of all urinary troubles within four months after the operation. We must remember that this was the feeble class. They had lost their grip, and had given up the fight.

The per cent of cures within one month after the operation, mortality and postoperative troubles, in this group, based upon the thirty cases treated, is as follows:

Cured, ten per cent; perineal fistulæ, six and two-thirds per cent; enuresis, three and one-third per cent; dysuria, three and one-third per cent; died, three and onethird per cent.

Of the ten in the incapacitated group of the first general class, there was not a wide range in their disability. They were incapacitated for business and pleasure by reason of the frequent necessity for passing urine, or using the catheter. Four of this group had never used the catheter, but were compelled, during the day, to use the urinal every hour, and at times more frequently. The six who were using the catheter could not tell when they would have to use it-sometimes once an hour, and sometimes the interval would be longer. The sensation of wanting to urinate, and a dribbling of urine, would come at the same time, thus compelling them to wear something either to absorb or to catch the urine that escaped before they could use the catheter. Each one of the six gave histories of cystitis, from one to five attacks, which had been relieved for the time. They had led catheter lives from two to five years. Each had residual urine from three to six ounces. None of this whole group of ten were septic when presented for operation. The oldest of this group was eighty-two, and the youngest fifty-five years. Perineal prostatectomy was done in each case. Results of the operation in these ten cases were: Nine were cured of all urinary troubles within one month; one had a perineal fistula for two months after the operation. The per cent of cures within one month after the operation, and postoperative troubles lasting longer than a month after the operation in this group, based upon the thirty cases operated upon, is as follows:

Cured, thirty per cent; perineal fistulæ, three and one-third per cent.

The histories of the partially incapacitated group, of the first general class, are about as follows: Ages, from sixty-two to sixty-eight years. For a number of years all had dysuria-more or less severe-not, sufficient, however, to cause any alarm, or to arouse any suspicion other than that they were growing older, and they attributed their trouble to that. This is the history of most prostatics. Each of the four gave a history of exposure to wet or cold, which was followed by complete urinary stoppage. A physician was called, passed the catheter and relieved the patient. After this followed catheter life for from one month to ten weeks. After one month one of the group could pass his urine quite well, and the other three at different times during the ten weeks. These patients had now intervals of from six weeks to four months before the trouble returned, and catheter life again commenced. During these intervals these patients attended to their duties as usual. They had led this interrupted catheter life for from two to four years when they were operated upon. They were all in good condition, none of them having had cystitis, and none of them were septic. Each one had from three to five ounces residual urine. Perineal prostatectomy was done in each case.

Results of the operations: Three were cured of all urinary troubles within one month. The fourth was operated upon February 13, 1905, and has been troubled with enuresis to the present time, July 9, 1905, but is nearly well. This patient remained in the hospital three weeks and made a very favorable progress, nearly all of the urine passing through the natural channel. I dressed the case at his home twice the next, or fourth week, and advised him to come to the office for further dressings. He came once, but did not return. After two or three weeks I dropped him a note asking him to come in, as I wanted to know how he was getting along. On examination I found an abscess had formed, deep in the perineal wound. This I opened. It discharged an ounce of pus. This was treated and it promptly healed up, also the perineal fistula, but enuresis continued, as above stated. I believe the abscess was the

cause of the long-continued enuresis in this case.

The per cent of the cures within one month, and post-operative troubles lasting

Fig. 3. Half size.

longer than a month in this group, based upon the thirty cases operated upon, is as follows:

Cures, ten per cent; enuresis, three and one-third per cent.

Taking up now the second general class, or that class of cases due to hypertrophy of the muscular and fibrous tissues, and subdividing this class, as we did the preceding, into the feeble, incapacitated, and partially incapacitated, we have, in this general class of six cases, one feeble, three incapacitated, and two partially incapacitated.

