The narrow utilitarian policy of urging a younger brother, nephew or son into a medical career, for the sake of subsequent assistance, or even because the senior may thus give greater assistance to the junior, for the latter's sake, is to be deprecated. We wish to emphasize, particularly at this season, when medical colleges are about to open, that each one of the many thousands of physicians, should exert his influence in a broad and wise manner, so that the medical matriculants may be of higher quality than ever before. The fact that better quality implies a smaller quantity, and that this diminution in quantity is indicated by purely economic conditions, need not and should not influence the advice given in any particular case. Fortunately, the conditions are such that economic and humanitarian ends may be served by the same wise policy, and the consistent carrying out of this policy will gradually bring about, not a medical Utopia, but a condition in which an adequately paid and sufficiently busied profession shall enjoy the prestige which can only be attained by an even balancing of the general law of supply and demand. THE annual crop of foot-ball accidents is about due. One accident has already been reported from the local field. - DR. HARRISON CONVICTED. Dr. A. S. Harrison, of Kennett, Mo., one of the foremost physicians of that section of the state, was convicted in the Circuit Court of Stoddard County on the 13th inst. of mayhem, and sentenced to serve five years in the penitentiary. The victim of the brutal assault was a farmer, Daniel Crites, who, with Harrison and one John Sweeney, had spent an afternoon drinking and had gone to a vacant house together, where they were joined by a fourth man. Crites tried to leave and was struck on the head and lost consciousness. When he recovered he found himself on the railroad track and suffering great pain; he rolled off the track just before the train passed. With great difficulty he made his way to town, and there it was first discovered that he had been mutilated. Harrison and Sweeney were arrested for the crime. Harrison denied having entered the house with the others, and also denied all knowledge of the crime, The evidence is purely circumstantial, but seems to have satisfied a jury. It is believed that a new trial will be granted. If a member of our profession did commit such a crime, we can have no time for sympathy, five years is too little punishment; but if there is a chance that he is innocent every aid should be his to establish the fact. The crime, if committed by a physician, is more heinous for the fact. TOBACCO SMOKING BY THE IMMATURE. We hold no brief for the cigarette, nor do we fail to recognize the fact that smoking by juveniles is an evil, but the case for remedying the evil is not helped by doubtful statements. poison and the suggestions, therefore, that Everybody knows that tobacco is a tobacco is injurious because of its impurity or adulteration or because poisons are added to it are altogether beside the issue. If the tobacco smoked were the purest possible leaf the evil of smoking by juveniles, in our opinion, would be not a whit the less. If it were other wise there would be no necessity for suppressing such smoking so long as the youth was supplied with pure tobacco. Since tobacco is itself a poison we need by the immature or its abuse by the grownno further argument against indulgence in it up person. We can well believe that certain tobaccos are more poisonous than others, but we very much doubt whether substances added to the manufactured leaf. Flavorings more injurious than tobacco itself are ever and sweetening substances, such as liquorice, glucose, and glycerine, are often added, but these are harmless compared with pure tobacco itself. Statements have been freely made that morphine or even cocaine is added to cheap cigarettes in order to give them immediate soothing qualities or "to soften" the flavor of an otherwise harsh-smoking tobacco. We cannot accept such statements applied, at all events, to cigarettes retailed at five or even six a penny. The tobacco in such cigarettes is of an inferior and inexpensive kind we admit, but we have not been able to find the smallest trace of foreign poisons in some very cheap cigarettes which we purchased only recently and submitted to careful analysis. We doubt whether it would pay to add such comparatively expensive poisous. Opium is not cheap nor is cocaine. Tobacco of common quality is at any rate infinitely cheaper. The danger of smoking arises from tobacco poisoning and it is the wholesale and unchecked poisoning of the child with tobacco, chiefly in the form of cigarette smoking, against which the nation. is asked to find a remedy. On what lines such a remedy can be made effectual we are not sure. It is obvious that different per. sons exhibit a different susceptibility to the poisonous action of tobacco even in the same country. In Oriental countries, however, excessive smoking, which is intensified by inhaling the smoke, commences almost from the cradle and is continued right through life apparently without any ill-effects.-The Lan cet. The Medical Society of City Hospital Alumni President, LOUIS H. BEHRENS, 374? Olive Street Vice-Pres., WALTER C. G. KIRCHNER, City Hospital Secretary, FRED. J. TAUSSIG, 2318 Lafayette Ave. CHAIRMEN OF STANDING COMMITTEES: Executive. A. Ravold, Century Building Entertainment, Frank Hinchey, 4041 Delmar Ave. OFFICIAL THE FEMALE PROSTATE.* CHAS. E. BARNETT, M. D. FT. WAYNE, IND. DISCUSSION. Publication, W. E. Sauer, Humboldt Building TRANSACTIONS. Dr. F. J. Taussig.