3k*& ^j^i».tv.^>^fifci ewuALauf Bf; ■ DISEASES OF THE GENITO-UBINABY ORGANS. / ALBAN GOLDSMITH, M. D., tT LATS PROFESSOR OF SURGERY IN THE MEDICAL COLLEOB OF OHIO, AND TH» COLLEGE OF PHYSICIANS AND SURGEONS OF NEW YORK. NE W: YORK: WILEY & HALSTED, 351 BROADWAY. 1857. f-'l^ -??fc/ J+L,,*, y Entered according to Act of Congress, in the year 1857, by % ALBAN GOLDSMITH, M. D., In the Clerk's Office of the District Court for the Southern District of New York. American Steam Printing Housk. 22 and 24 Frankfort St., N. Y. INTRODUCTION. I have been so often solicited to publish the results of my experience in diseases of the Genito-urinary Organs, that I have concluded to put forth this little volume, as a beginning; simply detailing a few of the facts that have come under my observation, and the inferences that I have thought could be rationally drawn from them. There are many other diseases that I might have included in this volume, particularly syphilis, as it is a subject that has long engaged my attention, and I had collected a great many cases, with drawings, by which I hoped to show that the various forms which this disease assumes, are the result of peculiarities of constitution • but some of my best drawings have been lost. It would have been well, if I had the time, (which I have not,) to have given the opinions and practice of other surgeons on these subjects; but this was not my object: I merely wished to state what I have found to be true, so that those practitioners who have not had opportunities of experience, may have • INTRODUCTION. an easy reference. Another reason that would detei me from entering into the discussion of the various diseases of these organs is, that it has already been very ably done by Prof. Gross, who has published, in a systematic and connected form, a full and compre- hensive account of the diseases of the bladder, which does him great credit, and he has thus filled a void, the existence of which I, among others, had long regretted. I have not written this book either for profit or reputation, as I have lived long enough to know that they are both " bubbles," but mainly, for reasons before stated, and also, so far as I can, to exemplify the truth of that great idea of Abernethy, "that local disease is dependent on constitutional irritation." A. G. CONTENTS. PAOB Prkface............................................... 3 Gonorrhoea.......................... g Local Disease............................................ g Symptoms............................................... 10 Pathology and Treatment.................................. 12 Extends to the Bladder.................................... 17 Swelled Testicle, or Bpididimitis............................. 22 Gonorrhoeal Rheumatism................................... 23 Popular Eemedies......................................... 25 Stricture op the Urethra..................................... 27 Spasmodic............................................... 33 Valvular................................................. 34 Indurated or Permanent Stricture............................ 36 Introduction of the Catheter................................ 40 Treatment of Stricture___•............. ....... .......... 45 • CONTENTS. PAGE . 59 Fistula in the Perineum.................................. Lithotripsy, or the Breaking of Stone in the Bladder........... 66 Cases illustrating the application of Lithotripsy................ ?5 84 Seminal Weakness........................................... Causes.................................................. Treatment................................................ 90 ILLUSTRATIONS. lithographs Plate 1—Bridle Stricture...................................... 34 Plate 2—Tabular Stricture.................................... 34 Plate 3, Fig. 1—Indurated Stricture............................. 36 Plate 3, Fig. 2—Indurated Stricture............................. 36 Plate 4—Stone in the Neck of the Bladder........................ 36 WOOD CUTS. Form of Catheters and Bougies..............................»... 38 Distention of the Bladder, &c.................................... 44 Civiale's Instrument........................................... 71 Jacobson's Instrument......................................... 72 Heurteloup's Instrument....................................... 73 G ONOEEHCEA. The question has often been asked : " What is Gonor rhcea ? Is it a disease that arises from contact with a specific virus, as in Syphilis, Small-pox, &c. ; or, is it a simple inflam- mation of the mucus membrane of the urethra, arising from contact with ichorous or irritating matter coming from the vagina or uterus, the result of deranged or vitiated secre- tion or excretion ?" Our answer to this question is, that a disease does sometimes arise (having all the characteristics of Gonorrhoea), from coition with females, where there is no ground for suspicion, and where, upon examination of the vagina, you cannot discover any symptoms of the disease. On the other side, it may be said that if this disease can be contracted from causes not specific in their character, why is it not more common in married persons?—for a vast number of all classes of females females are subject to morbid secretions in the vagina. The force of this argument I cannot deny. Yet I must say, (and I would not say it, if long experience did not justify me,) that a man should not be convicted of infidelity to his wife from the simple circum- stance of having a muco-purulent discharge from the urethra. I have, therefore, been in the habit of treating this malady as a LOCAL DISEASE. It has been argued with some plausibility that patients having Gonorrhoea are often attacked, during its progress, 2 10 GONORRHOEA. with inflammation of the joints, and what is called Gonor- rhoeal Ophthalmia: but, after observing many cases of this kind, I have come to the conclusion that these swellings of the joints and affections of the eye occur in persons who are constitutionally or incidentally pre-disposed to Rheumatism. In this view, I find, I am sustained by a gentleman of large experience in these diseases—Mr. Lawrence, formerly of St. Bartholomew's, London, who says: " It has appeared to us that the tendency to Gonorrhoeal Ophthalmia, as well as Gonor- rhceal Rheumatism, prevails in certain families. We are in the habit of attending two brothers, each of whom has had these two diseases, separately and conjointly, several times. It has also appeared to us that persons, prone to Rheumatism, independently of Gonorrhoea, are more prone to Rheumatism with Gonorrhoea than others are." It may be asked, how is the disease transmitted from the mucus membrane of the urethra to the eye and to the syno- vial membrane of the joints ? That can only be accounted for upon the principle that certain diseases are prone to pervade certain analogous tissues. SYMPTOMS. There is only one constant symptom in Gonorrhoea, and that is a discharge of muco-purulent matter. The next most common symptom is, more or less, pain in urinating, which is often attended with soreness of the urethra, chordee, sometimes inflammation and swelling of the penis, with constant desire to urinate—all these symptoms varying, according to the constitution and condition of the patient. When the inflam- mation extends to the bladder, there is pain over the pubis, with increased frequency of the desire to urinate. Swelling of the testicle is also a common occurrence, and is generally GONORRHOEA. -q supposed to arise from the disease extending along the semi- nal ducts. Hence, we find, the epididimus becomes affected first, and as the disease is mostly confined to that organ, it is generally called Epididimitis. In fact, the great variety of symptoms and forms that Gonorrhoea assumes, according to the condition, or constitution, of the patient, has been offered as an argument against the specific character of the disease. I think we may almost say that there would be no disease, if there was no imperfect development, no mal-formation, no vitiation in the secretions and the excretions. Persons have frequently called on me for treatment who have expressed great surprise that they should have contracted the disease, for, say they, we have been in the habit of cohabiting promis- cuously, for many years, and frequently with those from whom others have contracted disease, yet, until now, we have always escaped. Three students, on the evening of their arrival in the city, had connection with the same female. One contracted Syphilis, with a Hunterian chancre; one contracted Gonor- rhoea; the other escaped all disease. To show with what facility some constitutions throw off disease, I know a person who has had chancres twenty times ; he never would use any other remedy than a simple wash of nitrate of silver, which generally healed the sore in a few days ; he has escaped all constitutional symptoms ; he has reformed his habits, and is now a very healthy man, sixty-five years of age. Yet how much misery, sickness, and death has one chancre caused in generations of families! Health and beauty is the result of perfect development; sickness, and deformity, and early death, of imperfect development and vitiation. The nearer the approach to healthy action, the less liability to disease. How many of us have traversed hospitals for months, where the atmosphere was loaded with the seeds of 12 GONORRHOEA. disease, and have escaped ; but sometimes one of us, who has the soil in which the seed will grow, becomes a victim. For the purpose of explaining my views of the PATHOLOGY AND TREATMENT Of the disease called Gonorrhoea, it will be necessary to give cases, showing the various forms the disease assumes, and the particular treatment that is adapted to these varieties. First, we will endeavor to describe the disease, as it often occurs in well-developed individuals, whose general health is unimpaired. A. man, aged thirty-six, with a well-formed, broad chest, limbs tapering, small extremities, tongue clean, bowels regu- lar, habits temperate, called on me, with a yellow and free discharge from the urethra, with some pain in urinating: he had first discovered it the day before, three days after cohabiting. Injected his urethra with a solution of nitrate of silver, thirty grains to the ounce of water, directed him to eat but little, drink freely of parsley-root tea, and take a gentle cathartic at bed-time. The next day he informed me that the injection had been painful ; the discharge had been very free, somewhat bloody. His medicine operated, but now he had very little discharge. Injected a little cold water next day, he was well, and continued so. I could give a great many such cases as this to illustrate the idea that I wish to inculcate, which is, that when the general health of the patient is good, the secretions and ex- cretions unimpaired, nature requires but little aid to enable her to throw off the disease. In order to change the local action, use the injection of nitrate of silver, pretty strong. All we know of this remedy is, that it seems to set up a new ac- tion in the part, that nature can overcome more easily than GONORRHOEA. jp the original action ; it is called an alterative ; like most other medicine, we use it empirically, and experience has taught us its value. Then, for the purpose of diluting the urine, and rendering it less irritating, we give such remedies as increase it in quantity, for urine is always irritating to diseased surfaces; and for this purpose I have used for many years the parsley-root tea, and frequently old patients tell me that that they have relieved themselves with the use of cold-water injections and this tea only ; but this is always a dangerous confidence, and no one can tell what character the disease will assume, for it often happens that cases that promise easy cure, are very protracted and difficult to manage, as the following case will show : A gentleman, well formed, whose habits were not intern. perate, whose occupation required him to walk a great deal; his tongue was slightly furred, his general health was appa- rently good, he had contracted Gonorrhoea about four months before he came to me, and had treated himself, as he had often done before, with injections and balsam copaiba. The dis- charge was not very copious, nor high-colored. I treated him with injections and alterative cathartics, and diluent drinks, but he was not relieved. Upon examining the stream, I found it rather small. I found, too, that he was somewhat troubled with haemorrhoids. By the introduction of the large bougie with cold-water enema every day, he got well, but the case was very protracted. Now, in this case, for the want of adapting the remedies to the case, it continued until the disease extended along the whole of the urethra, the mucus membrane had become indurated—a state of things I often find in protracted cases ; hence the necessity of dilating the urethra, to stimulate the absorbents to take up their depositions of coagulable lymph. It is sometimes the case, when persons are troubled with 14 GONORRHOEA. haemorrhoids, there seems to be some connection between this affection and the running from the urethra, and I have found that cold-water injections, taken at the time of the fcecal discharge, with astringents applied to the part, have very much aided me in the cure of Gonorrhoea. Another kind of case frequently occurs, where persons have contracted disease in miasmatic regions, and it is appa- rently kept up by a vitiated condition of the system. A man, about forty years of age, well formed, was born at the North, but had been living in an unhealthy region at the South, where he had several attacks of intermittent fever. He had contracted Gonorrhoea about a year before he called on me ; his tongue was furred, his skin yellow, his bowels irregu- lar ; the discharge was pretty copious ; it had, once or twice, nearly ceased; he had used all the usual remedies; latterly he had been drinking gin, having been told that it was good for the disease. Ordered him to take proto-chlo. mer. and jalap, each ten grains ; to drink freely of parsley-root tea ; avoid all stimulat- ing drinks. The next day he had several copious bilious evacuations. Injected into the urethra a strong solution of nitrate of silver ; directed him to take sarsaparilla and Fowler's solution of arsenic; continued weak injections; used gentle cathartics to keep the bowels regular, with the continued use of the diluents, and in about two weeks the skin began to get clear, the general health to improve, and the discharge soon ceased. Now, here is a case of what we call biliary derangement, with a pre-disposition to intermittent fever, which prevented the system from throwing off the disease, and the indications were, to remove this derangement of the general system, and to allow healthy action to be restored. GONORRHOEA. 