Bismuth for Bowel Troubles and Typhoid. The First Gun for the Coming "Summer Complaint" Season.

Editor MEDICAL WORLD:-Please find inclosed $4.00, $1 for WORLD for 1904, and $3 for "The Story of New Zealand." Feeling indebted to THE WORLD and its readers, or rather its contributors, I would like to give my experience with bismuth subnit. I must state that I hardly ever need any other remedy in summer complaint, dysentery, etc., since I learned to use it as I do now. I use it in large doses, from 15 to 30 grains at intervals of 1⁄2 to 2 hours, as indicated. Calomel in varying doses is sometimes added to it with advantage, for bowel antisepsis.

I used it in the three last cases I had of typhoid fever with apparently the same success. As soon as the diagnosis was establisht and temperature reacht 1032° to 104° I gave about 25 grains once in 2 hours and kept bowels open with Rochelle salts to secure two or three passages daily. In 24 hours this relieved the headache and other aches, and reduced the temperature to 100° to 101°, allowing the patients to sleep as well as in health (as near as I could asertain) and to read during the day.

In all these cases I tried to reduce the amount of bismuth, giving the powders once in four hours, but then the temperature arose again to 1032 in 24 hours, and it required 12 to 18 hours of the former dosing to bring it down again to 101°. Now I made it a point to keep the temperature at 100° to 101°, no matter what it took. The first case I treated was a diarrhea case with hemorrhage of bowels. (This case spread the infection to the others who were in the same house and part of the time in the sick room.) This case required about 25 grains once every hour before diarrhea was controlled. As soon as the required dose was reacht the temperature fell to normal, this being the fourteenth day in bed. The other two cases were treated by large doses from the start; the fever was controlled, and both became normal on the ninth day after taking to bed. Some calomel was used during first week, and quinin in tonic doses three times daily was all the medicin used, except the lax

ativ. Now there is do doubt in my mind as to these cases being typhoid, but this not being a typhoid district I have no opportunity to further try this treatment; I will, therefore, give it to those who have use for it, as so many of the WORLD's readers have. In closing I will say that I don't expect all to have success with this, as much depends on handling it right; but I do believe that if properly used, it will disinfect the intestins and prevent ulceration and end the trouble in nine days. Be sure and use an honest bismuth-the one I used was Malinkrot's. H. L. BRYNILDSEN, M. D.

Vasa, Minn.

The Profession in Chile, South America.

Editor MEDICAL WORLD:-Having received several letters inquiring about this country (professionally), my answers have been about the following to all. Thinking that it may be useful to others who may need the same information, I wish you would publish the following:

I. 1. This is a Spanish speaking country, with a small percentage of English speaking population, which is located mostly in Santiago (the capital) and the principal provincial cities, such as Valparaiso, Iquique and Concepcion.

2. The law of this country requires one or two examinations, in Spanish, from all candidates, according to the diploma held. If the University here considers the diploma of good standing, the applicant has only to pass a practical examination; otherwise he has to pass the licentiate's examination, which is all theoretical, and then the examination for his M.D.

3. The American dollar is worth about three Chile dollars.

4. In Santiago the visits run from one to ten dollars (of course I mean Chile currency); in the principal provincial cities from one to five dollars a visit. Office and specialist's work is different. Collections are as bad here as they are everywhere else.

5. The nativ physicians and surgeons generally are pretty well up-to-date, and some of them are quite clever.

6. There are a few English, French and German doctors in this country. There are also lots of quacks, hospitals and free dispensaries (which are becoming a pest all over the world).

If any adventurous character decides to come to this country, I wish him the best of luck. THOS. H. COLE, M.D.

Los Angeles, Chile.

[Privately Dr. Cole writes the following; however, first see WORLD for last November, page 514, lower half of second column.

Many thanks for your kindness in publishing my last. Thru your kindness I have heard of my dearest

friend, Dr. Coates. I am sorry to know, thru Dr. Walter N. Sherman, of Fresno, Cal., that Dr. Coates died at Socorro, New Mexico, in 1883.

This illustrates the usefulness of THE MEDICAL WORLD, and shows that its circulation permeates every part of our great country, and reaches many other countries.-ED.]

