organs that the remedy is eliminated. In all cases the treatment must be adapted to the individual, and the particular condition of that individual at different times. Dr. E. O. Shakespeare has assumed editorial charge of the department of Hygiene and Preventive Medicine of the Dietetic and Hpgienic Gazette. Orificial Surgery.-The next annual class for instruction in orificial surgery will assemble in Chicago on the morning of September 4. It will have a four hours' daily session during the week. For particulars address, Dr. E. H. Pratt, R. 56, Central Music Hall, Chicago. Sodium Phosphate for Trigeminal Neuralgia In a rebellious case of trigeminal neuralgia, in which all of the usual therapeutic resources had been exhausted without affording relief, Glovieux, of Brussels, tentatively practiced subcutaneous injections of sodium phosphate, and with admirable results. The patient, who had suffered for two years, was completely relieved. Ten other cases of trigeminal neuralgia were treated similarly, with success in seven. A solution of thirty grains of sodium phosphate in three ounces of distilled cherry-laurel water was prepared, and of this from fifteen to forty five minims were injected daily. La Semaine Med. Influence of Faradism Upon Irritability of Muscle and Nerve.-From a study of the behavior of muscles and nerves to the stimulus of the fara dic current, Mann (Deutsche Archiv fur. Klin. Medicin) has found that the application for several minutes to a muscle or nerve of very weak currents, whose intensity is lowered below the minimum necessary to induce contraction, is followed by no change in faradic irrita bility. Stronger currents that induce muscular contraction cause diminution of irritability in a degree in direct ratio to the intensity of the current and the duration of its application, it matters not whether the muscle be stimulated directly or through its nerve. Faradization repeated regularly for several days gives rise to an increase in the irritability of the faradized muscle or nerve. the contemptuous and contemptible opinion of medicine in the minds of the world. Inexplicably, unconsciously, but so inevitably, the worldling rates the great physi cian immeasurably below the great general, statesman, or lawyer, and with the large majority there even arises medicine comes into thought. As to the pictures again a tinge or a downright dyeing of disrespect, when the impracticability of the art-treatment of medical subjects is sadly illustrated by the examples at Chicago. Seligman's "Billroth's Clinic" is well known to many through a cheap reproduction. Lessing's "The Sick Bed," and Jimenez's "Salle d'hopital, are hardly worth passing notice, and the treatrical clap trap of Heyl's "Before the Section" (sic) is wholly execrable. All are simply prosaic recitals, none being touched with the divine fire of art. Are such things necessities or misfortunes-errors of the artist or inherent in the subject? Aspidospermine.-Dr. G. Bordet (Les Nouveaux is a mixture of several products derived from the que Remedes) states that the aspidospermine of commerce bracho aspidosperma, but it possesses practically the properties, excepting the antithermic, which is stronger It increases the depth and amplitude of the respiratory than the contained quebrachine, of the pure alkaloid. movements, slows the heart, and lowers the temperature. Huchard has recommended this drug in dyspnea of functional origin. The dose is from one to two grains, which is soluble in water, with the addition of a few drops of a ten per cent solution of sulphuric acid, which however, should be neutralized by bicarbonate of soda, if it is intended for hypodermatic use. At first Nocturnal Laryngeal Spasm in an Adult. Herschell (Lancet) has reported the case of a literary man, thirty six years old, of markedly neurasthenic temperament, who for eighteen months had suffered from attacks of spasm of the larynx at night. these occurred about twice a week, on some nights two attacks taking place. Under appropriate treatment the attacks ceased for a time, but returned upon relaxation. of hygienic measures. The attacks usually occurred after late dinners and over indulgence in cigars. They set in about two o'clock in the morning, when the man Medicine and Art.-It seems worthy of com- is awakened with a sense of suffocation, from spasm of ment that among the thousands of pictures at the Co- the larynx, which prevents inspiration. This continues lumbian Exposition, illustrative of the art and customs for a few seconds, when the spasm partially relaxes and and types of every country and calling of the world, air is drawn into the larynx with a crowing sound. Af there are not half-a-dozen pertaining to medicine The ter nearly a minute the spasm entirely relaxes, but the query arises, is this because of any inherent qualities larynx feels sore and uncomfortable for an hour or two. of medical ideals and practices that do not lend them- During the attack the heart beats violently, while afterselves to esthetic treatmeut? Every aspect of life, ward the stomach is found tympanitic and distended. death, suffering, and wrong that the world has known is Eructation of gas is followed by relief and brings the portrayed by the painter or sculptor, all save the one attack to an end. Often there appears a spasmodic conaspect of illness and the medical saving of life. The dition of the orifices of the stomach, which prevents the heroism of the men who kill is found pleasing, but expulsion of the flatus upward or downward. There not the heroism of those who bring life out of death. was no evidence of disease of the heart, vessels or nervPerhaps this illogicality rests upon the larger one of ous system. American Electro-Therapeutic Association. The third annual meeting of the American Electro-Therapeutic Association will be held in Chicago, September 12, 13 and 14, at Apollo Hall, Central Music Hall Block. Members of the medical profession interested in electro-therapeutics are cordially invited to attend. Augustin H. Goelet, M.D., President; Margaret A. Cleaves, M.D., Secretary. RAILROAD NEWS Special Railroad Rates for the First PanAmerican Medical Congress to be held at Washington, D. C, September 5th to 8th Inclusive.