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days and, as I thought, was progressing finely, when he suddenly developed cerebrospinal meningitis and died in thirty-six hours. I recite this case to show a tendency that I have often noticed. I used all my persuasive powers to convince the old man that he did not have all the other diseases suspected, but failed to persuade him he had pellagra.

The progressive loss of hemoglobin I have found to be another constant symptom. With the appearance of the eruption, I find the hemoglobin to be from 80 to 90 percent; as the disease advances, I find that the hemoglobin goes down and down; when it reaches 60 to 70 percent, if the patient is a woman, I find she always develops typical hysteria; when it gets to 50 percent, whether in man or woman, the victim, without exception, becomes insane; finally, when it gets much below 50 percent, death ensues. The white blood-cells stay about normal. In all my experience I have seen only one instance of leukocytosis.

According to my observation, the eruption, or rash, is the beginning of the second stage in the disease. I think the "germ" finds lodgment in the stomach and sets up a catarrhal gastritis, and this increases the motility of the stomach as well as interferes with the proper digestion of the food. The food is forced prematurely into the alimentary canal in an improperly prepared condition, there to be acted upon by the bile, pancreatic juice, and the other intestinal secretions, the whole a fermenting mass and a propitious feeding-ground for all the pathogenic germs that may be found in the intestinal tract. This mass, instead of forming wholesome chyle for the proper nourishment of the body, generates toxins, ptomaines, and all the host of deleterious substances capable of poisoning the body. These are absorbed and poured into the blood current.

In the face of this invasion, the liver makes heroic efforts to detoxicate the blood, but it is finally borne down by the accumulated load of poisons and allows the whole poisonous mess to go freely circulating in the blood current. We now find the nervous system staggering under * the increased irritation, and at last nature

hangs out the red flag of danger in the rash we see upon the hands and arms. Just why this irritation always selects the gyrus centralis anterior in the frontal lobe of the brain I am unable to explain by any theory. As to why the rash will disappear, to reappear next year in a more aggravated form, I also am free to confess my ignorance; that these things happen, though, is a fact patent to every observer.

From the stage of irritation the next step is sclerosis, and then we have the interference with motion, the staggering gait, the inability to stand erect with the eyes closed, and other evidences of a sclerotic condition of the motor area of the brain.

The Author's Line of Treatment

For the sake of some country doctor who is far from any drugstore, I will say that, in emergencies, I have made many gallons of the following extemporized chlorine water:

Put 40 grains of chlorate of potassium into an 8-ounce bottle, then pour on the chlorate 2 drams of hydrochloric acid and let the chemical action begin, so that the yellow chlorine gas is beginning to escape. Now add about 2 ounces of water, let stand for about half an hour, then fill the bottle with water and you have a very good article. This I employ as a gargle and internally.

In connection with the chlorine water, I usually give calcium sulphide, 1 grain three times a day.

In a very few instances I have found the gastric irritation so acute that the chlorine water seemed to irritate. When this happens, I put the patient on the following, until he can bear the chlorine water: Fluid extract of condurango, 1 ounce; listerine, 1 1-2 ounces; liquor of potassium arsenite, 3 drams; carapeptic liquid, enough to make 4 ounces. Directions: One teaspoonful in water three times a day before each meal.

This treatment I have found all that was required in those cases that were of comparatively recent origin, when the nervous system was not badly involved and the hemoglobin has not got too low.

In cases of longer standing or where the changes in the nervous system have been

decided, this treatment alone will not suffice, because the whole system is staggering under the load of accumulated poisons and it cannot throw off all that it contains; and even though we stop the formation of any more, the system can not take care of what it already contains. Under these circumstances, I try to assist nature in its efforts at elimination by the use of hypodermoclysis and stomach lavage. I usualy give, by hypodermoclysis, from one to 4 pints of normal salt solution once or twice a day, the quantity depending upon the state of the patient. The stomach is thoroughly washed out every other day. When by these means I have thoroughly eliminated the poisons and feel that I have stopped their formation in the stomach and intestines, then I try to restore the hemoglobin to the blood and the hydrochloric acid to the stomach.

