afford to be with- 
out this work. 



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IMPORTANT 
FACTS 



III 



Pertaining To The Most Rational Treatment For INDIGESTION. 

INGLUVIN 

Not only Relieves the Symptoms, but Removes the Causoy by 
Its Peculiar, Active, Bitter Principle. 



IT 



TONES UP THE STOMACH 

INCREASES THE DIGESTIVE FERMENTS TO NORMAL 
STIMULATES THE GASTRIC AND INTESTINAL MOTOR ACTIVITY 
AS SISTS NATURE TO CARRY ON A NORMAL PHYSIOLOGICAL 
DIGESTION 



PILL INBLUVIN CCIIP- wbestive) 

— A COMPRESSED PILU UNCOATED. 

Combines all the excellent DIGESTIVE action of Ingluvin with 
the additional therapeutic value of Nux Vomica, Aloin and GIngerln. 



IT 



INCREASES THE BLOOD SUPPLY OF THE GLANDS AND 
MUCOSA OF THE STOMACH AND INTESTINES 

PREVENTS CONSTIPATION AND ACTS AS A CARMINATIVE 



INGLUVIN is indicated In all forms, including Nervous Dyspepsia, 
whether in the acute, sub-acute or chronic stage. 

IN8LUVIN IS A POSITIVE SPECIFIC FOR VOMiTINO IN OESTATION ANO THE 
POST NAUSEA FROM ANESTHETICS, CALOMEL, ETC. 

Prescribed in the same manner, dose and combination as Pepsin. 
LinRATURf AND SAINPLE8 CHEERFULLY SENT ON REQUEST. 

WHEN PRESCRIBING, SPECIFY WARNER A CO. AND AVOID SUBSTITUTES 

WM. R. WARNER. & CO. ■™'"^"««™, 

Philadelphia, New York, Chicago, New Orleans. 



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Therapeutic Suggestions. 
THERAPEUTIC SUGGESTIONS. 



GoNOBBHiEAL Cystitis. — With the 
ddoline of the acute and the onset of 
the subacute or chronic stage, the use 
of uriseptin will be of signal service in 
most cases. It should be administered 
in dessertspoonful doses with a teacup- 
ful of hot water four times a day. 

Injections into the bladder of warm 
solutions of boric acid usually give 
comfort to the patient. 



An Intebesting Clinical Case. — 
X, a white woman, twenty-two years 
of age, was taken into the hospital on 
account of syphilitic skin disease 
(roseola papula) ; a blennorrhagic 
vaginitis of most violent description, 
with strong congestion of the mucous 
membranes of the vagina. The latter 
was of violent hue, somewhat brittle, 
and yielded abundant secretion of a 
greenish yellow pus, which showed 
under bacteriological examination 
abundant colonies typical of gonococ- 
cas, diplococcus and other varieties of 
bacteria. The gonococci infection 
reached to the neck of the uterus, 
whose tissues suffered from the same 
degeneration as the vagina. Above 
the mouth of the neck — from which a 
greenish yellow and somewhat thick 
pus oozed — was a syphilitic ulcer of 
the size of a dime, clean at the bottom, 
livid in color and rather deep. 

Upon careful examination, the pa- 
tient was found to be pregnant in the 
third month, and, from the start, was 
subjected to energetic treatment as a 
serious case. 

Under the treatment employed she 
improved rather well ; but, though the 
blennorrhagia was not cured, the syph- 
ilitic manifestations of the skin disap- 
peared, and the ulcer at the neck im- 
proved somewhat until confinement, 
which took place at the eighth month, 
five months after her admission. 

The confinement was normal. How- 



ever, the patient was attacked by a 
great flux, and suffered a complete 
laceration of the right side of the neck, 
an incomplete laceration of the left 
side, an incomplete laceration of the 
rear wall of the vagina, and a two- 
thirds laceration of the perineum. The 
placenta was removed at once ; ample 
warm washes of a one per cent, solu- 
tion of permanganate of potash were 
appliea, and the uterus was stimulated 
by massage, but remained inert. All 
this was reported to me by the house 
physician. I arrived at the hospital 
four hours later, in company with the 
well-known gynecologist. Dr. Mendez 
Capote, who, upon having examined 
the patient, decided to sew up the 
lacerations. He washed out the vagina 
and uterine cavity completely, adjusted 
with the scissors the edges of the lac- 
erated tissues, sewed up the wounds, 
and touched the ulcer at the neck with 
the cauterizer; then he gave another 
wash and plugged with iodoform 
gauze. 

When the patient was on the operat- 
ing table she had fever, 38.4° C. At 
5 p. M. the fever was at 39""; then the 
vaginal plug was taken out, and a great 
intra-uterine wash of a one-half per 
cent, solution of permanganate was 
. applied very hot in a quantity of five 
liters. The fever was at 40^ through- 
out the night, and washes were given 
every four hours. 

The following day, at 8 a. m., tem- 
perature 40°, same local treatment. 
The fever lasted all day, falling to 39° 
by the wash, but rose again to 40°. 

The day thereafter, fever at 41°; 
same treatment, with more vaginal 
washes of bichloride of mercury be- 
fore the uterine washes; the fever 
keeps on at 41°. 

On the next day, at 8 a. m. (tem- 
perature 41.5°), I took out the stitches 
made on the day of confinement, 



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Therapeutic Suggestions. 



washed well both uterus and vagina, 
dried the latter with carbolated cotton, 
and conveyed into the uterine cavity 
eight grammes of pure hydrozone, 
taking care that this liqai'd should flow 
towards the vagina, into which I poured 
•about 60 grammes of the same liquid, 
tind drained the uterus with simple 
gauze saturated in hydrozone, while 
the vagina was drained by the same 
means. 

From that time on the fever declined 
slowly, and at 6 p. m. it was apyretic. 
The fever did not return, and the pa- 
tient's cure proceeds without further 
difficulty. 

This case, which is interesting by 
itself, proves of great value in setting 
forth two points, viz. : 

1. That, although the intrauterine 
injections of pure hydrozone may be 
dangerous, it can be applied if care is 
taken to keep th« neck dilated as much 
as possible. 

2. That in this case the superiority 
of hydrozone over the other treat- 
ments of puerperal septicemia, in con- 
nection with gonococcia, is indisput- 
able; and that this splendid result 
should encourage repetition of its ap- 
plication. (The son of the patient 
suffered from blennorrhagia in the 
eyes. He was treated with one-fourth 
per cent, solution of permanganate 
and instillations of pure hydrozone 
twice daily, alternating with cauteriza- 
tions of forty per cent, solution of 
nitrate of silver; and he kept liis 
sight.) — Dr. Matias Duque, Director 
of the San Antonio Hospital, Section 
of Hygiene; abstract from the Revista 
Medica Cubana^ April 15, 1903. 



S Sprgs., N. Y. 

Merz Capsule Co., 

Detroit, Mich. 
Dear Sirs: — ^Your No. 17 comp. 
santal is the best ever. Great results 
in nocturnal emissions with it. 

Send me another hundred, dollar en- 
closed. Yours, C. H. G., M. D. 
March 28, 1903. 



Bromipin, according to Dr. Gareis, 
is an excellent substitute for the alkali 
bromides in epilepsy — it does not pro- 
duce acne, is nutritious, and of great 
efficacy. — Munch. Med. Woch.^ xxii. 
No. 16. 



Glyco-Thymoline for Erysipelas- 
— Dr. Seneca D. Powell, of New York, 
applies 95 per cent, carbolic acid in 
erysipelas, and as soon as the skin 
turns white he applies alcohol to check 
the action. 

The Dietetic and Hygienic Gazette 
describes another treatment for ery- 
sipelas. It is to cover the area and a 
margin on the surrounding skin with a 
thick layer of white vaseline, and cover 
this with linen and a bandage to hold 
it in place. Apply twice daily. Its 
advantage over iodine applications is 
the absence of pain and irritation. 

In glyco-thymoline we have a remedy 
for erysipelas which lacks the toxic 
properties of carbolic acid and is far 
more efficacious than white vaseline. 
The following clinical history gives a 
fair idea of its action : 

Jno. Citatatto, M. D., of "New 
Orleans, writes: '*A young lady sent 
for me and upon my arrival I found 
her suffering from an attack of erysip- 
elas. I decided to try glyco-thy mo- 
line, and accordingly made a solution 
consisting of four ounces of glyco- 
thymoline to two pints of water and 
ordered the patient's face to be kept 
constantly covered with compresses 
saturated with this solution. With the 
very first application the itching ceased 
instantly. The swelling of the face 
disappeared very rapidly and after 
three days of this treatment my pa- 
tient was entirely cured.'' 



Treatment of Eczema or the 
Scalp. — ^Parker pleads for more pa- 
tience and perseverance in the treat- 
ment of this troublesome affection. So 
many physicians prescribe time or 
pronounce the condition hopeless that 
parents often discredit the physician 



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.ANASARCIN 

# (Oxydendroii-Sambucu8-5cilla Compound.) 

\ A SPECIFIC FOR DROPSIES 



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Doctor:— 

If you know a thing to be a fact, it is not wrong or 
unethical to say so. Neither does it smack of quackery or 
Charlatanism and should not shock the sensibilities of any, 
however refined, cultured or zealous of medical ethics for us 
to claim that ANASARCIN is a specific in dropsies, when 
clinical experience has demonstrated such to be a fact. If 
quinine ia a specific in malaria, much more is ANASARCIN 
in dropsies resulting from disease of the heart, liver or 
kidneys, because that a trial of it in hundreds, yea, thousands 
of cases has not resulted in a failure known to us where 
directions have been followed. 

Besides being a specific for dropsies, it is a permanent 
cure in the conditions mentioned when begun early and 
continued a sufficient length of time, i, e.^ until the diseased 
organs regain normal function. ANASARCIN is composed of 
the active principles of Ozydendron Arboreum, Sambucus and 
Urginea Scilla, and is sold exclusively to physicians or 
druggists for physicians. Trial box free with literature and 
testimonials furnished physicians on application. 



WINCHESTER, TENN., U. 5, A. 



\ 
\ 



ADDRESS — - ^ 

\ The Anasarcin Chemical Company ^ 

1^ — LONDON AQENTS — |^ 

# Tbos. CtrlMty 6t Co., 4'I0-I2 Old Swmn Lmae, Upper Tbmmes St, B. C. 

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INDEX, 



who promises recovery within a rea- 
sonable time. The first measure in 
successful treatment is a thorough 
washing and shaving of the head. Cas- 
tile soap and much water of a temper- 
ature not less than 100"* F. should be 
used. The same water should not touch 
the head twice, and pledgets of absorb- 
ent cotton are to be used to remove the 
crusts. When cleansed the head should 
be dried with a clean, soft towel. Dur- 
ing treatment the pillow-case should be 
consigned to the wash-tub each morn- 
ing and a clean one put into its place. 
These are not over-particular but im- 
perative details if favorable results are 
desired. Jugglery in prescriptions 
cannot avali, and rigid hygienic meas- 
ures, extending to all the surround- 
ings, must accompany medical treat- 
ment. The second step is in the case 
of nursinff infants, to treat the mor- 
bid constitutional condition generally 
found in the mother. The alterative 
iodia is nearly always applicable, and in 
severe cases should be administered 
to both mother and child. If the irri- 
tability attending the eruption requires 
special treatment, bromidia should be 
given. Some children will require an 
easily assimilated iron tonic. The bow- 
els must be kept open with a mild 
aperient, given in the early morning. 
Locally, boroglyceride is the best oint- 
ment. Ecthol is also a remedy of much 
value, being a powerful corrector of 
depraved conditions in fluids and tis- 
sues. It is employed diluted, accord- 
ing to the severity of the case, and 
sprinkled upon a thin cap of surgeon's 
cotton. The cap should be renewed 
and the old one burned dailv. 



Hat-Fever. — There are many theo- 
ries regarding the causation of hay- 
fever, including uric acid or other de- 
praved state of the system, micro- 
organisms in the air, and pollen 
from plants. Whatever theory is 
adopted and a systemic treatment 
undertaken to correspond with it, it 
has been found that intelligent local 
treatment is productive of great bene- 
fit. 

For this purpose a thorough wash- 
ing or douching of the nasal passages 
with a weak hot solution of Tyree's 
antiseptic powder has been found very 
beneficial. It cleanses the membrane 
of poisonous secretions, soothes its 
irritability, and tones it up and 
strengthens it to resist further invas- 
ion. By frequent repetition as soon 
as any feeling of discomfort begins to 
return, the attack can be greatly 
shortened, and the patient made com 
paratively comfortable throughout its 
duration. 



Mississippi Valley Medical Asso- 
ciation AT Memphis, Tennessee, Oc- 
tobeb 7-9, 1903. — One and one-third 
fare on certificate plan for the round 
trip. Trains leave St. Louis 7:20 
A. M., 1:30 noon, and 10:15 p. m. ; 
leave Memphis 7 :20 p. m., 10:55 p. m., 
and 8:20 a. m. Through sleeping 
cars, dining car, and buffet library 
smoking car. For full particulars 
write to C. C. McCarty, D. P. A., or 
T. F. Bowes, C. P. and T. A., St. 
Louis, Missouri — Illinois Central Rail- 
road. 



INDEX. 



OBIQINAIi ABTICLBS PAGE. 

Dermstologtcal Teaching in Madrid. By A. Ravogli, 

M. D.. orncinnatl, Ohro 187 

Hydrocele— Its Cure by a Simple Operatioa. By B. 

F. Lioorieh* M. D., Barbados, West Indies . . 190 

Prostitution in Japan. By Solomon Claiborne 

Martin, Jr., M. D., St. Louis 190 

A Plain Talk on Matters Pertaining to Genito-Uri- 

nary Anatomy, Physiology and Diseases. By Dr. 

Bransford Lewis, St. Louis 201 



Obiqinal Abtiolbs. paok. 

Bacteria as an Etiologic Factor in Skin and O«nito> 
Urinary Diseases. By Dr. Gottfried Trmntmann. 

Munich, Germany 2IO 

The Technique of Prostatectomy. By Nicholas 

Senn, M. D., Chicago, Dlinois 218 

SlLBOTIONB 220 

New Publioatioms 224 

TUKBAPKUTIC SuOGKSnONS 228 



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MCDIClNr 



A BI-MONTHLY MAGAZINE DEVOTED TO THE CONSIDERATION OF CUTANEOU8 
VENEREAL DI8EASE8 AND QENITO-URINARY 8URQERY. 

EDITORS 

S. C. MARTIN, M. D. G. M. PHILLIPS. M. 0. 

mtOTEMOR or OENMATOLOOV IN THE BAIINCS MCOIOAL OOLLEOC PNOrCMOR Or OCNrrO-URINARY OISCAMS ST. LOUIS OOLLEM OP 

PMVSIOIANS AND SUHOCONS. 
MANAGING EDITOR 
S. C. MARTIN. Jr.. M. 0. 



•T. LOUIS. 



SUBSCRIPTIONS AND ADVERTISING. 

The subscription price of this Joamal is |1.00 per year, in advance, postage prepaid, for the United States, Canada* 
and Mexico; |1 50 per yeai- for all foreigrn countries included in the postal union. Single copies, 25 cents. 

Advertising rates will be furnished upon application. 

Address all communications, correspondence, books, matter regarding advertising, and make all checks, drafts- 
and post-office orders payable to 

AMERICAN JOURNAL OF DERMATOLOGY, 
Fidelity Building, St. Louis, Mo., U. S. A. 



Vol,. VII. 



NOVEMBER. 1903. 



No. 6. 



THE NEW UQHT CURB. 

Bt Cobydon Euosni Rookbs, M. D., Seattle. Wash. 

The therapeutic qualities of light 
have been recognized and utilized — in 
an indifferent way — for so long a time 
that it is impossible to fix the date of 
the origin of the practice. The sun 
bath was probably employed during the 
period of sun-worship, and at a remote 
period the substitution of artificial 
light became a common practice. 
Among the people of portions of Asia 
we find their midwives treated post- 
partum inflammations by placing their 
patients before blazing fires. The ab- 
domen was uncovered and the woman 
placed before the fire and forced to re- 
main — regardless of her outcries — until 
in some instances the skin was blist- 
ered. Rheumatism was treated in the 
same manner. 

In many countries the sun bath is 
still a common method of treating va- 
rious forms of disease, especially rheu- 



matism and diseases of the chest. My 
attention was first drawn to the action 
of light by seeing Indians in the tropics 
applying light in this way. But it re- 
mained for Dr. Finsen to finally solve 
the problem of the practical applica- 
tion of light. Though his methods 
were crude and his theories incorrect,, 
nevertheless he opened the way to util- 
izing this agent which is destined to- 
revolutionize the practice of medicine. 
It is even now forcing us to abandon 
many pet theories and disregard much 
which the colleges and text-books have 
long taught us as proved facts. 

Dr. Finsen's apparatus appears to- 
have been designed for the treatment 
of lupus only, since the small area of 
light and the great length of time re- 
quired for exposure would make it im- 
practicable in the treatment of skin 
diseases covering large areas, such as 
we sometimes find in eczema. 

The doctor supposed he was destroy- 



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Original Articles. 



ing the germs of lupus by chemical ac- 
tion. Certain of the high vibratory 
forces sometimes called actinic rays 
have for a long time been improperly 
designated as chemical rays, and the 
belief is so thoroughly established that 
these have some peculiar -chemical ac- 
tion which is essential to the destruc- 
tion of pathogenic germs, that it is a 
difficult matter to discuss the action of 
light with most physicians. The fol- 
lowing is no more unreasonable than 
most of the so-called scientific experi- 
ments. In the Scientific American for 
June 20, 1903, page 473, Dr. J. W. 
Kime has an illustrated article upon 
light, in which he details the printing 
of photographs from negatives inclosed 
in the human mouth. Here ia * 'Ex- 
periment No^ 3— Penetrability of ac- 
tinic light." Then he tells us that **In 
these experiments the ttegatives were 
placed on the side exposed to the sun." 
In trying to prove the * 'Penetrability 
of actinie light" h% uses the combined 
rays in his experiments. In turning 
the face to the sunlight he used the 
combined force of the sun's rays — the 
very power for which I have been so 
long contending. Such men are not 
very close observeirs. These mistaken 
are very largely due to the universal 
spirit of error r^ardtng the action of 
actinic rays. The doctor is no excep- 
tion to the rule. Let it be understood 
that light has no specific chemical ac- 
tion ; that the chemical action depends 
upon the surface upon which the rays 
strike and not upon any chemical qual- 
ity in the rays themeelves, and we shall 
be better prepared to comjw^hend the 
law governing its therapeutic effeets. 

My investigations have been con- 
ducted wholly independently of Dr. 
Finsen's, for I soon became convinced 
that the violet rays were incapable of 
penetrating the tissaes, and therefore 
greatly inferior to my ideal of the 
power I sought. I abandoned all ex- 
periments with the violet rays after 
reaching this conclusion and turned my 
attention to the combined rays of the 



arc light, and of the incandescent lamp. 
I soon discovered that these were far 
superior as pain relievers to any agent 
with which I was acquainted. Still 
this was all unsatisfactory, for as yet I 
had been unable to discover the law 
governing their operation and was 
therefore applying them empirically. 
By changing the power of these lights 
I found that the results were very dif- 
ferent, and in this way I worked out 
what I believe to be the law governing 
the therapeutic action of light. 

With almost any light I found I covAd 
favorably modify most forms of skin 
diseases, but it was a long time before 
I could cure them. 

I soon abandoned the use of the arc 
light, a^ I found it wanting in many 
features which I believed to be essen- 
tial to the degree of success I desired 
9nd believed possible of attainment. 

I believed we were dealing with a 
force which would be far reaching in 
its results if we eoald dtscover the law 
governing its action so as to eiiiploy it 
intelligently. This I sought, rather 
than the curing of certain diseases by 
the empirical application of a power 
which mi^t be capable of great pos- 
sibilities. It was positively known that 
light is capable of destroying patho- 
genic germe when they are located upon 
tiie surface. Reasoning, a priori^ it 
would destroy them in any position if 
sufficient force were brought to bear 
upon them. For this purpose I con- 
centrated the rays from a 300 c. p. in- 
candescent lamp so as to obtain the 
highest power without bringing them 
to a focal point. Thie has proved the 
most satisfactory light with which I 
have operated. 

I believe our operations may be gov- 
erned by the following law, viz. : J%e 
fferm-de^troying power of light is equal 
to the sum of the vibratory forces em^ 
ployed. Now let us say that this gema- 
destroying power depends solely upoi^ 
the vibratory forces, and we shall have 
reached a point from which investig»- 
tions may be pursued iatelligently. 



