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V- do Aavaan tvnouvn 3nidio3w do Aavaan tvnouvn dNioiaaw do Aavaan tvnouvn dNiDiaaw do Aa IBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAF jo Aavaan tvnouvn dNiDiaaw do Aavaan tvnouvn aNioicnw do Aavaan tvnouvn dNioiaaw do a* OX THE i^ REPRODUCTIVE ORGANS AND THE VENEREAL. B Y JOHN M. gCUDDER, M. D. fROFESSOR OF PATHOLOGY AND THE PRACTICE 01' MEDICINE IN THE ECLECTIC MEDICAL tWSTITUTE ; AUTHOR OP THIS ECLECTIC PRACTICE OF MEDICINE, DISEASES OP WOMEN', DISEASES OP CHILDREN, MATERIA MEDICA AND THERAPEUTICS, THE PRINCIPLES OP MEDICINE, SPECIFIC MEDICATION, THE USE OP INHALATION'S, ETC., ETC. WITH COLORED ILLUSTRATIONS OP SYPHILIS. <( Honi soit qui inal y pense." THIRD EDITION. CINCINNATI: JOHN M. SCUDDER, PUBLISHER. 1890. WTA \S90 Entered according to Act of Congress, in the year 1873, BY JOHN M. SCUDDER, In the office of the Librarian of Congress. ] i i PREFACE. The author begs leave to introduce this work to the reader as a plain statement of facts which deserve careful consideration. It may shock the modesty of some, but it is to be hoped that the majority may see the necessity and the great good which may grow out of this study. Physicians have manifested a degree of mock modesty with reference to diseases of the reproductive function, which has prevented their investigation, and turned the man}' sufferers over to the hands of advertising quacks and char- latans. There may be some excuse for this in the " innate" modesty of man, but the time has now come when an intelligent knowledge is demanded. It will not now do for a physician to shrug his shoulders, and elevate his eyebrows at the mention of masturbation, spermatorrhoea, marital excesses, etc. There are a great many wrongs in the sexual life of the people causing disease, which might be righted did the physician know, and should he exert his influence in a right direction. His rela- tion to the public is not alone as a dispenser of drugs, he should be a teacher in addition. And to whom, if not to the profession, can the people turn for this information ? Some of the conclusions reached by the author may not suit the views or the prejudices of the reader, but all that is asked for them is a candid consideration. We live in a wicked world, and the millenium will hardly come in our time, and we have therefore to think of these sexual evils in the light of greater and less, and not as that which may be wholly eradicated. The writer has no VI Preface. desire to defend prostitution, but claims that the female prostitute is no whit worse than the male, and should receive the same treatment. Lastly, it has been the intention to point out that right education is the best means for the cure of these social wrongs, and that they can not be cured by the enactment of pro- hibitory laws. The chapters on the venereal disease have been written with reference to the wants of the general practitioner, and not the specialist. The description of disease will be found plain, and the treatment one which will give success. The author has endeav- ored to study the therapeutics of these diseases without prejudice, and has presented his conclusions both for and against certain powerful remedies, used in the treatment of syphilis. TABLE OF CONTENTS. THE REPRODUCTIVE FUNCTION,.....17-2? Instinctive, and will have gratification, 1. Use of, 2. Provisions for gratification, 3. Monogamy, 4. Apology for its consideration, 5. The moral aspect, 6. Bad teaching, 7. The marital mantle, 8. Influence of Religion, 9. The law of Moses vs. the law of Christ, 10. Retribu- tion in a future state, 11. Prohibitory laws, 12. Prostitution an ele- ment of our civilization, 13. Polygamy, 14. Physiology a better guide than religion, 15. First law of our being, 16. Training of children, 17. Innervation of the sexual organs, 18. Innervation from the sympathetic, 19. Influence of disease in women, 20. Abuse of the reproductive function, 22. Sympathetic relations, 23. Good innervation necessary, 24. Development of the species, 25. Spinal innervation, 26. Reproductive act reflex, 27. Examples of reflex in- nervation, 28. In cases of spermatorrhoea, 29. The reflex function in woman, 30. Coition becomes a habit, 31. Innervation from the brain, 32. Reproductive function in the brain, 33. Reproduction of the species, 35. Reproductive instinct, 36. Right and wrong associa- tions, 37. The millenium, 38. Development of the social evil, 39. Control of the social evil, 40. To mend a bad life, 41. Prostitution a species of monomania, 42. THE SEXUAL ORGANS, ------- 28-33 Classification, 43. The penis, 44. The prostate gland, 45. The vesi- culse seminales, 46. The testes, 47. The labia majora, 49. The labia minora, 50. The clitoris, 51. The meatus urinarius, 52. The vagina, 5.3, The uterus, 54. The fallopian tubes, 55 The ovaries, 56. viii Contents. GENERATION,..........33"4S No spontaneous generation, 57. Sperm cells and germ cells, 58 Pro- vision for the perpetuation of the species, 59. Passional attraction. 60. Sexual sense pleasurable, 61. Repugnance of the female, 62. Coition, 63. Instinct strongest in the male, 64. Marriage necessary, 65. Action of the male, 66. The seminal dischaige, 67. Variations in different persons, 68. The procreative age, 69. Action in the female, 70. Increased flow of blood, 71. Reflex action, 72. Action of the uterus, 73. Physiological errors, 74. The function of the clitoris, 75. The function of the uterus, 76. Disease of the sexual function, 77. Duration of the venereal act, 78. Women have less desire than men, 79. Coition incomplete, 80. Causes disease, 81. Immediate effect of the act, 82. Subsequent effect of the act, 83. Repetition of the act, 84. MASTURBATION, -_ i ----- - 49-63 Immaturity of the reproductive organs in childhood, 85. Sexual igno- rance in childhood, 86. Early abuse, 87. Habits easily broken up, 88. Masturbation in boys, 89. The health suffers, 90. Means of cure, 91. Remedies for, 92. Involuntary masturbation, 93. General treatment of, 94. Masturbation after puberty, 95. Followed by a sense of dis- gust, 96. Commencement of, 97. Effects of, 98. Thehabitsometimes lasts for life, 99. Singular cases, 100. Results of. 101. The habit may be broken up, 102. Requires a strong effort, 103. Influence of woman, 104. Active employment, 105. Influence of masturbation upon the mind, 106. Remedies for, 107. General treatment, 108. Masturbation in woman, 109. A vice of boarding schools, 110. Periods of life when the tendency is strongest. 111. Less gratification, 112. Ingenuityin gratifying desire, 113, Women suffer from masturbation, 114. Local disease, 115. Treatment, 116. Marital excesses, 117. Marriage gives freedom, 118. Absurd ideas, 119. Virility, 120. Marital excess the rule, 121. The wife suffers most frequently, 12 2. Injury to the health, 123. Moderate indulgence, 124. The complete act, 125. Prostatorrhoea and spermatorrhoea from abuse, 126. Im- pairment of the general health, 127. Single beds, 128, 131. Rights of the wife, 129. Rectifying marital wrongs, 130. PROSTITUTION, .........63-68 Sexual instinct, 132. Primitive man, 133. Ownership in woman, 134- Provisions of nature, 135. Early history of, 136. Has existed in every age of the world, 137. Loves darkness, 138. In Greece and Rome, 139. Modern prostitution, 140. Influence upon the health, Contents. IX 141. Causes disease of the reproductive organs, 142. Assignation houses, 143. Kept mistresses, 144. The duty of society, 145. Means of prevention, 146. Make labor honorable, 147. Inefficiency of legal enactments, 148. The male prostitute, 149. PROSTITUTION THE CAUSE OF VENEREAL DISEASE, 69-74 Prohibitory laws, 150. It may be regulated, 151. Early origin of venereal diseases, 152. Early medical writers, 153. In the fifteenth century, 154. Supposed origin in America, 155. Modern history, 156. Periods of virulence, 157. Influence of intelligence and wealth, 158. In armies, 159. Personal cleanliness, 160. Preven- tive means, 161. IMPOTENCE IN THE MALE,......74-81 Men value sexual power, 162. Mental suffering from loss, 163. True impotence rare, 164. Undue excitation, 165. In the newly married, 166. Treatment of, 167. Impaired innervation, 168. Treatment of, 169. Structural Impediments, 170. Malformation of penis, 171. Congenital chordee, 172. Chronic chordee, 173. Irritable urethra, 174. Stricture of the urethra, 175. Hypospadias and epispadia^ 176. Short fraenum, 177. Phimosis, 178. Paraphimosis, 179. Enlarge- ment of the prostate, 180. Hemorrhoids, 181. From the use of a truss, 182. Non-descent of the testes, 183. Varicocele, 184. Pen- dulous scrotum, 185. Structural disease of testes, 186. IMPOTENCE IN THE FEMALE. .....81-87 Less venereal excitement, 187. No reciprocity in the sexual act, 188. Mutual coldness, 189. Onanism, 190. Vaginismus, 192. Stricture of the vagina, 193. Fleshy or fibrous hymen, 194. Physical ina- bility, 195. Remedies, 196. Sterility, 197. Sterility dependent upon imperfect ovulation, 198. Treatment of, 199. Dysmenorrhea, 200. Congestion of the lower segment of uterus, 201. Incompati- bility of temperament, 202. SALACITAS. ....... - - 88-96 Lascivious madness, 203. At the period of puberty, 204. Treatment of, 205. In persons of regular life, 206. Obscene literature, 207. Treatment, 208. Of a debauched life, 209. Satyriasis, 210. Nymph. omania, 211. Clitoridectomy, 212. Suffering of widows, 213. Treat- ment of, 214. X Contents. SPERMATORRHEA. -------- 96-1iu Causes of, 215, 217. Stages of. 216. Prom local disease, 218. Irrita- ble urethra, 219. Masturbation as a cause, 220. Developed slowly, 221. Easily diagnosed, 222. General appearance, 223. First stage of the disease, 224. Influence upon the mind, 225. Influence upon the vegetative functions, 226. Mental disease, 227. Want of con- centration, 228. The advanced stage of the disease, 229. Prognosis is favorable, 230. Treatment, 231. Treatment, where there is hyper- emia, 232. Treatment, where there is ansomia, 233. Treatment, for the cerebral symptoms, 234. Treatment, for the prostatic disease, 235. Faith an essential, 236. Indications for special remedies, 237. Topical treatment, 238. Counter-irritation, 239. Spinal erythism, 240. Perineal atony, 241. Pendulous scrotum, 242. Hernia, 243. Distended bladder, 244. Must break off all vicious habits, 245. SPERMATORRHOEA IN WOMEN......110-1 IE A misnomer, 246. Man and woman alike, 247. Causes, 248. Nervous ills, 249. Plain English, 250. Continence necessary, 251. Two classes, 252. Symptoms, 253. Local erythism, 254. With anaemia, 255. Symptoms the same as in the male, 256. Diagnosis, 257. Prog- nosis, 258. Treatment, 259, 261. Treatment, topical, 260, 262. Spi- nal irritation, 263. DISEASES OF WOMEN INCIDENT TO PROSTITUTION. 116-143 Some suffer but little, 204. Vulvitis, 265. Similar to balanitis, 266. Treatment, 267. Chronic deep-seated vulvitis, 272. Urethritis, 273. Treatment of, 275. Irritable urethra, 277. Treatment of, 278. Vaginitis, 281. Diagnosis, 283. Treatment, 284. Chronic vaginitis, 286. Diagnosis, 287. Treatment, 289. Local remedies, 292. Acute metritis, 294. Treatment, 296. Chronic metritis, 300. Uterine dis- placements common, 305. Treatment, 30.6. Local treatment, 311. Ovaritis, 312. Treatment, 316. Neuralgia, 319. Situation of pain, 321. Treatment of, 322. GONORRHOEA OF WOMEN. ------ 133-135 Difference from the male, 327. Specific character of the venereal poisons, 328. Contact necessary, 329. Situation of, 330. Varies in intensity, 331. Varies in duration, 332 Symptoms distinct 333. Progress of the disease, 335. Rectal and vaginal tenesmus, 336. An examination, 337. The specific character of the disease may prevent treatment, 339. Local treatment, 345. Chronic cases, 346 Contents. xi SYPHILIS IN WOMEN........138-143 Three distinct venereal diseases, 347. The single sore, 348. The exam- ination must be thorough, 349. Propagation of the contagion, 350. May be developed upon mucous membrane or skin, 351. Local symptoms may be slight, 352. Hard and soft chancre may be present together, 353. Treatment, 354. Treatment of soft chancre, 355. Cauterization of hard chanore, 356. A chancre may be excised, 357. The stronger escharotics. 358. Mayer's ointment as a dressing, 359. Astringents and stimulants, 360. Dry dressings, 361. Treatment without cauterization, 362. Constitutional treatment, 363. DISEASES OF THE MALE ORGANS OP GENERATION, 144-216 Inflammation of the penis, 364. Symptoms, 365. Course, 366. Treat- ment, 367. Local treatment, 368. Balanitis and posthitis, 369. Has a sore penis, 370. Elongated prepuce, 371. Prepuce short and re- tracted, 372. Treatment, 373. Verrucca, 378. Gonorrhceal warts, 379. Situation, 380. A cause of irritation, 381. Treatment, 382. The means of removal, 383. Constitutional treatment, 384. Phimo- sis, 385. Phimosis in case of chancre, 386. Treatment, 387. Atten- tion to cleanliness, 388. CGdema, 389. Operation, 390. Circum- cision, 391. Circumcision conducive to physical well-being, 392. Elongated prepuce a cause of sexual excess, 393. Operation of Gross, 395. Paraphimosis, 396. Symptoms, 397. Treatment, 398. Operation for, 399. Urethritis, 401. Symptoms, 402. Diagnosis from gonorrhoea, 403. Usually milder, 404. Treatment, 405. Hem- orrhage from the urethra, 408. Diagnosis, 409. Treatment, 410. Urethral calculi, 411. Treatment, 412. STRICTURE OF THE URETHRA, ----- 160-179 An organic contraction, 413. Transitory stricture, 414. Exciting causes, 415. Treatment, 416. Congestive stricture, 417. Treatment, 418. Permanent stricture, 419. Cm?'" of, 420. Seat of, 421. Num- ber and character, 422. Degrees of contraction, 423. Results of stricture, 424. Symptoms, 425. Causes. 426. Diagnosis, 427. Treat- ment, 428. Treatment by dilatation, 430. Treatment by gradual dilatation, 431. Introduction of instruments, 432. Continuous dila- tation, 433. Over-distension or rapid dilatation, 434. Rupture, 435. Incision—internal urethrotomy, 436. External urethrotomy 437. xii Contents. PAGE Caustics, 438. Consequences of operations, 439. Retention of urine, 440. Perineal urethrotomy, 442. Puncture through the rectum, 443. Puncture above the pubes, 444. Puncture through the symphisis, 445. Extravasation of urine, 446. Treatment of, 44 7. Urinary abscess, 448. Symptoms of, 449. Urinary fistulae, 451. Treatment, 452. Penile fistulae, 453. Acute prostatitis, 454. Causes, 455. Treat- ment, 456. Constitutional disturbance, 457. Difficult micturition, 458. Duration of disease, 459. Diagnosis, 460. Prognosis, 461. Treatment, 462. Chronic prostatitis. 466. Causes, 467. Symptoms, 468. Violent paroxysms, 469 Diagnosis, 470. Prognosis, 471. Treatment, 472. Prostatorrhoea, 476. Errors in diagnosis, 477. Bladder is diseased, 478. Treatment, 479. Chronic cystitis. 482. Symptoms, 483. In some cases very severe, 484. Diagnosis, 485. Post-mortem appearances, 487. Treatment, 488. Local treatment, 507. External applications, 508 Orchitis, 509. Symptoms, 510. Course of the disease, 511. Gonorrhoeal orchitis, 513. Diagnosis, 514. Treatment, 517. Chronic orchitis, 522. Symptoms, 523 Diagnosis, 524. Prognosis, 525. Treatment, 526. Structural disease of the testes and scrotum, 534. Strumous disease of the testes, 535. Symp- toms, 536. Diagnosis, 537. Treatment, 539. Degeneration of the testes, 542. Diagnosis, 543. Treatment, 544. Cystic disease of tes- ticle, 546. Diagnosis, 547. Excision, 548 Cancer of the testicle, 549. Diagnosis, 550. Scirrhus, 551. Treatment, 553. Varicocele, 554. Causes, 555. Progress, 556. Diagnosis, 557. Treatment, 568. Operation for, 559. Hydrocele, 560. Diagnosis, 561. Treatment, 562. Operation for, 563. Hydrocele of children, 565. Hematocele, 566. Diagnosis, 567. Treatment, 568. Tumors of the scrotum, 570. Operation lor, 571. Sebaceous tumors. 572. Operation for, 573. Epithelioma of scrotum, 574. Description of Paget, 575. Treat- ment, 577. Arsenical paste, 579. Chloride of zinc, 580. Pediculus pubis, 581. Diagnosis, 582. Propagation, 584. Treatment, 585. VENEREAL DISEASES. ------- 217-2^ The result of venereal excesses, 587. Epidemic cycles, 588. Varia- tions in intensity, 590. Triality of the venereal poison, 591. Each a distinct virus, 592. Two or three may be present in the same per- son, 593. Diagnosis is sometimes difficult, 594. The specific conta- gions somewhat alike, 596. How to avoid the venereal, 597. Clean- liness the best protection, 598. Secondary syphilis contagious, 599. Coition with disease, 600. Usually contracted in the natural way, 601. Contents. xiii GONORRHOEA, .........221-257 A specific inflammation, 602. The virus a muco-pus, 003. Contact necessary to propagation, 604. Period of incubation, 605. Sexual intercourse the common origin, 606. Symptoms. 607. Chordee, 610. Duration, 611. Diagnosis in, 613. Chancre of the urethra, 614. Treatment, 615. Speedy cures, 616. Disease self-limited, 617. Local treatment, 618. Objects of, 619. Abortive treatment, 620. Nitrate of silver, 622. Much depends upon the method of use, 623. Nitric acid, 624. Chloride of zinc, 626- Sulphate of zinc, 625. Permanga- nate of potash, 627. Rest necessary in the abortive plan, 628- De- struction of the specific character of the virus, 629. To relieve the local inflammation, 636. Cold water cure, 637. Treatment with suppositories, 643. Tannin and glycerine, 644. Internal remedies, 646. Frequent micturition, 656. Chordee, 657. Treatment, 659. Phimosis, 661. Hemorrhage, 662. Abscess, 603. Unpleasant sensa- tions. 664. Enuresis, 665. Ischuria, 666. Prostatitis. 668. Cystitis, 670. Orchitis, 671. Gonorrhceal ophthalmia, 679. Symptoms, 680. Ulceration, 682. Treatment, 683. Free incision of the conjunctiva, 692. Gonorrhceal inflammation of the nose, 695. Treatment, 696. Gonorrhoeal disease of the rectum, 697. Treatment, 700. Cellulitis, 702. Gonorrhceal rheumatism, 703. Pathology, 704. Diagnosis, 705. Treatment, 706. Gleet, 710. Symptoms, 712. Diagnosis of conta- gion, 713. Treatment, 716. Gonorrhoea! sequelas, 721. Disease of the articulations, 722. Disease of the heart, 723. Disease of the spinal cord, 724. Effects may be very persistent, 725. Especially in women, 726. STPHILIS, ... - .....258-376 Definition, 728. Virus is contained in pus, 729. How communicated, 731. First a primary disease, 732. Primary syphilis, 734. Chancre and chancroid, 736. Chancroid the severest local disease, 737. Diag- nosis between chancre and chancroid, 738. Multiple sores chancroid, 739. Exceptions, 740. Cases from Ricord, 742. Illustration from Hopital du ^Iidi, 748. Inoculation, 749. Chancroid easily propa- gated, 750. Chancre only inoculable in second person, 751. Diag- nostic table, 756. XIV Contents. PAOE. CHANCROID, ..........269 Purely a local disease, 758. Period of incubation, 760. Multiple ulcer, 761. Situation of the sores, 762. Upon the prepuce, 763. Phymosis, 764. The chancroid painful, 765. Development, 766. Progress, 767. The virus resides in the pus globules, 768. Inflam- matory chancroid, 769. Sloughing, 770. Phagedenic chancroid, 771. Serpiginous chancroid, 773. May commence in a virulent bubo, 775. Treatment, 776. Escharotics, 7 78. Dressings, 779. Concealed chan- croid, 793. Treatment of inflammation, 795. Treatment of slough- ing, 797. Treatment of phagedena, 798. Treatment internal, 800. Bubo, 802. Upon the affected side, 803. Bubo of chancroid sup- purates, 804. Symptoms, 806. Bubo of indurated chancre, 809. Classification, 810. Virulent bubo, 811. Primary bubo, 812. Non- virulent bubo, 813. Diagnosis, 815. Treatment, 817. Treatment for abortion of, 818. Dressings, 822. Syphilitic vegetations, 825. CHANCRE,...........288 Incubation, 830. Situation, 831. Typical chancre, 832. Induration, 833. Ulcus elevatum, 833. Induration after healing, 835. Diagno- sis, 836. Constitutional infection, 842. Urethral chancres, 837. Se- condary symptoms without primary disease, 838. Treatment, 843. Escharotics, 844. Elevated chancre, 847. General treatment, 848. SECONDARY SYPHILIS,........29S Theory of disease, 855. Secondary symptoms may be transmitted, 856. Incubation. 857. Duration of, 858. Diagnosis, 859. Syphilitic erup- tions, 861. Prognosis, 862. General treatment, 863. Pathology of disease, 865. Indications of cure, 866. Mercury in, 867. Views of Dr. Bennett, 868. Swedish report on, 869. French report on 870. Action of mercury, 872. Seems curative in some cases, 873. Imper- fect teaching, 874. Mercury in indurated chancre. 875. Reverse the picture, 876. Has not been studied aright, 877. Indications and contra-indications, 878. Preparations of iodine, 880. Should be studied with care, 881. Iodide of potassium, 882. Iodide of ammo- nium, 883. Iodide of lime, 884. Saline diuretics. 885. The water cure, 886. Use of diluents, 887. The wet-pack, 889. Vegetable Contents. xv alteratives, 890. .Tonics and restoratives, 894. Compound tonic mix- ture, 906. Nitric acid, 908. Arsenic, 909. Chloride of gold and soda, 920. Baths, ^85. Medicated baths. 886. LESIONS OF SECONDARY SYPHILIS. - - - - - 324 Classification, 888. Pathology, 889. Disease of the blood, 890. Af- fecting the materials of nutrition, 891. A species of degeneration, 892. Syphilitic fever, 893. Increase of temperature. 894. Classed with the eruptive fevers, 895. Prodroma, 896. Hectic fever, 898. Treatment, 899. Special remedies, 904. Treatment of hectic, 905. AFFECTIONS OF THE SKIN AND ITS APPENDAGES, - 328 Erythema, 907. Papulae, 908. Squamae, 909. Lepra, 910. Pityriasis, 911. Psoriasis, 912. Vesiculae. 915. Bullae, 916. Rupia, 917. Pus- tulae, 920. Eothyma, 921. Impetigo, 922. Acne. 923. Tuberculae, 925. Ulcers, 931- Mucous tubercle, 935. Sometimes transmissible, 936. Gummy tumors, 942. Alopecia, 943. Onychia, 945. DISEASES OF THE RESPIRATORY APPARATUS, - - 341 Nasal cavities, 948. Ulceration of, 949. Treatment, 950. Local treat- ment, 951. Syphilitic laryngitis, 956. Ulceration, 959. Impair- ment of the general health, 961. Post-mortem appearances, 962. Treatment, 963. Disease of bronchiae and lungs, 968. Description of Aitkin, 969. Treatment, 970. DISEASES OF THE DIGESTIVE ORGANS, - - - - 353 Diseases of the mouth and throat, 973. Ulceration of throat, 974. Tubercle of tongue, 977. Fissures of tongue, 978. Gummata of throat, 979. Symptoms, 980. Destructive ulceration, 981. General treatment, 983. Local treatment, 984. Disease of the oesophagus, 985. Nervous dysphagia, 986. Disease of the stomach, 987. Disease of the liver, 988. Disease of the intestinal canal, 990. Disease of the rectum, 991. Mucous tubercle of the anus, 992. xvi Contents. DISEASES OF THE NERVOUS SYSTEM, ... - 358 Muscular pains, 993. Neuralgia, 994 Disease of the brain, 996. Gummata of the brain, 997. Degeneration of the brain, 998. Wilks on, 999. Symptoms of, 1000. Pain in the head, 1001. Paralysis, 1002. Syphilitic iritis, 1004. Symptoms, 1005. DISEASES OF THE BONES. - -.....362 Influence of Mercury, 1010. Nodes, 1011. Situation, 1012. Treat- ment of, 1014. Nocturnal pains, 1016. Treatment of, 1018. Syph- ilitic periostitis, 1019. Disease of the bones, 1020. Severity of the lesion, 1022. Syphilitic orchitis, 1023. Progress, 1024. But little power, 1025. Treatment, 1026. INFANTILE SYPHILIS,......- - 368 SYPHILIZATION, 370 O N THE REPRODUCTIVE ORGANS AND THE VENEREAL. THE REPRODUCTIVE FUNCTION. 1. The reproductive function in man is so purely animal in its nature, and so little under the influence of the moral sen- timents and the will, that we are surprised, not that diseases of these organs are fouud, but that they are not of more fre- quent Occurrence. The intense passional feeling that prompts intercourse between the sexes, may be and is controlled by education in the majority, but in a minority it is so in excess that it must and will have gratification at any risk, moral or ph3rsical. 2. It is probable that this needs be to perpetuate the species, otherwise the cares of parentage, and the struggles necessary to provide for offspring, would so influence man that the race would soon be extinct. As it is, there is no condition so ab- ject, no suftering so great, and no future so miserable, that men will not endure it to gratify this passion. 3. Society provides for its normal gratification, and for its legitimate use,s, by the marital relation. The pairing of the sexes is a law of nature; how it shall be done is a law of society, and is the outgrowth, as a general rule, of the needs of the people. In different ages of the world and in different countries we find variations of the marriage relation. In the 2 18 The Reproductive Organs. early ages of mankind, this relation was, in all probability communistic, there being no bonds between individual males and females, the women of a tribe being held in common. This would place man on the plane of the animal and vege- table kingdom, and would give free play to the law of " natu- ral selection," and the " survival of the fittest." Following this, came a division of women among the males, as a species of property; and as with other property, the stronger and more intelligent would secure the largest number, polygamy was the first result. 4. As men became organized into societies, and individual rights were recognized, the right of each man to a woman was conceded, and as the sexes became equal in numbers, monogamy was the necessary result. 