COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD ««««« HX641 39263 RC899 .Ov2 1 906 a non-surgical treat RECAP THE LIBRARY OF THE ASSOCIATION OF THE ALUMNI i OF THE COLLEGE OF PHYSICIANS AND SURGEONS IN THE CITY OF NEW YORK SCHOOL OF MEDICINE OF COLUMBIA UNIVERSITY Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/nonsurgicaltreatOOover A NON- SURGICAL TREATISE DISEASES OF THE PROSTATE GLAND AND ADNEXA BY GEORGE WHITFIELD OVERALL, A. B., M. D, CHICAGO EOWE PUBLISHING CO. 1906. Copyright, 1906 BV EOWE PUBLISHING CO. CONTENTS PAGE Introduction : 7 Chapter I. The Non-Surgical Treatment of Diseases of the Prostate Gland and Adnexa 11 Chapter II. Acute Prostatitis 21 Chapter III. Subacute or Chronic Prostatitis 24 Chapter IV. Chronic Congested Enlargement of the Prostate 75 Chapter V. Seminal Vesicles 90 Chapter VI. Hypertrophy of the Prostate 114 Chapter VII. Neuroses of the Prostate 151 APPENDIX Chapter VIII. Electro-Physics, Electrolysis and Cataphoresis 175 Chapter IX. Electro- Physics — Continued 180 Chapter XX. High Frequency Current 208 CLINICAL CASES PAOB I. Chronic Prostatitis and Prostatic Urethritis... 64 II. Chronic Prostatitis and Stricture 66 III. Prostatitis 68 IV. Prostatitis and Epilepsy 69 V. Prostatitis, Vesiculitis and Urethritis 71 VI. Prostatitis, Vesiculitis and Urethritis 73 VII. Prostatic Enlargement; Melancholia 102 VIII. Prostatitis; Vesiculitis; Rectal Ulcerations... 103 IX. Enlarged Prostate, Cystitis 105 X. Chronic Enlarged Prostate; Vesiculitis; Cys- titis 107 XI. Congested Prostate; Rheumatic Arthritis 108 XII. Prostatitis; Cystitis; Rheumatic Arthritis.... 108 XIII. Prostatitis; Prostatic Calculi; Cystitis 109 XIV. Prostatitis; Cystitis; Calculi Ill XV. Urethritis; Sympexia; Hemiparesis 112 XVI. Enlarged Prostate; Cystitis 113 XVII. Hypertrophy; Catheter Life 137 XVIII. Hypertrophy; Cystitis; Proctitis 138 XIX. Hypertrophy; Cystitis 140 XX. Hypertrophy ; Catheter Life 141 XXI. Hypertrophy ; Paroxysmal Tenesmus 141 XXII. Syphilitic Prostatitis 143 XXIII. Incontinence; Paralysis 146 XXIV. Impotency; Prostatitis 147 ' XXV. Chronic Priapism ; Prostatitis 148 XXVI. Chronic Priapism 149 XXVII. Chronic Priapism; Prostatitis 149 XXVIII. Chronic Prostatitis; Melancholic Mania 158 XXIX. Insomnia ; Melancholia 160 XXX. Sciatica; Spermatorrhea 164 XXXI. Impotency; Pollutions 172 XXXII. Pollutions; Prostatitis 172 XXXIII. Paresis; Prostatitis 173 XXXIV. Hemiparesis; Prostatitis 174 XXXV. Hemiparesis; Prostatitis 175 XXXVI. Vesiculitis. Metastasis 208 XXXVII. Cystitis, Mctastatis 222 XXXVIII. Prostatic Alescess, Metastatis 225 XXXIX. Tumor in Bladder, Hemorrhage 227 iv ILLUSTRATIONS PAGE I. Relation of the prostate to the bladder 12 II. Front view of bladder, urethra, prostate, Cow- per's glands and openings of ejaculatory ducts and prostatic ducts 14 III. Rear view of the same organs 15 IV. The mesenteric and solar plexuses of nerves sup- plying the prostate, bladder, rectum, kidneys and bowels 17 V. The spinal nerves distributed to the perineum and external genitalia 18 VI. Subacute or chronic prostatitis, as common among young men 25 VII. A battery and cystoscope 46 VIII. Urethral applicators and electrodes 53 IX. Urethral applicators and electrodes 53 X. The application of urethral electrode 55 XI. The application of cataphoresis to the prostate through the rectum 57 XII. A chronic congested, swollen prostate, as com- mon among middle-aged men 76 XIII. Specimens of prostatic concretions 87 XIV. Rectal ulceration as due to chronic prostatitis... 91 XV. The position of the kidneys 93 XVI. The application of cataphoresis to the vesicles through the rectum 98 XVII. Electrode devised by the author 101 XVIII. An exaggerated form of prostatitis- complicated with senile hypertrophy 114 XIX. Enlarged prostate with "third lobe." 129 XX. Modification of the Bottini cautery 133 XXI. Application of the cautery to the indurated third lobe 134 XXII. The sciatic nerve and its branches as influenced by prostatic disease 163 XXIII. Bipolar rectal electrode 169 XXIV. Application of the bipolar electrode 170 XXV. Construction of a faradic battery 191 XXVI. Electro-physical apparatus and wall cabinet 206 v PREFACE TO THE THIRD EDITION. The exhaustion in less than a year of the second double edition of this work, the flattering criticisms of the medical press, and the almost universal commendations of the readers, evinces the fact that the little book has filled the void for which it was intended ; namely, to aid the general practitioner as well as the specialist in the non-operative treatment of all those chronic diseases of the urethra, pros- tate, bladder, vesicles, kidneys, and their complications; together with the neurotic and metastatic sequelae, almost invariable concomitant therewith, as a result of hidden gonococci or other causes. Having profited by the numerous letters of inquiry from the readers of the former editions, I have endeavored in revising the present one to make so clear, and demonstrate so thoroughly my methods, that most any intelligent physi- cian may be enabled to successfully carry them out, pro- vided he is thoroughly equipped, conversant with the im- plements and has thorough knowledge of the pathology and complications of these troubles. While simplicity, plain illustrations and explicit demonstrations may not be necessary for some, yet there are many others, as betokened by their letters, who require such explanation. Thorough elucidation and demonstration, even to the point of sim- plicity, should not impugn the intelligence of any physi- cian. There has not been a year during the past twenty-five that I have not improved my methods of treatment in PREFACE TO THIRD EDITION. some way over each preceding one ; yet, the results obtained of late in the diagnosis and non-operative treatment of these troubles justifies the statement that greater strides have been made during the past year than for many years previously thereto. All these late improved methods, to- gether with the older ones, are thoroughly elucidated in this edition. The first of the late instruments to which I shall call attention is one especially devised for the general practi- tioner, as well as the specialist ; for the purpose of diagnos- ing and treating, in the simplest manner possible, all local- ized lesions of the urethra, from the meatus to the prostate and even within the neck of the bladder. It is an instru- ment that is less complicated and can be manipulated with greater facility and less local disturbance than any other equally efficient device. While I have several urethral endoscopes and cystoscopes, yet I use this instrument twenty times to that of illumination once. I have never used it with a physician or in the presence of one, that he did not note its marked simplicity and utility and ask where he could procure the instrument. In fact, many have remarked, "It is strange it has not been thought of before." When properly used, and with a specially indicated rem- edy, it dispells the bete-noire of gleet, as it enables the physician to locate the seat of the trouble and abate it. In connection with the instrumental treatment, I give in detail the drugs, together with their different strengths, which I have found by experience to be most suitable to individual cases. It is described and illustrated on pages following 64. My second equally efficient instrument is a specially devised mechanical vibratory massage apparatus. It can best be appreciated when practically demonstrated. It is especially indicated in chronic vesiculitis and prostatitis, PREFACE TO THIRD EDITION. atony of the bladder, prostate and contiguous organs. It is also indispensable in impotency that persists after pros- tatitis and vesiculitis have been relieved. While it is a potent agent alone in the treatment of these troubles, yet its efficiency can be greatly enhanced when indicated by connecting thereto a specially selected electric current; where one is thoroughly familiar with the properties of the latter; otherwise, it would be better not to attempt their conjoint use. Described and illustrated on pages following 102. The third is a thorough delineation of my method of applying the electro-cautery through the cystoscope to a tumor, vegetative growth, or rebellious ulcer at or around the neck of the bladder or prostate. By this method, one sees what he is doing and does not operate blindly. He can remove the cautery as often as desired, with the cysto- scope remaining in position, and note the result, or how much has been accomplished and when to discontinue. By this method there is absolutely no danger of hemorrhage, as it is thoroughly under control of the operator. Secondly, in those cases where the third indurated pathological lobe, which forms at the neck of the bladder, serving as a valve to obstruct the outflow of urine, can be removed, unless it has become too large, when the knife alone must be re- sorted to. As described and illustrated on pages following 136. Fourth, a more thorough explanation of the uses of the high frequency current in the treatment of these troubles with my specially devised instruments and apparati. In this current we have an agent the properties of which are inestimable in allaying acute inflammation and irritation; and is a positive and harmless germicide, especially indi- cated where the micro-organisms are deepseated and out of reach of ordinary lethal agents. PREFACE TO THIRD EDITION. In the second or last edition of the book I made only brief reference to the uses of this current up to that time. Since then I have had more extensive experience and have noted more carefully the use of this current, not only in the relief of pain, the diminishing of congestion, and allay- ing of nervous irritation, but I have carefully investigated its bactericidal properties. These latter are indisputable, not only with reference to the treatment of these diseases, but they have been reported extensively by other operators, and the germicidal properties are now too well established for refutation. In fact, the observance of this has been so noted in European countries, Germany more especially, that many have gone so far as to make claim that it is destructive to spermatozoa, and precautions have been established in many hospitals as a preventative of this. It is believed by some that its effect in this direction is per- manent, and men are rendered sterile thereby. My own investigation along this line during the past year has demonstrated that it is only temporary in its effect, and that the germs become permanently inactive and cadaverous more from the diseased condition of the gland than from the effect of the current. Other observers along this line corroborate this view. I wish to add just one word of caution regarding the uses of the different electric currents. While there are no more efficient auxiliary remedies in the whole range of therapeutic agents in the hands of those thoroughly familiar with their properties, yet to one not so versed it is better to leave them alone. At times a novice may make some most 'Tiappy hits," to be followed, probably in the next case, by irreparable damage. The late Prof. S. W. Gross, a most talented G. U. surgeon, in his work on Sexual Diseases of Men, pages 57 and 58, lauds highly both galvanism and faradism in these chronic troubles ; but mentions a case of superation of the testicles, terminating seriously, from injudicious galvanic treatment. Ultzman, one of the leading G. F. specialists of Ger- many, also commends in high terms the use of these cur- ix PREFACE TO THIRD EDITION. rents in the treatment of these diseases. He, too, cautions the inexperienced in their use, as much harm may result therefrom. I do not wish to be understood as' condemning the use of the knife in all cases and under all circumstances, for such is not the fact, as there are many cases where the knife is indispensable; but what I do claim, and, in fact, am corroborated in this view by many of the most expe- rienced and conservative surgeons of today, is, that the reckless use of the knife is resorted to much too often. I was much gratified in noting in the late edition (1905) of Prof. Keyes, in my opinion the leading G. U. surgeon of America if not in the world, where he comes out boldly in condemning too frequent operations and the too frequent use of instruments. I have been alone in fighting this barbaric instrumentation for the past twenty-five years, claiming it to be unscientific and capable of exerting much harm, especially in the deep urethra and upon the prostate and neck of the bladder; more especially in the hands of inexperienced operators. Dr. Keyes, like myself, must have observed many cases of irreparable damage to have brought forth the following statement : • (Page 288, 1905.) He says: "Twenty years ago no one operated upon the hypertrophied prostate. Today every surgeon approaches this organ with a knife or a cautery in his mind if not in his hand. The mass of literature upon this subject is appalling. Every one operates ; every one writes; every one defends his own views in his own way, and the result is that the varietv of operations almost equals the number of operators. * * * On one point only do they all agree implicitly, if not explicitly, viz., the prostate may not be operated upon with impunity." * * * On page 138 he says: "Harmful Treatment. — Finally, I have found certain methods of treatment harmful, and as several of them are constantly employed, I venture to record my objections. * * * "1. Sounds and dilators I object to absolutely. The massage and pressure of these instruments are beneficial in chronic anterior urethritis almost always, in prostatic hyperesthesia and congestion often, in simple posterior urethritis rarely, in gonorrheal posterior urethritis never. PREFACE TO THIRD EDITION. "2. Urethroscopy I object to on the same ground. The mechanical injury wrought by these instruments outweighs all the benefits they bestow." I could quote numerous other authorities in condemna- tion of the injudicious use of the knife and instrumenta- tion, but deem it unnecessary at the present time of the reign of conservative censure. During the past decade chemistry, the microscope and germ cultivation have incontestably demonstrated through- out the world the formidable character of the latent gono- cocci in perpetuating various chronic troubles of obscure nature, for many years after the prime infection. The prostate and seminal vesicles being their most common hiding places, are inaccessible to all other means known to the profession, except those described herein. While most all the instruments and modes of treatment described in the book can be used independently of elec- tricity with marked benefit and even to cure the majority of cases, yet with one thoroughly conversant with the uses of the different electric currents, much additional benefit can be accomplished. There is a debit and credit system to all treatment, and one should endeavor always to make the credit prepon- derate over the debit until cure is effected. In the use of sounds, dilators and endoscopes, in the hands of the majority of physicians, harm preponderates over the bene- fit. But where a positive diagnosis is requisite, all acute inflammation should be allayed ; then the cystoscope can be used tvitli impunity. Gonorrheal metastases being so inti- mately associated with chronic diseases remote from the seat of infection a physician is not justified in making a diagnosis until he has examined the prostate and vesicles. Synovial membranes, sheaths of nerves, and serous mem- branes are especially marked for gonorrheal poison ; al- though there is no part, from the top of the head to the heel, immune to its ravages. Dr. Clark, of ISTew York, in a recent article in the New York Medical Journal, claims that gonococci has invaded practically every tissue of the body and that no class of society is free from it, and that seventy-five per cent of the adult male are affected. He also holds that PREFACE TO THIRD EDITION. chronic prostatitis, sexual neurasthenia and other compli- cations result from this infection. In comparison to syphilis he places gonorrhea 100 to syphilis 1 — in number and gravity. I have recently noticed where a prominent G. TJ. special- ist has made the absurd statement that 10 per cent of all cases of prostatic enlargement over 50 is cancerous. I wish to state that not one-half of one per cent of cases that come under my observation are cancerous. It is, in my opinion, as I have stated in the main text of the book, that it is those chronic ulcerated conditions that they are unable to cure that are diagnosed either cancerous or tuberculous. The trouble lies in their being unable to reach and destroy the gonococci concealed within the pros- tate or vesicles, and as a result the micro-organisms con- tinue to pour out their poisonous virus into the gland and prostatic urethra, perpetuating the inflammation and ulcer- ation simulating cancer. These are the class of cases that I like to set for treatment. I shall state in this connection that an erroneous impres- sion prevails that I either have my instruments patented or control their sale. Thev are not patented, and any one can make or have them made as well as myself. I had some made for my own use and at the same time a few for others of mv friends. While I have not one dollar of interest in any instrument house, nor do I get one dollar of percentage for a single one of mv instruments sold, yet to avoid answering the numerous letters of inquiry of, "Who makes my instru- ments?" I embrace the opportunity of stating here that the Betz Co., Hammond, Ind., make them. I wish also to state that I can conscientiQusly recommend their _ Wall Plates, as I have of late made a thorough examination of them. In conclusion, I beg to state that I have labored hard and earnestly in an endeavor to master, in so far as pos- sible, the treatment of these formidable diseases and com- plications without having to resort to the knife. I have compiled, in this little volume, the results of more than a quarter of a century's work for the benefit of the profession directly, and the numerous sufferers indirectly, as I know of their manifold transgressions. INTRODUCTION. '^^^J' ''^^i In presenting this book to the profession, the author has, by avoiding theoretical discussion, endeavored to give a plain, practical and concise summary of the methods and results of the non-surgical treatment of Diseases of the Prostate Gland and their sequela? as demonstrated by more than twenty years of clinical experience. Some of the matter contained herein has heretofore appeared in the "Mississippi Valley Medical Journal" of March, 1883, and August, 1887; "Medical Mirror" of April, 1896, and the "Journal of the American Medical Association" of January 21, 1899, etc. A little over a quarter of a century ago the author completed his course of medical instruction under two of America's greatest surgeons, viz.. Professors S. D. G-ross and Joseph Pancoast. The teachings in vogue at that time (and there has begn little improvement since) re- garding the treatment of prostatic diseases were with sounds, the knife, the Bottini cautery, etc. Having fol- lowed the teachings of these eminent surgeons for some years thereafter with very unsatisfactory results, I began experimenting with local and constitutional medication, electrolysis and cataphoresis, with varied results. At times I would have the most "Tiappy hits," to be followed by an egregious failure. From time to time I devised and per- fected instruments with which to apply the combine! properties of medicines, electrolysis and cataphoresis for the purpose of stimulating vaso-motor contraction, reliev- 8 INTRODUCTION. « ing thereby congestion and inflammation, dissipating morbid tissue and chemically decomposing or breaking up lime or earthy concretions that form in the ducts and follicles of the prostate. I do not wish to convey the idea that I limit the treat- ment entirely to medicines, electrolysis, cataphoresis, etc., as there are some few eases in which the use of the knife becomes indispensable. I am fully aware of the incredulity of the profession regarding electrolytic treat- ment, since electricity has been so long in the hands of empirics. It is also true that electricity, like most potent therapeutic remedies, has been no exception to the rule of having had over-enthusiastic advocates who, at first, when its principles were little known, and before it had been placed upon a systematic basis, claimed for it properties beyond its field of utility, and would supplant therefor every other mode of treatment. There are others who, from lack of knowledge of the science of electricity (due to the fact that it was not taught in the medical colleges at the time they graduated), are prejudiced against its use in any form or for any purpose. They are content to grope in the old, beaten path, how- ever unsatisfactory may be the result. I regret to have to state that the large majority of works published upon electro-therapeutics are based upon theory or are mere compilations, unreliable in their teach- ings. Dr. S. H. Morrell in the "Times and Eegister," March 16, 1895, on "A Plunge into Electro-therapeutics," gives some wholesome advice to beginners, which thor- oughly accords with my views. He says: "If you wish to acquire skill in the use of electricity, don't set about it alone and don't rely on what you find in text books. If you can induce a reliable expert to take you as a student for a few months, do so, no matter what it costs. As INTRODUCTION. 9 there are various branches of electrical work in which special technique is employed, for instance, in genito- urinary and gynecological practice, you should obtain a short course of practical instruction in each. When you have devoted six months to an apprenticeship of this kind you will have laid the foundation for ultimate success." While the use of electricity is harmless in the hands of competent and experienced operators, yet I have seen some serious results follow its application, even by intelligent and prominent physicians who were not familiar with the principles of electro-physics and methods of electrolysis. It requires experience and tact as well as knowledge to succeed in the treatment of these complicated diseases, Just as it does in any other line of special practice. In brief, I shall state that after many years of research, I have been enabled to devise both ways and means by which to reach directly the seat of the disease. The past decade has been made memorable by the stand taken by some of our most distinguished medical and surgical teachers, in favor of conservatism against the indiscriminate use of the knife. Prominent among these I may mention the venerable Professor A. Jacobi of N"ew York, one of the most profoundl}^ erudite men in the medical profession, and whose experience extends over half a century in active practice. In an address delivered by him at the International Congress at Eome, April 4, 1894, on ^^Non-IsTocere" (Do no harm), he said: "The relative impunity of operative interference, accomplished hy modern asepsis and antisepsis, has developed an undue tendency to, and rashness in, handling the Tcnife. The hands take too frequently the place of brains. Who does not Jcnow that the alleged safety in operating tempts some of our skilled operators and the credulous public into use- less, or even contraindicated procedure?" 10 INTRODUCTION. In the dedicatory address delivered in the Senn Hall, December 17, 1902, by Sir William Hingston, Professor of Clinical Surgery at Laval University, Montreal, he gave warning that the surgeon's knife may be used too fre- quently. In part he said: "The immunity with which the most formidable operaiions are now performed has given confidence — might I not say a recklessness, possibly — which renders the staying hand of the physician of priceless value. Especially is this true when, as it some- times happens, the inexperienced surgeon hurriedly resorts to a tentative operation to establish a diagnosis where one more experienced would see no reason for the procedure. T have more than once observed the meddlesomeness of a surgeon to he in direct ratio to the measure of his inex- perience." Damage once done to the prostate by the knife is irre- parable. "Better bear the ills we have than fly to those we know not of." George Whitfield Overall. Chicago, III., May, 1906. CHAPTER I. THE NON-SURGICAL TREATMENT OF DISEASES OF THE PROSTATE GLAND AND ADNEXA. Of the various classes of diseases from which men suffer, none is of more frequent occurrence, none has more baffled the skill of the physician, or tried the patience of the sufferer, than that of the prostate. The frequency with which this gland is affected has been variously esti- mated by genito-urinary specialists; some holding that from twenty-jfive to fifty per cent of men suffer from its disease, others claiming that it is an exception to find a man past forty with a healthy prostate gland. When we note the highly sensitive organization of the gland, its psycho-sexual relation, its exposed position to the bladder, rectum and seminal vesicles, and the fact that it is pierced by the urethra and ejaculatory ducts, and that, moreover, it is frequently subject to excessive tax or abuse, we cannot wonder at the frequent functional or organic diseases incident thereto, the various nervous disturbances arising therefrom, and, owing to its inacces- sibility, the obstacles to be overcome in its treatment. The prostate is a musculo-glandular organ enveloped in a fibrous capsule. It is situated at and embraces the neck of the bladder. It is about the size and shape of a horse chestnut, with its base directed towards the bladder and its apex in front. It lies upon the rectum, being separated therefrom only by loose fascia. Its transverse diameter at the base measures one and one-half inches, its antero- posterior diameter (which corresponds with the length of 11 12 PROSTATE GLAND AND ADNEXA. the prostatic urethra) is one and one-quarter inches, and its depth three-quarters of an inch. It consists of two lateral lobes of equal size. Some writers mention a third or middle lobe, but this is re- garded by most authorities (and it will be so considered by the author) only as a pathological condition. The urethra passes through the anterior third of the gland, though occasionally the posterior. Fig. I. Fig. I shows the relation of the prostate to the bladder and prostatic urethra. The floor of the latter is a very complicated and highly sensitive structure and bears an important relation to the gland, both from a functional ANATOMY OF THE PROSTATE. 13 Fig. II. (R. W. Taylor.) 14 PROSTATE GLAND AND ADNEXA. and pathological viewpoint. In fact, it is really a part of the prostate itself. In the center and longitudinal direction of the floor is a small eminence (9), the verumontanum, or caput galli- naginis. Somewhat in front and in the middle of this eminence is a small cavity, the utricle (11). On each side there is a slight fossa, into which the ejaculatory (10) and prostatic (12) ducts open. The floor of the prostatic urethra is the most sensitive part of the entire genito-urinary tract and is considered the seat of the sexual orgasm. It is subject to pathological lesion more than any other portion of the urethral canal, owing to its complex structure, and to the fact that it receives the irritative secretions of the prostate and semi- nal vesicles, when these latter organs are affected. It is, in fact, an index of no little importance to the condition of the prostate. The orifices of the ejaculatory ducts or utricle often become dilated when disease of the prostate or vesicles exists, and are liable to engage the point of a small instru- ment, in an effort to force an entrance into the bladder, and becomes arrested, when a larger instrument will pass over these orifices and enter the bladder with ease. Dr. R. W. Taylor, of ISTew York, gives two excellent illustrations of these organs in his late work on genito- urinary diseases. Fig. II gives a front view, showing the bladder and urethra opening upon the front surface : 1, the trigone and orifices of the ureters; 2, prostate and prostatic urethra; 3, bulb of the urethra with opening of Cowper's glands; 4, verumontanum with orifice of utricle; 5, open- ings of ejaculatory ducts; 6 and 7, openings of the pros- tatic ducts. ANATOMY OF THE PROSTATE. 13 Fig. III. (R. W. Taylor.) 16 PROSTATE GLAND AND ADNEXA. Fig. Ill gives rear view of the same organs : 1, ureters ; 3, ampulla; 3, seminal vesicles; 4, prostate; 5, Cowper's glands; 6, bulb or urethra; 7, membranous urethra. Beneath the fibrous capsule of the prostate is a firm band of unstriped muscular fibers surrounding the base of the organ and reflected downwards towards the apex. The same fibers radiate throughout the gland in the form of trabecule, forming meshes, through which the vessels and nerves ramify. Interposed between these meshes there are also numerous follicles that secrete a milk}^, alkaline fluid, which passes out through the prostatic ducts upon the floor of the urethra. The arteries are derived from the internal pudic, vesicle and hemorrhoidal, which are branches of the internal iliac. The veins form plexuses around the base and sides of the prostate, bladder and rectum, communicating freely with the hemorrhoidal, spermatic, dorsal vein of the penis and pampiniform plexus. Thus the organs from which they arise, namely, the rectum, spermatic cord, epididymis and penis, are brought into close physiological and patho- logical relations with the prostate. Passive congestion or stasis of the veins of the latter cause a clogging of the veins of the rectum resulting in ulceration or hemorrhoids ; or, when the spermatic veins are involved, varicocele follows. NERVES. The nerves supplying the prostate are very numerous and sensitive. Those derived from the sympathetic system are supplied by the hypogastric and pelvic plexuses, as illustrated in Fig. IV. A double chain of sympathetic fibers, as illustrated by Fig. IV, connect with the mesenteric, renal and solar plexuses, bringing the bowels, kidneys and stomach ANATOMY OF THE PROSTATE. 17 Pig. IV. (Quain.) 18 PROSTATE GLAND AND ADNEXA. specially into intimate relation with the prostate and other pelvic viscera. A large number of spinal filaments, arising mostly from the sacral plexus, though some from the lumbar spinal nerves, are distributed to the prostate and adjacent organs, and communicate freely with the sympathetic. Fibers of the latter may be noted by reference to Fig. IV, as passing to the great sciatic (cr') nerve, before it makes its exit through the sacro-sciatic foramen upon the hips. ■^ Fig. V. (Hirschfeld and Leveille.) Fig. V shows the numerous branches of the spinal nerves distributed to the perineum and external genitals, which also communicate with the nerves of the prostate and pelvic viscera. FUXCTIOX. The prostate is an important genital organ, possessing the triple function: a, of expulsion of semen by means FUNCTION. IS of the rhythmical contraction of its muscular fibers ; b, of being the nerve center of the orgasm; c, of secreting, through its glandular structure, a fluid essential as a vitalizing agent to the spermatic germs. It is in this gland that the pleasurable sensation of the orgasm is located; the sensation being synchronous with the expulsion of semen. It is by this gland that the physiological impulse to gratify animal nature is indi- rectly exerted through the sympathetic and cerebro-spinal nerve centers. In fact, the gland has been appropriately called the seat of the sexual brain. The intimate recipro- cal relations of the cerebro-spinal centers and the prostate are very marked, both in health and disease. In health, excessive mental exertion, as by close study or business cares, will lessen the sexual appetite; while violent emotions, as grief, fright or anxiety, will tem- porarily suspend all desire. Men are by nature much more sensually inclined than women; and when they cultivate libidinous impulses, and associate with prostitutes, are liable to indulge their sex- ual propensities to such an extent as to develop passions that may lead to grave moral vices, like excessive inter- course or masturbation, resulting in lesions of the prostate, or some form of nervous disease. Just as mental disturbances influence sexual conditions, so in like manner do diseases of the prostate gland cause such various forms of mental disorders as inactivity, de- pression and numerous other neurotic aberrations. I have especially noticed that men between the ages of forty and seventy, suffering from chronic prostatitis lose the keen mental activity they formerly possessed. Their perceptive and reasoning faculties become sluggish and inactive. Owing to the contiguous relations, the direct source of 20 PROSTATE GLAND AND ADNEXA. blood supply, and the intimate connection of the nerves of the prostate, bladder, seminal vesicles and rectum, disease of the prostate cannot exist any great length of time with- out causing either functional disturbance or organic dis- ease of the others. Besides, inflammatory disease of the prostate often arises from chronic rectal troubles. Engorgement of Portal Veins and Pampiniform Plexus. ( Semi-diaoramatic. ) A. Aff^endix lermiformis. B. Urinary Bladder. C. Colon- Ascending. C^. Coloji— Descending. I. Small Intestine. L. Liver and Gall Bladder. P. Pancreas. R. Rectum. S. Stomach. T. Testicle . In addition to an involvement of the various important nerves and plexuses of nerves, both of the cerebrospinal and sympathetic nervous systems heretofore illustrated, there is also a clogging or congestion of the veins of this region, especially those of the pampiniform plexus, as a result of engorgement of the veins of the prostate, bladder, and rectum. Plate Via illustrates these veins in a congested state of enlargement, or turgescence. The veins of the bladder, bowels, testicles and prostate being so closely connected that the clogging of one neces- sarily involves the others, and so dams up the blood cur- rent as to affect many of the abdominal organs ; hence, you have as a result, congested enlargement or engorgement of the hemorrhoidal, the spermatic, portal and hepatic veins. As a result of this engorgement, there follows torpid liver, disturbed stomach, at times gaseous eructations and other times an acid, nervous form of indigestion. The bowels, too, become sluggish with gaseous accumulations in colon and even small bowels. These organs are so closely re- lated to one another that trouble arising in one is readily transmitted to others. Perverted function of the liver is especially noticeable in disease of the prostate. Physicians writing upon this subject have noted that the liver has the property of con- verting uric acid into soluble urea; but when it becomes congested indirectly from long standing prostatitis, uric acid crystals accumulate in the gall bladder, causing dull pain in that region, or under the lower ribs on the right side. The bowels, too, become sluggish, necessitating the constant use of some medicine. The stomach is almost invariably involved in sympathetic relation and it is dosed ad nauseum, when, in fact, there is nothing directly the matter with it. When the physician locates and removes the cause of the trouble, the patient does not know he has a stomach. Functional disturbance of the heart is not infrequent from the same sluggish, inactive condition of liver, stomach and bowels, superinduced by the prostate and bladder as prime offender. 20a PEOSTATIC DISEASES. Diseases of the prostate gland will be considered under the following heads : ACUTE PROSTATITIS. SUBACUTE OR CHRONIC PROSTATITIS. CONGESTED^ ENLARGED PROSTATITIS. SENILE HYPERTROPHY. TUBERCULAR AND SYPHILITIC PROSTATITIS. NEUROSES OF THE PROSTATE. CHAPTEE II. ACUTE PROSTATITIS. This form of disease of the gland usually results from harsh treatment of gonorrhea, by means of strong injec- tions, large doses of copaiba, turpentine or cantharides, or from injudicious use of instruments. The gland swells very rapidly and is extremely painful. The inflammatory condition usually extends to the seminal vesicles, bladder and entire pelvic viscera, giving rise to marked pain in the region of the perineum, rectum and groins. Dysuria is excessive and is often attended with incessant tenesmus. The attack is usually ushered in with a chill, which is followed by njild pyrexia. The desire to void urine is frequent and uncontrollable, the patient passing but a small quantity at a time. The irritation is often « 21 22 PROSTATE GLAND AND ADNEXA. transmitted to the rectum, giving rise to a sensation of fullness, and a desire to remain at stool. The latter symp- tom is especially prominent when vesiculitis coexists. Orchitis often supervenes which greatly increases the dis- comfort of the patient. Treatment. — The treatment consists mainly in pallia- tive measures, by way of rest in bed, anodynes in the form of hyoscyajnus, opiates and hot hip baths. The diet should be light and consist mostly of demulcents, as of barley water, which is especially indicated ; soups and other light nourishment. All injections or specific medication should be discontinued. Urethral instrumentation is strictly interdicted, unless there are indications of retention of urine. Should it be necessary to evacuate the bladder by catheter, which is exceedingly rare, a full dose of morphia should be admin- istered half an hour previously thereto. Eectal supposi- tories of boric acid, belladonna and opium give great relief. The bowels should be maintained in a laxed condition by means of saline cathartics. In from five to fifteen days the urethral discharge is re-established, unless complicated with orchitis, and gen- erally becomes quite profuse. This is followed by defer- vescence and the subsidence of all acute symptoms. At this stage I advise the free use of a five per cent solution argyrol in distilled water, to be injected deeply into the urethra, from four to five times daily, with an ordinary large sized gonorrheal syringe having a blunt point. I never advise a long nozzled syringe, as it often serves to perpetuate urethritis near the meatus. This treatment readily relieves all acute symptoms. Should the discharge continue excessively and longer than a week, after the subsidence of acute symptoms, I ACUTE PROSTATITIS. 23 add one grain of sulpho-carbolate of zinc to the ounce of the injection before mentioned. When complicated by orchitis, rest in bed is imperative. Local applications of belladonna and hamamelis with cold applications to the swollen testicle give relief. Anodynes internally should be the chief remedies. All acute symptoms gradually subside under this treat- ment, leaving a chronic gleety discharge, which is a "flag" to indicate chronic inflammation of the prostate or vesicles, and will be considered in the succeeding chapter. CHAPTER III. SUBACUTE OR CHRONIC PROSTATITIS. This affection of the gland is one of the most common diseases with which young men between the ages of twenty and thirty-five suffer. It is quite distinct from chronic congested enlargement, common to men of middle age, and from senile hypertrophy. A strict boundary line, however, cannot be drawn, with reference to age, in any class of diseases of the prostate. There are occasionally cases of chronic prostatitis that occur earlier than the twentieth year, while others are met with even past thirty-five with- out there being any perceptible enlargement of the gland. Fig. VII illustrates this form of disease: the red parts indicating the sites of the lesions. In the earlier stages of the trouble the inflammatory condition is confined to the ducts and follicles of the gland, but when of long standing it becomes diffused and involves the entire organ. Ordinarily there is little or no swelling of the prostate; and the bladder, seminal vesicles and rectum are rarely involved, as is common in the other varieties of prostatic diseases. In some aggravated cases, however, the inflam- mation extends to the vesicles, ampulla, vas deferens, epididymis or the globus major and minor. When the latter are affected small worm-like lumps can be felt at each end of the testicle, which are usually tender to the touch. Congestion of the pampiniform and hemorrhoidal plexuses of veins almost invariably result: the former causing varicocele, especially upon the left side, while the latter gives rise to a swollen condition of the rectal mucous 24 SUBACUTE OR CHRONIC PROSTATITIS. 25 Fig. VI. 26 PROSTATE GLAND AND ADNBXA. membrane resulting in protrusion, ulceration or the for- mation of pile tumors. These conditions are sequels to prostatic inflammation and not idiopathic diseases; and the cause producing them should be remedied before treat- ing the symptoms, or all phases of the disease should be treated at the same time. ETIOLOGY. The most frequent cause of this form of disease of the gland is chronic gonorrhea, but it is not, as many physi- cians believe, the only one. On a liberal estimate, about seventy-five per cent of these cases are traceable to gonor- rhea as the source of the trouble, while twenty-five per cent are due to other causes. Moreover, it is not a fact that the gland becomes affected only by mal-treatment of gonorrhea, as is usually the opinion of the patient, who is often encouraged in this view by rival physicians, as he "goes the rounds." It generally follows treatment even by the most skilled physicians, and, too, in cases where the patient exercises the greatest care. Prior to the discovery of the specific germ, by Neisser, in 1879, for gonorrhea, which he christened "gonocoecus," the medical profession were very much puzzled as to the cause, tenacity and complications of this disease. Such early authors as Selle (1781), Hunter (1786), Fournier (1806), Ricord (1836), Foucart (1846) and Brandes (1854) claimed that there was a direct relation between gonorrheal urethritis and rheumatism that occurred in conjunction therewith. Guyon (1836) and Thiry (1856) advanced the theory that gonorrhea developed a latent rheumatic diathesis. Guerin (1846) and Laseque (1876) held that gonorrhea was a disease, sui generis, with a long period of incubation. Lewin (1878) advanced the theory that gonorrheal rheu- matism was due to reflex irritation from urethritis. SUBACUTE OR CHRONIC PROSTATITIS. 27 Bernultz and Noeggerrath^ long before the discovery of the specific coccus, held that chronic gonorrhea in men was accountable for many of the ailments in women, who never had a true gonorrhea and whose troubles could not be traced to any other source. Like most great discoveries, that of IsTeisser was no exception to the general rule, and was met with strenuous opposition, until confirmed by the investigations of Bumm, Baumgarten, Finger, and many others in rapid succession. I shall not discuss here the various means of scientific research leading to the final establishment of the fact, which is now recognized as a proven postulate, that the gonococcus is a facultative micrococcus (schizomycete), found free in the purulent discharge of gonorrhea and within the substance of the pus cells. The latter feature, together with the fact that it does not stain with iodine, are two of its most characteristic diagnostic points. Various diplococci are often present, so closely simulating gonococci that the different methods, as staining, culture gi'owths, etc., have all to be used before a definite differ- ential diagnosis can be established. The gonococci, in common with most of the other micrococci, are anerobie and thrive only in a neutral or alkaline medium, and at a temperature of from 30° to 40° C. They feebly resist an acid medium, and in such have an ephemeral existence. Paradoxical as it may seem, from the tenacious manner with which this microbe clings to its victim, it is a delicate germ and readily succumbs to the effect of many germicidal agents, when brought in direct contact with them ; but the gonococcus is so minute that it conceals itself within the pus cells, subepithelial cells, the lacuna of Morgagni, Littres glands, the prostate and vesicles, and is out of reach of germicidal remedies as ordinarily used. 3b PROSTATE GLAND AND ADNEXA. Up to the time of the discovery of the gonococcus the remedies in use were directed^ mainly in an empirical manner, tovrards controlling the purulent discharge, it being unknown at that time that the ptis cells carted away millions of the gonococci, which were the true source of the disease. Keersmaecker and Terhoogen (followers of 01>erlander) say, "the gonococcus is extremely sensitive to desiccation.'" >:. * * .-.j^ ^^ hidden in the depths of the tissues and is protected against destructive agents." The gonococci are first implanted, fostered and propa- gated at or near the meatus, in a medium and locality most favorable for their development. They multiply very rapidly, work their way along the urethra, and, in spite of all measures to prevent it, to the prostatic part; thence directly into the ejaculatory and prostatic ducts and fol- licles. The orifices of these ducts being open gateways, though their walls are in apposition, offer no resistance to the passage of the germs into the channels of the prostate and ejaculatory ducts, where they become hidden within the follicles of the gland, and are thereby pro- tected from destructive agents as applied through the urethra by the usual methods. The course is also an open one to the seminal vesicles and vas deferens, to which they occasionally gain access. The cylindrical epithelium of the urethral mucous mem- brane is the normal abode of the gonococci. Here they re- main active and aggressive, but after leaving this their indigenous soil for that of the prostatic and ejaculatory ducts, they become lethargic and do not wander xery far upon alien ground. Hence they usually do not pass further than the interior of the prostate. The authoritative estimate of the proportion of all gonorrheal cases where the germs invade the prostatic ducts SUBACUTE OR CHRONIC PROSTATITIS. 29 and follicles, is placed at from seventy-five to eighty-five per cent; those that invade the vesicles, at from twenty to thirty per cent; and the vas deferens from ten to fif- teen per cent. This is about the proportion as demon- strated by the author's clinical experience, though the late fad of stripping the vesicles would place gonorrheal in- vasion of the vesicles at a much higher ratio. Since it is a positive fact, as proven by various pathol- ogists in their examinations of prostatic expressions, that the prostate is the chief abode of the latent gonococci; authorities differ upon the subject as to whether the germs themselves subsequently penetrate cellular tissue and the walls of blood and lymph vessels ; or that they remain dor- mant within the prostate secreting toxins, which latter are absorbed by these vessels and carried to remote parts of the body effecting metastasis, as manifested by rheuma- tism, arthritis or neuralgic pains in various parts of the body. Lindeman, Young and others claim that the affected nerves and joints are the result of the gonococci carried to these parts by the blood currents from a lesion localized in the genito-urinary tract. Bumm, Baumgarten, Neisser, Bochart, Gerbardt and Hartley maintain that metastatic diseases of the joints and nerves are the result of mixed gonorrheal infection. Guyon, Janet, Furbringer hold that these diseases follow as a direct result of ptomaine poisoning from the invasion of the gonococci in the tis- sues. There are others who advocate similar views all tend- ing to the same result. The author concludes, after summing up the opinions as expressed by the numerous investigators along this line, and recounting his own investigations and clinical expe- rience, that metastasis is the result, in the majority of instances, of the toxins of latent gonococci that originate within the prostate as result of the secretion of the germs ; 30 PROSTATE GLAND AND ADNBXA. and it is only in those cases where an abrasion of tissue in the genito-urinary tract ensues that the cocci themselves enter the circulation and are carried by the blood currents to remote parts of the body. When the latter occurs and the cocci are deposited within the joints, nerves, etc., they readily die, as it is a proven postulate that they cannot live outside of mucous surface; and the disintegration of their cadavers intensifies local metastasis. Taking either view, however, the question of vital im- portance is ]3ractically the same; which is, that the germs are concealed within the prostate, vesicles, or urethra, and if the gonococci can be destroyed in these organs, it stops the generation of toxins or destroys the germs themselves, as the case may be, and subverts their entering the sys- tem. Clinical experience has convinced me that both of these views are correct. However, the metastatic diseases are much more often the result of the toxins eliminated in the prostate, than due to the presence of the gonococci them- selves in the tissues. The latter condition rarely, if ever, exists unless there is some marked abrasion in the mucous lining of the urethra, prostate, or vesicles. Many observers have reported the discovery of diplococci resembling closely gonococci, and, too, that would decolor- ize by Gram's Method, and where cultures would produce a urethritis of three or four days' duration but not a true gonorrhea. The writer has noted many similar cases, from clinical observation, and has been thoroughly convinced that these germs are non-virulent gonococci, rendered sterile by their having remained dormant for so many years within the prostate or vesicles. During an acute exacerbation of prostatitis, causing ex- cessive discharge within the urethra, these latent cocci are swept along with the discharge "knd at times set up a ure- SUBACUTE OR CHRONIC PROSTATITIS. 