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If these rays are applied to a severe 
ease of eczema in which the diseased 
surface is extensive and the skin infil- 
trated, thickened add excoriated from 
scratching, the first noticeable efEectJs 
the almost immediate relief from itch- 
ing. The relief will continue for an 
iDdefimte period and as soon as the 
itching returns the light should again 
be applied. In severe cases two treatr 
ments dailj for a few days will speedily 
effect a cure. If but one treatment 
daily can be given the patie»t should 
be inatructed to bathe the parts with a 
mixture of carbolic acid and water 
whenever the itching returns. The 
mixture should be strong enough to 
occasion some smarting, and in a few 
minutes after application the parts 
should be carefully dried and dusted 
with talcum or other harmless powder 
to prevent chafing. The light acts 
equally well upon all forms of the dis- 
ease* Improvement often occurs with 
surprising rapidity. Cases which have 
for yeurs resisted every form of treat- 
ment will sometimes present remark- 
able changes in a few hours. If prop- 
erly conducted one operation will con- 
vince aayone of the value of light in 
the treatment of eczema. It is just as 
satisfactory in the treatment of most 
skin diseases, including the tubercular. 

If these rays be applied to carbuncle 
dixring the early period of develop- 
ment it will be aborted. In a few min- 
utes the pais and soreness will be en- 
tirely relieved or greatly modified. In 
severe cases, well • advanced, where 
there is great constitutional disturb- 
ances, light also relieves the pain and 
soreness, reduces the fever and at once 
inaugurates a more favorable condition 

No agent at our command bo quickly 
and certainly modifies the condition of 
indolent ulcers, whether syphilitic, 
tubercular, varicose or those resulting 
from other forms of blood poisoning. 
To this we m^bt add all forms of ex- 
crescences, such as warts, moles, ex-^ 
uberant granulations, etc. 

Lupuaalso may be included in the 



foregoing list. If the destruction of 
tissue has not been great it can be 
cured by dne treatment of fifteen or 
twenty minutes' duration. In no case 
have I found it necessary to resort to 
local anesthesia to prevent suffering; 
but the parts subjected to the rays 
should be thoroughly cocained. A 
strong solution, about 15 per cent, or 
20 per cent., is preferable. The neigh- 
boring parts should be protected by a 
number of moistened layers of sheet 
asbestos with openings the size of the 
uker. All scaly forms of skin dis- 
eases, if severe, should be treated in this 
way. 

Epithelioma is just as certainly cura- 
ble as lupus, but the mode of operat- 
ing is somewhat different. In most 
cases the patient should be brought 
under the influence of anesthetics and 
the diseased tissues thoroughly de- 
stroyed by the actual cautery. In a 
few days the separation will occur, after 
which the parts should be cocained and 
the light applied as for lupus. If, 
however, we are fortunate enough to 
see the case early, the cauterizing may 
be omitted. In an ordinary case, un- 
less forewarned, few operators will 
cauterize sufficiently the first time. 
From unfortunate experiences I have 
learned this lesson. Cauterize until 
you think it i^ enough ; continue until 
you think you are quite sure ; then cour 
tinue until you think you have done 
too much ; after that stage is reached 
continue as much longer as you dare, 
and it may be enough. You will save 
yourself much time and your patient 
much suffering by cauterizing thor- 
oughly the first time.- Be sure that 
the germ infiltrated tissues are thor- 
oughly destroyed. The actual cautery 
is used in these cases to expedite the 
destruction of such tissues, as it can 
be done more quickly, and I greatly 
prefer it to the knife, caustics or the 
high power of light. But in all cases 
the resulting ulcer should be, treated 
by light to make sure that all germs 
have been destroyed. 



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If all the indurated tissue is not de- 
stroyed by the first operation it will 
usually be better to apply the cautery 
a second time and follow with the light 
as before mentioned. After the slough- 
ing following the use of the cautery 
the disease will return if left to itself ; 
but I have found that if light is prop- 
erly applied the cure will be complete. 
I have a number of cases who have 
been cured more than two years in 
which the disease has shown no dis- 
position to return. It may fairly be 
said that this is a safe and certain cure 
unless the disease is far advanced or 
located in some unusually inaccessible 
place. Of course the technique in 
these operations counts for something, 
but that is readily acquired. After 
one successful case the operator ac- 
quires confidence in himself and the 
agent he is employing, which of itself 
will add much to his skill. The ^rst 
application of light, after cauterizing, 
will relieve the pain and soreness in a 
great degree. 

SYPHILIS INSONTIUM. 

Bt Ohablbs E. Caldwell, M. D., Oiaeiimatl. Ohio. 

In reporting the two cases of extra- 
genital syphilis which I have observed 
in my own practice in the last seven- 
teen years, there seems to be no valid 
excuse for entering into a long disqui- 
sition upon the history, etiology j pa- 
thologv or treatment of syphilis. 

Syphilis insontium differs only from 
syphilis ordinarily acquired, in its 
extra-genital location, in the igno- 
rance of its victim of the possible 
source and nature of the malady, and 
the somewhat greater difficulty of dif- 
ferential diagnosis to those not thor- 
oughly familiarized by frequent op- 
portunities of observation with the 
appearance of the Hunterian chancre. 

During some ten years' conduct of a 
surgical and venereal clinic at the Mi- 
ami Medical College, where I was ac- 
customed to treat many cases of syph- 
ilis, I never encountered a case where 



the extra-genital origin could be more 
than suspected. 

Both of my cases occurred in pri- 
vate practice ; both of them were in 
young, unmarried women of correct 
deportment, and both of these young 
women consulted me for what they 
had considered trivial sores on the lips, 
which had excited their apprehension 
by reason of their unusual duration, 
gradually increasing size and conse- 
quent disfigurement. 

Moreover, both of them presented 
themselves during the same winter. 

In neither one was there the slight- 
est room for doubt in the diagnosis on 
first inspection, diagnoses subsequently 
confirmed by the appearance of sec- 
ondary eruption, glandular induration 
and other indubitable signs of syphilis. 

There seems to be an opinion preva- 
lent among the laity, and among a 
great many physicians, that extra-gen- 
ital syphilis is apt to be of a more in- 
veterate type than that less innocently 
acquired. If there were anything to 
support such a contention, and I have 
never found any evidence for such, it 
would probably be owing to late recog- 
nition of the nature of the initial 
lesion, or failure to recognize it until 
secondary constitutional syphilis de- 
veloped. 

In the two cases coming under my 
observation, while the constitutional 
symptoms were unmistakable, the sub- 
sequent course of the disease was free 
from any unusual complications, and 
the recovery was complete, one case 
remaining free from sequelae three 
years after treatment, and the other 
five years, having in the meantime 
married and become the mother of an 
apparently healthy child. 

Case I. — N. F. presented herself at 
my office with what she called cold 
sore on the lip, but she said it was un- 
like any cold sore that she had had-be- 
fore as it was much larger and harder. 
I suspected the nature of the lesion at 
a glance, but on closer examination^ 
the marked cartilaginous induration,. 



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and the age of the patient, eighteen, 
the involvement of the submaxillary 
lymphatics, strengthened me in my 
opinion^ I questioned her carefully as 
to whether she were the object of at- 
tention from any young man, and she 



such as she had admitted.. The truth 
of his statement was subsequently cor- 
roborated by a physical examination 
of the girl, whom I sent to a private 
hospital for treatment. During her 
stay at the hospital she developed a 



Syphilis Insontinm— Lip Chancre— Collection of Charles E. Caldwell, M. D. Case No. I. 



confessed that she was engaged to a 
young man. Reproved to be a soldier, 
and upon confronting him with the 
'facts in the case and examining his 
mouth, I found that he had well-de- 
veloped mucous patches. He denied 
any further intimacy with the girl than 



marked syphilitic roseola, some noc- 
turnal headaches and tibial and sternal 
tenderness. She remained under ob- 
servation about one year. Three years 
afterward I saw her and she said she 
had hadno recurrence of symptoms,and 
from her general appearance, I had no 



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288 



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opportunity to examine her earefnlly, 
I should have thought her to be in the 
best of health. 

Case II. — M. W., age twenty-two, 
well-developed young woman, who in 
the years of development from twelve 
to fifteen had been under my care for 
epilepsy, and who had subsequently on 
the regular establishment of the men- 
strual function recovered entirely from 
her epileptic attacks, presented herself 
at my office in December, '98. 

She complained of a sore on her lip 
which she had considered a cold sore 
or fever blister, but it had grown worse 
for the past three weeks. 

The character of this sore was also 
unmistakable, the braH^ infiltration 
of the lip and characteristi# gcistly 
feel of the sore, with some soreness irf 
the throat and enlargement of the sub- 
maxillary glands, made me certain of 
the diagnosis. 

I questioned her with regard to her 
relations with young men, and she ad- 
mitted that a young man whose busi- 
ness, as she said, was following the 
races was her fiance, that her parents 
did not altogether approve of him, but 
that she had always found him gentle- 
manly and respectful. 

I asked to have the young man call 
at my office. He was away at the time 
but within a week put in an appear- 
ance. I questioned him^ found a his- 
tory of(syphilis, and there were present 
several large mucous patches on the 
tongue and the pillars of the fauces. I 
told him that he had infected the girl, 
and that in view of thedanger to others, 
and the advisability of impressing her 
with the need of regular medical su- 
pervision, I should have to acquaint 
her with the nature of her trouble. 

This I did in a general way without 
going into unnecessary detail. Three 
weeks later she developed a marked 
roseola with other symptoms of the 
disease. I examined the genitals care- 
fully for a lesion, but the girl was evi- 
dently a virgiti. She had a leucor- 
rhea and subsequently developed mu- 



cous patches at the posterior commia* 
sure of the vulva. She was under ob- 
servation and treatment for a year and 
a half. She then ceased to be a pa- 
tient of mine, having moved into a re- 
mote suburb. She has since married 
and is the mother of a child to all 
appearances healthy, although it will 
be interesting to see how it seems at 
the time of second dentition. 

Case III. — This case I add to the 
others as one of doubtful nature as far 
as the extra-genital infection is con- 
cerned. It is briefly as follows: A 
young man, age twenty-one, had been 
under my care for a period of three 
years for" syphilis. 

His case had never been a severe 
one. He had had few secondary man- 
ifestations, but the most troublesome 
sjrmptom was the recurrence of mucous 
patches in the mouth and throat. He 
was an habttual smoker, and in spite of 
remonstrances on* my part he would 
continue to smoke excessively. The 
result was that he would occasionally 
come back with a fresh mucous patch. 
Otherwise, he seemed perfectly well. 
Three years from the date of his chan- 
cre, he having been a year free from 
auy manifestations whatever, he an- 
nounced his intention to marry. I ad- 
vised him strongly to defer the wed- 
ding for another year. Much to my 
surprise the announcement of the wed- 
ding occurred shortly after. Within 
six weeks he appeared in my office 
with his wife infected with a syphilitic 
pharyngitis. It was unmistakable. 
There was no evidence of chancre either 
genitally or extra-genitally. Where 
was the woman's lesion? I do not 
know. All I do know is that she had 
an obstinate case of syphilis. 

She has since given birth to a child. 
As yet there are no manifestaUooa, 
but there is yet time for them ^mfh 
pear. 

I have reported these closes beeauaa 
I believe it is well for sudi -cases te he 
put on record. The pnblicati^Q of idl 
such oases will make the profeseioii 



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Diagnostic Features of small- Pox- melv in. 



9mo 



more alert to recognize what if unrec- 
<>gDized must prove the most insidious 
source of the wide-spread dissemina- 
tiofi of a disease which attacks the in- 
nocent as well as the guilty and spreads 
contamination in many pure homes. 



i0lAQNOSTiC FBATURBS OFSMALL-POX. 

Bt Gsobgx 6. Mklvin, M. D.. 
DanikAlologUt to Home for^IneiurablM, Ete., Bt. John, 

N. B. ^ 



To dtseuss the question of the diag- 
nosis of small-pox, that is to say, of 
genuine virulent, unmodified variola, 
would be like announcing that ^^the 
Dutch have taken Holland;" it would 
be going over something that has been 
definitely settled in the profession for 
two hundred years. Indeed, a blind, 
deaf-mute could diagnose a straight- 
'forward case of small-pox. All he 
need do would be to use his finger- 
tips; the far-famed **shotty" condi- 
tion would tell him the whole story. 
But since the introduction and almost 
universal application of vaccination, 
small-pox has ceased, clinically, to be 
the disease it once was. It is no long- 
er the most easily recognized of all 
disorders. So pronounced has this 
become, that an entirely new name is 
required to describe this condition, and 
in our {tactical acquaintance with it, 
probably three-fourths of the cases 
seen deserve the term varioloid instead 
of variola* And even this is not all. 
Varioloid is a modifieation stretching 
between wide extremes ; from a condi- 
tion hut little removed from the classi- 
cal disease to a state very little differ- 
ent - from the normal condition of 
health. Yet, as every one knows, 
tliis apparently trivial phase of the dis- 
ease is just as dangerous, so far as con- 
tagion and reproduction are concerned, 
aa the most violent instances of the 
hmnerrhagie or ^^black" type. 

In ovder, then, to approach the sub- 
Jeet in a practical and judicious man- 
matf several separate ideas mnst be 
moted a^d iHscumed. First among 



them is to definitely determine the 
class of disease in which it is proper 
to place small-pox ; second, the diseases 
which most resemble it; and third, and 
by no means least important, the quan- 
tity and quality of knowledge requisite 
inlthe examiner to properly recognize 
and classify it. To those three head- 
ings, then, I will address myself, in as 
brief but as dear a manner as pos- 
sible. 

1. The principle of evolution, so 
strikingly promulgated in the middle 
of the preceding centurv by the pro- 
found and almost divine genius of 
Darwin, leaves it ecarcely a matter of 
doubt but that mankind at first was af- 
fected by only a few, possibly only one, 
primordial disease. What that disease 
was, is, of course, far beyond the 
power of any one to say, or even to 
speculate upon, with anything like 
probability. The universal law of evo- 
lution, acting in this, as in every other 
department of nature, gradually differ- 
entiated the kinds and multiplied the 
number of those diseases. Even today 
we can trace, dimly indeed, yet clearly 
enough for our purpose, collateral lines . 
between many of our most important 
disorders. For example: those dis- 
eases attacking the lower iutestinal 
tract, as ordinary diarrhoea, cholera 
morbus, typhoid fever, typhus fever, 
yellow fever and Asiatic cholera, are 
all, to my mind, undoubtedly descended 
in successive or parallel lines from one 
ancient type. They are all germ-pro- 
duced, and that fact alone serves to 
solve the riddle of their causation and 
connection . If one species of pigeon has 
given rise to scores of varietiesi all dif- 
fering in appearance, manners, and 
favorite location : if one species of rose 
has, in like manner, evolved into a hun- 
dred, it does not require a very great 
stretch of the imagini^on to eonceive 
of one species . of germ being similarly 
evolved into a dozen or so, collateral, 
and yet distinct types, each having its 
owQ UMa^dlod of prapagation, its own 
favorite location, and its own method 



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of manifesting its effects upon the hu- 
man economy. A similar parallel 
could be drawn between a dozen or so 
diseases affecting the respiratory or- 
gans, and above all, because so appar- 
ent to the eye and touch, we see a very 
great number of diseases of the skin 
undoubtedly arising or descending from 
one primeval progenitor. All of us, 
with a taste for history, know perfectly 
well that even within historic times, a 
space of not, at the outside, more than 
3000 years, many of those diseases 
were regarded as identical. It is no 
answer to reply that it was merely the 
result of ignorance. To differentiate 
many of these disorders does not re- 
quire a profound knowledge of medi- 
cine in all its branches. What com- 
monly intelligent man, accustomed to 
meet with disease, could confound a 
typical case of measles with a like case 
of scarlet fever? Yet no such distinc- 
tion was known to the ancients. Were 
they, then, not only ignorant, but also 
stupid? We know the contrary. No 
more brilliant minds existed than those 
of some two thousand years ago, among 
the Grecian philosophers and physi- 
cians. We are, therefore, forced to 
the inevitable conclusion that at that 
time, and for long afterwards, there 
were not the well-established boundary 
lines between many of the allied dis- 
eases that there are at present. As 
time went by, those germs showed 
more and more predilection for partic- 
ular parts of the human body. I have 
elsewhere* discussed the remarkable 
favoritism of the tubercle bacillus for 
localized situations, this peculiarity be- 
ing so pronounced that it is becoming 
more than probable that, even in this 
one species of micro-organism, there 
are several distinct varieties . The cele- 
brated distinction recognised by .Koch 
between the human and bovine varie- 
ties, brings additional force to this 

*Vide article, by author, ** Report of One 
Hundred and Fifty Cases of Skin Disease," 
in the American Journal of Der^natology ^ 
March, 1901. 



hypothesis. This fairly well-dejGned 
law of segregation among germs led, 
early in the history of disease, to the 
classification of the so-called **local** 
diseases . It was not without difficulty, 
however, that this term, with its un- 
derlying idea, came to be incorporated 
into medical science. Indeed, there 
are not wanting yet, many authorities 
of very reputable standing that deny 
that there is, properly speaking, any 
such thing as a ''local" disease. It is 
not my intention to enter upon this 
controversy; we all know the ''pros 
and cons" of it already, and, also, that 
if strictly in theory there be no such 
thing as a disease attacking one organ 
of the body to the utter exclusion of 
all others, yet in practice it is so, and 
that scarcely anything in the way of 
classification has done more for the 
advancement and convenience of medi- 
cine than this principle. But small- 
pox, for long was denied a place in this 
category, and I am not at all sure that 
there is any great degree of unanimity 
yet, upon the subject. But, I most 
humbly submit, until such acknowl- 
edgment has been made, and small- 
pox be clearly recognized as, purely 
and simply, so far as any disease can 
be restricted to one organ, a disease of 
the skin, no great progress can be at- 
tained in its prevention and treatment, 
and doubt and disturbance will con- 
tinue to dog the path of the observer 
concerned in its detection and recogni- 
tion. • Here, permit me to say again, 
that I am quite aware that such a 
statement will not be accepted by, 
perhaps, a majority of those interested 
in the subject, but for that I am not 
responsible. It is not very long ago 
that I heard an old and very much 
respected member of the profession 
declare that th^ most important symp- 
tom in small-pox was the pain in the 
back ! That, in a nut-shell, illustrates 
the standpoint — the erroneous .stand- 
point, I respectfully contend, from 
which it is viewed by a great number 
of our physicians, even yet. The 



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Diagnostic Features of Small- Pox— Melvin. 



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truth, howerer, is slowly making its 
way. It is well known, although I 
have spoken of variola as a germ- 
produced disease, that its specific cause 
has not yet bet been isolated. Re- 
cently, however, Dr. Councilman, in 
a * 'Preliminary Communication on the 
Etiology of Small-pox," announces 
that he has succeeded in isolating a 
germ that apparently satisfies all con- 
ditions necessary to be the true causa- 
tive factor in this disease. Though 
not specially germain to our subject, 
it may be stated that, unlike the ma- 
jority of important pathological germs 
heretofore discovered, it belongs, not 
to the vegetable, but to the animal 
kingdom. In other words, it may be 
classed with the protozoa, and in this 
respect is akin to the famous and re- 
cently differentiated cause of malaria. 
I regret very much ray inability to 
have had access to the original mono- 
graph, but I quote from an apparently 
trustworthy review of it. He enters, 
at considerable length, upon the life- 
history and mode of operation of the 
germ in the human economy ; but the 
point to which I wish especially to 
give emphasis is his description of the 
final action of the germ just previous 
to the beginnings of the clinical mani- 
festations of the disease in the human 
subject. It is first necessary to say 
that he believes the germ to be the 
common causative factor in variola 
and cow-pox, or vaccinia. I quote: 
*'The whole process, as now known, 
takes place in the lower layers of the 
skin, where the germ penetrates the 
epithelial cells and takes up its cycle 
of development. In cow-pox it is 
chiefly amoeboid in character, and does 
not involve the nucleus of the skin- 
cell. In small-pox, on the other hand, 
it grows and there enters the nucleus 
of the skin-cell, where it undergoes an 
apparently sexual generation, ending 
in the breaking down of the nucleus, 
the disperson of the spores, and the 
setting up of the fever which consti- 
tutes the seizure of the disease, and 



the pustules which follow closely upon 
it." He does not claim thatitalon^ 
is concerned in the whole of the pus 
formation, as, undoubtedly, the well- 
known pus bacteria here play also a 
part. **It is, however," he says, **the 
efficient and main cause." The reason 
I have given this point such attention 
is, I think, clear. Nothing could more 
lucidly point out the purely dermal 
and local character of the disease* 
Just so surely as the germ of typhoid 
has an extreme predilection for Peyer's 
patches in the intestines, so surely 
does the germ of small-pox pick out 
the skin to pursue its life-course.* If 
more proof of the cutaneous nature of 
the disease were wanting, it would be 
seen in the remarkable success ob- 
tained in the treatment of the disease 
by enveloping the patient in blue light. 
Recent experiments have proved that 
this procedure cuts short the fever, 
aborts the pustules and entirely prcr 
vents pitting. Having then, I think, 
shown that the disease is essentially a 
skin one, a very great step forward 
has been taken as to its diagnosis. To 
an audience of general practitioners it 
is, perhaps, necessary to say that skin 
diseases depend almost wholly on ob- 
jective symptoms, or, as Flint very 
properly called them, signs, for their 
diagnosis. In fact, this should be 
true of nearly all diseases. We con- 
stantly place far too much stress on 
the subjective symptoms: upon what 

*Since writing the above I have noted the 
following, which further demonstrates the 
peculiar affinity of pathological germs for 
particnlar locations in the system: 

Proliferation in Micro- Parastic Infections: — 
'*In the case of the so-called toxin bodies, 
their selective activity on certain tissues and 
cells is well known — for example, the tetanus 
toxin, which acts selectively on the cells of 
the central nervous system. In the same 
way, certain micro-parasites exert this repro- 
duction reaction specifically — for exami>le, 
the coccidium oviforme excites proliferation 
on the epithelial cells of the bile ducts; the 
infective agent of syphilis excites prolifera- 
tion on the connective tissue cells.**— Keith 
W. Monsarrat,!M. B., F. R. S. C. Edin., in 
•'Etiology of New Growths." (^Brit, Med^ 
Jour,,^viM 27,1908.) 