-The Chesapeake & Ohio Railway, from Cincinnati or Louisville to Washington, D. C., is the quickest, most picturesque, interesting and comfortable line between those cities. Their trains are vestibuled throughout, lighted by electricity and carry the latest pattern of through first class coaches, Dining Cars and Sleepers. The scenery along the upper Ohio and Kanawha Rivers, through the gorgeous and canons of the New River, among the Peaks and Valleys of the Blue Ridge and Alleghaney Ranges and over the fertile plains and historic battle fields of Virginia constitutes a kaledioscopic panorama that for variety, beauty, grandeur and historic interest is unequaled in this country. Parotiditis Complicated by Orchitis, Prostatitis, and Hemoptysis.—Comby (L' Union Medicale) has reported the case of a gardener, twentynine years eld, who, after having worked all day in a hot house, was seized at night with a chill; the right testicle was noted to be swollen, red, heavy, and pain. ful. During the night there occurred sweats, with headache, pain in the back and in the extremities, so that sleep was prevented. There was also evidence of the existence of a mild prostatitis. On the following day delirium set in, and a day later still painful swelling ap peared in both parotid regions. dyspnea, and in the midst of a paroxysm of coughing, Ths rates of fare will be the same by all of the lines profuse hemoptysis occurred. Improvement now soon and while they have not been agreed upon, they will set in, and in a short time the man was convalescent. positively not be more than one and one-third fare for Examination of the chest failed to disclose evidence of the round trip. The one way rates ars as follows from organic disease; neither did the urine present any ab. St. Louis $19.25, Chicago $17.50, Cincinnati $14.00, normality. The treatment employed consisted in the Indianapolis $16.00, Louisville $16.00. administration of quinine sulphate, purgation, the ap plication of emollient compresses to the testicle, and a milk diet. There were fever and Poisoning with Turpentine.-Carveth (Cana dian Practitioner) has reported the case of a woman who at bedtime, took about half an ounce of old spirit of turpentine mixed with an ounce of whishey, in mistake for castor oil. The mistake was only noticed after the turpentine had been swallowed, but nothing was done at the time except to take a dose of castor oil. The patient shortly afterward fell asleep, but was awakened in the course of five hours with sickness of stomach. A little later she vomited, and after the lapse of several hours more she had a convulsion, followed by loss of consciousness. The pulse was weak, feeble, rapid; the face and lips pale; the patient restless, at times delirious and talking incoherently, but capable of being partly roused. Urine had been passed in generous quantity. Whiskey, spirit of nitrous ether, milk, and sweet oil were given, and warmth was applied to the body. Vomiting was induced by irritating the fauces The vomited matters had a strong odor of turpentine ten hours after the fluid had been taken. After free vomit ing, consciousness was regained and complaint was made of a burning pain in the right leg. Examination disclosed the presence upon the posterior aspect of the knee of a blister 5 by 12 inches in extent, the contents of which were watery and emitted an odor of turpen. tine. Gangrene of the superficial parts took place in this area, and fifteen weeks elapsed before the resulting ulcer healed. Tickets will be sold at those places September 1 to 4, inclusive, good to return leaving Washington as late as September 12. Ask for your tickets "via the Chesapeake & Ohio Railway. If you will advise me what day you will leave any of the places named and whether in the morning or evening and how many berths you will want I will reserve them through to Washington for you. Write for a copy of "Virginia in Black and White." The Following Resolutions were passed at the last meeting of the St. Louis Board of Health: WHEREAS, In view of the indefiniteness and insufficieney of official information as to who have been appointed consultants to the different hospitals under city control and are now holding such positions, the terms of such appointments and the duties and obligations toward the city of those holding them, it is desirable that a clearer understanding in this regard be had and some definite rule be followed in future; therefore be it Resolved, That the Board of Health hereby reconsid ers its action in this respect and vacates and annuls all existing appointments of this kind. And be it further Resolved, That the proper committee be instructed to prepare and submit to the Board a rule or plan to gov. ern all such appointments in future. The foregoing preamble and resolutions were adopted by the Board of Health on July 20 last, the object being to formulate a systematic plan by which appointments to the various institutions may be made in future. DR. OTTO E. FORSTER. VOL. XXVIII. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. ST. LOUIS, AUGUST 12, 1893. ORIGINAL ARTICLES A Rational Treatment of Prostatic BY G. WILEY BROOME, M.D., OF ST. LOUIS, NO. 7. necessary to remove to secure patency of the urethra, and is of course much influenced by the condition of the kidneys." No other treatment is recommended than that of Prostatectomy as you see, save systematic catheterism, and this only as long as it can be endured by the patient. In the light of a careful study of the subject, I am strongly impressed with the conviction that this teaching is wrong, and that Prostatectomy is not the best that may be done for the patients. That in fact all teaching that would have us attack the prostate gland by Professor of Surgery and Clinical Surgery, Woman's Medical College, a cutting operation as the only remedy for the cure of St. Louis; Surgeon to the Woman's Hospital; Consulting Surgeon to the St. Louis City and Female Hospitals, etc. Read before the Missouri State Medical Association at Sedalia, If we contemplate the teachings of the "American Textbook of Surgery", together with the more recent contributions from the same author, who (it is presumed) wrote the chapter upon the Diseases of the Prostate Gland, as reflecting the concensus of the opinions of the American Surgeons upon the methods of treatment in prostatic hypertrophy, as inculcated by him, then we must conclude that Prostatectomy alone is the only plan of treatment that holds out any hope for the relief of these suffering with this distressing affliction. the patients is defective, whether it adopts the method of Tobin, Mercier, Bottini, Harrison, Dittell, McGill, Belfield, Treves, Whitehead, Dolbeau's perineo prostatic dilator, or any like plan of operative procedure. I am also led to believe that McGuire's method of drainage, although a more palliative and rational management of these cases, is defective and exceedingly unsatisfactory in many essential particulars. It was Sir Henry Thompson who first struck the keynote to the principle underlying the rational treatment of prostatic obstruction, when he suggested the permanent supra-pubic drainage, and at the same time pronounced the dictum that a confirmed atony of the bladder, consequent upon prostatic enlargement, is incurable even by the removal of the obstruction. He contended himself with the treatment by drainage, the This teaching, coming from such high authority, wound being fitted with an apparatus to conduct the brings with it the conviction that it is sanctioned urine into a urinal. This plan I conceive to be the most and endorsed by the distinguished members whose rational and the best for the patient that can be done. names appear on the title page of that great work, That is a treatment that will remove that source of inis of itself sufficient to exert a powerful influence in tolerable suffering which so often renders old age unfavor of this method. Indeed, it has already manifested bearable, and death a happy release, and a method too itself, for the tendency seems to be wholly in favor of that does not entail a mutilating operation as Prossome one or other method of Prostatectomy. If we tatectomy does. I hold that to make such an operation turn to the chapter of the American Text-Book of upon a bladder when there are already putrefactive Surgery, in which the subject of Prostatic Obstruction changes going on besides chronic suppurative cystitis is treated, we will find the discussion of the subject in is not good surgery. Rest is what the bladder needs, the following terms: and rest is what the suffering patient is constantly praying for. "The results of experience thus far seem to show that the operation of Prostatectomy is justifiable in The health is already much impaired in these old. most cases of hypertrophied prostate in which cathe men, and to be subjected to a severe surgical operation terism is difficult or impossible or excessively painful under these circumstances, and that, too, to a particularand in which a high grade of cystitis has developed ly painful operative procedure, the outcome of which and septicemia or uremia is imminent. The prognosis must necessarily involve serious misgivings as to its is unfavorable in proportion to the duration of the ob- ultimate termination. There must remain grave doubt structive symptoms and the size of the mass which it is as to the justifiability of any method of treatment that does not give the bladder immediate and continuous surgeon finds himself practically forced to operation in rest. spite of these unfavorable circumstances. Systematic catheterism ought never to be instituted 4. If the general health is unimpaired and there is because in the first place, it is a source of an almost no evidence of renal disease, while the local symptoms unavoidable infection, especially if the patient uses it are pronounced, the case is obviously one of the most Unfor himself; and secondly, it, too, soon becomes a tantalus favorable for prompt operative interference. and cannot be used so as to drain the bladder perfectly. tunately the great majority of prostatics are not led to Sir Henry Thompson asserts that habitual catheterism consider operation until long after the break-down in for two years will permanently destroy the power of catheter-life has been followed by vesical and renal inthe bladder to empty itself. McGill, the champion fection and the superinvention of the general toxemia, advocate of Prostatectomy in