15 A different state of things may be illustrated by the fol- owing case : A man, about thirty-five, from a country town, called on me, who had been troubled with Gonorrhoea for more than twelve months. He had tried Homoeopathy, Hydropathy, and Allopathy : still the discharge continued, and never ceased more than a day at a time. He was a very tall man, and very well developed ; he had lived very abstemiously; his general health had not suffered much ; he had been troubled in the early part of the disease with the swelled testicle, which had confined him to his bed about a month ; his tongue was furred and white ; the bowels irregular, the discharge was light- colored ; he had sometimes suffered pain after urinating ; the epididemus was still a little indurated. Ordered a mercurial cathartic, combined with quinine, two grains ; parsley-root tea as constant drink. The next day used an injection of strong nitrate of silver with a long tube, so as to reach the neck of the bladder. A considerable dis- charge of yellow matter followed this injection; continued the injections, but much weakened. I then ordered" him to take cold-water enemas, sarsaparilla, with generous diet; and after a few weeks the discharge ceased. The peculiarities about this case are, that he had suffered from swelled testicle, and that the disease had lingered about the neck of the bladder ; his system was considerably run down. It was necessary to apply an active remedy di- rectly to the part, as well as to improve the general health, by alteratives and generous diet. We have cases, sometimes, in which derangements of the kidneys interfere with the progress of cure, as in the following: A man, about forty, of small stature, but moderately well formed—a clerk by profession—called on me, with a dis- 16 GONORRHOEA. charge from the penis, who said that it could not be Gonor- rhoea, for he had not cohabited with but one woman, who was beyond suspicion; that he had slight runnings before, and they had always come from having connection with this person, soon after her menstrual periods had ceased, and this he attributed to the same cause, but it did not pass off, as it had on the previous occasion. He also informed me that some weeks since he had a violent pain in his back and loins, which lasted several hours, but it had passed off after taking a dose of oil. This was evidently produced by the passage of a calculi from the kidneys to the bladder; his tongue was somewhat furred, some pain in passing urine ; the discharge from the urethra was pretty copious ; he complained of occasional uneasiness in the region of the kidneys, the external meatus was red and inflamed. I directed him to take a mercurial cathartic, use freely diluent drinks, and take six five-grain pills of Castile soap every day, two at each meal; turpentine frictions to the back at night. This plan was continued with the injections for about two weeks, with but slight amendment, when he was again taken with violent pain in the back and loins, which soon subsided, after taking oli rici, one ounce ; spirits turpentine, one drachm. The same treatment was continued. In about two weeks, the uneasy sensation in the back and the discharge from the urethra subsided. It is a well-known fact that morbid action in one part of the urinary apparatus affects to some extent the other parts : hence, the presence of calculi in the kidneys was a source of irritation that extended itself to the urethra, which rendered the mucus membrane of the urethra not only more liable to become diseased, increasing its susceptibility, but rendered it much more difficult to restore healthy action ; but soon after the passage of a second calculi and the disappearance GONORRHOEA. -j* of the pain in the back, the disease gradually yielded to medical aid. I am frequently called upon to treat cases of what are called gleet, that seem to have arisen from diseased action in the kidneys, and in almost all the cases that come under my care for treatment of catarrh of the bladder, I find the kidneys more or less affected; and in the postmortem examinations that I have made of persons who have died of diseases of the urinary organs, I find the whole urinary ap- paratus more or less affected. I have one pathological specimen, where the pelvis of the left kidney is enlarged, and contains a number of calculi; the bladder is indurated, full of corrugations and sacs, with stricture of the urethra, and fistula. It came from a person who traced it to a Gonor- rhoea, which had never left him for twenty years before his death, and, to use his own words, he " had taken balsam enough to swim a ship." Sometimes Gonorrhoea extends to the BLADDER. The patient will complain of frequent desire to urinate, and pain immediately after the flow of urine, with a painful. uneasy sensation above the pubis. It generally comes on suddenly after exposure to cold or dampness. I have two cases under treatment now—one can be traced to exposure at a fire; the other to sleeping in a basement that was damp. Generally, when the bladder becomes affected, the discharge from the urethra ceases, but almost invariably returns as soon as the bladder assumes its healthy condition. In ordinary cases, the disease will subside in a few days by the use of active cathartics, leeches to the perineum, dilu- ent drinks, and warm hip-baths. It frequently occurs, however, that as soon as the diseased action sudsides in the bladder. the urethra takes on a more active inflammatory action than 18 GONORRHOEA. previously, and particularly at the neck of the bladder, and it becomes necessary to apply the nitrate of silver injection to that part, and is also important to use cold-water injec- tions to the rectum. Cases very often occur where the protracted discharge from the urethra is the result of constitutional debility. A man about twenty-five years of age called on me, with light complexion, narrow chest, rounded finger-nails ; had suffered some from two attacks, within the last year, of Hemoptesis ; the discharge was of fourteen months' dura- tion ; his tongue was milky white ; bowels were costive ; his stomach was very irritable from the long use of balsam, cubebs, &c. ; the discharge was light-colored and not copious—no pain in urinating. Directed him to take blue mass, 10 grains ; sulphate of quinine, two grains ; followed with oli rici one ounce ; and to take every day eight of the following pills : $. extract of sarsaparilla, extract cincho. equal parts, two drachms ; oxyde of iron, three drachms, made into seventy pills, with a pint of ale or claret at dinner, with generous diet. Used at first a strong injection, afterwards modifying it according to indica- tions. In about a month, by pursuing this plan, his general health began to improve, and the discharge stopped. Now, in this case, there was a want of development, which is indicated by the narrow chest and rounded finger- nails. This latter symptom, rounded or imperfectly formed finger-nails, is one that I have been in the habit of impress- ing on the minds of students for thirty years past, and it is a very striking and important one, and is easily accounted for : the nails being situated at the extreme points of cir- culation, a vigorous arterial and capillary circulation, is re- quired for their development, and consequently where the blood is imperfectly oxydized in its passage through GONORRHOEA. ig lungs that are not well organized, and impelled by an arterial apparatus of feeble force, it necessarily follows that de- formity is the result. You observe another indication of debility : the discharge was thin and light-colored; there had been but little inflammation. It was what is generally called gleet. Therefore the system required a.tonic and al- terative course of treatment. I could cite a great number of cases of this kind, modi- fied by circumstances, and there is often great difficulty in regulating your tonics to suit the variety of cases. Some- times, I find, the vegetable tonics suit best; at others, the mineral, or a combination of them. Pure air and exercise are very important remedies. In these cases, when the disease has been protracted, yon will often find that the coats of the urethra become thick- ened, which deprives them of their natural oontractibility, and the discharge seems to be an exudation from an un- healthy surface. Under these circumstances it becomes necessary to use the bougie fre\|uently, to promote absorp- tion of this induration. Sometimes the disease seats itself most obstinately at the neck of the bladder, the vesicula seminalis become impli- cated ; semen i-s found mixed with the discharge ; there will be diminished sexual capacity. In this kind of case, you must resort to the use of strong nitrate of silver solutions applied to the part, by adapting your syringe to a catheter. I have also used with success a tonic astringent to the rectum, after the cold-water enemas; but your main reliance is to arouse the system to healthy action by general tonics and alteratives. In persons of this class, when the disease extends to the bladder, it becomes a di-sease of a serious character, and often terminates in a chronic catarrh, but by following the same 20 GONORRHOEA. general principles that I have already laid down, this termi- nation may be avoided. The best local remedy in chronic inflammation or catarrh of the bladder is to begin with injec- tions of warm water into the bladder once or twice a-day for a few days ; then add a few grains of nitrate of silver to the injections, and gradually increase the quantity of this salt, until it produces considerable pain ; then stop for a few days, and watch the quantity of mucus in the urine. If that diminishes, and at the same time the desire to urinate is less frequent, you may either resume the injections or not, as cir- cumstances seem to indicate. Another remedy that I have sometimes used with apparent advantage, particularly when there seems to be an enlargement or partial paralysis of the bladder, is a decoction of secale cornutum. The form that I prefer is the watery extract, in doses of from half scruple to half drachm. It is very important in the treatment of diseases of the bladder that the patient should be enabled to discharge all the urine contained in that organ ; for when it becomes diseased, it loses its vitality in proportion to its dis- organization ; in the same proportion it becomes a foreign or non-vital organ : consequently, when the urine flows into it, chemical action and decomposition is the result; sediment is deposited ; the urine becomes acrid and irritating, and if allowed to remain, is a source of irritation, and aggravates the disease. Another remedy that I have found valuable in this disease is warm salt baths, either general or the hip-bath. The monesia was highly recommended some years ago in catarrh of the bladder, in the following form : #. Monesia, fifteen grains; musk and camphor, each, seven grains ; gum traga., eight grains ; to make fifteen pills. Two morning and evening. I have in some particular cases used it with decided advantage. GONORRHOEA. 21 Generally, however, I have relied more upon astringent enemas used after cold water ; a very weak solution of sulph. ferri, I have found very useful. You will sometimes meet with cases of Gonorrhoea where circumstances to which the patient has been exposed have added to the violence of the symptoms, as in the following case: A young man, a native of New Orleans, whose general ap- pearance and health might be called good, contracted Gonor- rhoea, and started immediately on a long overland journey to New York, before the time of railroads: consequently he was very much exposed to bad weather, and fatigue, in open and rough carriages. When he arrived here, his penis was swollen, and the urethra in a high state of inflammation; great pain in urin- ating, with copious discharges from the urethra; tongue furred, with other febrile symptoms; one of his testicles be- ginning to enlarge. Ordered 10 grs. of sub. mur. mer., and 10 of jalap, with a warm bath. On the next day his testicle was much enlarged; the other inflammatory symptoms had somewhat subsided. I continued the antiphlogistic treatment for several days, using a watery solution of mur. of ammonia to the testicle and penis, with leeches to the spermatic cord, below Poupart's ligament. In about two weeks the swelling of the testicle and other inflam- matorv symptoms had nearly subsided, and the discharge was rapidly diminishing under the use of the nit. of silver injec- tions, when he was taken with swelling and pain in the knee and wrist joints. By the application of—first, blisters, then, after a few days Goulard's cerate, with compression by means 22 GONORRHOEA. of adhesive plaster and bandages—giving, internally, sarsa- parilla and iodide of potassium—he recovered. This young man had been exposed to a malarious atmos- phere, while acting as an engineer. His blood had become vitiated, and he was in that state that we call in this country bil- ious ; he was forced to travel over rough roads in an inclement season, without the power of using any remedial agents; all the symptoms were of the most aggravated form. It became necessary to use means for the purpose of allaying general irritation. This was accomplished by general remedies. It is not desirable to use strong nit. of silver injections in the early stages of cases like this, until the other inflammatory symptoms subside. I use, simply, cold water in the urethra, and cooling solutions outside, with emollient drinks, or, those substances internally that increase the quantity of urine, and render it less irritating; there are several of these that are highly spoken of. I think the parsley-root tea the best; but slippery elm and the bucku leaves are also very good IN SWELLED TESTICLE, OR, EPIDIDIMITIS, more correctly speaking, a variety of treatment has been recommended, but I have found no local remedy so effectual as the application of a solution of muriate of ammonia, in cold water, about an ounce to the gallon. Cloths wet with this should be constantly applied, so as to envelop the testicle. I do not know upon what principle a solution of this salt acts better than the simple cold water, yet I have used it so much, with apparent benefit, that I have become attached to the remedy. Leeches are often resorted to in Epididimitis, but in viti- ated constitutions the bites are apt to be followed by a GONORRHOEA. 