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ourptlients tell us. They may deceive 
II8» oonscioasly or unconsciously, but 
we<Nin, or ought to be able to, depend 
mpon what we can see, hear and feel. 
Therefore, I reiterate, when coming to 
a suspected small-pox case, we should 
firmly and unswervingly cast aside all 
ideas relative to the patient's story 
and look upon the true seat of the dis- 
ease — the skin — with unbiased and 
unprejudiced eyes. Should the case 
be small-pox, modified or unmodified, 
what shall we see or feel? I reply, in 
every instance, papules, in some phase 
of their development and situation, 
either under the horny layer, upon a 
level with it, or raised above it, and 
either true papules, vesicles or pus- 
tules. I make no mention of number. 
This may vary from, possibly, one or 
half a dozen to very many hundreds. 
But, unless there be papules, or their 
successors, I hold there can be no 
diagnosis of small-pox. We have here 
a local irritant, the suspected causa- 
tive germ. Irritation, everywhere, 
causes inflammation, which is nothing 
more or less than a temporary in- 
creased flow of blood to the irritated 
part. This increased blood supply 
lays down or builds up an abnormal 
tissue, abnormal both in kind and de- 
gree. This tissue is a tumor — this 
tumor is the papule. The causative 
factor of cancer, whatever it may be, 
is likewise an irritant, a precursor of 
local inflammation — a builder-up of 
abnormal or debased tissue : the pro- 
cedure is the same, or very similar, in 
both cases, one being acute, the other 
chronic. In the small-pox instance, 
this occurs in the cutis vera^ and ac- 
cording to a natural law — the law of 
least resistance — the papule becomes a 
veritable eruption ; it erupts or breaks 
through the thin physiological cover- 
ing above. The true disease resides 
in and about these papules; indeed, 
for the purpose of argument we need 
only concern ourselves with one single 
papule. The mere multiplication of 
them does not alter the principle of 



the disease, although it does affect its 
gravity. Just as cancerous tissue, 
breaking down, and in direct propor- 
tion to its size and situation affects the 
entire life functions of the body, so 
small-pox papules, almost, at times, 
infinite in number, and rapidly chang- 
ing into absorbable pathological prod- 
ucts, affect, in a profound manner, 
the general constitutional processes; 
hence, the fever, pain, vomiting, etc., 
etc. Flint, the very best of all Eng- 
lish medical writers, so far as elegance 
and accuracy of language go, in de- 
scribing the clinical history of the dis- 
ease, says that the amount and viru- 
lence of the eruption depend upon the 
acuteness and gravity of the constitu- 
tional symptoms, as fever, reduced 
action of the heart, etc. In the light 
of advanced knowledge the very re- 
verse is true. The constitutional symp- 
toms arise from the the skin-lesions, 
and not vice versa. We have all heard 
of variola sine eruptione^ but few of 
us, I think, have seen it; nor do I 
think it will ever be seen again. It is, 
I have not the smallest hesitation in 
saying, a figment of the imagination. 
All such cases have been observed, or 
supposedly observed, in epidemics of 
the disease, when the reputation of 
some gentleman was at stake in the 
matter of prognostic diagnosis, if I 
might coin a phrase. This, or lack of 
accurate knowledge concerning the 
pathology of the disease, amply acr 
counts, in my mind, for all such anom- 
alous instances. The case for the 
appearance of ghosts is a thousand 
times stronger than is the case for 
small-pox without eruption. Yet few 
of us have had the pleasure of meet- 
ing the former. 

The relative importance of the con- 
stitutional symptoms are not denied; 
but in view of the fact that in nearly 
every case of di£Scult diagnosis in 
small-pox they are nearly always either 
absent or very slight, and that each 
and all of them may be present in any 
one of a dozen or more diseases, re- 



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Diagnostic Features of Small- Pox—Melv in. 



248 



sembling to a greater or less degree 
variola itself , I claim that in obscure 
cases (and these are the only ones with 
which we are concerned) almost ex- 
clusive attention should be centered 
upon the eruption. Enough has al- 
ready been said as to the character of 
this eruption. It is papular, not macu- 
lar; progressively and invariably 
changeable, not stationary ; and is alto- 
gether dependent upon the localized 
causes, and not upon the constitutional 
symptoms, the later being, in truth, 
only symptoms. 

Having dwelt, perhaps, inordinately 
long upon this heading, let me hurry 
on to briefly me&tion some diseases 
with which small-pox may be con- 
founded. I say **may be confounded,*' 
not the reverse, for the ^eat danger 
in any epidemic of the disease is not 
that it should go unrecognized, . but 
that ordinary and generally harmless 
cutaneous eruptions may be taken for 
it, to the inexpressible detriment and 
danger of the unfortunate individual 
subject to them. For, undoubtedly, 
when public excitement is aroused and 
fear is at fever heat, it does not require 
any great amount of courage to pro- 
nounce a suspected case one of small- 
pox. Where courage and knowledge 
are required is when one pronounces 
such a case not one of the suspected 
disease. 

2. I will not attempt an exhaustive 
list of variola-like diseases. As is 
more practical, I will give a few illus- 
trative incidents, occurring in my own 
practice, during the epidemic of 1901- 
1902, in this city. (1) At the request 
of a prominent general practitioner, 
who, by telephone, informed me that 
he strongly suspected small-pox, I ex- 
amined Mrs. . Found the fore- 
head, hands, wrists and arms covered 
with a papular eruption. Papules 
small, pointed, hard, scarcely sensi- 
tive, dark, and of coppery color. Had 
been in situ several days. Throat 
somewhat inflamed, and, upon strip- 
ping, found an extensive fine papular 



rash over the whole body, of about the 
same age as the more pronounced and 
comparatively larger papules upon the 
exposed surfaces. My diagnosis of 
secondary syphilis^ was confirmed by 
the woman herself upon the spot, and 
afterward by other and more trust- 
worthy information. Here there was 
every reason to suspect the epidemic 
disease, and the attending physician 
was by no means to blame for doing 
so. Nothing could more nearly re- 
semble the papular stage of smail-pox 
than the woman's exposed surfaces, 
and nothing less than a thorough ex- 
amination and the presence of that 
almost undefinable something never 
absent from .a syphilide could possibly 
remove the doubt. (2) A child, fe- 
male, about seven years old. Had 
been vaccinated ten days before. Over 
posterior aspect of hands and extensor 
surfaces of wrists and forearms, 
around both temples and under chin 
were a number of pustules, perhaps 
twenty or thirty. They were flattened 
on top and covered with thick crusts. 
Scratch marks were somewhat in evi- 
dence, especially upon the forearms. 
Upon examining the vaccination sore, 
found copious inflammatory products 
present and discharging, and well- 
marked linear scars, the result of 
scratching. For fear of possible con- 
tagion, the father had remained at 
home three days already, being an 
employee of the I. C. E. postal depart- 
ment. Upon reassuring him that im- 
petigo was, if not non-contagious, at 
least far from dangerous, he with 
great satisfaction resumed his employ- 
ment. Here, again, the observer (not 
anxious, at such a time, to take too 
many risks in examining for himself) 
was amply justified in being suspicious. 
Many cases of varioloid have passed 
through the whole disease with less 
evidence of an eruptive disorder than 
this child presented. Of course, seen 
at a time when no question of small- 
pox was agitating the public, it would 
have cost the physician not a second 



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thought; the application of a simple 
mercurial ointment would probablj 
have been the beginning and end of 
his connection with it. But during 
other periods, when scores are being 
attacked and thousands are in fear, 
every skin eruption in the communitj 
should be examined, and not only ex- 
amined, but definitely pronounced 
upon. We should ^Dt be content in 
saying it is not small-pox, but should 
take pains, and no pains should be 
thought too great, to ascertain exactly 
what it is. Too many of us have a 
comfortable habit, upon seeing an 
eruption of the skin, of remarking: 
*'0h, it's jutit a rash, and it's better 
out than in." Such a procedure may 
satisfy in ordinary times, but should 
not obtain when small-pox is epidemic. 
No eruption, however trivial or insig^ 
nificant, is without a definite name and 
history. To doubt this would be to 
insult the memory and reputation of 
hundreds of indefatigable workers of 
Europe and America who have raised 
dermatology to the most exact, com- 
plete and precise of all branches of 
medical science. (3) In February, 
1902, I was requested by the medical 
superintendent of the alms-house to 
see an elderly female who had been 
admitted the evening previous. He 
informed me that upon his examina- 
tion that mot-ning he had discovered 
her to be completely covered with a 
papular eruption that very much re- 
sembled small-pox. In company with 
that gentleman and Dr. T. E. Morris, 
at that time in charge of the small- 
pox isolation hospital, we found her 
in the condition named. A more 
equable and complete papular distribu- 
tion I never saw. With the exception 
of the face, palms and soles, the whole 
surface was involved. They num- 
bered at least half a dozen to the 
square inch, were only of medium size, 
were either covered with a pustular 
point or else flat-topped and bleeding 
or excoriated, the result of beheading 
with the finger-nails. Scarcely any 



history relative to the eroption could 
be obtained from her. A close in- 
sp^tion, however, revedbd numeroos 
' scars and cicatrices, the sites of older 
lesions, as well as parallel linear 
streaks, indicating vigorous and long^ 
continued scratching. The attendants 
testified that upon admission she was 
in a deplorable condition from dirt, 
and that her whole body was the host 
of very numerous pediculi corporis. 
Indeed, after the vigorous scrubbing 
she had undergone, the ova of the 
pediculi capitis were to be seen on the 
margin of the scalp. Taking these 
facts into consideration, it was not dif- 
ficult to arrive at a diagnosis negative 
to small-pox, and to indicate her dis- 
ease or condition by an appellation 
fortunately of little use in this country 
— phtheiriasis or **louSy disease." Yet, 
as before, there was abundant excuse 
in a time of general fear, to be exceed- 
ingly cautious and suspicious in this 
case, and I have no hesitation what- 
ever in saying that no practitibner 
would have been censurable for impos- 
ing a temporary quarantine to await 
developments. I might go on, if space 
and time permitted, and give numerous 
dther illustrative cases met with in the 
same epidemic, all of them equally 
suspicious, but none of them having 
anything to do with genuine variola. 
But this paper already promises to be 
too long, so I will spare the reader the 
infliction. Here we have three in- 
stances, however — two of them dis- 
eases of frequent occurrence, and one 
very rare — of close simulation, clinic- 
ally and objectively, to modified small- 
pox. Impetigo and syphilis are of 
constant happening, especially among 
the class in which variola is most liable 
to spre^, the city poor living in con- 
gested districts and in a dirty condi- 
tion. 

It would be almost a loss of time to ' 
name the very many other cutaneous 
lesions capable of simulating the grave 
epidemic disease under discussion, but, 
perhaps, one or two more may be men^ 



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tioned. Herpes, in some of ita man^ 
forme, might readily excite fear iua 
time of general suspicion. More espe- 
cially that form of it often called Ay- 
droa herpetiformis^ frequently seen in 
pregnant , women. Of course a few 
days' observation would dear up the 
difficulty, but this is exactly what is 
generally denied to both patient and 
physician at such a time. Again, ery- 
thema multiforme might well be mis- 
taken for it, in a critical period. I 
well remember a very pronounced case 
of it I saw two years ago, not when 
there was any mention of small-pox, 
l^ut in which the patient herself, a 
washerwoman, was quite positive she 
had the epidemic disease. It is only a 
few months since, that I saw a case of 
neurotic eczema in a boy of twelve, the 
patient of one of our city physicians ; 
he was covered completely with a 
raised, almost papular eruption. The 
rash was so violent that it produced 
quite decided constitutional symptoms, 
among them being a considerable de- 
gree of fever. Seen at a time when 
variola was epidemic, no general phy- 
sician would have been justified in 
leaving the case undiagnosed for twelve 
hours. In like manner a number of 
other contagious lesions might be 
quoted, not, of course, closely resemb- 
ling small-pox, and capable of exciting 
no suspicion at a non-suspicious period, 
but. nevertheless, enough to cause anx- 
iety and engender mistakes where 
care is not taken, at other times. Any 
one can supplement the list for him- 
self. The point I wish expressly to 
make is that we should not rest satis- 
fied in merely coming to a negative 
conclusion as regards variola, but in 
each and every case clearly define and 
indicate the exact name and nature of 
the disease. By this means multitudes 
of unfounded suspicious and sensa- 
tional reports will be set at rest ; iden- 
tical diseases afterward appearing in 
the same family or neighborhood will 
be easily recognized, often without the 
interference pf a physician ; and, by 



far the best and most important result 
of all will be attained, no \infortanatQ 
will be spirited oflF to the horrors and 
dangers of an isolation hospital with- 
out certain evidence of being affected 
with the epidemic disease. 

3. I come, with much diffidence and 
perturbation of spirit, to the discussion 
of my third heading — tjie amount and 
quality of knowledge requisite to recog- 
nize and define the various varieties of 
variola. Of course, to that class of 
medical men, happily now very small 
in number, that think and generally 
act upon their conviction that all reg- 
ularly qualified physicians are, or 
should be, upon a par as regards medi- 
cal knowledge in all departments ; that 
refuse to recognize anything approach- 
ing specialism in medicine ; that believe 
that no amount of extra study, extra 
opportunity, or extra taste in a certain 
direction can make any one superior to 
another in any particular; on these 
gentlemen, I admit at the outset, my 
argument will be entirely thrown away. 
But I am persuaded that few, if any, 
now listening to me are in that class ; 
that none of us are quite so sure of 
such an universal uniformity, and I, 
therefore, am emboldened to go on 
with my case. Who then is the expert 
in the diagnosis of modified, obscure, 
or suspected cases of small-pox? If 
we follow the apparently almost unani- 
mous practice of this province, it is the 
man who has seen most cases of the 
disease. Only recently a gentleman 
was brought here from a neighboring 
province, at, I suppose, a very consid- 
erable expense for this purpose, and 
his sole or chief qualification, I under- 
stand, was that he had seen hundreds 
of cases of the disease. I wish to state 
that I speak only from newspaper re- 
port, but I believe such report to be 
substantially correct. Now, of course, 
such gentleman may have had qualifi- 
cations far broader and greater than 
that I have indicated, but such were 
not mentioned, nor do I believe, if he 
did possess them, were they the cause 



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ORIGINAL Articles. 



of his selection by our authorities. Is 
this then the sole requirement for a 
correct differential diagnosis of vari- 
ola? I hold it is not. If so, then th^ 
man who has never seen anything but 
a Corinthian column in architecture 
would be an infallible judge as to 
whether a certain column was Doric, 
Ionic, or Corinthian; All these de- 
signs have innumerable gradations and 
modifications. There may be but an 
almost infinitesimal difference in an in- 
stance between a modified Doric and a 
modified Corinthian . The column may 
be really Ionic, but our judge, never 
having seen such design, being pressed 
for an answer of (and should a negative 
reply be returned, great loss may be 
experienced by the column's rejection), 
what will be his answer? Human nat- 
ure being as it is, there are ninety- 
nine chances out of a hundred that he 
will risk erring on what to him is the 
**safe" side, and say that the column 
is Corinthian. But to come nearer to 
our own profession. What is meant 
by the term diagnosis? Does it not, 
of itself, naturully infer a choosing? 
And, if a choosing, does it not inevi- 
tably follow that there must be more 
than one to choose from ? And if there 
be more than one to choose from and 
a correct choice be desired, does not 
such correctness depend upon a real 
and intimate acquaintance, not with 
one of the objects to be chosen from, 
but with them all ? Do we not know 
that one of the very best and safest 
methods of diagnosis is by ''exclu- 
sion?'* We have a patient suffering 
from fever, cough, etc., etc. We find 
he has not pneumonia, that he has not 
pleurisy, nor hydrothorax, nor empy- 
ema, nor pronounced bronchitis, or, 
may be, one of a dozen or more dis- 
eases of the chest we may think of, 
and knowing also the symptoms of 
phthisis, find that he has some of 
these, is not this the most absolutely 
safe diagnosis that can be made ? Yet, 
how could such a diagnosis be possible 
to one who has not an exact and fa- 



miliar acquaintance with the excluded 
diseases? Or, in what position would 
an examiner be, if in a suspected 
phthisical case, he found many of the 
symptoms of other diseases, and not 
one unmistakable one of consumption, 
and yet know little or nothing of the 
other diseases? I say the idea of a 
specialism, in diagnosis y of any one 
disease, is an anomaly, an absurdity, 
and a contradiction of terms. There 
can be no such thing. There may be 
such specialism so far as treatment is 
concerned, but certainly not as regards 
diagnosis. Specialism implies an in- 
timate, accurate and exhaustive knowl- 
edge of a large number of allied or 
collateral diseases, or eke of an equally 
large number affecting a particular 
part of the body. Indeed, the chief 
reproach, and the truest one, that can 
be brought against specialism, is that 
it tends to restrict medical knowledge 
to within too narrow limits, and so to 
exalt a certain variety of diseases to a 
height they are not entitled to. What, 
then, can we say of a specialist re- 
stricted to one disease, and that, re- 
garding diagnosis ! ! If there be a 
tendency to exalt a whole variety, will 
not that tendency be immeasurably 
stronger when it is restricted to but 
one disorder? But some one may say 
that such a man is likely to have a 
knowledge of allied and collateral dis- 
eases. If so, the whole question is 
settled, and I have nothing more to say. 
Such a man is the man in the right 
place. But, in the case of the sup- 
posed small-pox expert, the very re- 
verse is likely to be the fact. Is the 
man at the head of an epidemic hos- 
pital likely to meet with, and be in a 
position to investigate, at his leisure, 
cases of psoriasis, syphilis, intertrigo, 
phtheiriasis, eczema, and the hundred 
and one other cutaneous lesions with 
which it is necessary to be acquainted 
in dermatology? Is he not, on the 
contrary, the man least likely in the 
world to meet with such cases ? I feel 
I need not push the argument further. 



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However imperfectly I have put it for- 
ward, and I know only too well its 
imperfection, I am sure every reason- 
able man will see the point. What is 
the reason our medical journals and the 
medical world in general is deluged 
with such absurd titles as ^'Cuban 
itch," **pustular chicken-pox," **Ha- 
vana hives," ** Southern scabies," and 
scores of othjBr equally senseless and 
foolish names? Is medical nomencla- 
ture so scanty that this unmeaning 
twaddle has to be foisted upon it ? We 
all know the reason. These names 
are merely the poor coverings of inac- 
curate and insu£Scient knowledge; the 
inky exudation of retreating medical 
cuttlefish ; the spurious coin in place 
of the pure gold of medical science. 

I need scarcely state, therefore, the 
conclusion of my argument except for 
the mere purpose of completeness. 
That conclusion is that small-pox oc- 
cupies no unique position in medicine 
as regards diagnosis. To recognize 
obscure cases of tertiary syphilis, or of 
psoriasis, or of eczema, and, more par- 
ticularly, to distinguish one from the 
other, requires an intimate and ex- 
tended knowledge of diseases of the 
skin. To do the like with small-pox 
requires merely like conditions. 



CANCER OP THE PROSTATE AND THE 
SELECTION OP CASES POR 
SUPRAPUBIC PROSTA- 
TECTOMY.* 

Bt Reginald EUlbbison, F. R. C. S., 
Surgeon to St. Peter's Hospital. London, England. 

I propose offering you a few re- 
marks on the subject of prostatectomy, 
and will commence by introducing a 
case which may be regarded as a typ- 
ical one. I showed this patient at the 
Polyclinic a short time after the oper- 
ation. Sixteen months have now 
elapsed, during which period he has 
been actively employed earning his 
living. Thus you may judge as to the 

♦Delivered at the Medical Graduates' College and Poly- 
clinic. 



permanent results which we may hope 
to obtain in well-selected cases after 
this operation. 

