Finger in dermatology are among this number. If the objective point be the classes of one of these more prominent men, a wait of several months may be necessary before an opening exists. There are men in Vienna to-day who have waited six months for some special course meanwhile filling in the time as best they may. One-third the time spent here will be lost, as a rule, waiting for some special line of work. This condition works a greater hardship upon the unprepared than any other obstacle encountered, and cannot be too strongly emphasized. Do not come to Vienna unless prepared to stay one-third longer than necessary to do the required work. While the work as at present laid out seeks to cover the whole field of medicine, the great bulk of it is advanced in character and best suited to those above the average in training and experience. Vienna is, at bottom, a training school for specialists, and fully one-third, if not one-half the number who come here would fare better at home. The courses are arranged to run twenty hours, one hour a day, three or more days per week. Most of them are completed in less than four weeks, and as much material as possible is crowded into this period, with scant attention to elementary teaching. In some of the specialties, notably the eye, ear, nose and throat, an attempt is made to co-ordinate the work; but as a rule, each course is independent and no attempt is made at gradation. Relative to the excellence of the various courses and their practical value, there is of course, a great diversity of opinion. They are all good, theoretically, but many of them lack practical essentials. Those on the eye, car, nose and throat are considered superior to any offered elsewhere in Europe. In obstetrics and gynecology as much cannot be said; these subject being taught, in the main, as well in America as here; and the same applies to operative sur gery and internal medicine. The German is a therapeutic nihilist and gives. scant attention to methods of treatment. Hamburger, without doubt, gives the best course on pediatrics in the world to-day for English speaking physicians; and the same can be said of Lorenz in orthopedics. Holzknecht in x-ray work is considered a world wide authority and gives the only course in Europe on bone pathology. It is for pathology and clinical diagnosis, however, that the general practitioner, if he is wise, seeks out Vienna. The work is elaborate and exhaustive and the abundance and variety of the material affords splendid opportunity for study. The best courses given on these subjects, or those enjoying the greatest popularity are those of Stoerk, Kovacs, and Exner in gross pathalogy, medical and surgical diagnosis, respectively. The work of Stoerk is all advanced; he never shows anything but rare and complicated cases, and deals very little with minutiae. Kovacs is renowned for his hair splitting differentiation, and revels. in the abstruse and obscure. Exner is more liberal and occasionally descends to simple things; but he, too, loves complications and finds it hard to keep clear of them, while the medical profession of Vienna fairly teems with brilliant young men and famous older ones, the conviction persists that her medical prominence is due not so much to this fact as to the abundance and variety of her clinical material and the manner in which it can be used. Not only does this apply to Vienna, but to all medical Europe as well. To sum up; the sick poor are used for teaching purposes when required; if those in need of medical attention seek state or municipal aid, they must lend themselves to the advancement of medical science; from this there is no escape, and until America adopts a similar system the advantages, especially in research work, will lie on this side of the water. Prostatitis BY J. A. RIEBAL, M. D., Columbus, Ohio. Professor of Genito-Urinary Diseases in the Ohio Medical University. OONER or later every practitioner is sure to be confronted with the problem of the prostate, because it is an inevitable attendant of advancing age in his patients. And there is no problem which is calculated to give him more vexation or to more severely tax his professional resources. Dr. Riebal's paper is directed toward the questions involved in diagnosis, rather than to those of treatment, under the maxim that a disease properly diagnosed is half cured. He tells us especially how to differentiate it from seminal vesicultis, which it often closely resembles. At some future time we hope to be able to prevail upon the author to give us a companion article on the different methods of dealing with this most vexed condition in old men. There is no organ in the human body of which the physician has less definite knowledge than of the prostate yet there are few conditions which can be more accurately diagnosed than chronic prostatitis. This is probably the most important complication of gonorrhoea, for the reason that the gonococci with all their infectious qualities unimpaired in the diseased tubular glands of the prostate may be unsuspected. Chronic prostatitis is important on account of the profound disturbance of the general nervous system as well as impairment of the sexual function. In the majority of cases the disease originates in an attack of acute catarrhal prostatitis which becomes chronic or by slow insidious extension through the prostatic ducts of an inflammation from the posterior urethra. In the latter case is not always due to gonorrhoea, but may have originated from sexual ex cesses. An opportunity has