The only feeble one in this class was seventy-one years old; catheter life seven years constantly, and two years interruptedly; history of repeated attacks of cystitis; almost constant enuresis; septic condition of bladder marked; patient could only walk a few steps without resting; patient was put to bed, bladder constantly drained by means of residual catheter. Passing the catheter in this case caused great distress, and produced much irritation of the prostatic urethra, hence we used the residual catheter, which did not irritate or cause suffering. The bladder was washed three times daily with a solution of permanganate of potash. Water was given freely, also milk. This treatment was continued for seventeen days, when perineal prostatectomy was done. The gland shown in Figure 4 was taken from this case. Result: The patient made a good recovery, with the exception of a perineal fistula, which continued two months after the operation. The per cent of post-operative troubles, lasting longer than a month,

based upon the thirty cases treated, is as follows:

Perineal fistulæ, three and one-third per

cent.

Of the three incapacitated, of this general group, each had been leading catheter lives from three to five years. Their ages were, respectively, fifty-six, sixtytwo, and sixty-seven years. Each had residual urine, from three to four ounces. Frequent catheterization characterized each case. Each gave a history of several attacks of cystitis, which had been temporarily relieved. None of them were septic when presented for operation. Perineal prostatectomy was done in each case, with the following result:

All recovered within one month, having perfect control of urinary apparatus. Per cent of cures within one month in this group, based upon the thirty cases treated, is as follows:

Cures, ten per cent.

Of the partially incapacitated group, in this general class of six cases, there were two cases. Each was sixty years old. Each gave a history of dysuria for several years, then complete stoppage of the urinary flow, following exposure to cold. Relief was gained by the use of the catheter. Interrupted catheter life followed for two and three years, respectively. During the periods of catheter life there was tenesmus, sometimes of the rectum, and often of the bladder. These patients were incapacitated during the periods of catheter life. There was three and four ounces residual urine, respectively. Perineal prostatectomy was done in each case, with the following results: Complete relief from all urinary troubles within one

Of the third general class, in which there is hypertrophy of the fibrous tissue alone, there were two cases. Making the subdivisions of this class, we have made of the other classes, into feeble, incapacitated, and partially incapacitated, these two cases belong to the incapacitated group: Their ages were, respectively, sixty-three and sixty-five years. Each gave a history of cystitis which had been relieved temporarily. Each had three ounces residual urine, and tenesmus of bladder and rectum much of the time, for which both were using opium suppositories. Micturition, painful and frequent in each case. Bladders were not septic when presented for operation. Perineal prostatectomy was done in each case, with the following results: Both cases were cured within one month. The per cent of cures in this group, based upon the thirty cases treated, is as follows:

Cured, six and two-thirds per cent.

Of these thirty cases, the following summing up is of interest. Twenty-two, or seventy-three and one-third per cent of these cases, belonged to the class of large, soft prostates. There were in this class one death, or three and one-third per cent, of the thirty cases treated. There were six cases of post-operative troubles, lasting more than one month, or twenty per cent of the thirty cases treated.

Six, or twenty per cent, of the thirty cases treated, belonged to the second general class, or to that class in which there is hypertrophy of the muscular and fibrous tissues. In this class there was one case, or three and one-third per cent of the thirty cases treated, that had post-operative troubles lasting more than one month. Two cases, or six and two-thirds per cent, of the thirty cases treated, belonged to the third general class, in which the fibrous tissue alone hypertrophies. There were no post-operative troubles in this class.

These figures show that in these thirty cases there was not quite three times as many cases in the first general class, or group, of large, soft prostates, as were in the other two general classes, but that the per cent of mortality and post-operative troubles, lasting more than a month in this class, was seven times greater than in the other two classes combined.

These figures show that of these thirty cases operated upon, nine, or thirty per cent, of them belong to the feeble class, and that of these nine, one died, or three and one-third per cent of the thirty cases treated; and five, or sixteen and twothirds per cent, of the thirty treated had post-operative troubles, lasting longer than one month, placing twenty per cent of the thirty treated, who died or had post-operative troubles, in the feeble class. In the other two classes of incapacitated, and partially incapacitated, there were twenty-one cases, or seventy per cent of the thirty cases treated, with no mortality and only two cases, or six and two-thirds per cent of the thirty cases treated, that had post-operative trouble lasting longer than a month.

