the urethra through the ejaculatory ducts, though it may burrow its way through the perineum and rupture externally, as an ordinary rectal abscess.

In making an examination of the seminal vesicles it is almost absolutely necessary to have a distended bladder, for without this it is impossible for the finger of the examiner to reach the vesicles, and only practice can do so then; but my experience has been, that if the patient is in proper position, the bladder distended, and the examiner having a proper conception of the feel of the vesicles, they can almost always bring them within reach of the finger. But it takes practice of long standing to intelligently diagnosticate their feel in health and disease, and to properly treat them in this way when chronically inflamed, just as the trained finger of the gynecologist or ear of the auscultator.

Inflammation of the seminal vesicles was first described, I believe, by Lloyd, about 1889, and since then this disease has been very accurately studied by Fuller, of New York, and many obscure pathological conditions of the male generative organs have been thereby cleared up.

The cause of seminal vesiculitis is almost always, though not entirely, due to gonorrhea extending into the deep or prostatic urethra and thence down the ejaculatory ducts into the seminal vesicles. Tubercular disease is sometimes the cause, and by the rough use of or the use of unsterilized instruments, the inflammation can be set up in these or

gans.

Excessive masturbation, coitus interruptus, or prolonged ungratified sexual desire, may produce a chronic congestion of the organs, and thereby favor bacterial invasion, and thus, in an indirect way, favor inflammation.

Tubercular disease sometimes affects these parts and sets up a chronic inflammation, the same as in other parts of the body affected with tubercular trouble.

Vesiculitis may be either acute or chronic. In the acute variety we have very much the same symptoms as those of acute posterior or prostatic urethritis. Urination is painful, as is also defecation, and there is throbbing pain in the perineal region. Sometimes we have a retention of urine. To make a positive diagnosis, we have to introduce the finger into the rectum, when we may feel the hot and swollen vesicle, but this is so painful to do that it is very seldom satisfactory, and I have never been able to get a patient to consent for a second examination. The patient has fever, and all the symptoms of an acute inflammation in other parts. An abscess may form, and most often rup

The prognosis of acute vesiculitis is good except when it results in the chronic form of the disease, which often lingers indefinitely. In the treatment of this disease we can do no better than to follow the advice of Hilton, in his excellent work. "Rest and Pain." The patient should be put to bed, and absolute quiet enjoined. The bowels should be kept in a soft condition, but not too active, for fear of intensifying the inflammation. The urine should be kept alkaline, and hot fomentations over the perineum. Light diet should be given-in fact, the same treatment as in other parts inflamed. The testicles should be supported, so as to remove any pressure by their weight. Hot saline rectal injections are often very good. Opium suppositories and the internal administration of opiates to the point of relieving the intense pain, should be given. The introduction of any kind of instruments into the urethra during the inflammation is absolutely forbidden, unless we have a retention and are forced to use a soft catheter in the bladder.

The patient should be kept in bed, and an antiphlogistic treatment kept up until recovery is complete, which is usually about a month. This last to guard against the disease assuming a chronic form.

In the chronic form we usually have most of the symptoms of the acute disease, but in a very much reduced degree. In fact, the associated painful sensations are sometimes so mild as to be scarcely noticeable. Sometimes the painful sensations are felt in one or both testicles, the scrotum, bladder and in the end of the penis, even more so than in the vesicles, and in this way may lead the physician to mistake other parts to be the seat of the disease. Sexual excitement always increases the painful sensations, and generally some pus and often blood is mixed in the urine. If we have had a case of gonorrhea at any previous time, which has infected the deep urethra, and have pus in the urine and also blood, with pain in the prostatic region and rectum, and especially so after sexual excitement, we should suspect chronic inflammation of the prostate or seminal vesicles, or both, and if we make a rectal examination in the proper manner, we can verify our diagnosis by the tenderness the pressure of the finger produces upon these parts. And right here is where the important part of our examination. and treatment is to come to the front; for if this part of the examination and treatment is not done just right, it were best 'twere not done at all.

The patient should stand with the legs straight and the body doubled over, in almost precisely the position of schoolboys playing leapfrog.