The patient at the time of operation 
was sixty-seven years of age. He has 
been under my notice since 1899, when 
I performed vasectomy for him for en- 
largement of the prostate. At this 
time the enlargement had made con- 
siderable advance, he was entirely de- 
pendent on the catheter, and had been 
so for some time, and this greatly in- 
terfered with his work as a compositor 
and seriously injured his health by 
preventing him obtaining suflScient 
continuous sleep and rest. The case 
proved too far advanced for vasectomy, 
and the relief he obtained from this 
operation was insufficient. 

On February 5, 1902, after examin- 
ing his prostate and bladder with the 
cystoscope, I performed suprapubic 
cystotomy for him and enucleated sep- 
arately with my finger the two large 
lateral masses I am now showing you. 
The prostatic urethra remained intact. 
The total weight was five ounces. The 
patient made an uninterrupted recov- 
ery, the function of the bladder has 
been completely restored, and the use 
of the catheter discarded since the day 
the operation was performed. 

If the conditions could always be se- 
cured as they existed in this instance, 
the operation of prostatectomy would 
be attended with very little risk, whilst 
the results would be uniformly good. 
In the study of the various forms and 
structures the enlarged prostate pre- 
sents will be found the key to the ap- 
plication of operative surgery to this 
part. 

The first question I would raise is 
relative to malignant disease of the 
prostate — is it common or not, and 
what should be our attitude to it ? My 
belief is that carcinoma of the prostate 
is far more common than we have been 
led to believe. In performing over 
one hundred vasectomies on different 
persons for enlargement of the pros- 
tate, the operation failed to benefit the 



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patieDt in several instances, for tiie 
reason that the growth proved to be 
carcinomatous. 

' And this leads me to consider how 
we are to recognize this state, and thas 
to avoid attempting useless prostatect- 
omies. In the early stage there is 
considerable difficulty in doing this. 
Carcinoma of the prostate is not in^ 
frequently met with in younger per- 
sons than in the ordinary forms of 
prostatic enlargement or adenoma. 
Cancer of the prostate may occur at or 
about the age of fifty, and in this re- 
spect corresponds with carcinoma of 
the female breast. It is usually asso- 
ciated with considerable lumbar and 
sciatic pains. Later on it involves 
more or less of the chain of glands in 
the groin, including the femoral, which 
it indurates. Examination by the 
rectum not only finds the gland of 
stony hardness but of marked fixidity 
on pressure. Slight haemorrhages are 
occasional, but serious alterations in 
the character of the urine and obstruc- 
tion to catheterization are often de- 
layed. Loss of flesh is usually noted. 
These are the ordinary symptoms of 
carcinoma of the prostate. 

In several instances I have seen, 
where the diagnosis was verified by 
microscopical examination, the disease 
was marked by slow progress and the 
slightness of the local symptoms that 
were present throughout. It appeared 
to prove fatal by the general decay that 
was induced rather than by any inter- 
ference it occasioned with the func- 
tion of micturition, thus contrasting 
with advancing forms of ordinary pros- 
tatic hypertrophy. 

On the other hand, the adenomatous 
prostate, which often assumes very 
considerable dimensions, and is best 
suited for, treatment by prostatectomy, 
presents very different local conditions. 
When examined by the finger in the 
rectum there is a feeling of less fix- 
idity about it relative to the pelvis. 
The bowel is freely movable over it. 
Though firm and bossy to the touch it 



is wanting in that feeling of stony 
hardnees which is so characteristic of 
the carcinomatous prostate. 

Where an operation is contemplated 
DO examination for the purpose of di- 
agnosis can be considered con^ete 
without the use of the electric cysto- 
scope. Upon this often turns whether 
a prostatectomy should be undertaken 
at all, or whether the case permits of 
the substitution of a more limited pro- 
ceeding, as will be illustrated later on. 
As viewed by the cystoscope the differ- 
ences between hypertrophy and carci- 
noma may thus be stated. 

Carcinoma of the prostate, in by far 
the greater portion of cases, is of a 
hard and slow-growing nature, closety 
resembling scirrhus of the breast, both 
microscopically and to the naked eye. 
As a rule there is not very much in- 
travesical projection of the prostate in 
these cases, and what there is, is of an 
uneven and irregular outline. On the 
other hand, the large, soft adenoma- 
tous prostate presents, as a rule, a con- 
siderable enlargement into the bladder 
cavity with a smooth, rounded surface. 
The most general arrangement of these 
adenomatous masses are these: — 

(1) As a collar-like general enlarge- 
ment of the prostatic ring encircling 
the prostatic portion of the urethra. 

(2) As an enlargement of the two 
lateral lobes, thus squeezing and flat- 
tening the urethra from side to side, 
the greatest diameter of that passage 
thus becoming vertical. 

(3) An enlargement of the poste- 
rior or middle lobe, either as a sessile, 
rounded swelling under the mucous 
membrane of the apex of the trigone, 
or with a thick pedicle, thus closely 
resembling afibro-papillomain appear- 
ance. 

(4) Or there may be a combination 
of any or all of the preceding varie- 
ties. 

It is thus obvious that the cystO' 
scopic appearance of the adenomatous 
prostate varies very much according to 
the direction of the growth. UsualVy 



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the contour oan be made out fairly ac- 
cnrately^ aud the observer can say that 
he has to deal with a lateral lobe en- 
larffonent, a collar-like enlargement 
with projecting middle lobe, or an en- 
largement mainly of a pedunculated 
nature. The importance of this is ob- 
vious, for in the last-mentioned case a 
simple twisting off of the pedunculated 
middle lobe would be sufficient to re- 
lieve all symptoms, as I shall presently 
show, and is a much less serious pro- 
ceeding than removing the whole of 
the enlarged gland. It should also be 
noted that the mucous membrane 
covering the very large adenomatous 
masses is often of a peculiarly glieten- 
ing character, and sometimes presents 
little cyst-like swellings, which, when 
viewed in profile, are semi-translucent. 
I have not observed this appearance in 
cases which eventually turned out to 
be carcinoma. 

I am laying considerable stress on 
the importance of recognizing carci- 
noma or cancer of the prostate when 
it is the cause of the CDlargement, and 
distinguishing it from ordinary hyper- 
trophy or adenoma, for the reason that 
it may be little short of a calamity to 
submit a person to a prostatectomy 
should the enlargement eventually turn 
out to be of a malignant nature with- 
out knowing it. Formerly it was not 
a matter of so much importance when 
the catheter and the irrigating syringe 
represented the mechanisms commonly 
employed in the treatment of prostatic 
obstruction, for to this extent malig- 
nant and non-malignant growths might 
be treated on almost identical lines. 
At the present time these conditions 
are changed, and now that the pros- 
tate is approached operatively much 
on the same principle as the breast and 
other organs of the body, it is of the 
first importance that we should recog- 
nize beforehand the precise nature of 
the enlargement we have to deal with. 

I have within the last two years 
performed prostatectomy in two cases 
which speedily proved to be carcino- 



matous. I think such cases should not 
be allowed to pass without notice in 
relation to the subject I am now deal- 
ing with, and I will therefore briefly 
give some particulars and show what 
was removed. 

Case 7. — The first case was that of 
a patient, aged sixty-four, whom I saw 
in 1901. He complained of frequency 
of micturition, both day and night, 
and occasionally involuntary dribbling. 
A catheter had been passed before I 
saw him, but there was no residual 
urine. * It was therefore clear in this 
instance that the frequency of mictu- 
rition was not due to retained urine, 
but to some other cause of irritation. 
The patient's history pointed to pre- 
vious attacks of renal colic, for which 
he had been under treatment at Carls- 
bad. The last attack of renal colic 
had been two and a half years before 
I saw him. He had passed uric acid 
gravel in the urine, but not stone. 
Examination by rectum showed the 
prostate to be extremely hard, par- 
ticularly at one point, where it gave 
the sensation as if a stone was impact- 
ed there. Further, the patient com- 
plained of dull aching about the but- 
tocks and thighs. The muscles were 
flabby and the patient was losing flesh. 
He complained much of the frequency 
of micturition, which disturbed his 
rest and greatly distressed him both 
day and night. As there was no resid- 
ual urine to draw off, the catheter 
was useless so far as this symptom was 
concerned. 

Later on some difficulty arising out 
of the increasing size and hardness of 
the prostate occurred, and the use of the 
catheter then became necessary. Oc- 
casionally a few drops of blood werd 
passed. I was not able at that time 
to detect any enlarged glands either 
in the groins or femoral regions. The 
patient became very anxious about his 
condition, and having heard of cases 
where the prostate had been success- 
fully removed, he was desirous, other 
measures failing, of submitting to this 



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operation. I gave it as my opinion 
that the case was not a favorable one 
for prostatectomy, as it was not un- 
likely the growth would recur, and 
that there could be no guarantee that 
the whole of the disease was removed 
at the time of the operation, as in the 
case with adenomas involving the part. 
On the other hand, the patient urged 
the pain and frequency which attend- 
ed the introduction of the catheter, 
and the uselessness of all the means 
that had hitherto been employed to 
relieve him. I could not absolutely 
deny the possibility of the growth 
proving to be one of those densely 
fibrous prostates which are occasion- 
ally met with. But in my judgment 
the weight of evidence was against 
this. 

However, at the request of the pa- 
tient an attempt was made to extir- 
pate the gland by the suprapubic 
route. I felt to some extent justified 
in doing this, for the reason that it 
was evident tio long time could elapse 
before it would be necessary at all 
events to open the bladder for the 
purpose of allowing the urine to es- 
cape. The prostatic urethra was rap- 
idly becoming blocked up by the in- 
vading growth and catheterism would 
soon be impossible. Prostatectomy 
was therefore performed in February, 
1902, ^our months after the patient 
had been under my observation. The 
prostatic mass could not be enucleated 
with the finger, and had to be removed 
in several portions in this way. 

The progress of the case was dis- 
appointing. Though the patient re- 
ceived immediate relief by the freedom 
with which the urine escaped by the 
open wound, and got rid of the dis- 
tress connected with catheterism prac- 
ticed under great difficulty, the growth 
within three or four weeks of the op- 
eration returned in the original site. 
It became necessary to fit a permanent 
drain pipe in the suprapubic opening, 
which enabled the patient to pass 
urine painlessly during the remainder 



of his life. The prostatectomy, how- 
ever, proved useless, and the patient 
died from the recurrence of cancer in 
the part four months after the opera- 
tion which had been undertaken for 
its removal. Secondary growth man- 
ifested itself in the spine about the 
ninth and tenth dorsal vertebrae. On 
microscopical examination the growth 
proved to be of a mixed character. 
The periphery of the mass was adeno- 
matous, whilst the center was carci- 
nomatous. The growth cut like scir- 
rhus of the breast, and yielded typical 
*' cancer juice" on scraping. Mr. 
Watson Cheyne saw the patient in 
consultation with me. 

Case 2. — The second case was that 
of a professional man, aged sixty-one, 
who consulted me in April, 1901, for 
frequency of micturition. As in the 
preceding case, the use of a catheter 
indicated that there was no residual 
urine in the bladder to account for this 
symptom, and that some other cause 
for it was to be sought. The prostate 
was examined per rectum, and it was 
fouiid to be large and hard. It was 
noted, however, that the rectum was 
freely movable over it, and that the 
growth was not unduly fixed within 
the pelvis. I did not see the patient 
again till January, 1902, when the 
symptoms had become more urgent. 
The frequency of micturition had 
greatly increased, and with this a ne- 
cessity for the use of the catheter. 

These symptoms were so urgent that 
on January 5th suprapubic prostatec- 
tomy was performed. What was ap- 
parently a fibro-adenoma of the pros- 
tate was enucleated with some diffi- 
culty in two pieces by the finger. The 
bladder had evidently for some time 
been immensely distended. The 
mouths of the ureteral orifices were 
so large that they would each admit 
the tip of the forefinger. The naked- 
eye appearance of the growth was 
that of an adenoma, which the first 
microscopical examination confirmed. 
A further examination,' which included 



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a complete section of the mass re- 
moved, unmistakably indicated its car- 
cinomatous nature as in the previous 
case. 

Early in April, 1892, this patient 
sailed for the Cape in a professional 
capacity, apparently in excellent health, 
and passing urine quite naturally. 
About four months after operation he 
had one or two slight attacks of htema- 
turia, which were evidently connected 
with recurrence at the original site. 
He was able, however, to complete 
two more voyages out and home, when 
he returned to this country with the 
abdominal cicatrix and contiguous 
glands largely involved in carcinoma, 
and with the scrotum and legs much 
edematous. This had all taken place 
within the course of sixteen months. 

During the last few months my at- 
tention has been called to several in- 
stances of prostatic enlargement, which 
should be included with those I have 
just mentioned. They are not cases 
which should be submitted to prosta- 
tectomy. At all events, the prospect 
of recurrence should have full consid- 
eration. 

But though a deliberate prostatec- 
tomy may not be advisable in cases of 
this kind, there can be no doubt that 
carcinoma of the prostate often, 
sooner or later, leads to conditions 
where operative interference is called 
for; I refer more particularly to 
the effects of obstruction so caused 
upon the contents of the bladder. A 
suprapubic opening may give immense 
relief to *the patient whose bladder is 
distended with clots or foul urine. 
This is a substitute for a catheter 
which may be advantageously utilized. 

I would like to say a few words in 
reference to some modern develop- 
ments relative to the treatment of cer- 
tain inoperable forms of prostatic ob- 
struction. I refer to those instances 
where the enlargement is presumably 
of a cancerous nature. It is a painful 
thing for a surgeon to say to a patient, 
**I cannot advise the removal of your 



enlarged prostate, for the reason that 
it is probably malignant." ** Is there 
nothing you can offer?" is probably 
the rejoinder to this. Within the last 
few months my attention has been di- 
rected to the use of the Roentgen rays 
and high-frequency currents in some 
of these inoperable cases of prostatic 
carcinoma to which I am referring. 
This is ground upon which I would 
tread with much caution. My interest 
was first drawn to this subject by some 
admirable papers on the use of the 
x-rays and the Finsen light in connec- 
tion with the treatment of lupus and 
other semi-malignant forms of ulcera- 
tion. At the present time I have two 
cases of malignant disease of the pros- 
tate, or what I take to be such, under 
daily treatment by means of these 
agencies. In alleviating pain, and in 
apparently favorably influencing the 
further development of these growths 
as judged by the patient's sensations, 
physical condition, and examination of 
the part with the finger, I am favor- 
ably impressed by what I have seen. 
The process is a painless one, and will 
be continued on the ground that it 
appears to have contributed to the 
comfort of the patients. It seems im- 
possible that so powerful an agency 
can be brought into contact even mo- 
mentarily with living tissues without 
influencing their nutrition. Whether 
for good or for evil, or for neither in 
instances such as these, has yet to be 
determined. I think, however, from 
what I have seen, it is worth a trial, 
and this it is having. 

To revert. I opened these remarks 
by illustrating what may be regarded 
as the total enucleation of the contents 
of the prostatic capsule. I will now 
consider some cases where partial pros- 
tatectomy may be substituted. 

If we study a number of specimens 
of enlarged prostates, we shall find in 
a certain proportion that the obstruc- 
tion is occasioned by a limited portion 
of the gland which has become hyper- 
trophied or excessive. The most com- 



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moD form of this variety is where the 
floor of the gland becomes pendulous^ 
and by blocking micturition renders 
the nataral escape of urine as impos- 
sible as if the orifice of the bladder 
were commanded, by what is known in 
mechanics as a ball valve. In all other 
respects these prostates are naturally 
disposed. Let me illustrate what I 
mean by a case. 

In April, 18i^9, 1 saw, at the request 
of Sir Douglas Powell, a gentleman, 
aged fifty-five, who was suffering from 
stone in the bladder. I performed 
litholapaxy upon him, and removed a 
stone composed of oxalates and phos- 
phates weighing over one-half ounce. 
I should mention that he had been 
using his catheter for twelve months, 
and had been absolutely dependent 
upon it for three weeks before the op- 
eration. The patient made a rapid 
recovery from the operation, though 
he was never able to dispense with the 
use of the catheter afterwards. 

In August of the same year the op- 
eration of litholapaxy had to be re- 
peated, as in this short interval an- 
other stone had formed, which was 
also successfully removed in the same 
way. On this occasion the stone was 
formed of phosphates, which is the 
usual kind in the case of recurrences. 
Again he made a speedy recovery so 
far as the removal of the stone was 
concerned. The patient, however, 
still remained dependent on the use 
of the catheter. By September, 1900, 
he had formed other stones, which 
were removed in like manner. He 
still remained dependent on the use of 
the catheter. For the fourth time, in 
February, 1901, he again applied to 
me with symptoms of stone. Feeling 
sure that this rapid recurrence of stone 
was not due to any fault in the opera- 
tion or to any want of care on the part 
of the patient or his medical attendant, 
before proceeding to remove the stones 
I examined the patient with the cysto- 
scope. The view thus obtained of the 
interior of the bladder was extremely 



interesting. There was no enlarge* 
ment of me lateral lobes of the proa* 
tate, but the third or middle lobe was 
prolonged, and took the form of a 
pendulous mass which projected up- 
wards into the bladder, and evidently 
played the part of a ball valve. 

Thus the urine was mechanically 
prevented escaping from the bladder^ 
except when the catheter was used, 
and being allowed to decompose, the 
formation of phosphatic stones neces- 
sarily followed. I should add that 
under cover of the projecting lobe of 
prostate a portion of two calculi were 
seen by the cystoscope. This condi- 
tion at once explained how these stones 
were formed, and I decided upon re- 
moving that portion of the prostate 
which was hypertrophied, as well aj 
the stones it partially concealed. It 
seemed to me quite unnecessary to r^ 
move the entire prostate, and I there- 
fore advised the minor operation. 

This was done by opening the mem- 
branous portion of the urethra on a 
grooved staff, as if for median lith- 
otomy ; this enabled me to pass a pair 
of forceps into the bladder, with which 
I seized and twisted off the polypoid 
excrescence of prostate as you see in the 
specimen. Subsequently I withdrew 
two calculi and introduced a temporary 
perineal drainage tube into the blad- 
der. In a few days the latter was 
withdrawn, when the wound rapidly 
closed. 

It is now over two years since this 
operation was done, the patient has 
had no further recurrence of stone, 
and what is also of great importance, 
he has never had occasion to use the 
catheter since, though he had been de- 
pendent upon this instrument for so 
many years previously. 

It was quite clear in this case that 
the partial enlargement of the prostate 
which I have described was the direct 
cause of the recurrence of stone from 
which this patient suffered for so many 
years. Further, this case illustrates 
the great assistance the cystoscope 



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affords in ali cases of this kind. It 
old^y showed how limited the pros- 
tfttie ealargeoient was, and how this 
could be removed by a very idmple and 
safe operation* The days are now 
past when the cystoscope was regarded 
as a toy. Every one who desires to 
obtain a practical knowledge of the 
disorders affecting the urinary tract 
must make himself acquainted with it 
if he desires to diagnose and treat cor- 
rectly the disorders of this part. 

Partial operations on the prostate 
must be limited to such conditions as 
I have just illustrated. They are not 
to be recommended when the entire 
organ is more or less involved in a 
hypertrophy. Two instances have re- 
cently come under my attention where 
no permanent good followed supra- 
pubic cystotomy and the removal of 
some portions of the enlargement. In 
one the suprapubic opening never 
closed, as the urine failed to escape 
by the natural channel, whilst, in 
the other, though the suprapubic 
wound healed by the aid of a retained 
catheter, the patient could never dis- 
pense with the latter instrument. In 
the latter case I advised that an at- 
tempt should be made later on to rec- 
tify this by a more complete enucle- 
ation of the balance of prostate that 
remained. This I heard was followed 
by a most satisfactory result, the pa- 
tient within a month after the revised 
operation obtaining full voluntary 
power over the act of micturition, be- 
sides other advantages. 

There is another point to which I 
should like to refer in connection with 
the subject of entire enucleation of the 
prostate as now practiced. 

There can be no doubt that in the 
majority of these cases the prostatic 
urethra is more or less damaged, if 
not'estirely removed. This is evident 
from the elimination of specimens 
after removal. 

This mass, which weighs three 
ounces, and the stone below it, was 
removed from a gentleman, aged sixty, 



in November, 1901. He had been 
completely incapacitated from profes- 
sional work by the constant use of the 
catheter. He is now in excellent 
health and urinates normally, though 
his prostatic urethra was included in 
what was removed. 

The question has been raised, ^^Is 
there not some liability to what 
amounts to a urethral stricture after a 
wound of this kind?" I have met 
with an instance where there is some 
evidence of this being the case. The 
prostate was removed from a gentle- 
man, aged sixty-seven, in February, 
11*02. The urethra was somewhat 
freely separated on the anterior aspect 
of the prostate in front of the junction 
with the membranous portion. The 
whole canal was no doubt much tough- 
ened by the very long dependence on 
the catheter, and by no less than eight 
crushing operations for stone which 
had preceded the prostatectomy. Since 
the latter operation this patient has 
had some trouble in passing urine. 
Sometimes a good stream passed, at 
others no urine could be voided until 
after the introduction of a bougie. A 
good stream then immediately fol- 
lowed. Apparently there was an ob- 
struction of a valvular nature which 
thus caused the difficulty in urinating. 
It could not be called a stricture, as 
after the hitch was overcome just at 
the entrance to the bladder a No. 14 
metal bougie, English gauge, passed 
easily. Three months after the pros- 
tatectomy I passed a urethrotome and 
divided what seemed to be a fibrous 
band or bend at the point where the 
hitch occurred. This completely freed 
the urethra for all purposes and the 
patient has since had no further 
trouble in urinating naturally with a 
large stream. 