Europe, differs from this a combination of sapremia, septicemia and chronic ureconclusion, but adds that it is one of the strongest mia, which renders them such unfavorable subjects for arguments in favor of early operation, since catheterism, the surgeon." (That is what we presume he means for the chief palliative measure, which replaces it,may within Prostatectomy). two years, so ruin the bladder that it can never recover. In a preceding paragraph of this article, the author In order to enable you to compare the methods of refers to the operation and to those who have objected treatment as taught in the American Text Book of Sur. to it in the following terms: "Prostatectomy, in spite gery, etc., by the advocates of Prostatectomy with the of the unfavorable opinions of the operation formed and methods of treatment by supra pubic drainage, as advo- expressed by Socin, Guyon, and Sir Henry Thompson cated by Sir Henry Thompson and his followers, it will has steadily gained in the estimation of the profession be necessary to quote at some length from the American and is today a well recognized and justifiable surgical Text Book of Surgery, and the recent contributions procedure applicable to a large number of cases." from the same sources, and also from the last edition "It was in the year 1869", Sir Henry Thompson inof Sir Henry Thompson's work on Diseases of the forms us in his last edition that he "decided to inGenito-Urinary Organs, the principles of whose plan troduce a tube into the bladder of patients suffering of treatment, I propose to advocate in this paper, I severely from prostatic obstruction, above the pubes entertain a confident hope that all who will carefully to be permanently retained there as the constant compare and impartially examine the different methods channel for the urine. of treatment will be fully convinced of the superiority of Sir Henry's methods over those of the advocates of Prostatectomy. In the text book, the indications, etc, for an opera tion are given in the following words: "The amount of muscular power remaining in the bladder walls may be roughly estimated by the size and force of the stream of urine which the patient can project, (a) unaided, and (b) through a catheter. If doubt exists as to feebleness of propulsive power is due to obstructive or degenerative causes, the common association of the latter with the evidences of general sclerosis should be remembered and given due weight. Usually, however, remembered and given due weight. Usually, however, catheterism will clear up this doubt by removing the obstructive element and thus demonstrating the degree of vesical atony or rigidity which is present. 2. The quantity of residual urine is important as showing both the amount of obstruction and the capa city of the bladder. If it is large in spite of the presence of good muscular power, it should be regarded as distinctly indicating Prostatectomy. 3. The condition of the urine and the vesical mucous membrane is importrnt. Sterile urine, i. e, absence of infection of the mucosa with pyogentc or saprophytic organisms is a most favorable factor as regards prog nosis; but recurring cystitis, especially when it is associated with vesical paresis, either atonic or sclerotic, is an indication for prostatectomy, although it undoubted ly increases the danger of death from sepsis. If with the cystitis there is difficult or painful catheterism, the Just as a tracheotomy tube may serve some patients for years as the only channel of air into the lungs." He adds further: "Now, instead of giving you any details of the cases in which I have thus operated, as I have sometimes done, I may say in general terms that the result has always been advantageous in a certain degree. It is unquestionably a proceeding capable of mitigating the sufferings of an aged and infirm patient, to whom hourly catheterism is a slow but fatal form of torture. In order to be of real service in the way of prolonging life, and rendering it fairly comfortable, the operation should be resorted to at an earlier period than has usually been chosen, certainly at a stage before the last painful manifestations have appeared or have given notice of their approach. But I am about to propose a modification of the preceding which I believe will render it more valuable." "About three years ago, I performed digital exploration for an advanced case of constant and painful catheterism, and removed six encysted calculi, draining the bladder afterwards with great relief to the symptoms; but in about three-fourths of a year I was again consulted, owing to their reappearance. I then decided, instead of making the puncture above the pubes described, to perform the supra-pubic section as for litho tomy, having complete confidence in the safety of the modern operation, so as to enable me to lay open to view and examine every part of the bladder and then let it heal so far as to admit a tube through which in future all the urine should pass. I did so in June 1886, and found the mucous membrane of the bladder coated for the greater part with a dense fibrous deposit, number from the old men who died at that institution during the last few months and on whose bodies postmortems were made. I have one of these specimens here, and from it and the bladder in which it grew, one can readily imagine how difficult it would be to estab lish a low-level channel by a cutting operation upon the prostate. McGill, and others who, advocate the prac tice so strongly, aim at establishing a low-level channel as you are no doubt aware, by the operation of