5. If we are to study this subject intelligently, and espe- cially with reference to the prevention of disease, it is neces- sary that we fully comprehend the nature of the reproductive function, the intense and sometimes uncontrollable passional attraction between the sexes, and the outgrowth from this of the marital relation and its laws as a means of protection against the abuse of the sexual organism. If any apology is necessary for the free discussion of the subject, this must be my apology. 6. The Moral Aspect of the Case.—We are met at the threshhold of this investigation by a class of moralists who say—" it is not wise to discuss the subject;" "it is impure and can but lead to impurity." Whilst it is patent to all that the " social evil," so called, runs riot, and that our whole people are influenced to some extent by sexual vice, these say that from its very nature it must not receive consideration from society or from law, and especially do they insist that no means looking to the modification of the evil shall be adopted, because that would necessitate its recognition—" there is only one way, enforce the commandment—Thou shalt not com- mit adultery." The Reproductive Organs. 19 7. Such teachers ignore the necessity of the reproductive function, the intensity and at times uncontrollable character of the passional desires of the sexes, and that it must and will have satisfaction, and that it may be controlled to the good of society or abused to its harm. 8. With these everything is good that is covered by the marital relation, everything is evil outside of it. Covered with the marital mantle, they give unbridled license to their own passions, frequently at the expense of the health, happiness and lives of their hapless wives, and yet they can not see that other men and women are of like nature with themselves. Such men are pious and religious withal, but their piety is pharisaical and their religion based upon precepts four thou- sand years old, which were given for the guidance of a pecu- liar and pastoral people. The commandment, "thou shalt not commit adultery," reads very differently in an age and to a people who practiced polygamy, and could have wives suf- ficient to satisfy their desires, to what it would in these times and to our people, when it is difficult to get and support one wife. 9. If those who dispense religion are to control popular opinion upon these subjects, and thus force law-makers and sociologists to ignore the evils that follow sexual vice, only in so far as they enforce the prohibitory law of Moses, then in- deed we can not expect any relief. Experience has shown that no wrong of this character can be righted by prohibitory laws, and that it will not grow less by ignoring its existence. 10. The Christian religion miscalled, which enforces the harsh rule of Moses—" thou shalt not," instead of the gentle precept—" Come unto me all ye that labor and are heavy laden" of the Divine Teacher, stands to-day, as it has stood for a thousand years, in the way of every effort to control sex- ual wrong, and efface venereal disease. It stones the " woman taken in adultery," instead of saying, "Neither do I condemn thee ; go, and sin no more." 11. With an education that postpones retribution to a 20 The Reproductive Organs. future state, and promises relief from the consequences of all wrong-doing by simple repentance, at that period of life, pos- sibly, when the capacity for wrong-doing is lost, we can hardly expect that these wrongs will be righted. It might not be necessary to say this, it would not be necessary to speak of the moral aspect of sexual vice, did not the teachers of religion put themselves persistently in the way of all laudable efforts to control it. 12. If we must have the prohibitory laws of the Jews forced upon us, give us also their means of protection. En- force circumcision as a means of lessening the libidinous im. pulse of the male, and the danger of contracting and commu- nicating disease. Enforce the law3 of purification of women; and above all, provide for the wants of women, and by years of Jubilee for an equalization of property. Give us all of thie olden time or none. 13. Our civilization has within it, and as an essential part of it, the germs of prostitution and all sexual vice. Our edu- cation, habits, and methods of life, tend to the undue develop- ment of sexual passion, and of necessity entail prostitution when marriage is not possible or sufficient. 14. We fiercely denounce polygamy when practiced by Mohammedan or Mormon, yet wink at it when the use of many women is a vice of the wealthy in our midst. We for- give the man all sexual sins inside or outside of the marital relation, yet deuy to the woman the chance of repentance and reformation, and to the child born out of wedlock the name, protection, and support of its father. 15. Physiology a Better Guide than Religion.__Physi- ology is the best guide to a correct understanding of this sub- ject. If we can understand clearly the demand made by the reproductive instincts, how they may be exercised for the good of the individual and the species, how they may be controlled by calling into action other functions of body and mind, we will be in a better position to guide and control them. The Reproductive Organs. 21 16. The first law of our being, always operative, and un- changing as the " laws of the Medes and Persians," is, that as any function of the mind or body is exercised, it gains strength. If by education, dress, association, public spectacles, etc., we ex- cite sexual feeling, we may expect it to grow. If on the con- trary the child is educated and trained to work, the sexual in- stinct remains in abeyance, until such time as it may have legitimate use. 17. If one would train children to avoidance of these evils, he would call into activity other functions of the mind, strengthen the will, develop the body, and give no food to sexual desire. Chastity was a necessary result of the full de- velopment of man in the olden time. The mental and physical gymnast of Greece or Rome had abundant procreative power, and yet we do not learn that it was ever abused, as in our time. We do not learn in the history of the memorable voy- age of the Trojan chief Eneas, that Dido or other of woman- kind had to suffer from their libidinous desires. INNERVATION OF THE SEXUAL ORGANS. 18. The reproductive organs in male and female receive their nervous supply from three sources—the sympathetic nervous system, spinal cord, and brain. By the first they are intimately associated with all the vegetative functions ; by the second they are associated with other automatic functions, and they are to some extent independent of the will; and by the third they are associated with certain functions of the mind, and are to a certain extent controlled by the will. 19. From the Sympathetic. — The innervation from the sympathetic is very important, especially in the female. The procreative act is cerebro-spinal because muscular, but the life of the new being, its development and growth, is purely veg-f 22 The Reproductive Organs. tative, and must be controlled by the vegetative system of nerves. We have marked examples of this in gestation, dur- ing which, there are frequently sympathetic lesions of the digestive apparatus, deranging the processes of digestion, blood-making, nutrition, waste and secretion. We have other examples in lesions of the circulation, temperature, etc. 20. In some diseases of the female reproductive organs, the sympathetic nervous system suffers, and all functions con- trolled by it are impaired. Thus in apparently slight disease of the cervix-uteri, or displacement, we sometimes have marked loss of appetite, impaired digestion and blood-making, with a wrong of the circulation, nutrition and waste, that seem out of all proportion to the cause. 21. We find similar manifestations of disease in the young female, from disturbance of the menstrual function alone. In some cases the impairment of the vegetative functions is such as to cause the most extreme marasmus, as in chlorosis. 22. And thus we find, also, that abuse of the reproductive function in women will give rise to most serious general dis- ease. One has but to look at the married women he meets, to find examples of this, and to see its manifestation in almost every direction. The ill health of married women is, to a very considerable extent, far more, I am sure, than is usually thought, attributable to this. 23. In diseases of the reproductive function in man, we observe the same sympathetic relations. Among the train of symptoms following onanism, and attending spermatorrhoea, are lesions of digestion, blood-making, nutrition and waste. So in some structural diseases, as in chronic orchitis or pros- tatitis we find that degeneration of tissue is a very common result. 24. In disease of the reproductive organs or functions then, attention to the sympathetic system of nerves becomes a most important part of a rational therapy. Indeed those means which prove most successful in the cure, act upon and through this system of nerves. All function is depen ' -,t The Reproductive Organs. 23 upon structure—as is the structure, and the force acting upon it, so is the function. There are two factors in the problem of healthy or diseased action—the structure of the organ, and the nervous force applied to it. To get normal structure, we want normal sympathetic innervation, which controls the re- newal of tissue, and with a proper supply of blood, and nor- mal use, we get a right condition of the organism. Now let nerve force be rightly applied, and we can but have normal function. 25. As the physical development and life of the species must be, to a considerable extent, dependent upon the integ- rity of the procreative function, and its right use, Ave can see how society at large has a right of inquiry into those evils, and the use of means for their correction. If sexual vice only influenced the person sinning, it might be claimed that it should pass unnoticed, as a part of that individual freedom we prize so much. But as it influences the physical life of the man, and at times of associate women, and perpetuates itself in the offspring for generations, society has just claims to give it consideration, and devise means for its prevention. 26. Spinal Innervation.—The reproductive apparatus in both male and female is abundantly supplied with spinal nerves, its various parts being thus associated in action, and the function, to a certain extent, rendered automatic. These nerves are both sentient and motor, and we have the most marked examples of reflex action, impressions being conveyed to the spinal cord, and the impulse sent from it, without the cognition of the brain. 27. The reproductive act is, in its principal part reflex, or determined by the spinal cord. The mind may, from desire, determine the copulative act, and the will may influence the voluntary muscles to that end ; but the erythism of the organs, and the final ejaculation in the male—venereal spasm in male and female—are purely automatic, and from the spinal cord. 28. This is clearly proven in some diseases of these organs. 24 The Reproductive Organs. An irritation of the prostatic urethra will determine an erec- tion, the same as an influence of the mind. So will an irrita- tion of the bas-fond of the bladder, in some cases of phosphu- ria and uric acid deposits ; and occasionally ascarides of the rectum, or disease of a distant part of the urinary apparatus. Not only will these causes determine the turgescence of the organs, but will also through the sentient spinal nerves induce the venereal orgasm, without the copulative act, or anything to simulate it. 29. In some cases of spermatorrhoea, we find the emissions distinctly epileptiform in character from the beginning. There has been no erotic impulse of the mind, possibly no sexual thoughts or desires, the venereal orgasm being purely reflex, and unconsciously performed. Again, we find that a certain actiou often performed, becomes automatic, and thus onanism frequently develops this reflex action, and though the mind be kept free from sexual excitement, emissions con- tinue to occur. 30. This is particularly the case with women, and is not unfrequently the cause of the impaired health of widows. The sexual organs have been accustomed to frequent excite- ment, and the spinal cord to this reflex action. The venereal orgasm relieves the nervous system from excitement, and so long as it is complete the health does not suffer. If now the sentient nerves of the reproductive apparatus are periodically excited, the sexual stimulus withdrawn, there being nothing to determine the completion of the reflex movement, the nervous system must eventually suffer severely. 31. We find occasional instances of a similar character in men. Under the maiital relation they have for years been accustomed to the frequent and regular performance of this act. The «pinal cord becomes accustomed to it, as much as itdoe3 to defecation and urination, and if now from death or some other cause, there is an arrest of its performance the health suffers. The Reproductive Organs. 25 32. Innervation from the Brain.—The reproductive func- tion is not only vegetative and automatic, as we have seen, but in man it is intimately associated with certain operations of the mind, and may have its representative organ in.the brain. In the lower forms of animal life it is vegetative alone, in the lower vertebratse it is reflex or automatic, in the higher vertebratse it is instinctive as well as automatic, and in man it is promoted and influenced by the mind. In all, so far as we know, the instinctive prompting is pleasurable; in most the act is one of exquisite pleasure, though it may be followed by pain or entail death. 33. Certain operations of the brain are in part instinctive, and among those are sexual attraction, the desire for progeny, and the love of children. In the old scheme of phrenology, in which the brain was mapped out, and the function of its several parts designated, we had the organs of amativeness and philoprogenitiveness — the one giving sexual love, and prompting to the reproductive act, the other the desire for and the love of children. Whether the phrenologist has well located his organs, or can determine their development by cranial bumps, we will not stop to inquire, but there is abun- dant evidence that these functions of the mind do exist, and must be represented in the structure of the brain. 34. Any consideration of this subject, therefore, that should ignore the function of the brain, would be imperfect, if not erroneous, for we have our conscious life in and through the brain ; and as it is, to a considerable extent, is the devel- opment and function of the body at large. 35. Let us assume as granted that the sexual organs are designed for the reproduction of the species alone, and for no other purpose. That in so far as the instinct toward the venereal act, or pleasure derived from it, is concerned, thev are but wise provisions of nature to this end, and are not ob- jects of the action. Nature provides an incentive that in- sures the perpetuation of the species, and the man is wise who accepts the pleasure as the result and not as the end. 26 The Reproductive Organs. 36. We may say that the reproductive instinct is associated with two groups of mental functions—the one moral the other purely sensual — the one leading to 'its right use, the other to its abuse. 37. In the first it is associated with love of country, love of home, love of children, love of use, " and the love of women which passeth understanding." In the second it is impelled by animal sensibility, with which it is so intimately related, and is associated with the love of display, the love of rule, the love of self, and of sensuous gratification. Associ- ated with the first, the function is controlled to the good of the individual and the species; associated with the second, and it is used for sensuous gratification, without regard to the rights or well-being of others. 38. If the time ever comes when the world is freed from sexual vice, it will be when the education from youth up is in the right direction. When children are trained to love of country, home, their species, children, use, and to the higher and purer love of man for woman, then we need not fear that the sexual function will be abused. Such training is possible, such training is surely profitable, and in so far as physicians can influence the people, the influence should be in this direc- tion. If the girls of a family are thus educated, and these functions called into action from youth up, there will be little danger of their lapse from virtue; the ranks of prostitutes will have to be replenished from other sources. If boys are thus trained, these functions of the mind having vigorous growth, they will have respect and regard for women, and will be chaste in thought, word and deed. 39. If on the contrary children are raised to regard the pleasures of sense as the highest good ; if fine houses, clothino- and people are the subject of thought and desire ; if associated with persons who are lax in morality, and manifest it by dress, look, word, or deed; if the sexual passions are unduly stimulated by reading the fictions of the da}% by the semi- obscenity of the leg-drama, and other popular plays, and !,v The Reproductive Organs. 27 much of the amusement of " society," then we will probably get a crop of what we have sown—" ye have sown the wind, and ye shall reap the whirlwind." 40. In so far as society attempts to control or overcome the " social evil," it must be done in this way. Laws for re- pression are useless. It is of no avail to say, " thou shalt not steal," when the education of a portion of the people is dis- honest—steal they will, though the punishment, as in the olden time, was death. It is of no use to say, " thou shalt not covet," when children are trained from youth up to covet- ousuess. It is of no use to say, " thou shalt not kill," when we train that portion of the mind that puts " murder in the heart." And it is of no avail to say, " thou shalt not commit adultery," when we so train our children as to develop the love of pleasure, and the sexual desires. Theft, covetousness, murder, adultery, are fruits of a vicious education, and we will reach the " millenium " when we have learned this lesson, and have trained our children rightly. 41. " It is never too late to mend," and it is never too late to commence a good education to amend a bad life. If we would educate and train our criminals to the use of the better functions of the mind, and to a proper control of those which have become criminal, we might redeem them from vice and make them useful members of society. The sinner is sick, let him have that care and humane attention that we give to physical sickness. 42. The prostitute of either sex may be classed with monomaniacs or with the intemperate. The sexual wrong can be controlled by some, by others it can not. When the will is sufficiently powerful, all that is necessary for redemp- tion is, that the person be placed in such circumstances that he can exert it in freedom; if the will is not sufficiently strong at first, then such safeguards should be thrown around the person, as will give protection until the mind is trained by orderly use. 28 The Reproductive Organs. THE SEXUAL ORGANS. A brief description of the anatomy of the sexual organs may refresh the mind of the reader, and give a better under- standing of some of the subjects we will discuss. In both sexes, the sexual organs are alike surmounted by an eminence of cellular tissue enclosing fat, and covered with stout capilli or hairs. The integument receives an abundant supply of sensory nerves, which associate it with the organs of copulation. This elevation, called the mons Veneris in the female, in some persons possesses sexual sense in very high degree, and anything which excites it calls forth an increased circulation to and turgiclity of the erectile tissue. 43. The sexual organs of both sexes may be divided into the external or copulative, and the internal or reproductive. The copulative organs are formed in part of erectile tissue, and are very abundantly supplied with nerves of sensation from the spinal-cord and brain. The reproductive organs proper are principally supplied from the sympathetic nervous system. In the Male.—The organs of generation are the penis, the prostate gland, vesicular seminales, and the testes. 44. The penis is composed of two erectile bodies, the cor- pora cavernosa and the corpus spongiosum. The first forms the upper or larger portion, the second the lower and smaller portion aud the extremity or glans penis, and contains within it the canal of the urethra. The penis has a very firm attach- ment to the bones of the pelvis, and is supported from above by a strong ligament. It is covered with a delicate integu- ment, loosely attached to the body of the organ by fibrous tissue, and terminating in a fold—the prepuce—which has an attachment to the body of the organ behind the glans. The penis is abundantly supplied with blood, and by the peculiar situation of a pair of muscles, the erectores penis, the v< iuS The Reproductive Organs. 29 are compressed, the organ made turgid with blood, and thrown in a state of erection. 45. The prostate gland, situated at the commencement of the urethra properly belongs to the sexual organs, furnishing a secretion to be admixed with that of the vesicalse seminales and testicles. 46. The vesiculce seminales are situate between the base of the bladder and rectum. They are two lobulated membran- ous pouches, which probably serve as reservoirs of semen, though they furnish a secretion peculiar to themselves. Side View of the Pelvic Viscera of the Male Subject, showing the Pelvic and Perineal Fasciae. 47. The testes are contained in a cutaneous pouch—the scrotum, which is divided into two lateral halves by a septum. They furnish the male sperm for the fertilization of the ovum, ^nd discharge their secretion during copulation by ascending 30 The Reproductive Organs. ducts, the vasa deferentia, which passing upward through the^ inguinal rings, descend on the wall of the bladder to the vesiculse seminales. 48. In the Female.—The external organs in the female are the mons Veneris already described, the labia majora and minora, the clitoris, the meatus urinarius, and the entrance of the vagina the introitus to the reproductive organs proper. The internal organs are the uterus, Fallopian tubes, and ovaries. 49. The labia majora are two more or less prominent cuta- neous folds extending from the mons Veneris to the perineum. containing areolar tissue, fat, and erectile tissue. Their prom- inence depends, in most women, on the amount of adipose tissue, though in some the erectile tissue is in such proportion as to give prominence when the organs are excited. Exter- nally the skin is covered with hair, and supplied with nerves from the same" source as the mons Veneris. Within the fissure, the liningmemb'rane gradually loses the character of the skin and assumes that of mucous membrane. 50. The labia minora are lesser folds of the lining: mucous membrane, extending from the clitoris backward for three- fourths the extent of the opening. They contain a plexus of vessels, forming a species of erectile tissue, and vary very greatly in prominence and extent in different persons. 51. The clitoris is thought to be the analogue of the male penis, and to possess the sexual sense in greatest degree. The truth is, probably, that it is a rudimentary orgaiv very like the male mammas. In some women it is large, and com- posed of erectile tissue, it is erected during vascular excite- ment, and being freely supplied with nerves, adds to the voluptuousness of coition. But in others it can scarcely be detected, even during excitation, though they possess the sexual sense as fully developed as the others. 52. The meatus urinarius is found immediately behind the clitoris, and from it may be traced the urethra, about an inch The Reproductive Organs. 31 and a half in length, imbedded in the vesico-vaginal wall. The urethra has an erectile coat, in some women remarkably developed, and it also is in a turgid condition during sexual excitement. 53. The vagina is a membranous canal, between five and six inches in length along its posterior wall. It is composed of an external muscular coat, a middle layer of erectile tissue, and an internal lining of mucous membrane. The muscular coat consists principally of longitudinal fibres, continuous with the superficial layer of the uterus. The amount of A SIDE VIEW OF THE VISCERA OF THE FEMALE PELVIS. I. The symphysis pubis; to the upper part of which the tendon of the rectus muscle is attached. 2. The abdominal parietes 3. The collection of fat, forming the prominence of the mons Veneris. 4. The urinary bladder. 5. The entrance of the left ureter. 6. The canal of the urethra, converted into a mere Assure by the contraction of its walls. 7. The meatus urinarius. 8. The clitoris, with its prseputium, divided through the mid- dle. 9. The left nymphEe. 10. The left labium msjus. 11. The meatus of the vagina, narrowed by the contraction of its sphincter. 12. 22. The canal of the vagina upon which the transverse rugae are apparent. 