The narration of the last case leads 
me to give prominence to a method 
of dealing with some forms of pros- 
tatic enlargement which seems to have 
some advantages I will presently note. 

In 1881 I read a paper before the 



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Royal Medical and Chirurgical Society, 
based on some cases where tumors of 
the prostate had been saccessfully 
enucleated in the course of operation 
for stone in the bladder, by lateral 
and bilateral lithotomy, and I advo- 
cated the proceeding as bearing upon 
the remedying of prostatic enlarge- 
ment **by means other than those 
commonly recognized/'* 

The most striking case I then re- 
corded was that of a man, aged sixty- 
seven, with a large oxalate stone in 
his bladder and an hypertrophied pros- 
tate, who was sent to me by Dr. H. G. 
Samuels, when I was surgeon to the 
Liverpool Royal Infirmary, and upon 
whom I operated in September, 1881. 
As the stone and prostate were both 
large I made a bilateral section of the 
latter by means of which I removed 
the stone with forceps and enucleated 
with my forefinger the obstructing 
prostatic mass, which proved to be a 
considerable adenoma. The patient 
made a good recovery and completely 
recovered his voluntary power of mic- 
turition. The specimen was again 
shown at the Manchester meeting of 
the British Medical Association (1902) 
in the course of a discussion on pros- 
tatectomy. 

In the discussion which followed the 
reading of my paper before the Royal 
Medical and Chirurgical Society, Sir 
Henry Thompson, Sir William Savory 
and Mr. Christopher Heath took part, 
when it was stated by the first named 
speaker that my suggestion **was 
practical and well worthy of consider- 
ation." 

After the lapse of twenty years I 
have deliberately applied the process 
which in my first paper I regarded as 
*<an accident" occurring in the course 
of a lateral lithotomy operation. I 
have very little doubt, in the light of 
what is now being done in regard to 
prostatectomy, more especially in its 
relation to cases complicated by vesical 
stone, that what I described as being 

* Trans. Royal Mod. Chlr. Society, vol. bcv. 



undesignedly done in 1881, probably 
represents in 1903, in conjunction with 
the closure of all perineal cystotomy 
wounds, by the use of sutures and 
suitable drainage tubes, a most efficient 
and rational method of dealing with 
this combination of disease. Li this 
way provision is made for the removal 
of the stone, the obstruction contained 
within the prostatic capsule, and for 
restraint of haemorrhage in a combined 
manner which has not been previously 
attempted. I will proceed to mention 
particulars of a case where this process 
was recently employed. 

It was that of a member of our own 
profession, whom I saw in February 
this year (1903). Twenty-five years 
previously he had a stone removed 
from the bladder by crushing, by Mr. 
Christopher Heath. He remained 
well until two years ago, when symp- 
toms of enlarged prostate caused 
him much continuous pain. I 
examined him under an anaesthetic 
later on, and found the prostate uni- 
laterally enlarged to a considerable 
extent. Though he was not depend- 
ent on the catheter his calls to urinate 
were frequent and distressing, and I 
concluded that it was best to make an 
exploratory incision within the area of 
the prostatic capsule, and to remove 
an obstruction which I believed to be 
what Sir Henry Thompson described 
many years ago '*as a prostatic tumor 
encapsuled in the interior of the 
gland." 

For this purpose I made the ordinary 
incision as for lateral lithotomy, which 
gave free access through the membra- 
nous urethra to the prostate and en- 
abled me to readily remove the tumor 
I am now showing. It is figured ex- 
actly as removed by enucleation with 
the finger. 

It will be seen that it is about the 
size and shape of a tennis ball. Had I 
required more room or found it neces- 
sary to enucleate the opposite lobe, the 
bilateral incision through the prostatic 
capsule would have provided this. 



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Enucleation was readily effected by 
using the two forefingers of my right 
hand whilst downward pressure was 
exercised above the pubes with the 
left, the entire operation only occupy- 
ing a few minutes. 

One of ray gum-elastic drainage 
tubes was passed through the wound 
into the bladder, and the incision 
closed around it firmly with sutures. 

I would incidentally mention that 
for some years preceding the more 
general adoption of litholapaxy as a 
substitute for lithotomy, 1 had been in 
the habit of thus closing perineal 
wounds made for the latter purpose. 
In this way haemorrhage was arrested 
and by conveying the urine outside 
the bed patients were kept dry through- 
out. 

Further, the dependency of the 
drainage as compared with suprapubic 
-cystotomy certainly favored more rapid 
repair. . In forty-eight hours or so the 
«tiff gum-elastic drainage tube, which 
permits of side-packmg with gauze if 
hsemorrhage continues, was removed 
and a soft rubber one, with control tap 
for the urine, was substituted. 

The patient left hospital within a 
fortnight from the date of operation, 
though the wound had not completely 
healed. His condition is greatly im- 
proved and the function of micturition 
is so completely restored that he is 
looking forward to resuming profes- 
sional employment. Two months after 
the operation I had the pleasure of 
submitting the patient to Mr. Heath, 
together with the growth that had 
been removed. 

An idea may be formed as to the 
amount of room afforded for with- 
drawing a growth or etone from the 
bladder, and for conducting the neces- 
sary manipulations with the finger, 
from the accompanying diagram. It 
was made from the transverse section 
through the middle of a frozen gland, 
-and shows the lines of a lateral and a 
bilateral section, as well as other di- 
rections of incision. In the enlarged 



prostate these dimensions may be con- 
siderably increased without impinging 
upon the capsule^ It will be observed 
that the downward or upward incisions 
through the prostatic area from the 
urethra, which would correspond with 
a median perineal section, offer a more 
limited access as compared either with 
the lateral or bilateral incision, single 
or combined. Further, the latter two 
will drain incontinently without a tube 
should this for any reason be required, 
whilst this is not the case, or very im- 
perfectly so, with the median sections. 
Further, it is to be remembered that 
the downward incision into the gland 
necessarily sacrifices the ejaculatory 
ducts, should this be a point deserving 
consideration. 

The chief advantages connected with 
this form of prostatectomy are that 
the bladder is not opened, no portion 
of the urethra is removed, the after- 
treatment is more comfortable to the 
patient as not entailing a suprapubic 
opening, and a more rapid convales- 
cence. 

The procedure I have described is an 
interesting example as to how history 
may repeat itself in connection with 
surgical work. Further, it illustrates 
how accidents, or what Paget spoke of 
as ^'calamities in surgery," may be 
importantly utilized. We have another 
illustration of this in the failures of 
nephrotomy, contributing to the devel- 
opment of important observations in 
connection with the treatment of some 
forms of albuminuria and nephritis by 
surgical means, a subject in which I 
have also been much interested. 

In two instances I will briefly narrate 
suprapubic prostatectomy followed - 
some weeks after perineal drainage 
had been employed for the relief of 
retention and purulent cystitis. In each 
case at that time the patients were in 
too serious a condition for submitting 
to removal of the prostate. 

The first instance was that of a pa- 
tient aged sixty-three, who I saw in 
consultation early in 1901 with Dr. 



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Skartnan, of Sydenham. There was a 
preyioas history of a severe spinal in- 
jury, and the local condition rendered 
it likely that there was a suppurating 
sac entering above the large prostate, 
the contents of which were discharged 
into the bladder. For two years he 
wore his control drainage tube with 
considerable comfort, and his health 
improved. After consultation with his 
medical attendants. Dr. Umney and 
Dr. Hale White, I advised a suprapu^. 
bic prostatectomy, which was per- 
formed in March, 1903. Six months 
after this operation he writes me, <*I 
have, been to Brighton for a month. 
The amount of pus does not decrease, 
but the removal of the prostate cer- 
tainly has caused me to suffer far less 
inconvenience." 

The second case was that of a pa- 
tient aged seventy-three, who I saw in 
consultation with Dr. E.J. Lewis, Mr. 
Edmund Owen and Sir Thomas Smith 
during the early part of 1903. His 
condition in the first instance was a 
very serious one from prostatic ob- 
struction and suppuration. As a tem- 
porary expedient, as in the previous 
case, perineal puncture was performed. 
After this he improved slowly, and as 
there was every prospect of his having 
to wear the drainage tube for life he 
preferred to undergo, later on, a more 
radical procedure. His appetite and 
strength having been greatly restored, 
perineal prostatectomy .was performed 
five months after the previous opera- 
tion. There was nothing particular to 
note except that a stone was found 
concealed by the lobes of the prostate. 
He had been sounded previously with- 
out it being detected. Its relation to 
the prostatic lobes showed this to be 
impossible. The Roentgen rays might 
perhaps have indicated its presence. 
Both wounds healed well and quickly, 
the perineal opening favoring this by 
supplying a means for dependent 
drainage. 

In reference to the mortality of 
prostatectomy, I do not think the 
number of cases or the periods of time 



they cover are sufficient at present to 
enable us to iurive at conclusions 
which can be deemed very guiding or 
conclusive. Information for this 
purpose should be of the fullest kind; 
and include partial as well as complete 
prostatectomies, whether suprapubic 
or perineal. I am not at all sure 
whether what are called **partjal pros- 
tatectomies" are not the more fatal 
of the two, as these would include the 
malignant and fibrous types of pros- 
tatic enlargement, as opposed to the 
adenomas, which are easily and quickly 
shelled out with little or no heemor- 
rhage. * 

I am disposed to think that the mor- 
tality which would embrace these va- 
rieties is not much less than what 
Fuller placed it in his earlier articles * 
on suprapubic prostatectomy, namely, 
15 to 18 per cent. Even if brought 
down to a 10 per cent, mortality this 
should make us careful in advising it 
or in setting aside what the catheter 
and the wash bottle can do, though 
fully admitting the inconvenience of 
these. 

If these operations were confined to 
the enucleable adenomas, or to use the 
term applied to them by Sir Henry 
Thompson, prostatic tumors encapsul- 
ed in the interior of the gland, I have 
very little doubt that the mortality 
would be considerably lessened. It is 
where severe structural lesions have 
to be inflicted for the purpose of ef- 
fecting removal with the finger where 
risk comes in, in the form of shock 
or hemorrage, and it is to some of 
these cases that the term partial re- 
moval is assigned for obvious reasons. 

Enlargement of the prostate is a 
wide subject, and permits of a good 
deal of variety in treatment, operative 
and otherwise. In placing these views 
before you I think we are much in- 
debted to my colleague, Mr. Freyer, for 
the communications he has made, here 
and elsewhere, in reference, more es- 
pecially to suprapubic prostatectomy. 

•••Diseases of the Gealto-Urinary System " (Maemil- 
Ian, 1900). 



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SBQREOATtON OF LBPBRS. 

Bt 6. G. Mabtui, X. ]>M 8t. LomU. 

In Norway leprosy is so oommon 
that the goverDiuent has f o«ad it nec- 
essary to provide hospitals or what 
they call ** Homes" for the treatment 
and care of this class of patients. In 
Bergen and Trondhjem elaborate insti- 
tutions of this kind have been estab- 
lished, in each of which an average of 
one hundred and fifty patients are un- 
der treatment. In these institutions 
these unfortunate people are treated 
with the greatest tenderness and al- 
lowed the utmost personal liberty con- 
sistent with the welfare of the com- 
munity. Dr. Lee has charge of the 
sanitarium at Bergen, and Dr. Sand is 
in charge of the institution at Trondh- 
jem. Dr. Hansen has supervisory 
control of these establishments, but 
spends the most of his time visiting 
cases in various parts of the country 
which have been reported as leprous. 
His diagnosis determines the fate of 
the patient he visits. If he happens 
to be a leper, he is sent to one of the 
^ 'Homes," otherwise he is not dis- 
turbed. In Bergen the **Home" is lo- 
cated in the central part of the city, 
but in Trondhjem it is built on the 
outskirts of the city, and in both insti- 
tutions the inmates are allowed, if in 
good p)iysical condition, to visit any 
part of the city they wish, provided 
this is done with permission of the 
physician in charge. Dr. Sand has 
been in charge of the institution at 
Trondhjem thirty years, and Dr. Lee 
has been in charge of the *'Home" at 
Bergen twenty years. Both of these 
gentlemen told the writer that they 
had never known a healthy person to 
contract the disease by oomins: in con- 
tact with leprous patients. This also 
included the nurses and attendants of 
these institutions. In other words, 
they did not believe the disease was 
contagious. They were in favor of 
segregation because under this system 
better medical attention was provided 



1^ bett^ hygiene enforced, and tliese 
w^e the best means of preventing th^ 
spread of the disease. These views 
surprised the writer, as he knew Drf 
HsAsen, who is at the head of the lepr 
rosy management in Norway, was the 
father of the lepra bacilkis, and pro- 
fessed to believe in its contagious ten- 
dencies. Both Dr. Sand and Dr. Lee 
affirm there is no curative treatment 
for leprosy, but that occasionally a re- 
covery would take place spontaneously 
under judicious hygienic management* 
Dr. Sand kindly furnished me with 
some important statistics of the insti- 
tution in Trondhjem, of which he has 
been director from 1861 to 1900, an 
abstract of which is herewith ap- 
pended. 

The relation of the different forms 
of leprosy to each other is as follows : 
1707 cases had been treated during 
the long period of about forty years. 
Of these, 588 persons, from different 
causes, had been discharged from the 
institution, and 1124 had died. The 
number of tubercular cases (1145) 
was more than double that of the 
maculo-anesthetic lepers ( 533 ) . With 
reference to sex, the numb^ of males 
( 1080) was nearly double that of fe- 
males (598). The difference between 
the number of treated maoulo-anee- 
thetic males (327) and tubercular f^ 
males (392) is relatively insignificant; 
while the number of tubercular males 
(75;5) is about four times as great as 
that* of the maculo-anesthetic females 
(206). The same statistics show that, 
in all, 1124 died in the institution; of 
these, three-fourths (835) from the 
tubercular form, and only one-fourth 
(289) from the maculo-anesthetic; 
about two-thirds (733) were males, 
and only one-third females (891). 
Altogether, 442 (297 males and 145 
females) were on the following grounds 
discharged: Cured, in all, 6(1 male 
and 5 females). In addition to these, 
several recovered who preferred to re- 
main in the institution. Admitted for 
observation, and later (as non-lepers) 



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Original articles 



discharged, 28 — namely, 12 males and 
16 females. On the grounds of in- 
sanity prior to 1880 (when there was 
no department for insane), 7 were dis- 
charged. Discharged for improper 
conduct, 46 ; of whom 33 were males 
and 13 females. Discharged for a 
variety of causes, 41. TransfeiTed 
for various reasons to another institu- 
tion, 18. Left without permission, 
296 (males 209 and females 87). Of 
the above discharged invalids, 199 
were taken back, amon^ whom, how- 
ever, was none of those dismissed as 
cured. Since 1880, when a department 
for insane was established, a total of 
798 lepers have been treated. Of these, 
47 were insane ( 23 males and 24 fe- 
males). Of these 47 insane cases, 10 
(4 men and 6 females) came from 
other institutions. Deducting these 
from the 47 cases, there are 37 left, 
which gives a percentage of 4.70 to 
the whole number treated in the insti- 
tution (788). 

The medium age shows itself two 
years higher in tubercular males (39.91 
years) than in tubercular females 
(37.77 years), although the duration 
of the disease in males is about three- 
fourths of a year less (9.24 years) 
than in females (9.98 years). This is 
explained by the fact that, in the tu- 
bercular form, the average age at the 
outbreak of the disease is about three 
years higher in males (30.69 years) 
than in females (27.79 years). In the 
maculo-anesthetic form, on the other 
hand, the medium age in males is 
about two years less (50.74 years) 
than in females (52.57 years); as, 
however, the duration of the disease 
in males is about five and a half years 
shorter (14.28 years) than in the 
females (19.76 years), the relation re- 
mains the same so far as the average 
age at the outbreak of the disease is 
concerned. 

In this form of the disease females 
are about three and one-half years 
younger when they are attacked 
(32.81 years) than the males (36.46 



years). With respect to the period of 
treatment in the institution, the lepers 
who are admitted have on an average 
passed more than half of the period of 
sickness (11.24 years) at home (6.93 
years), and only a part of the last half 
in the institution (4.31 years). And, 
also, it maybe said that the females 
defer their entrance longer still (7.64 
years) than the males (6.54 years). 
The difference is mainly limited to 
those affected with the maculo-anes- 
thetic form, for the duration of the 
disease before entrance to the institu- 
tion for tubercular males and females 
is nearly the same (5.68 and 5.84 
years), while for the males affected 
with the maculo-anesthetic form it is 
9.98 years, against 12.45 years for fe- 
males of the same form. The medium 
age for both sexes and forms of the 
' disease together is 42.33 years. The 
age at the outbreak of the disease for 
both sexes and forms of the disease is 
31.09 years; therefore, the duration 
of the disease for both sexes and forms 
of the disease is 11.24 years. The du- 
ration of the disease before admission 
to the institution for both sexes and 
forms of the disease is 6.93 years. 
The treatment period in the institution 
for both sexes and forms of the dis- 
ease is 4.31 years. The relation of 
the disease to married couples is as 
follows: In 478 marriages between 
lepers and non-lepers, only 15 cases 
appear where husband and wife were 
attacked. In 5 of these cases the hus- 
band and in 10 the wife first became 
leprous. In 463 of 478 marriages no 
infection followed. This gives a per- 
centage of non-infection of about 97. 
When we consider that the outbreak 
occurs mostly at the age of ^marriage, 
that is from 20 to 40, we cannot avoid 
the conclusion that leprosy, as a rule, 
is not conveyed from individual to in- 
dividual by constant contact. It is 
generally accepted that the disease is 
caused by the lepra bacillus, but the 
only reason for this belief is found in 
the constant presence of this bacillus 



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GenitO'Urinary Anatomy— Lewis. 



250 



in the disease. No well-authenticated 
case of its production hj inoculation 
has ever hekxk recorded, and that is the 
only reliable means of deciding this 
question. In view of the evidence we 
have that leprosy is practically a non- 
contagious disease, it is doubtful 
whether any government is justified in 
isolating or segregating these uqfprtu- 
nate people against their will. .At all 
events, before they are deprived of 
their liberty, it devolves on the gov- 
ernment to prove beyond a doubt that 
tjiey are a menace to the health of the 
community in which they live. 



porary , relief ; while a permanent ci^re 
may be expected from operative meth- 
ods, backed up with regftlar treatment 
covering a good length of time. 

A mistake not infrequently made by 
persons is to*^believe they have strict- 
ures when they have none. T^iejLare 
examined, fotr instance, with a sonand 
which runs up against the cut-off mus- 
cle, making a definite ^ and decided ob- 
struction to the further entrance of 
the sound; the case is diagnosed as 
'* stricture" when there is none — the 
obstruction having' teeti produced by 
a perfectly normal affair, the cut-off 
muscle. 



A Pj^fN TALK ON MATTERS PER- 

TAININQTO QEMTO'URtNARY ANAT' 

OMY, PHYSiOLOQY AND 

DISEASES. 

[CONTINUID rSOM SBPTKMBIB ISSUE.] 

By Dr. Branstobd Lfcwis, of St. Louis, 
Professor of G^euito-Urliiary Surgery, Mariob-Sims-Beaa- 
mont Medical CoUeee; ConstUtant in Qenito-Urlnary 
Surgery. to the Female Hospital, Bebekah Hos- 
pital, etc. ; Member of American Association 
of Genito-Uri'nary Surgeons, American 
Medical Association, Etc. 

Stricture of the Urethra is an ab- 
normal narrowing of the urethra at 
some point or points (Fig. 15); usu- 
ally caused by either uncured gonor- 
rhea or some direct injury, such as a 
fall astride of a fence or against the - 
pommel of a saddle. Scar-tissue forms 
from either of th^se two causes, and 
in the course of time (Contracts, nar- 
rowing more and more the caliber of 
the urethra, lessening the size of the 
stream and interfering wij:h the ready 
outflow pf the urine. If neglected, it 
tends to grow worse, and also to dam- 
age other of the urinary organs. 
Stricture cannot be cured by medicines 
given in any manner or form; cor- 
roding applications of ''medicated 
bougies'' used for '*eating out" the 
stricture dimply cause more scar-tissue, 
ultimately making matters worse, in- 
stead of better. The regular passage 
of steel sounds will stretch and in- 
crease the caliber of the strictured 
urethra, giving grateful, if only tem- 



Chancroid, Chancre and Syphilis. 

