tution, temperament, in short, the physical condition of each and every individual patient, and he asserts that this is "urgently important," to which we must most certainly all agree, as no two cases of anything are exactly identical. When we begin to differentiate individualize our cases we are beginning to prepare ourselves to understand that the little things are important and are what make for or against in medicine, and that it is essential that the physician discerns the differential difference in the individual and act accordingly if he would obtain results satisfactory and reliable to both himself and patient. If this is not true, the physician in a sanatorium is a superfluity, an unnecessary evil. The nurse can give the routine treatment, No. 6 at 6, 10, 2, and 6, and No. 9 at 6, 10, 2, and 6; and tell each one that is what they all get and all any gets, and if any one is not O. K. that " he got what they all got." But Dr. Hayden gives us to understand that he individualizes his cases and that he "administers drugs to successfully combat each symptom as it may present," to which we must agree; we must know and successfully combat the symptoms in each case as they present. One may have one manifestation, and another an entirely different one. One may sleep all the time, another cannot even get sleep. There is one other point that I have seen very forcefully demonstrated, which on first thought may not appear to the reader of material importance, yet I have seen its importance proven. Reference is had to the character of remedy or rather the preparation used in treating alcohol and drug addicts, more especially the alcoho habitue. The writer saw one case of an alcohol addict who appeared cured and at case, and so declared himself, denying any craving or even desire for stimulants, who was given a dose of tincture cinchona that kindled the old fire of desire, which burned so fiercely as to again land him in continual drunkenness. Such a result is not rare. I am reliably informed of an instance where the taste of liquor in pudding aroused such an overwhelmingly irresistible craving for alcoholic stimulants as to not only cause him to yield, but held him enthralled for seven years in miserable and inextricable bondage. We cannot or should not say he could This is one of differen have avoided it, could have resisted, etc. tials, one of the marks, an element of the individual, which go to make up the difference in men, and prevent all being exactly alike. Consequently, to the writer it appears of material importance to avoid anything containing alcohol during the treatment of these cases, as well, or more especially than after. And since we have active principles in alkaloids, glucocides, etc., admirably and adequately covering the therapeutics of all addicts, I desire to emphasize the importance and desirability of using them and avoiding every remedy containing alcohol and the very semblance of alcohol. Is it not mandatory that we throw not one straw in the way while exercising reclaiming efforts in behalf of a drink-cursed soul? There are active principles obtainable, of all remedies needed, and these may be used in any and every way demanded to meet requirements; and when given by mouth in hot solution they are almost as speedily effective as when given hypodermatically. Being active and susceptible of exact dosage, the physician knows definitely and precisely the amount used in each and every case. and what to expect from each dose, or practically so. When Dr. Hayden says that he "successfully combats symptoms as they present," we conclude he is an acute observer and a discriminating therapist, and keeps supplied with the very best therapeutic agents. His practice sounds like it must be adequate and thorough, which none may deny being right practice. The active principles are pleasant, safe, the most reliable, portable, and convenient to bring about physiologic equanimity and systemic adjustment in the acquired neuroses of addicts, with all their incident disorder and distress. Sometimes we may think seemingly little things are not important or some little manifestations need no attention. But there is no class of cases that requires the physician to keep as thoroughly in hand and in detail as does the class embracing all addicts. Consequently when we desire a certain effect we usually need to have that effect speedily. The perturbed, impatient neurotic with an incompetent and wavering physiology needs certainty of effect, and when we attempt to harmonize and qualify such a body no element of uncertainty should be tolerated. If we want the atropine effect would we guess how weak or strong some tincture of belladonna was and give a few doses to find at last it was not effective? Certainly not; we would administer the remedy we needed the effect of — atropine-feeling sure we would get atropine effect. We cannot afford to tolerate any element of doubt, and why should we use belladonna when we only want atropine effect? And so it is with every drug, if we want an action, give the active remedy that has that action, that it may act unhindered by companion principles or worthless elements, allowing no uncertainty to creep in to delay or vitiate results. In conclusion I desire to commend the SOUTHERN PRACTITIONER, and also Dr. Hayden, for his careful consideration of a neglected and little or badly understood class of cases, which is usually poorly treated or sadly mistreated. Very respectfully yours, J. ROBERT LANDERS, M. D. Selected Articles THE PRESENT STATUS OF SURGERY OF THE HYPERTROPHIED PROSTATE.