13. The thick wall of separation between the base of the bladder and the vagina. 14. The wall of separation between the base of the bladder and the vagina. 15. The perineum. 16. The os uteri. 17. Its cervix 18. The fundus uteri. The cavitas uteri is seen along the center of the organ. 19. The rectum, showing the disposition of its mucous membrane. 20. The anus. 21. The upper part of the rectum invested by the peritoneum. 23. The utero-vesical fold of peritoneum. The recto-uterine fold is seen between the rectum and the posterior wall of the vagina. 24. The reflection of the peritoneum, from the apex of the bladder upon the urachus to the internal surface of the abdominal parietes. 25. The last lumbar vertebra. 26. The sacrum. 27. The coccyx. 32 The Reproductive Organs. erectile tissue varies in different persons, and is most abun- dant at the lower part of the vagina. The mucous mem- brane shows an anterior and posterior ridge or raphe, and between them it is thrown into numerous transverse ridges or rugae. The mucous membrane of the vagina is reflected upon the dependent portion of the uterus (the cervix uteri), giving it an investment, and reflected in the os, being continuous with the mucous lining of the cavities of the uterus. In its entire extent it is abundantly supplied with nerves of sensation, but possesses the sexual sense in highest degree at its inferior and superior portions. 54. The uterus is a pyriform organ, resting upon and partly depending in the vagina. In the unimpregnated state it measures about three inches in length, two in breadth at its widest part, and an inch in thickness, and weighs from an ounce to an ounce and a half. It is divided into fundus, body and cervix—the first being the superior portion above the Fallopian tubes, the second the portion between this and the neck, and the third the lower and constricted portion, principally dependent within the vagina. The walls of the uterus are thick, the cavity being quite small, and are composed of three coats—an external of peri- toneum investing the fundus and body, a middle coat of muscular tissue, which forms its chief bulk, and an internal lining of mucous membrane. The muscular coat is composed of layers of fibres so ar- ranged that there will be equal contraction upon the cavity from all directions toward the outlet. In the cervix their arrangement is such, that they can both open and close the os, and cause a vermicular movement from below upward. It has been thought that this muscular tissue was only called into action for the expulsion of the ovum, or some foreign body which by its presence and growth had aroused the de- velopment of the uterine muscular fibre. This, however, is The Reproductive Organs. 33 very certainly a mistake, for, as we shall see presently, it is called into action during sexual excitement, and is active during the venereal orgasm. The circulation of the uterus is peculiar and closely resem- bles erectile tissue, in the tortuous course of the vessels, their free anastomosis, and direct communication of many arteries and veins without the intervention of capillaries. The in- creased vascularity of the organ during the excitement of ovulation, has long been noticed, and we will call attention to the fact that a similar state is produced by sexual excite- ment, though not to the same degree. 55. The Fallopian tubes lead from the uterus to the ovaries, and are the conduits for the ova. Each tube is about four inches in length, and is terminated by an expansion—the fim- briated extremity—which is applied to the ovary during ovu- lation. 56. The ovaries are to the female what the testes are to the male, furnishing the germ of the future being. The ovary shows some fifteen or twenty ova in various stages of development, though in the tissue may be seen the germs of many others. They are discharged at each menstrual period, from puberty until it ceases at the " chauge of life." The nerves are principally from the vegetative system, though a branch from the uterine system (sexual) passes upward and along the Fallopian tubes. GENERATION. 57. So far as we know, there is no such thing as " sponta- neous generation " in the age we are living in. Man, as well as all living things, vegetable or animal, is begotten of parents having the same structure and functions. All living organisms have one typical form—a cell—and from the 3 34 The Reproductive Organs. multiplication and adaptation of these come every form and function. 58. In the economy of nature, the new birth springs from the contact of two cells, a " sperm cell" and a " germ cell," the one communicating reproductive life to the other. Some species of plants and animals are hermaphrodite or bisexual, each individual possessing both male and female organs, and producing both sperm and germ cells. In other species the individual is unisexual, and it requires a conjunction of the two, male and female, for generation. 59. Nature makes wonderful provision for the perpetua- tion of species. In the case of vegetables, she gives wings to the sperm cells of some, to others motion, to others an attrac- tion to bee or bird that animal life may aid in bringing the two together. 60. In the higher animal life, we find the sexual sense and a passional attraction, which brings the sexes together and effects such conjunction that the object is accomplished. 61. Whilst the generative function is pleasurable in all animals, and this is the exciting cause of the copulative act. it is not essential to it in all cases, at least on the part of the female. If intromission ou the part of the male is possible without pleasurable sensations, then the sperm cells may be brought in contact with the germ cells, and reproduction effected without this element. 62. In the female we find this is frequently the case. In many species, and in some women, we find a repugnance to the embrace of the male, which requires much solicitation to overcome, and in some it is quite certain the copulative act is never pleasurable, may be in fact painful, and yet the inter- course be fruitful. We may account for this by regarding the essential elements of coition on the part of the female as reflex and vegetative, and if the purely sensitive nerves are not active, there may not be even the ordinary sexual sense, The Reproductive Organs. 35 63. Coition.—Though reproduction of the species may be the end of coition, it is not usually the object. The intense pleasure that attends the act is the exciting motive, and is partly instinctive and in part a function of the mind. Thus direct excitation of the sexual organs will develop the desire and impulse, as will the thought of the pleasure to be ob- tained, whether stimulated or not by sight or touch. We will find it necessary to keep this in mind whilst studying lesions of this fuuction, for a disease may equally have its origin and continuance in disease of the organs, or of the brain. 64. In most species the sexual instinct is strongest in the male, and nature provides him with the requisites for its grat- ification. In some it is increased strength, in others a bril- liant plumage, or similar attraction for the female, in all sufficient for the purpose. In man both sexes seem equally provided with the elements of attraction. Whilst the man has strength, and powers of persuasion, the woman has the beautiful plumage, and solicits with fine clothing, and many an art calculated to excite the sexual sense. 65. In our civilization the marital rite is necessary to the free and lawful exercise of this passional attraction, and we may regard it as the one impediment to the free play of the sexual instinct. Our laws recognize coition under the mar- riage relation, condemn it outside of this; and as they are but the outgrowth of our social life, society recognizes it in marriage, condemns it outside. 66. Action of the Male.—Excited by touch, or sight, or the thought of female charms, there is an increased nervous and vascular flow to the organs of generation. The erectile tissue becomes turgid with blood, and the penis erected and its sensitiveness increased. Introduced into the female organs, its play backwards and forwards, by friction upon the rugose walls of the vagina increases the excitement, until at last it becomes so intense as to call forth a reflex action from •36 The Reproductive Organs. the spinal cord, and a contraction of the muscles which sur- round the vesiculse seminales and the ejaculator muscles, and the semen is ejected with some considerable force. The com- pletion of the act is most intensely pleasurable, though the sensation is but momentary, and is followed by a correspond- ing degree of depression, 67. Most physiologists have thought that the discharge during a coitus was wholly of the semen in the reservoir of the vesiculse seminales, with the secretion of this gland and the prostate. I think this an error, for in many men a dis- tinct vermicular movement will be noticed in the epididymis and the course of the spermatic cord, and a contraction of the scrotum upon the testes which are drawn upwards. This is very marked immediately preceding and during the vene- real orgasm. We also find that persons with a lax and thiu scrotum, and dependent testicles, have feeble sexual power. From these facts we may conclude that the discharge is i;o part directly from the testes, and it may be wholly from these.* *The physiological explanation of the pleasure attendant on the sexual act is, perhaps, as follows: — " Accumulation of blood," says Kobelt, "causes, whenever it occurs in the body, a gradual augmentation of sensibility ; but in this case the glans penis, in passing from a non-erect state to the condition of complete tumescence, becomes the seat of a completely new and specific sensi- bility, up to this moment dormant. All the attendant phenomena react on the nervous centers. From this it appears that, in addition to the nerves of gen- eral sensibility, which fulfill their functions in a state of repose and also during erection, although in a different manner, there must be in the glans penis special nerves of pleasure, the particular action of which does not take place except under the indispensable condition of a state of orgasm of the glans. Moreover, the orgasm once over, the nerves return to their former state of inaction, and remain unaffected under all ulterior excitement "They are, then, in the same condition as the rest of the generative appa- ratus; their irritability ceases with the consummation of the act, and, together with this irritability, the venereal appetite ceases also to be repeated, and to bring about the same series of phenomena at each new excitation."-Kobalt "Die mannUchen md weiblichen Wolliut-Organt des Menschen und eimger Sauae thine," p. 35. The Reproductive Organs. 37 68. In some persons the act is performed in a sluggish, methodical way; there having been no cause for the full ex- citation of the organs, the sense of pleasure is very slight. In others again, it is so intense that considerable time is re- quired for the nervous system to completely recover from it. 69. The power of procreation is usually attained at the age of fourteen to sixteen years, at the period of puberU", and is marked by a change in the bodily constitution. The *To the use of the sexual organs for the continuance of his race, Man is prompted by a powerful instinctive desire, which he shares with the lower animals. This Instinct, like the other propensities, is excited by sensations; and these may either originate in the sexual organs themselves, or may be ex- cited through the organs of special sensation. Thus in Man it is most power- fully aroused by impressions conveyed through the sight or the touch ; but in- many other animals, the auditory and olfactive organs communicate impres- sions which have an equal power; and it is not improbable that, in certain morbidly-excited states of feeling, the same may be the case in ourselves. That local impressions have also a very powerful effect in exciting sexual de- sire, must have been within the experience of almost every one; the fact is most remarkable, however, in cases of Satyriasis, which disease is generally found to be connected with some obvious cause of irritation of the generative system, such as pruritic, active congestion, etc. That some part of the En cephalon is the seat of this as of other instinctive propensities, appears from the considerations formerly adduced; but that the Cerebellum is the part in Which this function is specially located, can not be regarded as by any means sufficiently proved. The Instinct, when once aroused (even though very ob- scurely felt,) acts upon the mental faculties and moral feelings; and thus becomes the source, though almost unconsciously so to the individual, of the tendency to form that kind of attachment toward one of the opposite sex which is known as love. This tendency can not be regarded as a simple pas- sion or emotion, since it is the result of the combined operations of the reason the imagination, and the moral feelings; and it is in this engraftment (so to speak,) of the psychical attachment, upon the mere corporeal instinct, that a difference exists between the sexual relations of Man and those of the lower animals. In proportion as the Human being makes the temporary gratifica- tion of the mere sexual appetite his chief object, and overlooks the happiness arising from spiritual communion, which is not only purer but more perma- nent, and of which a renewal may be anticipated in another world—does he degrade himself to the level of the brutes that perish. Yet how lamentably frequent is this degradation !—Carpenter's Physiology. 38 The Reproductive Organs. sexual organs are now more fully developed, hair appears on face and pubes, and the voice becomes rougher and stronger. The procreative power may last the allotted age of man— three-score years and ten, if not abused, but with the majority it fails at sixty or sixty-five years. 70. Action in the Female. — The woman may be, and frequently is, entirely passive during the act of coition. The sexual sense is dependent upon an increased flow of blood to and turgidity of the erectile tissue, and unless this is effected by excitation of the organs, or a mental influence, there will be neither pleasurable sensation nor venereal orgasm, at least of the external organs. 71. When excited, we find that there is an increased flow of blood to the entire reproductive organs, and the erectile tissue becomes filled with blood, the perineal muscles con- tract, the vulva and vagina are firmer, and the mucous mem- brane much more sensitive. In some rare cases this excita- tion and contraction is so great that penetration is difficult or painful. 72. The friction of the male organ upon these sensitive surfaces increases the excitement, until at last there is a reflex action from the spinal cord, and consequent contraction of the perineal muscles, and the muscular fibre of cervix uteri and vagina, with increased discharge of mucus, and the secre- tion of the glands of Bartholine. 73. It has been supposed that the uterus was wholly pas- sive during coition, and many theories have been advanced to account for the passage of spermatozoa to the uterine cavity and ovaries. The old idea of a gaseous emanation from the semen—halitus seminis—becoming untenable, the movement was attributed to the spermatozoa alone, which by some spe- cial affinity or instinct moved upwards through the cervical canal, uterine cavity and ovarian tubes, until they reached the female egg. A still later theory imagined that the fertiliza- tion was accomplished by means of a mucous plug filling the The Reproductive Organs. 39 canal of the cervix, which during copulation was extended to receive the spermatozoa, and was then drawn back with them, thus affording a trap to catch them or a convenient ladder for their ascent. Want of knowledge here is due to imperfect observation— to a want of facilities for observation. Yet I think it can be clearly shown, that the cervix uteri is a prominent actor in fruitful coition, and has in its structure the means to insure the reception of the male sperm, and transmit it upwards. In July, 1871, I published a brief article on this subject, from which I will quote . 74. " Error 1st.— That the sexual sense is located in the clitoris and the entrance of the vagina. We are taught that the clitoris is the analogue of the male penis, is formed of erectile tissue, is extremely sensitive, and in the sexual act is in a state of erection ; that the vagina is also erectile, and is supplied with the same nerves of sexual sense. " To complete the analogy, these parts should be freely supplied from the ovarian nerves, associating the external with the internal organs. But so far as we know, they do not receive a single filament. On the contrary, the entire nervous supply is from a nerve of common sensation—the in- ternal pudic, which is also distributed to the skin of the labia and the mons Veneris. " The clitoris is very variable in size, and in ninety-nine out of one hundred cases is rudimentary like the male mammse. JL't is not in a state of erection during sexual excitement, and in women who have the strongest sexual feelings and enjoy- ment the finger will hardly detect it on examination. In forty-two women examined with reference to this point — most of them public women—but six had a good develop- ment of clitoris, and of these four were not passionate. "In seven cases of extreme sexual excitation, simulating active spermatorrhoea in the male, (nymphomania), that have come under the writer's notice, but one had an enlarged clitoris. The complete extirpation of the clitoris, root and 40 The Reproductive Organs. branch, a la Spencer Wells, did not in the least lessen the trouble, nor the gratification obtained from sexual intercourse. " Writers on diseases of women uniformly agree that dis- ease or irritation of the external sexual organs is rarely if ever the cause of that severe nervous disturbance which so frequently occurs in the male, but that such disturbance inva- riably grows out of disease of the cervix uteri. " I wish to call the reader's attention next to the fact, that the larger number and some of the most intractable diseases of women we meet with, are diseases of the sexual function, and not of the sexual organs. These manifest themselves as lesions of innervation—of the functions of the brain and spinal cord—and lesions of the vegetative functions, through the sympathetic nervous system. Some of these diseases are very severe. In the one case the functional lesions of the brain assume the form of hysteria, monomania or insanity. In the other, there is an impairment of digestion, blood- making, nutrition, and waste, giving rise to loss of flesh and strength, to depravation of tissue, and at last to structural lesion. 75. "Error 2.—Locating the sexual sense in the clitoris may be called an error of commission. We wish now to refer to one of omission. " In tracing the nerves of the uterus we find that the larger number of spermatic branches pass from the ovaries to the uterus, and a dissection of the gravid uterus will very clearly show their distribution principally to the cervix. We also find it abundantly supplied from the hypogastric plexus, with mixed spinal and sympathetic nerves, which are also freely distributed to the vagina in its upper two-thirds. " If now we make a dissection of the cervix-uteri we find it composed principally of a tissue that is truly erectile, with but very few muscular fibres which are clearly continuous with the longitudinal fasieulse of the uterus. That which is known as the os-internum, and closes the cavity of the uterus is the true muscular wall of the organ. The Reproductive Organs. 41 " In sexual excitement there is an unusual fullness and elasticity of the cervix, a true condition of erection. Such excitement not unfrequently attends the making a vaginal examination by touch or speculum, and in many women the condition of erection is such as to prevent the introduction of the uterine sound, an examination of the canal of the cervix, or the introduction of a sponge-tent. " The venereal orgasm is followed by complete relaxation of the cervix, and such dilatation of its cavity, that a finger can frequently be passed into the os—a large sound passes freely to the os internum, and its cavity can be freely in- spected. " Diseases of the ovaries and cervix-uteri uniformly corre- spond, and the one will produce the other. Structural disease of the cervix uniformly affects the sexual and reproductive functions, showing the closest relationship between them. " The venereal organism of the female then is, the vaginal canal, the cervix uteri and the ovaries ; as it is the corpus spongiosum (glans penis) and cavernosum and testicles in the male. " It would seem to be hardly worth while, and yet it is necessary, to point out that the sexual function is one of the mind, as well as of certain organs called sexual, and that this function of the mind may become diseased. 76. " Spermatorrhoea is more a disease of the mind than of the sexual organs ; very frequently is wholly a disease of the mind, and must be so treated. So in women, the disease is very frequently of the mind in part, and may be wholly of it. In this the diseases of the two sexes do not differ, but in their course and history they do differ. Spermatorrhoea is de- veloped by self abuse, and is frequently perpetuated by it. The diseaee of the woman is produced by the abuse of the husband, and is perpetuated by this. " A right use of the sexual organs in the male is never fol- followed by disease, even though such use is excessive. It is 42 The Reproductive Organs. the abuse of the sexual function, and the imperfectness of its gratification, that produces disease "It is just the same in the female. If the sexual act is complete, so that both the mind and the sexual organism are satisfied, no disease arises even though there be excess in fre- quent repetition. But if the act is incomplete on the part of the female, the sexual organs being irritated merely, and the mind not gratified, then disease will surely follow. " I wish next to call the reader's attention to the diseases of the sexual function—as a function of the mind. The phy- sical lesions of the cervix-uteri are frequently grown from this, they are always rendered more intractable by it, as are the derangements of the menstrual function. "I am satisfied that a very large number of these nervous lesions are grown from frequent excitation of the sexual organs, without gratification of the sexual instinct. That is, there is frequently repeated sexual irritation, impairing the nervous system—both brain, spinal cord and sympathetic—■ until we have a condition closely approximating spermator- rhoea in the male—it is one of excitation with exhaustion. 77. " For this I have prescribed with very great success Staphysagria and Pulsatilla. Sometimes they are given singly, sometimes together or alternately. If there is undue excitation of the reproductive organs, Aconite with Macrotys, and rest, will be the treatment. If the reproductive organs are exhausted, with an enfeebled circulation of blood, then we use Hamamelis, Tincture of Phosphorus, and Ero-ot. "The remedies first named, are par excellence, the remedies for the disease of the sexual function, and the various nervous disturbances that flow from it. And not unfrequently what seems to be a persistent structural lesion will disappear under their use. " All writers on diseases of women agree that diseases of the cervix-uteri are among the most frequent met with and that it is these that so impair the general health. But no one, so far as my reading has extended, has pointed out the The Reproductive Organs. 43 relation between the disease of the sexual function and the structural disease of the cervix. No one, I think, has pointed out the true cause of these lesions. They do not arise from pregnancy or parturition, nor are they inflammations from cold. On the contrary, in ninety-five out of one hundred cases they are very certainly grown from sexual abuse. " These structural diseases manifest themselves in various forms. From simple excitation with determination of blood, to a condition of true inflammation with deposits. From a slightly enfeebled and congested condition, to that persistently tumid congested state, in which the cervix has increased to twice or even five or six times its natural volume. And with these we have altered secretion from the cervical canal, ero- sion, and ulceration of varying degrees of severity. "In the olden time I treated these lesions of the cervix with local remedies. The cervix was frequently cauteiized with Nitrate of Silver, Iron, or Carbolic Acid, in the milder cases ; with Potassse cum Calce or Caustic Potash in the severer. Now I never think of using such means, but depend upon direct remedies for the relief of the disease of the sexual function, and to restore normal innervation and circulation to the affected parts. " Rest from sexual excitation is absolutely essential to a cure in some cases. But in others a cure is obtained more quickly by a full gratification of the sexual instinct two or ;hree or four times during the lunar period. In those cases where the husband is persistent, in season and out of season, in satisfying his libidinous appetite, with corresponding feebleness in the act, a cure is impossible, and the life of the woman too frequently pays the penalty of the sins of the man. " Manv cases of severe and long continued ulceration have been treated with internal remedies alor.e. ManjT with only the employment of the five remedies, Pulsatilla, Staphysagria, Macrotys, Phosphorus and Hamamelis, and with a success never obtained with the older means." 