Comments upon "Osteopathy as Seen from

the Inside by an M.D. Osteopath." Editor MEDICAL WORLD:-I read the above mentioned article in November WORLD, page 510, by Horace P. Holmes, M.D., with much interest and said "Amen." I never read Dr. Still's autobiography, but I was fortunate (?) enuf to have been raised in the town where osteopathy had its birth. I knew Dr. Still when his word was not good for ten cents. (Is it worth any more yet from a scientific standpoint?)

He was then (twenty-eight years ago) called doctor. Whether he was a graduate or not I do not know, but he was so regarded. He always was running after every fool thing that came along. Never had any practise, and when he dug up his Indian bones I do not know. He was called a spiritualist, and passed as a magnetic doctor among the white people, one who could tell you where all your aches and pains were by simply looking at you, and among the colored people as a kind of a voodoo doctor.

My mother had pneumonia when I was a boy. Our family physician said he had done all he could; that nature would have to do the rest; that she would get better or worse before twenty-four hours; that if we wanted anybody else to see her, to send for him. Some one said get Dr. Still; that he could tell you all about your trouble and never ask you a question, and make you feel better by simply making a few passes over you. Still was sent for. He walkt into the sick chamber, stopt at the foot of the bed and said to my mother, "Look at me." After standing that way a few minutes, he held out his hands over her, and without removing his eyes from hers, walkt around by her side, passing his hands back and forth a few minutes, laid them over the right lung and said, "there is where your trouble is;" and after raising his hands as if lifting something away from her, he said, "Now, you will be better in the morning."

She was. He produced a profound impression on both family and patient. But we never had him again. As I look back at it now I see nothing in it but the rankest quackery.

Another case: An old darkey woman, living across the street from my father's, was troubled with something like dropsy, as I remember it now. Several doctors had failed to give her

They sent for Still.

He came! He

relief. saw! He conquered! He walkt in as before; after watching the old darkey a few minutes, he made a grab for her leg, and after much pulling and twisting and a sound pinching of the great toe, he held up a live mouse by the tail and said, "There! You had a mouse in your leg and I have got it out and you will get well."

The old darkey got better and lived a year or two before she finally died of the same trouble; but to her dying day you never could have convinced the old auntie that Dr. Still did not take a live mouse out of her leg.

There are many other antics he used to cut up when I was a boy (I am now 40) which were equally as absurd. I have always regarded him as the rankest of rank quacks. He was hunting for something by which he could. fool intelligent people. The mouse trick would do for a poor old ignorant darkey, but not for intelligent people; neither would the mysterious "know all" and laying on of hands do, for that was too old. So he hit upon osteopathy; that was the stuff, for what does the average person know of the bones? It workt. It has made him a fortune. But all of his disciples I have seen have failed utterly to work his graft as successfully as he has done. Seneca, Kansas. URBAN G. ILES, M.D.

A Plea for Operativ Interference in Cases of Enlarged Prostate.

Editor MEDICAL WORLD:-It is not within the scope of this paper to say anything about the physiology of the prostate gland. I wish to say a few words about the anatomical relations of the gland, a few more about the etiology and pathology of hypertrophy of the prostate, the mechanics of prostatic obstruction to urination, and then a few more as to the best means of relief.

The prostate gland is a pale, firm, glandular body, which surrounds the neck of the bladder and commencement of the urethra. It is somewhat heartshaped, about the size of a walnut when in its normal condition, the base lying toward or upon the rectum and the apex toward the urethra. It is a spongy body, very liable to inflammation from gonorrheal infection, also to chronic inflammation and enlargement in men of sixty years and over, this being the age at which it is usually developt. In men of seventy, one in every eight has enlarged prostate. It may be considered the heritage of mankind; a large proportion, thirty or forty percent so it is said, of men past fifty years of age, suffer more or less from this condition. All men are liable to it as age advances.

In

many of course there is simply a slowness in passing urin, lack of force, some dribbling after the act, and perhaps a small amount of residual urin, which may not cause cystitis or perhaps much discomfort. In others, however, there is complete retention, necessitating the use of a catheter and perhaps frequent washing out of the bladder. This retention may be but temporary, from congestion, and when the congestion is relieved the patient may be able to void his urin again, without aid from a catheter.