scarcely been offered for observation of the changes in chronic prostatitis, but these are noted by gross appearance, by palpation, etc. The prostate is enlarged, the seat of a diffused swelling or enlarged in certain areas. By cystoscopic examination the prostatic ducts and their mouths are dilated as far as can be seen through the crystoscope with an inflammatory area around their mouths which keeps them open and gaping. The mouths of the ducts are filled with debris which may be easily forced out by the exploring finger in the rectum and by muscular contractions of urination. In other cases the mouths of the ducts are colsed and can only be demonstrated by pressure within the rectum. Symptoms. While it is possible for parenchymatous prostatis to give no evidence of its existence other than physical signs, there are certain subjective symptoms that appear and disappear as the inflammation varies in intensity. These symptoms are vague and are described differently by different patients but the usual symptoms are (a) frequent and urgent urination. (b) Partial or complete impotence. (c) Some complain of irritation as though there was a ball in the rectum mistaking it for constipation in the lower bowel. (d) Vague pains above symphysis pubes and weight in the lower belly, pain in back, and down the thighs. These symptoms are most always due to tension of the swollen prostate within its capsule. Mental symptoms which are grouped under the term sexual neurasthenia, may be absent, but are usually very strikingly manifested in the spirits and temper. These patients first complain of loss of strength, forgetfulness; there are meiancholic or hypochondriacal, there is irritability of temper and mutability of mental effort. Diagnosis. As the history of chronic prostatitis, seminial vesiculitis and chronic posterior urethritis are similar one can only make a differential diagnosis by an exmination of the patient. First, palpating the prostate per rectum. Second, microscopic examination of the fluid expressed from the prostate. On palpation of the prostate is found to be uniformly enlarged and tender, the right or left lobe only involved, or an irregularity on the surface of the prostate, which indicates that only a few tubules are affected. To distinguish between prostatitis and seminal vesiculitis is at times impossible on account of the seminal vesicles also being involved at the same time. On palpation of the prostate it is found that the secretions are more easily expressed than in normal conditions. This is what is termed the expressive-urine test which is made by massaging the prostate through the rectum expressing the contents of the prostatic tubules. In a normal prostate, after massage, the urine is milky from mixture with prostatic fluid while in diseased conditions flakes, masses and strings are formed by the thickened prostatic secretions. By inspection of this we cannot always form a correct opinion, and a centrifugal and microscopic examination must be made. Under microscopic examination if no pus is present prostatis can be excluded. The normal prostatic fluid is found to contain many elements-mucus, granular phosphates, oyxlate of lime, calciun phosphates, etc. (2) epithelium from the bladder, glands and ducts, (3) Anylond bodies occur most often in older subjects. (4) Phosphatic concretions are also found in older subjects. (5) Boettschner's crypts. (6) Spermatozoa are usually found under all conditions. Treatment. The confidence of the patient must first be secured for these patients are very suspicious that they cannot be cured. Internal medication-Tonics, saline cathartics, ergot, in half drachm doses four times a day. Massage of the prostate twice a week. Irrigating the bladder every second day oxy. of mercury 1 to 4000, permangante 1 to 5000, silver nitrate 1 to 10,000. TREATMENT OF DYSMENORRHEA. Siredey, in Quinzaine Therapeutique, gives the following advice regarding the treatment of painful menstruation: Before the flow begins to make its appearance the patient should be made to take a warm bath of a temperature of 98 to 100 degrees Fahrenheit, repeated, if necessary two or three times during the day, gradually increasing the temperature to 104 degrees F., if the condition of the patient permits of it. In addition, rest in bed must be insisted upon, and inunction by one or other of the following sedative mixtures, after the application of hot compresses or poultices: WE The Lymphatics BY E. C. HENRY, M. D., Omaha, Nebraska. Professor of Anatomy, John A. Creighton Medical College, E doubt very much whether, in ordinary teaching and practice, adequate attention is given to the physiology of the lymphatics and the part they play in health and disease. Dr. Henry gives a most interesting summary of the history of their discovery, which, as he rightly says, reads almost like a romance. He then points out their anatomical significance, and the relations which they sustain to certain disease processes, of which not the least important is the role they play in the metastasis of malignant growths. He enunciates the rule that when such a growth has invaded the lymphatics, operation is useless-except, we take it, as a palliative measure. He regards the lymphatic system, and properly, we think, as a large secretory gland. The discovery of the lymphatic system. reads like a romance. In the year of 1622 Asellius was one day showing his friend the arrangement of the nerves and the movements of the diaphragm in a dog, in turning the intestines to one side he noticed some