44 The Reproductive Organs. I have no doubt others have made similar observations, but feared to publish because the facts seemed contrary to the statements of physiologists, or from modesty—a failing pecu- liar to physicians. The opinion I have held is corroborated in a case reported by Dr. Beck, of Fort Wayne, Indiana, which I append :* *Mrs. H. L., aged thirty-two years, of strongly-marked nervous tempera- ment, blonde, married eight years, has one living child, son, seven years old; has had one abortion ; last pregnancy was six years ago; commenced to men- struate at fourteen years of age; present illness has existed six years, dating evenly with abortion ; symptoms which have been apparent during its course were dragging and weight in pelvis, more or less pain in back and loins, slight vesical and rectal irritation, inability to walk without great fatigue, in- ability to lift weight of any moment slight leucorrhcea, and a sinking sensa- tion referred to the epigastric region—supposed cause to be a " falling of the womb;" present condition as regards menstruation, menstruates regularly every twenty-eight days, normal as to amount and suffers no pain of any moment; leucorrhcea very slight as to amount, exists all the time, is white, glairy, and unmistakably uterine; pain is intermittent, by no means severe, and is referred to the back, loins, inguinal and sacral regions ; locomotion is impeded to a great extent by the consequent fatigue; as to other symptoms, she is usually constipated, and has a copious eruption of acne upon the face; of physical signs, the touch shows the os uteri just inside the vulva?, the specu- lum was not used; the probe shows the pelvic-uterine axis to be changed con- siderably, but no flexion of uterus, and probe enters cavity two and one-half inches. Diagnosis, prolapse of the uterus in the second stage; treatment, me- chanical support to the uterus by means of Mcintosh's stem pessary, and in- ternally ferruginous tonics, iodide of potassium, and liq potass, arsenit. This much for the history of the case, as compiled from an office examination. Calling at the residence of the patient next day for the purpose of adjusting the uterine supporter, I made an examination by the touch, and, upon intro- ducing my finger between the pubic arch and the anterior lip of the pro- lapsed cervix, I was requested by her to be very careful in manipulating those parts, as she was very prone, by reason of her passionate nature, to have the sexual orgasm produced by very slight contact of the finger. Indeed, she stated that this had more than once occurred to her, when making digital in- vestigation of herself. Here then was an opportunity never before afforded any one to my knowledge, and one not to be lost upon any consideration Carefully separating the vulva? with my left hand, so that the os uteri was brought clearly into view in a strong light, I swept the right forefinger across The Reproductive Organs. 45 78. Duration of the Act. — The duration of the act is very brief in healthy persons—but a few minutes—though we find considerable variation in different persons of both sexes. In some men the excitation is so extreme that penetration is hardly effected before the venereal orgasm occurs. In others there is a tardy and not complete turgescence of the erectile the cervix two or three times, when, almost immediately, the orgasm occurred and the following is what was presented to my view: The os and cervix uteri had been firm, hard, and generally in a normal condition, with the os closed so as not to admit the uterine probe without diffi- culty ; but immediately the os opened to the extent of fully an inch, made five or six successive gasps, drawing the external os into the cervix each time pow- erfully, and at the same time becoming quite soft to the touch. All these phe- nomena occurred within the space of twelve seconds' time certainly, and in an instant all was as before; the os had closed, the cervix hardened, and the re- lation of the parts had become as before the orgasm. Now I carefully questioned my patient as to the nature of the sensations experienced by her at the period of excitement, and she is very positive that they were the same in quality as they ever were during coition, even before the occurrence of the prolapse; but admits that they were not exactly the same in quantity, believing that during coition the orgasm had lasted longer; although not at all or in any respect different as to sensation. I had almost forgotten to make mention of the intense congestion of the parts during the "crisis," and introduce the statement here. "When, in connection with the statement of the patient, who is a very in- telligent and appreciative lady, I add my own observation to the effect that there was no inflammation of any kind present either in theos or cervix uteri, the vagina, bladder, or rectum, and that the parts were in an entirely normal condition except as to position, I think we had the phenomena before us which are always present during coition ; and the passage of the spermatic fluid into the uterus was explained fully, satisfactorily, and beyond the shadow of a doubt. I do not doubt that many of my readers have seen in streams of water, sometime during their lives, a species of fish known as the "sucker," which has a very peculiar shaped mouth. These fish, when at rest in the water, pass the water through their mouths and out at their gills as all other fish do, but, in doing so. they make a peculiar suction motion with their mouths, in which the mouth is inverted into itself. Precisely such a motion does the uterus make during the period of sexual excitement. This is a homely illus- tration, I am aware, but I know of none other in nature which answers so well. 46 The Reproductive Organs. tissue, and necessarily there is a want of sensitiveness in the penis, and coition is prolonged and the venereal orgasm ob- tained with difficulty. This is especially the case where the organs are exhausted by sexual excesses. 79. As has been already remarked, women have less desire, a more tardy turgescence of the erectile tissue, and less sensi- tiveness of the sexual organs. Probably the venereal orgasm is not complete, in the majority of women, once in ten times, and I have been informed by intelligent married women, that they had never experienced it, and had rarely felt any plea- surable sensation. In some it is experienced just after a menstrual period, and not at other times, or when there has been long abstinence. SO. Iu some the excitation of the female organs is so slow, that the man completes the act before the sexual nerves have been sufficiently aroused to call forth reflex action. Many cases of disease are produced in this way. The husband has strong desires, and has frequent connection for gratification, but each time he only arouses sexual excitement in the wife without gratification, and the female organs are left in a state of turgescence without natural relief. 81. It may be remarked that coition produces less exhaus- tion, and conduces to the health of the parties, when the act is complete with both. That it may be so, the sexual organs should not be abused, and the sexual act should be performed as well for the satisfaction of the opposite party, as for self- gratification. We may notice further that the imperfect coitus leads to abuse of. the sexual organs, especially upon the This then is the explanation of the passage of the spermatozoa to their des- tination : the act of coition arouses some special nervous action in the uterus which causes it to act in the manner above described, when the "crisis" ar- rives. I do not believe that the operation is either purely physical, or simply mechanical, but feel sure that the great nerve-centers have more or less the control of the matter, although perhaps this is not now demonstrable.—&. Louis Medical and Surgical Journal. The Reproductive Organs. 47 part of the male, for the vasa deferentia not being fully re- lieved, there is continued desire. 82. The Immediate Effect of the Act.—The immediate effect of the act is a temporary exhaustion and languor, and in many persons a desire to sleep. In some rare cases the excitation during the venereal spasm is so extreme as to cause death. Thus cases are reported in which men have died sud- denly on their wedding night, and more frequently we have coroner's inquests on men found dead in houses of ill-fame, without any trace of ill-usage or poison. 83. In the majority of persons, where connection is not too frequent, it is followed by a sense of self-satisfaction and fresh vigor. Lallemand remarked, " When connection is fol- lowed by a joyous feeling, as well as fresh vigor; when the head feels more free and easy, the body more elastic and lighter; when a greater disposition to exercise or intellectual labor arises, and the genital organs evince an increased vigor and activity, we may infer that an imperious want has been satisfied within the limits necessary for health. The happy influence which all the organs experience is similar to that which follows the accomplishment of every function neces- sary to the economy." There is no doubt but that the proper gratification of the Bexual function is conducive to health and longevity; and if bo we very reasonably conclude that the abuse of the function predisposes to disease and shortens life. 84. Repetition of the Act. — We are frequently asked, when cautioning persons against the abuse of the sexual organs, "how frequently should connection be had?" The quotation from Lallemand, just given, is a very good answer. When the individual feels buoyant and vigorous after its per- formance, it is not too frequent; when languor persists for some time, or there is a sense of feebleness of the organs, it is too frequent. 48 The Reproductive Organs. Some persons might for a time have connection every night without exhaustion, and I have known men who kept it up for many years. In rare cases the rutting propensity is so great that coition is had several times in one night. In others, and probably the majority, once or twice a week will be the extent of full capacity.* *In Jeremy Taylor's rules for holy living wo find the following advice for married persons: " In their permissions and license, they must be sure to ob- serve the order of nature and the ends of God He is an ill husband that uses his wife as a man treats a harlot, having no other end but pleasure. Concerning which our best rule is, that although in this, as in eating and drinking, there is an appetite to be satisfied, which can not be done without pleasing *hat de- sire, yet since that desire and satisfaction were intended by nature :or other «nds, they should never be separate from those ends, but always be ,oined with all or one of these ends, with a desire of children, or to avoid fornication, or to lighten and ease the caret and sadnesses of household affairs, or to end ar each other ; but never with a purpose, either in act or desire, to separate the sensuality from these ends which hallow it. "Married persons must keep such modesty and decency of treating each other that they never force themselves into high and violent lusts with arts and misbecoming devices; always remembering that those mixtures are most innocent which are most simple and most natural, most orderly and most safe. It is the duty of matrimonial chastity to be restrained and temperate in the use of their lawful pleasures; concerning which, although no universal rule can antecedently be given to all persons, any more than to all bodies one propor- tion of meat and drink, yet married persons are to estimate the degree of their license according to the following proportions:—1. That it be moderate, so as to consist with health. 2. That it be so ordered as not to be too expen- sive of time, that precious opportunity of working out our salvation. 3. That when duty is demanded, it be always paid (so far as in our powers and elec- tion) according to the foregoing measures. 4. That it be with a temperate affection, without violent transporting desires or too sensual applications Concerning which a man is to make judgment by proportion to other actions and the severities of his religion, and the sentences of sober and wise persons always remembering that marriage is a provision for supply of the natural necessities of the body, not for the artificial and procured appetites of the mmd. And it is a sad truth that many married persons, thinking that the floodgates of liberty are set wide open, without measures or restraints (so thev sail in the channel), have felt the final rewards of intemperance and lust bv their unlawful using of lawful permissions. Only let each of them be tern The Reproductive Organs. 49 If sexual intercourse is too frequent the man suffers in two ways—from the drain upon the system by the forced secretion of semen, and by the exhaustion of the nervous system from over-excitation. The woman more frequently suffers from nervous exhaustion, if the coition is complete, and from nervous irritability if there has been excitation without the venereal spasm. MASTURBATION. 85. During childhood, the sexual organs are immature, and the sexual sense should be in complete abeyance. It is true that the child possesses sexual sensibility, and it need but be called into exercise to develop rapidly. Hence in the training of children all such causes of excitement, whether of the sexual organs, or of the mind, should be avoided. 86. With the majority of children there is entire igno- rance in this respect, and here very surely " ignorance is bliss." But children are very imitative and learn rapidly, and sometimes the seeds of future ills will be sown by care- less parents or servants; and in some cases accident teaches the child that excitation of the sexual organs gives pleasure. 87. I have known cases, as young as two years, where it required much care upon the part of the mother to break up the habit of exciting the sexual organs to erection. The little fellow had found by accident or otherwise that handling perate, and both of them be modest. Socrates was wont to say that those women to whom nature had not been indulgent in good features and colors should make it up themselves with excellent manners, and those who were beautiful and comely should be careful that so fair a body be not polluted with unhandsome usages. To which Plutarch adds, that a wife, if she be unhand- some, should consider how extremely ugly she should be if she wanted ' modesty ; but if she be handsome, let her think how gracious that beauty would be if she superadds chastity."—Bell and Daldy Edition, 1857. 4 50 The Reproductive Organs. the penis, or rubbing it, was pleasant, and would persist in doing it. If continued, it very surely impairs the health— the child loses flesh and strength, and the nervous system suffers. 88. In the majority of cases the habit is readily broken up by careful attention. In very young children the clothing may be so arranged, that the hands can not reach the organ ; in all, the mother should endeavor to control the habit by persuasion and judicious-reproof. 89. Boys will learn the practice of masturbation as early as six or eight years, if thrown in company with older boys who are addicted to the habit. It seems like a good joke to the older ones, and they frequently gratify their prurient im- agination in this way. Parents can not be too careful, even of young boys, and especially is it impolitic to let them asso- ciate with, or sleep with those who may be suspected of mas- turbation. 90. The health of young boys frequently suffers more than when the habit is acquired at a later age. It is noticed that the child is not as free and open as before, is bashful and timid, the hands involuntarily seek the sexual organs in sleep, and sometimes in the day. They become nervous, are easily startled, the sleep is broken, and finally we have loss of flesh and strength, impairment of the mind, and it may be convul- sions. 91. In the majority of cases the habit may be broken up, by careful attention on the part of parents. The nobler faculties of the mind should be called into play, prompt him to be " manly," and withdraw him from the society of those who would lead him astray. Such a boy should be carefully guarded, and for weeks or months should be constantly under surveilance, though without his knowledge. In the majority of cases, it does not require a very long time, if there is a complete suspension of the habit, and forgetfulness of it aa well. 92. In some cases the nervousness that is so prominent The Reproductive Organs. 51 may be arrested by—fy Tincture Pulsatilla, gtts. v.; Water, 5iv. ; a teaspoonful every four hours. If there is irritation of the bas-fond of the bladder and urethra—fy Tincture Eryngium, gtts. xxx.; Tincture Pulsatilla, gtts. v.; Water, 5iv. ; a teaspoonful four times a day; or ~fy Santoniue, grs. xx.; Sugar, 5ij- Mix, and make forty powders—one three times a day. 93. In some rare cases, the evil has become so fixed, that masturbation is performed involuntarily, or at least the suf- ferer has no power to withhold his hands. So serious does it become at times, that the excitation is effected with the legs, when the hands can not be used. Here it becomes necessary to make such application to the penis as will make excitation of it impossible. Acetum Cantharides, Cantharidal Collodion, or Dupy's Cantharidal Oil, will serve this purpose—a very small portion being applied in two or three places whilst the boy is sleeping. He need not know but what this soreness is natural, indeed it is better that he should think so, and attri- bute it to the practice of masturbation. 94. The general treatment will be that indicated for the relief of the nervous suftering as above, and such restorative medication as may be indicated. If the habit is once arrested, we will see a marked improvement in a few weeks, and with careful surveilance, it may be completely broken up within the year. When epileptic symptoms show themselves, or there is a marked impairment of the mind, the Bromide of Ammonium in the usual doses, will be found the most effective remedy. 95. From the age of twelve to eighteen masturbation is a common vice, few boys escaping wholly. It is learned by as- sociation with others, whether in school or in company for play, or wherever or whenever boys are brought together. At the age of puberty the sexual organs have an increased development, and become more sensitive to excitement both local and mental. The youth feels the attraction of the oppo- site sex, and the sexual organs respond readily to sensuous 52 The Reproductive Organs. thoughts. Intuitively he is conscious of their pleasurable use, and it needs little prompting from others to gratification in this way. 96. In all right minded boys this gratification is at first followed by a sense of disgust, and they repeat it with hesi- tation. But after a time they are no longer affected in this way, prurient thoughts take prominent place in the mind, and prompt to self-abuse. It is a repetition of Pope's couplet:— "Vice is a monster of such hideous mien," etc. 97. Masturbation is most frequently commenced wher? boys are associated together, but the habit is most destructive when its practice is continued alone—" solitary vice." Ail the victim goes on, he has less and less power to resist, even though he may know that it is injurious, and may havu the desire to quit it. The unnatural drain upon the system impairs the general health, and the abnormal excitation injures the nervous sys- tem. The youth loses energy, is sluggish in his movements, his shoulders droop forward, looks down, and bends forward when he sits; evidently there is impairment of nutrition and loss of tone. His character has also changed, he is no lono-er open and free even with his associates, seeks solitude, and is diffident and bashful when in the company of women. In some cases they become irritable and fretful, have little courage, are easily startled, and do not sleep soundly.* *" However young the children may be, they get thin, pale, and irritable, and their features become haggard. We notice the sunken eye, the lono- cadaverous-looking countenance, the downcast look which seerns to arise from a consciousness in the boy that his habits are suspected, and, at a later period from the ascertained fact that his virility is lost. I wish by no means to assert that every boy unable to look another in the face, is or has been a mas- turbator, but I believe this vice is a very frequent cause of timidity. Habitual masturbators have a dank, moist, cold hand, very characteristic of great vita. exhaustion ; their sleep is short, and most complete marasmus comes on; thev may gradually waste away if the evil passion is not got the better of; nervous The Reproductive Organs. 53 98. In rare cases the condition becomes pitiable. In ad- dition to loss of flesh and strength, and the ability to work, play, or study, the nervous suftering becomes extreme. The sufferer is haunted by the fear that he will lose his mind, or that something unpleasant, he knows not what, may happen to him. His mind dwells constantly on his unpleasant con- dition, and his morbid fancies run riot over all the unpleasant things he may have heard of. Sometimes the mind is per- manently impaired, or epilepsy is induced. 99. The habit of masturbation is sometimes persisted in through life. Recently a case was reported, in which the party confessed to its practice almost every night from boy- hood up to the age of sixty-nine. Yet he was a married man, had raised a large family, and did not seem to suffer from the excessive drain. Such instances are very rare, for usualty, the onanist fails of success in life. 100. In persons of mature years it is singular to what ex- periments prurient thoughts will prompt. In my earlier prac- tice I had a ludicrous example. A man, some forty years of age, rang me up one night. He had something covered up in front of him and seemed to be suffering severely. A brief explanation and inspection showed that he had inserted his penis, when flaccid, through the neck of a bottle and was fast. There was nothing to do but break the neck of the bottle, which was accomplished with but slight injury to the organ. Our surgical authorities report many similar cases. Among these, the man who fitted his wedding ring over the penis, another who employed a napkin ring, and others who employed rings of other kinds. The operation of filing or cutting them off", was not a very pleasant experience. Prob- ably one of the most ludicrous cases was the man who, taking a bath, fancied the opening of the stop-cock would afford " a symptoms set in, such as spasmodic contraction, or partial or entire convulsive movements, together with epilepsy, eclampsy, and a species of paralysis ac- companied with contractions of the limbs."—Lallemand. 54 The Reproductive Organs. good opening for a young man." His cries brought assist- ance, and he was found suspended to it by his penis. 101. Self-pollution is the cause of many of the chronic diseases of the reproductive organs, especially of prostator- rhcea, spermatorrhoea, and sexual debility. The undue stim- ulation of the organs and prurient thoughts lead to nocturnal emissions, which persist even after the sufferer sees the evil effects of masturbation, and ceases to abuse himself. And from this involuntary excitation may grow all the lesions which we will have to study. 102. As a general rule, we find that the habit of mastur- bation may be readily broken up, if proper measures are taken. A full explanation of the evil consequences that are likely to ensue if it is persisted in, and an appeal to their better instincts, will frequently be sufficient. If there is any one thing that a man values more than another, it is the capacity of a man sexually. Let the youth know that self- abuse is followed by impaired health of body and mind, and sexual debility and disease, and you present the strongest argument for continence. 103. It is true it requires a strong effort to break up the habit, when it has been followed for a length of time. Quite as much, probably, as to stop drinking, opium eating, or other habits of intemperance. It requires a strong motive, but this subject may be so presented as to offer the strongest inducement to quit forever the pernicious habit. 104. Breaking up associations with idle and dissolute young men, and bringing the youth into the society of the opposite sex, is very important in many cases. Rarely do we find self-abuse in either sex, in our public schools, or where there are mixed classes. Free association with the opposite sex of the same age is almost a sure protection against this vice, as it may also be a means of cure. This is a strong argument in favor of the education of the youth of both sexes together, and one that should not be overlooked. Add to this the fact that youth educated in mixed classes are less The Reproductive Organs. 