31 thritis of short duration, but they lack sufficient vitality to create a true gonorrhea. But, should the cocci enter the blood current, phagocytosis would be the most probable re- sult ; or, coupled with the lethal effect of blood serum upon the germs, they could scarcely escape destruction. More- over, it is an indisputable fact that gonococci cannot live except within a mucous membrane, and, should it be pos- sible for them to escape the destructive agents before men- tioned, in their transit along the blood currents, it would seem impossible that they could live sufficiently long, out- side of a mucous surface, to effect metastatic pathogenesis, except by poisons resulting from their death and decay. I dwell upon this point at some length because the ques- tion is an important one and one that is presented almost daily in active practice, in regard to obscure chronic dis- eases. Should these germs be carried to various parts of the body, and, if it were possible for them to live indefinitely as they do within the mucosa of the prostate, but few who have had gonorrhea could withstand their ravages. Be- sides, it would be impossible to reach them, if scattered over the entire body, with destructive agents that would not prove fatal to the patient. The columnar epithelium of the mucosa within the prostate being in closer anatomical relation to that of the urethra, serves to perpetuate the lives of these germs better and longer than other mucous surfaces, though they do not propagate therein. The mild alkaline reaction of the pros- tatic secretion also ministers to the maintenance of their lives. Clinical results following the treatment of the prostate, together with frequent examinations of the prostatic ex- pressions, have convinced me that the prostate is the chief abode of the latent gonococci. I have traced, in numerous 32 PROSTATE GLAND AND ADNEXA. instances, the origin of remote arthritic and neuralgic pains indirectly to the prostate, by destroying the hidden germs within the gland, which were evidently the fons et origo malorum, and which was evidenced by the imme- diate disappearance of all symptoms. The destruction of the gonococci within the prostate having suppressed the generation of the toxins, and the poisons being no longer carried through the lymph and blood channels to the tis- sues, all pain would disappear and recovery would be rapid. On the contrary, were it probable that the gonococci had lodged and remained alive, within the Joints and other tis- sues, instead of their toxins, local treatment of the prostate would not relieve the condition, and it would be impossible to do so where polyarthritis existed. Serous and synovial membranes and nerves are espe- cially marked for the morbific effects of the toxins of gonococci. The pathological changes that occur as denoue- ment of the toxins, in the joints and serous cavities pro- duce conditions favorable for the development of diplococci or streptococci, that closely simulate gonococci; which have given credence to the extensive migration of the lat- ter. Owing to the tenacious sequels of gonorrheal infection, and the metastasis resulting therefrom, it is the opinion of many physicians that, when one once has gonorrhea, it is never entirely eradicated ; and that it is attended with greater fatality than syphilis. The latter view is generally conceded, taking the sequels of gonorrhea into considera- tion. Prostatic expressions have shown gonococci to be pres- ent in the fluid, thus forced out, for many years after complete subsidence of all gonorrheal symptoms. Some writers have discovered latent gonococci in the gland as long as sixteen years after having had an attack. SUBACUTE OR CHRONIC PROSTATITIS. 33 The past decade has been prolific of much research as to the habits, life and pathogenesis of these germs, which has been the means of revealing obscure diagnosis in many instances; and especially since the discovery of their hid- ing place in the prostate. Furthermore, these germs may remain dormant secret- ing toxins that penetrate and maintain an inflamed pros tate, but not effect metastasis for a long period, yet cause reflex neurotic disturbances. When the gonococci have entered the prostate, they begin the secretion of toxins, which at first cause suba- cute, then chronic inflammation of the follicles and ducts, and subsequently parenchymatous affection of the entire gland; the result of which maintains a constant muco- purulent discharge tliat is poured out upon the floor of the prostatic urethra. This secretion must necessarily pass along the canal toward the meatus. The discharge may be so slight as to appear only as the "morning drop," or it may become desiccated by the warmth of the urethra, and noted only by gluing together of the lips of the meatus ?n the morning; or it may even escape observation alto- gether. Then again, the discharge may become quite pro- fuse at times as influenced by excitation, as by dissipation or other causes, and continue, regardless of all injections, sounds or other caustic applications to the deep urethra, or constitutional medication; as such treatments do not penetrate the ducts to reach the seat of the trouble. The gonococci may remain hidden within these deep tis- sues for years in a latent state, unless, by certain irrita- tive conditions, as induced by "haclio et venere" when a conious prostatic discharge is excited, and the germs are cff"^ried by the excessive secretion into the urethra, where they may become auto-inoculable, and set up a fresh al- though mild attack of gonorrhea, or a plain urethritis. 34 PROSTATE GLAND AND ADNEXA. It has also been demonstrated by Oberlander, Verhoo- gen. Finger and others that these germs may remain dor- mant for three or six years, or even longer, when, under certain conditions, they may become aroused to activity and manifest their pathogenesis ; though not in as virulent form as the prime attack. Numerous instances have come under the author's observation where, even among married men, unmistakable evidence of latent gonococci had been aroused to activity, developing an acute urethritis which could not be traced to another origin than that of auto- inoculation. OTHER CAUSES. During erotic excitement, whether normally or abnorm- ally, the prostate becomes hyperemic, either synchronously with or independent of penile erection. If this excite- ment is unduly prolonged, by toying with women, indulg- ing continuously in libidinous thoughts, association with prostitutes, masturbation, continence or excessive inter- course, it causes venous stasis or congestion of the gland, resulting ultimately in subacute or chronic prostatitis; which readily extends and involves the prostatic urethra and adjacent parts. This condition provokes a prostatic discharge similar to that of gleet and is often mistaken for such. This discharge being poured out within the urethra, induces prostatic urethritis in the same way as that of the toxins of gonorrhea, and which may extend the entire length of the urethral canal, rendering it tender and supersensitive. Many times have I known such con- ditions treated many years for gonorrhea, when there were no indications of the latter. It is somewhat difficult to define just what consti- tutes excessive sexual indulgences, as individuals vary so much in their physical organism and sexual propensities. SUBACUTE OR CHRONIC PROSTATITIS. 35 That which would be excessive and injurious to one man, might not be to another. Masturbation. — In addition to its local baneful effect upon the urethra and gland masturbation is attended with an excessive drain upon the nervous system, and is, con- sequently, more apt to provoke some form of mental dis- turbance, owing to the absence of the natural psychical stimulus of the opposite sex, than by the normal act. The evil effect of masturbation upon the prostate and vesicles primarily, and the nervous system secondarily, has been over-estimated by many, and treated with too much indifference by others. The fact of the almost uni- versal practice, at some time of life, among males, renders it a convenient source to which to attribute all the sexual and nervous diseases, not traceable to that of gonorrheal origin. Charlatans reap a rich harvest among youths and, too, older men, who, being over-sensitive, are too prudish or secretive to consult their family physician and fall an easy victim to their tenets and ruse. The family physician, too, is often accountable for this, by not making a thor- ough examination of the case when consulted, treating the matter with too much indifference, dismissing him with a tonic, or telling him it is "all in his head." The fact is that most of those addicted to the habit are so ashamed of it, that they will deceive the physician, in the large ma- jority of instances, by denying the practice altogether, or minimize the extent of indulgence so as to mislead him. Objective symptoms alone, as revealed by an examina- tion, can determine the extent of the lesion as induced by the vice. I place but little credence in what one says about the frequency or length of time he Tiad indulged (as they all say they have quit now). Phimosis or an elongated prepuce often serves as an 36 PROSTATE GLAND AND ADNEXA. exciting cause, both towards precipitating and perpetuat- ing the habit. The late Dr. S. W. Gross attributed the be- ginning and continuance of masturbation as due largely to the redundant foreskin. The deleterious effects resulting from masturbation are not due to the loss of semen, but to the nervous shocks and the local irritation to the sensitive urethra, prostate and vesicles, causing a congestion of these latter two or- gans; and a subsequent disturbance of the cerebro-spinal nervous sj^stem. While excessive sexual indulgence is de- pressing to the nervous and ph5^sical organism, and causes congestion and inflammation of the sexual organs, yet it is devoid of the nervous shock that attends the unnatural manner, as well as the local irritation resulting therefrom. The latter jDrovokes more frequent repetitions of the act. Opportunity, too, also favors frequent indulgence, and the sexual organ that suffers most is unquestionably the prostate gland. Cold weather or wet feet aggravate all conditions of the prostate and bladder, and it is often the case that one affected with chronic prostatitis is comparatively comfort- able through the summer, but begins to suffer on the ap- proach of cold weather. Then again one may have been conscious of the .existence of some form of bladder trouble for 3'ears, but of not sufficient gravity to consult a phy- sician, until having gotten his feet wet, or exposed to se- vere cold weather, when an acute attack is precipitated. All forms of prostatic diseases are subject to acute ex- acerbations and violent instrumentation; strong injections within the deep urethra, large doses of turpentine or can- tharides often provoke an inflamed condition of the gland. Horseback and bicycle riding are etiological factors of no small importance, and especially when the gland is al- ready tender or when there are other excitant causes. The SUBACUTE OR CHRONIC PROSTATITIS. 37 pressure of the saddle upon the perineum, and the jolting of a misstep of the horse, or by a rough road for the bicycle, is exerted upon the deep urethra or prostate. Many men, suffering from prostatitis, have told me that they had observed the ill effects of a ride upon their wheels. Continence. — A knotty problem, that' often arises in the treatment of diseases of the prostate, relates to the effect, that totally refraining from sexual congress, has upon the gland of robust persons not in position to nat- urally indulge their sexual propensities. As before stated it is a fact, recognized by all leading genito-urinary spe- cialists, that the prostate in all healthy men normally be- comes hyperemic during erotic excitement; and it is in accordance with natural laws, that such excitement occurs at certain intervals, regardless of whatever moral or persuasive influence may be exerted to the contrary. While this state may be greatly mollified by one's habits, and by surrounding influences to divert the mind in channels of chaste morality; yet the intrinsic excitation, as exerted by the sexual organs, in performing their normal functions, is transmitted to the sexual brain or nerve center, which, in turn, excites hyperemia, especially in the prostate gland and penis. This local congestion or nervous excitation can be controlled for a time without injury either to the gland or nervous system; but by continual recurrences of sexual erethism, engendering the accumulation of semen, over- distending the vesicles to the extent of causing discom- fort, and producing continuous prolonged prostatic hyperemia, finally results in congestion, irritation and in- flammation ; and, by reason of the highly sensitive nervous organization of the gland, and the reciprocal relation it bears to the sympathetic and cerebro-spinal nerve centers, various nervous disturbances of the latter are produced. I have had under mv observation several cases of chronic 38 PROSTATE GLAND AND ADNBXA. priapism and different forms of neurotic aberrations, evi- dently due to continence as the prime cause, and resulting eventually in chronic prostatitis, and all the attending sequels incident to the disturbance of the sexual organs, and nervous disorders. There are others where the surrounding influences, united with lascivious readings, libidinous thoughts and the intrinsic excitations of the normal functions of the or- gans, produce chronic sexual and nervous disturbances at a much earlier date and in a more aggravated form. For this reason I have usually much less trouble in treating married men than single. Age, vocation and physical condition must also be taken into consideration. It is not difficult for a man past thirty, of delicate physique and whose business involves mental exertion totally at variance with any lascivious im- pressions, to abstain from sexual relations for an indefinite period without injury resulting from violating natural laws. But in the case of a young man of robust health, whose occupation requires but little mental exertion, and whose surroundings and associates tend to excite lust, con- tinence would cause much prostatic irritation, congestion and inflammation. Alcoholic stimulants of all kinds tend to produce erethism and congestion of the gland and should be avoided. Beer and wines have particularly a baneful influence. SYMPTOMS. In most cases the symptoms are common in many re- spects to those of stricture of large calibre, localized urethritis, vesiculitis, or chronic gonorrhea; or all these may coexist. In many instances these are apparently free from any disease of the sexual organs, and are manifested by mental depression, lack of confidence, melancholia, im- SUBACUTE OR CHRONIC PROSTATITIS. 39 potency, nervous dyspepsia, impaired memory or insomnia. The eyes are usually dull, and often become so disturbed as to necessitate consulting an oculist. Dysuria is rare unless complicated with stricture, gran- ular urethritis or vesiculitis. In fact the urine being normally an aseptic fluid resists the development of pathogenic bacteria, although as many as thirty varieties of non-pathogenic bacteria are often present therein. GLEET. A slight continuous discharge is a prominent symptom of prostatitis. It unquestionably signifies the presence of a pathological lesion in some part of the genito-urinary tract. The origin £ind source of this discharge has been the subject of much comment and investigation, as well as diversity of opinion among genito-urinary specialists. The fact that such a discharge does arise from some ulcerated, granular or inflamed surface is indisputable; and the urethra, being the most favorable site for such, has suffered the burden of caustic applications and operative procedure. The writings of Dr. Otis, some years ago, attributing this discharge to infiltration, coarctation or stricture of large calibre, was followed by rash and indiscriminate cut- ting of the urethra for almost every conceivable trouble of the genito-urinary organs. Dr. Fuller states in his book on "Disorders of the Male Sexual Organs," that "as a re- sult of Dr. Otis' writings on strictures of large calibre, he had seen cases that had been cut for pus in the urine, which were of pelvic origin. He also reports a case having come under his care that had been cut seventeen times for stric- ture, when the cause of the suffering was vesiculitis. The author has seen quite a number of cases that had been operated upon two or three times for stricture, where 40 PROSTATE GLAND AND ADNEXA. there were no indications of such, but whose symptoms were due to prostatitis or vesiculitis, causing a constant gleety discharge. While the author thinks the criticisms of Dr. Otis' teachings are, at least, in part justifiable, yet any one hav- ing read Dr. Fuller's book, before mentioned, would infer that urethral discharges, as well as sexual disorders, were traceable almost exclusively to vesiculitis. While the title of his book is "Disorders of the Male Sexual Organs," yet I shall state that, with a conservative estimate, at least five-sixths of its contents is devoted to vesiculitis and a stripping of the vesicles. To state that the latter has be- come one of the fads of today is placing it mildly; and I shall venture the assertion that it will soon drop into as utter disfavor as that of the Dr. White's castration en- thusiasm as advocated a few years ago. There are others who are ready to accredit most of these symptoms to chronic urethritis. The book of Keersmaecker and Verhoogen, on chronic urethritis, is an excellent treatise upon the subject, and especially from a diagnostic point of view, evidencing extensive research, yet it appears that too much stress is placed upon local lesions of the urethra alone. Gleet is not a disease per se, but a symptom of an exist- ing lesion, and while it is generally understood to be a sequel of gonorrhea, yet scant discharges from the urethra occur from other causes so closely simulating it, that it is difficult to draw a marked line of distinction. The writer considers that when a persistent urethral discharge, mild in character, resists all urethral treatment it is symptomatic of prostatitis in some form. Vesiculitis may coexist, and the vesicles should be examined, but, as the large majority of cases of vesiculitis originate from the urethra, or prostate, whether due to gonorrhea, masturba- SUBACUTE OR CHRONIC PROSTATITIS. 41 tion or other causes, the infection or extension of the inflammation must necessarily pass through the prostate before reaching the vesicles, and hence must involve the former. It is therefore irrefutable that the prostate, being in closer proximity to the urethra, and owing to its ex- posed position to the bladder, is much more liable to be- come involved than the vesicles; yet the trouble, if of aggravated form, often extends and affects the latter. The urethra is still more exposed than even the prostate, and never escapes disturbance when disease of the latter has existed any great length of time; as the irritative dis- charge from the prostate or vesicles passing out into the urethra — their only source of exit — would eventually pro- voke urethritis; and upon examination, one finding a sensitive or inflamed canal, infers that the trouble was confined to the latter instead of the prostate. In fact, urethritis is often the most prominent subjective or ob- jective symptom. It is evident, therefore, that by treating and relieving the urethra for the time only, the symptoms would recur, and continue to do so until the prostatitis or vesiculitis was cured. The patient continues to return and report the same "morning drop," or forked stream, as indicating the gluing together of the lips of the meatus, as result of the drying of the discharge before escaping. This continues until the patience of both the patient and doctor becomes exhausted, and, to the great relief of the latter, the former goes to another physician, through the advice of a friend, with the same result — all dosing the urethra and stomach, as it is evident, that, by simply treat- ing the urethra, the trouble could never be relieved. Again, should the disturbance have originated in the urethra and extended to the prostate or vesicles, the same or similar symptoms would appear; which would necessitate the treatment of all three organs as before. Urethritis would 42 PROSTATE GLAND AND ADNBXA. be aggravated and perpetuated by the prostatic discharge. This chronic discharge has been the hete noire of the profession from time immemorial, since they have mostly confined their treatment to the urethra, or even should they realize its source, their means of reaching it have been inadequate. The urethra has withstood sounds, injections, cauteries and lavages for more than a century, and in many instances with some relief, but never cured. The objective symptoms reveal a red and often con- tracted meatus; as before stated the lips of which are frequently glued together, by the des iccated gleety dis- charge. Upon passing a bougie a boule the first tender point encountered is usually about six inches down the urethra, at the juncture of the pendulous with the membranous portion. Here there often exists an ero- sion, granular surface or probably a stricture. Should one of the former exist, without a stricture, the instru- ment may be arrested thereat, by the contraction of the muscular fibers, or external sphincter, due to local irrita- tion, as induced by the contact of the instrument with the sensitive point. The membranous part of the canal is quite tender, and the most favorable site for stricture, ex- cepting that part near the meatus. On reaching the pros- tatic portion of the urethra the instrument detects the most sensitive part of the canal, which imparts the feel- ing of roughness, indicating a granular surface over which the instrument passes. Juft as we regard the tongue as an index to the condition of the stomach, so in like man- ner do I consider the prostatic urethra symptomatic of the state of the prostate or vesicles. The instrument, if small, may enter the utricle and become arrested, or should the prostatic urethra be excessively sensitive the bougie may not pass on account of spasm; either of these condi- SUBACUTE OR CHRONIC PROSTATITIS. 43 tions may be mistaken for stricture, but it must be re- membered that an organic stricture never occurs in the prostatic portion of the canal. At times, when the urine is acrid, there is some diffi- culty in thoroughly evacuating the bladder. The irrita- tive effect of the urine upon the tender part of the canal causes a contraction of the circular muscular fibers of the urethra at that point, which subsequently relax and allow the passage of a few drops or a drachm of urine thereafter. Some have slight pain just as the urine starts, others at the close of urination, which is often attended with the sensation of still more to pass. The urethra, being the chief channel through which to reach the prostate for direct treatment, and often too, its local lesion provoking and maintaining prostataic affec- tions in many instances, must necessarily receive especial attention in the consideration of any form of the prostatic disease. The secretions of the prostate or vesicles, passing over the urethral mucosa, produce certain pathological changes. These changes are not uniform throughout the canal, but are generally confined to localized patches, where the epithelial coating loses its smooth, moist surface and becomes rough and hyperemic or granular. The most favorable site for these patches is the prostatic urethra (which never escapes involvement), the bulbo-membra- nous junction and fossa navicularis. In some cases the entire urethral canal is more or less affected. By means of a flexible bougie a boule, passed slowly along the urethra, the most inexperienced physician can readily detect the rough, tender patches. Every general practitioner should therefore supply himself with three sizes of these bulbous bougies — Nos. 12, 14 and 16, Am. The most accurate way of detecting the real character of localized lesions within the urethra and bladder, as well 44 PROSTATE GLAND AND ADNEXA. as the condition of the prostate and its ducts, is by means of a good urethroscope and cystoscope. Much credit is due Oberlander of Dresden in achiev- ing modern urethroscopy and cystoscopy. By his untiring efforts he succeeded in constructing an instrument through which a direct light could be transmitted to a localized area within the urethra or bladder. But the platinum wire used by him would become quite hot and it required a cooling apparatus that rendered the instrument large and cumbersome; besides encroaching upon the calibre of the instrument, limiting thereby the field of vision. So it fell to the lot of an American (Dr. Henry Koch of Rochester) to develop the mignon lamp, which consumes an energy of only four or five volts and 0.2 of an ampere. This lamp is practically devoid of heat, and can be inserted within the urethra or bladder for an indefinite time without the least inconvenience to the patient. Various improvements have been made within the last few years until now localized sores can be easily detected within the urethra, bladder or around the prostate, and medicinal applications applied directly thereto. Besides, there is no guessing at the morbid condition or its loca- tion. The size of the instrument I prefer is 26 F., and, if the calibre of the urethra is too small to admit of its en- trance, it is pathologically narrowed at some portion of the canal and should be relieved before attempting an ex- amination. The instrument should be carefully examined, ren- dered aseptic, and the light tested before it is introduced. In some few cases the urethra is so callous to instrumenta- tion that it is unnecessary to use an anesthetic, but where it is unduly sensitive I always use cocaine locally, as it is unpardonable to subject one to pain when it can be so SUBACUTE OR CHRONIC PROSTATITIS. 45 easily and harmlessly avoided. For this purpose I use from three to twenty per cent strength of cocaine, de- pendent upon the degree of sensitiveness of the urethra. In most cases the prostatic portion of the canal is the most sensitive, and the greater amount of the cocaine should be applied thereto. By means. of instrument No. IX. the medicine can be applied to any portion of the ure- thra or neck of the bladder as desired, and, by exercising any degree of caution, with impunity. The cocaine is drawn into the instrument by means of the bulb at the upper extremity, similar to that of a medicine dropper, and is pressed out in the same manner. If the upper por- tion of the canal is not tender, or but slightly so, I do not press the bulb until the instrument reaches the prostatic portion, when slight pressure is made, but not sufficiently to force out the entire amount of the fluid. The bulb is then allowed to expand, when the surplus of the liquid is again taken up. After waiting a minute or so the bulb is again pressed as before. This is continued several times before the entire amount is ejected. Should the pendulous urethra be sensitive, it can be applied along its entire length in the same way as before described. I use a bulb on my instrument that only holds twenty or thirty minims, so that a twenty per cent strength of cocaine can be used with impunity and the parts thoroughly anesthetized, whereas, by an ordinary syringe, as is generally used, it would be dangerous. It has become a fad among some physicians to cathe- terize the ureters, when more than one case of infection has been carried from the bladder into these tubes, thence to the kidneys. Besides, the cylinder of the plain cysto- scope is larger and gives a better field of vision. I also use a proctoscope or sigmoidoscope, which is constructed upon the same general principle as that ol PROSTATE GLAND AND ADNEXA. Fig VII. Fig. 8 illustrates the use of the cytoscope in viewing the interior of the bladder and locating a small tumor. 46a Fig. 9 gives a practical illustration of the cytoscope as used by the author to determine the exact state of the prostate and neck of the bladder, without guessing at their condition. 46b SUBACUTE OR CHRONIC PROSTATITIS. 47 the cystoscope. This is a very useful instrument in de- tecting the condition of the prostate, vesicles and rectal mucosa. Before having procured this instrument I was in great measure groping in the dark with reference to the diagnosis as to the real condition of the vesicles, peri- vesiculitis and the rectal mucosa around the prostate. I have found the best way to use the instrument is to pass it gently into the rectum and up to the sigmoid flex- ure; the obturator is then removed and the eye-piece, or metal plug, is inserted, together with the air bulb. Gentle pressure of the latter distends the rectum around the vesi- cles, and also prevents the fecal matter from dropping down within the tube. Mild distention of the rectum with air discloses the condition of the vesicles and sur- rounding tissues perfectly. The tube is slowly withdrawn and at the same time continuing the air pressure when the entire rectum and prostate can be accurately noted. The pressure of the air should not be too great or it will cause over distention of the colon and result in colicky pains. The voltage necessary for lighting these endoscopes can be obtained from cell batteries, provided they are sup- plied with suitable rheostats. The objection to cell bat- teries, however, is that the cells deteriorate with use, caus- ing, when much used, irregular current or voltage. I prefer the current from the direct incandescent cir- cuit, with a properly constructed controller, when the volt- age is uniform, whether used five minutes or all day long. Fig. VII. illustrates a battery or controller that meets all indications for this purpose. In fact, it is the best apparatus upon the market, as it controls the current from a fraction of a volt to that of fifty or more. It is not only useful for lighting these delicate lamps, but can be used for all electrolytic work and cataphoresis, besides supply- 48 PROSTATE GLAND AND ADNEXA. ing the primary and secondary faradic currents of any desired strength. NOCTUENAL EMISSIONS. Nocturnal emissions are not infrequent, and especially when granular prostatic urethritis coexists with inflamma- tion of the gland. Such lesion of the urethra inhibits its normal elasticity, which, as a result, can not be accom- modated to the elongated penis when erect, and produces an undue drawing upon that part of the tender canal that causes a fortuitous seminal discharge. One emission often irritates the prostate or vesicles and thereby causes a second or third in successive nights, and occasionally two in one night. In other cases there is a condition of atony, and a relaxed state of the ejaculatory ducts and gland, when an emission may take place without creating sufQcient sensation to arouse one from sleep. Again, these organs may be so sensitive, by reason of these lesions, that in an effort at sexual congress there is a premature ejection; even, at times, this may occur before intromission. There is frequently a prostatic discharge, that is mis- taken for that of a seminal character. These chronic dis- charges, from whatever source they may arise, rarely cause noticeable systemic disturbances, unless they are very ex- cessive. It is the pathogenic change in the prostate or vesicles, that depresses the nervous system, disturbs diges- tion and prevents in many instances proper assimilation. Often there is little or no systemic disturbance, and one may remain in apparent robust health for a long time, yet he is conscious of something being wrong with his sexual organs. There are others whose general health is very much impaired as result of disorders of these organs, yet have few subjective symptoms pointing directly thereto. SUBACUTE OR CHRONIC PROSTATITIS. 49 DIAGNOSIS. The diseases for which chronic prostatitis is most liable to be mistaken, are stricture and localized urethritis. The latter two may either succeed, coexist with or be excitant causes of the former. The prostatic urethra is the most common site of urethritis and is pathognomonic of prostatitis. As or- ganic stricture never occurs in the prostatic urethra, one familiar with passing of a bulbous bougie can easily de- termine when it has passed the membranous and entered the prostatic portion of the canal. This, too, can be de- termined by the length of the channel and the distance traversed by the bougie. Or, the operator may pass the bougie into the bladder, and, by withdrawing it, measure the distance and locate the points where it meets with re- sistance or roughness at the entrance of the prostatic urethra. There is also, at the point of roughness, a slight sensation of pain or irritation, which may not be felt at any other portion of the canal, or if at all, but faintly. Owing to the granulated and slightly swollen condition of the prostatic urethra, it encroaches to some extent upon the calibre of the canal, causing some narrowness. This condition may be mistaken for stricture. Furthermore, the channel being sensitive at an inflamed point, and the con- tact of the instrument with the mucous membrane thereat may produce reflex contraction of the circular muscular fibers simulating stricture. This either causes a grasping of the instrument or obstructs its passage for the time. As previously stated, if an instrument of small size is used it may enter the orifices of the ejaculatory ducts or utricle, as they are frequently dilated in these diseases, and becom- ing arrested thereby, create the impression that stricture exists. I have known such mistakes made often and urethrotomy performed therefor. 50 PROSTATE GLAND AND ADNEXA. The first morbific change that occurs within the prostate, is chronic catarrhal folliculitis. This condition may last for years, under strict observance of hygienic laws, and temperate habits with little or no manifest symptom than that of an occasional or persistent gleety discharge ; or the discharge may be so faint as to become desiccated after reaching the urethra, and noted by shreds in the first voiding of urine. Subsequently the inflammatory con- ditions extend to the interior of the gland and provoke interstitial prostatitis, causing soft infiltration with slight tumefaction of this organ; yet, there may be little or no local or systemic disturbance, unless there occurs an abrasion of tissue within the prostate, when the toxins or cocci may become absorbed and engender metastasis. It is quite common for some men, as influenced by these toxins, to become emaciated and delicate though suffering no pain or marked constitutional disturbance; while oth- ers remain in robust appearance, though suffering from metastasis, or pains anywhere from that of the back of their neck to their heels. Others become nervous from func- tional involvement of the cerebro-spinal centers, causing melancholia, impaired memor}', sciatica, paraparesis or many other forms of nervous disturbances. These changes may develop so insidiously as to create no uneasiness upon the part of the victim, unless the vesicles become involved, or the inflammatory conditions encroach uj)on the ejacula- tory ducts, narrowing their calibre or limiting their normal elasticity to the extent of obstructing the passage of semen altogether; or, should it pass through these narrow chan- nels, during sexual congress, it would be followed by dull pain, or marked nervous depression. Long standing disease of the gland develops a congested state and inflammatory complications of the bladder, rec- tum, vesicles, and, at times, the kidneys, but the latter are rarely affected to any serious extent. SUBACUTE OR CHRONIC PROSTATITIS. 51 TREATMENT. Owing to tlie diversity of symptoms, botli subjective and objective, and the complications tliat esist with individual cases, it is obvious that the treatment must necessarily vary in accordance with the existing pathologic conditions and indications. It is therefore impossible to establish a fixed rule, by which to be governed in the treatment of all cases. I can give here only a general outline of the course to be adopted; whereas a more detailed account will be given in the clinical reports that will follow hereafter. As the urethra and rectum are the only channels through which to reach the prostate for direct treatment, these must be rendered and maintained in a condition as free from inflammation or irritation as possible. As the larger por- tion of the prostate lies between and in contact with these two canals, it would be impossible to relieve the gland as long as these remain inflamed. Any acrid condition of the urine, whether too acid or alkaline, should be corrected. As before stated, in this class of diseases of the gland, the urine seldom requires special attention, since the bladder or kidneys are rarely affected. When there are no acute symptoms I usually give fluid extract of Triticum repens to render the urine bland and non-irritating. When over-acid, potassic citrate may be added thereto with benefit. There rarely exists an unduly alkaline urine in these cases, but when such is present, and attended with vesical irritation, cystogen tablets — four to eight daily — has proven invaluable in controlling this state. In excessive dysuria, or where there is an acute inflammatory condition of the prostate, hyoscyamus is indi- cated until all acute symptoms are relieved. For annoying priapism, or marked erethism of the genitalia, bromide of sodium, administered in ten or fifteen grain doses at night. 52 PROSTATE GLAND AND ADNEXA. gives temporal}^ relief, until cure of the prostate is effected. There are other constitutional remedies that are espe- cially useful in individual cases towards relieving the annoying symptoms until the morbid condition of the prostate is relieved. So much has been said and written of late years, regarding the use of cystogen and urotropin in genito-urinary diseases, that these drugs are given in a routine way without reference to their specific action. "While they have the property of correcting the excessive alkalinity of the urine in some cases, yet the liberation of formaldehyd in the urine is very irritating to the urinary passages, and, if they are prolonged any length of time, engender much vesical disturbance, dysuria and frequent micturition. "Staphisagria, thuja or oil of wintergreen in doses of from one to ten minims each, three to four times daily, are about the best remedies that can be used in chronic catarrhal conditions of the mucosa of the bladder or ure- thra. These three may be combined with marked benefit. They should be given highly diluted." Eadical treatment of the gland should be delayed until all acute symptoms of the urethra are allayed; unless, as in some cases, there is urgent necessity for immediate re- lief, or certain conditions of the gland provoke a continuous urethritis. In the large proportion of prostatic diseases urethritis coexists, which generally aggravates the trouble. To allay the sensitiveness of the urethra, I begin with the use of a three per cent solution of argyrol in distilled water, injected with an ordinary gonorrheal syringe, of large size. This is forced into the deep urethra or even bladder. Should a copious purulent discharge coexist, one grain of SUBACUTE OR CHRONIC PROSTATITIS. 53 sulpho-carbolate of zinc to the ounce is added thereto. I not only avoid instrumentation until all acute urethritis has subsided, but often defer my examination where sub- jective symptoms indicate such condition, until the acute symptoms have been allayed. The invariable result is re- duction of the inflammation and relief of the tenderness, so that a bougie may be introduced without pain. After the injection has been used from two to three days and all acute sensation in the urethra has disappeared, I then insert a soft flexible bougie, previously annointed with an Fig. VIII. Fig. IX. oil composed of one part of oil of eucalyptol to eight of benzoinol. As the sensation in the urethra diminishes the proportion of eucalyptol can be increased until it stings sharply. This combination so applied makes a stimulating yet soothing application to the canal. The bougie retains sufficient of the remedy to apply thoroughly to the entire mucous surface. The application should not be used more 54 PROSTATE GLAND AND ADNBXA. often than every second day, or in case of great tenderness, every third day. The injection can be continued at the same time until the acute symptoms have completely sub- sided. I generally use this treatment from one to two weeks, or in some rare instances longer before beginning the radical treatment. Before proceeding with the latter, I shall describe briefly my instruments, together with their modes of application. Figures VIII and IX illustrate instruments devised by the author for the special treatment of prostatic diseases. The central part of the instrument is metallic, and in- sulated throughout its length, except at the curved ex- tremity (as shown) and the point to which the cord is attached. A rubber bulb is fitted over the other hollow end. The exposed part of the metal at the end is per- forated, so that when the instrument is immersed in any liquid medicine and the bulb is pressed, then relaxed, it partially fills; when the bulb is again pressed the medi- cine is forced out in jets through the small openings, as illustrated. No. IX is used to apply the remedies to the prostatic urethra and neck of the bladder; but as the greatest trouble exists upon the floor of the urethra and within the ejaculatory and prostatic ducts, instrument No. VIII is used, as shown by reference to Fig. X. In the two conditions illustrated by plates VI. and XII. cataphoresis through the rectum and prostatic urethra, as shown by figures X. and XI., is especially indicated. In the latter the medicine is introduced through the curved, cup- shaped opening at the lower extremity, and, by means of a rubber-tipped syringe it is forced out through the open- ings at the other end, as indicated. The electric current and the medicine being limited to that part immediately opposite the prostate are transmitted to the gland by cata- pnoric action. SUBACUTE OR CHRONIC PROSTATITIS 55 Fig. X. By passing the electrode further up the rectum the same cataphoric action is exerted upon the vesicles when they are involved. , The instruments are so constructed as to meet all indi- cations for applying medicine directly to localized ulcers, or granulated patches, along the urethral canal, and effect cataphoresis, interstitial electrolysis, vasomotor contrac- tion, etc. It must be remembered, however, that the properties of the currents and remedies as used are limited to their ex- posed metal ends and only within an area of a few inches 5S PROSTATE GLAND AND ADNEXA. therefrom and dependent upon the strength of current. As the metal part (Fig. VIII) is in apposition to the floor of the prostatic urethra, the full influence of the current, for whatever purpose used, is concentrated upon that por- tion of the gland tunneled hy the ejaculatory and prostatic ducts, and the parts that are always affected in this dis- ease. The strength of the current, therefore, as well as the remedy, when used for cataphoresis, should be very mild. For topical applications or cataphoresis the alcohol con- tained in tinctures or fluid extracts is too irritating, so I always use aqueous extracts, when using organic sub- stances. For cataphoresis I prefer, in most instances, or- ganic preparations to those of inorganic, as the latter are more rapidly decomposed, do not penetrate the tissues, as do the organic by electric-osmosis, and produce interstitial electrolysis or their germicidal effects upon the micro- organisms when such are suspected For anodal cataphoresis a non-oxidizable electrode should always be used, or the electro negative elements will combine with it and form new compounds, which may be very irritating or wholly inert. An oxidizable electrode may be used in some instances with advantage to effect metallic cataphoresis, when the result of such combination and its properties are known. As, for instance, the anodal use of a copper electrode results in the formation of oxy- chloride of copper, which would be transfused throughout the gland and be of marked benefit in some cases. On the other hand, should a brass electrode be similarly used, a double combination would result and the formation of chloride of zinc would be very painful. The treatment of cases of gonorrheal origin should be somewhat different from those due to other causes. In the former, germicidal remedies should be used, although SUBACUTE OR CHRONIC PROSTATITIS. 57 I have clinically demonstrated in many instances phago- cytosis by the attraction of leucocytes, and, aided by the lethal effect of cataphoresis, all evidence of the germs dis- appear. The cathodal attraction of blood serum is of easy demonstration, both within and outside of the bodv. Fig. XI. Let a non-oxidizable electrode be attached to the anode and passed into the urethra, and, even with a mild current, it will soon become glued to the parts ; when, by reversing the poles the cathodal attraction of serum will loosen it very quickly. The experiment may be made by applying the poles in a similar way to a fresh beefsteak, when moist- 68 PROSTATE GLAND AND ADNEXA. are will rapidly accumulate on the cathodal side, while the opposite side will become desiccated. The electrolytic, cataphoric and dynamic properties of the different currents are indisputable. These properties can be used to effect synthetic or dialytic changes in both organic and inorganic substances; exert, by attraction and repulsion, oscillation of molecules of bodies ; and trans- fuse liquids through animal tissue. While these agents can be applied to destroy micro-organisms, dissipate mor- bific tissue and invigorate the atonic organs ; yet they can- not be used without due reference to the condition of the parts, the selection of the proper current and remedy to be used therewith, intervals, strength and length of time to be effectual and not engender harm. Before the parts can be restored to a healthy state, the morbid tissue or unhealthy granulations must be removed. The most satisfactory way by which this can be accom- plished, without direct or ultimate bad results, is, in my opinion, by electrolysis or cataphoresis, accompanied with suitable medicinal remedies. Nitrate of silver has been in use for that purpose from time immemorial, but it causes excessive pain, fails to penetrate the ducts and gland, and is often followed by cystitis, prostatis or epididymitis. The patient is often confined to bed for weeks, and, on recover- ing, is visited anew by the same trouble; which persists in a chronic condition, as before. Moreover, the nerves, ves- sels, follicles and parenchyma of the gland lack vitality and recuperative power, and, even after the morbid prod- ucts have been removed, require the invigorating influence of the current in order to bring about healthy granula- tions and a restoration of the organs to their normal state. The most satisfactory method of treating these organs is to thoroughly examine them with the cystoscope, and locate the ulcerated patches within the urethra, see defi- SUBACUTE OR CHRONIC PROSTATITIS. 