My favorite prescription for this purpose is as follows: Potassium nitrate, 1 dram; ferrous sulphate, 1 dram; nitrohydrochloric acid, 6 drams. Warm the mixture slightly, let it thoroughly digest, then add 2 drams of liquor of potassium arsenite. Directions: Take 6 drops in water after each meal. By giving the acid after meals, we stimulate the flow of acid in the stomach.

A certain number of patients cannot take the acid treatment; in which case I give an alkali before meals, also with the object of augmenting the secretion of normal acid, and I favor a combination like this: potas sium bitartrate, 2 drams; lithium citrate, 1 dram; elixir maltopepsin, sufficient to make 4 ounces. Directions: Take one teaspoonful in water three times a day before each meal. This mixture will sometimes act more favorably than the acid.

When we have rid the system of the poison and stopped its formation in the gastrointestinal tract, the after-treatment is a matter of individual choice. I usually give some preparation of iron, combined. with bitter tonics; also codliver oil.

Now, does this procedure cure? In a majority of cases, yes! In cases not too far advanced, when the changes wrought on the nervous system are not too pronounced, it will cure at least 75 percent.

Last year I treated twelve patients, two of whom died, while four strayed off into the hands of other doctors or moved awayanyway, I lost sight of them. Six got well. Of these six, one had a stroke of paralysis in January, 1911, and died the same day. One has had a slight relapse, but it yielded very nicely to my treatment, and the other four remain well to this day, showing not the slightest return of the disease.

This year I have treated thirty-one pellagra patients, Of these four died, four strayed away, twelve have been discharged with all appearances of being cured, ten are still under treatment but with every indication of getting well, one is under treatment but not improving. Of these four that died, three came into my hands in the last stages, when their cases had been pronounced hopeless by other doctors.

I do not believe the treatment is perfect, but it is given to the world with the hope that it may be a sign-post to other men, and that they will push the investigation further, so that we may eventually discover the true cause and a sure treatment for this disease.

I wish, in closing, to acknowledge my indebtedness to Mr. Geo. W. Watts, a philanthropist of our city who built and equipped the beautiful Watts Hospital at a cost of more than half a million dollars, and without which these investigations would have been impossible.

To Dr. Joesph Graham of our city I am indebted for the idea of hypodermoclysis. He was, I think, the first man ever to employ this method in the treatment ofthis malady.

To Dr. T. C. Kerns, resident physician at the Watts Hospital, I am deeply indebted for his untiring efforts in making the bloodcounts, estimating percentage of hemoglobin, and testing for gastric hydrochloric acid. Without his aid I could never have made these tests so thorough.

For the present I am done. Next year I hope to add still another mite to our knowledge of the malady. This year, and last, it has been a groping in the dark. I could not believe the accepted theories, and my own had to be proved out, by hard work. I hope I have added a little to our stock of knowledge. If I have, I am content..

I

Its Causes and Treatment

By WILLIAM J. ROBINSON, M. D., New York

Editor of "The Critic and Guide," "The Medical Review of Reviews," and "The American Journal of Urology"; Author of "Never-Told Tales," etc.

HAVE never subscribed fully to the Latin maxim, Qui bene diagnoscit bene curat-he who diagnoses well, cures well. For unfortunately there are only too many cases where the diagnosis is perfectly obvious, while the method of treatment leaves very much to be desired. Nevertheless none will dispute the statement that of two men equally proficient in treatment, the better diagnostician will have the larger percentage of successes.

Probably in no class of cases is the ascertainment of the underlying cause of the trouble so important as it is in the sad affliction which is designated as sexual impotence.

Knowledge of the Cause Is Half the Battle

Very often the mere finding of the cause is more than half of the battle won. The causes being very numerous and complex, great patience and judgment are required in taking the patient's history, and in no other class of diseases is the patient's complete confidence so absolutely necessary as it is here. And without it we are often helpless.