55 likely to sexual excesses when the}' have reached adult years, having better control over the sexual instinct, we conclude that as the world grows wiser, it will find safety at least in this regard in our public school system. 105. Active employment is an excellent means of break- ing up the habit. If a boy is employed from morning until night, both mind and body being engaged, there is less dis- position to prurient thought or sexual excitement, indeed in many cases the desire is wholly in abeyance. Lallemand re- marks, "The urgent necessity of recruiting each day the great waste occasioned by varied and progressive gymnastic exercise diminishes in an equal proportion the secretion of : emen ; for the economy only occupies itse'f with the repro- duction of the species when it has provided for the conserva- tion of the individual, as I stated when speaking of the in- fluence of nutrition on generation. 10b, In those cases in which the sufferer has become convinced of his error, and lias stopped the habit, but being alarm 'd b\ the possible results, allows his mind to dwell con- stantly on the subject, we may employ remedies to advantage. He is nervous and timid, has a fear of impending danger, with sometimes unpleasant sensations of fullness in the head or dizziness ; of tightness in the chest and precordial oppres- sion Occasionally functional heart disease springs from this nervous trouble, and there is palpitation or irregular action. In some the nervous excitation assumes an epileptic character, or epilepsy may be fully developed, and run its usual course. 107. For the head symptoms I have been in the habit of prescribing Pulsatilla, as — R Tincture of Pulsatilla, o*s. : Water, oiv.; a teaspoonful four times a day. If there is prostatic irritation with d;scharge, or the patient is morose and irritable, we may add the Staphysagria in the same pro- portion. For the epileptic tendency I have obtained better results from the Bromide of Ammonium 5ss. to Water 5iv. ; a teaspoonful three or four t'mes a day. Bromide of Potassium 56 The Reproductive Organs. may be used when patients are full blooded, and excitement of the sexual organs present, and Bromide of Lime at bed- time when the sleep is broken and not refreshing. 108. If the general health is impaired, we treat the patient according to special indications. If the indications for any medicine are pronounced, we will sometimes find that it will be a remedy for the nervous and mental lesions as well as the physical. Thus in a recent very severe case, the violet color- ation of tongue, nails, etc., indicating Nitric Acid, it gave rest and strength to the nervous system, good sleep, and there was a rapid recovery. MASTURBATION IN WOMEN. 109. Whilst our older authorities have almost wholly ig- nored the fact of self-pollution in women, some recent writers have given it undue prominence. We have already seen that the sexual sense was less developed in women than in men, and the desire for sexual gratification very much less. With most women the desire is only associated with love, and is probably as much or more for the pleasure of the loved one as for self-gratification. In the majority the sexual sense re- quires stimulation from mental impressions and emotions, and is developed by loving caresses, which by reflex action excite the sexual organs. The majority of women are, there- fore, wholly free from this vice. 110. In some, however, from disease, or from a wrong mental organization, or an undue sensitiveness of the sexual organs, strong sexual desires are awakened, and as they can not have natural satisfaction, masturbation is resorted to It is, probably, more frequently a vice of female boarding schools, especially where the pupils sleep together and are iiJt under proper restraint. The cases must be very rare when The Reproductive Organs. 57 the sexes are educated together, and they are also rare in convent education. 111. There are two periods in the life of women when there is the greatest tendency to self-pollution. The first is from the first appearance of the menstrual discharge to the full development of the body ; the second from the age of twenty-seven to thirty-five, especially in those who have been disappointed in love. At those ages also we find the greatest tendency to lapse from virtue, and the ranks of prostitutes are recruited from those ages. 112. There is not only the less imperative desire on the part of the female, but there is also less gratification from masturbation. Thus a girl may be persuaded by an associate to commit the act, but finding little gratification from it, and this little more than compensated by the loss of self-respect and disgust which follows, she never repeats it again. I am satisfied that these statements are correct, as I have them from ladies who have had a large experience as educators of women. 113. When once habituated to masturbation, the girl or woman exercises much ingenuity in finding objects to gratify her desires. Anything that is moderately smooth and of proper size answers the purpose, and if nothing can be had, the hand is made to answer the purpose. In some cases the excitation of the urethra is found more pleasurable than the vagina, and thus we have numbers of cases reported in which hair-pins, pencils, etc., have escaped into the bladder, and have been removed by dilatation, or an operation. I have had one case where a piece of turned wood, acorn-shaped, the ornament of an old-fashioned bed-post, was employed, and being fully introduced into the vagina could not be with- drawn by the woman. It required the use of the forceps, and considerable effort for its withdrawal. 114. Women suffer from masturbation in a similar manner to men. The undue excitement stimulates the emotions at the expense of the will, and the sufferer becomes hysterical, 58 The Reproductive Organs. and at times very despondent. She finds that her memory is impaired, she can not think clearly, loses her ambition, and the ordinary pursuits of life become burdensome. The gen- eral health also suffers, and the various vital functions are impaired. 115. In addition to this, the abnormal excitement of the sexual organs leads to local disease, and may produce any of the many lesions to which women are subject. The more common diseases are vaginal and cervical leucorrhcea, disease and flexions of the cervix, and prolapsus uteri.* 116. The treatment of these cases will be similar to that named for the other sex. When the injurious results are pointed out, and probably proven by the patient's present sensations, the habit will generally be abandoned. Parents *Perhaps the present is the most suitable time I shall find for alluding to a practice, unfortunately of not very rare occurrence, which, while it destroys the health of the body, if persisted in, impairs in no less a degree the powers of mind, and which is nearly always accompanied by leucorrhcea—I allude to masturbation. I do not believe all I have heard as to its great frequency, but that it is practised by many females is too true. In some, I have no doubt, it has been the result of uterine disease, the habit having been contracted acci- dentally in the first instance, in the efforts to procure alleviation from the irritation which so often exists about the orifice of the vagina- but, be the cause what it may, it is soon accompanied by vaginitis and endo-cervieitis, manifested by the presence of the well-known glairy cervical discharge. Beware, however, of charging a patient with being addicted to this degrading habit, because suspicious symptoms present themselves ; the dilated pupil, the downcast look, the uncontrollable excitement, which a vaginal examination causes, generally tell the tale ; added to this, there is often a severe lancinating pain complained of immediately over the pubes, and in several cases I have noticed that vomiting at night has been a prominent symptom. These dis- tressing cases can be cured by moral means alone; local treatment is useless, and generally injurious, for it attracts the patient's attention to the genital organs, the very thing we should be most anxious to avoid. I can not find words sufliciently strong to condemn, as I would, the barbarous practice of mutilating the patient by the removal of the clitoris. This operation is as use- less as it is disgusting, for there is no truth in the idea that in the clitoris alone is seated the nervous expansion which subserves the sexual orgasm.__A thill. The Reproductive Organs. 59 must never forget, however, that girls should never be ex- posed to such influences as will lead to self-pollution. 117. The nervous system may be relieved by the use of Pulsatilla, Macrotys, Staphysagria, and the Bromides, as has been described. A restorative treatment may be necessary, with bathing, out-door exercise, and especially some regular occupation. All disease of the sexual organs may be treated in the usual manner. In these cases frequent examinations, by touch or speculum, is much to be deprecated, and local applications should be used as sparingly as possible. MARITAL EXCESSES. 118. It is a common opinion that the marriage rite gives entire freedom in sexual congress, and few persons ever think that it may be abused. The man believes that now he may legitimately gratify the sexual instinct, and the woman thinks she is bound by the marital tie to yield to his solicitations. In sleeping together, (a very bad habit of married people), there is cause for undue excitement upon the part of the Husband, and abundant opportunity for its gratification. 119. Men have most absurd ideas of the marital demand. They think that the good impressions they may have made on the wife, and the affection they have won, may be lost, un- less they show that they have abundant ability to consummate the marriage rite. Probably this is one cause of marital ex- cess at first, and a fear of impaired virility may be a cause for its continuance. 120. As Acton well remarks, "This feeling of virility is much more developed in man than is maternity in woman. Its existence,indeed, seems necessary to give a man that con- sciousness of his dignity, of his character as head and ruler, and of his importance, which is absolutely essential to the well-being of the family, and through it, of society itself. It 60 The Reproductive Organs. is a power, a privilege, of which the man is, aud should be, proud—so proud that he should husband it, and not squander or deprave it. Too many a man, with a recklessness that can only be attributed to ignorance of its value, exhausts or de- files this noblest prerogative of his manhood, a possession as precious in its own way as that of chastity." But as we have already seen, the husband maybe disabused of the idea, that frequent coition is expected by the wife. Her passions are not urgent, and she is satisfied with occa- sional intercourse. Neither can virility be increased by this frequent use; indeed we find that the contrary effect ensues, and the virile power is frequently weakened, and sometimes lost by marital abuse. 121. Marital excess is the rule, a moderate and legitimate gratification the exception. None know this better than the physician, yet how rarely are they willing to state the facts, even though this may be a cause of severe disease, aud may endanger life.* *Tt is a common notion among the public, and even among professional men, that the word excess chiefly applies to illicit sexual connection. Of course, whether extravagant in degree or not, all such connection is,-from one point of view, an excess. But any warning against sexual dangers would be very incomplete if it did not extend to the excesses too often committed by married persons in ignorance of their ill-effects. Too frequent emissions of the life- giving fluid, and too frequent sexual excitement of the nervous system are, as we have seen, in themselves most destructive. The result is the same within the marriage bond as without it. The married man who thinks that, because he is a married man, he can commit no excess, however often the act of sexual congress is repeated, will suffer as certainly as the unmarried debauchee who acts on the same principle in his indulgences—perhaps more certainly, from his very ignorance, and from his not taking those precautions and following those rules which a career of vice is apt to teach the sensualist. Many a man has, until his marriage, lived a most continent life; so has his wife. As soon as they are wedded, intercourse is indulged in night after night: neither party having any idea that these repeated sexual acts are excesses which the system of neither can bear, and which to the man, at least, is absolute ruin. The practice is continued till health is impaired, sometimes permanently ; and when a patient is at last obliged to seek medical advice, he is thunderstruck at The Reproductive Organs. 61 122. The wife suffers far more frequently than the hus- band. Sometimes in the first weeks of married life, the ex- cesses of the husband are sufficient to impair her health, and he is forced to moderate or suspend sexual intercourse. In others the bloom slowly leaves her cheeks, she experiences aches and pains to which before marriage she had been a stranger. The vegetative functions are impaired, and she slowly loses flesh and strength, and in a year or two is pre- maturely aged. 123. This cause is supplemented by the cares and over- exertion incident to housekeeping, for which probably she is unfitted by age or education. Add to this the still further drain on vitality of child-bearing and nursing, and we need not wonder at the poor health of our wives and mothers. 124. Whilst it is true that moderate indulgence in sexual intercourse is conducive to health, in both sexes, it is certain that the marital relation is followed by an abuse by the majority. In some instances the husband suffers in his gen- eral health, whilst the wife grows vigorous. In others, and far more frequently, the wife suffers, the husband enjoying robust health. In rare cases, both parties suffer equally. 125. It may be said that sexual intercourse is not injurious to either party, when the act is fully complete in each. Even when frequent, we find the ill effects but slight, when com- pared with the imperfect sexual orgasm. This is well illus- trated by the cases of some prostitutes, who enjoy excellent health when they enjoy free intercourse with stout, virile men, but suffer when they are kept by one who lacks virility. I have known instances of this in married life—women who learning that his sufferings arise from excesses unwittingly committed. Mar- ried people often appear to think that connection may be repeated just as regu- lar!}' and almost as often as their meals. Till they are told of the danger the idea never enters their heads that they have been guilty of great and almost criminal excess; nor is this to be wondered at, since the possibility of such a cause of disease is seldom hinted at by the medical man they consult—Acton. 62 The Reproductive Organs. enjoyed excellent health with one husband, but had poor health with another, though all other conditions were the same. 126. Prostatorrhcea and spermatorrhoea may result from marital abuse, as well as from masturbation, and the symp- toms will not materially differ in the two cases. The condi- tion of the female, analogous to spermatorrhoea in the male, is most frequently produced by marital excess. 127. Acton remarks, " Since my attention has been par- ticularly called to this class of ailments, I feel confident that many of the forms of indigestion, general ill health, hypo- chondria, etc., so often met with in adults, depend upon sexual excesses. The directors of Hydropathic establish-' merits must, probably, hold some such opinions, or they would not have thought it expedient to separate married patient? when they are undergoing the water treatment. That this cause of illness is not more widely acknowledged and acted on, arises from the natural delicacy which medical men must feel in putting such questions to their patients as are neces- sary to elicit the facts." 128. Bedding married persons together is a very bad habit at best. Outside of the sexual abuse that springs from it, it frequently proves injurious, the feebler party losing life by simple contact. Add to this the absorption of the exha- lations from the body, inhaling the breath, or a vitiated atmosphere, and we find frequent cause for prescribing single beds, if not separate rooms. 129. The wife should not lose control of her person by the marriage rite. It is hers to say when the husband shall have intercourse, his to gain the end by endeavors to please. This is a law of animal life, and in no species is it violated but in man. 130. As a general rule there is little difficulty in rectifying these marital wrongs, when once they are determined. If a man has a true affection for his wife, and learns that he is causing disease by frequent intercourse, he will moderate his The Reproductine Organs. 63 passions, consent to single beds, or to absolute continence, for a time, if it is necessary. When a man is so brutish that he will gratify his desires at the expense of the health, happi- ness, or life of the wife, there is no marital bond that should compel her to submit. 131. I have had occasion to prescribe single beds very many times, and it has been pretty uniformly followed by better health, and greater happiness to both parties. It does not prevent normal sexual gratification, but it is a means of preventing abuse. The husband is necessarily placed in his proper relation, and must solicit the favor of the wife, and she will not be inclined to submit too frequently to injure the health of either. PROSTITUTION. 132. As we have already seen, the sexual iustinct in man is very strong, and under some circumstances, will have grat- ification. Entire continence through life is possible to some; continence to complete maturity, is possible to a large num- ber, though, as Acton remarks, it requires " a strong influence of the will, and a courageous self-rule." Proper training from childhood up will have strengthened the will, whilst at the same time the sexual instinct has not gained strength, by avoidance of those circumstances calculated to call it forth. 133. In the earlier ages of man, he was governed to a very considerable extent by purely animal instincts. And this function in all probability was exercised in a manner similar to that we observe in the higher mammalia. In our higher civilization there is no animal so libidinous as man, but as we descend toward barbarism we find there is less and less tendency to sexual excesses. Primitive man had women in common, and sexual selection was governed by the same laws as in the animal kingdom. The desire of the female 64 The Reproductive Organs. would be strongest at such periods as would render inter- course most fertile, and at these times the solicitations of the male would be most successful. As the female had the choice of a father for her children, she would most likely select the strongest and most attractive, and thus the condition of the race would be improved. 134. With an improvement of race and condition, would come better provision for the animal wants—shelter, food, clothing, and an idea of ownership—which would soon extend to women. As each individual would endeavor to obtain as much of all the goods as possible, men would strive for the possession of women, and the stronger and more highly de- veloped men would obtain a plurality. 135. Nature wisely provides for her creatures in all cir- cumstances of life. To a people practicing polygamy, a larger proportion of female births would be essential, other- wise a portion of the males would be deprived of wives. In those rare cases where a people practice polyandria, one woman having several husbands, a larger number of male births would be necessary. 136. It would have seemed that in those periods when polygamy was constantly practiced, prostitution would have been unnecessary. Yet we find it existing in the midst of and practiced by the much married, as well as by those who were restricted to one wife. Thus we read in Genesis that when Judah, going up to the sheep-shearing, saw Tamar sit- ting in an open place, " he thought her to be a harlot." "And he turned unto her by the way and said, Go to, I pray thee, let me come in unto thee. And she said, What wilt thou give me ? " This may be taken as the earliest record of prostitution, though the reason is doubtless from want of record rather than from absence of prostitution. 137. In every age of the world since we have written his- tory we find that prostitution has prevailed to a greater or less extent. There have been times when it was recognized and protected by law, and again periods when it was prohib- The Reproductive Organs. 65 ited and severe punishments meted out to the outcast women, but through all it has maintained its existence, and continu- ally renewed its votaries. No stronger evidence could be adduced that it is an absolute necessity of our present social existence, and that it would be the part of prudence to recog- nize it, and by judicious laws so regulate it that the least evil may grow out of it. 138. It is not necessary for our purpose to trace the his- tory of prostitution, as it is the same in all .countries and among all peoples. The lupanaria of Rome were not mate- rially different from the bawdy-houses of the present day, both loving darkness better than light. Yet a truth is forced upon us by the examination of this history—the evil becomes less as it is allowed more liberty, and is not forced to seek the cover of darkness, and the by-ways of great cities. 139. There was a period in ancient Greece and Rome when prostitution was not considered disgraceful, and when Thais, Lais, Aspasia, Phyrue, and many others were noted for their graces of body and mind, and held a desirable social relation. If history is to be believed, we would reach the conclusion, that chastity or unchastity has little influence in woman's degradation, as compared to the public ban which forces her to hide herself from all that is good in the world. 140. When we come to study prostitution in our day, Ave are surprised at its extent, and the powerful hold it has upon the people ; living and prospering, though prohibited by law and condemned by religion and social usage. It shows itself in many phases, from the common street-bawd, who sells her favors to whoever will buy, to the woman of education and refinement, who" finds pleasure, support and gratification of her love of dress and luxury in it. Of the common prosti- tute we have about one to each one thousand inhabitants ; and of those who do not make it an entire means of support, probably twice this number. 141. Prostitutes who lead regular lives do not suffer in health as many imagine ; but the larger number add intem- 5 66 The Reproductive Organs. perance to sexual excess, and from this, and disease of the reproductive organs, the larger number die young, the aver- age duration of prostitution being but about six years. Kept women, or those who see but few men, are usually healthy, and quite frequently live to a good age. 142. Diseases of the reproductive organs are frequent among prostitutes. The simplest forms are acute inflamma- tions of the uterus and ovaries from excess and intemperance, vaginitis and vaginal leucorrhcea, displacements of the uterus, and urethral and vesical irritation. In the majority there is a strong love of social pleasures, and a kindly feeling for others hardly surpassed in other classes. Insanity is of rare occurrence, and one is surprised at the knowledge of men and things shown by mere girls in age. 143, In large cities many women moving in good society visit houses of prostitution and assignation for the gratifica- tion of the sexual appetite. These most frequently confine their favors to one man, but sometimes exceed the common- bawd for promiscuity. These are not to be regarded as sinners par excellence, for in many cases they are women of most kindly feelings, and with this exception are inclined to do right. We may, indeed, regard it as a disease, as is in- temperance, and we pity more than we blame, and use reme- dies to cure, rather than means to punish. Surely the fact that they are women should not cause us to lose sight of our common humanity and the commands of charity. 144. Private women, or kept mistresses, will probably number as many as the regular prostitutes. Many causes are operative to replenish their ranks. Seduction possibly stands first, as it does in furnishing inmates of houses of prostitu- tion. Following this comes the love of dress, of ease, of luxury, without labor; strong sexual desires that must have gratification ; and last, though not least, the difficulty in pro- curing work that will yield a decent support, and that is re- garded as respectable. 145. Society might and should provide means for the pro- The Reproductive Organs. 