Ballinger, in his work on genito-urinary diseases, recommends the patient to be on his back and the thighs flexed up toward the abdomen. I have tried

this in several instances, and have never been able to reach the vesicles in this position, but if we have the patient in the leapfrog position, and a full bladder to press the vesicles down as far as possible, and with the left hand pressing over the patient's lower abdomen, and with a chair or stool upon which to place our right foot, and thereby bring our knee on a level with the patient's anus, so we may have a brace for our elbow, and with the index finger of our right hand well lubricated with vaseline, we can generally reach the vesicles by the combined pressure of the hand upon the patient's perineum, aided by the support of our elbow against the knee, by slow pressure overcome the resistance of the perineal muscles, and strip most, if not all, of the vesicles. This can only be properly done by repeated practice, and, if not properly done, had best not be done at all, for if the pressure of the end of the finger is too lightly applied, it does no good; and if too much pressure is brought to bear upon the chronically inflamed vesicles, the disease is aggravated. It is generally best to begin the treatment by using very light pressure of the finger-tip until our patient has become accustomed to the treatment, and also the inflamed vesicle has become used to the massage, and to gradually bring more pressure upon the parts with each treatment, until the proper degree of pressure has been reached. This milking or massage should be repeated at least once a week at the beginning, and continued until the inflammation and tenderness have ceased to exist; and, as the disease begins to yield to the treatment, the intervals from one stripping to the next should be increased.

At each treatment the vesicles should be stripped from five to ten times, slowly and firmly, and the treatment kept up until no secretion appears at the meatus after the stripping, and until the soreness from the pressure of the finger has ceased.

During the treatment the general health should be kept in the best possible condition, and any other trouble should be met by the appropriate treatment for its special cause. It is like an army capturing a fortified post-the stripping processs is the siege gun planting shot in the main fort, but the skirmish line must be looked after at all points by attending to any general derangements that may arise.

Horseback and bicycle riding should be prohibited, and during the active treatment coitus and sexual excitement should be kept in abeyance.

Tubercular vesiculitis, when correctly diagnosed, should receive the same general treatment as tubercle in other parts. As a rule, local interference in the tubercular form of the disease is to be prohibited.

DISCUSSION.

DR. T. ATCHISON FRAZIER, Marion, Ky.: This is a paper that is worth while to study and discuss. This is a subject that is much more far-reaching than the average physician realizes. My attention. was called to this subject in particular about five

years ago by a friend, and since then I have never missed an opportunity of studying the subject, and I find, after careful study and careful examination, that many and many of the cases that are treated of the two conditions differs widely; therefore, if as cystitis are really vesiculitis, and the treatment a diagnosis is not made, if a differentiation is not made between the two, we might do much damage. with our treatment.

Now, Dr. Baughman has described milking of the prostate, and I believe that is easily done after a few years of experience and careful study. It takes a great deal of patience. We must go at this matter just as we would auscultate a heart and get the murmur. We must take our time, we must take pains, and we must, as the essayist stated, begin gently, very gently, and a great deal of damage might be done by these manipulations in the acute form of the inflammation. But a man that has a reasonably long finger, and will take his time, will be successful. I never fail to do things that I undertake for want of patience. The trouble is that we do not give the time and careful study that is necessary for success. You take all of our great men in the medical profession, and they devote a lifetime to the study of one question. And that persistence is going to give success in this, as well as in almost every disease that we as physicians have to contend with.

A MEMBER: I am very glad to say that my experience in vesiculitis has not been quite as large as that of some of my friends, but I heartily concur with Dr. Baughman in regard to the difficulties that present themselves in the treatment of this disease. So far as diagnosis goes, the things upon which I put my trust are the pain, increased sexual desire and frequency of urination, where these things did not exist previously. not exist previously. So far as acute prostatitis goes, I have never had a case which I could examine satisfactorily. I have tried repeatedly, but each time when I got to where I thought I would have a satisfactory examination, the patient nearly collapsed with pain. I could get a sort of general boggy feeling, and as time goes on this becomes more marked, and in some of these old chronic cases the vesicle is like a fibroid cord.

I have one case that is of a good deal of interest, that I would like to mention. that I would like to mention. This man had some time ago been affected with gonorrhea. When I got to him he was one of the most deplorable ob-jects I ever saw. His prostate was immensely large and exquisitely tender, his posterior urethra

in such condition that I could not make out the vesicles at all. He had almost total retention of urine. I had him try to urinate, and the best he could do was about two or three drachms. I tried to relieve this man by catheterization, and after a long time succeeded, and after working with him several days I decided the only thing was to drain his bladder, which I did. I succeeded all right, and got his bladder condition and posterior condition under good control. He finally got well and went home, and a short time ago he reported to me that during intercourse he was unable to have ejaculation. I examined him carefully, and found the vesicle in a state of chronic inflammation. I have stripped the vesicles and massaged the prostate very thoroughly,

and the secretion that he passes is comparatively clear. I forgot to say that these ducts were patulous.