The causes of impotence being, as stated above, very numerous, we shall have to be rather concise in their discussion. They are, more or less in the order of their importance, as follows:

Masturbation. This is a very common cause, because, as I have stated elsewhere, practically every human male begins his sexual life with masturbation. And while the habit if commenced fairly late and practised moderately in the majority of cases leaves no ill effects, there is no question that if commenced at the age of ten, twelve or fourteen and indulged in immoderately, it may, and usually does, lead to relative or complete impotence, temporary or permanent.

Pollutions. What we said about masturbation applies with equal force to pollutions. Pollutions of moderate frequency are harmless. But if frequently repeated and of long standing they may ultimately lead to impotence.

Spermatorrhea.-We do not meet frequently with cases of true spermatorrhea, but when we do, we generally also have to deal with relative or complete impotence.

Prostatic Congestion. An inflamed or congested prostate may be the cause of impotence, but not invariably so. On the contrary, in some cases an inflamed and irritable prostate may lead to an increased libido sexualis, and apparently also to more vigorous erections.

Urethral Congestion.-Congestion of the prostatic urethra is a frequent and wellestablished cause of sexual impotence. The hypersensitiveness of the urethral mucous membrane is sometimes exquisite and renders an erection impossible or imperfect and ejaculation premature. The most common cause of such urethral congestion is a severe chronic gonorrhea. And thus gonorrhea, besides causing suffering and death among women, blindness among the newborn, sterility in men and women, is also the cause of one of the most distressing afflictions of the male sex-impotence.

Age. This is, of course, a very important factor, for all men become impotent if they only live long enough. But if we attempt to answer the question, At what age do men become impotent, at what age is impotence physiological, normal? we find we cannot do so; for, in the sexual sphere more, perhaps, than anywhere else, is each man a law unto himself.

In many men the sexual power begins to decline at the age of 40 and becomes extinguished at the age of 50. Many men

are just as powerful at 50 and 55 as they were at 30, while not an insignificant percentage remains perfectly potent and ardent at the age of 65, 75, and later. I have had a patient who had his first gonorrhea at the age of 68! Since the death of his wife, three years previously, he had been indulging in masturbation and illicit intercourse. He wanted to be cured of his gonorrhea, because he decided to get married. He assured me that, not only could he indulge in intercourse nightly, but that the desire to do so was very greatirresistible.

There is also a class of cases which I have not seen referred to anywhere, but which are interesting from a physiologic point of view. I refer to men who become sexually stronger after the age of 40 or so. I have known several men who assured me with absolute positiveness that their sexual power-duration of the erection, ability to repeat the act—was considerably stronger at 45 than at 35 or at any previous age.

Sexual Excess.-Sexual excess may per se be a cause of impotence. Every physician who has sexual diseases to treat can testify to that. I have now the following case under treatment: Patient, X. Y., 25 years old, in perfect health in every respect. Led a model life. He masturbated only moderately for a period of three or four years; suffered with occasional pollutions (about once a month). Had had no intercourse until his marriage, six months ago. Indulged immoderately, six to eight times in twenty-four hours. After two months of this honeymoon orgy he began to notice. a decline both in libido and in strength and duration of erections. But instead of giving his system a rest, he kept right up, incited to the excesses by his wife. In another month he lost all desire and was unable to get an erection. Apparently both the erection and the ejaculation centers were completely exhausted.

Fortunately in almost all such cases the impotence is only temporary, though the former vigor may never be regained. As a rule complete sexual rest, with proper tonic treatment, brings about the desired result. But while this is true of adults, it is not true when the victims of sexual excess are

boys. In them the impotence may become permanent. I know of cases of very young boys (eight, ten, twelve, and fourteen) who had been seduced by vicious servant maids and nurses and forced to perform the act the best they could several times a day. Some of those victims never recovered, remaining impotent for life.

Nothing injures the sexual apparatus so much as its premature abuse. The excess that will in the adult cause but little or only temporary damage will in boys cause terrible and sometimes permanent havoc.