59 nitely the condition of the prostate and bladder. Then the treatment can be applied directly to the diseased parts. It is only after all the acute symptoms have been allayed by the methods heretofore detailed, that the electric treat- ment should be used. As ultimate results depend largely upon the proper se- lection, control and application of the currents, as well as upon the suitable remedies to be used in connection therewith, I shall take it for granted that the reader, be- fore proceeding further with the detailed electric treat- ment that follows, is thoroughly familiar with the subjects of electro-physics, electrolysis and cataphoresis as described in Chapter VIII. Before beginning electric treatment, the operator should carefully examine the battery and conducting cords, to as- certain whether the former is in perfect working order, and the latter are intact and connected with the proper poles. The latter he should frequently test in order to be certain as to their proper applications. This may seem an excess of caution, but if the operator himself was being treated, and had experienced the result of forgetting to turn off one switch, or turn on another, or, still more important, to note carefully the position of the commutator, he would agree that these points can not be too forcibly impressed. Even now, after many years of experience in manipulating all kinds and makes of batteries and accessories, I never fail to use these precautions. In using the galvanic current for electrolysis or cata- phoresis, it is important never to shock the patient. Al- though probably no harm would result, yet the patient would always be in fear of a repetition of the shock, even if he did not discontinue treatment altogether. To avoid this, a large sponge or carbon electrode, about eight inches in diameter, is attached to the cord (which is previously 60 PROSTATE GLAND AND ADNBXA. connected with the indifferent pole of tlie battery), and • placed within easy reach of the patient — preferably upon the stomach — that both hands may be used if necessary. The active electrode is then placed in position for treat- ment, and the cord attached thereto. Up to this time the patient has not been allowed to touch the sponge, or in- different electrode, with his hands. He is then instructed how to touch it gently with the fingers of one hand, and gradually bring them down until the palm is flat upon it. Should it be desirable to increase the efficiency of the ac- tive electrode, the other hand can be placed iipon the sponge in the same way. The greater the surface of the indifferent electrode, the greater, in direct proportion, is the efficacy of the active electrode. Before removal of the latter, the hands should first be removed, in the same man- ner as they were applied. Should it be necessary to re- verse the poles during the treatment, by means of the com- mutator, or in any way, have the hands removed first and then replaced in the same manner as before described. By observing these precautions there will be no shock. A battery should be so constructed that the current can be gradually increased from the minimum to the desired strength without interrupting the circuit. The suscepti- bility of individual cases varies so greatly that I would al- ways advise the use of the mildest current and the shortest duration during the first few treatments. Whenever there is an indication of pain, the treatment should be discon- tinued at once. I rarely use local anesthesia, even in the case of nervous patients with excessively hyperesthetic urethras. The sensation is one of the best guides to the strength of the current to be used, and the length of time it is to be continued. We must bear in mind the objects to be accomplished by treatment, viz., the removal of morbid products and the SUBACUTE OR CHRONIC PROSTATITIS. 61 relief of passive congestion by stimulating vasomotor con- traction, thereby reducing inflammation. These can be obtained without producing undue pain. Pain causes con- gestion and inflammation, and it is impossible to state just how many volts or milliamperes should be used in the beginning or at any time during the treatment. A current of sufiicient strength to relieve one patient might be inert in a second case or even harmful to a third. I begin with from five to ten volts in the circuit, and never occupy more than three or four minutes during the first or even second treatment. Most beginners, and, in truth, nearly all, with whose work I am familiar, try to do too much, and in too short a time. As to the selection of an instrument, I rarely use an electrode smaller than No. 14 A, which, unless there is a stricture, passes readily into the prostatic urethra, and thence into the bladder, without engaging the openings upon the floor of the prostatic urethra. I always begin the electric treatment by using the electrode, as illustrated by Fig. IX. With this I denude the prostatic urethra of the unhealthy granulations, by means of cathodal applications. These treatments are never made of tener than on alternate, or, more frequently, third days. In some highly sensitive cases I allow a week to elapse between treatments, and use a bougie with benzoinol ointment, in the interval. It gen- erally takes from three to five treatments to remove all the granulations, which can be detected in the urine, if passed in a bottle, for two or three days after each treatment. In making a cathodal treatment, the kind of metal used upon the point of the electrode is a matter of indifference, as the electro-positive elements do not affect it. But in anodal treatment the electro-negative elements, as oxygen, acids, etc., combine with most metals very readily. In thcbe I always use an electrode of platinum or gold point; 63 PROSTATE GLAND AND ADNBXA. unless I wish to procure a local effect by means of the metallic combination with the elements. For example, after denuding the prostatic urethra of the granulations, in order to bring about healthy action, I often make an anodal application with an electrode having a solid copper point, with very happy results. The action of the acids of the electrolytes upon the metaL together with the tonic effect of the anode, brings about renewed vigor of the tis- sues. Those new combinations also penetrate the gland by cataphoric action and have the same healthy effect upon it. The selection of remedies to be used by cataphoresis Mathin the ducts and upon the follicles and gland, must be made with reference to the electrolytic effect of the cur- rent. As water and salt enter largely into the composition of animal tissue, free oxy-chloride can alwa3-s be expected in an anodal application. So complex are the chemic constituents of many reme- dies, the electrolytic effect of the current upon them, and the recombinations resulting from the union of the electro- negative elements with reference to their relative affinity, that in many instances, it is difficult to determine exactly what the changes are and the combinations formed thereby. The frequency with which urethral instrumentation should be used depends upon the condition of both the prostate and urethra. Should the inflammation and su- persensitiveness of the canal have been greatly allayed by injections and bougies, as before described, then electrolysis or cataphoresis can be employed every fourth or sixth day, alternating with the use of the bougie the second or third day. The interval between the use of the bougie and that of the electrode should either be two or three days, depend- ing upon the sensitiveness of the urethra and prostate. Should tenderness of the canal still continue, the injec- SUBACUTE OR CHRONIC PROSTATITIS. 63 tion should be used uninterruptedly. In some instances urethral instrumentation should be used only once a week. The advice of Sir Henry Thompson in this connection is very valuable and should be rigidly observed. He says : *'Eemember that the introduction of an instrument is more or less of an evil never to be resorted to unless a greater evil be present which its employment may probably rem- edy." It is always better to err upon the conservative side, and to do too little rather than too much. There is one other point of special importance that I wish to impress forcibly upon the minds of my readers — one that I learned by obser- vation — and it is this : after a patient has been treated for some four to eight weeks in succession it is better, in the majority of cases, to discontinue all treatment for one, two or even three weeks. This is in order to give "vis medicatrix naturae" a chance, and to rid the gland of the disintegrated products which result from interstitial changes, as caused by electrolysis or cataphoresis. In the large majority of cases the improvement is more marked than if the treatment had been uninterrupted. This fact was noted in many instances where I was treating men who lived at a distance, and who had to return to their homes on account of business or for other reasons. On their return I would find great improvement ; and in many instances complete recovery would result, which obviated the necessity of a return for further treatment. Much depends upon the caution and skill of urethral in- strumentation. I think it would be well for many physi- cians to adopt the suggestion of Sir Henry Fenwick (sur- geon to the London Hospital), where he says to his assis- tants : "Every dresser should be induced to pass a full sized steel bougie upon himself once or twice. Ho would then appreciate the need of the utmost gentleness in ure- 64 PROSTATE GLAND AND ADNEXA. thral instrumentation." I have seen much harm result from the injudicious use and rough handling of instru- ments in the treatment of the prostate gland. The treatment I have detailed does not interfere with the patient's daily business. But, on the contrary, he be- gins to feel better and fitter for work in a few days after the treatment is begun. I invariably interdict the use of alcoholic drinks, and especially beer or fermented wines, during treatment; as they have a tendency to increase local congestion and in- flammation, and, besides, cause increased precipitation of uric acid. I do not otherwise restrict the diet, in the ma- jority of cases. Fig. Xlla illustrates an instrument devised by the author for the special purpose of treating and diagnosing any ulcerated surface anywhere along the urethral canal, from the meatus to the neck of the bladder; and even prostate. I use this instrument and Fig. IX on page 53 r.iore than any other. In fact, they are indispensable to any physician who has to treat any cases of chronic dis- eases of the urethra or prostate gland. To use this instru- ment properly, first allay all acute s}Tiiptoms, as detailed on pages 51, etc. The next step is to have the patient void his urine and lay in recumbent posture with hips elevated. He will thus avoid having urine to dilute or neutralize the medicine, and the effect of the application will be similar to applying a remedy to an ulcer outside the body. Then make a local application of from five to ten per cent of eucaine or cocaine to the deep urethra with instrument ISTo. IX, page 53; after awaiting five minutes to anesthetize the deep urethra, which is the most sensitive part, place the ends of two wooden applicators in a glass of water, then reverse and immerse the other ends of the applicators. After these are thoroughly wet, twist a small piece of absorbent cotton on each end of the PROSTATE GLAND AND ADNEXA. applicators, as illustrated Fig. Xllla. It is important to have the sticks thoroughly wet or the cotton might become detached from the stick and become lodged within the urethra. The next step is to insert the obturator in the tube, then pass instrument slowly down the urethra until the end enters the neck of the bladder, when withdraw the obturator and insert the applicator with the cotton, as shown by Fig. Xlllb ; withdraw the latter and look at the cotton and note whether it is bloody. Move the tube a little at a time, first deeper, then withdraw until you note blood upon the cotton, which indicates an ulcer, or granu- lar patch; then insert other end of the cotton applicator with whatever medicine may be desired to treat the ulcer or granular patch. I use for this purpose from two to five per cent solution of picratol, argyrol, petrogen, thallin, etc. Case I. — Chronic Prostatitis and Prostatic Ure- thritis. Aged twenty-four; single; history, as given by himself, is as follows: "When eighteen he had gonorrhea which lasted about nine months. During the first stages of the disease dysuria was excessive, the discharge from the ure- thra being very copious, and followed by vesical tenes- mus, chordee, etc. He had several succeeding attacks, which lasted only a few weeks, during which time there was but little pain or disturbance of any character. A gleety discharge followed, continuing up to his twenty- first year, when he was pronounced strictured, and treated for such by means of steel sounds. The treatment was very painful and at first followed by bloody discharges. This was continued for about a year, during which time there was a continuous gleety discharge. His health was much impaired; there was a dull aching sensation in the region of the perineum, especially when walking or stand- ing. He changed physicians; sounds were used as before, but larger, and producing hemorrhage attended with great 64a Pig Xlla, Fig. Xllb. SUBACUTE OR CHRONIC PROSTATITIS. 65 pain. His health continued to grow worse; he became very thin; suffered with anorexia, emissions and weakness of the sexual organs, dull headache, despondency and lack of confidence. Upon examination I found the meatus red, inflamed, and the lips glued together. There was a granular ulcer in the fossa navicularis about an inch behind the glans penis. On the introduction of a bougie a hoiile, there was little sensitiveness of the urethra until the prostatic por- tion was reached, where roughness offered a slight resist- ance to the passage of the instrument, indicating a granu- lar ulceration, and extreme tenderness. On withdrawal of the instrument pus and mucus were found adhering to it. Microscopical examination did not reveal any gonococci. Upon pressure through the rectum there was very slight tenderness of the gland and little or no swelling. TREATMENT. On the second day after the examination I made an application of ointment composed of the oil of eucalyptol one part to benzoinol eight. This was repeated on the third day thereafter, when there was some less tenderness. Two days afterwards the ointment was again applied and the tenderness became still less apparent. Three days thereafter treatment by electrolysis was instituted, by means of jSTo. 14 electrode, with five m.a., lasting three minutes. There was at the time a slight stinging sensa- tion, followed by a mild mucopurulent discharge. On the second day an injection was given, one grain of sulpho- carbolate of zinc to one ounce of a ten per cent solution of argyrol, to be used four times daily. On the third day after the electric treatment the ointment was again used, the injection being continued in the interim. The discharge became less, and three days afterwards electroly- 66 PROSTATE GLAND AND ADNBXA. sis was again applied with eight m.a., for three minutes; slight watery discharge followed the treatment. Small granules and shreds were noticeable in the urine. There followed an improvement in every respect; discharge scarcely perceptible. Cataphoresis was now applied through instrument No. VIII, with five per cent solution of argyrol, ten m. a., for five minutes; slight sensation, little irritation following. The case was treated thereafter by means of cataphoresis (a one per cent solution of thuja — Aqueous — ^being used), an ointment, alternating every third day for one month. Treatment was then discontin- ued for ten days, when patient returned feeling greatly relieved; no discharge, cataphoresis used with thuja, one per cent strength, ten m.a., three minutes, causing slight stinging; no ill effects following. Ten per cent solution of argA^rol was applied in the same way to the fossa navicularis. The patient was then treated once a week by means of cataphoresis, with twenty per cent strength of verbascum for a month, when he was discharged — cured. This case was under observation for several years after dismissal and there was never any symptom of the former trouble. In regard to the remedies used I may state that thuja is a non-alcoholic extract of arbor vitse, which I have specially prepared for me. The alcohol contained in tinctures is too irritating, unless well diluted, when the resin in thuja is precipitated, and the medicine is ren- dered inert. Case II. — Prostatitis, Stricture. Gonorrhoea! history of seven years standing, with fre- quent recurrences; gleet constant. Patient had stricture in the membranous urethra, six and one-half inches from the meatus — ^caliber 12 A. Immediately back of the stric- ture and extending through the prostatic urethra was a SUBACUTE OR CHRONIC PROSTATITIS. 67 granulated ulcer. There was apparently no obstruction to the flow of urine nor pain during the time, but at the close of the act there would be slight pain and dribbling of urine, lasting from three to five minutes. At times a milky discharge preceded the flow. This preyed upon his mind, as he believed it was spermatorrhea, for which, as he said, "he had taken barrels of medicines."' He was troubled with sexual and moral hyperesthesia, insomnia and hypochondriasis. The discharge proved to be a per- verted prostatic secretion containing also mucus and pus cells. He was in good flesh, though pale and easily tired upon exertion. Sexual relations were very erratic. At times several weeks would pass without the least desire or even erection. Then again there would be an almost insati- able propensit}', but in attempting the act ejection would occur before intromission, followed by a dull aching in the region of the perineum. Applications of benzoinal ointment were made on alter- nate days three times. On the second day, after the last ointment treatment, electrolysis was applied to the stric- ture, a 14 A. electrode having been attached to the cathode. The strength of the current was gradually increased from five to twelve m.a., for five minutes, when the electrode passed the stricture. There was no pain until the stricture was passed, and the electrode came in contact with the granulated ulcer behind it, which was very sensitive and somewhat painful. The circuit was immediately broken and the electrode withdrawn. On the third day thereafter a bougie ISTo. 12 A. was introduced, and passed easily into the bladder. Three days afterwards electrolysis was again applied in the same manner as before with five m.a., for three minutes. The electrode entered the bladder without resistance, and with very little sensation. This was fol- lowed as usual by a slight muco-purulent discharge. Cata- 68 PROSTATE GLAND AND ADNEXA. phoresis was then instituted with one per cent strength of Ichthyol every fourth day for three weeks. Complete re- covery resulted. Case III. Single; aged thirty-four; consulted me for "nervous- ness." He had been a very successful business man, hav- ing charge of a large force of men in an extensive estab- lishment. He was naturally very reticent with men and timid with women. He had never had any venereal disease, and in fact had no subjective symptoms of sufficient importance to justify an examination of the genital organs. Thinking that close attention to business and long sustained tax of his mental powers had given rise to the disturbance of which he com- plained, I advised complete rest, and at the same time giv- ing him a tonic, as he was somewhat anemic, though in good flesh. He left my office in good spirits, intending to spend a month or two in the Cumberland Mountains, fish- ing and hunting. In about ten days, to my surprise, he returned, saying that he believed, had he remained up there a week longer, he would have gone crazy ; that, while he was away, he did not think he had averaged two hours' sleep in the twenty-four, and having nothing to do but to think of himself and his condition made him worse than when at work. The objective symptoms, as revealed by an examination, showed an excessively hyperesthetic urethra, so much so that the introduction of a soft bougie caused him to partially swoon and break out into profuse prespira- tion. He was allowed to remain upon the table, in recum- bent position, for half an hour, when he fully recovered, saying that the instrument did not pain him very much, but that it caused a peculiar, indescribable sensation that rushed to his head and caused blindness. The night fol- SUBACUTE OR CHRONIC PROSTATITIS. 69 lowing he had the best sleep that he had experienced for six months. I had him inject a ten per cent solution of argyrol three times daily for a week in order to allay the hyperesthetic condition of the urethra before proceed- ing further with the examination. Upon questioning him further upon the subject, I was alile to elicit from him the fact that in his early youth he had practiced masturbation to a very limited extent, but had not done so for fifteen years prior hereto. He also admitted that he had attempted intercourse twice only and had such an utter failure, and was so disgusted with him- self, that he had never had sufhcient confidence to make a third effort. He had noticed a milky discharge at times just preceding the passage of urine, and also when at stool, especially if costive. Further examination of the gland showed it to be ex- cessively sensitive both through the prostatic urethra and rectum. A bougie was introduced every third day into the bladder, and a suppository composed of five grains each of boric acid and aristol introduced into the rectum at night. At the end of the third week urethral catapho- resis was instituted. The treatment was similar to that given in the former cases, except that only cataphoresis was used and only once a week. Complete recovery fol- lowed after four months' treatment. Case IV. — Prostatitis, Epilepsy. Married; aged twenty-eight, thin, nervous, wild eyed and as restless a man as I think I ever saw. He was born and raised in the country by an intelligent, well-to-do widow. At about fourteen he began masturbating, and at sixteen had epileptic fits. They assumed a periodicity and at first recurred about every four weeks, then every two weeks, often followed by two or three attacks in one or the 70 PROSTATE GLAND AND ADNBXA. succeeding day. They continued to grow more frequent and severe until he would have two or three attacks a week. He was at first treated by his lodal physician with bro- mides, which controlled them to some extent in frequency and severity, but at the expense of his physical and ner- vous system. He went the round of neurologists in N"ew York, Cincinnati and St. Louis for ten years. The last physician, after having had him under treatment for more than a year, trephined him, as he said, for too much blood upon the brain. Still there was but little temporary re- lief. He had taken bromides until he was almost an im- becile, when he returned home. His local physician ad- vised him to get married, which he did about nine months before coming under my care. The objective symptoms, as determined by an examina- tion, revealed phimosis in a marked degree, the glans penis and meatus being red and very sensitive. The ure- thra was so extremely hyperesthetic that an attempt at introducing a bougie almost threw him into convulsions. My first step in the way of treatment was to circumcise him, then by the use of injections of argyrol, to allay the supersensitiveness until I was enabled to make an ex- amination of the prostate, which was quite irritable and sensitive. On account of the extreme tenderness of the urethra and prostate I passed a bougie only once a week, continuing the injection at the same time. The bromides were also continued, but in smaller doses. He had been taking the bromide of ammonium in scruple doses three times daily. I gave him bromide of sodium in ten grain do_ses three times daily, gradually diminishing to eight, five, then five twice a day. The epileptic attacks became less frequent and severe until they again assumed periodic- ity, returning every twenty-eight days. I had him discon- tinue the use of the bougie and began that of cataphoresis SUBACUTE OR CHRONIC PROSIATITIS. 71 with mild solution of argyrol. Patient was under treat- ment fourteen months. For five months before he was- dismissed he had not had an epileptic attack, nor had he taken a dose of bromide for three months. Eleven and one-half months from the time he began treatment his wife was delivered of a girl baby. The patient became quite strong and corpulent, returned to his mother's farm, and I have not heard from him since. Quite a number of cases similar to the last two have come under my observation. They were traceable to dis- ease of the prostate and exhibited a variety of neurotic disturbances as a result of masturbation, continence, or excessive sexual indulgence. In the treatment of this class of diseases, when I sus- pect the lurking of gonococci, and that the prostatitis is due to the toxins secreted by these germs, I use ichthyol or other germicidal agents by means of cataphoresis, after having allayed all acute symptoms by the process before described. In those not due to gonorrheal infection, I prefer aqueous extract of verbascum, thuja, echinacea, or a combination of two per cent solution of equal parts of the latter two, and used in the same way. Case V. — Prostatitis, Vesiculitis, Prostatic Ure- thritis. Single ; aged thirty-three. The only subjective symptom of which this man complained was total impotency. Other- wise he was in fairly good health, and attended his busi- ness daily. He had never indulged in alcoholic drinking. He had masturbated some in early youth, but abandoned it quite soon for sexual indulgence, which he carried to great excess. This inordinate indulgence was maintained for five or six years, when an impairment of function was noticeable. This condition continued to grow worse, until 73 PROSTATE GLAND AND ADNEXA. a physician was consulted^ who prescribed aphrodisiacs. Temporary excitement followed the use of the drugs, which was soon followed by complete collapse. Other drugs were tried without avail. The physician endeavored to persuade him, as he had no apparent physical ailment, that "it was all in his head." He never had gonorrhea, or any kind of venereal disease. A second, third an'd fourth physician was consulted; each of whom treated him simi- larly to the first without the least benefit. Neither of the doctors made a physical examination, as they took it for granted, that, as he had never had gonorrhea, there was no lesion of the genital organs causing the trouble. This treatment extended over a period of six years, and, strange to state, no quack remedies were taken in all this time. Upon passing a bougie a houle, I noticed very little sen- sitiveness until the prostatic portion of the urethra was reached. Examination with the cystoscope revealed an in- flamed and granular surface along the floor of the pros- tatic urethra. The other portion of the canal was normal. The prostate and vesicles were slightly tender upon pres- sure. As revealed through the proctoscope the rectal mu- cosa opposite the gland and vesicles was red and somewhat inflamed, but not abraded. On the second day, after the examination, ISTo. 14 A. bougie was passed annointed with benzoinol ointment. It entered the bladder quite easily, and with very little irri- tation. Two days thereafter cathodal electrolysis, with No. VIII electrode 14 A., using ten per cent strength of argyrol, was introduced. This application was attended with a current strength of ten m.a., and of five minutes duration. Two days afterwards a sinusoidal treatment of the prostate and vesicles through the rectum was given. Applications were given alternately through the rectum and urethra for ten weeks. The nocturnal emissions oc- SUBACUTE OR CHRONIC PROSTATITIS. 73 curred only about once every three or four weeks. At times he would pass six weeks without an emission, which I did not consider abnormal, nor did they depress him. This proved to be one of the most obstinate cases I ever treated, which was due evidently to the long continued use of aphrodisiacs. Case VI. — ^Prostatitis, Vesiculitis and Urethritis. Single; aged twenty-seven; gonorrheal origin. This young man. had gone the rounds of first the druggists, then the quacks. He was suffering intensely from dysuria, pain in the back, perineum and left groin. There was a gleety discharge, which, at times, was profuse, then again, very scant. It was his first attack, and it had been running for eighteen months. His treatment had consisted of injections, systemic med- ication, irrigations and sounds. The meatus was very much contracted, and the urethra was tender throughout its entire course. There were localized patches along the canal much more sensitive than at other points. The rec- tum was quite tender and often protruded while straining to void urine when at stool. The parts were so tender that I did not attempt a thorough examination at first. I had him inject a ten per cent solution of aqueous extract of argyrol five times daily. He was also instructed to in- troduce a suppository of boric acid, ten grains, and extract of belladonna, three-quarters of a grain, night and morn- ing. After three days the acute symptoms had greatly subsided, when the benzoinol ointment was begun. Exami- nation was made at the end of a week, disclosing three granular patches in the urethra ; the first at one inch back of the meatus, the second at six inches and the last in the prostatic portion. The rectum was inflamed and abraded opposite the prostate and very red and tender high up and about the vesicles. 74 PROSTATE GLAND AND ADNEXA. The treatment was similar to that before described, ex- cept that ichthyol was used in cataphoresis, it being a more decided germicidal agent. The injection was continued during the first month's treatment to control the urethritis. Eecovery followed three months' treatment. There are many similar cases to these with various com- plications. At times the bladder is involved but it very rarely requires special treatment. It readily recovers as soon as the other troubles are relieved. It is exceedingly rare that the gonococci invade this viscus; and especially with young men whose urine is almost invariably aseptic and noxious to these germs. Occasionally I find some cases where ulceration upon the floor of the prostatic -urethra resists the methods of treatment before detailed. In such cases I bring the ulcer into view by means of the cystoscope, which I prefer for this part of the canal to the urethrascope, and touch it with twenty per cent of ichtbalgon or fifty per cent of argyrol. Where the prostate or vesicles are very tender, I often suspend urethral treatment for some days, and apply through the rectum to these organs the secondary faradic current with from fifteen to twenty thousand ohms re- sistance. This treatment acts as an analgesic and allays local irritation. CHAPTEK IV. CHEONIC CONGESTED ENLARGEMENT OF THE PROSTATE. This affection of the gland is common in middle age, and occurs more frequently between the ages of forty and sixty. It is, however, not infrequent as early in life as thirty-five and even past seventy without the existence of senile or fibrinous hypertrophy. I have had three cases — one seventy-two, another one year older and a third sev- enty-nine — with congested enlargement, and inflammation of the gland, seminal vesicles and neck of the bladder, without fibrinous induration. The idea, so generally prevalent among the profession, that, when a man past forty or fifty has any disease of the prostate, it is indurated hypertrophy and incurable, is er- roneous. This disease of the gland is one of passive ve- nous congestion, soft submucous infiltration and a swollen enlargement of the organ, which generally results in in- flammation not only of the gland itself, but of most all the other pelvic viscera. It is somewhat analogous to the congested and inflamed condition of the uterus and its appendages. Not every woman that has venous stasis and an inflamed womb has fil^roid tumors developed within its wails. In fact, the latter is rare as compared with the number of cases of the former. In like manner fibrinous tumors, or hypertrophy of the prostate, is rare as compared with the numerous occurrences of congested enlargement. • I have treated quite a number of cases of this class of prostatitis, that had been treated by different physicians for many years, and pronounced hypertrophy and incura- ble. Some of these cases had not only been treated by the family physicians, but by many of the leading specialists in this line. 75 76 PROSTATE GLAND AND ADNEXA. Fig. XII. ENLARGEMENT OF THE PROSTATE. 77 It is somewhat difficult in some cases to diflEerentiate at first between congested enlargement and fibrinous indu- rated hypertroph5^ The diagnosis will be considered more at length under the head of diagnosis that will follow upon this subject. I shall add here, however, that, basing a statement upon my own clinical experience, at least twenty cases of congested enlargement of the gland occur to one of hypertrophy. I do not include in this estimate chronic prostatic folliculitis common to young men. Cause. — The most potent etiological factors, productive of this form of disease of the prostate, are common with those that excite chronic inflammation of the gland as de- tailed in Chapter III. When folliculitis is not arrested and it is permitted to extend and induce parechymatous pros- tatitis and plastic exudation, interstitial infiltration is the natural sequence. The exudate, thus produced, extends to the muscular fibers, and its pressure upon the blood and lymph vessels increases stasis, and chronic enlargement and infiammation of the entire gland results. Inordinate indulgence in alcoholic liquors, whether char- acterized by excessive bouts of drinking or a moderate though constant habituate, excites and increases congestion of the gland; and, where any previous lesion of any part of the genito-urinary tract exists, it is aggravated. Es- pecially is this fact more apparent when beer or fermented wine is employed. Since it has become a proven fact that, in from seventy- five to eighty-five per cent of gonorrheal cases, the cocci invade the gland, and there remain dormant indefinitely, producing poisons that maintain a slow though constant irritation, besides that engendered by the germs them- selves and the debris of their cadavers, chronic inflamma- tory enlargement of the gland should receive more prompt attention than is generallv accredited it. One reason that 78 PROSTATE GLAND AND ADNEXA. it fails to arouse the uneasiness its importance demands is because of the insidious manner of the progress of the disease, and of the variable character of the subjective symptoms. At times all symptoms may be entirely lacking, or they may recur in a somewhat aggravated form necessi- tating the consulting of the family physician, who may not give it the significant attention requisite, and usually dismiss the case, without examination, by prescribing a diuretic, and permit the development of the gland until it becomes quite serious. Any form of dissipation aggravates the trouble; but it has been particularly noticeable with that class of men who have at some time of life been addicted to alcoholism and its companion in crime, excessive venery. Lesion of the gland, whether of gonorrheal origin or due to other causes, is more easily excited by stimulants, at least for a time, until a complete breakdown follows. In other instances the irritation arising from lesion of the gland, whether due to dissipation or other causes, creates an insatiable sexual desire, that affects the central nervous system to such an extent as to cause mental disturbances of various kinds. Such persons are often too modest to reveal all the facts to their family physician, and fre- quently endeavor to deceive even the specialist whom they may consult. It is much better, in such cases, for total impotency to supervene than to provoke an immoderate drain upon the nervous system, by excessive sexual con- gress, which often results in paresis, impaired memory or even insanity. It was no doubt due to this fact that only a few years ago castration was advocated, and performed quite frequently for insanity. It was claimed that marked relief followed the operation in some cases, while others were reported as cured. Ulceration of the rectum, whether result in ^^ from uros- ENLARGEMENT OF THE PROSTATE. 79 tatitis, IS usually concomitant therewith, or, originating from other causes, evidently provokes and maintains pros- tatic congestion and inflammation, on account of its being in such close proximity to the gland. Horseback riding, and especially those who do very much of it, aggravates an existing prostatitis, even though it may not be the prime cause of it. I have found this trouble quite prevalent among country physicians, who are compelled to visit their patients on a horse. Bicycle rid- ing has equally as bad, if not worse, effect upon the gland. ■I do not think moderate riding either upon a horse or wheel has any injurious effect upon the prostate, when it is in a healthy condition, and the rectum is free from ulcera- tion. In fact, the irritation is transmitted to the gland by the saddle through the rectum and lower urethra. Cold often excites congestion of the prostate, and, when prolonged or habitually exposed, it especially aggravates an already inflamed gland. Violent and long continued use of instruments are potent causes of enlargement of the organ, and especially when large sounds are employed, pressing upon the inflamed gland. The practice is a com- mon one and is generally advised by surgeons ; and, in fact, is almost universally used. Unless the sound is handled by a skilled operator the end of it strikes the gland in such way as to do much harm. Strong injections and cautery applications to the pros- tatic urethra often produce serious trouble. The admin- istration of aphrodisiacs for impotency, which is a common symptom of this disease, has a pernicious effect upon the gland. The exciting by these medicines, of a diseased gland, incapacitated for its normal function, to produce an abnormal congestion and orgasm, often provokes serious trouble. It is a very general practice of giving these reme- dies in a blind manner, without having examined the pros- 80 PROSTATE GLAND AND ADNEXA. tate with the view of discovering the real cause of the trouble. SYMPTOMS. The symptoms are somewhat common to those of chronic prostatitis of young men, except that, in this form of disease, there are more complications, and, in some cases, a higher degree of inflammation, as a result of the large size of the gland impeding the free flow of urine. Often vegetative growths spring up in the prostatic urethra, and around the vesicle neck, which at times project into the anterior part of the bladder. These may develop into polypoid tumors, that flop about the neck of the bladder like a valve, and shut off the flow of urine, for a time. These tumors are very vascular and inclined to periodical hemorrhages. Prostatorrhea may be constant or periodical, and is often mistaken for spermatorrhea. The former may be so slight as to appear only in the form of gleet ; or it may pre- cede the flow of urine, when it has accumulated within the prostatic urethra, in the form of a milky fluid. Others have the white discharge just at the cessation of the pas- sage of the urine. When the latter occurs the discharge accumulates within the prostatic ducts; and by spasm of the prostatic sphincter in expelling the tardy urine, ejects also this secretion. In other cases, and especially when vesiculitis coexists, spermatic fluid may also pass. These fluids are usually mixed with pus and mucus. The urine in these cases is almost invariably abnormal. Its changed condition depends mostly upon the extent of lesion, the size of the gland, the length of standing, and the bladder complications. The vesicle neck is the first part of that viscus to become involved, and, in most cases, it does not extend further, unless of very long standing. The urine generally changes from its normal acid reaction ENLARGEMENT OF THE PROSTATE. 8] and aseptic condition to that of alkaline^ and is no longer innoxious to bacteria, but favors their development. The action of bacteria upon exfoliated mucus favors pyogene- sis and the production of ammoniacal urine. The latter is exceeding^ irritating to the bladder and especially at the neck, causing frequent and painful urination. This is particularly noticeable during the day, when standing or walking, as the urine gravitates to the neck or tender part of the bladder or prostate. The prostatic urethra, being, as a rule, the most sensitive part of the genito-urinary tract, is often rendered spasmodic by the acrid urine, and the unpleasant sensation of still more to be voided even after the evacuation of the bladder; or it may cut off the flow for a few moments, when it again relaxes, and allows the passage of a small quantity of the urine. The irrita- tion of the gland or bladder is frequently reflected to the kidneys, causing polyuria, that is mistaken by many for diabetes or Bright's disease. This condition may last a long time without effecting any organic disease of the kid- neys. Systemic disturbances are quite common, either as a re- sult of metastasis, or as a direct sequel of the diseased gland. Toxins or ptomaines emanating from the latent gonococci, and carried by the blood currents to the joints, nerves and serous membranes, induce metastatic rheuma- tism, neuralgia, peritonitis, perityphilitis or various other troubles from the back of the neck to a pain in the heel. As a direct or reflect neurotic disturbance, arising from disease of the gland, tlie sciatic nerve, or some of iti branches, is the most frequently affected. Pain over the hip or in the calf of the leg is common. This may also ex- tend to the back, and become so serious as to impair the use of one or both legs. There is often tenderness in the region of the perineum. 82 PROSTATE GLAND AND ADNEXA. or a dull heavy aching sensation, which is felt while stand- ing or sitting. I have known some who could not ride in a buggy with any degree of comfort; others who were ne- cessitated to carry rubber cushions, hollowed out in the center, around with them. The objective symptoms revealed by examination through the rectum is an enlargement of the gland, which gener- ally protrudes as an oval mass upon its front wall. If in- flammation of the gland coexists, there is either redness or lesion of the mucous lining of the bowels at that point. Upon examination with the sigmoidoscope (Fig. VII), the same condition of the membrane may be noted higher up, opposite the seminal vesicles, together with an inflamma- tory complication of the latter. Pressure upon the gland, through the rectum, deter- mines the extent of the inflammatory state which is usually reflected to the glans penis or perineum. It requires an experienced touch of the finger to determine whether this enlargement is due to a swollen condition (the result of passive venous stasis and soft infiltration) or to indurated hypertrophy. In the former, both lobes of the prostate are usually about equally swollen and tender, and, while somewhat firm to the touch, do not feel cartilaginous. The lobes of the gland appear more symmetrical, and are not nodulated. In indurated hypertrophy the portion of the gland that is involved is quite firm and in most cases feels nodulated, just as fibrous tumors as developed in any other organ of the gland (as in the mammary) might re- veal themselves to the touch. This subject will be con- sidered more fully in the chapter of senile hypertrophy of the prostate. COMPLICATIONS. The neck of the bladder invariably becomes involved, and is generally quite sensitive to the touch of an instru- & ENLARGEMENT OF THE PROSTATE. 83 ment or to the effect of acrid urine coming in contact with it. The inflammation is usually confined to a limited area of the mucous lining of the bladder immediately adjacent to the neck or base of the prostate, as illustrated in Plate II. But in cases of long standing, attended with much congestion and inflammation of the prostate, the trouble extends and may involve the entire mucous lining of the bladder. And as this condition of the bladder is the result of prostatitis, the latter must be relieved before any per- manent benefit can be expected in treatment of the former. In fact, I have found that in the large majority of cases the little benefit that would accrue from the antiseptic so- lutions in washing the bladder is more than counteracted by the ill effects of passing an instrument for the purpose, over an inflamed prostate. Besides, when the bladder is in the state to require such treatment, the urine is no longer aseptic, but the putrefaction of the exfoliated mu- cous favors pyogenesis. Andrews and others have demonstrated that the bacilli which inhabit only that portion of the urethra near the meatus and in the fossa navicularis, are constantly present and non-pathogenic in this region, but become pathogenic when carried by instrumentation to the bladder, and set up a muco-purulent discharge, when the condition of the urine favors such. Andrews further states that the use of antiseptic agents sufficiently strong to destroy bacilli in the bladder would be injurious to the tissue with which they come in contact. I have noticed in a great many cases where muco-purulent matter existed in large quan- tities in the urine, that the amount diminished as soon as the wash was discontinued and the inflammation of the gland was reduced. There are, however, cases in which the catheter is necessary to evacuate the bladder, and in such instances the use of some antiseptic solution in irrigating it is of great value. 84 PROSTATE GLAND AND ADNEXA. The urine in these cases is usually of deep straw color, of acid reaction and high specific gravity. Normally it is of slight acid reaction, greater in the morning when first voided after being retained through the night, less so about two or three hours after breakfast, when it may become neutral or slightly alkaline. Should it retain a strong acid reaction throughout the day, the condition is abnormal and irritating to any chronic or acute inflam.- matory tissue with which it may come in contact. The abnormal acidity of the urine in these diseases is due mostly to crystals of uric acid, which usually coexist with those of calcium oxylate. Aside from their chemic action, these fine needle-like crystals are mechanically quite irri- tating to mucous surfaces. Epithelia, mucus and pus are nlso present in proportions varying with the extent of prostatocystic involvement. In other cases phosphatic urine predominates. Here the urine is over alkaline and more than neutralizes the normal condition of acidity or even the excess as caused by uric acid. It is exceedingly acrid in its local effect, and, in connection with mucus and pus, favors the devel- opment and propagation of bacteria. It is usually of light color and, upon standing, has a flocculent mass of mucus and pus which are readily deposited. After some hours it has an exceedingly offensive odor; and, if urea be present in large quantity, ammonia is given off. Urea often exists in large quantities and is deposited in red or blood like crystals on the sides and bottom of the vessels. While these abnormal constituents of the urine are irri- tating and aggravate prostato-cystitis, yet they are the re- sult and not the cause of prostatitis. With alkaline phosphatic urine, some neurotic compli- cation is usually concomitant, especially in the case of pa- ENLARGEMENT OF THE PROSTATE. 