90 troublesome sore, difficult to heal, and I have seen some cases in hospital practice, where the whole scrotum sloughed off, and I was obliged to take a portion of the surrounding skin to form a new scrotum; therefore, I generally apply leeches to the cord just as it passes from under Poupart's ligament: in this part you come nearer to the source of the circulation of the testicle proper. When the disease assumes a chronic form, and the swelling continues after the inflammatory symptoms subside, it is necessary to resort to an ointment, composed one part, ung. hydr.; one part extr. belladona; six parts lard, or to the ung., iod. potas., together with compression by adhesive straps; using the suspensory bandage if the patient moves about. This patient also suffered from GONORRHCEAL RHEUMATISM. For the cure of this affection, I have generally found that in the local treatment there is nothing better than blisters, followed by Goulard's cerate, and the compress with adhesive plaster and bandage. Generally this affection will be found in persons of rheumatic diathesis, and when the general health is not too much impaired, the calomel and opium treatment will be found very effectual. But the main reliance is to be placed on constitutional remedies, such as the iodine and sarsaparilla. I have sometimes had cases of Gonorrhoea that seemed to be connected with disease of the skin; for example, when the irruption on the skin shows itself, the discharge will cease. and when the irruption subsides, the discharge will return. I lately had a case where there had been a very slight dis- charge for some months, that seemed to resist all local reme- dies, when suddenly a patch of eczema showed itself on the 24. GONORRHOEA. thigh, near the scrotum ; the discharge ceased, and he recov- ered under the use of alteratives and tonics. There is another form in which it is often presented, after the discharge has almost subsided from the urethra: the patient, by pressing the head of the penis, will discharge a small quantity of matter, which comes from just posterior to the glans. These cases I have generally treated by distending the urethra with a weak solution of deu. clo. mer., and they are often very troublesome. Another of the sequela of Gonorrhoea is irritability, and discharge from the neck of the bladder, often attended with an involuntary discharge of semen. In some cases the sem- inal ducts will assume a morbid action, and semen will pass at the time of the alvine evacuation. When this form of disease presents itself in a person whose system is weakened and exhausted by long-continued dis- charges from the urethra, or by masturbation, the tonic treat- ment will naturally suggest itself. At the same time, the application of a solution of nit. of silver to the neck of the bladder, will stimulate the parts to healthy action, and lessen the irritability. It would be well to mention that I have had cases where the symptoms were so similar to Gonorrhoea, that it was very difficult to distinguish the difference. A gentleman called upon me with a discharge from the ure- thra. I asked no questions, and he volunteered no information. I treated him for about a week without apparent amendment, when, upon inquiry, I found he had not had connection with woman for six months, but that he felt a pain in the rectum when the fasces .were passing. Upon further inquiry, I found he had accidentally swallowed a part of the flat bone of a duck. In a few days he passed the bone, and the dis GONORRHOEA. 25 charge ceased. The sharp-edged bone had lodged in folds of the rectum, and produced an inflammation extending to the urethra. I once attended four children of the same family, three girls and a boy, who were all subject to a discharge, resem- bling Gonorrhoea, which was evidently owing to ascarides in the rectum. It may be said to be a common disease in girls, but very rare in boys. So far, I have not alluded to the POPULAR REMEDIES for Gonorrhoea, and the reason is, that I am not in the habit of using them, except in cases that cannot attend me at my office regularly. Under these circumstances, I prescribe the capsules of either balsam copaiba, or the cubebs; but I am cautious in their administration, particularly the copaiba, for I have seen so many inveterate cases of dyspepsia pro- duced by this remedy, that I am unwilling to prescribe its use for any length of time, and nearly all the quack remedies are composed of this substance in a disguised form. It some- times produces an eruption on the skin. Purgatives are a most valuable agent in the treatment of Gonorrhoea, and I know a gentleman who has a large practice among the laboring classes in this city, who relies almost entirely upon the following prescription: # Cucum. Colocy., ^ss. Sal. Prunele., 31s. Gum. Gamb., gr.xv. Sang. Drac, jss. Aq. Bullens, lb.?. A wine-glass full two or three times a-day: But large practice is not always an indication of success. 4 26 GONORRHOEA. Another remedy that has been highly recommended to check gonorrhoeal discharges is the sulphate alumine, but, so far as my experience goes, it has not answered expecta- tions. It has been used in combination with cubebs, in some cases that are commonly called gleet, it seems to be indicated, and I think may be found useful. It is the practice among surgeons, when writing on the treatment of Gonorrhoea, to caution practitioners not to use strong injections, for fear of producing stricture. Now, Ave have had a very long experience in the use of strong injec- tions of nit. of silver, and we never yet have seen stricture result from that cause; and, we confess, we cannot see why an inflammation produced by a strong injection would be more likely to produce stricture, than an inflammation arising from Gonorrhoea itself; and the principle upon which we sup- pose the nit. of silver to act, is the setting up of an action of a different form from the original one, and one that is more easily subdued, and not so deleterious in its character ; and it seems to me that it does not necessarily produce another inflammatory action, but that it simply destroys the acrid quality of the discharge, perhaps by chemical decomposition ; for I find that it is necessary to use a syringe with a long tube attached to it, so that I can introduce it the whole length of the urethra, or as far as the morbid action extends. A great variety of injections have been recommended in this disease, such as solution of acet. of zinc, acet. of lead, chlo. of lime, opium, tannin, and lately bals. copaiba has been highly spoken of. STRICTURE OF THE URETHRA. Obstructions to the free passage of urine may arise from a variety of causes, such as over-distention of, or tumors within, the bladder; enlargement of the lateral or posterior, or third lobes of the prostate gland, stone, tumors invading or pressing on the urethra, or from morbid contraction of the urethra itself. The last we call stricture, which is generally the result of some injury of the part, or follows a protracted, badly-man- aged, or neglected Gonorrhea. It may, however, be brought on or produced by disease of the bladder or kidneys, of long standing, or from injury of the urethra itself, or from a fall or bruise, from which inflammation follows. Such injuries fre- quently occur while riding on horseback, or falling astride some hard substance—such as sailors falling across spars, or persons in the country across fences; horsemen are often thrown upon the pommels of saddles. But generally your patient will inform you that he has suffered from Gonorrhoea at some period, and that he has not passed his urine perfectly since about that time. He often attributes his trouble to want of skill in the treatment, but it generally arises from his own neglect or imprudence. Many physicians place the patients under strict diet, during treatment for Gonorrhoea, and when the running ceases, the patient considers himself relieved; yet the parts of the urethra involved in the dis- ease are not perfectly restored : induration still remains, the secretions are not fairly established—the patient returns to full diet, and perhaps to irregular habits; the indurations remain, and increase from obstruction in the passage of the urine, and stricture results. Any thing that has the tendency, in any way, to impede the free and smooth passage of the 28 STRICTURE. urine, will produce stricture; for it generally begins by a deposition of coagulable lymph, either on the inner surface of the urethra, or in the surrounding tissues. All persons who have treated Gonorrhoea know that pa- tients will sometimes complain of pain in urinating, and slight chordee after the discharge has ceased, which is caused by the remaining induration, and this is apt to produce stricture, particularly in persons of irregular habits, and in those pre- disposed to rheumatic disease. Hence the propriety of some- times introducing a bougie to stretch the urethra, so that the indurations may be absorbed. We frequently find that this condition of the urethra keeps up a slight discharge, which is relieved by dilation. It may be well to speak here of the pre-disposing causes of stricture, for it is true that some per- sons are more liable to it than others. Persons of scrofulous diathesis are of this class. By scrofula, I mean imperfect development. This is the doctrine that I have taught these twenty years: but as I could not give a European father for it, it would not take root until lately, when it has come over the water. The urinary and genital organs of some individ- uals are imperfectly developed; in some, the whole apparatus jna,y be imperfect; in others, the penis is very small—the prepuce elongated, and the urethra very small; in others, the opening may be low down on the penis, approaching her- maphrodism, and in all the malformations of these organs, there is more or less imperfection of function, giving rise to disease. This class of persons I have found much given to Onanism, which brings on involuntary discharges. They are peculiarly liable to contract Gonorrhoea, and difficult to re- lieve. The disease is generally protracted, and liable to be followed by stricture. Let me illustrate by a case : Mr. G., aged twenty, applied to me: his penis was very small—his prepuce was very much elongated; he was unable to uncover STRICTURE. 29 the glans; he had practiced Onanism for several years; he had grown very rapidly—was tall and slender, of light com- plexion ; chest narrow, and pelvis small. He had been advised to cohabit, as a remedy for the Onanism, and soon contracted Gonorrhoea. After having for several months resorted to the usual treatment without relief, in a fit of desperation he took to drinking brandy, and high living, and to his surprise the Gonorrhoea subsided. In a short time, he contracted the dis- ease again, but this time the old remedy failed to relieve him, when he applied to me. There had been a discharge from his urethra for twelve months. There was considerable pain in urinating; the stream was very small; the prepuce was enlarged and indurated, and tender to the touch. I put him upon a course of alterative treatment; gave freely of emolient drinks—removed the elongated prepuce—clipped the frcenum, so as to allow the glans to be freely uncovered—gradually dilated the urethra—used injections, and he soon recovered. His general health improved, and the involuntary discharges ceased. In this case he was rendered liable to the disease by the poisonous matter insinuating itself within the prepuce, and being retained there. The usual antiphlogistic treatment debilitated his system, and increased the irritability of the parts; hence the tonic and invigorating influence of brandy and high living so invigorated his system, that it was enabled to throw off the disease. But, the second time, his system was not in a condition for the tonic treatment; his intemperance aggravated the disease, and induration and stricture followed. Here let me observe that I have noticed that persons whose glans penis is habitually covered, are more liable to contract both Gonorrhoea and Syphilis than where it is naturally un- covered. In the first case, the surface, or skin of the glans 30 STRICTURE. nearly approaches mucous membrane; in the latter, it more nearly resembles skin: hence the wisdom of circumcision. Another case in which imperfect development seemed to be the cause of stricture, was that of a boy, about eight years of age, supposed to have stone in the bladder, as he had ex- perienced pain and difficulty in urinating, from his earliest infancy. The penis was small; there was scarcely any pre puce; the glans was habitually uncovered; the urethra ter minated in a very minute opening at the anterior base of the glans, where the frcenum is usually attached; the stream of urine was very small, generally in drops, with great pain anc straining. On introducing a very small bougie, I found tht anterior covering to the urethra very thin for about an inch thence onwards it seemed to assume its natural thickness; bu\ at this point of change in structure was situated a very painful and contracted stricture. By incising the external opening, and dilating the stricture, he was finally relieved. Hence it may be seen that malformation or imperfect development ob- structing the passage of the urine, irritation, inflammation, and consequent indurated stricture was the result. Any malfor- mation that has a tendency to interfere with the free passage of the urine, is a predisposing cause of stricture. Another class of persons that seemed very liable to stric- ture is the gouty and rheumatic. It would seem that when- ever such persons (particularly the latter) have local inflam- mations, indurations are apt to follow; thus, when they receive a wound or an injury, it will be followed by rheumatic pains and indurations. I have treated a great number of persons of this diathesis, and found them very difficult to manage. The progress of cure is always slow, and they are constantly liable to a recurrence of the stricture. A case of this kind has been under my care for seven or eight years. The man is a paper- maker ; he is almost constantly suffering from rheumatism in STRICTURE. 