-The subject is certainly one concerning which we have very much to learn and one in which I acknowledge to have had little experience. The question of gonorrheal infection of these glands is one not given due importance either in the text-books or in general practice. In the deep ducts the gonococcus may reside a long time when in other portions of the genital tract it has disappeared, and doubtless serves to renew the infection in many cases As regards the treatment in these cases, I don't know whether we ought to undertake very active treatment in any of these gonorrheal infections about the urethra. It will usually get well by itself, and if over-treated, the disease will spread to the neck of the bladder, or into these ducts. I am free to confess that in the sections I have seen they have always been in the form of ducts. They have a single canal that penetrates rather deeply. In the majority of instances these cases will get well without treatment. I recall one case of an abscess of these ducts, in which during labor the abscess was literally emptied by the passage of the head and the pressure of the labor pains, so that a stream of pus came out through the urethra. The pus can often be milked out through the urethra, and this is preferable to rupturing through the vagina. One of the cases I have seen needed surgical interference. In the Bartholinian gland we have a single racemose gland, and if the canal be closed the drainage is poor and there will be a tendency to abscess formation. In these cases mere incision is not enough. A complete extirpation of the gland is necessary. But in these para-urethral structures we have merely a duct, and from general reasoning I should imagine the indications for operative procedure would not be as frequent as stated by the essayist. *Discussion of paper published August 25th, page 404. I don't recall having read of or seen any case in which there was any great hypertrophy of the tissue around these ducts, such as is found in the male. Even in cases of pseudohermaphroditism I do not remember any case where there was the formation of a prostate in place of these ducts. Dr. George M. Phillips.-The subject is an attractive and a new one. For the limited time I have been engaged in the practice of medicine I have treated the fewest possible number of women, and I have never had a woman remain obedient to treatment for more than the shortest while. We know today that there are new things so far as our information goes that should have been known to us a long time, and while these glands may be a counterpart of the prostate, yet it would require a great deal more to settle the question than what has been done. In the first place, there is a great deal about the prostate in the male that we don't understand. For instance, it was supposed when we commenced making prostatectomies that the ejaculatory power would be abolished, but I have made the operation in a number of cases where for several years the sexual power had been abolished, and following the operation the sexual and ejaculatory power had been restored, aud in one case the man assures me that these powers are greater than ever before, and he is now 67 years old. Yet I was taught to believe that this was the principal function of the prostate. If that is true, a woman does not need such power. You believe, Dr. Barnett, that these enlargements were the result of an inflammatory process as far as you could determine? Dr. Phillips.-Did this appear to be a ǹbrous process when examined microscopically? Dr. Barnett. --I do not know. Dr. Phillips. We should feel deeply indebted to the essayist for bringing this matter to our attention. There may be a great deal more in it than we are at first inclined to think. Dr. Scharff. This subject is a very interesting one. It has long been a question of the analogy of some gland or organ in the female with the prostate in the male. In the para-urethral glands referred to there is really not much real glandular tissue, while the prostate is to a great extent made up of glandular tissue. In gonorrheal affections of these para-urethral glands you find a small cell infiltration rather than a hypertrophy of the glands. In reference to the treatment of gonorrhea in the female I noticed that Finger establishes the location of his infection in one of four places, viz.: cervix uteri, urethra, Bartholin glands or para-urethral (Gänge) or canals, and applies his treatment to the affected part. It is also interesting to see how he draws the line of his responsibility from the gynecologist in these affections of the cervix, he treating them only as long as he thinks the disease is limited to the cervix, and has not gone over to the body of the uterus, tubes, etc., when he refers them to the gynecological department. Dr. Bransford Lewis.-I had anticipated the pleasure of trying to tear his paper up the back. That is one of the pleasures in receiving guests from the outer world, but I think Dr. Barnett has taken advantage of us, preventing this by bringing in something that we don't know anything about. I cannot say anything against the contentions of the essayist. If he establishes his case it will make another focus of infection for us to look out for and disinfect. My experience with the gonococcus is limited almost exclusively to the male organism. In some cases we have found that active treatment was not well borne for certain length of time. They will then do better if let alone, so far as local treatment is concerned, for a certain length of time, yet I have no confidence in their getting well ultimately without treatment. I do not have confidence in the necessity of resorting to internal and general treatment until the acute processes are over. It is necessary to get rid of the gonococcus. I have no faith in the recovery of the individual otherwise. The gonococci must be eliminated by some direct and radical mode of treatment. In a number of cases in the course of our examination of male patients we have seen not a particle of discharge from the meatus, and after having the urine passed in two glasses both were found negative, and yet when we milked the prostate and vesicles down would come a number of drops of gonorrheal pus. This is an illustration of the absolute necessity of going after the nidus before that patient has a ghost of a show of