In considering the conditions which cause retention and cystitis in these cases, it must be borne in mind that the size of the prostate is not an important factor, for a small prostate may cause complete obstruction, owing to its peculiar shape, or its situation, while a large one may not obstruct the outflow at all. I saw, when at Rochester, last May, seventeen glands, all sizes, from the size of a large horse chestnut up to as large as my closed fist. Yet one of the smaller ones caused its owner more trouble than the largest one, the owner of one of the smaller ones having had a catheter used as near as could be reckoned over three thousand times before he came for operation. He made a quick recovery and is well today. The gland is made up of lobes, a middle and two lateral lobes. The amount of trouble caused functionally, by the enlargement, is not so much due to size as to the part involved. An enlargement of the middle portion almost invariably results in urinary obstruction, but if the lateral lobes alone are concerned, the increase in size can be very great without necessarily interfering with urination.

Prostatic enlargement is serious not directly of itself alone, but only because it interferes with the exit of the urin. First, by causing decrease in the caliber of the prostatic urethra; second, by elevation of the level at the vesico-urethral orifice, causing residual urin by the inability of the bladder to empty itself fully; third, by its obstruction to the circulation of blood, causing congestion. Following naturally upon the imperfect evacuation of the bladder, and the chronic congestion spoken of, comes a train of morbid symptoms which begin with the prostate and ultimately extend thruout the whole urinary tract. Among the earliest symptoms of this trouble are difficulty in starting the flow of urin, feebleness of stream, undue calls to urinate, especially at night, loss of appetite, dryness of mouth, constipation. After catarrh of the bladder neck begins, the urinary symptoms become more prominent, calls to urinate more frequent, the urin becomes cloudy and deposits a white sediment. Thus far the patient may have been fairly comfortable, but now he is liable to one of two

events: either a sudden aggravation of a hitherto mild cystitis, or a complete retention of urin. The symptoms which may have been mild for weeks, suddenly, on the least chill, exposure, or shock of any kind, become worse and confine him to bed. Severe cases, unrelieved, usually prove fatal.

No disease has been so earnestly combated, or more carefully studied; but until recently it has defied science to do more than alleviate the suffering of its victims. However, surgery has finally won the battle, for in perineal prostatectomy has been found a safe and scientific method of radically curing this dread disease. Prognosis from a medical standpoint has always been discouraging. Sir Henry Thompson's view of the matter is that "medicin, as far as cure is concerned, has no place in the treatment of prostatic hypertrophy." Operations of various kinds have been recommended, lauded, and buried, because as a rule the results were not flattering. Castration, ligation of cord, galvano-cautery, electrization, irrigation, catheterization, medication, all have had their votaries, but as far as absolute cure is concerned, all have been weighed in the balance and found wanting. Not but that medicin is good, will relieve the symptoms, get the patient off our hands perhaps, but sooner or later he will come back to us again, or go to some other doctor, take swamp root or Warner's kidney cure, while the disease itself goes on from bad to worse.

An operation for prostatic obstruction, to be a satisfactory one, must meet several important requirements. It must be founded on sound and scientific principles. It must be practical in application. It must be productiv of the best obtainable results. It must be free as possible from danger. It must entail the least possible suffering. It must involve the least number of organs and tissues, and produce the smallest amount of mutilation, and must result in the end in practically a complete restoration of function. It should be followed by a safe and rapid convalescence, and should necessitate a very brief period of decubitus. In many respects the previous operations have failed to meet the above requirements. Take for instance supra-pubic prostatectomy. After a supra-pubic prostatectomy has been performed we have the patient in a thoroly unsatisfactory condition. He has a wound that is as improper as any that can be conceived of. It consists of an outer incised bladder wall, a lacerated bladder floor, and a more or less blind pouch beneath the bladder, from which the gland has been removed. This pocket, with its freshly torn blood vessels, and its open lymph spaces, becomes at once a receptacle of putrid, ammo

niacal urin, and can be relieved only by the most inadequate and unscientific attempts at drainage. The mutilation of the floor of the bladder is excessiv, infection is liable to take place, and incontinence is almost sure to follow. Convalescence is prolonged, distressing, and dangerous.