DR. J. N. RICKETTS: This is exceedingly interesting, and while my experience has not been so great in massaging vesicles, I have had three or four cases bearing upon the subject which might be of interest. I had one several years ago where an abscess ruptured into the rectum. Whether it was an independent abscess or not, I am unable to say, but in each of the three cases I had spermatozoa in the secretions from the rectum. That was a very interesting pathologlical condition to me, and I am sorry I was unable to determine what conditions existed before.

The case reported by the gentleman just now as want of ejaculation, I think there is no question about ejaculation, which was probably returned to the bladder and escaped with the urine, and so overlooked; otherwise the spermatozoa in the secretions would be found. I am glad to hear him report the case, because I have heard of other such cases, and I think that the ejaculation occurs backward, and the secretion becomes mixed with the urine.

DR. WM. A. ENGELBACH, St. Louis: I am especially interested in this paper from the standpoint of diagnosis. Three very interesting cases have been nunder my observation this year which have been misdiagnosed. One of these cases had been operated on for appendicitis, and the appendix removed, but with no result. Another had been referred to St. Louis for operation upon the appendix, and another had been diagnosed kidney disease. In the two cases which were mistaken for appendicitis, the mistake was allowable, because the cases presented a likeness. There was pain, tenderness, fever; and without an examination of the urine one could very easily support that diagnosis. These were both cases of chronic vesiculitis, and in the interval, according to the history, they had no symptoms at all, and that is one point I would like to know about. They would be apparently comfortable in every way, no sexual symptoms at all, when they would have sudden paroxysms of pain, which was a symptom of appendicitis. In both of these cases it was impossible to make out the seminal vesicles, but I found it an advantage, however, to have the patient in a lying position on his abdomen, and it seems to me that will present the vesicles back near the rectum better than to have him in a stooping position.

Any diagnosis whatever, as far as I am concerned, must be strengthened in some other way, and we have to differentiate this from the other conditions, such as calculi of the urethra and kidney disease; but in order to do that we have found it almost necessary to make a complete urethral examination. If we find everything negative, then we know that the trouble comes from the ejaculatory duct, because that is the only other one that empties into the bladder, consequently the prostate is usually excluded in local examination; and then, by making an exclusion of the seminal vesicles, the only thing left, you can prove pretty positively what is the matter.

In one of these cases the patient passed almost pure blood for a long time, and in another case he

had these sudden pains at intervals.

DR. CURRAN POPE: I trust you will allow me to say a few words. I have been making a special study of this for six or seven years, and have made a careful tabulation of cases and symptoms I have run across. One of these is a peculiar vasomotor state in which the body will remain stretched rigid if you will run your finger over the skin very lightly. This is frequently followed by profuse sweating. This will disappear very promptly upon treatment.

There is also a symptom that I call footache, or foot burning-that is, the patient complains of considerable aching of the feet, and also a burning or warmth in the soles of the feet, and very frequently the massage or stripping of the prostate will aggravate or increase these symptoms.

The other thing I have observed is what I call a cephalic gap. They feel like they had a large gap in the back of the head. This has occurred in quite a large percentage of cases that have presented themselves to me, and it is curious how quickly the symptoms will be aggravated by manipulations of the vesicles or prostate.

Another condition I have found has been the aggravation of neurasthenic conditions by the presence of prostatic or vesicular inflammation. I hope very shortly to be able to publish the studies I have made in some 250 cases of the disease we have been talking about.

DR. BAUGH MAN (closing): I want to thank you for the discussion of the paper, and I was very much gratified to hear Dr. Pope's experience in regard to this gap feeling. I have noticed that in a number of cases in the past. When they have been sitting down, talking to me in the office, they would keep their hand on their head, and especially have I noticed that after I would strip the vesicles.

Now, we must, of course, eliminate a good deal in making a diagnosis of vesiculitis. If I make a thorough examination and find there is no cystitiswhich I can do by taking two or three glasses and passing the urine through them, as you all understand how to do I can nine times out of ten exclude the bladder. It is very hard to tell whether we have vesiculitis or prostatitis and my experience is that where we have one we have more or less of the other through sympathy, if no other way, and where we have had a deep or posterior urethritis at any previous time, and have considerable trouble in the region of the prostate, and inflammatory trouble, we want to suspect that it is the vesicles that are at fault.

But the main point I want to impress in my paper is the manner of making an examination. I have reasonably long fingers, but I have always failed unless I had a pretty thoroughly distended bladder. That presses the vesicles down until, when we become thoroughly acquainted with the feel-we must train our fingers to that-with the patient in this leapfrog or bent over position, and with a brace on your knee, by slow pressure and having your fingers well lubricated, you can nearly always be successful. In acute cases I have never tried it, for the patient just simply could not stand it, and I think it would do more harm than good; but in chronic cases I have found it, as I said awhile ago, the siege gun in the battle.