67 tection of these women. Let the law punish seduction as a penitentiary offence (surely the crime against society is gross enough); let it legitimatize children born out of wedlock, that they may bear the father's name, and inherit in common with those born in wedlock, and the first cause will be to a considerable extent removed. 146. Let a people honor habits of industry and thrift, con- demn over-dress and display, regard men and women for their intrinsic worth rather than for the clothes they wear, and you will have removed the second cause. Man is an imitative animal. If fine clothes and accessories make fine people— and people are constantly planning and striving for this. If for it they risk their good name for honesty and fair dealing, take advantage of the neighbor, sell sons or daughters in marriage—why should we blame the woman who sells her favors for what society thinks so desirable ? 147. Make labor honorable, and pay women for the work they do, and we will have removed the last cause. We have made the honorable work of caring for a household servile, and treat the woman who aids the mother in her cares, as if she was of a different species. We complain of the scarcity of servants, of their incompetence, and forget that we have made both by lowering the character of the employment. 148. Can you prevent prostitution by legal enactments?* *"lt (the report) states that the women in the several places subject to the Acts attended with regularity throughout the year, and that in a few instances only was 't necessary to take proceedings before a magistrate. The Acts have exercised a repressive influence in several ways. Notwithstanding, we are told, the continued influx of common women from unprotected districts, the total number in the several districts on the 31st of December last had been reduced. The beneficial working of the Acts is, however, more clearly de- monstrated by the reduction in the number of juvenile prostitutes; and this is very striking The number of prostitutes in the different districts under the age of seventeen on the 31st of December last was nine; whereas in 1866, when the Acts were first put in force, there were three hundred and seventy- seven under that age. Again, on the 31st of December last, those under the age of eighteen were sixty-seven; whereas in 1866 there were five hundred 68 The Reproductive Organs. No. You can not even lessen it; indeed, many times it seems to gain strength by prohibitory laws. Laws against prostitution only cause it to seek by-ways, and hide itself from those who are not interested in it, but never from those who want it. They give secrecy—that which many men desire, and breed disease both moral and physical because there is nothing to control it. The laws are enforced against the women, never against the men. When a house of prostitu- tion is " raided," the women are exposed to the jeers and contumely of the crowded court room, are heavily fined, and sent to the work-house. The men taken with them are pri- vately discharged—and yet we call this a Christian country .' 149. Lastly, male prostitution is regarded as rather honoi. able than otherwise. A fast life is spoken of as rather a good antecedent in a man — and sowing wild oats as rather an agreeable divertisement. Such a man moves in good society, is received in moral families, is intimate witlfvirtuous women, is courted by the church, and marries. But the woman who has sown wild oats, God help her, can never return to society, can never earn bread by honest labor, is of necessity an out- cast. and ninety-five 1 The number of brothels has been reduced by eighty-six during the past year, many of those suppressed being of the lowest descrip- tion : seventy-one young creatures between the ages of twelve and seventeen, and one hundred and thirty-five women between the ages of seventeen and thirty-one, who were known to have commenced immoral practices, gave up that course of life upon being spoken to by the police; and the Assistant- Commissioners Keport contains individual instances of many girls and mar- ried women who owe their rescue from a life of sin and misery to the well- directed and humane efforts of the officials engaged under these Acts."__ Report on the effects of Acts regulating Prostitution.—Lancet. The Reproductive Organs. 69 PROSTITUTION THE CAUSE OF VENEREAL DISEASE. 150. In prostitution we have the cause of venereal dis- eases, and it has been supposed that laws for its suppression would eventually eradicate these. Thus, whilst ridding the world of a moral evil, we would get rid of the fearful disease which seems to follow it as a punishment. But the history of prostitution shows that the influence of prohibitory laws is the reverse of this. We have already seen that laws against prostitution are only partially enforced, can be but partially enforced. Their operation causes the social evil to hide itself in by-ways, and the very secrecy necessary serves as a cause for the propagation of infection, by prevent- ing cleanly habits and proper hygienic surroundings. The woman under the ban of the law, and liable to arrest and punishment at any time, loses that regard for her own health and others, that she would have with better surroundings. 151. It has been denied that laws regulating prostitution diminished the venereal diseases, and we are pointed to the statistics of Paris and some German cities as proof. It is my opinion, however, from the facts that have come to my knowledge, that it is possible to so enforce sanitary laws, as to greatly diminish the danger of infection, and eventually to get rid of the severest types of these diseases* *Captain McDonough, Chief of Police in St. Louis, in an official report says: "I will recapitulate a few of the moral effects produced by the St. Louis social evil law in this city, which, in my opinion, far outweighs any moral ob- jections which have been, or can be, alleged against it. "1. By this report it is shown conclusively that the number of public women has uniformly decreased each year. " 2. That they are more decorous in their manner in public. " 3. That the plying of their wicked trade upon the public streets has been almost entirely discontinued. "4. That a considerable number of abandoned women have been reclaimed and restored to respectable life, and, in several cases, married. 70 The Reproductive Organs. 152. As we can trace prostitution through the entire writ- ten and traditional history of man, so also can we trace the venereal disease. David doubtless suffered from this when he said:—"Mysore ran in the night; there is no rest to my bones, because of my sin. My wounds stink, and are cor- rupt, because of my foolishness, for my loins are filled with a " 5. That clandestine, or private prostitution, which often develops into open vice, has been materially checked, through fear of the legal consequences of such indulgence, when brought home to the offender. "6. That juvenile prostitution has been greatly diminished, if not wholly removed. * * * That the results have so far been encouraging, is beyond doubt. "The most enthusiastic promoters of the measure could not have hoped for a larger or more beneficent success than has attended its workings during the two years in which it has been in force. * * * The young and the heedless have been warned by the police of the consequences of entering a life of shame. The number of bawds has largely decreased, and the deaths, formerly very numerous, in consequence of diseases concomitant on a life of shame, have in a great measure been prevented. "Under the law, this evil has been removed, as it were, from the exclusive domain of the moralist and intrusted to practical heads and practical hands to give it shape and form, in order that, if possible, some good might result from a vice so stupendous and so mischievous; one which has existed and flourished in all nations and all countries from the time whereof the ' memory of man runneth not to the contrary.' St. Louis alone, on this continent, has grappled with the monster; and while it is not claimed that the authorities have suppressed it, or even expected to do so, nevertheless, by the intervention of the strong arm of the law and strict police surveilance.it has been stripped of some of its worst features, and great reductions have been made in the ranks of its votaries, as you may observe from the records of this office, and which are a part of this report." The Mayor of St. Louis has said: "As many are of the belief that the fact of legally regulating houses of prostitution causes an increase of the evil, I am happy to state that such is not the fact. There has been an actual decrease in the number of these houses and their inmates since the establishment of this law, and the decrease in disease is fully fifty per cent. If this be the case we think we have all just cause of congratulation that the cause of humanity is being benefited by the social evil ordinance, and that, looking at past re- sults, it can scarcely longer be called an experiment, but a success in all that its most sanguine advocates claimed for it. The Reproductive Organs. 71 loathsome disease, and there is no soundness in my flesh." Probably this is the earliest written account of the venereal, and it may be that this was not the infectious disease with which we are acquainted. 153. The earlier medical writers refer to disease of the re- productive organs, but their descriptions are not very clear, and it has been doubted by some whether syphilis was known, until about the time of the siege of Naples in 1494. Dr. Good in his Study of Medicine remarks : " It appears to have been known to the world from an early age, as I have remarked in the running comment to the volume of Nosology, that acrimonious and poisonous mate- rials are, at times, secreted by the genitals, capable of excit- ing local, and perhaps constitutional affections in those who expose themselves to such poisons by incontinent sexual in- tercourse. Celsus enumerates various diseases of the sexual organs, most of which are only referable to this source of im- pure contact; but the hideous and alarming malady which was first noticed as proceeding from the same source toward the close of the fifteenth century, and which has since been called almost exclusively venereal disease, has suppressed till of late, all attention to these minor evils, in the fearful contem- plation of so new and monstrous a pestilence, to various modifications of which most of the anterior and slighter dis- eases of the same organs seem to have been loosely and gen- erally referred; as though there was but one specific poison i-suing from this fountain, and consequently but one specific malady. On which account, much confusion has arisen in the historv and description of the disease ; and syphilis, its most stinking species, though commonly admitted, as we shall see presently, to be of comparatively recent origin, is by writers of considerable eminence, regarded as of far higher anti- quity." 154. The fifteenth century was noted for its immorality, and syphilis maybe regarded as the natural result of the vene- real excesses of that period. At the siege of Naples referred 72 The Reproductive Organs. to, both the besiegers and besieged seem to have lost all the better instincts of manhood. A venereal delirium was added to the other excesses of the period, and whilst the camps were filled with a multitude of female camp followers, the utmost license was allowed the soldiery. The bloody sorties from the city, hunger and thirst, numbers decimated by disease, and the innumerable woes attending war in that age, were inoperative to check the evil—indeed, served but to stimulate it. In the city, where the sufferings from the siege were still greater, there was the same venereal insanity, and the histo- rians seem at a loss to know whether the disease originated within or without. 155. At this period Columbus returned from his second voyage to America, and it was claimed some years after- wards, that the venereal disease was introduced into Europe by his crews, and was supposed to be the result of their in- tercourse with the natives. But Fracostoria, who was an eye witness of the entire progress of the disease, claims that it had made its appearance some weeks previously, and had already spread over Anvergne, Lombardy, and Italy. 156. From this period at least, we have a complete historv of the malady, and whilst there are undoubtedly periods of special virulence, and of comparative mildness, the general character of the disease has remained the same, and it has presented the same acute and chronic symptoms. 157. These periods of virulence and mildness are too marked to be mistaken, and if we examine into their causes we may learn an important lesson. In all periods of social turbulence, whether from Avar or other causes, the venereal disease has been virulent. It is associated with want and suf- fering, whether from bad harvests, unpropitious seasons bad hygienic surroundings, or epidemic influences. It orows milder in periods of profound peace, when a people are well fed, well clothed, and well housed; and especially when peace of mind is added to comfort of body. 158. Noticing these facts, we would conclude, that as a The Reproductive Organs. 73 people grow in intelligence and wealth, the comforts of life being pretty equitably distributed, the venereal poison will be less virulent. That as those addicted to prostitution are more kindly cared for by the government, and sanitary laws are enforced, the disease will be less frequent and less viru- lent. That just in proportion as prostitution is made crimi- nal, and is forced to seek darkness, and to be secure forced to neglect cleanliness and good hygiene, the disease will be more common and more virulent. 159. An army in the field is an excellent illustration. If badly " policed," and sanitary measures neglected, it will suffer severely from disease. But place it in charge of a medical chief, who will strictly police the encampment, and enforce the observance of hygienic laws, and good health is restored. We conclude, therefore, that a strict sanitary police of all houses of prostitution is one of the most important means of prophylaxis against venereal disease. 160. The necessity of personal cleanliness is so obvious, that it need but be alluded to. When this is strictly attended to, persons may escape contagion even though exposed. Atkins remarks, "From what has been written, it must appear clear that the only chance of preventing infection, alike on the male and female is personal cleanliness after sex- ual intercourse with strangers. The good that has resulted from pelvic inspection of females, as in Paris, Brussels, and other places, has been greatly attributed to the greater atten- tion to personal cleanliness which such inspections have brought about. If a man have sexual intercourse with a strange woman, let him wash the penis immediately after the act, taking care to cleanse the folds of prepuce, especially near the framum, and Ln the sulcus of the corona glandis. If a woman shall have sexual intercourse with a strange man, let her use a syringe with hot water, to wash out the vaginal sur- face, taking care to cleanse the folds of mucous membrane at the orifice of the canal, and of the labia pudenda." 161. Parkes recommended a wash of Sulphate of Ziuc. 74 The Reproductive Organs. Others have recommended Carbolic Acid, Sulphurous Acid, and Permanganate of Potash. But if we think for a moment that these agents, if strong enough to destroy the specific character of the virus, will excoriate the organs, we will not attribute prophylactic virtues to them. Certainly the best agents are water and soap. When the tissues are abraded, or delicate, it is probable that absorption takes place during copulation, and in such cases washing is of no benefit, for the most minute portion of virus absorbed is sufficient to infect. IMPOTENCE IN THE MALE. 162. Of all the faculties of mind or body, there are none that seem to be so highly valued as sexual power. Men will cheerfully endure bodily suftering, or the misfortunes of life, but let them once get the idea that sexual power is failing, or is likely to be lost, and they are most miserable. -We hear much about u manhood " and " its loss," as the crown of life, and its most serious misfortune, as if the soul of man resided in his penis, and his chief occupation was the begetting of children. All men seem to think somewhat alike in this re- spect. A man need not be a Sybarite to have these feeling for it is the case with the youth devoted to pleasure, as with the parson in gown and bands, or the grave and reverend senior who, from appearance, we would think had passed the period of care in this respect. 163. Whilst, as men, we might laugh at the absurdity of these feelings and this fear, as physicians we are called upon to give relief in these as in other cases. And whilst we may not place the exaggerated estimate upon those powers that others do, we can not fail to recognize the mental suffering that follows their impairment. 164. True impotence is very rare, and one may not see an The Reproductine Organs. 75 • example of it in a long practice. The most common forms for which we have to prescribe are from wrong innervation, undue excitation, and impaired innervation. 165. Undue Excitation.—In some cases the sufferer com- plains that the venereal excitement is such that the orgasm occurs before penetration can be effected. In others the ex- citement will culminate without a complete erection. In both the organs maybe in normal condition, and erection may be normal except in company with a woman. In some cases it is very certainly a lesion of the mind—the imagination is so active in this direction that the organs are uuduly stimulated. In others the over-excitation is from exalted sensibility of the reproductive organs. 166. Doubtless many men have suffered in this way for months, on first getting married, without complaint, until finally the undue exaltation of the nervous system wore off, but sometimes we are asked to give relief. I may give two cases as examples: L ----, Bat. 30, of temperate habits, steadily pursuing his occupation of carpenter, not addicted to masturbation, became so excited at the near prospect of marriage that he had noc- turnal emissions, and finally erections during the day with partial emission. He strove to control the feeling, aud finally consulted a specialist who prescribed large doses of Bromide of Potassium, with the effect to control the excitement for the time being, and advised the consummation of the mar- riage. Some weeks afterward he applied to me for aid. His countenance was haggard, step unsteady, appetite poor, tongue furred, bowels constipated, and mind bordering on in- sanity. The story was clear—though laboring under intense sexual excitement he had not been able to have connection. I assured him of relief, if he would follow my directions, and volunteered to make such explanations to the wife as would be satisfactory. Absolute continence for ten days was enjoined. A cold salt water sponge bath to spine and pelvis 76 The Reproductive Organs. recommended every morning; the bowels were gently moved with a saline cathartic; a single dose of Acetate of Potash to be taken in the evening; Tinct. Nux Vomica, gtts. ij. in the morning ; and for the nervous symptoms : 1$* Tincture Pulsa- tilla, 5ss. ; Water, 51V.; a teaspoonful four times a day. I need but say, that after the ten days, there was no trouble, and within the year I was called to assist in the delivery of the first child. B----, Bet. 24, has been married a week, and has not yet been able to consummate the marriage. He is of jovial tem- perament, and laughs it off", saying that so far as he is con- cerned he cares very little, but he is grieved on account of his wife. Emission is almost instantaneous upon erection, when the organ becomes flaccid and useless. Ordered : Bromide of Potassium, grs. xxx., two hours before retiring, and a local application to the penis of: 1^ Tannic Acid, 5ss. ; Water, 51V.; continuance for a few days, when the act was comfortably performed. 167. The treatment of these cases is thus pretty clearly outlined. Allay the patient's fears, and advise continence for a time. For excesssive venereal excitement, Bromide of Po- tassium. For the peculiar nervous fear, Pulsatilla. For the excessive sensibility of penis, a solution of Tannic Acid, or of Permanganate of Potash. 168. Impaired Innervation.—Persons who have suffered from spermatorrhoea frequently have difficulty in copulation. Iu some cases the erection is incomplete, in others it is so brief as not to give time for the act, in others the sexual stimulation is not sufficient to cause emission. In all of these cases we will find impaired innervation as a principal cause, and its restoration will give relief. 169. Treatment.—If there is impairment of the general health, the basis of treatment will be a judicious tonic and restorative course. "Occasionally Ave will find this sufficient. The Keprodi ctive Organs. 77 The special remedies Ave employ to strengthen the repro- ductive functions are Nux Vomica, Ergot, Iodine, Phosphorus and Belladonna. These are employed in the usual doses, and associated with the tonics and restoratives. I have been in the habit of prescribing, for the simpler of these cases; 1^ Extract of Nux Vomica, Iodine, aa. grs. vj.; Hydrastine, 5ss. M. Make thirty pills, and give one four times a day. The Prussian Phosphuretted Oil, in doses of five drops three times a day, is a valuable addition to this. In one bad case I ad- ministered this in combination Avith Cod Oil and solution of Strychnia Avith the most gratifying results. I generally direct the saltwater bath to the spine, abdomen, perineum and genitals, to be used on rising; in the mornino- with brisk friction. Instead of directing that he experiment Avith the virile member to determine whether he is getting well, I have him live a life of absolute continence, if unmar- ried, and but occasional intercourse if married. This I deem of the greatest importance. In those exceptional cases where the organs have been ex- hausted by excess, and Avhere the person wishes medicine by which he may continue his sexual pleasures, good morals would suggest that Ave Avithhold our aid ; yet, as medicine is an article of merchandise, and he Avill get it of some one else, if not of us, we may prescribe the Iodine pill as above. It is necessary that the patient should have the disease so explained to him, that the morbid fear that is so frequently noticed shall be removed, and for this purpose Ave will try to gain the patient's implicit confidence. If this is not done, Ave will frequently find our remedies unavailing. The patient should be directed to take exercise in the open air, to use a daily bath, confine himself to a nutritious and not stimulat- ing diet, and sleep on a hard bed. An entire abandonment of masturbation, and sexual excitement, as far as possible, is Imperative, and he should likewise be cautioned not to let his thoughts turn to these subjects. There is no doubt but that the Avill can materially aid in controlling this unnatural 78 The Reproductive Organs. excitation, and if possible it should be made to assist in the cure. 170. Structural Impediments.—Among the lesions pre- venting the sexual act, or causing sterility, Ave may study the structural diseases of the sexual organs Avhich serve as imped- iments. These might be grouped in tAvo classes—lesions Avhich prevent penetration, and lesions which preA^ent ejacu- lation. 171. Among the first, Ave may notice those cases in which the penis is congenitally attached to the abdominal wall, or inflammatory adhesions have been formed from ulceration of the skin. Three cases of this kind have come under my ob- seiwation, in tAvo of Avhich a surgical operation freed the member for legitimate use; in the other the malformation was associated Avith imperforate urethra and hypospadias. 172. Congenital chordee, from shortening of the corpus spongiosum has proven a bar to copulation, and a cause of sterility. Whether it is susceptible of cure Avill be a question for the surgeon, and would haATe to be decided by the condi- tion of the indiA7idual case. 173. Chronic chordee from gonorrhoea may persist for months or years. It is e\"idently caused by the organization of exudative material in the corpus spongiosum and mucous lining of the urethra. In one case of this kind, the con- tinued application of Tincture Veratrum, and the internal use of Iodide of Ammonium Avas sufficient for a cure. In an- other case, under the care of a friend, the patient Avas advised to get a fresh clap, Avhen the discharge Avas alloAved to con- tinue, sedatives being continually taken and applied, until a natural cure Avas effected. The treatment Avas a success, though I should not advise it. In 1871 a gentleman from California consulted me Avith regard to a difficulty of this nature, Avhich had been a source of annoyance to him for some seven years. So great Avas the pain from connection, that for the five years preceding he had not known a Avornan. The Reproductive Organs. 79 Examination of the organ showed no lesion, and I advised a trial—time had cured the case without his knowledge. 