getting well. We have had recently a case so re markable that I have never heard of anything like it. This patient had three ureters, one on the right side and two on the left side. Of the two on the left, one was infected with gonorrhea and the other gave perfectly clear urine. That patient had been treated by a number of most capable men. He had for two or three years had persistent by recurring gonorrheal infection. He had received very thorough treatment, yet every once in a while up would come this gonorrheal activity. The reason for this was never learned until we saw the three ureters. Then by three irrigations of the kidney pelvis we cleared up the whole thing and he has had no recurrence of the infection in seven months. We tried to cure him and could not do it until we discovered this extraordin ary source of infection. He might have gone on for twenty years just as well as for three years in this condition. It is not a matter of time; we must find these foci and Dr. Barnett has told us of a new one for the gonococcus. The more of these niduses that lie in the human organism the more difficult we find the work. I don't like to accept the burden Dr. Phillips has put on the prostate, that of accelerating the ejaculation of the semen I have looked upon it as an organism of glandular and muscular tissue with a fibrous tissue interlacing these two. The muscle at the base is a sphincter muscle for the bladder, and I would not expect the prostate to have the office of expediting the ejaculation of semen. Dr. Jacobson.-I do not agree with Dr. Taussig that we should not attack these foci. Especially in the chronic stage we ought to find them and with the new aids we have for the treatment of gonorrhea we ought to cure them, or I should say, assist the antibacterial forces of nature to bring about a cure. The different portions of the urethra can be ex posed and the retention cysts can be slit up. Then apply strong nitate of silver on applicators under the direct light of the electric endoscope. This treatment repeated frequently with assistance of antitoxins or antibodies found in the blood of the patient to bring about a cure. I believe in the greater majority of patients that have an attack of gonorrhea, the gonococci entirely disapears in from three to ten years, and greater number of males that have had said infection are able to discharge lively, healthy spermatozoa. Dr. Jacobson.-Certainly I have failed. It is much easier to locate these glands in the female than in the male. Sometimes they do not form retention cysts. You may press through the vagina and the pus will come right Ashton uses a strong ichthyol solution out. on applicator wrapped with cotton. If you let them alone, as advised by one of the preceding speakers, reinfection will often take place and the tubes may become involved, then you will have a salpingitis and a dangerous operation confrouting you. And always bear in mind when you find it necessary to remove the tubes, there may be such strong adhesions that you have to exercise great care and patience in their removal to prevent rupture of the tube or tearing a hole in the adherent bowel or bladder. Calculi have been found in these little pockets or cysts; there may be tuberculosis present, then excision with general antitubercular treatment is indicated. Dr. Norvelle Wallace Sharpe. -The ordinary infection is not very troublesome to the patient or to the physician in charge. Any infection which may be cured by the instillation of fluids is not troublesome, nor is it serious even when encountered in glands that may be removed. The real difficulty arises when the infection occurs in glandular structures where the focus is not easily reached. If it can be cured by a simple milking process, well and good. Fortunately the female urethra is short and we may readily expose the orifices of the ducts, or we have the further opportunity of splitting up the duct so as to reach the infected gland. The entire interest in this matter rests in the fact that we have a focus from which a re-infection may be started up at any time upon provocation. As to the surgical procedure, the following will prove a satisfactory routine: cleanse the urethra, examine the urethra, ascertain ducts from which pus or infected material escapes; cleanse same and instill what medicament seems indicated. If this prove insufficient, split ducts and make thorough local applications; if this too proves inadequate, extirpate the infected masses from the vaginal side. Suturing if the operation has been in normal tissue, packing if it has not. Dr. Wolf. I have had much experience in this matter because I was chief of Professor Lange's clinic in Vienna. The discussion has drifted a little from the subject presented. Dr. Barnett has presented something with which I have never met. These are not at all glands, they are only ducts. In the normal cases, they have not a trace of glandular tissue. I have never met a case where these ducts communicated with these glands. Dr. Barnett tried to make an analogy between these and the prostate. Possibly if he gave us a histological demonstration we would be readier to see the resemblance. have seen these ducts involved, and at Pro. essor Lange's clinic we had the surgical I method of splitting. We entered with a probe and then introduced a very fine scalpel and opened them. You cannot do the work by injections. The female urethra is very hard to treat, unless you have had large experience. We never forced the injections, always gently pressing in only so far as was easy, and I never got any infection by this means. It is very important to give attention to these para-urethral ducts. This is the first time I have ever seen any communication between the para-urethral ducts and the glands. It is, therefore, surprising to me to hear of these cases. The analogy is something really striking. Dr. Barnett has presented something new, and if he only would have taken the time and care to show us his tological proof, I would be glad to say that we have had the demonstration of a discovery. Dr. Barnett, in closing.