A CASE OF AMEBIASIS.*

BY LOUIS J. KROUSE, M.D.,

CINCINNATI.

Mr. H., aged twenty-eight, five feet eleven inches tall and weighing 180 pounds, of large frame, has been suffering for over eight years from chronic diarrhea, with muco-sanguineous discharges. He says that it first made its appearance in the fall of the year, while he was living in the South and eating a good deal of raw fruit; and began with pain, diarrhea and bleeding, and lasted only one month. He soon recovered from this attack, and enjoyed good health until the fall of the following year, when he had a similar attack, which lasted also for one month. From the second attack he also recovered, and felt well for one year, when he experienced his third attack, which lasted longer than the two previous spells, and from which time the blood and mucus has been constantly present in his stools. The diarrhea has kept up all these years. For months he would have from eight to ten stools or more a day, and then the movements would diminish in number to one or two a day. This has been going on for all these years. At the present time the movements occur twice a day, but they all contain more or less mucus mixed with blood. Says that he has been treated locally for the trouble several times, always with marked benefit. About one year ago he complained of pain in the lower bowels, accompanied by the above-mentioned diarrhea, which brought him to the care of a physician who advised an operation for its cure. The patient was operated upon and the ulcers were cauterized. What the character of the operation was, he was unable to state. Notwithstanding the operation and the cauterization of the ulcers, necessitating his staying in the hospital over three weeks, no benefit accrued from the treat

ment.

On October 30, 1909, he presented himself at the office. On digital examination it was noticed that the anal orifice was very sensitive to the touch, and the examining finger was tightly grasped by the sphincter muscles. As the finger entered the rectum it encountered a sharp band of cicatricial tissue at the junction of the skin and mucous membrane, where the pouches of Morgagni are situated, which band constricted the anal outlet. Nothing else of importance was noticed. On withdrawal of the finger it was noticed that the receding finger was covered with muco-sanguineous discharge.

The introduction of the proctoscope produced some pain, notwithstanding that the parts were well anointed with vaseline impregnated with cocaine. The instrument entered the anal canal readily, and followed the course of the rectum to the sigmoid junction. The removal of the stylet of the instrument was followed by the discharge of a mucosanguineous fluid. Visual inspection revealed the

* Reported to the Academy of Medicine of Cincinnati, November 29, 1909.

lower rectum to be empty of fecal matter; that the mucous membrane was pale in color, soggy and swollen; that the surface was marked with numerous small ecchymoses and ulcers; and that the entire inner lining appeared as if it was covered with a fine jelly-like coating.

The lumen of the gut was open and its caliber was not encroached upon. The gut resembled more a solid tube than a living membranous canal. The valves of Houston were decidedly thickened, their pliability greatly impaired. The whole mucous membrane, as far as could be seen, was of this character; not a single portion was normal in appearance.

We could only judge of the thickness of the gut by the appearance of the valves of Houston, which were enormously hypertrophied, and protruded into the lumen of the gut like stiff fibrous shelves. These valves were not pliable, and did not allow of their sagging whenever a fecal mass passed, but seemed to be fixed and to protrude into the lumen so as to interfere with the free movements of the alvine contents. These valves were pale in color, non-glistening and soggy in appearance; their exposed surfaces were studded with numerous small ecchymoses and ulcers, whose size ranged from a pin's head to that of a small pea. These ulcers and ecchymoses were not confined to the valves alone, but were also disseminated on the walls of the rectum.

A microscopical examination of the fecal discharges disclosed the presence of the ameba dysenterica.

As the ameba lives in the submucous coat of the large intestine, destruction of the overlying mucous membrane usually takes place. Often the area of destruction is large, and enormous ulcers are frequently encountered. The destruction of the mucous membrane, combined with the inflammation of the mucous layer, is the cause of the muco-sanguineous discharge.

The treatment of these cases consists in destroying the ameba. This can be best accomplished by irrigating the entire colon and rectum. Two methods can be used-high irrigation through the rectum, by introducing the nozzle of a syringe into the anus and flushing out the entire colon and rectum; or, what is much better, making an appendicostomy or a cecostomy, and through the artificial openings thus made flush out the entire diseased area. A combination of these two methods is frequently employed. A couple of gallons of fluid are used twice or oftener daily. This method of treatment must be carried out by the patient for months before a cure can be accomplished; and the artificial opening in the cecum or in the appendix ought not to be allowed to close before the lapse of one year.