Chancroid is an aggressive, local 
ulcer, usually or venereal origin, ob- 
tained in intercourse with an infected 
person of the opposite sex, although 
it is possible to be infected from an 
unclean, contaminated closet or article 
of clothing. It is a localized pro- 
cess, not involving the system of the 
affected individual. This is in marked 
contrast to chancre^ or syphilis^ which 
is a systemic disease, involving, in 
different persons, every organ or part 
of the body, and also presenting the 
various manifestations of the affection 
at any point, either inside or outside ; 
and. these various manifestations, in 
the first and second stages of the af- 
fection give rise to secretions that are 
contagious and capable of inoculating 
with syphilis any healthy person com- 
ing in contact with them. 

It is for this reason that the possi- 
bility of a person acquiring this dis- 
ease innocently or accidentally is so 
great. The babe or the wife, in using 
public utensils or closets, are alike 
endangered with respect to accidental 
contagion. 

Chancroid is a virulent and rapidly 
spreading, though local, ulcer, while 
chancre is an indolent and slow-going 
process, giving rise to no pain or even 
tenderness, often. It reminds one of 



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GenitO'Urinary Anatomy— Lewis, 



tb« axiom: ^Great oak» from Ikti» 
tfeoras grow^" ae it ia Ihft first stage 
or «rifi>eiioe of the <iBu»fti ol barge 
p n a aiWiti eg, sypbilis. The ohaiKre 
itself createe ac^ little ^fistturfaiHKe a^me- 
times that it k everio^kttd entirely, 
and the first that the patient observes 
is the later outbreak, the skin erup- 
tion. Chancre and chancroid are 
separate and. independent affections, 
bearing no relationship to one another; 
they may be inoculated onto the same 
individual, however, bed. will pursue 
their oaaal course, the chaacroid going 
tkv^ugh ita eourse ^pmkly asd healing 
up, pdMibly, before the ehanere W* 
giita to make itself manifest. 

Being a purely loeal disease^ chan- 
croid dbes not require any ^etemic 
traatment f o« its cure ; and the giving 
of mercury **t» keep it out of the 
Ufiied" is n serious errer that brings 
about eonf usioj:! and regret on variooa 
aceoonts* If the sore m a sypfaiUtio 
chancre^ it eannat possibly be kept 
oui of the Uood,. no* matter haw aet- 
iTely medicine may be given ; and if it 
is not syphilitic, it will not get into the 
Mood, whether medicine be given or 
not. The correct plan, in suck caaes, 
ia to aeeept only local treatment, un* 
less a syphilitie infection ra proved by 
the development of a skin eruption^ 
Off patches in the mouth, etc., after 
whMh comprehenrive and systemic 
treatment should be carried ost until 
the patient is cured. 

The diagnosis of ^philis should not 
be mnde on the local evidences only ; 
th^ are too erratic and deceiving to 
enaMe one to determine wbethdr there 



Fig. 10. — DQstructtoB of bone by syphilis. 

Fig. 11.— Tertiary syphilitic ulceraiion. .(^P? 
pia). 

Fig. 12. — 8cc€Midary syphilis. 

Fie. 13. — Destnictien of eyes and nose by 
syphilis. 

Fig. 14. — Loss of hair from syphilis. 

Fig. 16. — Strfctnre of the male urethra. 

Fig. is. — Large ehancroid in female. 

Fig. 17. — Destruction of eye, nose, and parts 
of face by hereditary syphilis. 

Fig. is. — Later aecondary syphilis. 



ia or is ftet a syphiUilia as well as a 
ehaneroidal inf e«iaoi>-^wbether it is a 
^^hflvdf" or a ***»lt'* seare, a» active w 
an indolent one. Tiako akn^y and th« 
dbvelopniant or non-development of en 
eraptioa» eto«:» can positively deter* 
mino the noaliter. 

Syphilie is ordinarily divituble inAn 
three stages of progreae: the irst,. or 
primary; the second, or aeeoedary, 
and the third, or t^tiary. The early 
manifesftationa of the disease are in- 
clined to be superficial^ kut numeroua ; 
the later ones, deeper and more sci- 
ons, sometiofess even destroying ti»e 
organs or parte of the body affected, 
ae shown in some of the aiQeompe^y- 
ing illustratione. While it is desirable 
that some of the early indications, ap- 
pemr^fNT the sake of penaitting a 
positive diagnosis, if nothing more — 
the later ones should be prevented by 
sujffitsieney of treatment. 

Tosoeure a conqplete aad permanent 
cure, the disease- requires prolonged 
treatment J over severtd years. This 
element of Hme is a necessary and im- ' 
peitant one. Heroic or over-vigorous 
treatments laeting but a few weeks or 
months, whether takea at Hot Springs 
QC not, do not suffice for permanent 
cure; the disease may become latent 
for a shorter or longer period as a ve*- 
suit, but it it liable to break out at 
any subsequent time, after months or 
years. On the other band* if the 
treal;ment is cajrriied on steadily and 
•suffieieptly orw thet required length of 
tirne^ a defisate and permanent cure 
may be expected in the large majority 
of cases; and, moreover, the same 
measures are usually «jb^»essful in 
keeping the disease under control 
throughout its early, active and ag^ 
gvef^sive^period^and -wkhouit intei:ruf4* 
ing the patient's work or usual voear 
tion, besides wardinic against the 
frightful blemishes of face or figuroto 
which neglected syphilis, leads. It is 
the negfecied cases that are f olrlowed 
by innumerable reeurrenees, locoiao- 
t<»r ataxia, paresb, nerve-degenera* 



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tioDs and hereditary transmission. 
Sach effects are seen in the clinics 
among the poor classes, now-a-days — 
among people who have not the energy 
or the time or the opportunity to take 
the proper care and treatment. Prac- 
tically the one exception to this rale is 
that in which a particular case is un- 
usually aggressive or rebellious, which 
sometimes happens. It is such cases 
as these that should be sent to Hot 
Springs, Arkansas, occasionally. There 
they are enabled to take a much larger 
dosage that is required, and, also, they 
make a business of attending to their 
needs in a regulai* and systematic man- 
ner. Ordinary cases do not require 
treatment at Hot Springs. 

He^^maphrodism. — ^This is a condi- 
tion about which there is much specu- 
lation by the general public — a condi- 
tion of double genital equipment, that 
is supposed to afford the possessor the 
beatific ability to hold intercourse with 
either sex. As a matter of fact, the 
condition is more ideal than real. Of 
the many cases that have been dis- 
cussed in medical literature, as well as 
the numerous ones that have not come 
to the literary surface — there is hardly 
a hamlet that does not lay claim to the 
dignity of numbering a *'morphodite" 
among its inhabitants— only a half 
dozen or so have been proved to be 
real hermaphrodites, possessing gen- 
ital organs of both sexes (testicles, 
penis, ovaries, womb and vagina) ; all 
the rest have been spurious, or, as* 
they are termed in medical parlance, 
pseudo-hermaphrodites. Two such 
cases are illustrated: one a male, with 
a blind pocket resembling a vagina; 
the other a female, with an enlarged 
clitoris resembling the organ of the 
male. Unless perverts, their sexual 
inclinations are toward the opposite 
sex, as they should be naturally. 

Confusion and life-long embarrass- 
ment sometimes result from lack of 
information on this subject by parents 
who, not recognizing the true situa- 
tion, allow a child to grow up as a boy 



or a girl, and do not discover the true 
sex until adolescence is attained, when 
a change in clothing and associations 
is attended with newspaper notoriety 
more generous than desirable. 
627 Century Building. 

jT 
SOME CASES OF HYDROCELE CURED BV 
IODINE AND CARBOLIC ACID IN- 
JECTIONS. 

Bt J. 0. LUK«, M. D., Ocilla, Georgia. 

I have had quite an experience in 
the last six or eight years with hydro- 
cele in almost all ages, from one^ year 
up to sixty-five. Will report some of 
the worst and then my method of cure : 

Case 1. — J. B., white, age thirty- 
eight years. Following history: Five 
years ago while loading a bale cotton 
on wagon strained himself in back 
badly, and felt effects of strain in right 
testicle at time, but paid very little 
attention at time to it, but in a month 
or such a matter, noticed that testicle 
was enlarging, which kept on until it got 
so large it was burdensome and greatly 
in his way while walking about or at- 
tending to his farm work, and for last 
year had been unable to plow or do any 
work on farm. When he came tome, 
I was surprised at his being able to go 
around at all. When I saw the enor- 
mity of his scrotum, it reached near 
half way to his knees and was so tense 
until almost felt hard like tumor, and 
he complained of heavy dragging pain 
in his back and would feel nauseated 
all the time. I found on close examina- 
tion that I could outline the testicle, 
so I took hypodermic needle and passed 
into sack and found the clear-like 
fluid, after which I inserted a cocaine 
injection as low down in sack as I could 
to miss testicle, after which I took a 
small [trocar with canula and passed 
into sack, withdrew needle and let fluid 
escape, and found that I had twenty- 
eight ounces ; after which I took eqiml 
parts carbolic acid and iodine, two 
ounces,' and with rubber sjnringe passed 
through canula into sack and kneaded 



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Multiple Chancre in the Negro— Lofton. 



268 



the empty sack and testicle gently 
but thoroughly, after which I let what 
of the solution would pass out, 
through the canula and had him lie 
quiet for half-hour, after which put 
him on a well-fitting suspensory and 
sent him home six miles, and he re- 
ported to me in ten days as cured and 
has remained so up to this time, which 
was about five years. He never com- 
plained of pain at any time from 
the treatment and got up and walked 
out to buggy when ready to go home. 

Case 2.—D. M., white, age sixty- 
one. While riding horseback eight 
years ago, his horse fell into a hole 
and came near throwing him off and 
mashed his testicles, and he suffered 
severely for several hours, when got 
easy and thought nothing more of his 
trouble for some time. Now he 
found his right testicle was giving him 
some trouble and gradually growing 
larger, which condition went on for 
near eight years, only giving him slight 
trouble ; it then got to where it gave 
him some pain and he came to my 
office, a distance of thirty miles, and I 
drew off nearly two ounces of fluid and 
injected same as other case and let him 
go home, but two years later he re- 
turned in same condition and I carried 
him through the same treatment again 
and made a cure up to time of his 
de^th, which was three years after. 

Case 3. — Child, two years old ; fam- 
ily history good ; health good. Three 
months ago mother noticed right tes- 
ticle swollen, and had father to bring 
him to my office. On examination, 
found he had hydrocele, and I followed 
my plan on other cases and made a 
cure, which was four years ago. And 
I have several other cases I could re- 
port, but this is sufficient and conclu- 
sive that the injection will cure most, 
if not all cases. I have in my experi- 
ence had to repeat the injections in but 
two cases, and they were both cured 
with second injection. And I have had 
no after-trouble in any case. Had no 
pain in but one case, and that was a case 



in which I left a quantity of the iodine 
and carbolic in the sack, and it set up 
no trouble, but caused the old man a lot 
of pain for about six or eight hours, 
but his case was cured ; and should I 
fail on second time, I would continue 
just as long as my patient would let 
me do so to use the same treatment. 
I believe it will cure all cases of hydro- 
cele that are curable. 

MULTIPLE CHANCRE IN THE NEQRO. 

By Luckn Lofton, A. B., Ph. D., M. D,. Emporia. V». 

Ex-President Seaboard Medieal Auociation of Virginia 

and North Carolina. 

The text-books at the command of 
the writer refer to dual chancre as be- 
ing exceptional. This thoroughly co- 
incides with my experience as f ai* as 
the white and semi-white race is con- 
cerned, but, upon the other hand, it 
has been my experience to observe, as 
a rule, double chancre (especially 
when located upon the genitalia or its 
covering) in the negro subject. In 
fact, out of twenty-nine cases of syph- 
ilitic infection that came to me for 
treatment so far this year (1903), 
twenty-one were negroes ranging m 
color from a ginger-cake brown to a 
•*charcoal white"the ages rangingfrom 
two years to fifty-three years old ; six 
were mulatto women, and four were 
deeply colored, though they were born 
that way (colored). The one aged 
two years presented a double chancre 
of the '<stub," one immediately be- 
hind the left side of the crown, and 
the other almost surrounded the mi- 
nute orifice of the glans. The fore- 
skin, as is usual, was quite long, and 
was easily retractable. His married 
first cousin was responsible for his 
condition, though she only possessed 
the classic alpha. No treatment other 
than cleanliness was given this baby, 
as developments were needed to com- 
plete the diagnosis. In due time all 
necessary evidence was produced. The 
reason this little patient was found in 
this condition was due to the fact that 



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h» oootinaally toyed with his gewtals 
and cried when any undue prcssore 
wa^ i»ada thereon. 

The ten women displayed the genu* 
ine Hunterian product, from the lab)» 
major» to the os nteri. One case, 
however, especially, which impressed 
me among the ten, was a married 
woman who had a chancre located at 
the anterior fourchette, and one on the 
tip end of the second finger of the 
right hand. She was a '* washerwoman" 
and having her hands submerged a 
great deal in strong lye-water gave 
rise to an artisan's eczema, and no 
doubt while either examining her gen- 
itals or masturbating, the sore finger 
was thus inoculated about the time 
the initial lesion appeared; or, more 
probable still, in manipulating the 
male organ she was infected. 

Another member of the above pre- 
sented a double chancre of the left 
labiae minoree, situated about one-half 
inch apart. The remainder are not 
worth a detailed description. 

In regard to the ten men, every one 
but two possessed redundant prepuces, 
a thing you will observe in ninety-five 
per cent, of your negro G. U. patients. 
Circumcision is an unknown luxury to 
the **coon'' in the South. 

Two displayed dual chancres of the 
lining of the prepuce, three had double 
chancre of the distal . portion of the 
foreskin, while four had them located 
in and around the meatus urinarius. 
One presented a most interesting pict- 
ure in that he went the other nine one 
better, and presented three well- 
defined so-called initial lesions. This 
is the only case of the kind I ever saw. 
He was a Baptist deacon, and was no- 
toriously popular among the fold, evi- 
dence of which (in a sense) was incon- 
testable. I purposely avoided any 
cautery or astringent measures in this 
instance; in fact, I saw him every 
we^k for three months, and had him 
wear apiece of ''medicated" absorb- 
ent cotton to ''absorb" the "sores," a 
hing he most readily assented to, for 



in his youth be had ^'bhmdered and 
was burned," and dreaded the sight of 
AgNOj, HNOs, or any of the mild 
measures so fondly held in reserve for 
such cases by the wily G. U. man. 
These lesions ran a most desirable 
course, and each appeared to do its 
best to be classic in every acceptation 
of the term. The secondary manifes- 
tations came on in due time and then 
the diagnosis was clinched. Under 
appropriate treatment they faded away 
like snow under a noonday sun. 

Now as to the cause of the dual 
chancre in the negro. 

Both male and female are in many 
instances extremely loose in their 
methods of cohabitation ^ and cleanliness 
is a thing commonly tabooed. A great 
many of the colored women who de- 
light in carnal pleasure and abuse, do 
so on the sly and in consequence no 
attention is paid to hygiene. Then 
i^ain, some are so polluted as to par- 
ticipate in carnal indulgence with from 
two to ten men in one night without a 
thought of cleansing themselves. They 
keep company with the lowest order of 
negroes and white men, and being ig- 
norant and indifferent: to the law of 
hygiene, never think of Investigating a 
possible partner's approech. I have 
known really decent appearing colcnred 
women to cohabit with syphilitics who 
were in the worst stages of the disease 
and who came to me for treatment 
afterwards with a "flying out" of the 
skin, as the women call a secondair 
eruption. Being closely questioned, 
would impart the knowledge that so 
and so "gave it to them." The<je wo- 
men are very often trusted cooks 
among splendid .white families, and 
not a few are nurses. 

Belative to the male element as to 
the probable cause of his contagion, 
elongated prepuces that keep the glans 
penis continually in an irritated condi- 
tion, filth and a possible susceptibility 
to syphilis. 

The negro at his best is an amalga- 
mated being, and it is reasonable to 



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Sexual Vigor im the Male-Boynton. 



DM 



assert that the powem of resistance 
are a great deal less in his otganism 
tkan he of a pare and undefiled 



Then consider hia mode of living, 
hie food, his clothings ht& debauches, 
and his lack of intelligence regarding 
isatter^-fact affairs and jou will 
oeaee to troncter. 

Think of ten in a family living on 
five dollars per month and sleeping 
huddled in one small room without 
ventilation, even when one or more 
might lie ill with typhoid fever or some 
such dtaease. He sleeps, hot or cold, 
with his head buried under cover. I 
have entered such a cabin early in the 
morning and upon ent^ing, before any 
ventilation had taken place, the stench 
I'd meet would be almost unbearable, 
and physicians are not choice, either, 
regaining odors. 

The greatest curse that overshadows 
the negro's pathway today is his igno* 
ranee of the laws of sanitation and hy- 
giene. When he is lifted from his 
thraldom of ignorance, superstition 
and the immoral slough in which he 
has paddled about in for nearly fortj' 
years, his body will be a mass of pure 
muscle and his brawn equal to with- 
stand the ravages of disease from all 
quarters. As he is now, instead of 
fighting for a better and purer moral 
and physical life, he drifts and ebbs 
with his surroundings, not caring for 
future generations, but relies, with the 
strictest obedience, upon the old prov- 
erb, ''Sufficient unto the day is the 
evil thereof.'' 

<r 

CAVSBS OF IMPAiRED SEXUAL VtOOR IN 
THE MALE. 

By C. B. Boynton. M. D., SmithAelcU Utah. 

Admitting that hereditary causes, 
trauKuatism and non-venereal diseases 
may sometimes be followed by sexual 
weakness, this article will be based 
upon the cases that iu fifteen years 
have come to the writer's notice. 

Not all cases of heart disease are 
sexually weak, yet some are, and thus 



in their effort to perform their^ duttee 
creditably may inflict further injvary 
upcfto their hearts and other eorgans. 
The moral effect of informing such 
men that their over^strong sexuality m 
killing them is good. 

Viewing themselves in this way they 
will exercise self-restraint, but infovm 
one of these men that his wealc heaort 
ia undermining his sexual system and 
he will go ahead and kill himself. 

The relation that venerea) diseases 
bear to sexual weakness has been 
hugely handled by abler pens than 
mine and I wiH mit rehash the sub- 
jeet. 

I wiD not deny but in some cases 
masturbation has led to sexual weak* 
ness, but my observation leads me to 
believe that the actual masturbation of 
itself causes very little sexual weak- 
ness. The masturbater that has read 
quack literature and is hypochondri- 
aea) is another thiog. 

Two years* asylum practice con- 
vinced me that where the insane zstA 
idiotic masturbate the habit was surely 
caused by the mental disease and not 
the mental disease by the habit. Fur- 
thermore, I believe that an able-bodied 
insane man is not injured much, if any, 
by masturbation. The best worker 
we had in the asylum was the worst 
masturbater in the institution. He was 
a garrulous, witty patient, a great 
reader, rational for a few minutes, in- 
clined to make the most of his in- 
sanity, optimistic, lively, very excita- 
ble, usually cleanly ; at times maniacal 
and withal the most interesting and 
harmless man in the institution. At 
forty, although he had masturbated 
every day or oftener for twenty years 
or more, erectile power was prompt 
and perfect. If my m^nory serves 
me right, this man's insanity dated 
from some acute disease in childhood. 

Epileptics are frequently mastur- 
baters, but it takes more than mastur- 
bation to cause epilepsy. 

My none too extended observation 
leads me to believe that children of 



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great mental and scholarly precosity 
have smaller sexual organs than others 
with less grey matter. That the female 
''scholar" certainly is more often the 
girl with an infantile uterus, is a well- 
known fact. One prolific cause of 
sexual degeneracy is sexual excess 
stimulated by intemperance. Many of 
these unfortunates have masturbated 
in their past and continuing their ex* 
cesses in drink, blame their sexual 
troubles to youthful indiscretion. 

Plenty of men who are sexually as. 
able as they should be, borrow much 
trouble from the fact that under cer- 
tain circumstances they begin to doubt 
their power. The male sexual func- 
tion should never be insulted by doubt, 
else it is very apt to act in an unbe- 
coming manner and cause the patient 
more anxiety. Doubt often starts from 
the fact that conscience is hurting the 
man or discovery is likely. His com- 
panion may ridicule him and his doubt 
may become very alarming. Then 
when he reads the ad. of some quack, 
he is rendered half insane with fear, 
he introspects; begins to '<treat,'' and 
with loss of appetite and sleep becomes 
in many senses an invalid. 

Then there is the married man whose 
wife does not respond and even allow 
him connection under protest. The 
fault may or may not be hers, but the 
best sexual system in the world will 
degenerate under such conditions. In 
time with such a wife a man will have 
perfect erections until the act itself, 
then the function fails ; again he may 
ejaculate prematurely because she is a 
little kinder to him than usual ; or still 
again he may lie awake all night ready 
to act but restrained by her refusal. 
When at last she submits he fails by 
pure exhaustion and she may make his 
state more horrible by anger and dis- 
gust. 

There are men who lejarn to fear a 
wife's reproof, so that this fear para- 
lyzes them sexually. 