Prostatectomy, which I believe to be wholly impossible without greatly endangering the life of the patient. often met with in old-standing cases, and firmly ad hering thereto much phosphatic grit; this, with considerable trouble, I detached, removing the whole. The wound now rapidly diminished in size, and I was soon able to carry out my intention of enabling the patient to walk out of doors in about a month's time. To the supra-pubic region was fitted a silver plate, with an opening in it, transmitting a silk gum tube, No. 20 English scale, which projected less than an inch on the outer side, and was inclined downwards two or three inches on the inner side, thus conveying from the bladder all the urine as soon as it arrived by the ureter. If it were possible to remove a portion of the projectTo the tube on the outer side was attached the ordi- ing prostate by the suprapubic procedure sufficient to nary urinal worn by persoes requiring such a conve- secure a low-level channel and perfect drainage of the nience and into it all the urine passed without leakage floor of the bladder through the urethra, as advocated or trouble. After a little adjustment the contrivance by McGill, I, notwithstanding, believe the procedure is answered so well that the patient went abroad and wholly unjustifiable, and particularly unjustifiable and spent the winter there in the enjoyment of health, inhuman if there be the highly irritable conditions that walking three or four miles daily." follow cystitis or prolonged catheterism and other like "He has continued thus, with slight occasional causes. For unless the results of the operation afford troubles, to the present time (autumn 1888), and has the patient complete rest and perfect drainage of the not used a catheter since. He removes and cleanses bladder any such operative procedure must necessarily the tube once daily and washes out the small cavity prove a failure. You may readily perceive, that as I which remains as bladder, for the pelvis is largely cannot endorse the operation of Prostatectomy, not occupied by a prostate almost as big as a cocoanut. He even the more alluring surgical treatment first outlined has no pain and has long given up the use of morphine, by McGill, I need to mention the various other operawhich he formerly consumed in large quantities." tive procedures recommended and practiced for the Mr. Buckston Brown's suggestion as to the retention relief of prostatic obstruction only to dismiss them as of catheters in restive patients, by means of a lead inadequate and not worthy of imitation. I wish to state stillett, only tends to handicap the patient all the in this connection, however, that if a prostatectomy more, and thus aggravate the distressing symptoms could ever seem to be justifiable, certainly the urethral already existing, although he deprecates Prostatectomy route could hardly ever become popular. and thinks it a dangerous operation, but unfortunately I may add, admits that it is only necessary in men already broken in health, and uncertain even in cases of recovery, of being followed by release from the need of using the catheter. There can be no doubt but these cases of prostatic obstruction are due to an intra-vesical growth and the severity of the symptoms in a case of hypertrophy of the prostate bears little or no relation to its apparent size as felt in the rectum. An old man, 74 years of age, called at my office the other day, whose prostate is quite as large as my fist, but the enlargement is almost entirely backward, urinary symptoms only manifesting themselves within the last few days. McGill classifies the various forms of the intravesical growth that produce urinary symptoms into (1) a projecting middle lobe pedunculated or sessile; (2) an overgrowth of the middle lobe and of the two lateral lobes, forming three distinct intra-vesical pro jections; (3) enlargement of the lateral lobes only; (4) a uniformly collar-like projection encircling the orifice of the urethra. As intimated at the outset of this paper, our whole aim should be to secure prompt and permanent rest to the bladder of these unfortunate patients, and not as is added by Mr. E. Hurry Fenwick to also permanently remove the cause of the obstruction. It is almost wholly impossible by any of the operations heretofore described, besides the failure of those operations to secure complete and prompt physiological rest of the bladder, they all for the time being, at all events, aggravate the already distressing symptoms and In a series of may hasten the fatal issue of the cases. lectures recently delivered and which are conspicuous for their thought and labor, Mr. Mansell Moullin care. fully and intelligently reviews the question of operative treatment of the enlarged prostate. In criticising the operations which have been devised for the relief of the complications arising from enlargement of the gland, he very properly propounds the significant inquiry as to involve too great a risk to human life. whether the operation of prostatectomy does not The plan of treatment I have been practicing and the one that has given more satisfaction than any other, I I have preserved several specimens illustrating a can describe in a few words. I may add right at this series of cases, as one autopsy occurred after another in point that the class of cases most suitable for the operaold men at the City Hospital of St. Louis. These tion are those which have reached the stage of prostatic specimens are not a selected variety. but include a obstruction at which the American Text Book of Sur |