31 some form or other; his business exposes him to changes from a moist and warm atmosphere to cold winds, and every time that his rheumatic affection returns, his urethra con- tracts. I have observed, also, that in these kind of constitu- tions gonorrhoea is generally very troublesome, and, when protracted, is apt to be followed by stricture. At one time he gave up his trade, and, finding himself so comfortable under the change, he thought he might return to it with impunity, but in a few weeks he came to me again, with his stricture as bad as ever. I could cite a great number of similar cases, which go to show the intimate connection that sometimes exists between stricture and rheumatism. There are several local diseases that predispose to stricture, such as enlargement of the prostate, and catarrh of the blad- der. I had a case that arose from an induration in the spongy portion of the penis, which slightly impeded the regular pas- sage of the urine; eventually a stricture followed that was verv troublesome to keep open. I was called upon by a gen- tleman, having an obstructionin his urine, and found a calculus lodged in the membranous portion of the urethra, which had been there some months; after removing the calculus, the part remained indurated and thickened; the stream was small, and it required several weeks' dilatation to remove the stricture. Sacs in the course of the urethra may be the cause of stricture. There is a gentleman who calls on me two or three times every vear, to have his stricture dilated, and when I pass the bougie it stops at the membranous portion, and seems to go a short distance into a ml de sac; but by withdrawing it and ele- vating the end of it a little, it can be passed, and by enlarging the opening with bougies, the stricture passes off in a few days, and does not return for some months. A great deal has been written with a view of illustrating the condition of the parts, the form and situation of stricture. 32 STRICTURE. In nearly all the post mortem examinations that I have made, I have found the surrounding tissues indurated, and where the disease has been of long standing, the urethra itself thick- ened and contracted. This state of things may exist through- out the whole canal; it may exist in several different parts; it may extend an inch or more, or it may be confined to a very small portion of the urethra. I have had a few cases where the whole urethra felt externally like a cord, and on attempting to pass a bougie, have found it tortuous; in some of these cases there is great irritability, and I have difficulty in allaying it, so as to introduce the bougie. In some cases, a small, pliable gum elastic bougie, without a stilet, may be used successfully. It is stated that out of ninety-eight specimens of stricture in the Museum of the Royal College of Surgeons, twenty-one only were situated in the membranous portion, and seventy-nine anterior to the triangular ligament. According to my experience, it may occur at any part of the urethra, but the most common seat is between the glans and the membranous portion. Many of those cases occurring at the triangular ligament are produced by improper management in attempting to in- troduce catheters and bougies. When it occurs in the glans itself, it is generally congenital, or arising from some malfor- mation. I have seen cases where the froenum extended up to the meatus, and whenever the erections took place, the head was drawn forward, making coition sometimes difficult. In persons with this malformation, onanism is likely to produce stricture. I have also observed, that persons who have naturally small urethras are pre-disposed to stricture. Various classifications have been adopted by surgeons when treating of stricture. The most natural division seems to me to be spasmodic, \ STRICTURE. 03 bridle, or valvular, and indurated; they may exist separately or in combination. [See plates.] Spasmodic stricture, so far as my observation extends, arises from some irritation, or disease of the bladder or kid- neys, the passage of calculi, excessive venery, disease of the neck of the bladder, the vesiculoe seminalis, or gonorrhoea. Civiale says, "that various irritating causes sometimes produce a sudden contraction of the canal of the urethra, which renders emission of urine difficult and painful, and often stops the passage altogether; and that these spasmodic stric- tures are often produced by excessive venery," and cites the following case: " W. N., an Italian, aged 30, having had gon- orrhoea several times, for which he had taken no anti-phlogis- tic remedies, and which continued to show itself when he was irregular in diet or drink, coition always produced stric- ture of the urethra, which lasted some hours, and when the erections were prolonged, retention followed, which was re- moved with difficulty. Since he had abstained from coition, he was not troubled with either disease." Segalis says, " Spasmodic stricture is the result of abnormal contraction of some of the muscular fibres entering into the structure of the urethra, and is characterized by its duration; that it never occurs in any part of the canal that is not sur- rounded by muscles, and mostly occurs in the membranous portion." He also says that "it may be produced by any thing that agitates the nervous system." It is said that the celebrated Rosseau was subject to spas- modic stricture all his life, and when a post mortem was made, there was no organic lesion found Mr. Bingham says "that it is well known that nervous irritation in muscular parts often occasions partial and ob- stinate contractions, and where this effect takes place in the urethra, it constitutes what is generally called spasmodic 5 34 STRICTURE. stricture; but as the expression is often applied to any kind of stricture that can be dilated to the full size of the urethra, so nervous irritation, muscular contraction, and, to a certain degree, inflammation may be present in spasmodic stricture, as may be observed in the following case : I was called to see a gentleman who had just arrived from New Orleans ; he had contracted gonorrhoea before he left— had been dissipated in his habits, during the voyage, suffering from pain in the back, and over the pubis, passing his urine in drops with pain and difficulty. After he was freely leeched on the perineum and pubis, had taken a warm bath, I at- tempted to introduce a catheter, but found the spasm and con- traction so great that I desisted, and ordered a large dose of calomel and Dover's powders—put him into a warm bath; in a few hours his urine was passed with a little more freedom. He then took a large dose of castor oil. As soon as it oper- ated, I found I could pass the catheter; the inflammation and contraction having passed away, his gonorrhoea was relieved in a week or two. He was not afterwards troubled with stricture. This was evidently spasmodic stricture, brought on by irritation and inflammation ; and I am inclined to think that most cases of spasmodic stricture result from diseased condition of the parts, or some of the contiguous organs. Persons who have had slight strictures for some time, may be attacked with spasmodic stricture, and retention after an excess in drinking, or exposure in wet and cold; but as soon as the constitutional irritation subsides, the spasm will cease. In plates 1, 2, 3 may be seen what is meant by Bride or Valvular Stricture ; in plate 1, we have bride, under which a horse hair has been passed; just behind the stricture yon see the urethra is enlarged, and, from constant distention in the efforts to urinate, several slight cuts du sac are formed. Cases are often met with where there is but a single bridle Plato 1. Plate '1 STRICTURE. 35 or filament extending obliquely or otherwise across the ure- thra. In taking an impression of them with a wax exploring sound, they may be easily discovered; and I have several times had cases where, on the introduction of a large bougie, the bride would break; there would be a slight discharge of blood—the stream would assume its natural size, and the patient be relieved. Some years ago, a friend of mine called on me to sound him for a stone. On introducing the sound, I met an obstruction, which gave way quite suddenly to a slight force; the sound then passed into the bladder. On drawing the sound, there was some blood flowed. He has never been troubled with any difficulty in that region since. These bridle strictures are often combined with the val- vular. They seemed to be produced in this way: Diseased mucus surfaces are liable to generate or form filaments of coagulable lymph, particularly when an irritating fluid is con- stantly acting on them (a phenomenon that may be seen in diseased bladders). The mucus surface of the urethra being- diseased, and the constant irritative action of the urine upon it, causes the filament of coagulable lymph to be deposited on its surface ; these go on increasing, until an obstruction in the passage of urine is the result; as soon as this takes place, the efforts made to pass it increase the irritation of the part; more lymph is thrown out to make new formations; the pas- sage of urine being still more obstructed, inflammation ex- tends to the surrounding tissues, and permanent stricture is formed in combination with valvular, as in plate 2. The valvular stricture is very manifest in plate 3, fig. 1, where it seems to involve the greater portion of the urethra. Sometimes the stream finds its way under the base of the valve, and another passage is formed, as in plate 2. These valvular strictures present great varieties of form and character. I have a preparation in my collection, where 36 STRICTURE. a small stone had got into a valvular stricture, but I could not learn whether the stone had caused the stricture, or that its passage had been arrested by the stricture. The existence of stone habitually in the neck of the blad- der, will cause stricture, as illustrated in plate 4. This specimen I met with when making pathological in- vestigations in cholera: there was an abscess partly surrounding the prostate gland; the stone had formed abed for itself: the irritation extending to the urethra; stricture at the membran- ous portion had followed. Finding the catheter would not pass, I removed the parts, and found them as represented. By INDURATED OR PERMANENT STRICTURE is meant that condition of the parts, where the surrounding tissues become solidified by the deposition of coagulable lymph, diminishing the vascularity of the parts. It may be confined to a particular portion, or may extend to the whole of the urethra. In this specimen, (plate 3, fig. 2,) the covering of the urethra is thickened, and a part of the spongy portion is filled with coagulable lymph. I have frequently had patients of gouty and rheumatic diathesis, where the spongy portion was indu- rated from the glands to the triangular ligament. I have now a case where the stricture is situated just within the glans penis. It frequently occurs within two inches of the meatus- externus, and is often very troublesome to relieve. I had a case of a sea captain, where the stricture extended from the glans penis inwards about one inch; the stream was very small; the surrounding parts felt solid upon pressure. I found the pain and difficulty of dilatation so great, that I laid it open with a knife. He had got it into this condition by his own treatment while at sea. II! M;Hi. ale ,». I'I" _ I.lie .i W.i re ±. STRICTURE. 