85 tients who notice the deposit in the urine and associating it with Bright's disease, contemplate an early demise. As these abnormal conditions of the urine are only symp- toms, and not an idiopathic disease, the trouble which gives rise to them must be relieved before any permanent benefit will result. It is necessary however to remove, as far as possible, all properties of the urine that are irri- tating to the prostate, until the latter can be restored to its normal condition. Variations of the urine are symptoms of much import- ance in this disease, and should be given more than passing observation and chemic test. The epithelial cells, Bott- chers crystals, sympexia, and spermatozoa as revealed by the microscope, are symptomatic of special lesions, and in- dicate the complications that attend disease of the pros- tate. Thompson's and Goldenberg's two glass test, as well as Jadassohn's three, may be misleading unless subjected to microscopical examination. The first part of the urine passed into a vessel may contain a large quantity of float- ing shreds or glary mucus, and the latter part voided into a second vessel may be free from any debris. It would be evident that these shreds were washed from the urethra, but it is by no means proof that they originated there. Secretions from the prostate or vesicles escape into the urethra, pass along that canal until they become dried and cling to its walls. Mucus and other abnormal secretions, being of sticky material, form shreds of various size and fhape. Treatment confined to the urethra alone would never relieve the condition. In many cases treatment of the prostate alone would clear them up, while in others the vesicles too require treatment. In many instances. where the bladder is affected, a large quantity of mucus and pus appear in the urine, and especially when the ffland is swollen or enlarged so as to interfere with the 86 PROSTATE GLAND AND ADNBXA. thorough emptying of the viscus. Blood may also be pres- ent, either escaping from the prostate or urethra, or mixed with the urine. Dark colored urine indicates its presence, and signifies, in the majority of cases, the existence of a polypoid or vegetative growth protruding from the pos- terior prostatic wall. PROSTATIC CALCULI. There are certain concretions, so called- prostatic calculi, that form in the prostatic follicles and ducts after adult life. Sir Henry Thompson, who has described them fully, reports that, "of one hundred prostates examined, these bodies were found in all of them." In younger subjects they are very small and can be detected only by the aid of the microscope, while in older prostates they can be readily seen with the natural eye. They are entirely dis- tinct from renal or urinary calculi, which begin to form either in some part of the kidney or bladder and continue to develop, by accretion, until they may reach considerable size. The concretions of the prostate are usually small and rarely develop to a size larger than a pea. Inflamma- tory conditions of the gland, preventing the normal se- cretions, tend toward developing these bodies, just as a catarrhal condition of the bladder, and cystitis, produce urinary calculi. They are less firm than the latter, and are composed mainly of calcium and sodium phosphate, both of which substances are electrolytes, and are readily dissipated by interstitial electrolysis. Owing to their exceedingly small size, they very rarely give rise to trouble in young men; but in older men with swollen inflamed prostates, they act as foreign bodies press- ing upon the different portions of the sensitive gland, and give rise to irritation, which is manifested by frequent micturition, vesical tenesmus and pain in the region of the ENLARGEMENT OF THE PROSTATE. 87 prostate, perineum, glans penis or fossa navicularis. They are usually rough upon their surface, and, when they de- velop to the size of a pea, often give rise to prostatic ab- scess. Fig. XIII. shows a photo engraving of specimens of these concretions, that were passed by a patient sixty-one years of age, with an exceedingly tender and irritable prostate, during the evening following a treatment by cataphoresis. The urine was passed into a porcelain vessel, and allowed Fig. XIII. to remain over night. On the following morning it was poured off, the residue adhering to the vessel. The vessel was then rinsed with clear water and the residue was scraped from the bottom of the vessel, and preserved. It was firmly glued together by a muco-purulent admixture, which was broken apart in pieces of different sizes, as shown. There was quite a large quantity of these pieces, making in all about a drachm. The large majority of these were destro3^ed by experimenting upon them with the combined properties of different chemicals and electrolysis, in order to determine the agents that would be most active in their disintegration, and, at the same time, the least ir- 88 PROSTATE GLAND AND ADNEXA. ritating to the gland. The remaining pieces were pasted to a piece of dark paper and a photo engraving, or "haU tone," made from it, as illustrated. These experiments were carried out with a one per cent solution of chloride of sodium and water, as the conduct- ing medium, which is practically the same as that of the prostatic urethra, when the solution is applied to the gland. The experiments were first made with non-oxidizable electrodes, without medical agents, first the anode, then the cathode being used as active electrodes. These were made with mild currents of long duration, then strong for a short period, with due heed to the electrolytic changes of the conducting medium, and the presence of oxy-chloride at the anode as a result.- Oxidizable electrodes, of various metals, with the anode as active pole, were next tried. I then experimented with various medicaments, using both oxidizable and non-oxidizable electrodes, affecting thereby changes upon these deposits by means of cataphoresis and interstitial electrolysis. The conclusions at which I ar- rived by the experiments and chemical observance were that the concretions are subject to electrolysis. Cataphoric medicaments are only required to reduce any inflammatory condition of the gland which served to increase the cal- careous deposits. SYMPEXIA. In addition to the calcareous formations that are so generally present in the ducts and follicles of the con- gested prostate, there exists occasionally a lumpy, gelatin- ous substance of a whitish or light red color, called sym- pexia. These bodies vary in size from that of a small pea to twice that amount. They frequently become quite firm and provoke much local irritation of the gland and vesical neck, causing frequent and painful micturition, and even abscesses in the prostate, when thev become too firm and ENLARGEMENT OF THE PROSTATE. 89 large to pass ofE through the ducts. They have also been detected in the seminal vesicles, where doubtless most of them begin to form from pent up, unhealthy semen and the morbid secretions that result from the inflammatory condition of the vesicles. They no doubt assume their firmness in their tardy course through the prostate, where they mingle with the calcareous matter as formed in the latter. They do not pass at regular intervals, seldom daily, and usually follow the emptying of the bladder or the dis- charge of fecal matter while at stool. I have noted some cases where they would pass once or twice a week, then not again for a month. Wben they pass often, they are of lighter color and less firm than those that have been pent up in the gland for a longer time. Their mere presence causes great annoyance to many men who mistake them for semen. They may occur in any stage of prostatitis, in young men as well as older. I have noted them more fre- quently in young men, leading a life of continence, or in middle aged men of long standing prostatitis. THE LIVER. Just what relation the liver bears toward the prostate I am unable to state, but in common with other investigators, 1 have noticed that there is a functional disturbance of ilie former following disease of the latter. The liver per- forms the important role of being the chief organ in con- verting the insoluble uric acid into soluble urea; and, whenever there is a disease of the prostate, crystals of uric acid, often in large quantities, make their appearance in the urine. It is claimed by some that this arrest of the function of the liver is due to nervous reflexes provoked by disease of the prostate. CHAPTEE V. SEMINAL VESICLES. The seminal vesicles and prostate, owing to their con- liguous relations and allied functions, and to the fact that the latter is tunneled by the ducts of the former, are in close pathologic relations. As the swollen prostate must inevitably encroach by pressure upon the ejaculatory ducts, limiting thereby their elasticity and diminishing their cal- iber, increased exertion is necessarily required to expel the semen through the narrow channels; and, should these or- gans be inflamed or tender, pain would follow the ejection of semen during or immediately succeeding sexual inter- course. The pain is usually felt in the region of the perin- eum, lower part of the rectum, or along the course of the vas deferens in one or both sides of the groin. RECTUM. With the exception of the neck of the bladder and sem- inal vesicles, the rectum is most frequently involved as a result of chronic prostatitis. The part most often affected is the front surface immediately opposite the prostate. Inflammation of this organ, owing to its close proximity to the rectum, readily extends to the latter. The plate shows the position where it most often occurs. If the in- flammation is of short duration and the gland is only slightly affected, the rectum at this point will show a con- dition of redness, with only a limited protrusion of the prostate, and without abrasion of the surface of the mu- cous membrane. In cases of long standing prostatitis, where there is considerable protrusion of the gland into the 90 SEMINAL VESICLES. 91 rectum, there is, as an almost invariable result, lesion of the mucous surface, and this being constantly irritated by the passage of fecal matter, in turn reacts upon the pros- tate, serving to increase the irritation and inflammation of the latter. Fig. XIV. KIDNEYS. The kidneys are very rarely involved, although the pain in the lumbar region of the spine, together with the turbid urine, often leads one to suspect such disease. The pain felt in the lumbar region, at about the fourth or fifth vertebra, has no connection with the kidneys, though it is usually spoken of as "pain in the kidneys." This pain is in the center of the back and very low down, while that of the kidneys is much higher, on each side, and beneath the borders of the lower ribs, as illustrated by Fig. XV. 92 PROSTATE GLAND AND ADNEXA. The inflammation occasionally extends from the pros- tate to the bladder, thence through the ureters to the pelvis of the kidneys, provoking pyelitis, and even inter- stitial nephritis. Some twelve years ago I attended a case, of fifteen years' standing, suffering with stricture, prostatitis, cystitis and nephritis. The trouble extended to the pelvis of the left kidney, and subsequently to the entire organ. Suppura- tion ensued, which was followed by an abscess on the back over the left kidney. The abscess had formed, and had been evacuated three times during the preceding two years, before I saw the patient. He had suffered constant pain in that kidney, and was in very bad health. The abscess formed, and was evacuated only once during the early stage of my treatment. He afterwards became strong and healthy, and lived eight years. I never saw him during his last illness. His death was reported as due to nephritis, though no autojosy was made. TBEATMENT. The treatment of chronic congested enlargement of the prostate gland is somewhat similar to that described in the former chapter on prostatitis. One must take into consideration the age and health of the patient, the degree of discomfort to which he is subject, the extent of com- plications, tenderness or inflammation of the gland itself, urethra or rectum, and the urgency or necessity for the relief of any conditions from impending danger to life. There are only two ways by which we can reach the prostate for direct treatment, viz., through the urethra or rectum; and as these organs are so closely related to the prostate, both by contiguity and continuity of structure, and are in such close sympathetic relation with it, they are generally pathologically involved. They therefore SEMINAL VESICLES. 93 Fig. XV. 94 PROSTATE GLAND AND ADNBXA. require treatment in order that tlie prostate may be reached without causing pain or inflammation to these channels, for the inflammation is liable to extend and in- crease the already existing trouble of the gland. So my first step is to give relief to all symptoms of an urgent or dangerous nature; then allay, in so far as possible, all inflammation of the urethra and rectum, by rendering the passage of urine and fecal matter over these tender, and probably abraded surfaces, as non-irritating as possible. Diet. — In ordinary cases I rarely restrict my patients in their diet, except in regard to particularly indigestible food, such as cabbage, pork, cucumbers and the like. I do prohibit alcoholic liquors while the patient is under treatment, and especially fermented ale, beer or wine, as they directly tend to disturb the circulation, liver and kidneys, causing an excessive precipitation of uric acid, and biliary discharges, and increasing local irritation to the urinary and rectal passages, and in particular to the prostatic urethra, and neck of the bladder. I have mentioned in a former chapter that I began the radical treatment with my urethral electrode No. 1-1, A, which is passed down the urethra gently, after having previously made the electric connections before described, and with three to five milliamperes in the circuit. During the first treatment the application should not last over one or two minutes, and the electrode should be passed over the entire surface with the current in the circuit, to rid the canal of whatever granulations might exist at any point in its course. Cataphoresis should not be used dur- ing the first treatments, and if the urethra or pjostate is very tender, the electric treatment should not be given oftener than every third, fourth or even seventh day. Cathodal applications should always be used during the first few times. SEMINAL, VESICLES. 95 As a rule blood will not be produced by these treatments, if the preliminary steps are attended to. But it occasion- ally happens that some highly congested granulations or vegetative growths are denuded from the surface of the prostatic urethra; in which case a drop or two of blood may follow. No harm will result, but the operator should be warned thereby not to apply the electric treatment too often or with too great strength. I usually follow up such a condition with an injection of verbascum, if it had been discontinued; then two days afterwards with the bougie, with benzoinol, or an ointment of the extract of verbascum and benzoinol, which is quite soothing. At other times I use with mild electrolytic applications a mixture of ben- zoinol and verbascum with electrode No. VIII. Cata- phoresis is only slightly effected by this means, as osmosis of oils without emulsification does not take place. Only a local soothing effect is produced, but the oil has the additional property of protecting the surface for a time from the irritating secretions that may occur. It is also essential to have the patient void urine just prior to the treatment, then to remain upon his back for a few minutes afterwards, that the urine, by gravity, may remain away from the vesical neck, or prostate, until what- ever irritation may have been caused by treatment has subsided. All of these points, however trifling they may appear, require careful consideration in view of the tender and inflamed condition of the gland and adjacent organs. After the acute symptoms have subsided, cataphoresis can be employed with impunity. This is effected in two. ways, first by means of liquid medicines, as illustrated by Fig. X ; secondly, by , anodal applications of oxidizable electrodes. The latter is accomplished by using a metal point to an electrode of copper, zinc or iron, when there will form the oxy-chloride of copper, zinc or iron. Each 96 PROSTATE GLAND AND ADNBXA. of these excites a quite sharp, burning sensation and should be applied only directly to the seat of the trouble^ which is usually on the floor of the prostatic urethra. These new substances of oxy-chlorides of copper, zinc or iron, after forming, will penetrate the gland by following the direction of the current, from positive to negative, and cause a dull aching sensation throughout the region of the prostate, perineum or rectum. They should be given only a short time and with a mild current, especially during the first few treatments. The electrode will adhere to the tissue, and should not be removed until the current has been reversed for one or two minutes, when it will loosen. An acute discharge often follows such applications, and the patient should be advised of the fact, or he may sus- pect that he has an attack of gonorrhea or that he has been infected by the instrument. Obstinate chronic cases are much benefited by this method of treatment and yield more readily through conversion of the chronic into an acute state for the time. Injections of ten to fifteen per cent of verbascum or argyrol readily allays the acute condition. Instruments should never be passed into the urethra daily, and from the very beginning of treatment the rec- tum should ' be carefully examined. Should it be very tender, as is often the case at first, suppositories of boric acid and aristol, five grains each, inserted night and morning, will soon put it in condition for examination by speculum or sigmoidoscope without anesthetising the patient. I alternate the treatment by giving rectal appli- cations, as illustrated by Fig. XI, on the days following the urethral treatment. I began the rectal treatment by using the secondary faradic current, interposing at the time, into the circuit from two thous^d to twenty-five thousand ohms resistance. This treatment is very sooth- ing, and, in most cases, affords instant relief from any SEMINAL VESICLES. 97 uncomfortable feeling that may exist in the region of the perineum, rectum or prostate. Medicinal applications are made to the rectum at the same time. While the oscillating molecular movements, as induced by the current, favor absorption of the medicines, yet eataphoresis is not effected thereby. The benefit accruing from the secondary faradic current is chiefly, if not wholly, that of its mechanical action; and, owing to the close proximity of the pole to the gland, as shown by Fig. XI (the current being concentrated and flowing only in that direction), the extremely rapid vibratory motions exerted upon the molecules of the morbid tissues so dis- turb them as to cause their absorption l^y capillary attrac- tion. This may be illustrated by placing medicine of any kind upon the skin of any part of the body and rapidly rubbing it, absorption takes place much more quickly than if the medicine remained quiescent. Fig. XVI illustrates the application of a longer elec- trode to the seminal vesicles. Gentle backward pressure exerted by the fingers upon the lower end of the electrode causes similar movement of the upper end upon the vesi- cles, and produces mild contraction of the latter. This has a soothing effect upon these sacs, and at the same time rids them of their morbid contents, reducing the inflammation of the organs, and that, too, without pain. To procure the best results, this application must be made with ten thousand ohms resistance interposed. After all acute tenderness of both the prostate and vesi- cles has subsided, I apply to both organs the sinusoidal current in the same way, and with high resistance inter- posed, as before described. This current as explained in Chapter VIII both acts mechanically as the faradic, and also exerts a magnetic influence upon the atoms of the tissues, causing molecular disturbance by the attractive 98 PROSTATE GLAND AND ADNEXA. and repulsive power of unlike and like, so as to favor their solubility and absorption, and their expulsion through the medium of discharges from the gland. It also exerts a strong germicidal effect. Fig. XVI. Whatever causes the pathological condition of the pros- tate — whether it is the inhabiting of its mucosa or cellular tissue by latent gonococci, or bacteria adapted to the locality of its special epithelial lining — it is certain that diffusion of medicinal agents by cataphoresis, and inter- stitial electrolysis within the gland, disturbs these germ? by rendering their habitat inimical to their existence. SEMINAL. VESICLES. 99 Just how this is accomplished it is somewhat difficult to explain; but bacteriologists have demonstrated that the gonococci favor an alkaline medium, but whether the}^ are destroyed by cataphoric diffusion of anions, as of acids, oxygen, etc., or die from lack of a suitable medium, when the gland is aroused to activity, or the dynamic effect especially of the sinusoidal, or -directly as the result of electrolysis as induced by cataphoresis, I cannot state; but I do know, as a fact demonstrated by numerous re- sults of such treatment, that the pathogenic condition is changed, the morbid discharges are arrested, and the patient is restored to health. To know the precise result of such treatments is more gratifying to me than to dis- course at length upon some far-fetched scientific theor)^ The method as here detailed effects all that can be accomplished by digital manipulation of the prostate or vesicles; and, too, without irritation, I often have com- plete emptying of the vesicles follow rectal treatment by means of the sinusoidal application. Infiltration or thick- ening of the rectal mucosa also occurs around both the prostate and vesicles, when the disease is of long standing, which is readily dissipated by this treatment. Treatment of the prostate and vesicles through the rec- tum can be given oftener, stronger, and of longer duration than through the urethra. MEDICINAL TREATMENT. But little constitutional medication is requisite. In some cases where acute symptoms exist, it is necessary to control them for the time until the cause is removed. An acid condition of the urine serves to maintain it in an antiseptic condition, unless the acidity be in excess of 0.43 as determined by acidemetry. In such cases citrate of potassium, or some lithia water or salt, gives relief. I 100 PROSTATE GLAND AND ADNEXA. concur in the view, as expressed by Finger, that the indis- criminate use of alkaline mineral waters in these cases is pernicious. There is a tendency, after passing middle age, to the accumulation of earthy salts in the body (which is conducive to senility, and the constant use of such waters adds to the evil). Besides changing the urine from its normal acid reaction to that of alkaline, it favors the development of bacteria. When the urine is of light color, and alkaline in reac- tion, whether due to excessive phosphates or to the decom- position of mucus and pus, cystogen, in five-grain doses, three or four times daily, is indicated. When it is admin- istered it liberates formaldehyde, and acts by controlling to a limited extent the development of bacteria. It should not be continued any great length of time, as it becomes irritating to the bladder and vesical neck. These remedies are only intended to give temporary relief until the cause is removed, which is the relief of the prostate and vesicular troubles. The bladder is very rarely diseased per se, but is almost invariably the result of the extension of inflammation from the prostate and uretlira, or to the obstructive flow of urine by the enlarged gland. Diuretics are only indicated where there is an appear- ance of symptoms of uremic toxemia, scantiness of urine or an excessive quantity of urea. Many suffering from long-standing diseases of the pros- tate become anemic, and the necessity for hemogenic agents arises. For this purpose I have relied upon citrate of iron, which is less irritating to the stomach than most of the other chalybeates. These remedies are only intended as valuable adjuncts temporarily until radical relief of the gland is effected. Fig XVII. illustrates an electrode, as devised by the SEMINAL. VESICLES. 101 author, that marks a new era in the treatment of varico- cele, orchitis and their sequels, impotency, etc. It con- sists of an insulated cup-shaped receptacle, near the bottom of which is a metallic binding post for the attach- ment of a cord from a battery. On the inner side of the cup and attached to the binding post is a copper plate, XVII which serves the purpose of diffusing the current through- out the fluid as contained within the cup. When in use the electrode is filled to about four-fifths with plain or medicated water, and the entire scrotum and testicles are immersed therein. That portion of the electrode to which the cord is attached is placed in the rear and pressed firmly against the perineum to prevent the escape of the fluid. A large sponge electrode, seven or eight inches in 102 PROSTATE GLAND AND ADNEXA. diameter, is placed over the lumbar region of the spine. This is better accomplished by the patient sitting in a chair with a thick book at the back so as to press the electrode to the spine. The current is then increased to the desired strength, care being observed not to cause shock. The current thus applied charges the fluid in the elec- trode, which passes up through the spermatic cords and other organs, acting as a tonic to the muscular and dis- tended coats of the veins, causing their contraction, there- by relieving their turgescence and tenderness, and giving tonicity to the cords and scrotum, which enables them to support the testicles and maintain them in their normal position without the aid of a suspensory bandage. Where there still remains impotency or depression of the genital organs after relief of prostatitis, the current thus used, passing through the genito-spinal center and the genital organs, will often restore their normal func- tions after everything else fails. This method of treatment does not act as a stimulant or excitant of the genital organs, as do some medicines, to be followed by subsequent depression, but serves as a tonic and restores natural vigor. Fig. XYIIIa illustrates an instrument also devised by the author for the special treatment of the prostate and vesicles through the rectum. The upper electrode part is insulated about two-thirds and is screwed to the vibrator. It is five inches in length and when inserted may be passed up so as to come in apposition to the entire vesicles; or withdrawn and concentrated upon the prostate alone. The vibrations can be regulated from 3,000 to 10,000 per minute. The instrument is indispensable in the treatment of vesiculitis, as there are no other means known to science that will reach these organs. It has been attempted to Fig. XVIIIa. PROSTATE GLAND AND ADNEXA. treat them by finger massage, but it is well known to any one familiar with anatomy and the position of these organs that the fingers are too short to reach them. Be- sides, it is patent to any one familiar with these troubles that simply the introduction of the fingers for the treat- ment of the prostate and vesicles is nothing compared in utility with the high vibratory action of this instrument. When properly used, it is painless, and in some instances very soothing. Its after-effects are very marked. The cases where the instrument is specially indicated is chronic vesiculitis, chronic inflammation of the prostate and neck of the bladder, impotency, and atony of all these organs. In long standing inflammation of the bladder, prostate and vesicles they lose their tone and become partially IJaralyzed, and there is nothing that so aroused normal activity as the use of this instrument. If these organs are at all tender, the upper end of the instrument must be directed back from the vesicles and the vibrations made slowly. These can be increased from 3,000 to 5,000 or on up to 10,000, as improvement in the way of diminished in- flammation progresses. To one not thoroughly familiar with the electric current it is much better to use the instru- ment alone, but there are many cases of vesiculitis where the sinusoidal current used in connection with the rapid vibrations greatly enhances its utility. There are many cases whereby the slightest pressure, not enough to give pain when pressed gently against the vesicles, completely empties them of a muco-purulent discharge. At times, shreds and tube casts pass off in the discharge. Why I state 102b PROSTATE GLAND AND ADNEXA. that tlie instrument is indispensable in tlie treatment of these troubles is^ that I had never been able to thoroughly relieve chronic vesiculitis and impotenc}" as a result of an impairment of the functions of these organs, until I began the use of this instrument, nor have I kno"^vn of any other means. When used in connection with either the sinu- soidal or high frequency current, it destroys any gonoeocci or other micro-organisms that infest the vesicles. Before I began the use of this instrument in the treatment of vesiculitis, I was almost at sea, but now I undertake their cure with as much confidence as that of any other organ. The use of this instrument takes the place of finger massage which was so highly lauded a few years ago, and even now it is still being practiced by some physicians. The advantage of the mechanical massage alone is one thousand to one over finger massage, and with the con- joint use of the sinusoidal or high frequency current it is two thousand to one. Case YII. — Peostatic Enlargement and Melancho- lia, Obscure Origin. Bachelor; forty-eight years of age; weight one hun- dred and seventy pounds. He had practiced masturbation in early life moderateh' — ^never had gonorrhea. Always lived in a small town and had been successful in business. Up to his forty-fifth year he had been in good health. About that time he began occasionally to pass sleepless nights, and grew gradually worse. This continued for about one and one-half 3-ears, when he became melancholy 102c SEMINAL. VESICLES. 103 and despondent about his business. His brother had noticed, at times, mental aberration, and, after consulting the family physician, decided upon placing him in a sani- tarium. The patient tacitly consented to go, but on the evening before the day of departure, he surreptitiously left his home, and wandered about from place to place for more than a month, when, upon incjuiring for a physician, he was directed to me. He was very secretive as to his family and home, but talked very intelligently and freely about himself, his wanderings, habits and the foolish things he did that induced his brother to think he was verging upon lunacy, and of which he himself was . cognizant. The subjective symptoms pointing to disease of the gland were quite meager, and he was loth to submit at first to an examin- ation. The urethra was very sensitive throughout its length, and, in the prostatic part, quite painful to the touch of the flexible bougie. The gland protruded into the rectum to the extent of flattening fecal discharges. Digital pres- sure upon the jorostate through the rectum caused an aching pain in the region of the perineum and bladder. He was treated alternate days with a flexible bougie that entered the bladder easily. The faradic current was used, each intervening day, through the rectum with ten thousand ohms resistance. The inflammation of the pros- tate and urethra readily subsided after ten days' treat- ment, when cataphoresis to the prostate was instituted, both through the urethra and rectum with ten per cent strength of acjueous extract of verbascum. His recovery was rapid, and at the end of the first month he was sleep- ing normally, and his mind restored. The treatment was continued two months to reduce the enlarged gland. Ee- covery was permanent. 104 PROSTATE GLAND AND ADNEXA. Case VIII. — Prostatitis, Vesiculitis. Rectal Ulcer- ation. Bachelor; aged forty-four, had first attack of gonorrhea at twent5^-two, which was quite severe, and continued for several months, finally terminating in gleet, and, as he thought, stricture. He had several mild attacks of acute gonorrhea, the gleet continuing during the interim. He had been treated several times for stricture with sounds. He suffered constantly with his back and limbs, and had made several trips to Hot Springs, Ark., for rheumatic arthritis. He was always benefited by the Hot Springs baths, but the pains would recur in from four to six months thereafter. Upon examination I found the urethra slightly tender an inch back of the meatus, and upon tho lower surface. The other portions of the canal were healthy, except the prostatic; which was very much in- iiamed. There was no organic stricture, nor do I think he ever had any, though he had been advised several times to submit to an operation for such. The long standing granular inflammation of the prostatfc urethra, with the enlarged gland, had encroached upon the caliber of the canal at that point, narroAving it and obstructing the free flow of urine, at times, when it was acrid ; and also the free entrance of an instrument to the bladder. The gland was swollen as determined through the rectum, and painful upon pressure, which was reflected to the gians penis. Both lobes of the gland were equally involved. Immediately opposite the prostate, upon the front rectal surface, was an elliptical ulcer an inch and one-half long and three-fourths of an inch wide. The vesicles were also tender, and the rectal mucosa opposite them was inflamed and thickened but not abraded. After several examinations of prostatic expressions gonococci were finallv discovered. SEMINAL VESICLES. 105 The acute symptoms were treated as before detailed, which was followed by cataphoresis, using one per cent solution of ichthyol, through the prostatic urethra. The prostate and vesicles were treated at first with the second- ary faradic, followed with the sinusoidal current. The ichthyol had a very happy effect in this case, and was the only remedy used. Eecovery was rapid, and there has been no return of jDains ; it has been three years since. Case IX. — Enlarged Prostatitis, Cystitis. Bachelor; aged sixty-nine; robust, had led an outdoor life. He had gonorrhea in early manhood, and quite a number of attacks thereafter. He had suffered with his bladder and prostate for fifteen years, and had been treated by massage of the gland, sounds, irrigation and cautery applications to the deep urethra. He had just left a genito-urinary specialist when he consulted me, who had treated him with large sounds daily for six weeks. He was suffering with frequent and painful urination, voiding it on an average of every thirty minutes during the da}^, and hourly at night. The urine was of light color, laden with mucus, pus, urea and of ammonical odor. I did not attempt an examination at this stage, but gave him five grains of cystogen every four hours, alternating with twenty minims of the normal tincture of hyoscyamus to the drachm of triticum repens. In conjunction with this, a suppository, containing ten grains of boric acid and one-half grain of belladonna, was introduced into the rectum night and morning. Eest in bed was also enjoined. After three days the acute symptoms had been allayed, when an examination revealed a congested enlargement of the prostate, prostatic urethritis, and cystitis. He had been washing out the bladder with boric acid daily, which I had him discontinue. lOG PROSTATE GLAND AND ADNBXA. He was treated similarly to those before described, after acute symptoms had been allayed. His improvement was rapid, and at the end of the third month the urine was cleared up, and voided about four times during the day and once through the night. He would occasionally pass the night without having to get up, then again he would have to pass his urine twice in the night. After his return home he continued to improve until conditions were about normal for a man of his age. Five years later he began having some difficulty in start- ing the flow of urine; then periodical hemorrhages would occur. By cystoscopic examination I detected a sma'U vegetative growth, almost the size of the end of one's small finger, attached to the lower part of the neck of the blad- der. It was highly vascular and would bleed freely when touched. Its free extremity floated about the vesicle ori- fice and acted as a valve that at times shut off the flow of urine. I had an electrode made, the metal part of which hooked around the tumor, so as to affect it only ; the metal end of the electrode was perforated that medicinal reme- dies could be applied, thus procuring the combined effects of electrolysis and cataphoresis. After the third week's treatment it ceased to bleed, became less tender and showed much atrophy. Six months afterwards hemorrhage again recurred. Cystoscopic examination revealed a short pedical of the tumor with an abraded surface. This was promptly healed and he has had no further trouble with it. Similar patients have come under my care, suffering with vegetative, polypoid, vascular or semi-fibroid tumors protruding from the base of the prostate into the bladder, which act as a valve to obstruct the passage of urine. Some of these cases have yielded readily to the treatment as described; others have been persistent and unyielding. Those that have proven so rebellious to treatment have been of fibrinous character. SEMINAL VESICLES. 107 It has been necessary, in some of the latter, to use the electric cautery, as illustrated. (Fig. XVI.) Case X. — ^Cheonic Enlaeged Prostatitis, Vesiculitis, AND Cystitis. The patient was seventj^-two j^ears of age, costive, con- stant pain in back and perineum, the latter necessitating his using a rubber cushion, hollowed out in the center, to sit upon. The urine was alkaline, heavily laden with mucus and pus, one-fifth of which would be a semi-solid mass upon settling; and, at times, strongly ammoniacal. Fecal matter passed in lumps or flattened. He had been treated by the usual methods, with sounds and irrigations. The prostate was very large but not tender upon pressure. The vesicles were similarly affected. The prostatic urethra was quite tender. He had a constant urethral discharge. Urethral and rectal applications were used to the pros- tate for six weeks. The improvement was most marked in every way. He returned home, where he remained two months, then came back for further treatment. He was now able to ride about in his bugg}', dispensed with his cushion, but was still unable to evacuate his bowels with- out the use of medicines. There was only a trace of sedi- ment in the urine, and the urethral discharge was scarcely perceptible. He remained under treatment four weeks at this time. The prostate was reduced almost to normal, the urine had changed to an acid reaction, free from sedi- ment, and with specific gravity of 22. He was free from pain. He returned home and I did not see him again for two years. He had been comfortable during all this time, with the exception that he occasionally had quite copious and irritative urethral discharge. Upon examination at this time I found the prostate, about normal in size and non-sen«itive. The vesicles were tender, and the rectal 108 PROSTATE GLAND AND ADNEXA. mucosa surrounding them thickened, and unduly red. Applications of five per cent strength of picric acid was used directl}' to the vesicles with the sinusoidal current daily. The first treatment was followed with diminution of the urethral discharge. This discharge had also ren- dered the prostatic urethra tender, which required similar treatment. At the expiration of two weeks he was dis- missed. I heard from him some time after he returned home, stating that there had heen no return of the dis- charge, and that he was riding horse-back averaging fifteen miles, almost daily. Case XI. — Congested and Enlarged Prostate, Ureth- ritis, Eheumatig Arthritis. Married; good physique; aged forty-eight. He had been confined to bed for four or five months prior to seeing me, with polyarthritis. He had been dosed with all the rheumatic remedies about which the profession have any knowledge, with only temporary relief. There was little or no swelling of the joints, but they were attended with much pain and creaking when moving them. He was unable to dress himself, but was able to walk about. The prostate gland was very tender, both through the urethra and rectum. There was no apparent urethral discharge, though the prostatic part of the canal was very sensitive. He began improvement after the first week, and the stiff- ness and pain in the joints left him at the end of three months' treatment of the prostate and vesicles by cata- phoresis. Case XII. — Enlaeged Prostatitis, Cystitis, Eheu- matig Arthritis. Bachelor; aged thirty-eight, of robust physique. Had gonorrhea at twenty-two, followed by several attacks. For SEMINAL VESICLES. 109 eight years he suffered with frequent micturition, both day and night. There was little or no discharge. He began suffering at first with pains in his hips and calves of legs; then in his wrists and shoulders. There was no swelling of the joints. He was occasionally troubled with fortuitous seminal discharges, which was followed by impotency. The prostate was only slightly enlarged, but quite ten- der, both through the urethra and rectum. He was treated at one time with sounds, but more recently by massage of the prostate. The latter was very painful to him. Four weeks' treatment by means of cataphoresis effected a per- manent cure. Case XIII. — Enlarged Prostatitis,, Cystitis. Pros- tatic Calculi. A mechanic, aged sixty-two, married. Xo gonorrheal history. He had never taken a drink of alcoholic liquors nor used tobacco in any form. Up to his fifty-fifth year he was free from any symptoms of disease of the bladder. prostata or kidneys. About that time he began passing urine more frequently than normal and it became notice- able when chilled, or his feet were wet, that it irritated his bladder, which necessitated him to evacuate his bladder more frequently, both day and night. He resorted to the ordinary domestic remedies with temporary relief. Sub- sequently he began, during paroxysms of dysuria, to pass some blood at the cessation of the flow. The hemorrhage became more marked in time, and was accompanied with pain in region of the perineum and bladder. All symp- toms increased in severity, compelling him to seek relief. He then consulted a genito-urinary specialist, who began the use of sounds. This aggravated his symptoms. He next underwent the Bottini cautery operation. This was 110 PROSTATE GLAND AND ADNEXA. followed by some temporary relief, when he relapsed into still worse condition than before the operation, and was confined to his bed for several weeks with some form of fever. On recovering from the fever he came to me for treatment. He was very much emaciated, anemic, and voiding urine on an average, during the day, of every fifteen minutes, and at night about every forty minutes. He suffered with constant pain in his back. The urine was strongly alkaline and contained a heavy sediment of mucus and pus, of ammoniacal odor, and occasionally tinged with blood. I began treatment by giving him five grains of cystogen three times daily, and ten minims of normal tincture of hyoscyamus every three hours during the day. Locally, I applied benzoinol to the urethra, and the secondary faradic current, with fifteen thousand ohms resistance, to the pros- tate through the rectum. He was also given a suppository containing ten grains of boric acid and three-fourths of a grain of extract of belladonna at night. This treatment rendered him much more comfortable, and prolonged the intervals of micturition. At the expiration of two weeks his condition was so much improved that I began the use of cataphoresis through the urethra, and the sinusoidal applications to the gland per rectum. This treatment was continued regularly for two months, with marked improve- ment. He returned to work handling heavy machinery, and I did not see him again for three months, when he returned with the same symptoms somewhat aggravated. Treatment was again resumed with variable results: at times there would be much improvement, then he would relapse into his former condition. During all this time, however, he was continuously at work carrying heavy machinery. One day following a treatment of urethral cataphoresis to the SEMINAL VESICLES. Ill prostate he passed quite a quantity of prostatic concre- tions, varying in size from a pin point to a mustard seed, as illustrated by Fig. XIII, page 87. He finally became discouraged with my treatment and sought the advice of another physician. I did not hear anything further from him, but about one month thereafter I incidentally noticed an account of his death in a hospital as a result of an operation. I never learned the nature or purpose of the operation. Case XIV. Was similarly affected to that of the foregoing. He, too, had been operated upon with the Bottini cautery and by the same physician. On the fifth day after the opera- tion he had a violent hemorrhage which lasted several hours, rendering him unconscious and almost pulseless. The hemorrhage was finally controlled after many hours' work by the physician. This patient was treated in similar way to the preceding one, and improved more rapidly. In fact, he was so far relieved of irritation about the bladder and prostate that I thought at one time he would ulti- mately recover, but he, too, had some operation performed upon his bladder or prostate, and I have never since learned the result. In these cases there were no indications for the Bottini operation ; and I do not hesitate to state that it was made, as I have known of others, in an empirical manner, with- out reference to the exact diagnosis of the condition of the prostate. The bleeding, as result of the operation, relieved for a time the congested state of the gland, and it, together with long rest in bed, relieved temporarily the inflamma- tion, but at the expense of the irreparable injury to the gland, as denouement of the cut and cicatrix. The only indication where such an operation is at all justifiable is 112 PROSTATE GLAND AND ADNEXA. in those cases where an obstruction forms at the neck of the bladder by way of a firm fibrinous band; or, in other words, wliere there is a development of the third or middle lobe of the prostate. When the latter condition exists to such an extent as to obstruct the flow of the urine, it may be severed with little danger to life, either directly or indirectly, and especially after the case has been prepared for such an operation by the reduction of acute congestion and inflammation. This treatment will be considered more at length in the succeeding chapter under the treatment of the hypertrophied prostate. Case XV. — Prostatitis, Vesiculitis, Peostatic Urethritis, Sympexia, Hemiparesis. Merchant; married; aged fifty-five; gonorrheal his- tory. He had been treated several times by means of sounds, massage of the prostate, internal medication, etc., — the same result. Examination showed an enlarged and inflamed prostate, perivesiculitis and inflammation of the neck of the bladder. The right leg became impaired and grew gradually worse; then the arm and hand on that side followed after a year's existence of the trouble. There were various shaped lumps of a tenacious character that passed from the urethra, at times following the evacuation of the bladder in the last efforts to expel its contents and again on evacuating the bowels when costive. There was a perverted sexual pro- pensit}^, often a previous discharge of semen during sexual congress, then again a condition of inertia. The gland was enlarged and inflamed, the rectal mucosa, around the vesicles, was thickened and unduly red. The prostatic urethra was very tender. The lumpy discharges (sympexia) consisted of mucus, calcareous matter and disintegrated semen. SEMINAL VESICLES. 