of mental diseases is today an arbitrary one, and we now merely place psychoses in groups if possible, leaving, if necessary, a large number of cases unclassified.

RECAPITULATION.

Paretic dementia is a significant term, and should in the absence of a more suitable name be retained in our nomenclature of the psychoses. It should, however, be remembered that we have in this disease a widespread organic affection, with changes accentuated in the brain, but with demonstrable lesions in the different systems of the body. It is known that in many cases of paretic dementia vascular and visceral changes may be quite often detected, and for this reason it is claimed by some that paresis is a specific systemic disease and must have an isolated etiologic agent. I would, however, suggest as opposed to this a comparison of the more general morbid lesions found in paretic dementia, with pathologic lesions detected in other organic brain diseases. Until such a comparison. is made and proper deductions induced it seems to me that we are justified in considering paretic dementia as an organic brain disease, with superimposed mental symptoms. Such an opinion does not destroy the morbid entity of the disease, but allows us more latitude and gives us an opportunity to more thoroughly recognize why we have in this disease a disease of protean form, with a syndrome showing many consistencies and contradictions. If we are inclined to such a belief we are more prepared to admit that the differential diagnosis of paretic dementia may clinically be a matter of extreme difficulty.

The frequent occurrence of the anomalous case of paretic dementia, the increasing frequency of the early adult case, and the more thorough individual analysis of our cases of general paralysis of the insane indicate that there must be widespread and varying etiologic agents.

It is interesting to note as bearing upon Mott's idea of the disease. that heredity is now recognized as an important predisposing agent. We have made an investigation and believe that heredity is a factor of importance, and may be regarded in many cases as a true predisposing cause. We also believe that heredity in these cases is similar to the heredity observed in other organic nervous affections. A consideration separately of the many causes advanced for the production of paretic dementia makes it more apparent that in this disease we have a predisposition, which in a considerable number of cases may be inherited.

We are not yet prepared to say with certainty that we can isolate the condition or factors responsible for the development of general paralysis of the insane. In common with other organic brain disease. it is probable that there are many causes acting directly and indirectly to produce the disease. The apparently clear diagnostic points which are advanced for the purpose of distinguishing paresis from other diseases are at times of little value, and I think that many of us will

admit that we place these doubtful cases either in organic dementia, or more particularly perhaps leave them unclassified.

When differentiating this disease clinically, as is well known, we bear in mind, first, the character and degree of mental involvement; second, the presence or absence of physical signs. To this we must add the knowledge gained from lumbar puncture. The feasibility of lumbar puncture and its practical application in diagnosing the organic insanities, and particularly in distinguishing the organic from the nonorganic psychoses, cannot be doubted; but, as with other clinical methods its limitations must be remembered, and our findings considering our present understanding of this procedure must receive careful attention. This diagnostic method, however, has already proven of value and is worthy of more extended use. We have made it a routine measure, and we believe it has assisted us in differentiating the simple insanities from the mental affections having an organic basis. The results we have obtained, however, have been substantiated by other clinical examinations.

It must be acknowledged that we have no one pathognomonic clinical sign and our "positive signs" after all are only suggestions.

Summarizing these brief remarks on the differential diagnosis of paretic dementia, I would say that the inconsistencies manifested in the clinical syndrome of the disease make it imperative that we diagnose by correlation of symptoms. Certain mental and physical signs occurring during the course of the malady may be highly suggestive but are not conclusive. We should always guard against placing undue importance on one symptom. Lumbar puncture in the organic psychosis offers a field for research and may prove to be a valuable diagnostic agent.

GENERAL CONCLUSIONS.

(1) Paretic dementia is an organic brain disease, with superimposed mental symptoms.

(2) The clinical inconsistencies frequently observed in paretic dementia and the presence of analogous symptoms in other organic brain diseases make it seem improbable that in paretic dementia we have a definite mental entity directly related to the disease. The variability of the mental symptoms thus expressed has its analogy in other brain affections.

(3) In common with our knowledge of other organic brain diseases with attendant mental changes, we may regard the paretic syndrome as capable of being produced by numerous causes.

(4) Heredity of indirect type is probably a not infrequent predisposing element to the disease.

(5) The clinical differentiation of paretic dementia is often impossible. The late appearance of the so-called characteristic mental and physical signs may prohibit a concise diagnosis.

(6) The diagnosis of paretic dementia should only be made by a

correlation of the mental and physical signs. There is no one pathognomonic clinical symptom.

(7) The differential diagnosis, clinically, is often a matter of extreme difficulty: the distinction from arteriosclerosis of the nervous system, brain syphilis, chronic alcoholic insanity, with organic brain changes, cerebral tumors, and brain sclerosis may be impossible. Such a differentiation is particularly difficult in the early or incipient stages of these diseases.

(8) If we consider paretic dementia as an organic brain disease, the mental changes being secondary, we can more easily recognize and appreciate the vagaries of the malady. By comparing the mental symptoms observed to those occurring in other organic brain diseases we are more clearly impressed with the fact that in a case of paretic dementia there can be no well-defined clinical picture. Of necessity we must have multiform mental and physical signs.

Pontiac, Michigan.

THE VARIOUS GROSS PATHOLOGICAL CONDITIONS OF THE URETHRA AS REVEALED BY THE

URETHROSCOPE.*

NOAH E. ARONSTAM, M. D.

PROFESSOR OF DERMATOLOGY IN THE MICHIGAN COLLEGE OF MEDICINE AND SURGERY.