Now, we will compare these results with those of perineal prostatectomy. The patient is placed in lithotomy position and narcotised, usually with chloroform; the parts are of course shaved, scrubbed with green soap and sterilized. The bladder and urethra are irrigated with saturated solution of boracic acid. A staff is introduced and a median incision is made in the perineum. The membranous urethra is divided on the staff. The incision is deepened till the prostate is reached, blunt dissection being used to give as free exposure as possible. The prostatic urethra is then dilated with a divulsor or with the index finger of the surgeon, and a rubber retractor is introduced into the bladder. This rubber retractor consists of a rather firm rubber tube with a soft rubber distensible ball on the end, which after being forced into the bladder in a collapst condition, is pumpt full of water and clampt. The bulb within the bladder presents a shoulder at the bladder neck, which when the stem is pulled upon, brings the prostate well within the reach of the operator's index finger. The stem is then turned up out of the way and held by an assistant, serving at the same time to keep the scrotum out of the way. Now, after incising the capsule, the operator proceeds to enucleate the gland with his finger, one lobe at a time, beginning generally on left side. Sometimes the gland comes out intact; at others it comes one lobe at a time. The rubber retractor serves also to govern the flow of blood; as each lobe is removed, the pressure of the bulb at once closes the space. After the operation is finisht the patient is in the best possible condition, with a most satisfactory kind of wound, considering what has been accomplisht. A rubber tube is introduced into the bladder thru the wound and cut urethra, and packt around with iodoform gauze. Thru this the bladder is kept empty, and washt out every day, with boric acid solution. The drainage is not up hill as in the supra-pubic form, but directly in the line of gravitation. The wound is a simple median incision, of pyramidal shape, with base to surface. It is straight and accessible, no blind pouches, no opening into the bladder itself, and it is not contaminated by the urin. Of course this last applies only to the time the tube is in place. After the sixth, or seventh day the tube is removed, but by that time the surface is covered with granulations, the cystitis is very much

improved, and the danger of infection is practically past.

Now as to results: Dr. Jones of St. Mary's Hospital, at Rochester, where I took a patient for an operation of this kind last May, had operated on seventeen patients for this complaint without a death, all being cured. These patients' ages ran from 60 to 78 years, and Dr. Parker Syms of New York wrote me that he had operated by this method on 21 patients, all the way from 50 to 79 years, without a death from any cause, either immediate or remote. All were cured of residual urin, all were able to hold their water, having no incontinence. Some have been able to go all night without rising, some have had to rise once. They were able to hold their water three or four hours during the day. Some of them were feeble old men, others were in good general health. There was no case of septic poisoning, no inflammatory reaction, no shock, no grave troubles of any kind. I, myself have treated at one time or another eight or nine of these cases in the past twenty years, and altho they were relieved, and helpt at the time, yet I must own to you that every one, except the one operated on last spring, are dead and buried, some of them years ago, others later.

My patient that was operated on as above stated was seventy-six years old, was taken first one year ago last March, with an attack of kidney and bladder trouble; had another during the summer of last year; got better and was all right again to all appearance, till March of the present year. He came to me at first with loss of appetite, said he had some pain down in pelvis, either in bladder or rectum-did not know just where to locate it. Liver and bowels inactiv. I gave him a dose of calomel and the usual treatment for kidney and bladder trouble. He got better and I was about to stop coming to see him, when one cold snowy day he went out and helpt his man shingle on an outhouse a little while. He was taken with a chill and sent for me. I found him in some pain, making a little water every few minutes. After a hot hip bath and some medicin he felt better, and I went home. At bed time a messenger came, saying he was in more pain, and wanted something to stop it. I sent down some gr. morphin tablets. In an hour messenger came back again saying "I must come down again myself at once. This I did and staid until he became easy, about midnight. In the morning I found the pain gone, and from then on no more morphin was required, but I found I had a case of absolute retention of urin. I drew his water with a catheter, and found it dark colored, bad smelling, bloody, and inclined to throw down a liyer of glairy mucus on the bottom of the basin.