white cords in the mesentery which he had never seen before. He completed his demonstration but the next day he went back to look at the white vessels he had seen, but to his astonishment they had all disappeared. Asellius was a fine anatomist and a thoughtful student. He saw that the only essential difference was, that after first operation the dog had been fed about an hour before, in the second case the dog had had no desire for food owing to his previous operation. So he reasoned that if he would feed a dog, wait an hour or so the vessels would reappear. Imagine his satisfaction when he found his reasoning correct. He called the vessels lacteals because of the white fluid they contained. At that time physiology taught that all food stuffs must be worked over by the liver before it could pass into the blood, so Asellius taught that the lacteals entered the liver. Years before Eustachius found the thoracic duct which he found emptying into the veins of the neck, but skillful as he was he got lost when he followed it into the abdominal cavity. He did not find the receptaculum chyli. That is not especially surprising as the chyla cyst is usually absent and its place is taken by three or four diverticuli into which the lumbar and intestinal trunks empty. It took about one hundred years to work out in detail the lymphatic system as we understand it today. During all these years the medical profession have looked on the lymphatic system as the great drainage canal of the body, and only within the last 15 or 20 years have such men as Poirier and Cuneo shown that this is but one of its many uses. It is to call your attention to these other uses that I write these lines. At least one-third the weight of the human body is fluid in the form of lymph moving in the lymphatic channels. The lymphatic channels added together would make an immense cyst whose wall is a secreting membrane for the lymph is not a transudation from the bloodvessels, but is the result of vital cell activity. Not only do the lymph vessels secrete this own peculiar products but they receive the internal secretion from the ductless glands; so that the products of the Thyroid Thymus-Supra-renals are poured into it. All the fluid in the lymphatic channels is strained from one to three times before it is allowed to enter the blood stream. This straining is accomplished by passing through a lymph node and comprises changes both chemical and mechanical. In the abdominal cavity we find from three hundred to four hundred lymph nodes and it is to this group of glands we are indebted for at least one of the white blood corpuscles namely the mononuclear lymphocyte. So the two great functions of the lymphatic glands are to stop invasions and to provide soldiers. It is interesting to note the variations in animals. How the circulation is carried on, for example in amphibians the lymph nodes contain muscular fibres which enable them to rythmically contract like the heart. In the frog the lymph canals empty into the veins in the pelvis as well as in the neck. Another interesting point is seen in the lymphatic tissue arrangement. In the lower animals such as the siren the lymphoid tissue is arranged in the submucous coat of the alimentary tract and is not differentrated as in the high types. In man we find a collar of lymphoid tissue at the junction of the mouth and pharynx. We call part of this tissue Tonsil, nasal or phayrngeal according to location. The soft palate and uvula is full of lymphoid tissue. This adenoid tissue is placed as a sentinal to guard the alimentary and respiratory tracts. The oesophagus and stomach contain very little adenoid tissue, but out to the left of the stomach is the spleen, the largest collection of lymphatic tissue in the body. In the upper part of the small intestine we find some lymphatic tissue and as we approach the junction of the small and large intestine we find Peyer's patches and solitary glands, and last but not least, Tonsil, Spleen, Peyer's patch and appendix are all the same kind of tissue and may be infected with the same germs. Typhoid fever may have its primary lesion in the tonsil or in the appendix quite as well as in Peyer's patch. Some of those cases of typhoid fever that finally developed an abscess in the side were simply the adenoid tissue of the appendix breaking down, the same as in regular appendicitis. That case of appendicitis you had and called in the surgeon to operate on and after the operation ran a regular course of typhoid fever, simply had the primary lesion in the appendix and later the other Peyer's patches became involved and the typhoid took its usual four weeks' course. The importance of the lymph canals has been only partially recognized by the Surgeon even in recent years. He knows that they carry infection and distribues malignant neoplasms; but even today few Surgeons recognize how wide is that distribution and how free in the anastomosis. Only today I read the report of a famous New York Surgeon on cutting out half the tongue for cancer and a discussion was raised as to taking out the adjacent glands. If a man will spend a few hours studying the arrangement of the channels in the tongue and note this wide distribution extending almost to the sternoclavicular articulation, he will not stop with any half tongue dissection. A few years ago I saw Wertheim's Charts hanging on the walls of his private office, they presented a picture. never to be forgotten, more than three hundred women had submitted to his very radical operation for cancer of the |