174. An irritable urethra may prove an impediment tc copulation or to emission. The erection is painful, and as the turgescence of the organ becomes greater before the orgasm, the pain becomes so excessive that it can not be borne. In other cases, though the orgasm occurs, the erythism of the urethra is such that there is no emission, until the erection passes off, Avhen it slowly oozes away. For these cases I Avould advise the internal use of Veratrum with the alkaline diuretics. The Tincture of Veratrum might be applied over the course of the urethra once or twice a day. and a hot bath used in some cases. For an injection, a solution of Sulphate of Hydrastia will prove the best remedy. In some cases, the symptoms would suggest Pulsa- tilla, Staphysagria, or Hamamelis. 175. Stricture of the urethra rarely prevents the sexual act, though it may prevent emissions, and thereby be a cause of sterility. For treatment the reader is referred to the article on this subject. 176. Hypospadias and Epispadias may be causes of impo- tence. In some cases the urethra may be restored and the fis- tula closed. If not, and the man is virile, it is proposed to receive the semen from the fistula, and artificially impregnate the Avoman. 177. The frcenum of the penis is sometimes so short as to incurve the organ and prevent copulation ; or it may be so attached to the meatus as to prevent emissions. Clipping with a pair of scissors gives relief, care being taken to avoid hemorrhage from the little artery found in this fold. 178. Phimosis may be an obstruction to copulation, or may prevent emission. In some cases the opening in the prepuce is very small and not in front of the meatus, and in these Ave very frequently find more or less structural disease—ulcera- tion, thickening of the prepuce, calculus formations, etc. Circumcision is the better treatment in these cases, but if the 80 The Reproductive Organs. patient will not submit to it, let the prepuce be slit up on a Grooved director, or with probe-pointed scissors, and the glans exposed. . Cullerier recommended several of these incisions. Dress the part with cold water. 179. In some rare cases a paraphimosis becomes a source of trouble. There is no difficulty at ordinary times, but in the increased turgescence before the orgasm the glans be- comes strangulated, and emission prevented. An incision at one or more points, with the edges kept apart whilst the pro- cess of healing is progressing, will give relief. 180. Enlargement of the prostate from chronic inflamma- tion, hypertrophy, fibroid or cystic growths, may prove a cause of impotence. A careful examination of the organ will detect the lesion, and in some cases it may be relieved. 181. Hemorrhoids may cause impotence. Possibly from pressure upon the vesiculaa seminales, or doubtless in some cases from an impairment of the pelvic circulation. The he- morrhoidal condition, with relaxation of the perineal tissues, frequently impairs virile poAver, and may cause entire impo- tence. In some of these cases a well adjusted elastic support to the perineum, in addition to the usual treatment of hemor- rhoids Avill give relief. 182. Acton claims that the use of the common truss for hernia, occasionally proves a cause of impotence. " When a case of the kind comes under my care, and the patient com- plains of want of sexual poAver, I always examine how the truss pressess. If I see any reason to suppose that it can by any possibility be the cause of the symptoms, I attempt in the first place by diet and abstinence from certain articles to cause absorption of fat in the mesentery and omentum ; this being done I attempt, but with great caution, to reduce the size of the truss. It is singular hoAv often this can be done with safety. I find that not only are the sexual poAvers often recovered Avhen the pressure is thus relieved, but that the penis, when it is no longer thrust aside, regains its natural size when that has diminished." The Reproductive Organs. 81 183. Non-descent of the Testes is always a cause of impo- tence. The man may seemingly have full virile power, the copulative act well performed, and emissions that seem natu- ral, yet there is sterility. On examination the semen is found to contain no spermatozoa. 184. Varicocele may be a cause of impotence. In this case a well adapted suspensory bandage will give relief, but if very bad, an operation should be had for the radical cure. 185, Pendulous scrotum, the testes having no support, and dragging on the spermatic cords, may prove a cause of impo- tence. Iu most cases of this character virile power is feeble, and the copulative act is imperfectly performed. The use of a suspensory bandage, stimulant and astringent baths with friction, and especially Hamamelis, may be employed Avith good results. 186. Structural diseases of the testes, preventing the secre- tion of the seminal fluid, or obstructing its emission, prove causes of impotence. Some of these are amenable to surgi- cal treatment. E\Ten hydrocele will arrest the secretion, and prevent its discharge. IMPOTENCE IN THE FEMALE. 187. I have already called attention to the fact that women have much less venereal excitement than men, and that it is not necessary in many cases for reproduction. Many women never have a pleasurable sensation in sexual commerce ; in others the venereal orgasm is slight, and of rare occurrence; in some it is Avell marked and intensely pleasurable, and in the very fe\v the sexual sense has as much development as in man. 188. We find cases, in which there is no reciprocity in the sexual act. The man is very excitable, and has the venereal orgasm before the female organs are in a condition to re- 6 82 The Reproductive Organs. spond, and the woman never has any enjoyment from the act. In such cases the woman's health Avill sometimes suffer severely, and the nervous symptoms of spermatorrhoea Avill be developed. 189. In some cases there is a natural coldness on the part of the woman ; it may be from enfeebled innervation, Avhich can be remedied by medicine.* This Avant of sexual power may be but the expression of imperfect ovulation, and we then direct our means to an improvement in this respect. *With seeming diffidence she entered upon the recital of the old, old story, so familiar to physicians, the aggregate of which points to " uterine diffi- culty.'' As the story progressed, our mutual bashfulness diminished, and by mutual hitches we intensified our propinquity to each other. The peroration accomplished, I found myself feeling her pulse, examining her tongue, etc. I now informed her in one rigidly formulated sentence, that a perfect diag- nosis of her difficulty would involve a vaginal examination. She did not faint nor go into " hysterics," but gracefully and piously assented. As she prepared for the ordeal, I noticed a certain nervousness about her, different from that which results from genuine modesty, and my perceptions were put on the qui vive. Her excitement increased as the moment for the final act drew near, and when I touched her genitalia, a quiver went through her frame. [I will say in this connection that although I am not religiously careful in my avoidance of the clitoris, I did not touch hers. My observation has convinced me, contrary to the dicta of early teachings, that clitorises, as a class, are not as explosive as nitro-glycerine.] When I introduced my finger, her actions became such as to convince me that she was in the thrills of the venereal or- gasm. Here was a pickle indeed, and all my assurance, added to my full sense of innocence, were scarcely sufficient to prevent a well-defined feeling of sheepishness. Observing my embarrassment, she broke out in a flood of apologetic protestations, ending in a confession of her "great weakness," viz.: uncontrollable sexual desires. She acknowledged that she had practiced onanism many years, not by titillation of the clitoris, nor by the introduction of her finger or anything else into the vagina, but by friction across the mom Veneris, effected with the palm of her hand. She stated furthermore that very many of her sisters in Zion were in a condition similar to hers, and that almost all of them were afflicted with prolapsus uteri, caused as she believed by standing and dancing so long at a time. The reader may draw his own conclusions touching the wisdom of those doctrines which involve the viola- tion of natural law, and which consign its devotees to lives of mental slavery and physical wretchedness.—Dr. Cooper, Eclectic Medical Journal March 1873 The Reproductive Organs. 83 The use of those restoratives that may be indicated, among which are the Hypophosphites, Cod-Oil, Arsenic, in some cases Lime-water, with the special stimulants, Iodine and Nux Vomica, as heretofore named, will frequently prove beneficial. 190. In some cases the habit of onanism has been the cause of a Avant of pleasure in sexual congress, and possibly of sterility. Acton gives a case of this kind.* *A gentleman came to ask my opinion on the cause of want of sexual feel. ing in his wife. He told me he had been married four years. His wife was about his own age (twenty-seven), and had had four children, but she evinced no sexual feeling, although a lively, healthy lady, living in the country. I suggested several causes, when he at last asked me if it was possible that a woman might lose sexual feeling from the same cause as men. "I have read your former edition, Mr. A.cton," said he, " and though you only allude to the subject incidentally, yet from what I have learned since my marriage, I am led to think that my wife's want of sexual feeling may arise, if you can affirm to me that such a thing is possible, from self-abuse. She has confessed to me that at a boarding-school, in perfect ignorance of any injurious effects, she early acquired the habit. This practice still gives her gratification ; not so connection, which she views with positive aversion, although it gives her no pain." I told him that medical men, who are consulted about female com- plaints, have not unfrequently observed cases like that of his wife. It appears that, at last, nothing but the morbid excitement produced by the baneful prac- tice can give any sexual gratification, and that the natural stimulus fails to cause any pleasure whatever. A similar phenomenon occurs in men, and this state is seldom got the better of as long as self-abuse is practised. I feared, therefore, that his surmises were correct, and that the lady practised self- abuse more frequently than she was willing to admit. So ruinous is the prac- tice of solitary vice, both in the one and other sex, so difficult is it to give it up, that I fear it may be carried on even in married life, where no excuse can be devised, and may actually come to be preferred to the natural excitement. Venereal excesses engender satiety just as certainly as any other indulgences, and satiety is followed by indifference and disgust. If the natural excesses of masturbation take place early in life, before the subjects who commit them have arrived at maturity, it is not surprising that we meet with women whose sexual feelings, if they ever existed, become prematurely worn out Doubt- less sexual feeling differs largely in different women ; and although it is not my object to treat otherwise than incidentally of the sexual economy in women, yet I may here say that the causes which in early life induce abnor- mal sexual excitement in boys operate in a similar manner on girls. This 84 The Reproductive Organs. 192. Vaginismus may prevent sexual congress. The sexual organs are so excitable that the thought of the act causes in- tense congestion, and contraction of the muscles of the peri- neum ; or the slightest touch is sufficient to occasion the spasm of the muscles and intense sensibility of surface. In some cases this spasm of the structures is most intensely pain- ful, and lasts long after the cause has subsided. The milder cases that I have seen have been readily relieved by the internal administration of Gelseminum, and rectal in- jections of Lobelia and Tincture of Opium. Should this fail, forcible dilatation under Chloroform, or a division of the sphincter vaginee is recommended. 193. Stricture of the vagina is readily recognized, aud tin? canal being continuous to the ceiwix uteri, dilatation with graduated bougies, offers a successful treatment of the diffi- culty. 194. A fleshy or fibrous hymen may offer an obstruction to sexual congress which can not be overcome, but the knife and finger readily break it doAvn. 195. Physical inability to perform the sexual act is very rare, but the mental repugnance is not uncommon. Such women should not marry, if the condition is known before, and it should be just cause of divorce, if developed after marriage. Two cases of the latter kind have come to my knowledge, and rendered the lives of both husbands and wives very unhappy. It is possible, sometimes, that remedies may relieve the peculiar sensitiveness of the nervous system upon which this occasionally depends. I have seen one case in which very marked relief came from the use of Pulsatilla and Macrotys ; the remedies not only relieving the mind, but rec- tendency may be checked in girls, as in boys, by careful moral education in early life. But no doubt can exist that hereditary predisposition has much to do with this, independently of education and early associations. It is publicly maintained by some credible persons that there are well-known families for instance, in which chastity is not a characteristic feature among the females, The Reproductive Organs. 85 tifying a wrong of the menstrual function, Avhich was followed by conception and a cure, though the patient had suffered for some ten years, and Avas sterile. 196. In some cases, where the fault is in the reproductive organs, remedies may be directed to these. Stimulating AAThen there is want of normal excitement; sedative when the ex- citement is too great. Electricity will, no doubt, prove a valuable remedy in many of these cases. 197. Sterility is not dependent, in most cases, upon inability to perform the sexual act in either sex. As Ave have already seen, the reproductive function in the female is to a consider- able extent independent of any sexual feeling, and conception Avill occur Avhen the woman has been Avholly passive, and has had no sensation of sexual orgasm. To a more limited ex- tent this is true of man, and he may beget children with- out the marked pleasurable sensations that the majority ex- perience. 198. In the female, sterility is most frequently dependent upon imperfect ovulation, rather than structural Avrong in the reproductive canals, though this is the cause in some cases. This imperfection may or may not be marked by menstrual irregularities: if these are present, they serve to point out the remedies for the case. Imperfect ovulation may be divided into three classes : 1st. Where there is undue excitation of the ovarian nerves, and determination of blood ; 2d. Where there is impaired innervation aud congestion ; 3d. Where there is impaired nutrition, neither of the previous conditions being present. 199. In the first class of cases, Macrotys and Pulsatilla are favorite remedies, and during the menstrual mollimen Vera- trum. If there is undue excitement of the mind, Avith refer- ence to this function, I would give Pulsatilla ; or if there Avas undue nervous excitation of the organs. Macrotys is a remedy when the nervous excitation is associated Avith deter- mination of blood. Veratrum and Macrotys are associated wheu the general circulation shares in the excitement. In 86 The Reproductive Organs. plethoric persons, these means are associated with cooling purgatives, saline diuretics, and a spare diet. In the second class, we would think of Cannabis Indica, Hamamelis, Staphysagria, Tincture of Phosphorus, and Ergot, with such general restorative means as may be indicated. In the third class of cases, we employ a general restorative treatment, as may be indicated, Avhich will embrace the bitter tonics, Iron, Hypophosphites, Cod Oil, Arsenic, and animai foods. Here as elseAvhere success Avill be to a considerable extent dependent upon a careful examination for special indi- cations for remedies. I would rather trust for success, upon one remedy, when clearly indicated, than upon the entire list of restoratives as generally used. 200. Dysmenorrhcea is not an uncommon symptom in ste- rility of women. It may be dependent upon stricture of the os internum or cervical canal, but in most cases it is a func- tional lesion. There is undue excitement of the sympathetic and spinal nerves distributed to the uterus, and in most cases this is associated Avith an erythism of the semi-erectile tissue of the organ, which prevents the free escape of the menstrual blood. This condition may be remedied in a large majority of cases by the use of: fy Tinct, Pulsatilla, Tinct. Macrotys, aa. 5ss.; Water, giv.; a teaspoonful four times a day. Com- mence four or five days previous to the menstrual period, and continue until the discharge is free and painless, repeating the treatment every month until a cure has been effected. 201. The opposite condition, congestion of the lower seg- ment of the uterus, may or may not be associated with pain, and yet be a cause of sterility. Examination shows the cer- vix enlarged, with the peculiar tumid, waxy appearance of tissue and enfeebled circulation, whilst the touch gives a sense of fullness with impaired circulation and nutrition. The os may be patulous and open, Avith free secretion from the cervical canal, or it may be constricted. These cases are benefited by the use of Pond's Hamamelis, Tincture of Phos- The Reproductive Organs. 87 phorus and Staphysagiia, and associafed with a good general treatment a cure may be anticipated. 202. This brief consideration of the causes of sterility would be incomplete without an allusion to the most common of all causes, incompatibility of temperament. In every locality instances may be observed of healthy couples Avho have no children. Both husband and«A\-ife have healthy reproductive organs, and there are neither physical nor functional reasons Avhy they should not be fertile. In many cases, a prior or second marriage has been fruitful in both parties, proving conclusively that the Avrong is of neither party as an individ- ual, but an incompatibility of the two. Prof. Powell first called attention to this fact, and pointed out the means by Avhich such incompatibility might be determined. The sim- ple statement " that persons of absolutely the same tempera- ment are sterile," expresses the fact; and that as they approx- imate this sameness, the offspring will be non viable.* "Law I. When the constitutional similitude -of the respective sexes is such that a qualified observer can not detect an appreciable difference, ste- rility will be the result of their marriage. Illustration: Washington and his wife were, respectively, sanguine, and it is known that sterility was the re- sult. Between Gen Jackson and his wife there was a nominal difference of constitution ; he was bilious sanguine, and she was bilious: nevertheless they were physically the same, both being exclusively vital, and it is known that sterility was the result. The first Napoleon and Josephine were, in person, greatly different, and in constitution they were nominally as different, and in constitution they were nominal'y as different, and yet there was no physi- ological difference. He was sanguine encephalo-bilious lymphatic, and she was bilious encephalic; consequently they were, respectively, compounded of equal varieties of vital and non-vital conditions, and it is known that sterility was the result of their alliance. Law II. When the constitutional similitude of the respective sexes is less than complete, or is appreciably different, progeny will result, but it will be dead-born, imbecile, scrofulous, deaf, blind, or in some otherwise imperfect. Illustration: I can furnish three hundred examples of this law, but as they are not historically known, they would be of no value in this relation. I can cite one, however, which is historically known, viz.: the first Napoleon and his second wife. Her temperament was bilious encephalo-sanguine, and his The Reproductive Organs. SALACITAS. 203. We employ the old designation of Dr. Mason Good to designate a class of diseases characterized by inordinate sexual passion or lust, including as it does the disease in male and female. Like other affections it varies in intensity, from the passion that is under control at ordinary times, to the lascivious madness to which the names satyriasis and nymph- omania have been given. temperament I have indicated. There was between them an appreciable dif- ference of constitution, and the result of this difference was one son; but the difference was too small to secure to him a normal viability, for he died of a scrofulous affection of the lungs, at the a#e of eighteen years. It is most indisputably the fact, that a considerable difference of constitution must ob- tain between the respective parties to a marriage, to secure to offspring a soundly viable constitution. To discover the least difference consistent with a physiological marriage was indispensable, but before discovering this the conviction became forced upon me that my discovery could not become of general utility without the discovery of a laAV of universal application. By a great amount of observation and study, I succeeded in discovering the desired law, and it is of easy application, and will universally secure a physiologically legitimate offspring, and the greatest possible happiness to the parents. Those, therefore, who make domestic happiness, and a really useful progeny, conditions of marriage, must observe the following law: Law III. One of the parties must be exclusively vital—that is, must be either sanguine, hilious, or sanguine-bilious (the last being a compound of the two former, is also vital), and the other party must as certainly be more or less non-vital, that is, more or less lymphatic or encephalic. All marriages, in contravention of this law, are physiologically incestuous, and the conse- quences will be vicious in proportion to the delinquency. Law IV. The greatest dissimilitude of constitution that can obtain be- tween the sexes, when they are respectively of the same species, is that which obtains between a vital and a non-vital temperament—and this is the most favorable to progeny. But marriages of this character are greatly impracti- cable in any country. It is a very remarkable fact in the physiology of human procreation, that a high degree of constitutional dissimilitude is about equally unfavorable to progeny It has been seen that a hi by either sending for a catalogue of schools, seminaries and colleges, under the pretense of sending a child to attend these places, or else by sending out a circular purporting to be getting up a directory of all the scholars and students in schools and colleges in the United States, or of taking the census of all the unmarried people, and offering to pay five cents per name for lists so sent. I need not say that the money is seldom or never sent, but I do say that these names, together with those that come in reply to advertisements, are sold to other parties; so that.Avhen a man desires to engage in this nefa- 94 The Reproductive Organs. he Avill commonly be found accustomed to, may assist him in the attempt; but in general the mind is as corrupt as the body, and the case is hopeless. He perseveres, hoAvever, at his peril, for with increasing Aveakness, he will at length sink into all the miserable train of symptoms which characterize that species of marasmus Avhich is usually expressed by the name of tabes dorsalis, and Avhich Ave have described already." rious business, he has only to purchase a list of these names, and then your child, be it son or daughter, is as liable to have thrust into its hands, all unbe- known to you, one of these devilish catalogues. You will please observe that this business is carried on principally by the agency of the United States mails, and there is no law to-day by which we can interfere with the sending out of these catalogues and circulars through the mail, except they are obscene on their face; and there are scores of men that are supporting themselves and families to-day by sending out these rubber goods, etc., through the mails, that I can not touch for want of law. There are men in Philadelphia, in Chicago, in Boston, and other places, who are doing this business, that I could easily detect and convict, if the law was only sufficient. There was one year ago published in and about New York and vicinity, 144 different obscene books I have seized the stercotvped plates, steel and copper plates, etc., for 142 of these books. There were four publishers on the 2d of last March ; to-day three of these are in their graves, and it is charged by their friends that I worried them to death. Be that as it may, I am sure that the world is better without them. One man, since the year 1842, (according to his account book that I have), has published some eighteen or twenty different books, and has never, to my knowledge, been arrested, but has for years been the victim of black-mail by the detectives of New York city, and in this manner has been practically licensed by them to do this business. It is with great pleasure that I state, that the refusal of President Grant to pardon those who have been convicted of this offense in the United States Courts, and of Gov. Hoffman those who have been convicted in this State in the State Courts, has sent dismay into the camp of these men, and will go very far toward checking this business. The district-attorney and his deputies are ready to prosecute any and all cases when they are brought to their notice, and there is no question about these men having justice done them if con- victed before any of our judges ; so that all we want to break up this nefarious business, is a broader law. I present these facts for your consideration I have the honor to be, with great respect, Sir, your obedient servant, ANTHONY COMSTOCK Hon. C. L. Merriam, House of Representatives, Washington. The Reproductive Organs. 