-In naming this paper "The Female Prostate," the question came to me whether medical men would not I just look upon that as belittling the subject, or putting out a red flag to attract attention. In my opinion, and I bave been investigating this subject for four or five years, we have the histological proof. If I had named my paper the "Deep Urethral Glands," the man practicing medicine would have thrown it aside, and said it was nothing to him. Some of the older men will tell you of the formation of an abscess and the reformation, etc. wanted to bring the subject to the attention of the profession. If I am wrong I want to be set right, and if some one will prove that we have abscess formation without glandular tissue, which to my mind is practically impossible. And, according to the size of the abscess, there is enough to call attention to it, even if there is no glandular tissue. Dr. I have Phillips is a doubting Thomas. found hypertrophic glands in a number of dissections. I had a section for Dr. Sharpe to examine, but somehow the section never got there, but I believe the tissue was both glandular and muscular. As to the analogy, we have the prostate in the male and the deep urethral glands in the female, we have Bartholin's glands and the vesiculae seminales. As to constitutional trouble from the Neisserian infection, I think we have more constitutional trouble than from any other infection with the exception of tuberculosis. the bladder work I think Dr. Lewis is at the very top of the heap. Understand me, I don't believe this is a big subject, but I do believe it is a little subject that needs attention. believe there is communication between the duct and the gland, and that it will be proven histologically. In THE MEDICAL FORTNIGHTLY Issued Tenth and Twenty-Fifth of Every Month. THOMAS A. HOPKINS, Editorial Staff: O. E. LADEMANN, Internal Medicine. JOHN MCHALE DEAN, Surgery. F. P. NORBURY, Nervous and Mental Diseases. R. B. H. GRADWOHL, Pathology and Bacteriology. WALDEMAR FISCHER, Ophthalmology. A. LEVY, Pediatrics. W. T. HIRSCHI, Therapeutics. A. F. KOETTER, Otology. HERMAN STOLTE, Laryngology and Rhinology. Editorial Rooms, Suite 319-321 Century Building, St. Louis. EDITORIAL Specialism as it Sometimes is. WE often hear it said that we live in a day of specialism in all lines of commercial and scientific activity, and in the abstract this appears to be an ideal state, but it is an unfortunate fact that the term "specialist" has, in medicine, no necessarily limiting or warranting signification. The problem of specialism would be simple indeed were specialists always men of special attainment in their special line, and did they confine their attention to the work to which they profess to limit themselves. We have in mind a man recently arrived from the University of Vienna, but shortly graduated, who posed as a specialist, telling of special training to bear out his claim in gynecology, pathology and bacteriology, surgery, urology, dermatology and internal medicine, all within a few weeks, his line depending on his audience. He was getting his bearings when he found the line he thought the most promising in this community, he announced himself a specialist therein, but there is no indication that he confines himself to it. Graduates of American schools are less rash, for they know local conditions and appreciate that they cannot command so credulous an audience, but their real unpreparedness when they announce themselves as specialists is frequently quite as apparent. four years spent in medical study does not prepare a man to launch himself as a specialist, such an one must spend years rounding himself out in general work and special post-graduate study before he is fit to be regarded as specially an authority in any brach. Speaking to this point the editor of the Post-Graduate says: A "We have always considered it an axiom that a man may be an excellent physician without knowing anything at all about surgery, but we believe just as firmly that no man can be a first class surgeon who is not a good physician. The reasons will easily appeal to any thinking man, but when we state the fact that there are a number of surgeons in our experience who are extremely skillful in surgery itself, and yet cannot grapple with the simplest medical complication in a case, we are not putting too high an estimate upon the necessity of the surgical practitioner keeping up his reading and observation, and, if he can do so, his experience in general medicine. When it comes to the narrow specialties of the eye, ear, throat, and so on, the same dictum holds, and the failure to attain the best results is often due, not to the lack of skill in the specialty, but to the lack of knowledge in general medicine." A knowledge of general medicine and the maintenance of a well-rounded medical character is essential to success in a specialist's work. We all know specialists who can see only their own little group of organs, and who view every obscure trouble as originating from some disorder within their province. Acute diagnostic acumen would frequently send cases to the internist or back to the general practitioner which are treated by the urologist. We too infrequently hear of a specialist returning a patient to the general practitioner, because he fails to find anything within his province; he doesn't fail, because to him every symptom points to his field, and he can see no other. The real day of specialism will be the time when only those will aspire to this dignity who have drunk deep of learning and who have a breadth of scientific horizon which brings within their vision the whole realm of medicine, even though they may not choose to tread all its devious and varied paths. Such there are now, and it is to them that we look with gratitude for they keep the good word specialist from utter disrepute. |