THE urethroscope is a valuable means in the diagnosis of the various pathologic conditions affecting the male urethra. What may seem obscure on a cursory examination, may, with facility, be recognized when the above instrument supplements our investigations. The affections of the urethral canal are not as uniform as it was commonly believed heretofore, as a great number of causes may give rise to identical symptoms. Should we fall into the routine of treating the effects instead of the causes, the results will be far from satisfactory.

The rational and appropriate treatment of the different morbid states of the urethra presupposes (1) a knowledge of the technique of urethroscopy, both anterior and posterior; (2) a familiarity with the normal and pathologic aspects of the canal; and (3) the particular method of treatment suitable to each individual case.

We distinguish between anterior and posterior urethroscopy. The former constitutes the examination of the anterior urethral segment, that is, the first six and a half inches of the canal, while the latter is directed towards the exploration of the remaining one inch and a half of the urethral tract.

The following is the technique of urethroscopy, both anterior and posterior:

It is superfluous to say that the urethroscopic tube-the anterior of which is straight, while the posterior is somewhat curved, with a fenestrum in its curve-must be scrupulously clean and thoroughly

*Read by invitation before the NORTHERN TRI-STATE MEDICAL ASSOCIATION at Put-in-Bay, Ohio, July 31, 1906.

sterilized in boiling water. After having sufficiently cooled down, it is lubricated with a lubricant composed of a decoction of Irish moss, to which a small quantity of some antiseptic agent has been added. The patient is then put in the recumbent posture, the meatus and glans penis cleaned with a mild antiseptic, and the tube introduced gradually and slowly without much effort on the part of the operator. No force should be used in inserting these tubes, save the most gentle propelling motion, taking care not to lacerate the delicate mucosa of the urethra. Should the canal prove impassable on account of an abnormally small calibre or the presence of stricture, it should be previously made patulous by gradual or forcible dilatation with sounds until it admits number twenty-four (French), when the urethroscope will readily enter the canal; the obturator is then withdrawn, the little lamp inserted, the coil attached at both ends and the battery turned on, when the lumen of the canal will spring into view. If the patient is very nervous the canal may be anesthetized with a two per cent solution of cocain. The normal appearance of the urethra is that of a uniform pinkish hue, without any appreciable variation throughout its length.

The scope of this paper does not permit the author to enter into an exhaustive discussion of the different lesions elicited in the anterior portion of the urethra by urethroscopy. However, the most salient features of the different pathologic conditions will be briefly enumerated:

(1) An abrupt change of the pinkish hue of the mucous membrane to that of an anemic or colorless shade would suggest a stricture in its formative or organized state.

(2) Small puncte studded here and there throughout its extent, indicate an acute or subacute inflammation.

(3) Livid areas denote a chronic inflammatory state of the urethra. (4) Granular spots are not infrequently detected; they are of great significance, as they suggest an affection sui generis, termed granular urethritis, a malady very obstinate and resistent to treatment.

(5) Lines or bands of a dark red color, which may be regarded as the formative stage of the so-called linear stricture.

(6) Superficial erosions, commonly found within the first inch and a half of the urethra near the fossa navicularis.

(7) Ulcerations of various types, both superficial or deep, may also be discerned by the urethroscope.

The tube is gradually withdrawn after the fenestrated field has been thoroughly inspected, until the entire length of the urethra has been successively viewed. The small lamp causes but little heat and occasions no irritation or sensation of burning. Should, however, the patient complain of a smarting or burning feeling, then the battery should be turned off for a moment, after which inspection may be resumed.

After the tube has been withdrawn, the meatus and glans are again

washed with some antiseptic solution and the patient given a capsule, composed of two grains of quinin sulphate and five grains of urotropin, in order to prevent urethral chill, which is occasionally apt to ensue in nervous individuals. Urethroscopy should never be attempted in acute inflammatory conditions of the canal, lest a great deal of harm be created in doing so.

Urethroscopy is a diagnostic means of especial value in chronic inflammatory states of the posterior urethra, preeminently so in granular inflammatory involvement of the latter. To detect and properly interpret the particular morbid conditions affecting that part of the canal means half of the cure achieved. The lesions of the posterior urethral tract are nearly the same as those already mentioned in dealing with the anterior urethra, with the exception of erosions and ulcerations, which are not so prone to appear in that particular location. Once the morbid condition ascertained, the treatment readily suggests itself to the intelligent physician.

To enter into a full discussion of the latter will require more time and space than has been allotted to the author under the present circumstances. Suffice it to state, however, that the eradication of certain pathologic states, as determined by the urethroscope, is but a question of time and perseverance on the part of both patient and physician, so greatly is the treatment facilitated by the procedure above delineated. Detroit, Michigan, 106 East High Street.

MEDICOLEGAL QUESTIONS.

E. S. MCKEE, M. D.

Professional Secrecy.-An interesting decision of fundamental importance was lately given at the high court of justice at Leipsic. A woman had contracted syphilis from a man and after his death recovered damages from his brother and heirs. The medical attendant of the deceased was summoned as a witness, but declined to give testimony on the ground that the law imposes silence on medical men in regard to facts concerning their patients. The plaintiff's council, on the other hand, claimed that the law of secrecy was no longer binding after the patient's death. The court decided that only the patient himself was competent to release his medical attendant from the obligation of professional secrecy, and since he had not done so it was presumed that he did not wish the facts concerning his illness to be made public after his death.

Civil Responsibility and Syphilitic Infection.-M. Thibierge read a most intersting paper on this subject before the Paris Society of Legal Medicine. He said that in case of sexual infection action is very seldom brought, for legal proof is decidedly difficult to obtain. Cases of infection through employment arise almost exclusively among glass blowers. A recent judgment of the court of compensation has