Despite Contrary Assertion, Continued

Continence Is Harmful

Sexual Abstinence.-I am firmly convinced that continued complete abstinence from any sexual gratification may result in partial or complete, temporary or permanent, impotence. I am well aware of the fact that some physicians deny this possibility. I am also aware of the fact that some societies have even passed resolutions to the effect that intercourse was unnecessary to perfect health. But to this I will reply that one positive testimony counts for more than one hundred negative testimonies. If a hundred physicians have not seen any impotence resulting from abstinence, then it is their good luck or their misfortune. It may be simply an accident in their practice, and their testimony cannot go far in comparison with the testimony of physicians who have seen cases of impotence for which they could find no other etiologic factor than that of abstinence. I could give several cases from my practice, but two will suffice.

Case I is that of a physician 35 years of age. He practised intercourse moderately. between the ages of 18 and 24, and his sexual power was normal. At the latter age fear of venereal infection, mixed with suddenly arisen moral scruples, determined him not to indulge any more until he married. married. The struggle to overcome his desire was a hard one, but became gradually easier. He would have occasional emissions accompanied with strong erections; but gradually the latter became weaker and the former rarer, until sexual matters almost completely ceased to bother him.

If he had a desire or if a lascivious picture presented itself to his mind, he suppressed it ruthlessly by a strong effort of the will. At the age of 34 he became acquainted with a young lady whom he was very anxious to marry. But before broaching the subject at all he decided to test his virility. The test resulted in complete failure. He made several attempts with public and semipublic women, but in each case he failed miserably. He could neither get up a desire nor an erection. He is improving under energetic treatment, but it is questionable whether he will ever regain his full vigor, for both the penis and testicles show quite some atrophy.

Case II is that of a drug manufacturer, 38 years of age. He is not only a pious but a sincerely religious man, and he considered extramarital intercourse a heinous sin. His passions were very strong, but he never masturbated; he suffered from moderate pollutions accompanied with powerful erections. The erections became gradually weaker, but the pollutions did not increase in frequency. At the age of 38 he decided to get married and came to consult me as to his virility. The sexual organs showed no abnormality, no atrophy. I told him that in a case like his, where he had had no erection, practically, for years, it was a risky matter to pronounce an opinion and that a positive decision could be arrived at by a test only. This, of course, a religious man such as he could not think of doing. He married, and another terrible domestic tragedy (the wife is only 24) has been added to the already fearfully long list. He is completely impotent so far as performance is concerned, though he is not lacking in desire.

Nature does not allow us to trifle with her. She does not permit any organ to remain inactive, any function to lie fallow for years without meting out punishment: the organ atrophies more or less and the function is destroyed.

Those Society Resolutions

As to those resolutions passed by some societies to the effect that intercourse is unnecessary and abstinence perfectly harmless, I regret to say that all such resolutions

have so far been passed by societies that are tinged or fully impregnated with religious or moral bias. They have not been passed by calm, scientific investigators; they have been passed by good but rather narrow men and women, with a certain object in view, for a certain purpose. That purpose has been to decrease the immorality of licentiousness, that is to say, the sin of illicit intercourse, and to guard the young men from the dangers of venereal disease. But while the purpose, being both moral and hygienic in character, is a laudable one, I maintain that the statement that intercourse is entirely unnecessary for one's perfect health (note that some of the resolutions have it that illicit intercourse is unnecessary-just as if nature made a difference between licit and illicit, between legal and illegal) is a falsehood, and that moralists and theologians have no right to sail in the garb of unbiased scientists.

As to the danger of venereal disease, it is a reality and the contraction of venereal disease is a great misfortune. But I will here repeat the words of a physician friend, words which I do not subscribe to, but which give some food for thought. Said this physician friend: "I would rather have our young men run the risk of venereal infection than have them become confirmed masturbators and impotent." These words acquire special weight nowa-days, when the venereal prophylactics in our possession reduce the danger of venereal infection to nothing, or to a negligible quantity.

And I will add this: A wife can be protected against her husband who has had a gonorrhea; nothing can be done for her with a husband who is permanently impotent.

Coitus Interruptus vel Reservatus.-The abominable practice of withdrawal or interrupting coitus just when an ejaculation is about to take place and when both parties are at the highest point of tension is one of the poisonous fruits of our modern civilization. Though not unknown in ancient times, and even mentioned in the Bible, it is only within the last quarter of a century or so that it has come into widespread use. The modern husband and wife,

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