How different is the lot of a man 
whose partner flies into his arms with 



ardor, from that of him who has to 
overcome a mountain of objections ere 
he can gain the goal where he is not 
welcome. The one may continue sex- 
ually perennial until eighty and the 
other fail to function perfectly at 
forty. 

But is this failure of woman to do 
her part sexually different from what 
might be expected? I think not. 

1. Girls should be reared for mar- 
riage ; not to be self-supporting spin- 
sters. 

2. Women should be taught that, 
sexual apathy is something to their 
shame or an indication of infirmity, 
and then they will, as they should, 
separate from a husband when it is im- 
possible for them to experience sexual 
pleasure. 

3. Religious teachers should impress . 
the idea that it is the duty of all m>r- 
mal human beings to have offspring. 
That it is as much a sin to disobey the 
commandment, "Multiply and replen- 
ish the earth" as it is to lie or steal. 

Without the desire for offspring the 
furnace of love is left without fuel 
and care becomes a monster. A civil- 
ization too elaborate for maternity is 
sounding the knell of its own doom; 
it is cowardly and selfish. No wonder 
in such events Cupid dies and Psyche 
becomes sexless. The pith of the diffi- 
culty lies in the pervei^sion of woman; 
the avoidance of conception ; the strug- 
gle of womankind to become inde- 
pendent and self-supporting. 

In the presence of this feminine 
perversion the male also tends to be- 
come a sexual pervert and degenerate. 
This is not laying the burden of the 
blame upon woman, for, considering 
the intemperance of the male sex, it is 
no wonder that so many women desire 
to be independent. When a man 
learns to love his beer and tobacco bet- 
ter than he can love a home and a wife, 
we would expect that girls, as a mat- 
ter of self-preservation, will plan to 
become self-supporting. 



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Parasitic Scalp DiseaseS'<jOttheil. 



367 



SVBLAMINB IN THE TREATMENT OP 
PARASITIC SCALP DISEASES. 

By WlLIiLAJI S. GOTTHWIi. M. D., 

Dermatoloeist to theOity Hospital, Lebanon and Beth 

Israel Hospitals. New York City. 

When sublamine was introduced as a 
non-irritant disinfectant equal to mer- 
curic chloride in bactericide energy, 
and possessing far greater powers of 
tissue penetration, it at once occurred 
to Dr. Gottheil that the drug had a 
most important sphere of usefulness, 
not only as an external antiseptic, but 
also as a remedy in various parasitic 
dermatoses and as an antiluetic. For 
the toxicity, causticity and irritancy of 
corrosive chloride limit its use iii the 
former and make its injection in syph- 
ilis our last resort instead of the regu- 
lar treatment. 

Sublamine was found by Eroenig, 
Blumberg, Schenck, Zaufal, Paul, Sar- 
wey and others to* possess the same 
bactericide power as the bichloride, 
but to be so non-irritant that even 2 
per cent solutions can be employed if 
required, and to have a far greater 
peneto-ation than the older drug, as it 
does not coagulate albumen. 

During the winter of 1901-2 a ring- 
worm epidemic broke out in a large 
orphan asylum to which Dr. Gottheil 
and Dr. George H. Fox were derma- 
tological consultants. The matter was 
brought to their attention only when 
the epidemic had assumed alarming 
proportions. Some four hundred and 
fifty out of the nine hundred children 
were affected. Many, of course, had 
only a light form, but there was a large 
proportion of deep infection and kerion. 

The serious nature of such a state 
of affairs is well known. Kingworm 
of the scalp is not, ordinarily, a grave 
affection ; but even under the most fa- 
vorable circumstances and with the 
most careful treatment it lasts for 
months. In public practice the ma- 
jority of cases are not cured at all. 
They go from clinic to clinic, getting 
now a little better and now a little 
worse, until puberty is reached and the 



malady cures itself. Meanwhile these 
children are excluded from school and 
grow up in the streets. A similar 
epidemic in the institution some years 
before had nearly led to its permanent 
closure. 

The diagnosis was confirmed by mi- 
croscopic examinations and cultures, 
and a laboratory was organized for 
both methods and the control of re- 
sults. Proper isolation was enforced; 
and observation wards were instituted 
in which apparently cured patients 
were kept for three weeks after treat- 
ment was ceased. No case was dis- 
charged until cure had been repeatedly 
proved. All other necessary sanitary 
and therapeutic arrangements were 
made. One hundred and fifty of the 
infected .girls were transferred to Dr. 
Gottheil's skin service at Lebanon 
Hospital. 

The patients were divided into 
squads. Every head was closely shaved 
once a week as soon as the inflamma- 
tion had subsided sufficiently to permit 
it. Twice daily each head was thor- 
oughly scrubbed with brush, green 
soap and hot water. 

The remedies employed were chrys- 
arobin, formalin, croton oil, bichloride 
of mercury, carbolic acid, iodine, and 
ethylenediamine-citrate of mercury and 
sublamine in various strengths. 

A most determined effort was made 
to have proper records kept ; for here 
was a chance to determine by compar- 
ative tests which plan of treatment 
gave the best results. Dr. Gottheil 
was not successful in this, however. 
Lack of discipline and the fact that 
often the names of the children were 
unknown or imperfectly known, or in- 
terchanged, helped to create confusion. 
The patients were scattered in four 
buildings and at least a dozen wards. 
Lack of room necessitated incessant 
transfers of well and sick children. 
Changes in staff and servants further 
complicated matters. Hence the rec- 
ords were in a very unsatisfactory state 
when the epidemic was ended. 



\ 



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Original Articles, 



Chrysarobhi was soon abandoned. 
It was impossible to keep the children 
from getting it into face and eyes, and 
there was a good deal of trouble with 
dermatitis and conjunctivitis. The dif- 
fuse brown stains on the skin doubled 
the time required for examinflction. The 
Same objection was made to iodine. 
This in combination with goose grease 
has lately been highly recommended 
by Dr. Jackson, or New York, and is 
undoubtedly an effective preparation. 
The menstruum is comparatively ex- 
pensive, however, for use on a large 
scale, and it caused coloration. At 
Dr. Fox's suggestion a number of 
cases weri> put upon it, but treatment 
was soon changed. 

No definite results were obtained 
from saUcylic acid in any form and 
concentration. The same is true of 
pure carbolic acid, followed by alcohol 
when too irritating. Pure formalin 
was used in some cases by a house 
physician without Dr. Gottneil's con- 
sent. It cured the patches to which 
it was applied, of course, but at the ex- 
pense of sloughing and destruction of 
scalp tissue. In 10 per cent, solution, 
which was well borne, it did not seem 
to make much change in the patches. 

Bichloride, sublamine and crotoji oil 
were found sufficient for all cases. 
The first was employed in 1 : 1000 so- 
lution, but many could not stand its 
vigorous use twice daily, and often only 
1:2000 could be used. Its effect was 
very slow, probably because of deficient 
penetration, but we persisted in its use 
for purposes of comparison. In most 
cases final recourse was taken to 33 per 
cent, of croton oil. This was applied 
several times in succession until a vig- 
orous reaction took place. Then an 
ordinary soothing application (usually 
3 per cent, salicylated oil) was used 
until the inflammation subsided, when 
the bichloride was again employed. 

Of the two ethylenediamine-mer- 
cury compounds, sublamine was more 
largely used. At the time the epidemic 
began the citrate was the only prepara- 



tion obtainable ; but since the proper- 
ties of the two are similar they can be 
considered together. They are much 
less irritant l^n hleUbwle. All stood 
1:1000 sublamine -very well; indeed, 
in obstinate cases 1 : 750 was used with- 
out trouble. Stronger solnttons than 
that, however, gave trouble. It is pos- 
sible, of course, that the shaving and 
scrubbing rendered the scalps hyper- 
sensitive. But sublamine is much less 
obnoxious to tender or inflamed skins 
than bichloride and can be used in 
about twice the strength permissible of 
the latter. 

Over one hundred cajses were treated 
with sublamine. As with the other 
dru^s, they were not selected but in- 
chided cases in all stages of the affec- 
tion; some had merely a single patch, 
whilst others were in an advanced and 
generalized stage of the disease. In 
the latter class were a number of older 
children who had had ringworm of the 
scalp for years and whom we suspected 
with good reason to be uncured cases 
from an epidemic of several years ago. 
They had been for months and years 
at Bandall's Island, the city institution 
for orphans, and had been sent back to 
the asylum as cured. That this was 
not the case, hdwevor, is shown by the 
fact that some of them formed part of 
the contingent of chronic scalp cases 
that were ^ways present in the asylum 
and which undoubtedly formed the 
nucleus of the present epidemic. Some 
of the cases were not cured when tl^e 
epidemic ended. Dr. Gottheil believes 
that they belong to the small number 
of really incurable cases and that their 
retention in the institution wilt lead to 
further trouble. 

All others did very well indeed under 
sublamine. Its action was naore rapid 
than that of bichloride, as. might be ex- 
pected from the fact that with equal 
bactericide power it has greater pene- 
tration, and can be employed in nrach 
stronger solution. There caabe no 
doubt that it was the most effective 
treatment employed. 



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Parasitic Scalp Diseases— Cottheil. 



260 



Dr. Eckstein assisted in the micro- 
scopic and bacteriologic test for the 
presence of ringworm at the beginning 
of the epidemic. The astonishingfact 
was noted that a parasite indistiogaish- 
able from that of ringworm could be 
cultivated from scalps that were ap- 
parently perfectly healthy. The tri- 
chophyton was seemingly present on 
most or all the scalps, possibly in an 
attenuated or non-virulent form. Per- 
haps it was the usual form kept in de- 
pressed growth by prophylactic meas- 
ures. The bacteriologic test of 6ure 
was therefore abandoned and only 
macroscopic evidences relied upon. 
Cases in which repeated cultures had 
been made with negative results, and 
which were therefore discharged as 
cured gave positive cultures later, 
though their scalps were appparently 
healthy. 

V^ 

UVf^RlDROSIS OF THB PBBT TREATED 

BY FORMALIN. 

From observations made on soldiers 
in the French army, Vaillard reports 
favorably upon the results of formalin 
treatm^it for excessive sweating of 
the plantar surface of the feet. 

The effect of formalin is to deo- 
dorize the perspiration when it is 
fetid; to harden the epidermis, 
thereby avoiding the consequences of 
maceration; to diminish or totally 
suppress the glandular secretion by its 
action upon the epithelium; and fi- 
nally to heal the excoriations by its 
local antiseptic action. 

The strength of solution employed 
varies from the commercial formalde- 
tyrde (40 per cent, formalin) to 2.5 
per cent., according to the nature of 
the case. If there is much maceration 
{Mid excoriation of the skin, the weak- 
est dilution should be applied at first, 
and then rapidly increased in strength. 



The m^etfaod of application is to 
bandage wet compresses to the soles 
of the feet three or four times in the 
twenty-four hours, care being taken 
to protect the interdigjtal surface, 
rince here formalin causes great pain 
and often excoriation. The p^iod 
dufing which the applications are 
made necessarily varies from twenty- 
four hours to eight days, according to 
the strength of the solution used. In 
those cases in which the pure formal- 
dehyde can be used the cure is almost 
immediate. The benefits derived from 
the treatment are only temporary, 
lasting from a few weeks to three 
months, but are quickly renewed by a 
repetition of the applications. 



ANESTHETIC TO THE URETHRAL 
TRACT. 

Bt B. MiAD Hammond. M. D.. BxAndjr Station, Vlxginia. 

In introducing a catheter or bougie, 
as an anesthetic to the urethral tract I 
use — 

BL Antipyrine, 

Pow. camphor aa 5 J 

Liq. alboline xj. s. ft. J iv 

M. Sig. — Use an ordinary glass ear syr- 
ingeful as an injection into the urethra a few 
minutes prior to introducing instrument. It 
will render the operation comparoiively 
painless. 



CLINICAL LBCTVRBS ON DISEASES OF 
THE SKIN. 

The governors ef the New York 
Skin and Canc^ Hospital announce 
that Dr. L. Duncan Bulkley will give 
a sixth series of clinical lectures on 
Diseases of the Skin in the out-patient 
hall of the hospital on Wednesday 
afternoons, commencing November 4, 
1903, at 4:15 o'clock. The course 
will be free to the medical profession. 



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270 



New Publications. 
NEW PUBLICATIONS. 



DiSKABBS OF TUB Skin. By Maloolm Morris. W. T. 
Keener & Co., Chicago. 1903. 

This very neat and reliable manual 
on diseases of the skin will prove serv- 
iceable as a guide to the student, and 
convenient for reference purposes to 
the general practitioner. Many im- 
provements have been made in this 
edition, both by additions and elimina- 
tions. The book, as it now appears, 
is up-to-date, conservative, practical 
and thoroughly trustworthy in its 
teachings. It deals largely with the 
fundamental principles and practice of 
dermatology, without devoting any 
special attention to divergent theories 
or minute details of treatment. The 
strong points of the book consist in a 
clear presentation of disease with a 
brief mention of the best methods of 
treatment. This is a merit seldom 
possessed by the average manual of 
skin diseases. 

Analysis OF THX Sexual Impulse— Lovs and Pain— 
Th» Sexual Impulse in Women. Third volume in 
the aeries, '^Studies in tiie Psychology of Sex." By 
Havblook Ellis, L. S. A. (England) , Fellow of the 
Medico-Legal Society of New York and Anthropo- 
logical Society of Berlin; Honorary Fellow of the 
Chicago Academy of Medicine, etc. ; general editor of 
the Contemporary Science Series since 1890. Extra 
cloth, $2.00 net, delivered. Sold only to physicians, 
lawyers, clergymen, advanced teachers and scientists. 
Philadelphia, Pa.: F. A. Davis Company. Puhlishers, 
Nos. 1914-16 Cherry street. 

The above book contains a vast fund 
of information on a subject which is 
seldom discussed, but of vital impor- 
tance to society, especially from an 
anthropological and medico-legal stand- 
point. The author is admirably 
equipped for the study of sexual psy- 
chology, but the subject takes such a 
wide range and is so difficult to mas- 
ter, that its complete elucidation from 
available data is a hopeless task. Sex- 
ual instinct and sexual impulse are so 
multiform in their manifestations, both 
normal and abnormal, that they be- 
come unfathomable, and hence insus- 
ceptible of analysis. The author, 
however, has, at the cost of much 
time and labor, obtained data from an 



immense variety of sources that have 
enabled him to turn a bright light on 
the different phases of this interesting 
subject. 

Diseases of Infancy and Childhood. By Heket 
KOPLIK, M. D. Lea Brothers & Co., Philadelphia, 
Pa. 1903. 

While, in late years, there has been 
an abundance of literature on the sub- 
ject of pediatrics, it has not been 
available to students and physicians in 
the form of elaborate text-books em- 
bodying the results of aggregate re- 
search. This work, however, takes 
cognizance of the progress in pediatric 
science made by the English, Ger- 
man, French and Italian nations, as 
well as American, and at the same 
time the author states clearly and 
forcibly the results of his own obser- 
vation and clinical experience. The 
various subjects discdssed are presented 
in the following order: Infancy and 
childhood, premature infants, diseases * 
of the new-born infant, injuries in- 
flicted during birth, specific infectious 
diseases, diseases of the mouth, phar- 
ynx and larynx, diseases of the gastro- 
enteric tract, diseases of the respira- 
tory tract, diseases of the heart and 
pericordium, diseases of the nervous 
system, general diseases, diseases of 
the lymph nodes, ductless glands, and 
diseases of the blood, diseases of the 
bones, diseases of the liver, diseases 
of the kidneys and diseases of the skin . 

The Internal Seobbtions and the Pbinoiplbs of 
Medioine. By Chables E. De M. Sajous. M. D. 
Vol.1.- F. A. Davis Co., Pablishers, Philadelphia, 
Pa. 

The above volume is remarkable for 
its departure from the beaten paths of 
investigation, and both on account of 
its elaborate preparation and the 
pre-eminent standing of the author in 
the medical profession, is entitled to 
careful study by every progressive 
member of the profession. The 
theories herein set forth, if fully sus- 



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WMch yields thirty times its vol- 
ume of •• nascent oxygen *' 
to the condition of 

is daily proving to phj-sicians, in 

some new way, its wonderful efScacy 

in stubborn cases oi BoMema^ Paoriasia, Salt Rbeuta, Itoh. 

Barber's Itohf Eryaipelaa, Iry JPoiaoving, Ringworm^ 

Herpes Zoster or Zofia, ete. Acne^ 'Pimples on Pace 

are cleared up and the pores healed by NYOROZONC and GLYCOZOMC 

in a way that is 

magical. Try this 

treatment ; results 

will please you. 

FuTI method of treat- 
nent In my book, 
•* The TbeiapeuticAl 
Applications of Hy* 
drosone and Glyco- 
sone ' ' ; Serentecnth 
Edition, 33a pafres. 
Sent free to physicians 
on request. 



Prepared pnly by 




Chemist and Graduate of the ** Ecole Centnle des 
Arts et Manu&ctures de Paris " (France) 

57-59 Prlnc« Street, New York 



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273 



Nmw Publications. 



tained by practical demonBtratioto^ will 
necessitate a readjastment of the f un- 
daoaeotal principles of medicine. The 
author claims that the ant^ior and 
posterior pituitary bodies are the gov- 
erning oent4M*s of all Tital processes. 
That, while the antwior pituitary body 
insures oxygenizati^i of the blood 
through the adrenal s^retion, the pos- 
terior pituitary body adjusts and gov- 
erns the functional activity of all the 
organs through the nervous system. 
That the thyroid gland, the anterior 
pitwtary body and adrenals are func- 
tionally united and constitute thB ad- 
renal system. That symptoms of dis- 
ease are manifestations of over-activ- 
ity or insufficiency of the adrenal sys- 
tem. The inference to be drawn from 
these premises would seem to be that 
the primary object of treatn^nt of dis- 
ease should mainly consist in an effort 
to restore and maintain a normal phys- 
iological action of the adrenal system. 
It is not advisable to hastily accept ^>r 
reject the findings of the author. His 
views are frankly and ably presented, 
and are deserving of thoughtful oes- 
sideration. 



Thb AiOEBiOAir PooKCT Mkdioal Diotiokakt. Edited 
by W. A. Vbwman Dorland. M. D. Oontatuhiff 
the Pronnnolatlon and Deflnitton of the Prfnolpai 
Wordi Used in Medicine and kindred leienoes. With 
566 pages and 64 extensive tables. Philadelphia, 
New York, London: W. B. Saimders ft Company. 
1903. Flexible leather, with gold edges, $1.00 net; 
with thumb index, $1.25 net. 

In this little work, now in its fourth 
edition, we have a pocket dictionary 
equaled by none on the market. It is 
a wonder to us how the editor has got- 
ten so much information in such a 
small space. In this edition several 
thousand of the newest terms that 
have appeared in recent medical litera- 
ture have been added, and the entire 
work subjected to a careful revision. 
Since the work has come to us for re- 
view we have had many occasions to 
refer to it for definitions of new words, 
and in no instance have we been dis- 
appointed. We believe that the work 
in its new form will meet more fully 



than ever a realdmuand on the part of 
physicians and atudents. 

ThI AMIBIOAir ILLXTSTIULTKD Mn>IOAL DlOTIONAHT. FoT 

PraetitioneTS and Students. A Oomplete Dictionary of 
the Terms Used in Kedielne, Snxiery, Dentistiy. Phar- 
macy, Chemistry, and the kindred branchea, imdud- 
ing much eollateral information of an enoydabodie 
eharaeter. together with new and elaborate Tables of 
Arteries. Musdes, Nerres. Veins, etc.; of Bacilli. 
BaotMla, Microcooei, Stmptoeooel; Spovymie Tables 
of Diseases. Operations. Signs aod S y m pto ms, Stains, 
Tests, Methods of Treatment, etc., etc. By W. A. 
Newman Dosi^and. A. M., M. D.. editor of the 
"American Pocket Medieal Dictionary.*' Handsome 
Inse octavo, nearly SOO paffes, bound in full flexible 
iMither. Philadelphia. New York. London: W. B. 
Saunders & Company. 1903. Priee, ^.50 net; 
irith thumb Index, 96.00 net. 

The rapid exhaustion of two large 
editions cannot butbegrattf3dng proof 
to the editor and publishers that this 
exceQeat work meets the varied needs 
of physicians and students better than 
any other dictionary on the market. 

In this (the third) edition several 
hundreds of new terms tliat have been 
added to the vocabulary of medical 
sciences have been incorporated and 
clearly defined. The entire work, 
moreover, has evidently been subjected 
to a careful revision, and many of the 
tables (notably those of Acids, Bacte- 
ria, Stains, Tests^ Methods of Treat- 
ment, etc.) Jiave been amplified, And 
their practical value greatly incvemed. 
It is only by such constant and care- 
ful revision t^at a medical dictionary 
can hope to reflect the progress of 
medical science, and the usefulneoB of 
this work by this present revisk>n has 
been very largely extended. 