Fig. 5. Two-thirds size. Another estimate with these figures gives us the following:

Of these thirty cases treated, there were nine feeble, one of whom died, or eleven and nine-tenths per cent. Five of the nine had post-operative troubles, lasting longer than a month, or fifty-five and five-ninths per cent. There were twenty-one cases in the other two classes of incapacitated and partially incapacitated. Two of them had post-operative troubles, or nine and onehalf per cent. In other words, there were not quite half as many cases in the feeble class as there were in the other two classes combined, but the per cent of mortality and post-operative troubles, lasting longer than a month, is more than seven times greater in the feeble class than in the other two classes combined.

Of these thirty cases, two, or six and two-thirds per cent, had enuresis. Three, or ten per cent, had perineal fistula. One, or three and one-third per cent, håd dysuria for more than one month after the

operation.

[Written for the MEDICAL BRIEF.] Asthma.

The final outcome of the thirty cases is as follows:

Died, three and one-third per cent; well within one month after the operation, seventy-three and one-third per cent; well within two months after the operation, ninety per cent; well within four months after the operation, ninety-three per cent; well within six months after the operation, ninety-six and two-thirds per cent.

The history of these thirty cases teach us several things:

First, that the hypertrophy of muscular tissue, together with over-cell growth, is the pathologic condition in a very great majority of troublesome hypertrophied prostates. That in this class we should expect the largest per cent of post-operative enuresis, for the reason that in this class the prostate is much larger and heavier, and produces the greatest amount of damage to the musculature and nerve supply of the bladder wall, prior to its removal, tending to prove that post-operative enuresis is due to damage done by the prostate during its diseased condition in the body, and not to damage done the tissues during the operation.

Second, that while the per cent of mortality and post-operative troubles are high, in the feeble class, they are not so high as to deter us. While the mortality of the feeble in this group of thirty cases shows a mortality of nearly twelve per cent (which we have, perhaps, wrongfully charged to the operation), there would have been one hundred per cent of mortality due to the disease without the operation.

Third, that if patients are to reap the best results, with the least possible risk, they must seek the operation before they reach the feeble class. Hence, the necessity of the family physician, who sees these cases first, advising the operation before catheter life is commenced; for after that it will not be accepted in most cases until it fails, at which time many of these will have entered the feeble class.

Fourth, that the per cent of cases in the third general class, or small prostates, due to hypertrophy of fibrous tissue, is very small. From this class we expect most post-operative troubles, due to traumatism and hemorrhage at the time of the operation.

4625 Greenwood Avenue.

BY J. H. JERGESEN, M. D.

Milwaukee, Wis.

[No. III.]

Hay fever, or hay asthma, as it is often called, is purely a neurotic affection and the seat of trouble is strongly suspicioned to be in Meckel's ganglia; and probably, in some individuals, the olfactory are involved; for example, in such cases where the odor of roses and new-mown hay brings on an attack. I said that there is a strong suspicion that hay fever is caused through an irritation of Meckel's ganglion. This interesting organ, we know, lies in the spheno-maxillary fossa, at the outerside of the spheno-palatine foramen, and in front of the anterior end of the Vidian canal.

It may not be necessary to say any more about these nerves but for a few whose Gray or Morris occupies a place of prominence on the top shelf. Which reminds me of an old woman who was visited by her pastor. She answered his admonishment to study the Bible, that she had lost her spectacles five years ago and was too poor to buy new ones. When the pastor reached for the Bible it was covered by a half inch of dust and when it was opened, lo and behold, there he found her old glasses! For the benefit of such isolated cases we shall append our reflexion in connection with the formation, anatomy and distribution of the nerves connected with Meckel's ganglia, as being a probable factor in hay-fever.