113 He was anemic, emaciated, costive and dyspeptic. Cascara was given to relax the bowels. Cataphoresis was given by way of urethra and rectum, through the prostate, after the preliminary course to relieve acute symptoms. Complete recovery followed five months' course of treat- ment. The lame leg was somewhat sluggish and heavy for a year afterwards, but finally regained its normal condition. Case XVI. — Enlarged Prostate, Cystitis. Farmer; aged sixty-one; married. He had gonorrhea in early youth, but recovered from it with little incon- venience. He had little or no trouble until about in his fifty-fifth year, when he noticed the necessity of evacuating the bladder more frequently than natural through the day; and having to arise once or twice during the night. This continued, worse at times, then better, until he began pass- ing some blood with the urine, during the periods of exacerbation. In addition to the enlarged and con- gested gland the cystoscope revealed some small vegetative growths about the size and shape of the tip of a sharpened pencil. These were touched with a very small quantity of crystal phenic acid, then dried with a piece of absorbent cotton so as not to smear the acid over a large area. Cata- phoresis was. then used, and recovery followed. The man grew to be quite robust. CHAPTER VI. HTPEETROPIIY OF THE PROSTATE. True hypertrophy of the prostate consists chiefly in indurated enlargement, as an outgrowth of the muscular fibers of the gland. The pressure as exerted by this adven- titious tissue upon the blood vessels and gland tissue per- verts their function, and ultimately induces parenchy- matous inflammation of the entire gland. This form of disease is characteristic of old age. It rarely occurs in men under fifty-five, and more frequently after having passed sixty. Sir Henry Thompson places the time of life at which it most frequently occurs at from fifty-five up to seventy, but that it rarely develops after seventy. Dr. Keys places the time of its usual appearance after fifty. It must not be inferred, however, that in all men past fifty-five, who suffer with prostatic disease, it is senile hypertrophy; but on the contrary, more men suffer from congested enlargement, during that period of life, than from a hypertrophic induration of the gland. While this disease is characteristic of old age, yet excep- tional cases occur at a much earlier period of life. It is quite common among physicians to accredit all forms of diseases of the prostate to hypertrophy and place the time of its occurrence anywhere from twenty-one up. In fact many chronic urethral diseases that have proven rebellious to the ordinary methods of treatment have been pro- nounced hypertrophy. It might be likened to Fothergill's interpretation of rheumatism, which, as he states, "in- cludes the lightning pains of locomotor ataxia to the boring sensations of syphilitic ostitis." 114 115 XVIII. Fix. XVIII. illustrates a condition of true hypertrophy of the prostate, showing extensive growth of the third lobe, which so encroaches upon the neck of the bladder as to occlude the flow of urine. It also shows an extension of inflammation to the bladder, vesicles and rectum. 116 PROSTATE GLAND AND ADNEXA. Clinical experience has demonstrated that the large majority of men troubled with prostatitis even past fifty do not suffer from hypertrophy of the gland, but of con- gested enlargement. I have treated and cured many men suffering from the latter, that had been treated for senile hypertrophy and pronounced incurable. Such errors have not been confined to the general practitioner, but many had been treated by some of the leading genito-urinary specialists CAUSES. ' The etiology of the disease has never been definitely determined. Several of the French writers have consid- ered it analogous to the atheromatous condition of blood vessels, heart and other structures of the body, due to old age, and as result of undue accumulation of the earthy salts from the impaired functions of the eliminative organs. The various hypotheses as advanced by different writers upon the subject are wholly speculative. It cannot be due to over use of the organs, congestion, or inflamma- tion of the gland of long standing, though the latter evi- dently tends in some instances to convert soft infiltration, as a result of such inflammation, into firm fibrinous struc- ture; yet I have known of numerous men who suffered more or less with prostatitis for twenty-five or thirty years, but were free from fibrinous induration of the gland. Dr. Keyes says : "The prostate is analogous to the uterus in the female, in regard to the nature of the muscular tissue, which composes it, and this analogy is further borne out by the tendency of both organs to develop fibrous tumors (so called) after middle life." The morbific changes that take place are not uniform, as in congested enlargement of the gland, but are usually nodular, or one lobe may be affected, independently of the HYPERTROPHY OF THE PROSTATE. 117 other. The muscular band at the neck of the bladder is almost invariably involved, sooner or later, forming a firm bar which serves to obstruct the flow of urine. This often marks the chief subjective factor in the first stage of the disease. Later this bar may develop to such an extent as to cause retention of a part of the urine, which undergoes decomposition, inducing thereby local irritation of the bladder, tendency to the development of calculi, or sepsis. Subsequently as the induration increases, it presses upon the vessels and gland structure until congestive inflammation supervenes. The abundant anastomosis of the veins of the prostate and bladder, with those of the hemorrhoidal, causes venous stasis in the rectal mucosa resulting in the formation of tumors, or an abraded mucous surface within the rectum. SYMPTOMS. The symptoms must necessarily vary with the extent of the disease, and most of them are similar to those of con- gested enlargement of the gland as heretofore described. The enlarged gland generally presses upon the rectum and interferes with the free evacuation of the bowels, causing constipation, and often flattening of the fecal matter, as it passes the obstruction. It is also somewhat difficult to start the flow of urine, at times, or even to thoroughly evacuate the bladder. The residual urine may dribble away, even after cessation of the flow, onto the clothing, to the great annoyance of the man. Pressure upon the nerves of the prostatic, hypogastric and sacral plexuses provokes various reflex disturbances. Prominent among these are pains in the back, hips and limbs, disturbance of the stomach, which is a very common sequel of any form of prostatic disease. The bladder often becomes largely distended, from an 118 PROSTATE GLAND AND ADNEXA. over-accumulation of urine^ impairing the detrusor urinae to the extent that the}- are unable to expel all the urine. This residuum increases as the disease progresses, and becomes offensive from the decomposition of mucus and urea. Bacteria develop in large quantit}^ and the patient is in constant danger of septic poison. Sepsis is especially liable to a catheter habit, inasmuch as the microbic flora, always present about the meatus or fossa navicularis, are carried by the catheter into the bladder where conditions are favorable for their development and engendering of septic poison, as clinical investigation has proven, that it has been impossible to maintain an antiseptic urethra. The catheter life of a patient has been estimated at an average of from four to five years. Sir Eeginald Harrison gives this as the average time. There are exceptional eases on record, where men have lived fifteen or twenty years using the catheter several times during the twenty- four hours. DIAGNOSIS. The disease, for which hyperthrophied prostate is most likely to be mistaken, is congested enlargement of the gland, as before described; and, it is not easy, in many instances, to differentiate between them, since each occurs during the same period of life, and many of the subjective symptoms and complications are concomitant. In the early stage of hypertrophy the diagnosis may easily be made. In this the gland is much less sensitive, unless it has been subject to harsh treatment by sounds, caustic applications or other procedures, when acute in- flammation may have been the result thereof instead of the disease, per se. In extreme old age, where the disease had been of long standing, or complicated with cystitis, vesiculitis or rectal tesions, it becomes somewhat difficult to differentiate HYPERTROPHY OF THE PROSTATE. 119 between the two conditions. The points upon which I rely, after taking age into consideration, are (a) the length of time of the noticeable existence of the trouble; (b) the presence or not of a urethral discharge and its character; (c) the general contour of the gland as deter- mined through rectal examination; (d) the condition of the prostatic urethra and bladder. In view of the first consideration, should the patient be under fifty-five years of age, the indications would favor congested enlargement, rather than indurated hypertrophy. Should the patient, on the other hand, he over fifty-five and the trouble had been noticeable prior to fifty, it would also be a negative point to hypertrophy. The long stand- ing existence of a urethral discharge, whether perpetual or intermittent, favors congested enlargement. Micro- scopical examination revealing latent gonococci or Bottch- er's crystals indicates the latter. In hypertrophic conditions of the gland it appears firm and unsymmetrical to' digital examination, through the rectum. It may be nodular from the presence of tumors in one or both lobes. Both lobes of the gland are rarely of the same size and consistency, and there is little or no tenderness upon pressure, unless inflammation has extended to the gland from complications of the bladder or rectum, or the extreme size of the organ has obstructed the flow of urine and caused a congested inflammatory state of its glandular structure and bladder. When such condition exists, there is often a profuse discharge both from the gland and vesicles. In enlargement from chronic congestion the lobes of the prostate are uniform in size, less firm, unless it is very much swollen and the capsule is subjected to extreme tension. It is also tender upon pressure; the tenderness extending to the gland penis or perineum. 120 PROSTATE GLAND AND ADNEXA. The bladder in the hypertrophied state, and advanced stage of the disease, becomes sacculated as result of some of the detrusor urinae becoming partially paralyzed from over distension. In these sacs calcareous matter is often deposited, forming at times stones of such size as to be detected easily by the cystoscope, when not covered by folds of the muscular walls of the bladder. In the majority of instances, where calculi have become imbedded within these sacs, distension of the walls of the bladder by air reveals them through the cystoscope. Another valuable diagnostic point is that the prostatic urethra is almost invariably elongated. It is somewhat difficult to describe just how to determine the elongation. One familiar with urethral instrumentation can detect the passage of the triangular ligament and membranous urethra, and the entrance of the prostatic portion of the canal, and, therefore, the distance traversed by the instru- ment before reaching the bladder. The differential diagnosis with reference to these two diseases of the gland are very important, inasmuch as one condition is curable and the other is not, and the curable one is so often mistaken for the other, and the patient sub- jected to dangerous and useless operations, that are irre- parable. TREATMENT. Hypertrophic prostatic diseases, owing to their intracta- bility, have been made, by the ambitious surgeon, the ob- ject of many operative procedures, each of which chal- lenges its predecessor in the endless suffering entailed upon its victims, or in its lethal dangers supplying topic for lengthy discourses upon the superior claims of each operation as revealed by the autopsy. Before proceeding to describe my method of treatment in cases of senile hypertrophy, I shall briefly refer to HYPERTROPHY OF THE PROSTATE. 121 some aspects of the surgical operations by which a radical cure of the disease is attempted. The prevalence of the disease has offered a tempting field for the exploitation of surgical ingenuity and the innumer- able methods proposed; those of Tobin, Mercier, Bottini, Harrison, Dittell, McGill, Belfield, Treves, Whitehead, Dolbean and others, have one and all found enthusiastic followers and formed the subject of our medical literature upon this subject. Surgical operations for the relief of urinary troubles resulting from enlargement of the prostate fall into two classes. The first consists of the various methods by which the gland is attacked directly; the second embraces the procedures that aim at reduction of the blood supply of the swollen organ and consequently atrophy thereof. The direct interference of the diseased organ is effected through the urethra (as in the Bottini operation), or by the perineal route (so-called lateral prostatectomy), or by means of suprapubic incision. By the latter method, the gland, especially the middle lobe, is removed bit by bit with the rongeur forceps, or a wedge is cut out with scis- sors, or the organ is destroyed with Paquelin's cautery or the galvano-cautery. Prostatectomy by combination of suprapubic and perineal methods has also its followers. The operations undertaken for the purpose of reducing the blood supply of the gland and so bringing about an atrophied condition, are either direct or indirect in charac- ter. The direct consists in ligating the arteries which feed the prostate, i. e., simultaneous ligation of both internal iliac arteries. The indirect method is orchidectomy. The theory on which this procedure is based being, that the hyperemic condition of the genital system is produced by nervous reflex through the presence and secretions of the testicles. 122 PROSTATE GLAND AND ADNEXA. This multiplicity of surgical methods of dealing with the hypertrophied prostate has its parallel in the variety of theories that have been propounded as to the cause of the disease, as, for instance, that of Guyon, who regards it as simply a part of the constitutional condition peculiar to old age and characterized by arterial sclerosis; or that of Harrison, who regards the growth as compensatory in character and secondary to certain bladder changes. Others believe that prolonged, ungratified sexual excitement causes enlargement of the prostate. But here we are met with the difficulty of distinguishing cause from effect, for there is plent}'' of evidence to show that the enlarged pros- tate is a cause of abnormal sexual excitabilit}^, in some eases, while in the majority it has the opposite, of causing impairment or total impotency. Therefore it is clear that cause and effect may be transposed. In general it may be said that nothing whatever has been demonstrated as to the real cause of senile hypertrophy. Each and every one of the surgical methods to which I have referred is open to the most serious objections. It must be remembered that the patients upon whom they are practiced are generally very much reduced in health, that the surgical operation is of a particularly painful nature, and that the results have been either utterly unsatisfactory or at least equivocal. On account of the celebrity of Bottini's operation and to show the dangers which lurk in it, I will here say a word or two regarding it. Enrico Bottini's galvano-cautery radical operation for hypertrophy of the prostate was first per- formed in 1875. The instrument as used was catheter- shaped, of medium caliber with short beak carrying a platinum plate (f inch in length) on a porcelain disc. The plate, rendered red-hot by electric current, was used to cauterize the prostate. In a short time this cauterizer HYPERTROPHY OF THE PROSTATE. 12'3 was discarded for a prostatic incisor, the instrument con- sisting of a male and female arm. A platinum knife (f inch long) in the male arm leaves the female arm on work- ing an outside screw, and a cooling mechanism prevents burning of the parts by any other portion of the instru- ment than the knife. The incisor removes the mechanical obstruction to the outflow of the urine by slowly burning a groove or grooves through the enlarged prostate. Con- siderable modification of this instrument was effected by Freudenberg, who made the knife of an alloy of platinum and iridium, increasing ' thereby its hardness and power of resistance. The technique of the operation is of the most delicate nature, involving the length, direction and number of cuts to be made, the rapidity with which the}^ ought to be made and the amount of current necessary for heating the knife. Besides all this there is the danger of the knife's bending sideways and the difficulty of removing it without the consequent pain and hemorrhage. It is obvious, there- fore, that even if the operation had proved effective and free from dangerous consequences, it would, from its at- tendant difficulties, be absolutely lethal in its nature save in the hands of the most skillful and experienced electro- surgeon. But even where all the details of the operation are per- fectly understood, where the utmost care and skill are brought to bear upon it, where there is clear knowledge on the part of the operator of the exact conditions exist- ing in the bladder neck, the dangers are too numerous to allow of anything but a theoretic interest in the Bottini cautery. Among the dangers that attend its employment are : absolute retention of urine, hemorrhage which is apt to occur from five to ten days after the incision when the sloughs are thrown off, perforation of the urethra, drib- 124 PROSTATE GLAND AND ADNBXA. bling and sepsis. The latter risk forms the most serious objection to the Bottini method. Infection may take place not only through the wounds of the prostate, but also through the kidneys. Soluble and insoluble matter ascends from the bladder through the ureters to the pelvis of the kidney, enters the lymphatic veins and uriniferous tubules and is hence conveyed to the right ventricle. The foreign substance is then carried by the current of blood into the other organs, principally the lungs and liver. The risk of sepsis may be imagined when it is remembered that cystitis, or the conditions preliminary to its development, are present in every case of enlarged prostate. Numerous pathological changes are present in the bladder lining as well as in the prostate gland and adjoining organs, and a wound caused by the Bottini instrument is all that is necessary to produce serious inflammatory conditions. Even such an enthusiastic advocate of this operation as Dr. Willy Meyer admits that the dangers attending it are real and numerous and closes a discussion of them with the following significant remark: "At present, it would seem, we are justified in stating that the larger the prostate, the greater its blood' supply, especially the more enlarged its venous plexuses, the more pronounced the purulent catarrh of the prostatic urethra as well as of the bladder and even of the pelvis of the kidney — ^the more dangerous is the operation." The Bottini operation might be justifiable in some in- stances were it true, as the operation purports, that the disease is confined to the indurated bar at the neck of the bladder. But such is not the fact and on the contrary the lateral lobes also present pathological changes. Should the patient even survive the operation it practically pre- cludes any other treatment for radical relief, except pros- tatectomy^ when it would be extremely rare to survive two operations. HYPERTROPHY OF THE PROSTATE. 125 Eegarding the other surgical methods above referred to but little need be said here. Prostatectomy, whether by the suprapubic or perineal route, or by combination of these methods, is always accompanied by the danger of sepsis, hypostasis, and above all of uremia. This opera- tion has become quite popular of late years. I fully concur in the opinion expressed by Dr. Orville Horwitz, as published in the- Medical Times of August, 1901. In summarizing the results of one hundred and sixty-one operations for the relief of senile hypertrophy of the prostate, he says : "With the exception of ligation of the internal iliac arteries, prostatectomy is the most dangerous of any operation that has been recommended for the relief of prostatic obstruction, due to hyper- trophy." Orchidectomy, objectionable on real as well as sentimental grounds, is doubtful in its results. Only a few years ago, when the operation was enthusiastically advocated by Dr. J. Wm. White, it was quite frequently performed. Now, like others that have their day, it is very rare. In three cases upon whom I have noted the operation they have suffered intensely from hysteria, melancholia and various other reflex nervous conditions. Ligation of the iliac arteries is spoken of with hesitancy by those who have performed it. Of three cases reported by Meyer, he says that one was partially improved, one was not improved at all and one died. Suprapubic drain- age (which is recommended by Sir H. Thompson) is distressing to the patient and wholly unsatisfactory, for not only is the wearing of a urinal a source of constant annoyance, but no device that has been tried can prevent leakage, while there is a standing danger of infection through the constantly open communication with the air. 126 PROSTATE GLAND AND ADNBXA. THE AUTHOE^S METHOD OF TREATMENT. Having reviewed the pathology, complications, and ob- stinacy of this most formidable disease, also the opera- tions that have been devised for its relief, I shall give an outline of the methods I have found most effective, (a) for impending dangers to life, (b) to mollify distress- ing symptoms, (c) in removing the morbid products of the gland, without jeopardizing the life of the patient. There are many symptoms and conditions of this dis- ease, that are common to congested enlargement of the gland, which require similar treatment. The methods advised for the relief of acute complications are espe- cially indicated in hypertrophy. Individual cases, how- ever, necessarily require special treatment, to meet indi- cation that arise at different stages of the disease. One of the most difficult problems to combat, in connection with hypertrophy, is the impediment to the flow of urine: which engenders most of the dangerous sequels of the disease; and, unfortunately, the patient defers seeking relief until some serious or distressing symptoms prompt him. This is generally followed by the indiscriminate use of the catheter, and is often repeated from day to day until prostatic urethritis, and cystitis, is provoked, and paresis of the detrusor uringe results. The latter con- dition makes the bladder so dependent upon the catheter as to render it difficult to overcome the habit even when the cause of obstruction is removed. The first indications for treatment is to relieve, in so far as possible, all acute symptoms. As this method of treatment has been fully described in the preceding chap- ter, I shall deem it unnecessary to repeat here. As the acute symptoms begin to subside the calls to evacuate the bladder will become less frequent, and the necessity for the use of the catheter will correspondingly be diminished. HYPERTROPHY OF THE PROSTATE. 137 It is impossible to prevent a condition of urethritis, just 30 long as a catheter must be passed over an inflamed surface for the purpose of the evacuation of the bladder. The oftener it is passed the more trouble it provokes. I do not wish it understood, however, that I advise the dis- pensing with the catheter altogether, as it is required, at timeS;, for the over-accumulation of urine. The bladder should be encouraged to expel its contents whenever it can be accomplished without much effort or straining. As the acute symptoms are relieved the normal evacuation of the bladder becomes more easy. When the catheter habit has been established, the bladder becomes sacculated and the detrusors in state of inertia. It is not wise to defer the use of the catheter too long; it is also better not to permit the bladder to become too much distended, as it serves to impair its muscular walls. When the hladder is very much distended, from the accumulation of a large quantity of urine, it should never be entirely evacuated at one time, as it is liable to cause shock that might prove fatal. In the early stage of hypertrophy, where the urine is not wholly retained, but somewhat impeded in its flow, and the prostatic urethra has not been rendered acutely sensitive from congestion or instrumentation, I begin the use of cataphoresis both through the urethra and rectum. The effect of the current alone revives the lethargic con- dition and softens the indurated tissues. The medicines as used in connection therewith aid in the reduction of the existing inflammation and decomposing the abnormal products, that form as result of unnatural growth of the parts. After having allayed the acute symptoms, I '^'liammer" at the prostate both through the rectum and urethra until the indurated tissue begins to soften, then atrophy. It 128 PROSTATE GLAND AND ADNEXA. takes quite a long time in some cases, where the gland has become quite large, complications of the bladder and rec- tum exist, and the health of the patient impaired. In some cases from six to twelve months of treatment is necessary to reduce the gland to that extent where the urine can be voided without the use of the catheter. I do not advise continuance of treatment uninterruptedly during all this time, — I generally advise constant treat- ment for six weeks or two months after the subsidence of the acute symptoms, then the patient is instructed to wait one or two months when it is again resumed. The amount of reduction of the gland thus effected is per- manent. There are certain pathologic changes that take place in the bladder walls as a denouement of the obstructed flow of urine, which, in some instances, cause paresis of a part of its muscular fibers that form sacs, which retain a certain amount of residual urine. In other instances, from long and continued use of the catheter, atrophic degeneration of the muscular coats of the bladder occurs that so impairs its force as to render it useless for the expulsion of the urine. Whenever such conditions of the bladder exist, fermentation of the residual urine is inevit- able, which results in the development of pyogenic bac- teria and ammonuria. When this trouble of the bladder is due to impaired function, it can be relieved by applica- tions of the sinusoidal or primary faradic currents, which restore its tonicit}', and enables it to expel its contents. But, when it once becomes sacculated, it can never be en- tirely restored. In the majority of cases of true hypertrophy the bar at the neck of the bladder, or the so-called third lobe of the prostate, is the chief offensive factor. This muscular band is, usuall}^ the first to become indurated and enlarged. HYPERTROPHY OF THE PROSTATE. 129 and, owing to its position, it serves as the most effective barrier to the outflow of nrine, by mechanically obstruct- ing its exit. This condition exists, frequently at its in- ception, without tenderness or any inflammatory symp- toms. Fig. 17 illustrates this condition. Fig. XIX. (Coulson.) Showing enlarged prostate with "third lobe," through the base of which a false pas- sage has been made. The Bottini operation was devised, more than a quarter of a century ago, for the special relief of this trouble. The operation, as originally purported, properly used, and, with strict reference to this pathologic condition, was scientific and gave much temporary relief. But, like most all valuable procedures, it has been greatly abused, by 130 PROSTATE GLAND AND ADNEXA. blind and indiscriminate use, for almost every inconceiv- able disease of the prostate without, in many instances, the first semblance of diagnosis. I have seen several men upon whom the operation had been performed where un- mistakable evidence of a congested enlargement of the gland existed instead of indurated hypertrophy. The objections to the Bottini operation are that it gives only temporary relief, even when properly used, and the condition of the gland correctly diagnosed. This bar, as before stated, is usually devoid of acute sensitiveness; but the cicatricial tissue following the operation is always exceedingly tender and inflamed. It also favors develop- ment of vegetative and polypoid growths. Some of these form quite large tumors, which evidently result from lesion by the Bottini operation. The cut by the cautery, at the entrance of the bladder, is constantly bothered by septic urine, on account of its gravitating to this point. The injury once performed is irreparable. The same may be said of all other operations upon the gland; but there are some instances where neglect of timely treatment necessitates an operation for the relief of impending dan- ger to life. 1 do not wish to be understood as taking the stand against all operations, as there are some few that are imperative, and I advise them; but the tendency of the day is too much in favor of indiscriminate cutting, with- out reference to correct diagnosis. Delay of treatment is often responsible for serious pathologic conditions necessi- tating the use of the knife ; but, as expressed by the vener- able Jacobi: "The knife takes too often the place of brains." In regard to the Bottini operation I shall quote Dr. Joseph B. Bissell, in Medical Record of November 10, 1900. He writes : "Bottini's operation does not adequate- HYPERTROPHY OF THE PROSTATE. 131 ly appreciate the cause of the obstruction. It does not treat the condition complicating the hypertrophy. It does not allow for drainage of a dirty wound. In a word it is unscientific and unsurgical. Bottini reported five success- ful cases in two years with this instrument. Later he modified it, so that at present it resembles a lithotrite, in having a male and female blade. In the former is a plati- num knife;, which leaves and returns to the groove of the female blade by the turning of a screw, and is connected to an electric current. A scale at the outer extremity shows the depth of groove cut. A cooling apparatus sur- rounds the instrument so that. it is kept free from heat while the knife is raised to a white heat. Freudenberg modified the instrument by making the blade of iridium alloy, rendering it firmer and less difficult to heat, and also in various other ways changed it greatly to its advan- tage." He further says: "Dr. Willy Meyer, to whose writings. on this procedure I am indebted, has carried out almost to perfection the methods and manner of using this instrument. He prefers the street current with a rheostat, but a fifty ampere storage battery can be taken to the patient's house, if necessary. Dr. Meyer's personal cases, twenty-four in number, show eight per cent mortal- ity directly due to the operation, with thirty-eight per cent of cures." The Bottini operation is not so simple or easy as, at first sight, one would expect. It is an operation of de- tail, and one which requires care and skill and an inti- mate and clear knowledge of the exact condition of affairs in the bladder neck. It is an operation by no means de- void of danger. Death, following suppression of urine immediately succeeding this procedure, has occurred sev- eral times to my personal knowledge. Freudenberg re- ports a case in which he cut through a fold at the base of 132 PROSTATE GLAND AND ADNBXA. the bladder; sepsis and death resulted. Perforation of the urethra and sepsis are reported. Pulmonary emboli have been found at autopsies. Hemorrhage is a constant danger, and all the greater, in that it comes on at the time the sloughs are thrown off, about five or ten days after the incision. It may take place earlier. Cystotomy and tam- poning have been necessary in a number of cases, in order to save the patient's life. Absolute retention is not an in- frequent immediate result of the operation. In one of Meyer's cases he was obliged, for this cause, to tap the bladder over the pubes for three days. Pain and severe tenesmus, almost unbearable, are not infrequent complica- tions. Bribbling is an occasional sequel which may be permanent. But the most serious of all the objections to Bottini's method is the risk of sepsis. In every case of enlarged prostate which comes to us for treatment there is already a cystitis, or all the elements preparatory to its development. There are present a number of pathological changes in the mucus and other coats of the bladder as well as the tissues of the prostate gland and it« adnexa. A trauma, such as is done by the Bottini instrument, is all that is needed to light up an inflammation in these tissues. The destruction of a considerable amount of tissue in a closed sac, and leaving it there without a drainage, seems to me to be a surgical negligence without any excuse. To say that it is done with every antiseptic precaution is saying what is impossible. The cicatrization produced by Bottini is said to prevent or complicate seriously any further radical operation upon the gland. Moreover, this pro- cedure does not take into account the real cause of the obstruction and its sequences, or at least affects only a small proportion of them. If the retention, cystitis, and their results were caused by a bar or a collar or other obstruction at the lower portion of the vesical opening HYPERTROPHY OF THE PROSTATE. 133 only, the Bottini apparently would be the indicated oper- ation always, provided free drainage afterward could be instituted to prevent septic infection. A catheter tied into the urethra, to my mind, is a brutal and painful relic of the dark ages of genito-urinary surgery. Most of the cases which have come under my observation, that had been operated upon by the Bottini method, have been com- plete failures; in all of these, however, with the exception of one case, the operation has been contraindicated. One of these cases, I can recall, was reported at a meeting of a medical society as a remarkable cure, when in less than a week thereafter, I noticed his name in the death list, followed by "uremic poison." Fig. xx; Fig. XX. illustrates an instrument devised by the author for relieving this indurated enlargement at the neck of the bladder. It is similarly constructed to that of the Bottini instrument, except that the cauterizing part is flat instead of a blade. It is not intended to cut, but sear the indurated surface, as illustrated. This operation is attended with practically no danger, and converts the hard resilient tissue into a soft granular surface, that admits the action of cataphoresis, and atrophy of the obstruction, without danger to life. In fact, it seldom requires confinement of the patient to his room more than one day. Many never discontinue work more than an hour or two, but I always advise at least a day's rest. Fig. XXI. shows the application of the cautery to the indurated third lobe. 134 PROSTATE GLAND AND ADNEXA. The technique of this operation is first to produce local- ized anesthesia of the prostatic urethra. This is accom- plished by applying, with instrument shown in Fig. IX, Fig. XXI. a twenty per cent solution of cocaine; to intensify the localized action of the cocaine I use anodal cataphoresis. I then wait ten minutes for the action of the anesthetic. The cautery should always be tested before its introduction HYPERTROPHY OF THE PROSTATE. 135 into the urethra, in order to note carefully the required amperage and to see that the apparatus is in perfect work- ing order. The cautery surface should be of deep red color and never at a white heat. It is held in apposition to the enlarged bar, at firsts only one or two minutes. The patient should be retained in a recumbent posture for at least one hour, and, better still, two or three hours after the operation. The bladder should always be evacuated prior to the operation, and a soft catheter passed to see that it is thoroughly emptied. The urine should be main- tained in an antiseptic condition, and if of alkaline re- action, benz-ol cps or cystogen should be given. Thuja is especially soothing to the genito-urinary tract in some cases, and can be administered in combination with potas- sium citrate with much relief when the urine is unduly acid. The cautery application can be repeated within a week or ten days. Cystoscopic examination of the gland should be made to note its condition just before the cautery is applied. After the second or third cautery application cata- phoresis through the prostatic urethra should be instituted about every second or third day by means of a one per cent solution of thuja or aqueous extract of hydrastin. These treatments should be given very mildly at first and discontinued if attended with much pain or hemorrhage. In many cases a copious muco-purulent discharge follows the cautery application, as a result of the disintegrated enlargement. If such discharge becomes very profuse or irritating to the urethra, an injection of two grains to the ounce of sulphocarbolate of zinc should be used. Softening and atrophy of the gland becomes quite noticeable in from one to two months, and the urine is voided more easily, less frequently and becomes free from the heavy muco-purulent sediment. 13G PROSTATE GLAND AND ADNEXA. After the iecond month I usuahy discontinue all treat- r/.-n: ;:r a certain length of time, Tarvlng from three vrech; t; t~o months. By this means the natural restora- tive processes are favored, after discontinuance of the irrits.tion iicivohed h" the treatment. The mi.iirity of ir.i-n vrho suS'er from hypertrophy of the tihrd !:':e reoyj.ire treatment as heretofore described, f:r it h:i5t a ye^r. when the gland becomes reduced to £u;h an extent as to render them comfortable the remain- der of their lives. Others require treatment occasionally, every :r-e. fv:. :r three years; and only for a short period at a time. Tins treatment gives them an option on living many years in comfort, rather than endure the suffering entaii::. "y the obstructed flow of urine, or the dangers directiy attending the knife, or its subsequent effects. There are many cases of hypertrophy, where a vege- tati"e or t'iyr::! growth springs from the posterior part of the mi hhe or tiiird lobe at the neck of the bladder, and, floating in the urine, serves as a valve to imj)ede its free exit. Sucl'i conditions are especially suitable for this oper- ation. The in^tr^irr.ent is passed well into the bladder and tovrards the :ror-t surface : it is then reversed and brought bacltvraris and forvrards. when the concave surface (con- taining the cautery) engages the tumor. It is held in contact with the tumor about one and one-haK to two minutes. The patient should remain in bed for some days after the operation. Fig. XXIa is the author's special method of applying the electric ■ i :ery through the cystiscope to a tumor or "'::i'>t:t:- e .'rov-;?. or nicer at or around the neck of the ijj.iiu.aii or pio.-mLe^ that have resisted other methods of treatment. This method of treatment has entirelv super- seded that illnstrated and described on pa?es 1.33 and 134. The advantages of this are obvious at a glance, as one sees PROSTATE GLAND AND ADNEXA. what he is doing and does not operate blindly. The cautery blade can be removed at the will of the operator as often as desired, and he can note the results accomplished towards destroying this abnormal condition. By this means he can control completely any hemorrhage by having the blade at red heat instead of white. In order to operate by this method one requires a current transformer where he has the direct incandescent, and also a resistant converter to chano-e the current from a fraction of an ampere to that of ten or twenty amperes. The cautery handle is so con- structed that by means of a set screw one can make and break the circuit at the will of the operator. The current should never be closed until the cautery blade is in apposi- tion to the tumor or part to be treated. The apparatus should also be tried and seen to work absolutely perfect be- fore attempting the operation. There are many cases where there is simply an obstruction of the outflow of urine as a result of the third abnormal lobe formed just at the neck of the bladder. This method should always be tried before resorting to the knife, as the latter is not only ex- tremely dangerous to the patient's life, but even should he recover from the operation, he only exists for a few years more or less in misery. While this method somewhat simu- lates that of the Bottini cautery, which is a blind empirical cutting into parts with cautery blade at white heat, without knowing the extent or even the amount of hemorrhage that takes place. So dangerous has been this later operation that it is now practically abandoned. Of course, there are some cases where the tumor at the neck of the bladder, or appended to the prostate, has become so large and indolent that nothing short of the knife can promise even temporary relief. Besides m.en are so prone to postpone treatment of this kind that the morbific condition becomes irreparable. Case XTII. A lawyer; aged sixty-eight; married; no venereal history. He had observed some slight difBculty in voiding urine for about five years. There was no pain attending the act, but it required longer time than normal, and some effort to thoroughly evacuate the bladder. This condition 136a Fig. XXIa. HYPERTROPHY OF THE PROSTATE. 137 gradually became more manifest, until he observed that he could not entirely empty the bladder. He then con- sulted his physician, who began the use of sounds, and the catheter. The urine became turbid, ammoniacal and very offensive after standing. Washing of the bladder was resorted to, without any relief. When he consulted me he had to use the catheter from four to five times during the twenty-four hours. He was enabled to expel by force, at times, from one to four drachms. It contained a large quantity of mucus and pus, strongly ammoniacal in odor, and alkaline in re- action. Both lobes were hypertrophied — the left one more marked. The bar at the neck of the bladder was especially large, and firm. There was no tenderness upon pressure of the gland through the rectum. Its large size obstructed the fecal discharge, causing constipation. There was very slight tenderness in the prostatic urethra, notwithstanding the long use of the catheter. I began the use of cataphoresis with one per cent solu- tion of thuja through the prostatic urethra on alternate days. The sinusoidal application was made to the gland, through the rectum, the intervening day, making therefore daily treatments to the indurated prostate. The thuja was gradually increased to ten per cent strength. Five and ten per cent solutions of potassium iodide were also used. I had him discontinue washing the bladder. Five-grain doses of cystogen were given three times daily. The use of the catheter was continued as required to evacuate the bladder. At the end of the first month's treatment, it was necessary to use the catheter on an average of every second day. At times he would not use it oftener than the third or fourth day, then again daily for a few times. The urine remained normally acid without the use of 138 PROSTATE GLAND AND ADNEXA. medicine and had become much less ofiensive, and the sediment reduced to one-fifth the quantity it formall}' contained. This condition continued, with some interruptions, for four months. He would occasionally go two weeks without using the catheter, then again having to use it daily for a few days. His general health was much improved, having gained fifteen pounds in weight. The treatment was dis- continued for a month, and again resumed, and continued two months longer, when he returned home. The first letter I received from Mm, a month thereafter, he was somewhat discouraged. I will quote his second letter. which followed about a month later : '■T)ear Doctor : Since I wrote you, I have improved in health, and seem to be almost well. The day after I wrote my last letter, the improvement commenced in a marked degree, and the gain has been steady and well sustained. I have gained in weight and strength. My digestion is good and my bowels are working in a natural way. There is no heavy or thick sediment in my urine and no pain in the bladder." I have not heard from him since. Case XYIII. Hypertrophy of prostate, cystitis, proctitis. Physician, aged sixty-nine; married; had gonorrhea in early man- hood, from which he readily recovered. He had ridden horse-back a great deal up to his sixty-fifth year, without discomfort. About that time he began to feel an uneasi- ness in the region of the perineum. The flow of urine had also become sluggish, and somewhat difficult to start. He abandoned the saddle for a buggy, when he soon found it necessary to use a pneumatic rubber ring for a seat, and to empty the bladder with catheter. The catheter had HYPERTROPHY OF THE PROSTATE. 139 been in use for more than a year when I first saw him. His general health was very much impaired. ITpon examination I found the left lobe very much enlarged, the right less so, but quite nodular. There was very slight pain upon pressure of the gland. The adjacent tissues were somewhat congested and tender, from ob- structed venous circulation. The muscular bar at the neck of the bladder was very large and firm. Failing to procure much relief by means of cataphoresis, I restorted to cauterizing the bar at the neck of the blad- der, with my modified Bottini instrument (Fig. XX). This was accomplished by placing the patient in the lith- otomy position, with the knees drawn back, and the limbs held in position by means of leg rests. The hypertrophied bar was thoroughly cocainized, using a twenty per cent solution, with instrument (Fig. IX.) prior to the opera- tion. The cautery band of the instrument was tested, be- fore its introduction, and only carried to a deep red heat, not white. It was moved slightly to each side of the in- durated bar in order to act upon a large surface. It was allowed to remain two minutes, when the circuit was broken and the instrument removed. The patient was kept upon his back for some hours, to prevent the urine from gravitating to the cauterized sur- face, and twenty minims of deodorized tincture of opium were administered. There was no hemorrhage following the operation, and very little pain. Elixir lithamine was given for the purpose of maintaining the urine in an anti- septic condition. The catheter was used as often as required to evacuate the bladder. The bowels were maintained in a lax condi- tion. The patient was permitted to go out on the third day. One week after the operation cataphoresis was in- stituted alternate days for two weeks. The patient then 140 PROSTATE GLAND AND ADNEXA. passed from half to one and one-half ounce of urine at times. The catheter was used from two to three times a day. Cauterization was again used in the same manner, three weeks after the first treatment, followed by cata- phoresis. Improvement in general health was very marked. The urine at times would flow quite freely for two or three days, then become sluggish, requiring the catheter. At the end of four months he returned home. I have heard from him several times since. He writes that he is compara- tively comfortable, and uses the catheter on an average every thirty-six hours; occasionally he goes two or three days without using it, then again once daily. Case XIX. Married, aged sixty-three; obstinate flow of urine had begun two years previous; prostatic urethra was very tender. Frequent use of catheter caused daily hemorrhage. Urine, heavily laden with pus and mucus, was very of- fensive upon standing. The first cauterization gave great relief, and checked the hemorrhage very materially. After the second treatment there was only a trace of blood. The case was treated similarly to the preceding one for five months, when he was able to dispense with the catheter altogether. I still use cataphoresis once or twice a month. The urine is normal some days; at other times somewhat cloudy. Case XX. Widower, aged seventy-one; very sallow complexion and emaciated. He had been troubled with evacuating the bladder for at least ten years. He had been a very active business man, though of sedentary character. The disease developed very slowly. He had led a catheter life for three HYPERTROPHY OF THE PROSTATE. 