37 Before entering on the treatment of stricture, it will be proper to speak of the different kinds of catheters and bougies, and the method by which these can be introduced into the bladder with the greatest facility. For the purpose of drawing off the urine, or for exploring the urethra of a well-formed adult, a common silver catheter, No. 8 or 9, is the best. I say pure silver, so that you can alter the curve without danger of breaking the instrument; when there is alloy in the silver, it is liable to break in changing. In some cases of stricture, where the passage is surrounded by indurations, or is tortuous, the gum elastic bougie is best. It may be used with or without a wire stylet: sometimes, by withdrawing the stylet an inch or more, we may facilitate the passage in allowing the instrument to adapt itself to the irregularity of the urethra. For catheters and bougies a variety of substances have been used. For many years I was in the habit of using silver, but requiring a large number, and of various dimensions, I have adopted soft iron. They may easily be made from wire of different sizes, from No. 2 up to No. 16, and when used by persons who have studied accurately the structure and rela- tive positions of the urinar}r organs, they are as good as any other. In the hands of a dextrous operator, the curve of the instrument is not of much importance, where the stricture h not much contracted, or not situated posterior to the bulbous portion; but in difficult cases, it is very important that the curve should be adapted to the size of the pelvis or the obesity of the patient. The curve of the bougie or catheter should occupy 150 degrees of a circle, except 30 degrees of the point, which should incline inwards *th of an inch, as may be seen in plate 6; this divergence from a circle at the end will be found useful when the prostate is enlarged, or the 38 STRICTURE. bladder elevated by retention of urine. The size of the circle will be regulated by the age or obesity of the patient. The largest diameter of the circle may be five inches for corpulent adults; from that down to three inches, according to the size of the pelvis and condition of the surroundings. Some dis- cretion is necessaay for regulating the point of your bougie for dilation. I prefer the conical termination. In stricture, where the passage is very small and indurated, the point should be small, as in fig. No. 1. If it is a bridle stricture, and not much indurated, the blunter point in No. 2 will not be so liable to entangle itself within the folds of the urethra, and by that means get out of the track, and make a false passage. For the INTRODUCTION OF THE CATHETER the patient should lie on his back, with his head and shoulder.0 elevated, his knees a little drawn up, so as to relax as much as possible all the muscles connected with the pelvic region oi the neighboring tissues. Some persons have recommended the standing position, for the introduction of the straight bougie, but in treatment of stricture there is no advantage gained, either by the use of the straight bougie, or by placing the patient in the standing position. Having placed him at per- fect ease, standing on the left side of your patient, take the handle of the instrument (well oiled) in the right hand, as you would a pen, holding it loosely; then, holding the penis with the left hand, pass the end of the bougie into the penis, holding your right hand obliquely over the left groin, until the instrument, being introduced to the arch of the pubis, lays flat in the groin and obliquely across the pelvis, and in line from the left tuber ischai to the penis. Then slowly elevating the handle of the instrument upwards and inwards, towards the symphysis pubis, keeping the inner flat surface of the STRICTURE. STRICTURE. 4^ handle facing the abdomen, allowing it to pass more by its own weight, than by any force or guidance of the hand; for, if there is no obstruction, very little force is required, and in many cases nothing but the weight of the instrument, if it is made of solid metal. When the handle of the instrument stands perpendicular to the body, the point of the bougie is at the membranous portion; here, if the instrument does not pass with perfect ease, depress the handle gently, and use a gentle pressure, which may be continued for some time; if it does not then pass easily, oil your finger, and also the region of the anus; and, gently introducing your finger into the anus, find the end of the bougie, elevate the point with the finger, pressing gently with the right hand on the handle, it will soon pass into the bladder. Although these directions will greatly aid the student in the introduction of the catheter, yet a thorough knowledge of the anatomy of the urethra, with the surrounding tissues, and of their functions—with frequent practice on the dead and living—can only give the necessary facility to enable him to practice successfully this, sometimes, most difficult of operations. And it is advisable for the student who wishes to acquire the necessary tact, to carry a catheter with him in all his anotomical and pathological investigations, and introduce it on all occasions, when it can be done Avith propriety. In this way he will acquire that valuable aid so necessary to the surgeon—finger-end tact; and he will also, in the course of his investigations, often meet with valuable pathological specimens to add to his collection. It is impossible to give directions for the introduction of the catheter that will enable the student to meet difficult cases of stricture ; for they assume such an infinite variety of form and character, that it will necessarily modify the mode of procedure, according to circumstances; but, as a general 42 STRICTURE. rule, gentle, long-continued manipulation, with a perfect knowledge of the anatomy, and the relative position of the parts, with the introduction of the finger in the rectum, for the purpose of giving the end of the instrument the right direc- tion, will succeed in the most unpromising cases. Retention of urine in stricture generally arises from some derangement of the s}'stem: the patient has either been on a frolic, exposed to cold or wet, or to some unusual excitement, which has brought about the difficulty. Hence the necessity, before using the catheter, to administer nauseating purgatives, warm baths, &c, so as to produce a decided effect upon the secretions and excretions; and my experience leads me to believe that cys totomy is an operation that is rarely required for retention of urine, when the case has been properly managed; yet! have known it resorted to where I have afterwards found no permanent obstruction whatever. A gentleman, traveling in the Western States, was taken with retention. A physician was called; he could not pass the catheter; he resorted to puncture above the pubis; and when the patient applied to me, two weeks after the operation, he was passing his urine through a tube in the opening. I introduced a catheter into the bladder by the urethra, without the least difficulty. Kept it there until the wound healed, and the patient was restored —without any trouble in passing his urine. In this case it was very evident that the necessary and proper means had not been adopted to relax the parts previous to resorting to the operation. I could cite a number of other cases where cystotomy has been unnecessarily performed. Indeed, it would be painful for me to report the many mistakes made in these kind of cases, which have come under my observation, for the want of proper knowledge. One will illustrate : A gentleman accidentally fell down a cellar-way; when taken up, his lower extremities were paralyzed, and it was soon found STRICTURE. 43 that his abdomen was distending from the accumulation of urine in the bladder, owing to the paralysis of the muscles of that organ. Several physicians were called in, and a number of attempts were made to introduce the catheter, and draw off the urine. At last the catheter apparently passed into the bladder, but nothing followed but blood. After a variety of unavailing efforts, it was concluded, upon consultation, that the bladder was filled with clotted blood, and that the urine could not pass on that account; it was, therefore, decided to puncture the bladder. As preparations were making for this operation, I arrived, having been sent for by one of the friends of the patient. I was requested to examine the case before the operation was performed. After hearing all the circumstances of the case, I took the catheter, and introduced it without the least difficulty, and the man was relieved, and the paralysis passed off in a few days. Now, " what was the difficulty in this case ?" If we look at the anatomy of the parts concerned, we find the urethra, as it passes out of the arch of the pubis, is firmly bound down to its position by the trian- gular ligament, and that the lowest and latteral portions of the bladder are surrounded by bone and viscera; consequently when the bladder becomes distended, it rises in the pelvis, and is pushed forward and upward—as illustrated by the plate, No. 3; and the more the bladder is distended, and pushed up and over the pubis, the more the urethra is length- ened and contracted. And it may at once be seen that, on introducing the catheter, in proportion to the distention of the bladder, must be the depression of the handle and the elevation of the point of the instrument, and distance required for insertion. Thus it may easily be seen that, if the end of the instrument is not turned up, so as to follow the inner sur- face of the pubis, it will get out of the passage, and pass up un der the prostate ; and I have known cases where it was passed 44 STRICTURE. No. 3. into the rectum, and by experienced hospital surgeons. Onf case came under my charge, where this accident occurred and the greater part of his urine was passed by the rectum I succeeded, however, in getting a catheter into his bladder retained it there a few weeks, and he recovered. But hir venerial powers were destroyed, and his young and beautiful wife, to whom he had been a short time married, left him. I could tell a number of accidents of this kind, but one more will be a sufficient warning to young surgeons, and verify what was said by John Bell, and in which sentiment I concur, that the introduction of the catheter is often the most diffi- cult operation in surgery: Some 25 years ago, it was the fashion in Paris to treat strictures by passing the conical bougie. One day, in going the rounds of the hospital, I saw an eminent surgeon introduce a conical bougie of a large size ; he used considerable force, and great pain was manifested by the patient. The bougie was secured in the bladder, and I saw nothing more of the patient, until a few days afterwards I was in the dead rooms, and I saw the man laid out, with the STRICTURE. 45 bougie secured in his bladder. With the assistance of a friend, I removed the parts, carried them to my room, and made careful dissection, which specimen I have kept in my collection. I found that the bougie had passed out and under the urethra, at the bulbous portion, and re-entered the blad- 'er, just back of the prostate. THE TREATMENT OF STRICTURE Must depend upon a variety of circumstances; almost all mrgeons who have written upon the subject, have advo- cated particular plans of treatment; some recommend cauterization, with nit. of silver, or with the vegetable caustic; and others, by dilation, either by simply passing the bougie, or by securing it in the urethra until the urine passes around it. I have treated them upon all these plans, but I mostly rely upon gradual dilatation; yet cases often occur where other methods are advisable. The consti- tutional treatment of stricture has been too much overlooked by surgeons generally. All local disease, if not generated, is aggravated by a vitiated state of the system generally, and particularly by derangements of the viscera, connected with the alimentary process. Consequently, it becomes very im- portant, before you apply local remedies, to see that all the secreting and excreting organs are performing their functions properly. It is, however, true, that the local disease some- times becomes so prominent, as to materially affect the gen- eral health, in such cases, that both should be attacked at the same time. It rarely happens that you are called upon to treat a stric- ture that you will not find a furred tongue. This is nearly always an indication to give a mercurial cathartic ; and if one does not remove it in a few days, I repeat it, particularly if the general strength of the patient is good; if not, I add 46 STRICTURE. quinine to it, which supports the system, while the mer- curial corrects the secretions. One distinguished surgeon that I know, advocates emetics in stricture; and I know that he has found an emetic, given every third day, to aid very much in promoting absorption in indurated stricture. Patients who have been laboring under stricture for a long time, in our southern climate, become very much exhausted. It would not be prudent, in such cases, to give active cathar- tics or emetics; but you may regulate the secretions and excretions in such cases, by giving tonics, alteratives, and diluents. It was wisely said by Abernethy, that the progress and termination, and often the origin, of disease, was dependent upon constitutional derangement, and the remedy that would the most effectually remove this was a great desideratum in medical science. The agent he adopted for the accomplish- ment of this object, was mercury, in the form of what is com- monly called blue pill; it being, perhaps, less irritating to the bowels than any other form of that metal. This article has been denominated, in medical phraseology, an alterative, because it changes, alters, or increases the action of the secreting and excreting organs—those organs that throw off the effete matters in the blood; it being purified, healthy action is restored. The constitution, or the vis medi- catrix natura,&s Cullen calls it,is enabled to remove the local disease ; and since his time, no medicine has been more used and abused. In practice you often meet with persons to whom this remedy does not seem well adapted, and it is sometimes hurtful. Since the discovery of the various preparations of iodiie, physicians supposed that a good substitute for mer- cury had been found, and in many cases it is an invaluable remedy, and seems to be both alterative and tonic; but it does not always answer the purpose, but becomes an irritant, STRICTURE. 