* BY WALTER LEE MUNRO, M. D., PROVIDENCE, R. I. IN presenting this subject to you to-day, it is not my intention to give you the results of my experience it has been too limited. nor yet to advance any new theories or new methods in technique, but to review, however imperfectly, what has been accomplished by others, working in a larger field, and to endeavor to show you what we can offer to-day in the mitigation and cure of a class of cases which only a few years ago were as hopeless as any with which we were called upon to deal. We must acknowledge at the outset that we have been a little slow here in Rhode Island in appreciating and extending to our patients the benefits of the grand work which has been developing elsewhere. * Read before the Rhode Island Medical Society. Reprinted from Medical Age, October, 1906. While modern prostatic surgery is the growth of the last few years, a beginning was made almost three-quarters of a century. ago. Prostatic hypertrophy was at first regarded as "an excrescence of the neck of the bladder," and was accordingly attacked. through the natural passage. Leroy d'Etiolles first proposed incision and scarification of the prostate through the urethra in 1832, and in his work we see the germ of the Bottini operation of the present day. He was closely followed by Guthrie, who devised instruments for snaring the projecting middle lobe. Mercier, in 1837, devised an instrument somewhat like our urethrotomies. In 1856 he exhibited a galvano-cautery instrument resembling the Bottini. This was further improved in 1877, but was not used to any extent until it was taken up by Freudenberg in 1897. Since that date it has had ardent advocates, and much of the work of perfecting instruments and technique has been done in this country by Hugh Young, Guitéras, and others. One great objection to its use was found in the fact that the operator worked entirely in the dark. To obviate this, Tenney, in 1904, added an endoscopic attachment which enabled the surgeon to see what was being done within the bladder. Lateral lithotomy for the removal of stone from the bladder is one of the most ancient operations, and in connection with it polypoid growths were occasionally twisted off. Hence it was natural that attention should at first have been directed to this route. To Guthrie belongs the credit of first advising and practicing a method of treatment by incising "the bar at the neck of the bladder." Others attempted tunnelling the prostate and draining the bladder, using sometimes sharp instruments, like a large trocar, sometimes various modifications of the galvanocautery. All of these procedures were abandoned as dangerous and futile. Gouley, as has been so often pointed out by Watson, was the true pioneer of modern prostatic surgery, for he, in 1873, first operated for the removal of the entire prostate. He elaborated his method and taught it to others, among them Watson, by whom it was kept alive; but it failed of proper recognition by surgeons at large, and was not appreciated at its full value until the flood-tide of prostatic surgery brought it into prominence. From 1890 to the present time a long list of operators have followed in his footsteps, working in various ways and with varying technique, devising new instruments and perfecting the operation, until we have, as the result, modern, scientific perineal prostatectomy, based on anatomical grounds and thoroughly systematized. The first recorded operation for hypertrophied prostate by the suprapubic route was by Ammusat, in 1827, who removed the middle lobe with scissors. McGill did much to establish this method in England. Fuller and Guitéras have developed and improved the technique. Castration, first proposed very cautiously by White in 1893, vasectomy, ligation of the internal iliac, and a number of other procedures have either been entirely discarded, owing to their futulity and inherent dangers, or are rapidly becoming only historically interesting. (For many of the points in this brief historical review I am indebted to Dr. Ballenger's admirable article in the Medical Record of February, 4, 1905.) While, then, scattered surgeons, seldom collaborating and frequently ignorant of each other's results, had broken ground, but little practical work had been done up to fifteen years ago, and we had little or nothing that was new to offer unfortunate sufferers from prostatic troubles. The reader recalls reporting and discussing a case before this society at about that time, which ran the usual course from bad to worse and terminated in cystitis, pyelonephritis, uremia, and death. The most advanced surgical procedure practiced by me in that case was aspiration of the bladder after the breakdown in catheter life, nor did the discussion by the Fellows elicit any reference to more radical procedures. Since that time progress has been rapid and steady. It has not always been along logical lines, and much of the work done has since been discarded or discontinued, but the surgeon has learned as much, maybe, from the failures as from the successes, and prostatic surgery is to-day as firmly established and as con |