141 years. During the first year he only used the instrument about once every second or third day, then daily, and, finally, four to eight times in the twenty-four hours. He was very costive, dyspeptic and anemic. At times there was only a trace of blood following the use of the catheter. The urethra was not sensitive. Eectal and urethral treatment were applied regularly for three weeks with the view of restoring tonicity to the organs. Nutri- tive tonics and massage were also given at the same time. Six cautery applications were made during the period of seven months, cataphoresis was used between these treat- ments during the interim. At the expiration of that time he had gained twenty pounds in weight; his mental vigor was restored, and he could void urine during the day with- out the use of the catheter, but at night was necessitated to draw it once and occasionally twice Case XXI. Aged seventy; married. For about seven years he had been periodically annoyed with his "kidneys and bladder," as he expressed it. At first he was troubled only about every four or five months, the attacks lasting two or three days, but not hindering him from his business. The paroxysms continued to become more frequent until he consulted his physician. He suffered excruciating pain and vesical tenesmus, and the physician resorted to the use of morphia for its relief. These paroxysms had recurred so often that the patient had become addicted to the use of the opiate. When sent to me by his physician he was taking from two to three grains of morphia daily and was using the catheter every twenty to thirty minutes when not under the influence of the drug. I placed him in a hospital so as to obtain the best care, gradually cut down the amount of morphia each day, sub- 143 PROSTATE GLAND AND ADNEXA. stituting the following prescription for its sedative prop- erties : E. Fluid ext. hyoscyamus one ounce. Opium deod. tr two drams. Triticum repens, q. s four ounces. M. Sig. — Teaspoonful in water every two or three hours. When the local irritation in the prostate and bladder had somewhat subsided I used the cautery instrument as in the preceding case. I kept the patient at a hospital for a month, during which time the use of morphia had been completely abol- ished, and the use of the catheter had been reduced to once, occasionally twice, in the twenty-four hours. His general health had so much improved that he removed to a hotel, but still had an attendant. He showed marked improve- ment from that time on ; using the catheter less frequently and having little or no pain. Upon calling to see him one morning, I found he had a high fever, severe vesicle tenesmus and paroxysmal pain every few minutes, his condition being much worse than at any previous time. The reverse in his condition was the result of his attendant deserting him to attend a ball the night before; the weather was exceedingly cold, the fire had completely gone out, and the patient was forced to get up into the cold room to use his catheter, becoming thoroughly chilled through, and the fever followed. The condition increased in severity, ending in the patient's death on the third day. The majority of cases of hypertrophy of the prostate that have come under my observation have been so amenable to cataphoresis and local applications as not to necessitate the electric cautery. It is only in those cases where the bar at the neck of the bladder has become so large as to obstruct the flow of urine, that it has been necessary to use the cautery. HYPERTROPHY OF THE PROSTATE. 143 There are other cases, of rare existence, however, where a pedunculated tumor forms from the posterior border of the prostate and protrudes into the bladder, in which the electric cautery is especially indicated. Many cases, too, are presented where vegetative or poly- poid growths occur around the vesical neck, demonstrable by means of the cystoscope, which yield readily to local applications, and that do not require electro-cautery. I could continue to report numerous cases with various com- plications in this connection, but deem it unnecessary to prolong the list. SYPHILITIC PEOSTATITIS. Little mention has been made by authors of syphilitic prostatitis. I, too, had overlooked it as a prominent etiologi- cal factor of prostatitis until two very characteristic cases had come under my observation. There is no reason, to my mind, why the prostate should not become subject to the influence of constitutional syphilis as well as the tes- ticles. All cases of syphilitic prostatitis that I have noted have resulted from the tertiary form of the disease. Case XXII. Aged forty-four; single; sailor. He had had several at- tacks of gonorrhea, the first at about twenty. At about thirty he had sj^philis. He had no recollection of secondary symptoms. He took constitutional treatment for only about six months, and even then not regularly. There were blotches upon the lower and outer portion of his shin bone, simulating syphilides. His rectum was badly ulcerated, extending about three inches from the anus. . The prostatic urethra was excessively tender. In fact, he had most of the symptoms attendant upon chronic enlarged prostatitis. 144 PROSTATE GLAND AND ADNEXA. I teated him by the usual methods for prostatitis, rectal ulceration and vesiculitis, ignoring the s^^philitic history of the case. He improved readily for six weeks under the local treatment, and then remained about the same for two weeks without further improvement. I then discontinued all treatment for two weeks, when he returned, suffering with syphilitic orchitis. There was no pain in the testicle, nor did it exhibit any inflammatory symptoms. There were no indications of its swelling during the time he was under treatment by the urethra, nor were there any acute symptoms of the prostate or bladder. He was advised to apply lotions of hamamelis, alternating with acetate of lead, and report at the end of the week. By this time the testicle had become quite large, but not the least tender. He also began complaining of pains in his lower limbs. I now placed him upon potassium iodide constitutionally and applied ten per cent strength of oleate of mercury locally to the scrotum. This treatment was continued reg- ularly for a month, when the pains had subsided in the limbs and the testicle was much reduced in size; besides, the local irritation of the prostate was much ameliorat&d. The same or similar constitutional treatment was continued at regular intervals for two years, which controlled pros- tatic irritation better than anything else. A second case, very similar to the foregoing, except that the tertiary symp- toms were more marked in the outset, yielded in like manner and was kept under control by constitutional treat- ment alone, after the local trouble had been relieved. TUBERCULOSIS OF THE PEOSTATE. Of all diseases of the genito-urinary organs, it requires greater elasticity of the imaginative faculties to diagnose this form of disease of the gland than that of any other organ of the body; yet there are writers who describe ac- TUBERCULOSIS OF THE PROSTATE. 145 curately the tubercular nodules as detected by examina- tion through the rectum. Of late I have come to look upon it only as a loop-hole through which to escape the respon- sibility of failure to relieve an intractable case of chronic prostatitis by the means usually in vogue — namely, the sound, cautery, massage. The diseased prostate, as much or more than any other organ of the body, often provokes mental and physical de- pression, which results in emaciation, a hacking cough, and prepares favorable soil for the development and propaga- tion of pulmonary tuberculosis. Many of such cases have come under my care that have yielded readily to treatment of the gland, and restoration to perfect health. ASPEEMATISM. This is a peculiar and rare condition, in which there is a competent erection, and, at times, a slight orgasm, with- out ejection of semen. Taylor says: "Lesion of the pros- tate being so often the cause of aspermatism, I always ad- vise an examination of the gland through the rectum." He claims also that aspermatism is caused by the ejaculatory ducts becoming plugged up by sympexia, preventing there- by the escape of the semen into the urethra. He mentions a typical case, as reported by Beliquet, where relief fol- lowed the escape of a large quantity of sympexia through the urethra. Occlusion of the ejaculatory ducts by pros- it tatic calculi have been reported by different authors. I have observed two cases of aspermatism following chronic prostatitis, one of which was of especial interest owing to some novel symptoms connected therewith. Case XXIII. A young man, thirty-two years of age ; single ; traveling salesman. He had been very dissipated for ten or twelve 146 PROSTATE GLAND AND ADNEXA, years by way of hard drinking and excessive sexual indul- gence. He rarely became intoxicated, however, but drank continuously. He had had gonorrhea quite often, followed by gleet, with which he had suffered for the past ten years. During one of these carousing bouts he was stricken with paraplegia and incontinence of urine. He had been in this condition for twelve hours before I saw him. The urine was passing involuntarily from overflow of the blad- der, indicating paralysis of sphincter urinae. I treated him for the prostatic trouble, and in about two weeks he began showing improvement, which continued steadily imtil, at the end of the third month, he was able to stand upon his feet and pass urine normally. He went home and I did not see him again for more than a year, when he returned to my office walking with a cane. He laid his cane aside to show me that he was not forced to use it, as there was but little indication of his former paralysis. He reported that he had had no trouble in void- ing urine for some months ; but that one peculiar symptom was that he was able to have an erection and intercourse normally without passing semen, and without any sensa- tion in the way of orgasm. He also stated that the erec- tion could be produced at will and maintained for an in- definite period, often several hours, enabling him to com- plete the act of intercourse several times with no ill effects except prostration from physical exertion. I have heard from him several times during the past five years. He re- ports his condition about the same as when he saw me last. His health otherwise is good. Case XXIV. Was that of a man of forty-eight years of age ; married ; very corpulent ; healthy and in perfect condition up to two years before seeing me. He had then begun to suffer with ASPBRMATISM. 147 chronic enlarged prostatitis and from that time was totally impotent, manifesting all the symptoms usual in such cases. He was treated, and practically relieved of the symp- toms. There was a normal recurrence of the functions of the sexual organs, enabling him to have intercourse with- out discomfort. About a year thereafter, he reported to me that he had begun to have trouble in the way of lack of emission of semen during intercourse. It would pass about midway the urethra, where it would stop, apparently from lack of force in the muscles to expel it. There was slight orgasm during the ejection. There are other cases of aspermia that result from oc- clusion of the ejaculatory ducts as result of cicatrix fol- lowing prostatic abscess; other cases have been reported where the ducts were closed by prostatic calculi, thereby obstructing the passage of semen. CHRONIC PRIAPISM. In some cases we meet with the converse of impotence (impotentis coeundi) as due to chronic prostatitis and prostatic urethritis. While the initial causes, in most in- stances, of the inflammatory conditions are the same, yet it is often found that these have been aggravated by the use of sounds, caustic applications to the deep urethra, or other violent measures. The localized inflammatory focus, situated usually in the prostate and caput gallinaginis, reacting upon the sexual brain independently of mental influences, causes prolonged irritative erections that are exceedingly wearing upon the nervous system. These distressing erections more frequently occur during sleep, arousing the man by their irritative effects and disturbing his sleep for hours at a time. Para- doxical as it may appear, men so effected are generally im- potent and are incapable of obtaining an erection under 148 PROSTATE GLAND AND ADNEXA. normal influences. There are others similarly affected where one sexual congress only intensifies the desire for a repetition, which is repeated until complete mental and physical collapse results. Case XXV. Chronic Priapism, Frostatic Inflam- mation. Man, aged fifty-four; healthy from all external appear- ances; very temperate and a good business man. He had had one attack of gonorrhea, from which he had appar- ently recovered. For four years he had been annoyed with persistent erections at night, which would often last two or three hours at a time, necessitating getting up and walk- ing the floor to get relief. On attempting intercouse there was a complete collapse of the organ and utter failure, re- gardless of all efforts and remedies used for the purpose. He had been subjected to the use of sounds, aphrodisiacs, bromides and massage of the prostate without benefit. Immediate relief followed restoration of the inflamed gland and prostatic urethra to their normal condition. Case XXVI. A minister, bachelor, aged forty-two, and an exceedingly intellectual man, consulted me for chronic priapism. He had been annoyed with the erections for about five years. At first, it only disturbed him at night, but for the past three years it had annoyed him both day and night. He had consulted many physicians regarding the trouble, and several had given him different forms of bromides, which, as he said, had only served to impair his mental faculties, without giving any relief to his embarrassing condition. He requested me not to give him anything that contained any of the bromides, as it was necessary for him, in his line of work, to maintain an active brain. He further CHRONIC PRIAPISM. 149 stated that these erections often remained hours at a time, even during the day, which maintained the organ in a ten- der and often painful condition. He stated that he had lived a perfectly virtuous life, and there was no reason to question it. I explained to him that the symptoms indi- cated a local inflammation of the prostate and adjacent organs, and that systemic medication could never relieve it. The gland was very sensitive, and quite rebellious to treatment, owing, doubtless, to his abstemious habits. After six months of irregular treatment of the prostate and prostatic urethra the irritation subsided and there was no further trouble with the erections. Case XXVII. Physician; single; age thirty-eight; never had gonor- rhea. He began having trouble when about twenty years of age. He was treated with sounds at first, without re- lief, then injections and systemic medications. "For the past twelve years," as he states, "he has been tortured with erections, the organ remaining erect for hours at a time. There has also been a gleety discharge for fifteen years; at times it is scarcely noticeable. Seminal emissions, too, occur, at times, even two or three within a week, then again not for a month. Emissions now occur without much sen- sation. They make me dreadfully weary, causing pain in back and back of neck. I can't stand mental work, and my memory I find is perceptibly failing. I have treated my- self, and was treated in New York by two physicians for two years, one of whom gave me bromide of sodium and ergot for the annoying erections without the least benefit. The other used cold sounds and massage of the prostate — all of which gave no relief." In case of this nature the prostatic urethra and the gland itself are very tender and much inflamed, which on being relieved, all other symptoms are allayed. 150 PROSTATE GLAND AND ADNEXA. MAEEIAGE. The question of when a man should marry, who has had chronic gonorrhea, prostatitis or any perverted sexual func- tion, has been one of paramoimt importance, and has elicited much discussion and various expressed opinions among genito-urinary specialists throughout the world. Men suffering from one or more of these troubles are frequently advised to marry before procuring relief, which has entailed untoward misery, unhappy unions and often separation. This subject was discussed at great length at the Sixth Congress of the German Dermatological Society, at Strasburg, in 1898, and it was the concurrent opinion of those present that just so long as gonococci could be de- tected in the secretions, they were infectious. One other point upon which all agree is that the gono- cocci do hide and remain dormant for an indefinite period within the prostate and adnexa, and, while it has been proven that these germs are especially susceptible to ger- micidal agents when brought into direct contact with them, how are you going to reach them ? As Weiss says : "What means do we possess to entice these parasites to the sur- face ?" There is no means known to the profession of en- ticing them from their hiding places, and the only way to get rid of them is to destroy them within the gland by cataphoresis or electro-magnetic influences. There are other diseased conditions of the prostate, how- ever, not dependent upon gonococci, that are equally as es- sential to relieve before marital relations should be ad- vised. The cause and treatment of these have been given in a previous chapter. CHAPTEE VII. NEUROSES OF THE PROSTATE. The sexual organism, of which the prostate is one of the chief factors, is so intimately blended with the central and sympathetic nervous systems, that disease of this gland provokes the most varied neurotic disturbances. The lumbar spinal center, sacral plexus and great sciatic nerve of the cerebro-spinal system and the hypogastric plexus of the sympathetic, are in such close reciprocal rela- tion to the nerves of the prostate, that disturbances in the organs to which the former are distributed are frequently the first precursors of disease of the gland. Often have I seen men who had been dosing their stom- achs for dyspepsia, their livers for torpor, their bowels for constipation, their heads for neuralgia, treating sciatica for malaria, plastering their backs for Bright's disease, taking sea voyages for melancholia, when the origin of their trouble was centered in the prostate, and the relief of which cured their other ailments. There are many of these cases, too, that have no subjective symptoms directly pointing to dis- ease of the gland, yet upon examination the objective symp- toms would be most marked. The erroneous idea that prevails among many physicians and the majority of laymen that disease of the prostate only results from some venereal disease, or is a sequel of senility, deters them from an examination of the gland for these obscure troubles. 161 152 PROSTATE GLAND AND ADNBXA. NEUEASTHENIA. This is one of the most prominent sjanptoms in diseases of the prostate and is manifested in almost every conceiv- able form of nervous disturbance. The disease so com- monly referred to as "nervous prostration" might, in the large majority of instances, be traced to the prostate, should the attending physician take the care to examine the patient for this trouble. The examination is easily made, and even should such trouble not exist, it is better to be aware of the fact, and so dismiss one probable etiological factor than to continue groping in the dark and dosing the patient "ad nauseam." Because of the almost universal belief of both doctors and laymen, that to suggest disease of this gland would imply that at some time in life the patient had had some form of venereal disease, the physician is loth to make such suggestion. And, even should he muster courage to do so, he would, in all probability, be met with the prompt reply, "Why, doctor, I never had any disease there in my life." It has been difficult for me at times to convince people that these troubles are not always the re- sult of venereal disease. But, when the patient understands that the doctor's desire to know positivel}^ that no such disease of the gland exists is in order to discard it as a pos- sible cause, the patient will, in almost every case, submit to an examination, and, by means of the lougie a hoiile the trouble in the prostatic urethra will be detected. The ex- amination through the rectum or by cystoscope could be made at the time, or on some other day, should ob- jection be made. Many cases of nervous troubles of an obscure origin have been cleared up in this way. Sexual neurasthenia is not an idiopathic disease, and rarely, indeed, can it not be traced to the prostate or genital organs as the prime cause. NEUROSES OF THE PROSTATE. 15^ I remember hearing a lecturer, at the Blockley Hospital, Philadelphia, say that he had often declared that he would not vote for any man to graduate in his class who failed to suggest examination of the prostate in answer to the following question: "What would you do if a man pre- sented himself with an obscure nervous disease ?" At the time I considered the statement absurd — especially as the lecturer was not a Jefferson professor — but I have since often thought it a very wise utterance. Genito-urinary diseases of men as result of prostatitis and the various functional nervous disorders related there^ to, whether as cause or effect, are in the same condition that diseases of women were in fifty years ago. At that time the nervous symptoms that accompanied such dis- orders in females as lacerations of the cervix or perineum, congestion and displacement of the uterus and ovaries, were succinctly, if unscientifically, grouped under the head of hysteria, and these symptoms treated without reference to the cause and often without the least effort to arrive at a correct diagnosis. And today the nervous maladies result- ing from a morbid condition of the prostate gland, such as mental depression, morbid fears, nervous dyspepsia, pal- pitation, deficient mental control, headache and backache, are generally dismissed in the same easy fashion to the category of hypochondriasis. Considering the immense importance of the problem in- volved in the relation of the genital function to the nerv- ous system, and the vast amount of suffering entailed upon mankind by the igcorance of the patient and the indiffer- ence of the physician in regard to these problems, remark- ably little effort has been expended in their solution. Whether there is or is not such a disease as spermatorrhea, and if there is, what is its nature and effect ; when are in- voluntary emissions pathological- what are the various 154 PROSTATE GLAND AND ADNEXA. kinds of impotence, and liow should they be treated; how are morbid conditions of the prostate gland and urethra reflected to the nervous system ; how do nervous and other diseases affect the genital functions? — ^these and other problems of great practical interest have only within very recent years begun to attract the attention of the inves- tigator, while the profession at large are as yet almost blind as to their importance. While the excitant cause of sexual neurasthenia is trace- able in the majority of instances to disease of the prostate, yet there are other exacerbating etiological factors that should be taken into consideration. Prominent among these are excessive cigarette smoking, alcoholic stimulants, business cares, domestic worries and climatic conditions. All these have to be taken into account as concomitant fac- tors in genital neuroses. The symptoms of sexual neurasthenia are so protean in- nature, that, according to the prominence of one or other stage of its development, it is frequently diagnosticated as oxaluria, lithemia, or disease of the imagination. Its real and tangible cause is either overlooked, or an attempt to discover its source neglected. The physician is usually content to guess at the cause, prescribe some in- noxious remedy and await the result. Others resort to nux vomica or its alkaloid, combining or alternating it with various other aphrodisiacs, which serve to excite an already tender or diseased prostate. The man returns from time to time and reports some better, then worse ; when, in fact, he is growing gradually worse all the time. This condition may continue for a long time, until the man finally be- comes aware of a twitching of the muscles of the lower limbs; in others the fingers tingle or there is an impair- ment in the use of an arm, noticeable in writing or hand- ling a knife or fork while eating. In others, the lower NEUROSES OF THE PROSTATE. 155 limbs feel heavy or numb^ requiring an effort to raise them in walking. Many men begin with pains in their back, which extend over their hips, down to the calves of the legs. The latter is a very common symptom, owing to the close relation of the sciatic plexus to that of the prostatic plexus and asso- ciate ganglia. Melancholia is a very common sequel of prostatic dis- ease, and it, just as other neuroses resulting from disease of the gland, assumes a periodicity at first; subsequently it may become continuous. I have clinically observed in men suffering from prostatic neuroses that the periodicity is markedly analogous to the menstrual epoch of women, in that it first appears in paroxysms of about four-week in- tervals; and, as the disease becomes more aggravated, it assumes a periodicity of two weeks ; when, as the gravity of the disease becomes serious, it is daily or continuous. I would advise, in these obscure nervous diseases, or even in any chronic condition, where a monthly exacerbation appears, the examination of the prostate. In some cases the periodicity is manifested in bouts of drinking. It may seem absurd to some; and, if on examining the gland it is found to be healthy, there is no harm done; when you can then dismiss it as being the most probable etiological factor. Clinical observation has demonstrated that young men suffering from prostatitis of the sub-acute form, are more subject to paraparesis; while middle aged and old men affected with congested enlargement of the gland are more subject to hemiparesis. "While this is not an invariable rule, yet in the very, large majority of cases, if the prostate is examined in these paralytic diseases, it will be found to be diseased. Melancholia and mania may follow either char- acter of the disease, but it is rare in senile hypertrophy. 156 PROSTATE GLAND AND ADNEXA. The innumerable symptoms that result from reflex ir- ritation of the prostate are brought about by the sympa- thetic system or vaso-motor nerves as well as by those of the cerebro-spinal system. The more highly developed the nervous system of the individual, the wider the effect pro- duced by the shock of any disease of the gland. But in the spreading of the effect, the intensity at any given point is diminished. This furnished the explanation of the seeming paradox that strong constitutions are. more liable to severe local disease than are neurasthenics. The mole- cular changes produced by disease meet with far less re- sistance in highly involved organizations which are good conductors of every kind of motion, while the resistance offered by a strong constitution tends to produce local functional disease. Thus it is that functional excesses in the strong tend to produce excessive functional nervous diseases. The same fact serves to explain another apparent para- dox, that nervous hysterical patients, who run the gamut of nervous disorders every day of their lives, are frequently long lived ; disease, as it were, proving an antidote to dis- ease. The destructive force of disease which meets with vigorous resistance in a strong body, concentrates itself locally with lethal violence, while in the weak, nervous constitution, it is conducted away, attenuated and rendered comparatively innocuous. MELANCHOLIC MANIA. This is one of the most distressing as well as varied in its manifestations of any of the neurotic diseases follow- ing prostatitis. Among the incidents of most every phy- sician, long in practice, the proverbial phrase that "It never rains but it pours'' has been tangibly presented at some time of his professional career. It fell to my lot NEUROSES OF THE PROSTATE. 157 some years ago to have had quite a number of these cases of melancholia following in close order to one another. Case XXVIII. Chkonic Prostatitis and IIelaxcholic Mania. Merchant; aged forty-four; very emaciated, though strong and an active business man. For two years he had suffered with occasional attacks of nervous depression fol- lowed by hot, alternating with cold, flashes. These "spells" as he termed them, had gradually grown more frequent and aggravated. At first they would occur every three months, then monthly, and finally every two weeks. His temperature would never rise more than one-half degree, even when he said he felt as though he was burning up. I inquired as to the condition of his kidneys, bladder and sexual organs. He was very reticent regarding them and at first strenuously objected to an examination. Finally upon submitting to an examination, the prostate was found to be exceedingly sensitive and slightly swollen. It was so sensitive that he refused to have it treated. He con- tinued to grow worse until he was advised by his wife and friends to take a rest. He went to a country town and en- gaged rooms at a hotel. He had been there just about ten days when he had "one of his spells." His wife sent for a phj'sician, who, after having examined the man, pre- scribed some innocuous remedy and left. After having taken one dose of the medicine, the man conceived the idea that his wife had connived with the doctor to poison him for the purpose of procuring his money. He violently op- posed taking another dose of the medicine, to avoid which, having been persuasively urged to do so, he leaped from his bed and ran out of his room in his night clothes down the stairs from the sixth floor to the oflice, screaming "murder." He maintained that I, onlv, knew his constitu- 158 PROSTATE GLAND AND ADNEXA. tion and was capable of prescribing for him. He had his wife wire me to come and see him (some two hundred miles distant) . Several telegrams were sent daily for three days, when I finally decided to go. On my arrival at noon, and making myself known to the clerk at the hotel, he said that my patient was in the dining room, across from the office, and for me to walk in and get my dinner. I was cordially greeted by both man and wife, who requested me to order my dinner. Questions were immediately pro- pounded by the man regarding incidents at home, evidently, as I understood, to avoid mention of his health. He was quite cheerful, apparently, and discussed different sub- jects intelligently. The subject of his health was not men- tioned until on leaving the dining room, he requested me to go with him to the parlor, where he narrated the inci- dents before mentioned, in a very quiet and rational man- ner, explaining his reasons therefore. He stated that he had had "one of his spells," and that the first dose of medicine was poison, and that he had acted in that way to attract the attention of the police, that they might arrest and lock him up until I could arrive to treat him. I re- mained with him several hours and left him in the best of spirits; he consenting to remain there several weeks until he regained his health. On the following morning I heard that he had returned home and was violently insane. He was arrested by the police and incarcerated. He sent for an attorney, to whom he explained that he had been arrested and imprisoned for sinister purposes. He was released, as he was as rational, apparently, as any one. In a few days thereafter he again became violent and was placed in custody at his home. During these at- tacks he would suffer with continuous priapism both day and night. During the rational intervals he would be comparatively free from the annoying erections. He NEUROSES OF THE PROSTATE. 159 was carried to the asylum in this state, where he re- mained a few months and died. Case XXIX. Insomnia, Melancholia, Prostatitis. Clerk; aged thirty-eight; married. Very large and ap- parently in robust health. I was called in consultation to see the man, when the attending physician gave the following history : The patient had never had any ven- ereal disease, but had been addicted to excessive venery in early youth, and, at times, until within the past two years. He has paroxysmal periods of excessive sexual desires. One sexual congress seemed to intensify the propensity for a second or third in rapid succession. This would last for three or four da3'S, when he would lapse into a state of melancholy and insomnia. He had first noticed the attacks monthly, attended with only slight depression of spirits; but for six months prior hereto he would be scarcely relieved of one attack before the recur- rence of a second. He would not average more than five hours' sleep during the twenty-four, and only then under the influence of a narcotic. There were few symptoms indicating prostatic trouble. The urine was voided more frequently than normal at times, and contained an ex- cessive quantity of phosphates and some uric acid. I advised an examination of the prostate; this was op- posed by the patient and not encouraged by the attending physician. I did not hear from the patient again for six months, when I was again called to see him with his phy- sician. He had grown steadily worse and, though taking from sixty to eighty grains of sulphonal daily, he was sleeping not more than three hours during the twenty- four. He had developed a religious mania and was sing- ing and praying much of his time. He had now become totally impotent. I again insisted upon an examination 160 PROSTATE GLAND AND ADNBXA. of the genital organs, which revealed both chronic pros- tatitis and vesiculitis. Immediate improvement followed treatment of the gland and vesicles, and today he is a healthy, active business man. I could report several other similar cases with various complications that have come under my observation, where relief of the prostate and vesicles was followed by com- plete recovery of all other nervous symptoms. The perversion of the sexual organs, as cause of lunacy, gave rise to the advocacy and practice, in some of our asj^- lums a few years ago, of castration for its relief. Melancholia as a result of prostatitis does not always develop insanity. I have noted its manifestations in the most varied phases of hysteria, mental and physical weak- ness, obstinate pessimism, and occasionally extreme op- timism. One hysterical patient that I can recall would lie down upon the floor and roll over and cry for a time and then laugh. He was forty-four years old, married, had three children, and never had gonorrhea. His prostate was so tender that he fainted when it was gently touched. He recovered entirely from his nervous sj^mptoms after the relief of the prostatic trouble. These cases all have an exceedingly sensitive urethra, even those that never had gonorrhea. Dyspepsia and constipation are common sequels of pros- tatitis, often, too, when there are no indications of dis- ease of the gland. I recall one case that was brought to me by a former patient who had suffered with indigestion and flatulency for several years. During this time he had consulted many physicians and had taken all the indi- gestion remedies advised by both physicians and drug- gists. He was existing solely upon milk and some form of Battle Creek food. There was not an objective symp- NEUROSES OF THE PROSTATE. 163 torn pointing to any form of disease of the gland, and I hesitated very much to suggest an examination of it. He readily submitted to an examination, to my surprise, wlien I found the gland slightly affected. I had him dis- continue the use of medicines and eat sparingly for a few weeks. I treated the gland through the urethra and rectum on alternate days and did not give him a single dose of medicine. He fully recovered and gained twenty pounds in weight within two months and has never had a symptom of his former trouble since, though he eats anything he wishes. Other cases of indigestion, with pronounced symptoms of disease of the gland, have been quite common. Sciatica or affections of some of the branches of the sciatic nerve are common sequels of prostatitis. Fig. XXII. illustrates the nerve and some of its branches. Those distributed to the muscles of the calf of the leg are more frequently affected, even when the great sciatic es- capes. I recall one man fifty-two years old, who had sharp, darting pains in the calves of his legs, and, at times, in the thigh. He had been treated with "goat lymph" and otherwise for locomotor ataxia several years. His prostate was exceedingly sensitive. After the third treatment of the gland his pains disappeared and never returned. I have seen several cases who had pain only in the heel. One of these had been suffering intensely for about a week, both day and night. He never had gonorrhea, nor had he any prominent symptoms of prostatitis. The pain immediately disappeared after the first treatment of the gland. It returned some days afterward, but finally left him entirely, after the gland had been relieved. 162 PROSTATE GLAND AND ADNEXA. Fig. XXII. (Gray.) NEUROSES OF THE PROSTATE. 163 Case XXX. Sciatica, Prostatitis, Spermatorrhea. Clerk; aged twenty-six; single. He had gonorrhea of a severe type when twenty-one, which was long continued. He thought that he had never fully recovered from the attack. Some two years after the prime inception of the disease, he noticed a continuous oozing from the penis, vital depression and impaired function and erections. Subsequently pain in the back and left hip developed. It grew worse when sitting for a long time. Exercise re- lieved the pain for the time. He would pass several weeks frequently without noticing any special inconvenience, when, suddenly, he could scarcely arise from his chair. The attacks became insidiously more severe from month to month, until he had a severe paroxysm that confined him to bed for six weeks. During this time he sufEered in- tensely, necessitating the use of large doses of opium for relief. The muscles along the course of the sciatic nerve became very much atrophied, leaving a depression in the limb. He had taken almost every conceivable remedy, together with a course of baths at Hot Springs, Arkansas, which only gave temporary relief. The direct static spark over the spine and along the course of the nerve gave the most relief, for the time. Upon examination I discovered a slight stricture in the membranous urethra, chronic prostatitis and vesiculitis. The sciatic pain was permanently relieved soon after beginning treatment of the gland. Massage of the limb restored it to its normal size. IMPOTENCY. Impotence may exist in a modified degree, or amount to total functional incapacity. There may be only a defi- 164 PROSTATE GLAND AND ADNEXA. ciency of erectile power, or desire and capacity may both be lacking. Or, again, erectile power may be normal at times, when free from erotic excitement, and then be- come flaccid and useless in the presence of women. Some- times an erection takes place at the proper time, but it does not last sufficiently long for intromission, much to the disgust and chagrin of the man. Sometimes prema- ture ejaculation occurs, but often no emission takes place. I shall not attempt here a discussion of the mechanism of erection, but it is chiefly under the influence of the ner- vous system, which is controlled mainly through the "sex- ual brain" as situated in the prostate, or, as many think, in the caput gallinaginis. There is no paralysis or loss of power in the muscular or vascular conditions of the organ that affect the mechanical part of the erection. Failure to perform the act, at some one time, often be- comes so impressed upon the mind of the man that even after the restoration of the prostate to its normal condi- tion, it requires several efforts to restore confidence. I recall the case of a libertine, who, suffering from prostatitis, had made repeated failures with his mistress, and after having been restored, would still fail with her, yet complete the act perfectly with other women. There is often diminished sensibility of the penis and scrotum, which appear also cold and lifeless. Impotency due to disease of the prostate and vesicles is almost invariably attended with seminal loss in some form; that is, in young or middle aged men. The terms in general use for unnatural seminal discharges are some- what confusing, as they are often used synonymously. Those to which I adhere are nocturnal or involuntary sem- inal discharges, pollutions and spermatorrhea. The first occurs in one's sleep and is attended with an orgasm that generally arouses him. Pollutions may take NEUROSES OF THE PROSTATE. 165 place at any time, but more frequently during sleep, and emissions occur in a similar way to the former, but in a passive form, and not attended with an orgasm, which rarely arouses one from sleep. Spermatorrhea takes place in a slow, dribbling man- ner, without erection or orgasm. It produces the sensa- tion as though something was running from the penis. The latter may be concomitant with either of the acute forms. Moreover, it is often the case that prostatorrhea only exists, which is mistaken for spermatorrhea. Kervous depression or moodiness is not usually due to the loss of semen, even when seminal discharges are promi- nent, but to the incessant reflex nervous irritation to the cerebro-spinal centers as result of the diseased gland. Should an emission occur when asleep, and not oftener than ten days or two weeks, in a man of vigorous habits, it should not be considered pathological, when the man had abstained from all sexual relations during that time. Ultzman and S. W. Gross concur in this view. I cannot impress too forcibly the importance of an ex- amination of the gland in these obscure cases, as I know too well that physicians are prone to neglect such, and yield too readily to an obduracy upon the part of the pa- tient to submit to an examination because of over prudery, or that it suggests venereal disease. I can recall several suicides of prominent business men, who, if their prostatic conditions had been properly diag- nosed and relieved, could have been saved an untimely death. Men suffering from melancholia, as a result of pros- tatitis, are much more able to resist the evil effects of the disease when employed than when idle. It is very unwise to advise such men to go away for a rest. I have known of several instances where men were so advised, and who, 166 PROSTATE GLAND AND ADNEXA. having no other mental employment than to brood over their ailments, became maniacal or suicidal. The simple knowledge of impotency so preys upon the minds of some men as to aggravate their physical and mental condition, impair their digestion, disturb their sleep and wreck their health. STERILITY. Potentia coeundi does not always imply potentia gen- erandi. The latter depends entirely upon the procreative power of the semen, while the former implies the ability of the man to complete the act of coitus. It is a well-known physiological fact that healthy pros- tatic fluid is essential to perpetuate the lives of the sper- matic germs until they reach their destination of impreg- nating the ovum. The vesicles, too, are important factors towards maintaining the vitality of these germs. The prostate and vesicles are in such close proximity and so allied in their physiological relations, that disease of one readily extends and involves the other. It is not infrequently the case that men are able to complete the act of coitus, yet the spermatozoa may be lifeless or so impaired in vitality from perverted prostatic secretions as to render them sterile. The wives of such men are too often subjected to all kinds of treatment and operations for barrenness, when the fault lies with the men. Several cases of this kind have come under my care, where relief of the prostate was followed by fruitful re- sults, PEOSTATOREHEA. Ultzmann says: "With every sexual excitement as soon as erection of the penis has occurred, long before ejaculation of semen has taken place, a clear, transparent, NEUROSES OF THE PROSTATE 167 viscid drop, like white of egg, oozes from the meatus. This clear, viscid drop represents the secretion of the ac- cessory glands of the urinary and genital tracts and con- sists of the secretions of the prostate, of Cowper's glands and the glands of Littre. Since the prostate is the largest gland in this connection, it is evident that the mass of this fluid must be the prostatic secretion. If this clear, viscid fluid is secreted in greater amount, indeed continu- ally and without sexual excitement, this condition is called prostatorrhea." The fact is that the normal viscid secretion attending sexual excitement and erections, is often mistaken for a pathologic state, when it really indicates a healthy con- dition of the gland and is premonitory to a seminal ejec- tion. This prostatic secretion serves to lubricate the chan- nels and favor the passage of semen, besides its aid in maintaining the lives of the spermatozoa. Prostatorrhea is due to an inflamed condition of the gland as a result of gonorrhea, masturbation or other sex- ual excitements. Prostatic calculi or rectal diseases may serve as exciting causes, but they are more frequently the effect and not the cause of the trouble. The differential diagnosis between prostatorrhea and spermatorrhea depends largely upon microscopic exami- nation of the secretion. The presence in the secretion of Bottcher's crystals and amyloid bodies would point strongly to prostatorrhea, while the presence of spermatozoa would not exclude that condition as a possibility, as spermator- rhea often accompanies prostatorrhea, though the latter is much more common. Azoospermia is a common sequel of prostatitis and vesic- ulitis, as the perverted secretions of these organs tend to devitalize and destroy the spermatic germs and render the man sterile. 168 PROSTATE GLAND AND ADNEXA. The urine in these cases is variable in quantity, and is usually of light color, containing small shreds or hook- shaped flakes. TREATMENT. Successful treatment of these conditions depends upon proper diagnosis and the removal of the cause. As the etiological factors are almost invariably traceable to the diseased prostate and vesicles, these organs must neces- sarily be relieved before any permanent benefit can be procured. As the .treatment has been discussed in previ- ous chapters, the reader is referred thereto for full details. There are some cases, however, of long standing disease of the prostate where, even after the gland had been cured. Fig. XXIII. there remain? an impaired function of the genitalia, due to lack of nervous energy. For relief of this condition I have devised a bipolar rectal electrode. Fig. XXIII. Fig. XXIV. shows the application of this electrode, oiie pole being directed to the prostate in front and the other to the sacral and hypogastric plexuses of nerves that min- ister to the pelvic organs. By passing the electrode fur- ther up the rectum the poles are in apposition to the vesi- cles in front and the genito-spinal center jDosteriorly. I have found this treatment very efficient in such cases. It is a common practice among physicians of giving aphrodisiacs in these cases, without attempting to ferret out the cause of the trouble, which serves to aggravate an already serious condition. I was surprised to note that the distinguished Dr. Ultzman (professor of genito-uri- NEUROSES OF THE PROSTATE. 