Thv Lover's Wobld. By Aliok B. Stockhak. M. D. 
Published by Stockham Publishing Co., Ohieago. 

The theme of this book is as old as 
tlie hills. It has been celebrated in 
song and tftory from time immemorial. 
It is a subject that has been studied 
for ages, and is still an unsolved prob- 
lem. Eivery man, woman and child 
think they understand it thorouglily, 
but when they undertake to define it 
they first begin to realize how little 
they know about it. This book takes 
up the subject of love and treats 4t in 
a masterly style. If it fails to deGne- 
ate its true character, it at least por- 
trays in a most engaging manner what 
it ought to he. 



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IMPORTANT 
FACTS 



III 



Pertaining To The IMOft Rational Treatment For INDIQE8TION. 

INGLUVIN 

Not only Relieves the Symptoms, but Removes the Causey by 
its Peculiar, Active, Bitter Principle. 



IT 



TONES UP THE STOMACH 

INCREASES THE DIGESTIVE FERMENTS TO NORMAL 
STIMULATES THE GASTRIC AND INTESTINAL MOTOR ACTIVITY 
AS SISTS NATURE TO CARRY ON A NORMAL PHYSIOLOGICAL 
DIGESTION 



PILL IHamVIH COBP- (waESTifE) 

" ■— A COMPRESSED PILU UNCOATED. 

Comi>ines all the excellent DIQESTIVE action of Ingluvin with 
the additional therapeutic value of Nux Vomica, Aloln and Qingerin. 



IT 



INCREASES THE BLOOD SUPPLY OF THE GLANDS AND 
MUCOSA OF THE STOMACH AND INTESTINES 

PREVENTS CONSTIPATION AND ACTS AS A CARMINATIVE 



INQLUVIN is Indicated In all forms, including Nervous Dyspepsia, 
whether in the acute, sub-acute or chronic stage* 

maUIVIN IS A HMITIVE SPECIFIC FOR VOIUTINa IN 8ESTATI0N AUD THE 
POST NAUSEA FROM ANESTHniCS, CALOMEL^ ETC 

Pil«serlb«d In th« sam* nnannar, do«e and combination aa Papain. ' 
lITEMTURf AHO UMPin OHHIIFIHIT SEMT OH REQUEST. 

WHEN PRESCRIBINQ, SPECIFY WARNER A CO. AND AVOID SUBSTITUTES 

WM. R. WARNER. & CO. "-'-"A'S«..™„ 

Phiiadeiphlay New York, Chicago, New Orleans. 



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Therapeutic Suggestions. 
THERAPEUTIC SUGGESTIONS. 



SPECIFIC URBTURITIS. 

The following will be found to be 
most successful in the treatment of 
specific urethritis: 

Bl Resorcin, 1 per cent 5^ 

Sig. Use as an injection four times a 
day. 

For internal treatment the following 
should be administered : 

Bt Uriseptin (Gardner-Barada)....giv 
Sig. One teaspoonfnl in hot water four 
times a day. 



ECZEMA AND STOJHATITIS. 

Bt H. Knox StxwAbt, M. D., Philadelpliia, Pa. 

Some months ago a gentleman pre- 
sented himself at my office. He was 
suffering from a complication of dis- 
eases. He was very miserable, much 
depressed both physically and men- 
tally. His lips and mouth were cov- 
ered with a sort of fungus growth, a 
sort of spongy excrescence, which pre- 
vented him from eating! His body 
and limbs were covered with a rash 
which resembled at first that of con- 
fluent measles. This rash soon began 
to crust, itched intolerably and scabs 
fell off, leaving a raw, excoriated sur- 
face. Internally, I gave mere. cor. 6x, 
sulphur 30x and acid carbolic 6x ; lo- 
cally, I employed glyco-thymoline 
alone. I used it in varying strength, 
from half and half to full strength ; it 
soon cleansed up the mouth and lips, 
which permitted the patient to eat 
food readily and thus improve his con- 
dition. 

He now made rapid progress. The 
glyco-thymoline stopped the itching 
and healed up the skin, leaving it as 
clean and clear as a baby's. 

PALATABLE VET EFFECTUAL. 

There is a wide-spread belief that 
physicians as a rule consider well- 
founded that cod liver oil is not only a 



remedy of decided power, but a food 
of very high value. Every physician 
knows, however, that a very large 
number of patients who should and 
doubtless would get much good from 
it cannot or will not take it. This is 
largely due to the fact that the ordi- 
nary preparations are so nauseating as 
tq cause serious digestive disturbances, 
while in many cases the stomach will 
not even retain them. It is "hotorious 
that the so-called **tasteless" prepara- 
tions are, indeed, tasteless because 
they contain no cod liver oil, but there 
is a preparation that contains all the 
potent elements of cod liver oil in a 
form pleasant to the taste and agree- 
able to the weakest stomach. We re- 
fer to Hagee's cordial of cod liver oil 
with hypophosphites of lime and soda. 
Eminent physicians pronounce it a tri- 
umph in modern chemistry, and pre- 
scribe it when cod liver oil treatment is 
indicated. In our hands results with it 
have been most satisfactory. — Massa- 
chusetts Medical Journal. 



CYSTOQBN. 

In cystitis, prostatitis, urethritis, 
pyo-nephrosis, pyelo-nephritis, gonor- 
rhea, enlarged prostate of the aged and 
stricture there is need of a reliable 
germicidal drug for internal adminis- 
tration. Cystogen serves to remove 
in these cases the chief source of ag- 
gravation, namely, the irritating prop- 
erties of the urine, by stopping fermen- 
tations and by holding the urates, 
phosphates and oxalates in solution. 
The administration of cystogen in 5 
grain doses four times a day causes the 
urine to become a solution of formal^ 
dehyde, capable of inhibiting pus, 
staphylococci, streptococci and the 
bacteria of the ammoniacal fermenta- 
tion of urine, and of at least control- 
ling the gonococci. - > 



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THERE IS NO OTHER 



reason for the conservative 
scientific physicians' unqualified 
endorsement and extensive 
employment of 

GRAY'S— TONIC 



Comp. 



than the simple fact of intrinsic 
merit. It yields incomparable results 
in general debility, ansmia, malnutrition 
and nervous exhaustion. 

THE PURDUE FREDERICK CO., 

No. 15 Murray Street, New York. 




regarding the caoMtion of HAY FEVER, inclndinff Uric Add or 
otfier depraved state of the system, Mlcro-OrKanisms in the air and 
pollen from plants. Whatever theory is adopted and a systemic 
treatment undertaken to correspond with it. it has been found that 
lntelli|:ent local treatment is productive of freat benefit. 4| For this purpose a thoroufb 
washing or douching of the nasal passages with a weak hot solution of TV««'s Aiati* 
••ptic Po^nr^l^r has been found very beneficial. It cleanses the membrane of poisonous 
secretions, soothes its irritability, and tones it up and strengthens it to resist further Invasion. 
By frequent repetition as soon as any feeling of discomfort begins to return, the attack can be 
greatly shortened and the patient made comparatively comforUble throughout its duration. 



W^ 



Tyr«e*B Antiseptic Powd$r, /irtt intro- 
duced /or treatment 0/ injlammation of 
the vaqina^ has proved to possess 
remarkable heating powers /or 
Mucous Membranss, 



tUi 



For full literature 
and sample, address 



I J« S. Tjree 



Chemist 



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a76 



Therapeutic Suggestions 



Gystogen is efficient in prophylaxis, 
preceding and. succeeding operative 
procedure in the genito-urinary tract. 

IT IS A BAD HABIT 

To whip up the waning physiologic 
functions of elderly people with stry ch- 
oline or alcohol ; after a short time the 
deleterious reaction is more certain 
than the primary stimulation. These 
patients need help of a character not 
furnished by a powerful stimulant — 
their functions need gentle reinforce- 
ment, and, ex{>erience proves, the best 
agent for this purpose is Gray's glyc- 
erine tonic. 

The atonic digestive disturbances 
almost constantly present in old age 
are promptly overcome by the use of 
Gray's tonic. It stimulates the enfee- 
bled digestive glands to secrete abund- 
ant supply of gastric juice. This in 
turn assists the assimilation of food 
and improves the general nutrition. 
Then, too, these patients feel better 
because the remedy acts as a prop to 
the entire system ; they are less lan- 
guid, are not so easily fatigued upon 
exertion and are mentally more alert. 
Many physicians report that the rou- 
tine employment of Gray's tonic in 
tiiose patients in whom are present the 
signs and symptoms of old age imparts 
a degree of comfort and well-being, 
free from after-effects, not obtainable 
from any other medication ; one phy- 
sician states *<it picks them up and 
holds them together." 

Another strong reason for the use 
of Gray's tonic in elderly people is 
that it wards off the tendency to in- 
flammations of the respiratory organs ; 
thisf act has been noted and commented 
upon for many years past, and is 
doubtless due to the fortifying action 
of the remedv upon the general con- 
stitution and its specific innuience upon 
the respiratory tract. 

Experience shows that it is good 
practice to administer Gray's tonic to 
all patients in whom are noticeable the 



symptoms due to advancing years. The 
absolute freedom of the remedy from 
depressing or other detrimental reac- 
tion makes it the safest and most pre- 
ferable means of combating the ex- 
haustion and enfeeblement of age. 



Daniel's cone. tr. passiflora incar- 
nata is most valuable in paralysis due 
to extreme nervousness. In severe 
headaches during the menstruation 
period, in nervousness bordering on 
delirium tremens and for women suf- 
fering from nervousness caused by 
uterine troubles. In this product phy- 
sicians have a desirable nerve sedative 
and antispasmodic, which may be given 
with the greatest advantage. In all 
diseases of the nervous system passi- 
flora controls the nerve forces. 



OcALA, Florida, Sept. 5, 1903. 
The Merz Capsule Co., 

Detroit, Mich. 
Dear Sirs: — The sample of your 
santal compound capsules sent me from 
your house by request were given to a 
patient with acute gonorrhea with the 
most gratifying results. 
I consider them fine. 

Yours truly, 
Jno. M. Thompson, M. D. 



I have used neurilla, and deeqi it a 
remedy of great value. Patieatt a hdy 
of middle age, suffering from nenroas 
prostration for past year. I tried sev- 
eral remedies indicated in such caaes, 
but with only temporary relief. She 
would soon become extremely nervous 
and irritable, and suffered greatly with 
insomnia. I finally put her on tea- 
spoonful doses of neurilla, and it 
worked like a charm. 

Rachael J. Eemball, M. D. 

334 Virginia street, Buffalo, N. Y. 



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Index, 



A DIAQNOSTIC CHART OF TUMORS AND 
PSBUDO TUMORS. 

Battle & Co. have just received a 
complete and unique chart on the above 
subject, compiled by Dr. Edward C. 
Hill from standard works on surgery 
and pathology. The subject matter is 
divided into solid neoplasma (sub-di- 
vided into benign and malignant 
growths) and true and false cysts. 
The general characteristics of each di- 
vision are given, and their twenty- four 
classes, embracing over one hundred 
varieties, are compared critically in 
columns under the following headings : 
Tissue, Topography, Number, Size, 
Conformation, Color, Consistence, Mo- 
bility, Sensibility, Surrounding Tis- 
sues, Occurrence, History of Growth 
and Miscellaneous Points. Features 
of special differential value are empha- 
sized by the use of italics. This chart 
shows almost at a glance for ready 
comparison all that could be learned 
in a diagnostic way from the perusal of 
hundreds of pages of ordinary text. 
It stands, indeed, to such books as an 
alias does to a gazetteer. This very 
convenient and valuable compendium 
is at the command gratis of any and 
every practitioner of medicine who will 
take the trouble of writing a postal 
card to Battle* Co., 2001 Locust. St., 
St. Louis, and at the same time men- 
tion the American Journal of Derma- 
tology. 



attention. You can spend a great deal 
of monej^ on this class of preparations 
if you wish to by paying for the water 
that is with them, but Mr. Tyree is 
selling only the powder, leaving you to 
mis it with water and so make your 
own solution. The powder itself sells 
at a very low price. This merits your 
attention. See advertisement in this 
journal. 



Chapabrin has proven to be a valu- 
able remedy in the treatment of dan- 
druff. It is a quick and permanent 
cure when used in the following form: 

Bl Chaparrin _ J } 

Glycerine _ ^.3 ij 

Myrica spirit q.s. J viij 

M. Si^. — Apply once daily for a week, then 
every third day for two weeks. 



TYRBB'S ANTISBPTIC POWDER, 

For leucorrhea, gonorrhea, gleet and 
all such conditions, should have your 



TANNOFORM IN INTERTRIGO. 

Dr. S. E. Ostrowsky has employed 
tannoform with excellent result in the 
intertrigo of small children. The drug . 
was used either as a dusting powder 
mixed with an equal part of starch, or 
as a 10-per-cent. ointment with vase- 
line. When the latter is employed, 
the inflamed area should be washed 
with a solution of boric acid before 
applying the salve. Forty infants 
were treated in this manner, and the 
most obstinate cases, which had re- 
sisted all other applications, yielded 
promptly to tannoform. The results 
are ascribed to its astringei^t and anti- 
septic properties. No irritation was 
observed even in the youngest infants. 
— Arch, of Pediatrics^ Vol. Xx, No. 9. 



INDEX. 



Original Articles paqk. 

The New Light Cure. Bj Corydon Eugene Rosen, 
M. D.. Seattle. WMhlngton 233 

Syphilis Insontium. By Charles E. Caldwell. M. D.. 
Cincinnati. Ohio 236 

Diagnostic Features of Small Pox. By George G. 
Melvin. M. D... 239 

Cancer of the Ftostate and the Selection of Gases 
for Snprapubic Prostatectomy. By Reginald Har- 
rison. P. R. C. S. 247 

Segregation of Lepers. By 8. C. Martin, M. D., St. 
Louis 257 

A Plain Talk on Matters Pertaining to Genito-Uri- 
nary Anatomy, Physiology and Diseases. By Dr. 
Bransford Lewla, St. Louis 259 



Original Articles. paok. 

Some Oases of Hydrocele Cured by Iodine and Gar« 
bolic Acid InfectionB. By J. C. Lake, M. D.. 
Ocilla. Georgia'. 202 

Multiple Chancre in the Negro. By Luden Lofton, 
A. B., Ph.D., M. D.. Emporia. Virginia 203 

Causes of Impaired SexuaTVigor in t^e Male. By 0. 
E. Boynton. M. D., Smithfldd. Utah 2es 

Sublamlne in the Treatment of Parasitic Scalp Dis- 
eases. By William 8. Gottheil, M. D 207" 

New PlTBLICATIONS , 270 

THERAPErTio Suggestions 274 

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INDEX TO VOLUME VII. 



OsieiNJLL Abtiolks. pagk. 

Action of lodlpin on the Vaaonlar System. Bj Dr. 
ElchardThausslg 42 

Actinomycosis «nd X-ray Therapy. By M. L. Held- 
Ingsfeld. M. D 47 

Aene Simplex 222 

Bacteria as an Etiologlc Factor in SUn and Genito- 
urinary Diseases. By Dr. Gottfried Trantmann . . .210 

Caosea of Impaired Sexnal Vigor in the Male. By G. 
B. Boynton, M. D 265 

Cancer of the Prostate and the Selection of Cases for 
Snprapnbic Prostatectomy. By Keglnald Harrison. 
P. R. C. 8.. ___... _..--.-.-_■ ___-. ....... ...^47 

Clinical Remarks on Some Advanced Forms of Ure- 
thral Stricture. By Reginald Harrison 16 

Cntaneons Angiomata. By Symmers 82 

Chronic Cystitis, Enlarged Prostate Complicated 
With. By R Parries. M. D 134 

Diverticula of the Male Bladder, Notes on. By Louis 
K. Schmidt, M. D 13 

Dermatological Teaching in Madrid. By A. RavogU, 
• M.D. .rr .!? 187 

Endovesicfd Surgery with Special Reference to Cys- 
toscopy and Ureter Catheterism. By P. Krelssl, 
M. D. : :. 18 

Enicarin as an Antipruritic. By Max Relchmann, 
M[. D,,... ... ......__.......--__.. . .- ........ 23 

Elephantiasis In Japan. By A. S. Aahmead, M. D.... 58 

Flagellation and Circumcision Among the Filipinos. 
ByChas N. Barney. M. D 220 

Genito-Urinary Anatomy. Physiology and Diseasea, A 
Plain Talk on Matters Pertaining to. By Brans- 
ford Lewis. M. D 201.259 

Hydrocele: Its Cure by a Simple Operation. By R. 
F.Licorish, M.D 190 

In the Present Status of Bacteriology, Can Its Rela- 
tion to Cutaneous Pathology be Definitely Defined? 
(A symposium) 1 to 12 

Koilonychia and Its Successful Treatment. By A. H. 
Ohmann-Dumesnil. M. D 24 

Median Perineal Urethrotomy and Cystotomy. By 
W. G. Spencer. M.D 141 

Multiple Chancre in the Xegro By Lueien Lofton. 
A. B.. Ph. D., M. D ^ .263 



Obioinal Abticlss. page 

Pathogenesis and Treatment of Diabetes Mellitus. 

By 8. C. Martin. M. D 33 

Prurigo and Pruritis. By S. C. Martin. M. D 54 

Pervert. A Sexual. By W. B. Parsons. M. D 71 

Prostatic Hypertrophy from Every Surgical Stand- 
point. (A symposium) , 93.132 

Pemphigus Vegetans. By L. P. Hamburger. M. D...148 

Prostitution in Japan. By A. 8. Ashmead. M. D 167 

Prostatic Surgery. By B. M. Rickette. M. D 168 

Prostitution in Japan By a C. Martin, Jr.. M. D...190 
Prostatectomy, The Techmque of. By Nicholas Senn. 

M.D 218 

Relation of the Ureter to the Bladder. By Byron Rob- 
inson. M. D 49 

Segregation of Lepers. By S. C. Martin, M. D 257 

Small-Pox. Diagnostic Features of. By George G. 

Melvin. M.D 239 

Sodid Position and Oceupation. By S. L. Eisner. 

M.D - 72 

Some Cases of Hydrocele Cured by Iodine and Car- 
bolic Acid Injecttons. By J. C. Luke. M. D. 262 

Spinal Anesthesia in Genito-Urbiary Surgery. By M. 

Krotosxyner. M. D 74 

Spermatorrhcea as a Disease Sul Generis. By J. A. 

DeArmand, M. D i 164 

Sublamine in the Treatment of Parasitic Scalp Dis- 
eases. ByWmiam S. Gotthell. M.D 267 

Syphilis of the Nervous System. By F. E. Coulter, 

M.D : 170 

Syphilis. Sublamine in the Treatment of. By M. 

Friedlander. M. D 180 

Syphilis, Third Act in the Drama of. By H. A. Rob- 

Wns, M. D 55 

Syphilis Insontlum. By Charles E. Caldwell. M. D...236 
The New Light Cure By Cory don Eugene Rogers, 

M.D „. 233 

Urticaria: Its Vagaries and Treatment. By S. C. Mar- 

Un, M. D 32 

Varicocele, A Simple Remedy for the Cure of. By 
Frank A. Brewer. M. D. 176 



mf^ 13I^O: 



IMMEDIATE RELIEF FOR AND PER. 
MANENT CURE BY THE USE OF 



«i^^ 



ANASARCIN 

Doctor: — Have you a patient afflicted with Bright's Disease, Valvu- 
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any other pathological condition in which there is loss of the natural 
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patient die without a fair trial of ANASARCIN, a combination of the 
active principles of Oxydendron Arboreum, Sambucus Canadensis and 
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Sold Only to PhysiciCLi\s. 

The Anasarcin Chemical Co. 

WINCHESTER, TENNESSEE. 

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Listerine 

An Internal and External 
Antiseptic 

The field of Antiseptic Therapy is constantly broadening to 
meet the requirements of multiplying causes of disease. 

With the advance of medical science many diseases hereto- 
fore supposed to be non-contagious are now known to be 
contagious, and many injuries never suspected of causing 
septicemia or pyemia are now known to be commonly asso- 
ciated with such conditions. 

Septic material in a great variety of forms gains access to 
the body both from without and within the organism, and to 
counteract its baneful effects an antiseptic adapted to both ex- 
ternal and internal use should be employed. 

Listerine is such an antiseptic, and is not only efficient, 
but is absolutely safe as an internal antiseptic. 

It is a staple product which is uniform, constant, safe, 
efficient and pleasant in its therapeutic action, besides is 
always ready for immediate and convenient use. 

There is no surgical procedure in which it is not adapted to 
meet septic conditions by the methods of 

Inhalation, AMzation, Irrigation, Injection or Local Application 

As a non-toxic, non-irritant antiseptic, Listerine fulfills 
innumerable indications in the treatment of diseases of the 
throat, respiratory passages, alimentary canal. Skin and 
Genito-Urinary Organs, and at the same time may 
be combined with any drugs required to meet special patholog- 
ical conditions. 

Lambert Pharmacal Co. 

St. Louis, Nlo. 



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