The ganglion receives its motor fibers from the Vidian nerve, and its sensory fibers from the maxillary nerve. Its sympathetic root is the great, deep petrosal portion of the Vidian, also, while the motor root comes from the great superficial petrosal, which also is incorporated in the Vidian nerve, and has its origin in the geniculated ganglion of the seventh The sensory root, as stated, is a filament from the second branch of the fifth (maxillary). The sympathetic has its origin in the carotid plexus, it unites with the great superficial petrosal, being a branch of the seventh to form the Vi

nerve.

dian nerve. The seventh nerve, we know, gives a branch to the vagus, and the vagus, as we know, has its origin in, and is intimately connected with, the respiratory centers at the bottom of the fourth ventricle in the medulla oblongata.

St. John Brooks and Arthur Robinson hold that Meckel's ganglia, together with its four associates-cilliary, spheno-maxillary, otic, and sub-maxillary-are vagrants which have separated from the Gasserian ganglia at an early period of development, associated, as they are, with the fifth nerve. This may be so. Certain it is that all are more or less affected in hay-fever. The branches of Meckel's ganglia are ten or eleven in number, and supply the nasal cavity, the pharynx, soft and hard palates; it anastomoses with the olfactory nerves in the superior turbinate region, and with the nasal in the inferior turbinate region. Practically all of the parts supplied by the nerves given off from Meckel's ganglia are involved in an attack of hay-fever.

Reading about hay-fever, one invariably encounters such statements: Hay fever is caused by the pollen being inhaled. In what manner can pollen produce hay fever? asks another; now that the pollen is with us, hay fever is also, etc.

I, for my own part, do not see my way clear to implicate the pollen in the crime any more than I can the roses. Odor from fried pork, odor from new-mown hay, the glare of the mid-day sun, arc-light glare, change of air from hot to cold or reversed, cold night air after a warm, bright day; even an approaching thunder storm is, in many individuals, a certain factor. We know hay fever consists in a burning sensation in the mucous membranes of the nose, pharynx, fauces, hard and soft palate, and conjunctiva of the eyes. The outward symptoms are: Lachrymation, red and swollen eyes, coryza, and sneezing, sneezing and sneezing without end.

Every individual has his own idiosyncrasy as to which of the numerous causes will produce an attack in them. Hay fever, as all other neurotic conditions, are of a progressive nature, and may, if they are let alone, assume an enormous possibility.

I was called to see a patient suffering from hay fever for eighteen years. It

I

was a bright summer day in August. found him in the cellar, blowing his nose for all he was worth. I sprayed his nose with a two per cent cocaine solution and put a few drops in each eye. The paroxysm soon ceased, when he told the following story:

"I had my first attack when I was about eight or nine years old; I was attacked while playing in some new-mown hay. My first attack was a severe one, but it only lasted about half an hour, and it was the only attack I had that year. The following year I had many fits of the same kind. And every year since that I have suffered in the same degree, only one year is a little worse than the other. At the age of eighteen I had my first attack of spasmodic asthma, and now I must fight against hay fever in daytime so as not to suffer from asthma at night; then, as sure as I succumb to the day attack I will surely wake up with asthma in the night.

"Three or four weeks, generally the last week in July, and three first weeks in August are spent in sneezing and fighting sneezing from nine to ten in the morning until four or five in the afternoon. Does the sneezing once get the best of me then I am lost for the day and the night, also, for surely I will wake up in the night with asthma; but am I able to overcome the tendency to sneeze I may within an hour be able to give my attention to other things and have a good night's sleep the following night. The most prominent symptoms are itching; itching in the nose, itching in the throat, itching of the soft palate, of the hard palate, of the chin, down the spine-itching, itching everything. The sensations are, as before said, itching, but if not relieved by sneezing, coryza and lachrymation, the sensation is as if red pepper had come in contact with the membranes mentioned.

"To fight off an attack it is necessary to be on my guard from early morning, especially if it is a bright day. As soon as I feel the first tingle in my nose I get out my handkerchief and begin blowing my nose, while I am making for this dark room. Here in this dark room I sit with my eyes closed, pinching my nose and blowing all the while and with all my force; if I can continue this desperate blowing without interruption, in the