169 nary diseases in the University of Vienna) advises the stroking of the external genital organs with electricity for impotency, yet further states (page 41) : "This method of treating impotence is not infrequently accompanied by the most excellent results, only it has its shady side, and Fig. XXIV. that is that nocturnal emissions are promoted, i. e., in- creased." Impotency, which is most often the result of prostatitis, should never be treated by exciting the genital organs either with medicines or electricity, until the diseased con- dition of the gland is relieved, when, in the large majority 170 PROSTATE GLAND AND ADNEXA. of cashes, the normal function is restored without the use of any exciting agents. There are some cases^ however, in whom stimulating aphrodisiacs arouse transient genital activity which is usually followed by total impotence and seminal losses. Prostatic Facies. — Just as Kelly describes an ovarian face in women, there is an analogous expression in most all men suffering from chronic prostatitis. It is quite noticeable in many men, which readily disappears upon restoring the gland to its normal condition. Glycosuria and albumen often appear in minute quan- tities where neurotic symptoms are prominent; but they are of transient nature and readily disappear as soon as the local trouble is relieved. Neither of these conditions implies disease of the kidney. Since Claude Bernard demonstrated that puncturing the floor of the fourth ven- tricle would produce albuminuria or glycosuria, it is now a Veil known fact that many nervous shocks cause them to temporarily appear. Imaginary Impotency. — Much has been written and spoken of impotence existing only in the head. Many of these expressed opinions have originated from some of the most prominent surgeons and genito-urinary special- ists, who had either failed to locate the cause of the trouble or to relieve it after having discovered the source. But very few of these cases are really imaginary. Case XXXI. Aged thirty-two; single. Never had gonorrhea. He had been addicted to sexual abuses followed by frequent emissions and chronic discharge. The first physician treated him with tonics, or constitutionally; the second with sounds ; the third with both. After having gone the rounds for six years, trying to get in shape to marry, he NEUROSES OF THE PROSTATE. 171 was advised to do so^ and that he would then become normal. The trouble continued. Two years after his marriage he came to me for treatment. I discovered an inflamed prostate and urethra. Normal functions re- turned just as soon as these organs were relieved, and without taking a dose of constitutional medicine. Case XXXII. x4.ged twenty-eight; strong and robust in appearance. He was not sure whether he had ever had gonorrhea or not, as some physicians had told him he had, and others that he had not. He was annoyed with excessive pollutions. Different physicians advised him to marry and that his trouble was in his head alone. He recovered his sexual powers when relief of his prostate was effected. PARAPAEESIS. This condition especially calls for a thorough exami- nation of the prostate gland and adnexa. For the past fifteen years, since I have had my attention more espe- cially directed to the prostate as an etiological factor in this trouble, I have not seen a single case of paraparesis or impaired function of the lower limbs where the gland was not involved, unless due to syphilis or lesion of the spine. This condition occurs more often in young men who have been subject to excessive masturbation or sexual indulgence. The onset of the trouble is usually manifested by a sensation of heaviness or weight about the lower limbs, which, as the disease progresses, becomes so marked as to interfere in climbing stairs. Tliere is rarely any pain in these cases at first; and should it supervene at all, it is usually manifested by a few darting pains in some of the branches of the sciatic nerve, in the region of the popliteal space or calf of the leg. 172 PROSTATE GLAND AND ADNEXA. The progress is usually of an insidious nature, and especially if due to masturbation. If due to excessive sexual indulgence and accompanied with a bout of drink- ing, it is liable to be sudden. I have seen cases of the latter where sudden paraplegia resulted. In rare in- stances of this affection, the pains, as before described, have been the prominent premonitory symptoms. Others still have described sensations as though something was creep- ing up their limbs. Case XXXIII. I recall the case of a man, twenty-eight years of age, who had been suffering eighteen months with paresis. There was no pain in the limbs, but the impaired function became more perceptible from week to week until there was total loss of power. During this time the young man had been treated by several physicians, some of whom diag- nosed the case as that of locomotor ataxia. Not one of them suspected the prostate as the cause of the trouble, or even examined it. When I first saw him he had no more use of his lower limbs than if they were made of rubber. I found him totally impotent, with a persistent prostator- rhea and occasionally nocturnal pollutions. I directed my treatment entirely to the prostate, when improvement began at once. In six weeks time he could stand upon his legs, and after six months he was back at work, and one could scarcely detect any defect in his gait. HEMIPAEESIS. This trouble is very common among older men suffering from enlarged inflammation of the prostate. The first manifest symptom is a dragging of one foot in walking, scraping of the pavement. This is often noticeable by one's companion before the person himself has observed it. NEUROSES OF THE PROSTATE. 173 Case XXXIV. I recall one case who said the first time he had his attention called to any defect in his left foot was by his wife, when walking upon the street, when she said : ''Will ! for goodness sake quit scraping your foot on the pave- ment." He had never noticed it before, and when his attention was called to the fact he went along for some distance without doing so again ; but his mind being with- drawn from his walking, he was again reminded of it by his wife. When dressing the next morning he first noticed that the sole of his left shoe was much worn out at the toe, while the other was not. From that time on he no- ticed a perceptible impairment of his left side. This was followed by loss of co-ordination in writing. This case applied to me for treatment eighteen years ago. I did not know as much about the cause of these troubles then as now, so I treated his spine by electricity, massage and mechanical movements for several months, which gave him temporary relief; but he was gradually growing worse from month to month. He finally men- tioned certain symptoms implicating the sexual organs that led to an examination of the prostate, which revealed the seat of the trouble. Noticeable improvement followed the treatment of the gland within two weeks from the time of its beginning. Three months thereafter he was able to resume his work and left the city. I did not see him again for nine months ; when upon his return he was so far well that his defect was almost imperceptible. Case XXXV. Merchant; aged fifty-six; married. Up to his fifty- third year he had been quite active. About that time he began to notice that he would scrape his right foot upon 174 PROSTATE GLAND AND ADNEXA. the pavement when walking. He could prevent this scrap- ing, at first, when his attention was directed to it; but immediately on withdrawing his mind from the sluggish foot, the scraping of the pavement would recur. He next noticed an impairment of his right hand when attempting to tie a bundle. He was unable to grasp a string sufTi- eiontly tight to tie a knot. This condition grew worse, l)y degrees, until he could not use his knife while eating. The leg was equally impaired. Both hand and leg began to im.prove after the second week's treatment of a congested enlarged prostate. The gain was steady for two months; but there was still an impaired function. I then began- the application of the bi-polar electrode as illustrated (Fig. XXIII.), passing the current through the prostate in front, and the sacral plexus and lower part of the spinal cord' behind. Marked relief followed this treatment. I recall another similar case of a harness maker, whose right hand became so impaired that he could not draw a thread in stitching. His right leg was also impaired. After being treated in a similar way to the foregoing case for six weeks, he was enabled to resume his work. The treatment was continued for six months, at irregular in- tervals, when he fully recovered. APPENDIX. CHAPTEE YIII. ELECTRO-PHYSICS, ELECTROLYSIS AND CATAPHORESIS. I shall treat these subjects in their chemic, physiolog- ical and therapeutic relations only in so far as they pertain to my subject. Introduction. A knowledge of the construction of batteries and acces- sories, the manner of producing the different currents, together with their various modifications, is as essential to their proper understanding and scientific applications as is that of chemistry, physiology and anatomy to the prac- tice of medicine and surgery. Anyone capable of using these potent agents in a scientific and practical manner with impunity should be able to make, or have constructed by his own directions, batteries, accessories and electrodes to meet all indications that arise. I have known of fre- quent instances where physicians were using the galvanic current who did not know, positively, which was the anode or cathode, yet there is as much difference in their effects as that of calomel and opium. Others regard the sinu- soidal and faradic currents as the same or similar in effect, when their properties are almost as different as that of the two poles of the galvanic. The empirical use of the currents is not confined to the country physicians, but it is often so used by some of our leading specialists, and so-called professors of electro- therapeutics. 175 176 ELECTRO-PHYSICS. I have had quite a number of physicians consult me who had diplomas in electro-therapy, that were ignorant of its first principles, and, too, where most of their teachings had been erroneous. A physician, a few months ago, called to see me, who was taking a course of instruction in electro- therapy. I asked him what were their teachings regarding the properties of the sinusoidal current. He said tliat one of his professors had said that it was the same in effect as the faradic currents. I then gave him a list of questions to ask his professors regarding the properties of the direct and alternating incandescent currents, the sinusoidal and induced. On the following day he reported at my office, and stated that he had propounded the queries, as I had suggested, to each of the lecturers, and that neither of them agreed upon any point. A lack of knowledge of physics and the properties of the different electric currents, as evidenced by teachers and writers upon the subject, has evidently given rise to the following from Dr. S. H. Morrell, in the Times and Reg- ister, March 16, 1895, on "A Plunge into Electro- Therapeutics,'" who gives some wholesome advice to be- ginners which thoroughly accords with my views. He says: "If you wish to acquire skill in the use of electric- ity, don't set about it alone, and don't rely on what you find in text-books. If you can induce a reliable expert to take you as a student for a few months, do so, no matter what it costs. As there are various branches of electrical work in which special technique is employed, for instance in genito-urinary and gynecological practice, you should obtain a short course of practical instruction in each. When you have devoted six months to an apprenticeship of this kind, you will have laid the foundation for ultimate success." I mention these facts only to illustrate why electro- ELECTRO-PHYSICS. 177 therapy is still regarded by many of our leading physicians as suh judice, who have not given it special attention or clinical study. Many of the most scientific physicians in the world at- test the fact that by the proper selection of the currents and accessories, and its appropriate application to certain pathologic structures, it relieves the morlhfic conditions with the impunity that cannot be effected by any other means known to science. The proper use of so intricate and yet so worthy a remedy could not be brought to perfection l3y a merely superficial series of experiments, nor can at present a pass- ing glance at a standard author warrant sufficient knowl- edge for successful treatment by its use. The different currents and different strengths, each are studies in them- selves that demand careful perusal on the part of the student, of each and every form separately, as though it were an independent study bearing only a distant relation to the common subject. This accounts for, in part, why the general practitioner too frequently wholly neglects the agent that will bring about the best results in the treat- ment of his patients suffering from prostatitis, and resorts to the use of drugs that will frequently do infinitely more harm than no treatment at all. Xot that it is a willful neglect on the part of a conscientious physician who always tries to do the best by his patients, but rather because, even though he would have sufficient time amid his numerous duties to study thoroughly the applications of the different currents, facilities for their use and necessary equipment in order to justify gratifying results would be wanting. In short, electrical treatment is a specialty that demands for the successful management of cases a specialist who can devote the greater part of his time to the supervision of special apartments and special equipments that cannot 178 ELECTRO-PHYSICS. receive ^lecessary attention in the busy routine of a general practice. In the hands of such a one sufficiently skilled to cope with the various forms of chronic prostatitis, and possessing all requisite appliances, the efficacies of electrical treatment cannot fail to prove itself as being far superior to all agents that may be employed for the relief of thi& form of disease. Electricity, like all other potent remedies, has its limit of utility, and it is only within these bounds that its bene- fits are claimed by the author. Electricity yields negative results wherever its applica- tion is not thoroughly understood, as where the galvanic current is applied where the faradic or sinusoidal should be used ; or when too weak or too strong a current — either has no effect or irritates the parts ; or when it is made to comprise the whole treatment, and no pains are taken to ascertain the underlying cause of the disease and that also judiciously treated, nor to build up the general system in conjunction with this treatment. As is the folly of treat- ing a patient with tonics with a view of adding weight to his body, and still denying him the proper food for the accomplishment of that purpose obviously evident, so also should be the treatment of a patient by electricity without attention to general hygienic principles. The efficacies of electro-therapeutics are denied by many physicians who, in good faith, have never devoted sufficient time to the study of its proper application, and hence every trial has been attended by failure; and those who, skeptically biased, have never directed their attention to its uses, and in order to smother its growing popularity declare it harmful in effect and too dangerous for use. Because a remedy is not rightly understood and its use is not attended with success merely for want of knowledge on the part of those who deny proper time to its study, it ELECTRO-PHYSICS. 179 does not necessitate abandonment on the part of others who are thoroughly versed in its effects, and in whose hands it does not fail; and much less should it be under- valued because subtle charlatans with medical pretenses ensnare unwary victims by its improper uses. In the hands of an incompetent physician most all therapeutic agents are dangerous, be it an opiate, massage or mustard ; and electricity is no exception to the rule; yet who would decry the beneficial effects of an opiate prescribed by an able physician. And since, therefore, most of our worthy remedies have a dangerous side, if carelessly employed, why then should the use of the electrical current be aban- doned when other agents, infinitely more dangerous, still maintain full sway in the treatment of diseases ? Electrical treatment is a method of treatment that has come to stay. Prejudice cannot uproot it, nor bungling usage soil successful records. Yearly, as new and more efficient methods and apparati are brought into use, its range of employment grows larger and its triumphs of success become more apparent. And today, from among all the various agents for the successful treatment of dis- eases of the prostate, electricity, in conjunction with suit- able medicinal remedies, incontrovertibly stands in the front rank. CHAPTEE IX. ELECTRO-PHYSICS. — CONTINUED. All substances, whether organic or inorganic, are capable of electric excitation. The electricity thus excited affects bodies differently. This difference in -the electric condi- tion of one body as compared with that of another consti- tutes what is termed electrical potential. Bodies are not under all circumstances of the same electrical potential; in fact, they vary very much in this respect. An element of higher potential is positive to one of lower negative, yet negative to another still higher. For instance, zinc is positive when coupled with copper, yet negative with sodium. The term potential, therefore, is a relative one. The earth is usually taken as the standard, and assumed to be at zero potential. All energy or chemic action exerted upon bodies of different potentials evolves electricity, and there is a con- stant tendency toward the establishing of an equilibrium between them, by the passing of the current from the positive or higher potential to the negative or lower. There being no absolute non-conductors, all bodies would soon be brought to an electric equipoise were it not for the constant generation, or evolution, of electricity by energy or chemical action as exerted upon bodies of dif- ferent potentials. It is a mistaken idea, as expressed by many, that the energy exerted by the diurnal and annual revolutions of the earth produces an inexhaustible supply of electricity. As the earth revolves through ethereal space there is no friction, no energy exerted; hence there could 180 ELECTRO-PHYSICS. 181 be uo electricity evolved. Astronomers agree that the earth has not lost a fraction of a second of time for hun- dreds of years; this would be impossible were there suffi- cient friction or energy exerted to evolve electricity. There are three ways by which electricity is transmitted between bodies, viz., conduction, induction and convection. It flows in direct proportion to the conducting media and inversely as to the resistance ; though always, other things being equal, in the direction of the least resistance. Conduction is the property possessed by bodies of trans- mitting electricity from positive to negative, when the conductive body is brought in direct contact with each pole. A knowledge of the relative conductivity and resistance of bodies, used in the construction of batteries and appur- tenances, is indispensable to a thorough understanding of electro-physics, electro-physiology, electro-therapy and electro-surgery. The best conductors for all practical purposes are copper, zinc or silver. The size of the wire in the conducting cords must also be considered, as the conductivity of the current is influenced markedly thereby. Especially should this precaution be observed when using a current of large volume or amperage, as in applications of the cautery current. Those of high tension and low amperage, how- ever, do not require such large cords. The term conduction is a relative one. The best con- ductors give a certain amount of resistance, and the longer the distance the current traverses from the generator or battery, the greater is the resistance, or impaired force of the current, other things being equal. As before stated, a large collection or size of wires overcome this to a great extent. There are also certain very poor conductors, or practically non-conductors (yet in fact there are no non- conductors so far known to science), that are used as 182 ELECTRO-PHYSICS. insulators. Insulation means the prevention of the ©scape of electricity from a conducting body, or wire, by so-called non-conductors. Glass, rubber, silk, wool, German silver and graphite are those in general use. Owing to the great resistance offered by German silver to the flow of the electric current, and, too, its property to withstand heat, it is very much used in the construction of rheostats. Graphite is also extensively used for the same purpose. These two substances are used almost exclusively in the manufacture of rheostats for utilizing the incandes- cent currents, both direct and alternating, for medical and surgical purposes. Induction is the force exerted upon bodies brought within the field of an insulated electric current, or magnet. This force is exerted by the attractive and repulsive prop- erties of atmospheric molecules, interposed between the insulated current, or magnet, and the hodj in close prox- imity thereto. By way of illustration, suppose a positive or negative pole of a magnet is brought within close relation to a plate of soft iron, though not in contact. The latter would become magnetized by induction. This is accomplished oy the well-known law of physics, that unlike attracts and like repels. The magnetic pole, whether negative or posi- tive, attracts the atmospheric molecules interposed between it and the iron plate. The molecules thus attracted be- come charged with the same magnetism, and are immedi- ately repulsed (like repels like) ; they are driven from the magnetic pole and strike the iron plate and impart to it the force obtained from the magnet. These molecules are so numerous and rapid in their course that they maintain magnetic properties in the iron plate just so long as it is retained within the field of the magnetic influence. A somewhat similar experiment of induction may be ELECTRO-PHYSICS. 183 given by the passage of a continuous electric current through an iusuiated wire surrounding a soft iron core, when a second insulated wire is wound over the first, but having no direct connection with it. A current is pro- duced in the second wire by induction, and passes always in the opposite direction to that of the primary current. Magnetism and electricity are interchangeable forces, or different manifestations of the same force, as they are readily convertible one into the other. The earth being the reservoir or store house of all unused electricity, it therefore constitutes one great magnet, into which all over- charged bodies of a higher potential tend to unload, as is illustrated by the lightning from the clouds passing to the earth. Moisture favors conductivity; hence the zig-zag form of lightning in its passage to the earth. Medical Electkicity. Electric currents are produced in different ways. Chief among these, in so far as this work is concerned, are those generated by dynamos, cell batteries and static machines. Dynamos are so constructed as to produce two different forms of current, the direct incandescent or Edison cur- rent, and the alternating. The direct incandescent current and the galvanic current, as generated by cell batteries (not the cautery) are the same in effect. Whenever the direct incandescent current of the 110 volt circuit is accessible, I would advise it to be used always in preference to that of any cell battery, for several rea- sons. First, because it is regular and constant. Whether used five minutes daily, all day or even a year, the current is invariable, accurately measured and of known electro- motive force. The cell battery must necessarily become weakened by use, as caused by the corroding of the positive element and exhausting of the excitant fluid. 184 ELECTRO-PHYSICS. There are various kinds of apparati, or batteries and accessories, made for the purpose of utilizing the direct incandescent current, by modifying them in various ways, for therapeutic purposes. They all tend to produce the same result of so harnessing the currents as to use any- where from one to one hundred volts, and so modifying them as to meet therapeutic indications. Anyone thoroughly familiar with the mechanism, the separate uses of the apparati and the different properties of the currents can handle them with impunity. A novice is much less likely to do harm with the direct incandescent current than with a cell battery constructed to produce the same electro-motive force. Still another advantage is that it gives only two-fifths of an ampere, while cell batteries give from one to one and a half ampere, and are, in con- sequence, much more iritating in procuring the same current strength. Cell batteries are troublesome and ex- pensive to keep in order, even by an expert; and often just at the critical moment there occurs a break in the circuit from an exhausted cell or from other causes. Good work, however, can be accomplished by means of them, although they require constant attention and testing to insure their being in good working order. While the electro-motive force, or voltage, as produced by cell bat- teries, depends upon the number, quality and condition of the cells in the circuit, yet the amperage, or volume, remains about the same whether one cell is used or one hundred; that is, when the positive and negative elements are alternately connected. Galvanic Cell. If two elements, metallic or non-metallic, differing in electrical potential, be connected at one extremity by a conductor and immersed in a fluid capable of chemie ELECTRO-PHYSICS. 185 action upon the higher, there is at once produced an elec- tric current which passes from the higher or positive ele- ment to the lower or negative. Substances so arranged in a cup constitute a galvanic cell. The more the elements composing a galvanic cell differ in electrical potential, all other things being equal, the greater in direct proportion is the electro-motive force arising therefrom. For example, a cell constructed of zinc and carbon generates a stronger current than one constructed of zinc and copper. Galvanic cells are constructed with regard both to cost and utility. Zinc is used almost exclusively as the positive element; carbon or copper as the negative. The cells in most general use are the Bunsen, Leclanche, gravity and dry, with their various modifications as made by different manufacturers. For all practical purposes, the open circuit cetl is best suited for stationary office batteries, as there is but little action or deterioration of elements except when in use. The only disadvantage attached to it is tha^, it cannot be used for any continuous length of time, since it requires rest to recuperate after an hour or more of constant use. Only a few minutes are required, however, to restore its activity. It is now the only cell used for stationary ofiice batteries, where the direct incandescent current is inacessible. The positive electricity arises from the zinc plate, passes through the fluid to the carbon, and out through the wire attached thereto, as the anode or positive pole, although it is the negative element. The wire attached to the zinc (the positive element) is the cathode or negative pole. When these wires are brought together there is formed a close circuit; when they are not connected there is an open circuit. The Bunsen cell is composed of zinc and carbon ele- 186 ELECTRO-PHYSICS. ments, with dilute sulphuric acid as the exciting fluid and bichromate of potash to prevent polarization. It was for a long time the principal one used in galvanic and faradic batteries, but, being objectionable to use on account of the fumes and corrosive properties of the sulphuric acid, it has been supplanted by the open circuit cells. Besides, the Bunsen cell is troublesome to use, inasmuch as the elements must be removed from the fluid when not in use; other- wise they will be destroyed. The open circuit cells (which include the dry, Leclanche, and their various modifications) of zinc, carbon, with muriate of ammonia as the exciting fluid, are the ones now in general use. They are less troublesome, require less repairing, and give a more constant current. The elements are not removed from the cups after using, and, with ordinary use, require attention less often than any other form of cell. The Galvanic Battery. "\¥hen two or more cells are so arranged that the zinc of one is connected with the carbon of another, there is formed a compound circuit, or galvanic battery. The different kinds of cells are all similarly connected in this arrange- ment for a battery. The Galvanic Cuerent. The current that flows through these various cells, when in proper connection, is known as the continuous or gal- vanic current. It is a current that traverses the circuit uninterruptedly and with a uniform strength varying in proportion to the power and endurance of the cells. In considering the construction of the galvanic battery we must call attention to the two closely allied yet distinct forms of current capable of being generated by the bat- teries properly constructed for each. They are intensity ELECTRO-PHYSICS. 187 and quantity currents, or, in other words, the continuouB current, as produced by an ordinary galvanic battery or dynamo and the cautery current. By way of differentiating these two forms, and in order to demonstrate their distinct utility, let us imagine two streams of water taking their origin from two separate reservoirs at the top of a mountain. The reservoirs are equal in dimensions, and capable of an equal supply ; they lie on the same level, and the descent of their streams is similarly gradual throughout their separate courses to the point where they diverge to turn water-wheels. Suppose that the orifice through which one of these reservoirs feeds its stream should become partly occluded. As a result the outward flow would be in a proportionate degree shut off. The accumulation of pent-up water would produce within the reservoir a pressure that in turn would cause the stream to gush forth with greater impetus. Sweeping along it would strike its wheel with much greater force, but, lacking the volume of the other stream, by reason of the occlusion at its source, would accomplish the same work differently. So it is with the currents of the intensity and quantity batteries. The intensity current, by virtue of its cell con- struction (the elements being smaller and alternately connected, and the distance between these elements and between the different cells being greater), like the stream impeded at its source, is resisted in its flow from one element to another and also from one cell to another. Thus it loses in quantity but gains in impetus or intensity. This is the form of galvanic current employed in medical treatment. The quantitative current, by reason of the proximity of its elements, the greater dimensions and exposure in sur- face of these elements, and the comparatively little resist- 188 ELECTRO-PHYSICS. ance offered in its course, like the unimpeded stream, flows through the circuit in greater quantity and gives virtually more power when used for motor or heating purposes. It differs from the intensity current in that its volume, passing through the circuit at a given time, is greater and more uniform, while that of the latter is less, yet more violent in form and of greater impetus. If these two forms of the galvanic current were succes- sively passed through a cautery knife, it would be dis- covered that while the current from the quantity battery would produce a white heat in the platinum blade, the passage of a current from an intensity battery would produce no perceptible effect and probably not even warm it. To explain this let us again refer to our illustration. Should the channels of both streams become similarly narrowed in their onward flow, it is evident that the stream whose progress had thus far been unimpeded would, by reason of its greater quantity of water, be more powerful; while the other, with far greater impetus, would again lack the volume to be of any avail. In flowing through the cautery knife, the quantitative current traverses a platinum wire, or blade, too small to carry the volume of current without great resistance in its passage ; as a result the current at this point is impeded in its flow, compressed into less area, rendered more compact, and hence heats the platinum point. The intensity current, however, lacking in volume, is not rendered sufficiently compact to even warm the blade, and it is only when this is passed through an intensely resistant and equally slender film (as bamboo in the incandescent light) that the current will be sufii- ciently condensed to produce heat and light. This is the reason why we cannot have a battery that will serve for both medical and cautery purposes without change of construction. An intensity battery may, how- ELECTRO-PHYSICS. 189 ever, be converted into a quantity battery by connecting all the zincs of the different cells to one another, so also joining all the carbons, and finally closing the circuit by connecting the first zinc with the last carbon. But this arrangement is impractical and never used. Another simple illustration of the difference between the two currents is as follows: Suppose an ordinary hose, one inch in diameter, is attached to a water plug of great pressure, and the water turned on. While it would throw a stream of water some thirty or forty feet by means of the force exerted by the high pressure, yet should this stream of water be thrown against a water-wheel four or five feet in diameter, it would have no effect upon it. On the other hand, a stream of water two: feet in diameter, of small force — even one-twentieth of that from the hose — if turned upon the water-wheel would, because of its volume and weight, begin to move it immediately. The units of measurement of these two forms of electric currents will be hereafter given. Construction of Batteries. There is a great difference in the quantity of current generated by both the galvanic and faradic batteries. Very many bateries of cheap construction are annually sold to the profession and laity. The currents in these are so intensely irritating and irregular that it is impossible to obtain any uniform results by their use. The quality of the galvanic current depends largely upon the cells used and the condition in which they are kept, while that of the faradic depends mainly upon the construction of the coil. In regard to the current as taken from the direct incandescent circuit, it is regular and invariable. Apparati are also constructed by means of which this current can be converted into great volume or 190 ELECTRO-PHYSICS. increased amperage, whereby it can be utilized for cautery purposes. This is first accomplished by means of a motor so constructed as to convert the direct into an alternating current, thence from the alternate by means of a second apparatus, called a transformer, into increased amperage, which can be used for cautery. The Faradic Currents. When a current from one or more cells passes around a bar of soft iron through an insulated wire, it magnetizes this bar or helix by induction. This remains magnetized as long as the circuit is closed, but is immediately demag- netized when the circuit is broken. Fig. XXV. Fig. XXV. illustrates the construction of a faradic bat- tery, from which we obtain the induced or faradic currents. By tracing the current from the carbon element c, fol- lowing the arrow up to the post, out to the point of the screw, and from there down the spring a, to which is attached an insulated wire that passes up and around the bar of soft iron and back to z, we have a closed circuit which attracts the piece of iron attached to the spring at a and draws it to 6. In so doing it removes the spring ELECTRO-PHYSICS. 191 from the tip of the screw (as is shown by tlie dotted linec) and breaks the circuit at this point. The circuit being broken, the bar of soft iron becomes demagnetized, and, the induction in the coil of wire being severed, the spring flies back to its former position. As soon as the spring strikes the point of the screw, the circuit is again closed; but also as quickl}' broken when the bar of soft iron again becomes magnetized. Thus b}^ rapid making and break- ing of the circuit, a current is produced, which is s3'nony- mously termed the induced, faradic or interrupted current. The Secondary Induced or Faradic Current. If a second insulated wire is wound around this first or primary cell, but not connected with it, and the current is passed through the primary wire, there is generated at the same time in the superadded coil a second current which flows through it in an opposite direction. As this second coil is entirely independent of the first, so far as direct connection is concerned (the wire merely running from the right S, around the primary coil and back to the left post S), the current is therefore produced solely by in- duction, and is known as the secondary induced, faradic or interrupted current. As compared with the primary, it is much more intense, yet with great resistance inter- posed it is soothing and acts as an analgesic. In regard to the question so frequently asked me, "What kind or make of battery would you advise me to get ?" one should first decide whether the battery is intended exclu- sively for the office or for portable use also. A good gal- vanic battery, with sufficient number of cells to give de- sired force, must necessarily be cumbersome to carry around. One constructed with dry cells is lighter and more convenient; yet I would never advise the procuring jf a portable galvanic battery for general use. 192 ELECTRO-PHYSICS. Units of Measueement of Currents. Cells vary greatly in regard to their current, strength or electro-motor force, so that it would be very indefinite, in denominating the electro-motor force of a current, to speak of so many cells or such a cell power. In order, therefore, to express more definitely the force or current strength, certain units of measurement have been adopted. They are the volt, ampere, milliampere and ohm. The volt is the unit of electro-motor force or pressure, as represented in a Daniel cell, which is taken as a standard and is usually designated by E. The ampere is the unit of quantity or volume of current strength, and is designated by A. The ohm is a unit of resistance, and is equal to that offered by the passage of a current through eight feet of No. 35 copper wire. It is designated by the letter E. The milliampere is the unit of current strength that passes through one's body when applied thereto; it is represented by M.A. The resistance includes that offered by the milliampere meter, conducting cords, the electrodes and the body of the patient. The resistance offered by the body varies in its different parts, and bears reference to its moisture or dryness; the mucous membranes offering the least resistance, and the palms of the hand, when dry, the greatest. The resistance of the current diminishes in direct proportion to the moisture of the surface of the body to which the electrode is applied, and also to the increased size of the electrode. By way of illustration, suppose we apply as indifferent electrode a sponge or spongiopiline, only one or two inches in diameter and moderately moist, to the palm of the hand; the resistance would be so great that scarcely any current strength would be registered upon the M.A. meter, ELECTRO-PHYSICS. 193 though fifty or seventy-five volts were brought' into the circuit. Now suppose the same size electrode was rendered quite moist and the hand again applied as before, the meter would register slightly more and the hand would begin stinging and be rendered very uncomfortable; at the same time but little work or effect would be accom- plished at the active electrode. On the other hand, sup- pose that an indifferent electrode is used, eight or ten inches in diameter instead of one or two, and well mois- tened, and that both hands are placed upon it ; then fifteen or twenty volts brought into the circuit would diverge the needle of the m. a. meter more than thrice as much as when the small electrode was used; there would be no discomfort in the hands, and the active electrode would accomplish more than treble the work. It is, therefore, evident that a large electrode should always be used at the indifferent pole. The different manufacturers of electric apparatus have so vied with each other in constructing cheap instruments to sell that a large majority of those placed upon the market give rise to more irritation in many instances than relief. It is impossible to procure uniformly good results with improperly constructed apparati. I have all my bat- teries, accessories and electrodes made to order, so that I know just what to expect from their use. In the applications of any of the electric currents, except certain forms of the static, there must be a closed circuit with the patient's body. And in these applications there are always an active and an indifferent electrode. These are used with especial reference to the effect it is desired to produce. The active, electrode is applied to the dis- eased organ or part affected, while the indifferent electrode may be placed in contact with any portion of the body that is most convenient. 194 ELECTRO-PHYSICS. In order to render the active electrode more efficient to a local lesion or diseased area, the electricity must be con- centrated upon the part affected. To accomplish this all the other portion of the electrode must be insulated except that in immediate contact with the diseased organ. By this means the healthy tissue is protected from the electro- lytic action of the current. The localized effect of the active electrode may be still further increased by counter- acting the resistance interposed at the indifferent electrode. This may be accomplished by increasing the surface of the latter, and having it quite moist. The surface of the skin gives marked resistance to the passage of the current when dry. This can be overcome, for all practical purposes, by means of a moist and large size electrode. The latter should be at least six or eight inches in diameter. The conductivity of any tissue of the body is in direct proportion to its moisture. Hence the mucous surfaces are much better conductors than the skin. The current passes from the positive to the negative pole and in the direction of the least resistance, which is usually the short- est route between the two poles. That portion of the body through which the electricity passes, except in the imme- diate vicinity of the poles, is very little influenced by the current, as it mainly acts as a conductor. Physiological Effects of Electric Currents. The properties of all electric currents, just as that of magnets, are limited at or near their poles. I do not mean that only that part of the electrode which is in immediate contact is active, but the activity is greatest when exerted nearest the pole, and, as it recedes therefrom, diminishes in direct proportion to the strength of the current used, and inversely as to the distance from the poles. This area may, therefore, vary from one to twelve or more inches. The polar effect of certain currents, however, may be ELECTRO-PHYSICS. 195 exerted upon an organ and transmitted to some remote part of the body. For instance, a nerve may be stimulated at or near its origin by the sinusoidal or the interrupted galvanic current, when the muscles to which it is distrib- uted are made to contract several feet distant. The effect of the anode of the galvanic current, aside from that of the electro-negative elements, is soothing contracts capillaries and acts as a hemostatic; while that of the negative is stimulating, dilates capillaries and tends to induce hemorrhage. Labile or stable applications of the continuous galvanic current acts mainly by way of electrolysis, cataphoresis and its stimulating effect upon the skin and circulation at its poles. The sensation of slight burning at either of these poles is due to the action of the chemic elements as result of electrolysis, and not to any heat in the electrodes, since there is no elevation of temperature in the latter. The interrupted galvanic current is exceedingly stimu- lating to nerves, muscles or any organ to which it is ap- plied. It is more penetrating than the induced currents, and is especially indicated in the treatment of the deep- seated organs. The rapid interruptions cause contractions and relaxation of the unstripped muscular fibers of blood vessels, which restores their tonicity, relieving thereby engorgement of congested organs. The physiological effects of the faradic currents, both primary and secondary, are stimulating tonics. They have no chemic or electrolytic action, and they exert their tonic properties chiefly in a mechanical way. These properties might be likened to a gentle though rapid massage. While they have neither cataphoretic or chemic effect, yet their action favors medicinal" absorption by mechanical excita- tion. By way of illustration, suppose a medicine is applied 196 ELECTRO-PHYSICS. to any portion of the body, its absorption can be facilitated by rubbing it within the skin. This illustrates the action of the faradie currents, except that they penetrate several inches within the tissue. The secondary induced current when applied with from ten to twenty-five thousand ohms resistance has marked analgesic effect. This is a property that is of special importance in the treatment of an ex- ceedingly tender or irritable j)rostate, as it can be used through the rectum and applied directly to the gland. Ee- lief from such treatment is often very noticeable and instantaneous. Its effect upon atonied vaso-motor nerves is quite pronounced. By restoring tonicity to the circular muscular fibers of the vessels the engorgement is relieved and inflammation reduced. These currents should never be given with sufficient force to cause pain or any un- comfortable sensation, for that counteracts the benefit that would accrue from their use. These currents have a remarkable effect towards restor- ing tonicity to the genital organs when they have remained in a state of atony or impotency for so long a time that, even after the cause is removed, they fail to respond to normal conditions. Dr. de Wattervill had advocated the use of the combined faradie and galvanic currents; but such has always ap- peared to me in the same light as a "shotgun prescrip- tion.'^ I have always obtained better results by applying the currents for specific effects, and alternating them as occasion required ; for instance, instead of giving the com- bined galvanic and faradie currents, as he suggests, for tonic purposes, I have always gotten better results by applying the faradie one day and the interrupted galvanic or sinusoidal the next. While there is a marked difference in the effect of tlie poles of the galvanic currents (and they should always be ELECTRO-PHYSICS. 197 used witK special reference thereto), yet the difference in the effect of the poles of the primary and secondary in- duced currents is so slight that it matters very little which pole is used as active or indifferent in treatment. The sinusoidal is one of the most valuable currents at our command for restoring tonicity to any organ of im- paired vitality. It also possesses in mild degree electro- lytic, cataphoretic, germicidal and mechanical properties. The rapid alternations of this current so act upon any molecular body within several inches of its poles that it magnetizes and demagnetizes the molecules composing the body, and, by the combined magnetic and mechanical prop- erties of the currents, so change their relative molecular positions as to alter their tissue. These properties are especially effectual following the electrolytic changes as a result of interstitial cataphoresis. Chemical Effects. The galvanic current has the power of decomposing chemic compounds both within and without the body, and breaking them up into their original elements. This can be demonstrated by passing the current through a solution of potassium iodide, when iodine will appear at one pole and potassium at the other. So also may water be de- composed into its two elementary gases. This property renders the current of great value both in decomposing morbid products and eliminating them from the body, but it is limited in its effect to, or adjacent to, the poles. Hence, in applying the current, an active and an indiffer- ent polar effect should always be taken into consideration. The active pole should be applied where it is desired to produce a specific effect, while the indifferent pole (usually a broad sponge, so as to spread the current over greater area, and consequently render it inactive at that pole) 198 ELECTRO-PHYSICS. should be referred to some remote part of the body. The greater the surface of the indifferent electrode, other things being equal, the more effective is the active pole. The large majority of physicians use an indifferent elec- trode of too small a size. It should not be less than eight inches in diameter. In most morbid tissue formation, as in the fibrous de- posit of stricture, and prostatic hypertrophy, the vital activity and reparative processes are much below normal and are especially subject to electrolytic action, whereby the electrolytes composing the tissue are decomposed into their original chemic elements and the parenchyma of the growth is destroyed. Only certain compounds are capable of disintegration by means of the galvanic current, which are known as electrolytes. As, however, electrolytes form the chief con- stituents of the bod}^, electrolysis is possible in any of its tissues, but more especially in morbid tissue of low vitality, that is incapable of reparation except by abnormal processes. This property of the current is of advantage to the surgeon in the removal of morbid growths, especially in such parts of the body or under such circumstances where surgical procedure by any other means would be injudi- cious, and at the same time attended with no little amount of risk, on the part of the operator, to the life of the patient. The products of this, decomposition are called ions; those collecting at the anode, anions, and those at the cathode, cations. Frequently the actual ions are not given off as such, especially the anions, which often combine with other substances forming new compounds. As a rule, however, the ions proper to each pole may be distinctl}^ recognized. In inorganic substances this may be easily ELECTRO-PHYSICS. 