47 and judgment and skill are required in its adaptation. Some thirty years ago, upon being appointed surgeon to an hospital, the druggist who furnished the medicines informed me that he had purchased at auction a large quantity of ex- tract of sarsaparilla that had been sent from England, but he could not sell it; and, having been on hand a long time, he requested that I would make a trial of it at the hospital. (The article was but little used in this country at that time.) There was a large number of chronic cases in the wards, that had been accumulating for a long time—mostly secondary syphilis and diseases of vitiation. As it was a cheap remedy, I accordingly ordered it freely used; and to my gratification, and to the astonishment of the house-surgeon, in from six weeks to three months, the wards were nearly clear of this class of patients. One of these was a man whose abdominal parieties had been removed by ulceration over a surface eight inches in diameter, leaving only the peritoneal covering. Since that time, I have been constantly in the habit of using this remedy whenever I have wanted to establish healthy secretion and excretion. I have used it in all its forms, but mostly in the form of extract. There is a great variety in the opinions of medical men, as to the use of this medicine; and many of the most eminent have pronounced it a mere placebo, while others, particularly those who have, the advantage of getting it fresh from the ground, have praised it very highly. Much of this diversity of opinion has arisen from the diffi- culty of procuring a pure and good article, and then having it properly prepared. The extract is rarely found of much value, unless the root is recently imported; and it requires the greatest care in its preparation; and it has been with great difficulty that I have been able to procure an article on which I could rely. Some years since, while attending a member of Dr. Brandreth's family, he informed me that he 48 STRCTURE. had succeeded in making extracts at a very low temperature, and he prepared for me an article that I used extensively, and found it very pure. Another article that I have used for a long time, and found very effectual in purifying the blood, is the extract or infusion of the guac wood, and it is admirably adapted to dispensary and hospital practice, on the score of economy. Then, after correcting the state of the secretions, the next thing is the local treatment; spasmodic or inflammatory stricture will require but little local treatment; by allaying constitutional irritation, the disease will generally subside; one or two introductions of the larger-sized bougie will aid in removing the difficulty. I was called upon, some time since, to treat a gentleman for gonorrhoea. He went on well for two or three days, when suddenly, upon getting his feet wet, he was taken with violent rheumatic pain in the region of the ankle-joint, and with retention of urine. After giving an ac- tive cathartic emetic, and placing him in a hot bath, I passed a small catheter. I found the urethra contracted from the fossa navicularis to the membranous portion ; as soon as med- icine operated, his retention was relieved; with a few inser- tions of the bougie, and two or three injections of nit. of silver in weak solutions, he was entirely relieved, both of the stricture and gonorrhoea. This was a patient who was subject to rheumatic affections; the urethra being already diseased, disposed the stricture to fix itself there. Another class of cases that may be spoken of here, are persons whose nervous systems are easily excited, and have suffered from gravel passing from the kidneys, which leaves behind a slight un- easiness in the back, which is aggravated by exposure and excesses of all sorts. They call on you, and say that the size ot the urethra seems diminished, and that they sometimes have pain in passing urine, particularly when the general STRICTURE. 49 health is deranged; upon introducing the bougie, you will find that the urethra is diminished in size. These patients can only be relieved by improving the general health, and a few introductions of the bougie. In a great many cases, where persons have applied to me with gleet—or rather a slight discharge, coming on occasionally, when the general health is impaired, or when the patient has been indulging in drink freely—they will tell me that they have had a slight discharge from the urethra ever since they had the gonorrhoea. They are not sensible that the stream is much diminished: but occasionally it is passed with pain; in these cases, you will find that there is contraction of the urethra, and that it is tender in a particular part, generally about three inches from the external meatus. These cases may be easily relieved by introducing a large-sized bougie, and dilating the urethra to its full extent; and then injections of nit. of silver will change the action, and the trouble will cease, provided the patient is not intemperate; but any indulgence will produce a relapse. Thus we are called on to treat a variety of mild forms of stricture, that only require the general health to be improved, and the slight disorganization removed by dilating the ure- thra to its full size. Stricture presents such an infinite variety in character and form, that it is difficult to give special directions for their treatment. As I have said before, bridles sometimes form in the early stage of stricture. I have, on several occasions, when introducing a large-sized bougie, found the passage completely obstructed; but by gentle pressure, the bridle would suddenly give way. I have seen some morbid specimens, where a single bridle extended across the urethra, which could easily have been broken. In the explorations of the urethra, where you have reason to believe in the existence 50 STRICTURE. of stricture, it is always the best plan to introduce a large bougie, until you come to the stricture ; then you can use the bougie with wax at the end ; by pressing a short time against the strictured part, you will get an impression that will guide you as to what course to pursue. You can also learn some- thing as to the condition of the parts, by placing the finger in the rectum; if the stricture is in that part, and there is much induration, you feel that the urethra is hard like a cord ; if the impression on the wax shows a conical form, by pressing gently with the conical bougie, you will find it advance a little ; you must not urge it too far, but use gentle pressure, for some two or three minutes, and then let the parts rest a day or two. Give your patient parsley-root tea to drink freely, and try the conical bougie again. Thus continue to make several successive trials, and in most cases you will eventually get past the stricture, by this gentle manipulation alone. It is especially important to avoid using much force when the stricture is situated just anterior to the triangular liga- ment. It is sometimes the case that you may introduce a large instrument better than a small one. I have often introduced No. 12, when I could not succeed with No. 6. In the size of the instrument, you must, how- ever, be regulated by the impression made on the wax. If the stricture is anterior to the bulbous portion, it is only neces- sary to introduce a small conical bougie, by gentle pressure, every day. or every other day, gradually increasing the size, until it is sufficiently dilated; but, in this last-named region. it is more liable to contract after it is dilated. Hence it is necessary to continue the introduction of the bougie for some weeks, until the induration subsides, and the parts assume their natural tone. In the treatment of stricture, 1 have, after long experience, come to the conclusion, that the majority of strictures that STRICTURE. 5J present themselves in ordinary practice, can be better treated by dilatation with the conical bougie, than by any other method; and upon examination of cases, on referring to my notes, I find that in not one case in fifty have I resorted to any other treatment; yet other methods have been so successful in the hands of many distinguished surgeons, that I am disposed to give them due consideration, and I must say all plans are attended with risk. The great danger in dilatation is getting out of the right track; this will often occur in the most skillful hands; but this always can be discovered, if due care is taken. I have generally, when I apprehended I was not in the right course, allowed the parts to rest a few days, to recover from the effects of the first introduction; then to pass an explora- tion bougie of wax, and get an impression of the part, and thia will generally aid you very much. If you have gone out of the track, allow the parts to heal; let the patient drink freely of parsley-root tea, and then make an effort with a bougie, with a larger point; press gently; if you do not get on, wait a day or two, and try again. Manipulate a little with your finger on the outside; change the curve of your instrument. Thus, by gentle and persevering efforts, in a majority of cases, you will succeed. I have in some cases made twenty efforts before I have succeeded : and I am satisfied if I make a slight advancement each time. There will generally a little blood follow, succeeded by slight suppuration, with an increase in the facility of urinating; and thus you are encouraged to persevere. Success in this process depends very much on tact: in watching the direction of the instrument, and in feel- ing the position from the outside. I have sometimes been led to believe that the instrument was not in. the canal, by observing the handle, when standing in the urethra. If much inflammation follows your effort at introduction, give your patient mercurial cathartic; but unless it runs high, pay no 52 STRICTURE. attention. Suppuration opens the passage as soon as it sub sides; you find your instrument will pass further, and it has frequently happened in very unpromising strictures that the instrument has passed at the first or second insertion, as you see in the following cases: A Mr. T----, aged 35, called on me with stricture; gen- eral health, good; system, in a like condition. He said I relieved him several years since, but he did not follow my directions, and it returned. Upon introducing a large instrument, I found the stricture at the junction of the bulbous with the membranous portion ; externally, the parts felt hardened. I introduced No. 6, with conical point; used gentle pressure for ten minutes; it entered some half inch, and was grasped tightly by the stricture. A few drops of blood followed; next day the stream enlarged a little. I passed a catheter, No. 10, with very little pressure, in ten or twelve minutes; I found it slowly passing, and soon went into the bladder,, but was grasped very tightly by the stricture. Some blood followed. I ordered parsley-root tea, and blue pill and jalap; directed him to call in three days. When he called again, he said he suffered a good deal of pain the night after the introduction, when urinating; but sine - then his str ji;m has been large and free. Continued the bougies every other day for three weeks, increasing the size to Xo. 14; directed him to continue to use it himself for some months. Many years ago, while a young practitioner, a man about 50 years of age called upon me with stricture, who for several years had never passed his urine in a continued stream. His urethra throughout the whole extent felt like a whip-cord; he had not had an erection for years; the pain in passing urine was very great. By careful manipulation I succeeded in passing, at my first essay, a small elastic catheter. A good STRICTURE. 53 deal of pain and suppuration followed, but his stream was in- creased in size. By increasing the size of the instrument, and introducing it every three or four days, for some weeks, he recovered, and had children afterwards. I find among my memoranda a few instances which show what difficulties occur in the progress of a case: Dec. 23, 1847.—Mr. W----, aged 35, called on me with a stricture. He had contracted gonorrhoea in the East Indies ; had been treated there and in England for stricture, where he was partially relieved, and again partially relieved in this city, about five years since. The size of the stream had been graduall}'" diminishing since that time ; the stream now was a mere thread in size; his general health not very good; tongue furred; ordered a mercurial catheter. Dec. 25.—Medicine operated well; introduced bougie, No. 6, down to near the membranous portion, where there existed an indurated stricture, plainly perceptible on the application of the finger to the perineum. On using the wax bougie, it presented an irregular bulbous form, but of which little could be learned in regard to the condition of the parts. I made some gentle efforts with a conical bougie, No. 6, without much progress; ordered diet, drink, and parsley-root tea at night. Dec. 27.—Made similar efforts every other day: changing the curve of the instrument, without much advancement, until Jan. 17, 1848—when I seemed to get in the right track, and passed the instrument an inch. Jan. 19.—Some little irritation followed the last intro- duction; introduced the same instrument into the bladder to-day; it was grasped very firmly bv the strictured por tion of the urethra, which extended near to the neck of the bladder. 54 STRICTURE. Jan. 21.—Introduced No. 7, and continued every other day to increase the size of the instrument, until Feb. 20th—No. 14 passed easily. He then used the in- strument himself for a few months; has had no return. In this case I found the wax of very little use, as it would not indicate the position of the opening. Hence, we were obliged to rely on gentle, varied, and continued efforts; and where the patient can get his water off, it will be generally found that at each attempt the facility of urinating will be increased, particularly if his diet is regulated and his general health im- proved, so that the necessity of increasing rapidly the size of the passage is rendered less important. I also find the fol- lowing case, which, I think, will illustrate some points in the treatment: Oct. 1, 1840.—Mr. B----, short stature, strong, robust frame, general health good, contracted gonorrhoea five years ago ; neglected it for about twelve months; found his stream diminishing in size, and once, after attending a sleighing party, he had retention for twenty-four hours, which was relieved by the catheter. This was three years before he applied to me ; since then, he has been under the treatment of several physicians—none having been able to introduce the catheter; and as his stream Avas getting very small, he placed himself under my care. Oct. 10.—Found his urine passing in drops, with great pain; every half-hour night and day, ordered mercurial cath., parsley-root tea. Oct. 12.—Less irritation; medicine has operated well; passed No. 10 to the arch of the pubis, where it stopped; I then introduced the wax, found on it the impression of two small, irregular passages. Continued emollient drinks. Oct. 13.—Pain in passing his urine rather less; comes away more rapidly. Introduced No. 6; by gentle pressure it STRICTURE. 