In our case we proposed to do a cecostomy, and then, through the artificial anus thus formed, flush out the entire colon from the cecum to the anus. As the patient could not afford at the present time to go to bed, we were compelled to give high enemata in order to irrigate the diseased area. The

fluid contained formaline, one drachm to the quart. So far the result of the treatment has been very satisfactory. The patient has expressed himself as feeling much better; the character of the discharges has improved, and the movements of the bowels are less numerous. Besides the irrigation, we have applied a solution of nitrate of silver locally to the ulThe amebæ are still found in the discharges.

Correspondence.

"THE BATTLE CREEK IDEA."

BUFFALO, N. Y., March 10, 1910.

EDITOR LANCET-CLINIC:

My letter under the above heading, which appeared in your issue of February 12, attracted the attention of Professor Irving Fisher, an able Yale mathematician, who wrote to the Franco-American Ferment Company, of New York, to enquire if my allegations were correct, and, if so, upon what they were based. I asserted, and still assert, that "yogurt," sold by the Good Health Publishing Co., is not the product recommended by Professor Metchnikoff; it does not contain the germ of Metchnikoff; the use of Professor Metchnikoff's name by anybody at Battle Creek is unauthorized by the head of the Pasteur Institute.

The general manager of the Franco-American Ferment Company has answered Prof. Fisher's letter, and has given me permission to quote from his communication. He has informed Prof. Fisher that capable bacteriologists have examined "yogurt" several times without finding pure culture of any bacilli or bacteria of any kind. "There was no evidence of the presence of the bacillus Bulgaricus on any of the (five) plates prepared," says the report of one bacteriologist.

Some months ago, through Mr. Franklin Bien, a New York attorney, Professor Metchnikoff demanded that the Battle Creek people cease using his name, portrait and writings to advertise their "yogurt." This they promised to do, after legal proceedings had been threatened. (Within a short time Professor Metchnikoff will be in a position to judge of the extent to which they have kept their promise.)

The following sentence is quoted verbatim from the letter of the general manager of the FrancoAmerican Ferment Company to Professor Fisher: "The use of Professor Metchnikoff's name in connection with such a bacteriological product as this ('yogurt'), is an absolute imposition, and the sale of such a product in connection with the name of Professor Metchnikoff is nothing more or less than obtaining money under false pretenses. You are at liberty to show this letter to the Good Health Publishing Co. or Dr. Kellogg. We are responsi

ble for all statements made here, and will stand by them."

Somebody at Battle Creek appears to have told Professor Fisher that some ferment was given to some Battle Creek man when that person visited Metchnikoff's laboratory in Paris, but the somebody referred to omitted to mention that this ferment was given without Metchnikoff's knowledge or consent, and that during last summer the Battle Creek people escaped legal proceedings by undertaking to discontinue all reference to the Pasteur Institute and Profesor Metchnikoff. The probability is that without such references their "yogurt" would never have had any considerable sale, but the elimination of these references after the country has been flooded with their leaflets, is not likely to stop its sale, especially when it is advertised to cure or relieve no less than eighteen diseases or symptoms of disease, ranging from appendicitis and typhoid (diseases) to dropsy and insomnia (symptoms).

Prior to making an investigation a short time. ago, I supposed that the methods of the Battle Creek Sanitarium were above suspicion. There is no doubt that many persons have derived great benefit from their visits to it. The same remark, however, is applicable to certain patent medicine hospitals. The process by which the Battle Creek institution entices sick persons to its premises is on a par with that adopted by the last-named places. I append two excerpts from Battle creek "followup" letters, which speak for themselves

(July 13, 1909.) "We are sending back to their homes every month, scores of men and women, who, though many were pronounced incurable before they came to us, are now in the enjoyment of excellent health.” excellent health." It does not require any legal astuteness to see that the object of this sentence is to mislead. "Pronounced incurable" by whom? Obviously everybody who does not die at Battle Creek is sent back to his or her home.

(August 25.) "A million people die in the United States every year, of whom at least four-fifths could be saved by the physiologic methods of the Battle Creek Sanitarium." This, no doubt, will appeal to persons who are suffering seriously, but its untruth is beyond dispute, and the use of such a device to lure the unwary is most objectionable and discreditable.

Good Health is a monthly magazine edited by Dr. J. H. Kellogg. It often contains articles that are helpful and practical. It is, nevertheless, a "crank" and "fad" publication, which gives the impression that the consumption of flesh foods is always injurious, and that half the population of the United States is suffering from auto-intoxication. "Healthful Living" is a booklet published by the Kellogg Food Company, which "has been organized and incorporated to manufacture and sell Dr. Kellogg's food products made after original and perfected formulæ."