199 demonstrated by passing the current through sodium chloride; the anion will appear in bubbles at the positive^, while sodium, the cation, will collect at the negative pole. Similar changes in organic substances may be produced by passing the current through a piece of meat, when firm albuminous eoagula will form at the positive pole, and gases will be seen to escape at the negative. It will also be observed that the meat upon the side of the anode will be dry, while the other side will be moist. As the tissues of the body are composed largely of water and salt, or chloride of sodium, the decomposition of these proximate principles by chemic action always results in the production of oxygen, chlorine or hydrochloric acid at the anode. The other constituents of the tissues are so insignificant as not to be taken into consideration. These elements (the anions) have a strong affinity for most all of the metals except platinum or gold. Hence, should a copper electrode be introduced into the urethra and at- tached to the anode, with a closed galvanic circuit, the oxy-chloride of copper would result. Should, on the other hand, an iron electrode be similarly used, chloride of iron would follow its use. When electrodes are used where the . electro-negative elements attack and combine with them they are termed oxidizable electrodes; those not attacked by these elements are noted as non-oxidizable electrodes. The electro-positive elements that occur at the cathode do not combine with any metal used as an electrode. Polar Effects. If an ordinary steel needle be attached to each pole of the batter}^, and, with a current adapted for electrolysis, an experiment be made upon a piece of meat, it will be noticed that the products accumulating around either of the poles will be entirely different from those surrounding 200 ELECTRO-PHYSICS. * the other; that, while the one needle is readily withdrawn and entirely unaffected, the other will stick with great firmness, and, after being removed, will show effects of having been subjected to some chemic change. If now the two parts from which the needles were withdrawn be subjected to microscopical examination, it will be seen that the part from which the unaffected needle was taken shows evidence of molecular changes, and suggests the fact that some disorganizing process has lessened the normal com- pactness of its tissue; while in the other (anode) in which the needle was acted upon, it will be found that there is an increase of material surrounding the pole, due to the coagulation of the albuminous constituents, and that in consequence the tissue is by far more compact than nor- mally. On testing the chemical reaction of these products, those of the coagulated tissue will be found to be acid, while the others are alkaline. These different phenomena are invariably proper to their distinctive poles, and if the needles are left intact and the poles reversed, their action upon the tissues of the meat will also be reversed. The experiment demonstrates two distinct effects of the current, each of which may be taken advantage of, inde- pendent of the other, by the use of electrodes especially adapted to this end; and from it we may also deduce the following important principles of electrolysis as a guide to the use of the proper pole. The positive pole coagulates albumen, causes fibrinous deposits and attracts electro-negative elements, such as acids, oxygen, chlorine, etc. The negative pole, in drawing to itself alkalies or bases, collects atoms that have no tendency toward combination, but, being absorbed and carried away by means of the circulation, lessens the amount of tissue within the electro- lytic field. ELECTRO-PHYSICS. 201 Electrolysis. Electrolysis is the process of producing chemic decompo- sition and disorganization of tissue by means of the gal- vanic current. In all compound fluids, dissolution, eithei' slight or in a marked degree, is constantly taking place by reason of the breaking up of the molecules composing the fluids into their primal atoms. Under normal circum- stances nature provides for this disintegration by its various processes of waste and repair, and no perceptible changes are e£Eected. Experiments demonstrate, however^ that by the aid of the electric current this normal decom- position can be promugated to such a degree that nature will be able no longer to counterbalance the overdrain upon her recuperative powers, and hence there will be a loss of compounds and subsequently of constituents in the parts where the high amount of dissolution is made to take place. This change occurs more readily and to a greater extent in morbid tissue because of its defective vital activity and its poor nutritive supply. Cataphoresis, or Electric Osmosis. Cataphoresis is the process by which fluids are trans- fused through animal tissue by means of the galvanic cur- rent. The passage takes place mostly in the direction of the current, viz., from the anode to the cathode, or from the positive to the negative pole. In order to pass by this process, all substances must be in a state of solution. Thickness of animal tissue is no barrier to the passage oi fluids as induced by this means. Diffusion of medicines by means of the galvanic current is not new ; it has been demonstrated by various physicians both in this country and in Europe. But it is only within the past decade that it has been systematically used and with a knowledge of its actual effects. 203 ELECTRO-PHYSICS. T. A. Edison read a paper before the International Congress at Berlin in August, 1900, in which he reported a case where he had employed cataphoresis for gout, show- ing that the current carries lithium salts into the bod}^ and gives great relief to a swollen joint. His method was to put one hand into a vessel containing a solution of chloride of sodium, in which the cathode was inserted, and the other into a vessel containing chloride of lithium, in which the anode was inserted. The lithium salt passed into the body, being detected afterward in the urine. As I have previously stated, the action of the currents, just like that of a magnet, is limited to their poles, and there is a middle line of neutrality between the poles. Fluids, therefore, do not pass entirely through the body by means of cataphoresis, but having penetrated the tissues at the poles they may be absorbed and enter the general circulation, as has been demonstrated by Edison and others. Medicines applied by the active electrode directly oppo- site and in close proximity to diseased organs penetrate them thoroughly, those nearest the pole becoming saturated with the medicine. In order to procure the best results in the way of cataph- oresis, unoxidizable electrodes, as platinum or gold, should be used; otherwise the electro-negative elements, as oxygen and the acids, would attack the metal and form new compounds at the anode, lessening thereby the cataph- oric action. With reference to the use of the cathode, it does not matter what metal is used, as hydrogen and the alkalies do not combine with it. Electrolysis and catapho- resis are always, to a limited extent concomitant, yet when an electrode is used that is not attacked by the electro- negative elements cataphoresis is more marked. Sulphuric, phosphoric and hydrochloric acids always ELECTRO-PHYSICS. 203 appear at the anode when applied to animal tissue, though the latter (hydrochloric acid) is in greater abundance. There is a tendency of the anode to stick closely to animal tissues when applied with an oxidizable electrode, such as copper, zinc or iron. This is due to the action of the electro-negative elements upon the metals, forming new combinations that adhere firmly to the tissue. In order to release the electrode, the current is reversed for a few minutes, when it again becomes loose and can be with- drawn. These elements are somewhat irritating to the tissue. They sting to an extent dependent upon the strength of the current used, but do not, as many believe, burn or cauterize the parts. While it is evident that electrolysis takes place in the large majority of remedies of multiple elements in the process of oataphoresis, yet some of the medicine passes with the flow of the current without being chemically changed. This is in accordance with the law of attraction and repulsion of atoms as induced by magneto-electric properties — ^that unlike attracts and like repels. So complex are the analytic and synthetic changes that occur in the tissues and remedies, as the result of the electrolytic and catalytic actions of the galvanic current upon them, that in many instances it has been only by numerous experiments that I have been able to determine just what chemic changes take place, and, in view of these changes, to select the best remedy for certain conditions and complications. In the use of any medicine for cataphoresis its chemic elements should be known, unless one decides upon a blind experiment or groping in the dark. Electrolytic action may be expected, at least to some extent, and some of the medicine used is decomposed into its chemic elements; so, instead of getting the effect of 204 ELECTRO-PHYSICS. the medicine as used, one gets that of one or more of its chemic elements. Let us take iodide of potassium for illustration, it being an electrolyte, and suppose the active electrode to be an unoxidizable metal, as platinum; then there could be no chemic action upon the latter by any oi the elements set free by electrolysis. Now suppose we use the cathode as the active electrode; the iodide of potas- sium would be decomposed into iodine and potassium, and iodine, being the electro-negative element, would tend toward the anode, which would be the indifferent electrode, and if the cathode is in apposition to the prostate the iodine must necessarily pass through the gland before reaching the neutral point between the electrodes. But suppose, on the other hand, that the anode is used as the active electrode; then the greater part of the iodine, as a result of the electrolytic action, would remain at the pole, and only a limited amount of it, together with the electro- negative elements, as potassium, hydrogen, etc., would be diffused through the gland on their way toward the cath- ode, and but little change would take place within the gland as a result of interstitial electrolysis, by means of these elements alone. The action of the poles of the galvanic current does not destroy tissue as does the cautery, unless the cautery cur- rent especially devised for that purpose is used ; but when applied to any part of the tissue, it decomposes it into its original chemic elements. The tissue, possessing no longer its normal anatomical constituents, becomes atrophied, and the parts disorganized are absorbed, as stated before. More especially do these changes take place in morbid tissue, defective in vital activity or recuperative power. As water and the chlorides of sodium, potassium, etc., constitute a large part of all tissue, oxy-chlorides are al- ways present at the anode when galvanic applications are ELECTRO-PHYSICS. 205 Fig. XXVI. '20e ELECTRO-PHYSICS. made; and, as these constituents have a strong afimity for metallic bases, they will attack any oxidizable metal used as an electrode for thatr pole, and form new compounds, even when medicines are not used. For example, should a solid copper electrode be applied to the prostatic urethra, the oxy-chloride of copper results. I often use this treat- ment, alternating with other remedies, when there is a rebellious tendency of the parts to healing. In some cases it has an almost magical effect, when the parts have re- sisted all other applications. If it is used very strong or for a long time, it causes a sensation of stinging or burning, due to the action of metallic electrolysis, and not to heat in the electrode, as might appear. For there is no eleva- tion of temperature in the electrode. It should be remembered that the electrode thus used will adhere tightly to the tissues. It should not be forcibly removed; but when the current is reversed, as before stated, the electrode slides away with ease. While a thorough knowledge of the properties and thera- peutic action of the different electric currents are pre- requisite to successful treatment of the prostate, yet it is impossible for one familiar with these to procure satis- factory results without suitable apparatus. Manufacturers have so vied with one another in placing cheap electric paraphernalia on the market that therapeutic failures are often traceable to trashy apparatus. Especially is this true since so few ph3'sicians have any knowledge of electro- physics and can tell when a battery, coil, rheostat or any other part of the outfit is properly constructed, but must rely upon what the manufacturer tells them. Fig. XXVI. illustrates a wall cabinet for use on the direct incandescent circuit that is as near perfect as is made. The resistance is effected through metallic wire and not graphite, and it is uniform, durable and reliable. It has a perfectly regu- ELECTRO-PHYSICS. 207 lated galvanic current, varying in force from a fraction of a volt to any desired strength required, which can also be used for lighting diagnostic lamps. It has the primary and secondary faradic currents, galvanic interrupter, etc. I have my sinusoidal apparatus wound specially to order in shunt, as before described. CHAPTER XX. The Uses of High Frequency and High Potential Currents ]n the Treatment op Prostatic Diseases and Sequelae. In discussing this subject, I shall avoid all theoretical views, of which there are many, neither shall I tax ni}' readers with a long, tedious history of its development and ■ therapeutic progress; but I shall endeavor to demonstrate its properties and therapeutic uses in as plain, practical and concise manner as is consistent with a clear elucidation of the subject. The profession are indebted to Xikola Tesla for the dis- covery of this most valuable therapeutic agent. It was in February, 1891, that he, by certain multiple windings, charging and discharging of leyden jars by means of alternating currents, was enabled to convert strong and comparatively frequent currents into currents of extreme high frequency — even to ten thousand interruptions per second. He further proved that it was possible to transmit such a current of ten thousand volts through one's body with impunity. But it remained for Oudin, d'Arsonval, Eochefort and others to take up the current at this stage, and by means of accessories, by way of resonators, solenoids, condensors, interrupters, detonators, etc., they have been enabled to increase the interruptions or oscillations and tension of the current to almost an inconceivable degree: so much so that I even hesitate to state that these interrup- tions or oscillations have been calculated above the million per second. In fact, the more frequent the interruptions and the greater the tension of the current, the less danger 208 TREATMENT OF PROSTATIC DISEASES. 209 and more soothing to the organs to which applied. A cur- rent may be passed through one's body, of such high de- gree of tension as to cause a brilliant glow of a sixteen candle power lamp held several inches from the person, without creating any other sensation than that of an exhil- arating warmth. But as I propose dealing only with the practical consid- eration of the current with reference to prostatic diseases, I shall refer those desirous of investigating along this line still further, to Freund, on High Frequency and Eadio- Therapy. Permit me to caution those contemplating pro- curing high frequency apparatus, not to be persuaded by interested manufacturers to get a coil with spark less than twelve inches. Then a good resonator with solenoid is in- dispensable when the tension and volume of the current may be so modified as to meet all therapeutic indications in so far as the capability of this current is concerned. Should you have a good static outfit, a resonator con- structed to use with it will greatly enhance its value. The fact that a high frequency current brought in eon- tact with morbid tissue will affect it is axiomatic. There are at least three ways by which change in the tissue takes place. The generation of ozone is unquestioned, and its effect toward converting an unhealthy, ulcerated surface into a healthy one is indisputable ; besides being one of our most efficient germicides. Secondly, the rapid vibrations effecting molecular disturbance within the tissues is evi- dent. Tlie favoring of osmosis, either by cataphoresis oscil- lations or rapid bombardment of the molecules of the tis- sues, is proven daily. Then, too, it does arouse to renewed energy lethargic organs, stagnant circulations and devital- ized nerves. It thereby fosters nutrition and assists nature. One of its greatest fortes is in reducing acute inflamma- tion, allaying local irritation and congestion, and, tbat it 210 TREATMENT OF PROSTATIC DISEASES. Fig. XXVII. (Illustrates the coil used by the author.) TREATMENT OF PROSTATIC DISEASES. 21j Fig. XXVIII. 212 TREATMENT OP PROSTATIC DISEASES. dissipates morbid tissue to a certain extent, I have demon- strated time and again. It is slow in its action and takes time and patience, as in the majority of the cases, having come under my observation, have had trouble for many years. I shall not attempt description of the various types of resonators and solenoids in common use, but will give brief outline of one of the most modern and convenient of which I myself use. Fig. XXVIII. illustrates the apparatus devised by Oudin, Dean and d'Arsonval: (R. Eesonator) ; (S. Solenoid) ; (D. Detonator or spark gap) ; (C.C. Condensors) ; (G. Spring clip) ; (A, Attach- ment of conducting cords (co) to resonator) ; (E.E. At- tachment of cords for free resonance). As it is a well known fact that there are no non-con- ductors, and more especially with reference to currents of high frequency or high potential, yet glass or rubber is the most common of materials used for insulation. Glass tubes (Fig. XXIX.) Fig. XXIX. of partial vacuum are the only ones that have been in gen- eral use in the treatment of prostatic and vesical troubles. But as the glass tube is equally conductile throughout its entire length, the current intended to be applied directly to the prostate by means of this tube is so distributed along the urethral canal that it has become so exhausted before reaching the prostate that its effect upon the gland or vesical neck is quite limited. To obviate this waste and to TREATMENT OB' PROSTATIC DISEASES. 2U concentrate the current upon the part affected^ I have con- structed an instrument (Fig. XXX.) that is insulated with vulcanized rubber throughout its course, except at the cord attachment and the other extremity. The current, obeying the well known physical law of passing where there is the least resistance, can be concentrated at any point desired by the operator. The instrument is also so constructed that medicinal applications can be made at the same time the current is used, either to effect cataphoresis or as a simple medicinal application to the diseased area. Hence, by means of this electrode, the current as well as the medicine can be concentrated directly upon the gland. Fig. XXXI. illustrates the application of the instrument directly to the prostate : Fig. XXX. The method of application I have found most effectual towards allaying local irritation and inflammation of the prostate by means of this current, is that of forced reson- ance of extreme high tension. This is accomplished by using a single insulated conducting cord attached to A, (Fig. XXVIII.), then connected to the urethral electrode and with the spring clip on the top coil of the solenoid (S.). Should it be desirous to increase the amperage or volume of the current in its application to the gland, then the solenoid should be interposed together with the resonator. This is accomplished by lowering the spring clip (S.) to the mid- 214 TREATMENT OF PROSTATIC DISEASES. Fig. XXXI. THE TREATMENT OF STRICTURE. 215 die or lower coil of the solenoid. This last application is more efficient in reducing or softening an indurated gland ; then, too, for destro}'ing large vegetative growths. But it should not be used until local irritation and inflammation should be first allayed, as before mentioned, when it can be instituted with impunity. The application by free resonance is effected by attaching one of the cords to binding post (E.), then to the electrode in application to the patient, with another cord passing from the other binding post (E.) and grounded; or in direct application to the patient's body with very large and very wet electrode. Should this not be very carefully ob- served the patient may be burned very severely. The current is also used in application to the prostate through the rectum, just as the other currents as heretofore described. In further consideration of the utility of the high fre- quency current, I shall give briefly the results of my ex- perience with it during the past few years. In the first place, when used in connection with the resonator and short detonator, it is one of the most positive analgesics we have. Its relief of pain is effected by toning up the nerves involved, instead of depressing them, as is the case with most all other anodynes. Another com- mendable property of this current is, that it is far reaching and penetrates the deep tissues that are inaccessible to other means, except those given constitutionally, with their disturbing influence upon the system. It, at the same time, generates ozone, a most active local bactericide, besides being a marked tonic to the lungs and the system in general, and especially to the nerves throughout the body. It is a well known fact that pain alone will per- petuate irritation and inflammation, and the relief af- forded by this current during the course of treatment of these tender organs, not only adds comfort to the patient, 216 THE TREATMENT OF STRICTURE. but materially hastens the progress of the treatment. I herewith append some very interesting and edifying experiments made upon hay infusoria with the high fre- quency current; in comparison with the other different elec- tric currents. •'m> s^ Fig. XXXIIe illustrates two glass slides which are sep- arated two centimeters by means of soft rubber around the edges and ends. On the inside of the rubber at each end nonoxidizable pieces of metal are so arranged that cord- tips (+j — ) are attached thereto. The space between the slides is filled with a solution containing the infusoria. Fig. XXXIIc. My first experiment was to transmit a mild galvanic cur- rent through the fluid, when the germs would immediately pass from the positive ( + ) to the negative ( — ) pole. The current was then suddenly reversed, when the germs would at once turn and move to the opposite pole. A strong current would cause them to move more rapidly. On breaking the circuit they would be slowly diffused through the fluid again. After a few experiments of reversing the currents of from one to three minutes' dura* tion, the germs became very sluggish. The sinusoidal current was then tried upon a fresh sup- ply of infusoria, when they would undergo very rapid oscil- lations, but would not move towards either pole. The oscil- lations of the germs were evidently due to the effect of magnetizing and demagnetizing of them by the rapid alter- nations of the current. The circuit was allowed to remain closed for five minutes, when many of the germs became inactive and the others sluggish. The circuit was then THE TREATMENT OF STRICTURE. 217 closed for ten minutes, when more than half of the in- fusoria were non-motile. The primary and secondary faradic currents were tried successively upon fresh supplies of the same fluid. The result was that little or no eflEect upon the germs was pro- duced, until the current was used too strong to be safe or harmless if applied to an individual. Clinically, I have found the sinusoidal current excep- tionally beneficial in gonorrheal vesiculitis, when applied, with from ten to fifteen thousand ohms resistance, through the rectum. The influence of the galvanic current is best exerted through the prostatic urethra, after the subsidence of all acute symptoms, and should not be used before. The high frequency current was used with fresh germs when they became paralyzed or immobile within ten sec- onds of the passage of the current. This current can be used either in the rectum or urethra with impunity. The Treatment of Stricture of the Urethra bi Electrolysis. As stricture of the urethra is one of the frequent com- plications of prostatic troubles, I shall append hereto a brief outline of its proper treatment. ^ Conservative surgeons have always advised dilatation as the first mode of procedure, since, if properly used, there is much less danger than by incision or divulsion. But dilatation is limited in its action, and is generally prac- tised for only temporary relief. One of the most essential requisites before the use of electrolysis is to prepare each case properly before attempt- ing the operation. Individual oases vary so much in regard to tenderness, irritation, amount of granulation, consist- ence, and length of existence, that it requires considerable 218 THE TREATMENT OF STRICTURE, experience to decide liow to jDrepare and when to begin operation. As I have heretofore described in detail the methods of allaying local irritation and inflammation of the urethra, I shall refer my readers to the chapter on that subject. The technique of the operation is as follows: A large sponge or carbon electrode, being attached to the cord, which is previously fastened to the anode of the battery, is placed within easy access of the patient. The minimum strength of the current is then interposed in the circuit, and the urethral electrode, being attached to the cord from the cathode, is passed down to the stricture. (See Fig. xxxii.) The patient then takes up the large electrode and holds it firmly in his hands. The current can be increased grad- ually to the desired strength without interrupting its flow. The susceptibility of individual cases varies so greatly that I would always advise the use of the mildest current and the shortest duration in the first few treatments. Whenever there is indication of pain, it should be discon- tinued at once. I seldom use local anaesthesia, not even in nervous patients with excessively hyper-aesthetic ure- thras. The sensation is one of the best guides to the foroe of the current used and the length of time it is to be con- tinued. It must be remembered that the current can be used longer and stronger near the meatus than in the lower urethra. The farther you recede from the meatus, in* direct proportion thereto must caution be used. The removal of the electrode from the urethra must be accomplished in the same way as its introduction. The patient must put aside the hand electrode, or catch it by the insulated handle, when the urethral electrode can be withdrawn without shock or pain. If this precaution is not followed and a shock is given, the patient never forgets it. THE TREATMENT OF STRICTURE. 219 and will always be nervous and uneasy at each successive treatment. I usually begin with a current strength of three milli- amperes, of from two to three minutes' duration. Should it not be followed by any local irritation, or but very little, it could be increased at the next treatment to five or six milliamperes, and for five minutes. In some callous cases I have used a current strength of ten to fifteen milli- Fig. XXXII. amperes, should it not be attended with pain or hemor- rhage. Fig XXXII. illustrates the author's method of removal of stricture by electrolysis. Eectal ulceration on its anterior surface, and from one to two inches within the anus (as L), is common; and lying in close proximity and opposite the prostate, aggravates 220 TUE TREATMENT OF STRICTURE. any inflammatory condition of the latter. I have occa- sionally met with ulceration high up in the rectum (as H). Such ulcers may have heen present for a long time with little or no subjective symptoms being manifest. Ulcers in the lower part of the rectum are generally attended with constipation, owing to reilex contraction of the sphincters that they induce. When such ulcer exists, it is almost impossible to relieve prostatic irritation without first relieving the ulcer. I usually make my applications about every five or six days, but am governed, of course, by conditions and com- plications that may arise. I never use now, an electrode smaller than No. 14 or 16 French, as it is liable to be passed into the orifice of a lacunae or caught in a fold in front of a stricture and cause a false passage. This pre- caution should especially be observed by a neophyte. A large electrode will decompose and enter a stricture more satisfactorily than a small one, and with less pain. A small one is more liable to cause some trouble, and espe- cially in the membranous or prostatic urethra. I have often treated strictures, even in the deep urethra, so con- tracted as not to admit the passage of the smallest size bougie, and where the urine would only pass in drops; when, on the second or third day after the electric treat- ment, and, too, without passing the stricture with the elec- trode, the urine would suddenly burst out in a bold stream, preceded by the forcible ejection of a plug of the strictural mass, which had evidently been detached by the effect of the current. At times this has occurred after the first treatment, though generally after the second or third. I pass a bougie once or twice between each electric treat- ment, and never use one that does not pass easily and without force. Some speak of the treatment as cauterizino; or burning out the stricture. There is no heat, not the THE TREATMENT OP STRICTURE. 221 slightest elevation of temperature in the electrode; hence there could be no cautery or burning. The process is one solely of chemical decomposition and disintegration of the strictured mass, which passes off as gases, discharges and even at times of large particles of the strictured mass itself. A FEW CASES. I hereby append a few cases that recently came under my observation. Case XXXVI. — Single; Age 27; Chronic Prostatic Urethritis, Vesiculitis^ Metastasis. The most prominent symptom with which this man suf- fered was that of weekly exacerbations of excessive pain in the right side, in the hypochondriac region. These attacks were attended with slight pj^rexia. The temperature often reached 101 and, occasionally, 102 F., in the evening. He had been suffering with these attacks for about eighteen months before consulting me. At first the paroxysms were mild, lasting one or two days, and passing off with little systematic disturbance, recurring the second and, occasion- all}'', the third week. These grew more frequent and severe in type, until, as before stated, he was having them weekly. He had had gonorrhea, at the age of 20, six years before. Up to that time he had been in fairly good health, and had apparent!}^ recovered from gonorrhea and there were not even any indications of gleet. These exacerbations had been attended with a low form of fever, which would last from two to three and, occasionally, four days. His physi- cian would give him some antipyretic and a good purga- tive, when he would slowly recover. Before recuperating from one attack he would have a second, and so on, keeping him constantly in a state of depression, and unable to at- tend to business. His ailment had been diagnosed as vari- ous troubles, all except appendicitis, and it is strange that no one had diagnosed it that. An examination revealed an inflammatory condition of 222 THE TREATMENT OF STRICTURE. the prostatic urethra, as well as the vesicles. The gland was slightly swollen. The secretions contained columnar cells, mucous and dead cocci. The prostatic urethra being extremely sensitive, the treatment consisted in an application of flexible bougies with benzoinol ointment to the prostatic urethra on alter- nate days. He was also treated on the second day with a mild mechanical massage to the seminal vesicles through the rectum. No electric current was used. At the expira- tion of one week, instillation was made to the deep urethra by means of my electrode applicator, of 1 per cent sol. of thallin sul. After the second week the high frequency cur- rent was added thereto. Two weeks after beginning treat- ment he had a slight return of his pain in the side, with slight pyrexia, remaining home only one day. The treat- ment was continued regularly, alternating one day through the rectum, and the second day through the urethra, when there was complete subsidence of these pains, and a grad- ual restoration to perfect health. This case is well authenticated, as it has been, and is even now, under the observation of several prominent physi- cians of this city. The rationale of the treatment in this case was unques- tionably exemplified in the arrest of the source of the in- fection by destroying the cocci hidden within the prostate and vesicles, and which were inaccessible by any other means. Case XXXVII. — History: Age 51; Married; Chronic Prostatitis, Cystitis, Vesiculitis, Gonorrheal Metastasis. Contracted conorrhea at the age of 26, which lasted him six months, and was followed with acute prostatitis, ure- thritis, cystitis. He suffered with periodical exacerbations for three years, subsiding in a form of gleet, from which THE TREATMENT OF STRICTURE. 223 he occasionally had symptoms of a slight discharge, or gluing together of the meatus. There were no marked indications of prostatitis, inflammation of the bladder, or any other trouble, until in his forty-fifth . year, when he began having attacks, of what he called rheumatism, in hig shoulders and back of neck, and occasionally in his back. There was an impairment of his left limb, by way of a heaviness, which necessitated a dragging of this limb, and he was unable to lift it as easily as the other. Some days it would be better, other days worse. Otherwise, health. good. He was an active business man. Two j^ears prior hereto he began to have excessive pains in back of neck and shoulders, extending to his fingers. Occasionally there would be a tingling sensation down the arm to the fingers, and he was unable to hold a pen to write. He noticed, about this time, too, that he was unable to shave himself. The pain grew so intense in back of neck that he could not sit in a barber's chair, with any degree of comfort, to be shaven. His digestion was good, bowels regular, weight normal, and usually slept well. He had been treated by some of the best physicians, with various kinds of medica- tion, including the different preparations of coal tar, salicilates, etc. In fact, he had taken medicines from physicians who knew as much, or more, than I, for the relief of these troubles. He had been treated by a nerve specialist, who applied electric currents to his spine, limbs and arms. At times this was followed with temporary relief, yet each month, for a year, he had noticed he was worse than the previous one. An examination revealed cystitis, prostatitis and vesiculi- tis of chronic nature. The gland was somewhat enlarged — swollen — from long standing low ffrade of inflammation. There was no acute tenderness of the parts, but a cellular infiltration of the rectal-mucosa in the region nf the pros- tate and vesicles. Chemical and microscopical examination of the urine 224 THE TREATMENT OF STRICTURE. and prostatic secretions revealed epithelial cells of squamous and columar variety, also debris of cocci, which indicated additional involvement of the bladder, prostate and seminal vesicles. My treatment consisted at first in local applications of argyrol to the prostatic urethra, by means of my urethral electrode applicator, using a 3 per cent sol. This was alternated on the second day with an application of a 2 per cent solution of picratol to the rectum. This treatment was continued for one week, and upon the subsidence of all acute symptoms I began giving the high frequency cur- rent, through the prostatic urethra, by means of the same insulated electrode applicator. On the second day I used vibratory massage, through the rectum, applying this first to the prostatic portion, then extending gradually up to the vesicles. These vibratory applications were given very cautiously at first, not permitting the instrument to come in contact with the front surface of the rectum against the prostate or vesicles. These were modified, also, in their frequency, and the vibrations were given about 4,000 to 5,000 per minute. All systematic medication was dis- continued. Improvement began at once, and from day to day it was most marked. After the expiration of two weeks the sinusoidal current was attached to the vibratory rectal electrode. Occasionally I alternated with the gal- vanic application through the prostatic urethra, with a view of effecting by cataphoresis the stimulating of absorp- tion and diminishing the size of the swollen gland. As be- fore stated, I gave little or no internal medicine, as he had taken for years and j^ears from men equally as competent, or more so, than I, that method of treatment. I could only see one indication for treatment — which was to destroy the source of the infection, remove morbid conditions, and nature would do the balance, which it did very effectually in this case. At the expiration of three months' time he THE TREATMENT OF STRICTURE. 225 did not have a pain, and the only symptom that still lin- gered was an occasional tingling of one of his fingers. At the expiration of six months, although he had dis- continued treatment three months prior thereto, I again saw him, and he reported that he was entirely well, and had no occasion to call upon a physician except socially. The result of treatment of this case incontestably demon- strated that the poisons thrown off by the pent-up cocci were absorbed and transmitted to remote parts of the body, where they exerted a baleful influence upon the sheaths of the nerves and the serous membranes. These tissues seem to be the special targets of attack by this virus. Case XXXVIII. — Age 30; Married; Chronic Prostati- tis, Cystitis, Abscess of Prostate, Metas- tasis, Etc. At the age of 20 contracted gonorrhea, which lasted eiglit months, during which time the inflammation was excessive. He was treated both locally and constitutionally. This was followed by gleet, which was continuous for two years thereafter, when he had a second attack of acute gonorrhea. This latter lasted about eighteen months. The inflam- matory condition was exceedingly severe, and was followed by gonorrheal rheumatism, cystitis, chronic inflammation of the prostatic urethra, prostatitis, and an abscess, rup- turing into the prostatic urethra. The inflammatory con- dition extended from the meatus to the neck of the bladder. Besides various local applications to the urethra, and con- stitutional remedies, he was operated upon at three dif- ferent times, two of which left fistulous openings; one at one-half inch and second at an inch from the glans. Sub- sequently a perineal operation was made for drainage, of eight weeks' duration, with a view of closing the fistulse. This was a failure, and the openings remained patulous. Two years later, the old perineal incisions opened, and for 226 THE TREATMENT OF STRICTURE. a few weeks he suffered with an acute attack of prostatic urethritis, prostatitis and cj'stitis, with profuse discharge through the perineal opening and the urethra. This dis- charge resisted all local and constitutional treatment by the best physicians of Indianapolis and Xew York for three or four A'ears, when he fell into my hands on the 26th day of February, 1905. Treatment was instituted with a view of reducing local inflammation of these various organs — urethra, prostate, bladder, rectum and vesicles — first by means of irrigation, using from 1 per cent to 3 per cent of argyrol. Subse- quently, argyrol was changed for picratol, using from one- fourth to 1 per cent strength. Applications of high fre- quency currents were applied over the region of the bladder and perineum, with a view of relieving local irritation and tenderness of these parts. This method of treatment was continued for three weeks before instrumentation was at- tempted. Local applications, through the applicator, di- rectly to the prostatic urethra, prostate and neck of bladder, were then made, using, at the same time, the high fre- quency current. These applications were made two or three times per week, depending upon the amount of irri- tation caused by the instruments. Eelief followed each treatment after the second day. The first day succeeding the operation there was considerable irritation, but the benefit derived in two or three days more than counter- acted the ill effect of the treatment. I was careful to note that the . credit side of the treatment more than counter- balanced the ill effect of instrumentation. These were the conditions for some two months before any marked subsi- dence of inflammation of these organs, and also of the urethral discharge, were noticeable, but the patient was comparatively comfortable. When treatment was first in- stituted, the urine could not be retained longer than from 30 minutes to 1^ hours, and retention was accompanied by THE TREATMENT OF STRICTURE. 227 considerable tenesmus. At the expiration of two months he could go from two to three hours during the da}^, and from four to five hours during the night, without voiding urine. At this time, cataphoresis, by means of both gal- vanic and high frequency currents, were applied from three to four times a week. There was gradually a subsidence of all infln mmation, and the urethral discharge had become almost imperceptible. Improvement in every respect was very marked. Complete cure was effected at the expira- tion of nine months, except the fistulous openings re- mained patulous. Case XXXIX. — Married; Age 56; Chronic Prostitis AND Vegetative Growth at Xeck of Bladder; Profuse Hemorrhage of Bladder. This man had been suffering with frequency of voiding urine for three years prior to seeing me. It first came on in a mild form, with occasional exacerbations. Finally, he consulted a physician, who was very prominent, highly educated, and thoroughly well up in his business, except in the treatment of this special trouble. He began using sounds, gradually enlarging them until he reached 26 F. He seemed to improve some after the acute symptoms had been allayed by this treatment. On ISTovember 4, after having had his usual treatment with the introduction of the sound, he noticed that he was passing blood. He went to see his physician, and found that the bladder was prac- tically filled with blood. He began means of stopping it by astringent irrigations, but was unable to control the hemorrhage, and the patient was sent to me for treatment. On arriving, I found the bladder distended and filled with clotted blood. The patient was very pale and very weak from the effect of the loss of so much blood. I immedi- ately evacuated the bladder, taking two hours to accom- plish it. During this time there was constant hemorrhage. 228 THE TREATMENT OF STRICTURE. which necessitated my entering the bladder with a cysto- scope to obtain the source. I found a vegetative growth attached immediately to the back of the prostate. This was bleeding very profusely. I then used a cautery, as il- lustrated on page 136, and stopped the hemorrhage. This cautery application was made every third day to the vegeta- tive growth until completely destroyed, leaving a very small pedicle. Treatment of the prostate was continued at irreg- ular intervals for two months, when the patient was dis- charged. He left and was gone four months, when he again returned, having a slight hemorrhage. Cystoscopic examination revealed another vegetative growth, small in size, attached to the prostate, by the side of the former pedicle. Two applications to this stopped the hemorrhage, and he has had no trouble since, is in good health, and is now doing active hard work. There is no question in the world but that the man would have died from hemorrhage had it not been con- trolled in the manner in which it was, and the only other means whereby the hemorrhage could have been controlled would have been a serious operation that would most prob- ably have cost the man his life. ir 50, 81 viii INDEX. Sciatic nerve — Irritation of 161, 162 Secretions — Action on gonococci 32 Of glands of Littre 167 Of Cowper's glands 167 Prostatic 16, 19, 29, 167 Semen — Expulsion of 18, 50 Over-accumulation of 89, 91 Seminal discharges — Classification of 164 Seminal vesicles 16, 89 Relation to prostate 91 Stripping of 29 Sexual appetite 19 Erratic 67 Excessive 78, 158 Sexual brain 19, 164 Sexual indulgence, excessive 35, 71, 78 As compared to masturbation 35 Sexual perversion 112 Shreds in urine 168 Desiccated discharge 50, 85 Removal of granulations 61, 65 Sounds— Injudicious use of 64, 79, 104, 105, 109, 112 Spermatorrhea 67, 80, 163, 165, 167 Spermatozoa 85, 165, 166, 167 Stone in bladder 86, 111, 120 Sterility 166, et seq. Stomach — Nervous relation to prostate 16, 117 Stricture 39, 40, 49, 64, 66 Treatment of 67, 215 Suppositories, rectal 2^, 73, 96, 105, 110 Surgical treatment of hypertrophy 121 et seq. Sympexia 85, 86, 87, 112, 145 Syphilis, as cause of prostatitis 143 Tenesmus 21, 64, 141, 142 Testicle , 24 Theories on metastasis 26, 281, 29 Thiry's theory on rheumatism 26 Toxins of gonococci 29, 30, 31, 32, 81 Treatment— Author's 126, 127, 128 Congested enlargement 92 to 99 INDEX. ix Treatment — Author's — Frequency of 61 Of acute prostatitis 22 Of acute urethritis 22 Of gonorrheal prostatitis 57 Of sub-acute prostatitis 32, 33, 44, 45 Of stricture 67 Per rectum 73, 96, 97, 103, 105, 102, 110, 127, 137, 141 Senile hypertrophy 120 et seq. Surgical 120 to 125 Technique of electric 59 Tuberculosis of prostate 144 U. Ulcerations 55, 57, 65, 74 As cause of gleet 24 Of rectum 11, 78, 104, 143 Uremic toxemia 102 Ureters 16, 67 Urethra— Prostatic 12, 27, 31, 51 Elongation of 89 Localized lesions within the 43 Membranous 16, 49 Urethroscope, use of 44 Description of 44 Urethritis — Caused by diplococci 30 Chronic 39, 40, 41 Prostatic ....19, 38, 49, 52, 64, 71, 82, 105, 106, 108, 112 Treatment of acute 22 Urine — Acrid condition of 43, 51, 80, 81, 99, 100, 104, 107, 110, 137, 140 Asepsis of 38, 74 Blood in 85, 110, 113 Conditions of 83, 84, 85, 91, 100 Dribbling of 117 Pus in 84, 85, 137, 140 Shreds in 50, 61, 65, 85, 168 V. Varicocele 24 Vaso-motor contraction — Result of current .55, 61 Veins of bladder 16 Of prostate 16 Of rectum 16 X INDEX. Verhoogen on chronic urethritis 40 On gonococci 28 Vesiculitis 22, 44, 50, 71, 72, 82, 104, 112, 113 Treatment of 97 W. Wet feet — Effect upon prostatic disease 36, 109 Wines — Cause of prostatitis 38, 77 Prohibited 94 Y. Young's theory on gonococci metastasis ■ . . . 29 Z. Zinc sulpho carbolate — In acute urethritis 23 In prostatic urethritis 53, 65, 135 DATE DUE HAYP ^ iViA n ^wt# C ^ W» Jl '^f,^l9§S JM^ f \ j Printed i In USA 1 RC899 0v2 1906 Overall non- surgical treatise on diseasesj COLUMBIA UNIVERSITY LIBRARIES 0043050590