55 passed about an inch into the strictured part, then it passed suddenly about an inch further. Not being satisfied that the bougie was in the right track, I questioned him very closely, when he told me, reluctantly, that on coming to the city, he had been prevailed on to put himself under the care of a physician at a small town on the road, who, upon introducing the catheter, had given him great pain, which was followed by a free discharge of blood, without affording him any relief. Being now convinced that a false passage was formed, I ordered him a brisk cathartic, emollient drinks, low diet, warm hip-bath, and rest for a few days, to allow the wound to heal. Urine passes—slightly better. Oct. 22.—Introduced No. 6; passed it a very short dis- tance into the contracted portion. From the 23d to the 30th, made a slight progress each day. His urine now passes in a stream, but very small; there is considerable discharge of pus, and pain in urinating. Con- tinued the same instrument with varied success each day, and sometimes every second or third day, according to the irri- tation produced, until December 15th—when the bougie No. 6 passed into the bladder, increased the size gradually to No. 10; taught him to introduce it himself; discharged him relieved, but not cured, as such cases require many months to be relieved entirely. I was asked to-day, by a patient, why I did not allow the bougie to remain some time in the urethra, as is generally recommended by surgeons. I answered, that I used to pur- sue that practice, but from long observation I had found it useless, except in such cases as I shall allude to. It is so much the fashion to treat stricture with caustic, and has been so highly extolled by men of acknowledged skill, that it would seem like egotism to neglect speaking of that plan. In the 56 STRICTURE. early part of my practice, I was constantly in the habit of using either the vegetable or lunar caustic, and even now I should resort to them under certain circumstances. The last time I used caustic was in the following case: A gentleman, from the West Indies, was sent to me by a physician. He had been several years under his care, with a very irritable indurated stricture, Avhich extended from within an inch of the meatus externus to the membranous portion ot the urethra. May.—He passed his urine in drops, with great pain; he was greatly debilitated, and the desire to urinate was very frequent. The parl-> were so irritable that he would not per- mit me to nse sufficient force to introduce the bougie ; I con- sequently applied the caustic in strong solutions, to allay the irritation of the urethra, allaying as much as possible consti- tutional irritation at the same time. May 14.—Has suffered increased pain for a few hours after the caustic w is applied. Ordered emollient drinks with Dover's powders. May 16.—Irritability somewhat allayed; passed No. 6 about an inch into the contracted part of the urethra. It gave great pain, altho i LITHOTRIPSY. Case 9.—A gentleman of this city applied to me, with symptoms of stone in the bladder. I found him in bed, with all the symptoms of this disease, together with constant pain and Aveakness in the back, Avhich prevented his Avalking or sitting up. He had been under the charge of several surgeons, one of Avhom came prepared to cut the stone out; but, upon intro- ducing the director, could not find the stone, and desisted from the operation. One of the surgeons had attempted lithotripsy, but could not seize the stone, and much pain and irritation folloAved. Upon sounding, and afterwards operating, I found a large stone, Avith what I supposed some smaller ones; he passed in the course of the day a considerable quantity of stone, and no pain or irrita- tion followed. In tAvo days I operated again Avith the same result. I continued to operate every day, until I had operated seven or eight times, doing but little each time, for fear of producing irritation, Avhich might extend to the kid- neys, as they Avere evidently in a diseased condition. Some irritation folloAved about this time, Avhich, hoAvever, soon sub- sided ; and as the pain of passing the urine, and the other symptoms, had been gradually subsiding, I hoped that it all was removed ; but after about tAvo Aveeks, he sent me Avord that the symptoms had returned; I then continued to oper- ate once a Aveek, until I had operated ten or fifteen times, remoA'ing, as I believe, several stones—at least four or five ; his relief Avas instantaneous, Avhen the last piece passed. Be Avent to London soon after, and Avas treated for his disease of the kidneys, and Avrites me that he has entirely recovered his health. Another Case.—A clergyman of New Jersey, from whom [ took a very large stone some ten or tAvelve years ago, came LITHOTRIPSY. 83 to me, Avith symptoms of stone ; upon examination, I found a stone about the size of a boy's playing-marble; broke it at tAvo operations, Avithout pain or irritation. I could give other cases, in Avhich I have cut for stone, since I have practiced lithotripsy, but I think, and I believe I can advance testimony to bear me out in the assertion that, with my present knoAvledge and experience with the instru- ment, there are feAv cases in which I cannot break the stone. I base this declaration upon Avhat is well knoAvn, an extensive experience in the treatment of calculous affections. From the results of these cases, it may be stated: 1st. That every person laboring under stone can be cured Avithout risk of life, provided they apply at an early stage of the disease, and in the case of young children, when they have not more than one stone. 2d. That lithotripsy, as at present practiced, does aAvay, to a great extent, with a bloody and (in all cases) dangerous operation. 3d. That it gives but little pain, and does not interfere Avith the avocations of the patient. It is certainly beyond dispute that it is a great impro\-ement in surgery, giving easy relief to a large class of patients, who have heretofore been doomed to linger out a life filled Avith torture, or submit to the hazardous ordeal of lithotomy. SEMINAL WEAKNESS Is a subject that Ave approach with hesitation, but it is fraught with so much misery to the human family, that Ave feel constrained to give Avhat little Ave know on the subject; it is also a branch of our profession, in which quackery runs riot, and leads to a great deal of misery. It may arise from a A-ariety of causes, but its most common source is onanism; a long continuance of this habit debilitates the general organs, impairs the general health, the nervous system becomes deranged, and melancholy and a host of other diseases folloAv. FeAv persons are aware of the extent to Avhich this habit of self-pollution exists in our country, but long observation has taught me to believe that it ranks among the most potent causes of ill health in our rising generation, especially in cities, and the chronic diseases to Avhich it gives rise are almost innumerable. I will mention a few of them : As the venereal act gives rise to a marked congestion of blood to the head, we may naturally infer that Avhen a person is predisposed to apoplexy, that any venereal excess would be likely to bring on an attack of this affection. I had under my care a gentleman, about 40 years of age, Avho had suffered from seminal weakness, Avith nocturnal dis- charges, the result of masturbation. He informed me that he suffered from pain in the back part of his head, and great prostration Avhen he indulged in this habit, Avhich he found it almost impossible to avoid. One night I Avas called to see him, in great haste. I found him insensible, Avith stertorous breathing, and violent priapism, Avhich continued until he died. Upon opening the cranium, I found the brain suffused SEMINAL WEAKNESS. §5 Avit' blood, especially the cerebellum. Tissot, Serres, Penel, Cruveilhier, and Hoffman, all detail similar cases. Chronic lesions, alteratives, tumors, &c, have terminated the lives of onanists. Desruelies cites a case Avhere there Avas paralysis of the right arm, convulsions of the left, and of the muscles of the face. On opening the cadaver an incysted abscess was found in the hemisphere of the brain. Gall gives an account of a boy addicted to this habit, Avhose cerebellum was found in a state of suppuration. Campbelle gives a case Avhere the entire cerebellum Avas absent, and in its place there was a gelatiniform membrane attached to the medulla oblongata. Of all the diseases that have their origin in self-abuse perhaps none is more common than epilepsy. The ancients considered the act of coition a sort of epileptic fit, and some persons, especially females, are insensible for some minutes after the act. I was consulted by the parents of a boy, about 14 years of age, Avho had been subject to this affection for more than a year. I found that the attacks generally occurred after he had retired to bed. His parents had discovered that his linen Avas A-cry much stained, Avhich induced them to consult me. He eATentually acknoAvledged the habit of onanism. After a year or two of treatment, change of air and circum- stances, and the incessant watchfulness of a pious and kind mother, he finally recoArered. Two other cases, someAvhat similar, have come under my observation. One proved fatal, the other had partially re- covered. Similar cases may be found recorded by Esquirol, Zimmermann, and Goupil. Lauret states that out of 106 patients Avith epilepsy. 12 were caused by onanism. I have treated quite a number of cases of chorea in young girls, produced by this habit of friction of the clitoris. Not long 86 SEMINAL WEAKNESS. since, I Avas consulted by the parents of a girl, about 11 years of age, who Avas at boarding-school (where I find this habit is mostly contracted). After investigating the case, I felt but little doubt as to the cause of the disease. The child was taken home, and closely Avatched, and the habit was soon discovered. I treated her with cold bath, tonics, change of air, &c. and she got over the chorea. In the early part of my professional life, I had under my care a case of chorea, produced by this habit, and, although by tonic and other remedies she was relieved of the chorea, yet it seemed impossible to break her of this horrible habit. She Avould steal aAvay from her nurse, and use the friction. I applied bandages, but she Avould manage to get them loose. I cauterized the vulva without effect; I then excised the clitoris, but it did not afford permanent relief. Her parents then took her to Europe, and she gradually, as she grew older, overcame it by her own resolution. She was a child of fine intellect. Cases have come under my care, where nurses have re- sorted to friction of the clitoris for the purpose of quieting children, and thus established this horrid habit. Dementia is the form of mental alienation that this unfortunate habit leads to. We could detail several melancholy instances that have come under our own observation. Diseases of the medulla spinalis, and cases of the spinal column, marasmus, Avith pul- monary consumption, and almost all the diseases of debility, have been attributed to this habit; but it will be generally found that the predisposition had already existed, and that masturbation was only the exciting cause; otherAvise the amount of disease in the human family Avould be greatly increased. Excessive venery after marriage, in persons of nervous temperament, often produces seminal Aveakness. Several times SEMINAL WEAKNESS. 87 I have been consulted by persons coming to this city from the interior upon a marriage excursion; some cases seemed to have arisen more from nervous apprehension, than any thing else ; rest and abstinence generally restored these kind of cases. Some have complained of their inability to procure erec- tions so as to perform the marital act; others, that the discharge of semen comes before copulation can be accomplished; others, that both the erections and discharges are imperfect, and require a long time to accomplish the act. Most of these kind of cases will be found to have been caused by self-pollu- tion. Some of my patients have attributed their difficulties to long-ungratified excitement. Another painful cause of this disease is gonorrhoea, where the disease has been of long standing, and has affected the whole urethra, or extended into the bladder. It is very apt to leave behind a gleety discharge, with which semen is generally combined, ending in Aveakness of the genital organs. Stricture and diseases of the kidneys sometimes cause weakness of the genital organs. It assumes, also, a considerable variety of symptoms. In some it affects the general health almost immediately. The patients become desponding, and disposed to retire from society. They become pale and emaciated, extremely nerv- ous, and easily agitated. In others, the trouble is local, and seems to be confined to the genital organs only. Gentlemen have frequently called on me, in apparently perfect health, who wished to marry, but expressed a fear that they would not be able to perform marital duty. They often complain of being subject to involuntary discharges, ANhich caused great debility of the genital organs. Some persons are naturally de- fective in genital power, and in these cases the external organs are frequently imperfectly developed. The penis will be small. gg SlfiMINAL WEAKNESS. the prepuce very long, so that the glans cannot be uncovered. In other cases, the external meatus is naturally Ioav doAvn on the under side of the penis, and, most likely, there Avill be a fis- sure in the gland, Avith scarcely any prepuce—approaching, according to St. Hilliare, the female sex. A feAv cases have come under my observation Avhere the external organs Avere not much under the ordinary size, yet the desire for coition had scarcely manifested itself. One remarkable case of this kind came to consult me : he said his friends wished him to marry, but that he had never experienced the same desires that others had described. He Avas a pious young man, had lived a very retired, laborious life in endeav- oring to support a widoAved mother. His diet Avas almost entirely milk and bread, and in the early part of his life he had lived exclusively on milk. I once had a case of a young man, about 18 years of age, whose right parietal-bone was fractured near its posterior part. He Avas a morose, quarrelsome felloAv, Avith strong passions. Upon removing a portion of the cranium, I found the dura mater ruptured, and a portion of the brain exuded, and, at periods during the process of cure, a quantity of the brain passed out of the Avound, but he eventually recovered, and his Avhole character changed. He became pious and gentle in his disposition, and he told me that his Arenereal passions scarcely existed, although almost uncontrolable before the injur)-, Avhich had, in fact, led to the quarrel in which the Avound Avas inflicted. The folloAving case was published by my friend and pupil, Dr. Donne, of Louisville, and illustrates the intimate connec- tion between the posterior portion of the brain and the genital organs: "Mr. S----, an athletic laborer, aged 25, apparentlv of crofulous diathsesis, temperament phlegmatic, not addicted SEMINAL WEAKNESS. 