From then on for ten days I was obliged to use catheter two or three times in each twenty-four hours. Washt out the bladder nearly every day with solution of boracic acid, in water as hot as he could bear it, till it came back clear, and used all the means in my power to relieve the retention and cystitis.

After the ten days had passed he began to make water partly without a catheter, and gradually got better. I found at this time that he was passing only about two-thirds of the water present in the bladder, each time he made water, because I could always draw about onethird as much more with catheter, if I had him lean over back of a chair, to allow residual urin to pass out. On making an examination per rectum I found prostate enlarged somewhat, and hard to the touch; not so large as I had felt in other cases but large enuf to account for symptoms. He said, "what is the matter with me, Doctor and what is it going to amount to?" I told him he had what was called enlargement of the prostate gland, and unless he would consent to go to the hospital and have it removed, it would be likely to cause his death in time. I said "this is the same complaint your brother had who died several years ago." He answered, "I will do whatever you advise me." I then wrote to Dr. W. B. Jones of Rochester and told him of my patient and his condition. That he was seventy-six years old, not very strong yet, had just been very sick. I said, "Shall I bring him soon or wait for him to grow stronger? His answer was this: "Your patient certainly needs the operation and if he is fairly strong at seventy-six it is safe for him to have it done. The operation as performed by Dr. Syms of New York and myself is entirely without shock." The patient, he said, sits up some every day after the first two days. It is safely performed upon men who would not recover from any other form of operation for the same difficulty.

So we went, reaching Rochester May 22. The operation was performed the next Tuesday, five days after. Time of operation seventeen minutes; prostate came out in two pieces, in all somewhat larger than a black walnut. The middle lobe was enlarged in such a manner that one part of it acted the same as a ball and socket valve which obstructed the outflow of the urin, but would push right out of the way of the incoming catheter. In twenty days he was back home again, doing finely. Doctor Jones advised me to irrigate bladder every day with sat. sol. boracic acid for a week, then every other day for a week. Pack operation wound lightly twice every day with bichlorid gauze, and balsam Peru. After that to use sound in urethra, once a month, for two or three months. In two weeks the operation wound

was healed, and cystitis cured. This was about the last of June. Since then I have used sound twice, examined twice for residual urin and found none. Has no incontinence; holds his water three or four hours during the day; gets up once or twice at night. Is flesht up, looks all right, works some, walks two or three miles a day without trouble. Had a bad cold once this summer, but no bladder symptoms declared themselves. In closing I wish to reaffirm my conviction that prostatectomy by the perineal route is the best and safest method of treating prostatic obstruction.

Tioga Center, N. Y. A. W. Post, M.D.

Drug Addiction.

Editor MEDICAL WORLD:-Recent issues of THE WORLD have contained somewhat extended references to the treatment of drug addiction, a subject in which I have long been interested, and have had experience of a practical nature.

Notwithstanding the oft-repeated assertion that the extent of drug addiction is being overestimated, and that the dangers to be feared from an increase of the same are more imaginary than real, it is, I say, nevertheless true that drug addiction, more especially that of opium, its alkaloids, and cocain, is today a cruel, merciless monster, whose almost relentless grasp holds in a thraldom infinitly worse than slavery, its legions of victims in all parts of the world.

The far reaching effects of this evil can scarcely be imagined, much less described, and only such as have seen promising young persons of both sexes gradually lose their ambition, their character, sacrificing their virtue and all that morality and religion teaches them to uphold and maintain, can understand the full import and extent of this great and growing evil. evil. It incapacitates the physician, defiles the sacred desk, sullies the ermin of justice, clouds the most brilliant intellects, and fastens its merciless fangs upon every class of people.

During the past two years I have been brought into contact with hundreds of slaves to various drugs. Morphin is undoubtedly more frequently used than any other drug, yet the number of cocain victims is appalling. The recent enactment by our Legislature of a law prohibiting the sale of cocain, more particularly aimed at the suppression of the sale of Agnew's and Birney's catarrhal powder, the labels of which plainly state that 2 percent of the powder is cocain, is a step in the right direction, but only the first. The infant almost "died a bornin'," for the second step, the enforcement of the law, has never been attempted. Wholesale druggists have given the information that the sale of cocain, or the powders men