89 to habits of intemperance, received a wound from a rifle-ball, Avhich penetrated the parietes of the cranium, immediately in the postero-superior angle of the parietal-bone, a feAv line? from the lamdoidal suture, and passed in a direction latterallj doAvnwards and backwards, Avithout making egress on the opposite side. An aperient state of the boAvels, light dress- ings, and elevated posture, were recommended, in conjunction Avith warm applications and frictions to the extremities, Avhich Avere cold. As no hopes, under circumstances, could be rationally entertained, the attendant physician AA-as compelled to resign the patient to his fate. Reaction Avas not established until about the third day after the injury; and its develop- ment Avas attended Avith inflammatory symptoms, Avhich, as they progressed, appeared to direct a peculiar sympathetic in- fluence to the genital organs. On the fourth day the dressings Avere resumed, large quantities of cerebral matter discharged, pulse more active : ordered mercurial cathartic, Avhich acted Avell. Fifth day, expressed a desire for food; gruel given him ; ate a small quantity, which was quite palatable. Priap- ism superATened in the evening, Avith delirium: ordered cold applications to the head, saline purgative; patient not so restless, purge acted Avell; rational next day on every sub- ject but that pertaining to venery. Sixth day, more delirious; obliged to exclude the female attendant from the apartment. Seventh day, very restless; language very obscene, and someAvhat incoherent; bowels open, discharges apparently healthy; expressed a desire for food; ate some panada. Eighth day, in a soporose condition, evincing still when roused a salacious disposition; priapism still continues. In this situation he survived nine days, apparently rational on every subject, save the one already alluded to; nor AA'as there the slightest abatement of the priapism, until a feAV moments previous to his death.'' 12 90 SEMINAL WEAKNESS. I could cite quite a number of interesting cases of this kind, but it is not my object in this little book to enter much into the discussion of any subject, but simply to give, in a concise manner, some of the results of my oavii observations. When gonorrhoea has been neglected, badly managed, or protracted in scrofulous or debilitated constitutions, especially if the person indulges in masturbation, it generally assumes a chronic or gleety form, and involuntary discharges of semen is a common consecutive. I have frequently had cases of patients Avho, after a violent gonorrhoea that had extended to the bladder, have lost, for a time, all sexual desire. In all cases, Avhere the genital organs are in a diseased con- dition from self-abuse, the moral and hygienic TREATMENT ire of the first importance. Hence, if you are not able to impress upon your patient the necessity of self-control, you must resort to forcible means. I have had many cases under my care of a most melancholy character, Avhen patients Avere perfectly reckless, having no control over themselves, or alloAving any one else to influence them. Others, again, mourning over their inability to control themselves, Avould meekly submit to all sorts of mechanical means for restraint. Cases similar to the following are of common occurrence, and sIioav the plan of treatment I have generally adopted : A boy, about 16, Avas brought to me. It Avas observed that he had lately become very melancholy, resorting to soli- tary places—aA'oiding his companions at school. The laun- dress reported his linen very much stained. I found that he had practiced masturbation for several years : that his parts had become so Aveakened, that the least friction Avould pro- duce a seminal discharge; and at night it frequently passed SEMINAL WEAKNESS. 91 involuntarily. 1 also found a slight trace of pus in the dis- charge. His general health Avas impaired; his tongue Avas furred; his boAvels habitually costive; his nervous system irritable; he had indulged in coffee and tobacco to excess; his appetite poor ; his digestion imperfect; his natural devel- opments were good; his head rather large for his lungs. I endeavored to portray his sad condition to him in high colors. Ordered him to take a mercurial cathartic, Avith three grs. of quinine. After this had operated, directed him to take a tablespoon full of the following mixture, morning and evening, in water and claret wine : #. Ex. Sarsap., § ss. Sesquiox. Ferri., I i. Nux. Moscha., ^i. Syr. Zinzi., fti. To sponge the body in cold water once a day, to use cold- Avater enemas after every stool, and at night to introduce into the rectum the following prescription, alloAving it to remain until morning: #. Ex. Cincho., Ex. Gentian, Pul. Moschi., a. a. grs. x. Tine opii., gtts. xv. Pul. G. Camp., grs. v. Solu. G. Arabic, I i. I directed him to keep his boAvels regular with pills of a. a. Comp. ex. Colocy. and castile soap. I applied a solution of nit. of silver, ten grs. to the ounce of water, to the neck of the bladder, every three or four days, by means of a little pump, g2 SEMINAL WEAKNESS. formed by placing on the end of the stiletto of a catheter a little cotton; required him to sleep in a hard bed ; to tie his hands to the bed-post at night. By these means he Avas par- tially restored, but not entirely, until he Avent to the country, and pursued an active out-door employment, so as to be able to sleep soundly at night. In these kind of cases it is often very difficult, oAving to the circumstances of the patients, to get them to use the necessary hygienic remedies, but in bad cases it is hardly possible to relieve them without this aid. In cases where the vesicula seminales is in a morbid con- dition, I find that no remedy is so effectual as the application of nit. of silver in solution. Much has been said and written against this practice, and many cases are detailed Avhere in- jurious results have arisen from it; but the reason Avhy it has proved injurious is, that it has been used Avithout due regard to the condition of the patient, and in no case ought it to be used until the secretory and excretory organs are in healthful condition; and if the irritation arising from its use is at all troublesome, I find it easily removed by a copious drink of parsley-root tea, or an enema of cold Avater ; and I have a few times in my life, Avhere the pain Avas very great, after inject- ing it freely and strong into the bladder, found it necessary to use Avarm Avater injections into that cavity. Another reason that may have led to difficulty from the use of this substance is, that it has generally been recommended to be applied in substance, or in a poAvder, placed in a port caustic, and any one can easily imagine that a very troublesome eschar might be produced in that Ava}\ In persons avIio have suffered a long time, and Avhere there is great nervous irrita- bility, it is best to use bougie for several days, to allay irrita- tion ; then use a weak solution, and gradually increase the jtrength. SEMINAL WEAKNESS. (,g Cases similar to the following sometimes come under my care: A man, about 30 3-ears of age, Avho Avas engaged in the Florida Avar, suffered, Avhile there, from a violent attack of dysentery. Since his recovery, he had never experienced sexual desire, and as he Avished to marry, he applied to me for relief. I found that his digestive apparatus Avas still someAvhat impaired; that he Avas subject to diarrhoea Avhenever he in- dulged in certain kinds of food. I ordered him country air and exercise, Avarm salt bath, a blue pill every four days, Avith simple diet, and as soon as his alimentary canal assumed its natural condition, I directed the folloAving alterative tonic : p. Ex. Sarsap., § ss. Iodide Potas., 3SS. Sesquiox Ferri., I ss. Syr. Simp., ftj. A tablespoon full morning and eA7ening, in Avater. To use the tonic injection, heretofore mentioned, modified so as to suit the irritable state of his rectum, and to keep his bowels regular Avith rhubarb. I then applied the nit. of sil- ver solution, and in the course of a feAv months he Avas restored. Was married, and had children. The folloAving case Avas lately under my care : A boy, about 18, Avho had been several years very much confined, and sitting at a desk, on a high stool, complained of constant sensation of coldness in the external organs of gen- eration, Avith contraction of the parts; entire absence of venereal appetite. His general health Avas very good. There seemed to be no apparent cause for the symptoms; he thought 94 SEMINAL WEAKNESS. it arose from sitting too long on a hard seat. I prescribed the folloAving tonic : #. Sesquiox. Ferri., $ i. Mix. Moscha., ^ij. Sem. Card., <;iij. Yin. Bordeaux, ifej. A wine-glass full at each meal; to use a suppository of Camp., Musk, and Opium ; to bathe his hips in warm water every night, and gave him ten drops of tine, cantharides tAvice a-day : increasing the dose until it produced stranguary ; then, to relieve the irritation, use freely the parsley-root tea; after a feAv days, to use it again. I directed him to go to the country, and Avork on a farm. After using the cantharides, he soon began to feel natural sensations, and finally recovered. Great care is necessary in the administration of the can- tharides. So soon as the least irritation at the neck of the bladder occurs, I commence Avith the emollient drinks; or if it does not subside rapidly, a brisk cathartic Avill soon giAre relief. I frequently combine nit. of potash Avith the drinks—they will give relief in a shorter time. I have generally used this remedy in cases AArhere the disease seemed to be strictly local, without general derangement of the health. I have some- times used this remedy Avhere the seminal Aveakness Avas ac- companied Avith a gleety discharge, AA'ith good effect. As an external remedy, applied to the perinaeum, cantharides will often be found beneficial in obstinate and protracted gleets. This substance is the basis of all the quack remedies that are advertised for the cure of seminal diseases, and I have several times Avitnessed serious effects from its incautious use In cases Avhere seminal Aveakness is produced by excessive venery in young married persons, they, of course, must be SEMINAL WEAKNESS. 95 treated upon the same general principles that I have indi- cated ; but generally abstinence will restore the parts to their original vigor. We have had a very interesting case lately, of a young gentleman who contracted the habit of self-pollution at col- lege. He Avas a hard student; graduated with high honors; contracted gonorrhoea soon after leaving college, of Avbich he was imperfectly relieved. His habits have been very stu- dious and sedentary. He Avas troubled Avith nocturnal emissions of a thin, glairy fluid from the urethra; there Avas a Aveakness in the loins and joints; great depression of spirits, with an affection of the eyes, resembling amaurosis. I advised him to give up all sedentary pursuits—take active exercise in the country—to use alteratives and tonics; cold bathing to the body in the morning, Avith hot hip-bath at night. I applied the nit. of silver to the neck of the blad- der frequently, and he has entirely recovered, after some twelve months' treatment. We might detail a variety of cases, and the treatment adopted, but there are so many circumstances to be taken into consideration, that must necessarily modify the course to be pursued in the management of these diseases, that it is only necessary to consider the best method Ave can take to improve the general health, and then the local remedies may be re- sorted to Avith good hope for success. I have met Avith several cases of partial paralysis resulting from excessive venery. A gentleman, about 40 years of age, applied to me, Avho complained of loss of venereal desire, and absence of erections. He did not follow my advice, nor Avould he sub- mit himself to treatment. In a feAv months, he complained of inability to empty his bladder ; and again, in a feAv months, I observed he tottered in Avalking, and Avas obliged to use a ;ane. He got into the hands of quacks: Avas umvilling to pay 96 SEMINAL WEAKNESS. regular physicians, being excessively penurious. He lost the use of his limbs; all the symptoms became aggravated, and in five years he died. In another case, paralysis of the right hand folloAved the seminal weakness. I have lately seen an article taken from the Charleston Medical Journal, in relation to the use of the plug in pertes seminales, which brings to my mind a case of hemorrhoids, that I treated partly by excision, and afterwards by the hemorrhoidal plug. This patient Avas also troubled with nocturnal emissions. After he had used the plug for some Aveeks, he AA-as relieved from both these affections, and I think it very likely that the plug had a salutary effect upon the seminal discharge, although it did not occur to me at the time, and I shall hereafter test the value of the remedy. THE END. IT»!*freS«HS ">'yttUr-Mr*lfaW m «**» ■■& QKSflr k *! %■***. 'jSTJW'l?