95 210. Satyriasis and Nymphomania are of very rare occur- rence, and will most usually be treated at Insane Asylums. "The pulse is quick, the breathing short, the patient is sleepless, thirsty, and loathes his food ; the urine is evacuated Avith difficulty, and there is a continual fever. In women the disease is often connected with an hysterical temperament, and even commences Avith a semblance of melancholy ; and I once had an instance of it, from local irritation, shortly after child-birth. The child having suddenly died, and there being no more demand for a floAAT of milk, the fluid Avas repelled from the breasts Avith too little caution, and the uterine region, from the debility it Avas yet laboring under, became the seat of a transferred irritation. Among females the disease is strikingly marked by the movements of the body, and the salacious appearance of the countenance, and even the lan- guage that proceeds from the lips. There is often, indeed, at first some degree of melancholy, Avith frequent sighings; but the eyes roll in wanton glances, the cheeks are flushed, the bosom heaA*es, and every gesture exhibits the lurking desire, and is enkindled by the distressing flame that burns Avithin." 211. Probably this madness is of more frequent occurrence in the female, and arises from a suspension of marital inter- course from death or other causes. The only marked case that I have seen, however, Avas in an unmarried woman of thirty-five years, but this was the result of a broken engage- ment of marriage. 212. Baker Brown lost his good name and business by re- commending aud practising clitoridectomy, for the cure of this lesion. But it was not original \yith him, for many years before the eminent Surgeon Dubois Avrote, " The organ was removed by a single stroke of the bistoury, and all hemor- rhage prevented by the actual cautery. The wound healed easily, and the patient obtained a radical cure of her distress- ing affection." Leveret performed the operation at a still earlier day, and though it is not to be recommended in all cases of excessive sexual excitement, there is no reason why 96 The Reproductive Organs. it should not be resorted to, when the organ is found enlarged and extremely sensitive. 213. Widows sometimes suffer severely from ungratified sexual excitement. In some cases the vegetative processes suffer. The appetite is variable and impaired, digestion and blood-making enfeebled, nutrition poor, and the surface assumes a peculiar blanched, salloAv appearance, and the tissues lose their normal elasticity and hardness. In others the repro- ductive organs suffer. She has irregular menstruation, con- gestion of ovaries and uterus, neuralgia, leucorrhcea, ulcera- tion, displacement, etc. But in the majority the nerve centers suffer most, and Ave find an unnatural depression of spirits, absence of mind, enfeebled memory, and the class of symp- toms usually attributed to " softening of the brain." 214. Of course the treatment of these cases Avill vary, ac- cording to the lesions, yet in many we will find most benefit from special remedies. Of these I think Bromide of Ammo- nium stands first, giving marked relief to the spinal and sym- pathetic systems. When stimulation is desirable, this maybe alternated with the Iodine Pill, heretofore named. In others still, Avhen the mind is much involved, Pulsatilla alone, or with Macrotys, will prove the remedy. SPERMATORRHOEA. 215. As Ave have already seen, the abuse of the sexual organs by masturbation or excessive venery Avill lead to an increased sexual desire, which may be under the control of the will, or independent of it. The first Ave have studied under the name salacitas ; the second Ave purpose to study under the name spermatorrhoea. 216. The disease maybe divided into three stages. In the first the sexual instinct can be controlled, and the involuntary action of the sexual organs is but occasional, and has not vet The Reproductive Organs. 97 impaired the general health. In the second, the sexual exci- tation and emission is markedly automatic, and though par- tially or completely under the control of the will, when the mind is active during the day, shows especial aberration when the will is suspended during sleep. In the third, the will has entirely lost command of the procreative function, aud the venereal orgasm is wholly automatic and involuntary. 217. Whilst the common cause of spermatorrhoea is self- abuse, we find many cases in Avhich masturbation has not been practiced, or if so, suspended long before the development of this disease. One of the severest cases that I have had to treat Avas wholly the result of irritation of the base of the bladder, from venereal disease and uric acid deposits, the patient having lived a continent life until marriage, and had then been moderate in his indulgence. It is not of frequent occurrence wherever the sexual function has had legitimate exercise, yet Ave will find cases of this kind in the married, and especially when sickness or loss of the Avife has pre- vented ordinary indulgence. As Ave ha\-e already seen, the sexual function may assume undue proportions from causes over AA'hich the patient has had little control. The emotional faculties predominating, salacious thoughts may repeat them- selves, even though the person strives against it, and in the end, growing by repetition, they finally exert a controlling in- fluence upon the organism. In some of these cases there is undoubtedly disease of the brain, aud a careful examination may detect this. 218. When Ave come to examine the condition of the re- productive organs, Ave find occasional causes of spermatorrhoea. It is true that in the majority of cases these have been devel- oped by self-abuse, but in some the structural lesion of the reproductive organs Avas primary, and the only source of trouble. 219. Among these may be mentioned the irritable urethra, especially the prostatic portion ; irritation of the prostate and of the base of the bladder; rectal irritation; eczema with 7 98 The Reproductive Organs. pruritus; balanitis; phymosis ; sub-acute orchitis ; cystic dis- ease of testes ; pendulous scrotum ; varicocele; irritation of kidneys. Most of these are but exceptional causes, yet one should never overlook their influence. 220. When Ave study masturbation as a cause of sperma- torrhoea, Ave can readily see how it is developed. Salacious thoughts frequently repeated, give strength to this function of the mind, and at the same time impair the Avill. The sexual instinct congenitally strong, grows by exercise, and the will-power, at best but sufficient for mental control, gradually loses its influence. Other functions of the mind may be so employed as to increase the wrong. Music, the loATe of the fine arts, and especially the love of the beautiful in dress, and social arts connected with women, may all seiwe to excite sexual emotions, Avhen the mind has already this bias. The abnormal excitation of the organs in masturbation tends to develop an undue sensibility of the spinal and sympathetic nerve centers, which eventually serves as a cause of the in- voluntary emissions. 221. The disease is usually developed slowly, and two or three years may elapse before the sufferer thinks it necessary to apply for relief. In rare cases, it comes on rapidly, and in a few months, the patient will shoAV the marked symptoms of the lesion. 222. In the majority of cases Ave have little difficulty in diagnosing spermatorrhoea, though it is not so easy to deter- mine the special lesion upon which it is dependent. Here as elseAvhere, Ave want to knoAV that the spermatorrhoea is but a symptom, and Ave must know the character of the lesions if Ave expect success from remedies. 223. There is something in the appearance of the patient that tells the story of sexual Avrong, before he has opened his mouth. The doAvncast countenance, the inability to look you fairly in the eyes, the unsteadiness of the eye, peculiar contraction of the levator labii superioris, and orbicularis oris foreshadoAV to you the story of sexual abuse continued until The Reproductive Organs. 99 the sexual orgasm is involuntary. As a general rule, the suf- ferer tells his story clearly and without prevarication. He realizes the character of the disease, and its dangers, and probably has made it a study, and read what he could obtain in relation to it, for months back. The only trouble many times is, that he knows too much, and the story is prolix. 224. In the first stage of the disease, Ave have the story of strong desire Avith difficulty controlled by the will. Of fre- quent erections, especially when excited by company, by sight or conversation, or in female society. Then there are noctur- nal emissions, once or tAvice a month, then every week, and finally oftener than this. Associated Avith this excitement, Ave have an increased secretion from the prostate, CoAvper's glands and canal of the urethra, which is discharged after micturition, defecation, upon lifting, and when the penis has been in a state of erection. 225. As the sufferer learns the nature of the disease, the mind becomes troubled. He learns to Avatch for the symp- toms, feels depressed after each nocturnal emission, is exces- sively annoyed by the prostatic discharges, for Avhich he is constantly on the outlook. As the mind broods over the trouble, the impairment becomes greater. He is forgetful, loses interest in the common affairs of life, cares little for society, and shuns women. Presently comes unpleasant sen- sations in the head of tightness, dizziness, inability to com- mand the muscles, tinnitus aurium, muscce volitantes, etc. 226. As yet, the vegetative functions may be but little impaired, but presently his appetite is variable, bowels in- clined to constipation, urine " badly concocted," secretion from the skin sticky, unpleasant, sour, the pulse shoAvs want of poAver, and irregularity, the tongue incurved, pointed and slimy, the facial expression characteristic, the movements un- steady and without energy, etc. Going further, blood making is impaired, the tissues are Soft and relaxed, he loses flesh and strength rapidly, and the nervous symptoms are greatly in- creased. Noav in some cases we Avill find commencing symp- 100 The Reproductive Organs. toms of phthisis, tabes dorsalis, structural disease of the brain, atrophy or tubercular or cystic disease of testes, atrophy of penis, phosphatic urine with disease of the bladder, etc. 227. The mental affection is a marked feature in every case, and eventually leads to structural disease of the brain. The first recognition of disease will frequently come in an unpleasant sensation of vertigo, associated with a fear of some impending danger. Soon the mind dAvells upon the re- productive lesion, and the fear of " loss of manhood," or permanent impairment of mind, becomes a source of constant annoyance. This is especially the case where the sufferer has possessed himself of the secret circulars of advertising spe- cialists, Avho use every means to increase the alarm.* *ln the first edition of my work on " Diseases of the Urinary and Genera,. tive Organs,-' I wrote a chapter entitled Syphiliphobia, in which I collected together a A^ariety of complaints that presented many of the characteristics of true disease. Since then, a wider knowledge of these subjects has sprung up. Hypochondriacs and a large class of patients who have leisure to dwell on their morbid thoughts and feelings have, by reading the books so freely advertised in the quacks' corner of the newspapers, come to the conclusion that they are suffering under spermatorrhoea—a word with which they are familiar. In this corner formerly five or six such advertisements directed public attention to the so-called disease; the headings of "Manly Vigor" and " Secret Diseases" have disappeared, and are replaced by the term " Spermatorrhoea," the form of sexual disease now in fashion ; and as, in such hypochondriaco-misanthropic persons, the sexual feelings are generally more or less affected, the conclusion is arrived nt that every one who, with a bad conscience, feels himself out of sorts, is suffering from spermatorrhoea. There is a fashion in diseases, just as there is in amusements or occupations. Patients come to us, half persuaded that they suffer in the way described, but still in doubt whether what they complain of is fancy or the real disease. In such cases we have to deal with ignorance, irritability of temper, and sometimes with true symptoms, though magnified by great exaggeration, and no incon- siderable alarm about the consequences. Conscience tells many that their previous lives have been far from faultless, and these pseudo-medical books exaggerate their indiscretion and predict the most awful consequences de- scribing trains of symptoms enough to frighten the most courageous. It is not difficult for my readers to surmise what must be the effect on the ignorant the weak-minded, and those already depressed by their fears, with no friend The Reproductive Organs. 101 As the disease progresses, he finds difficulty in concentrat- ing the mind on any object, and is listless and with difficulty interested in the daily affairs of life. This impairment will frequently be periodic. For some days he will feel bright and acti\'e, but from change of weather, slight indigestion, social surroundings, or a nocturnal emission, he will suffer this de- pression for some time. It is usually associated Avith some dizzintss, and want of nerve power, and not unfrequeutly Avith precordial oppression, and irregular circulation. 229. In the advanced stage, the memory becomes impaired, the mind receives impressions Avith difficulty, and fails to re- tain them, reasoning power is defective, and above all is the brooding fear, that finally the past and present will fade from consciousness, and permanent idiocy result. 230. Short of insanity or idiocy, and atrophy or structural disease of the testes, the prognosis is favorable. Of course the cure Avill require a longer time, and be more difficult the further the disease has advanced. There is, however, one pre-requisite to success : the patient must leave the care of the disease to the physician, and have a reasonable confidence in the success of the physician. Without this, medicine will do but very little good. 231. Treatment.—It is well to notice first that Ave may have tAvo distinct and opposite conditions of the sexual organs and of the nerve centers. In the one there is a condition of hyperesthesia, Avith hyperemia, in the other there is an en- feebled circulation and nutrition. The first class numbers but few cases, the last a large number in the advanced stage. 232. Recognizing the disease as associated with hypere- mia, the patient being full blooded and vigorous, we prescribe at hand to confide in or to calm their excited feelings. Too many throw them- selves into the meshes of these harpies, and the consequence is that they are fleeced to an amount that is almost inconceivable, except to those familiar with the swindling transactions of the class.—Acton. 102 The Reproductive Organs. as follows : fy Tinct. Veratrum, gtts. xx ; Tinct. Gelseminum, 5ij.; Water, 5iv.; a teaspoonful every three or four hours. The boAvels are moved occasionally Avith a saline diuretic and Sulphur, regular evacuation being insisted on ; if the urine is scanty and irritant, Acetate of Potash, in abundance of water. With this, if necessary, Ave prescribe Bromide of Potassium, grs. x. to grs. xxx., at bed time. The patient should live temperately, keep good hours, and have his time constantly occupied—hard labor, or exercise in the open air, being the best. 233. In cases where atony is a marked feature, we pursue the opposite course. The patient has Phosphorus in the form of the Hypophosphites, Phosphuretted Oil, Pills of Phospho- rus, Avith Nux Vomica, Iodine, Ergot. The Compound Iodine pill ansAvers a very good purpose, and Avill frequently prove the best stimulant. If the bowels are very torpid, they may be stimulated with equal parts of Sulphur and Cubebs taken at night, and Tincture of Nux Vomica, gtts. j. or ij. in a glass of water in the morning. The general electrical sponge bath is sometimes an important means of cure, the positive pole being placed at the coccyx, and the negative carried over the surface of the body, and especially up and doAvn the spine. In the more common cases, Ave have neither the one nor the other condition described above, the lesion being Avholly functional. There are two features of the disease which especially attract our attention—the head symptoms, and the spermatic and prostatic discharge. 234. For the unpleasant cerebral symptoms I most com- monly prescribe Pulsatilla in the proportion of 5ss. to 5j-, to Water, 5iv.; a teaspoonful every four hours. If this loses its influence, it may be alternated Avith Tinct. Cactus in the same proportion : this is especially a good remedy when heart- symptoms have been developed—a not unfrequent complica- tion. If the disease assumes an epiliptic form, Ave may use : R^ Bromide of Ammonium, 5ss. ; Water, giv.; a teaspoonful four times a day. The Reproductive Organs. 103 235. In many cases the prostatic discharge has caused the greatest alarm, and it is regarded as an iuvoluntary seminal emission—described by specialists as a dangerous feature of the disease. For this I usually prescribe the single remedy, Staphysagria, and Avith very marked suceess. The propor- tion is usually: Py Tinct. Staphysagria, 5j- ; Water, .^iv.; a teaspoonful four times a day. If this should lose its influ- ence, it is alternated with Tinct. Phosphorus, Hamamelis, or Eryngium. Frequently the discharge is entirely arrested Avithin twenty-four hours, by the Staphysagria, and though it may return from indiscretion, the remedy maintains a con- trolling influence. 236. As the patient feels relief from the unpleasant head symptoms, and increased mental freedom from the stimulus of the Pulsatilla, and he finds the unpleasant discharge is arrested or modified, he becomes hopeful, and this reacting on the vegetative functions, every process of life is improved. I do not alloAv the occasion to pass unimproved, in confirming the patient's belief that he is getting Avell, and his faith in the doctor and the medicine; and many times I have seen the case progress Avithout a single untoward symptom to a radical cure. But frequently the patient has backsets from various causes, and Ave will have to encourage his hope and faith to enable him to persevere to the end. 247. It may be well in this connection to point out the special indications for some additional remedies, which may be substituted for; or associated with those already named. Here, as in other diseases, I believe in giving anything that is pointed out by special symptoms, and if the indication for the remedy is sufficiently strong, trust the patient to the one alone. Belladonna is especially indicated Avhere there is marked dullness and hebetude, Avith disposition to sleep, expression- less face, dull eye Avith dilated or immobile pupils. Ergot may be used in similar cases, but especially if there is impairment of muscular power of the legs, Avith tendency 104 The Reproductive Organs. to drag them, and a sensation of fullness and Aveight in the perineum. Hamamelis is especially indicated Avhere there is an en- feebled venous circulation \vith fullness and relaxation of the perineum, congestion of the prostate, mucous membrane of the rectum, and hemorrhoids. ColUnsonia, Avhere there is an acute hemorrhoidal condition, Avith determination of blood to the pelvis. The dose is always small : R/ Tinct. Collinsonia, gtts. x. to 5ss.; Water, §iv. ; dose, one teaspoonful. Eryngium, Avhen the patient complains of pain in the blad- der, irritation of urethra, and difficult or painful micturition. Apis, Avhen the patient complains of superficial burning or itching, either Avithin the bladder, the mucous membrane of urethra, or the glans or prepuce. Erythroxylon Coca is a valuable remedy Avhen the nocturnal emissions are persistent and exhaustiA^e. It will sometimes effect a radical cure, there being no further trouble after its administration is commenced. Rhus, when the burning is more intense, and erythematous spots show themselves on scrotum, perineum, genitals or ab- domen. Orbital pain Avith flushed cheeks, especially on left side, is an important indication for the remedy. Bryonia, A\diere there is pain in the envelop of the testes, pubic pain, with pain and soreness of the back part of the head. Macrotys, when the patient has muscular pains, lumbago, deep seated pain in body of penis or testes, Avith sense of full- ness and occasional deep soreness of head. Santonine, where there is a tendency to retention of urine, but without the evidences of muscular atony. Iron, where the tongue shows solid blueness, the o-lans penis is continuously blue. Nitric Acid, where there is a marked violet coloration upon a rose-red tongue, or the same violet color of the glans penis. Thuja Occidentals, Avhere there is tearing, throbbing pain The Reproductive Organs. 105 sense of ulceration and raAvness, and in the urethra as if drops of water were running along; pain in the'crown of the head, and sense of tension about the nasal bones. Arsenic, where the skin is dirty and parchment-like, with impaired elasticity. Lime, where there is a tendency to suppurative inflamma- tion of connective cellular tissues. Stramonium, when the patient complains of tensive pains in the bladder, and extreme tenesmus in passing urine or feces. When the patient has become habituated to the use of Opium. Phytolacca, where there is a tendency to orchitis, enlarge- ment of the testes, Avith deep, tensive, dragging pain. Chelidonium,, where the skin has a leaden, sallow appearance, the tongue full, and of a dull, leaden color, urine very pale. Lobelia, if there is full and tumid mucous tissues, with en- feebled circulation. There are other remedies which might be of occasional use in these cases, but I have pointed out the more important of them. The hygienic means, and appropriate diet, will be suggested by each individual case. There are but feAv Avhich require a spare or Ioav diet; the majority want good food, for the better digestion, blood-making and nutrition are, the more rapid and permanent the cure. 238. When Ave come to study the topical treatment, we find great diversity of opinion. Lallemand regarded the disease as having a local origin in the majority of cases, and he pointed out the tenderness of the prostatic urethra as the cause of the sexual alteration. For this trouble he proposed cauterization with Nitrate of Silver or the Potasse Cum Calce. To introduce it he devised a special instrument, the porte caus- tique* Acton prefers the syringe with long urethral tube, * Lallemand's Plan.—A catheter should be passed in order to empty the blad- der, and to judge of the length of the urethra. This, the Professor recom- mends, should be done by stretching the urethra, and, as the catheter is with- drawn, watching the moment when the water ceases to pass. Having thus 106 The Reproductive Organs. and a solution of Nitrate of Silver, grs. x. to the ounce of water. I like Acton's method best, and would advise it discovered the length of the canal, if the finger be placed on the instrument at the point just beyond the glans penis, the exact depth to which the porte caustique should be subsequently introduced may be accurately ascertained. On the instrument which goes under Laliemand's name, there are means for measuring this distance which can be fixed by the slide seen in the Avoodcut. When I was in the habit of employing Lallemand's porte caustique, I did not find it necessary to pass a catheter, as I usually enjoined a patient not to drink on the day I propose applying the instrument, and requested him to empty the bladder immediately before its introduction. It is a good precau- tion, moreoA'er, to previously relieve the bowels by Castor Oil, or of an enema. The porte caustique must be prepared in the following manner:—"Fuse sonii broken pieces of Nitrate of Silver in a watch-glass held over a spirit-lamp bf means of a pair of forceps, taking care to apply the heat at first at some dis tance, otherwise an explosion may take place; when fused, the caustic should be poured into the little cup, allowed to dry, and the projecting portions re- moved by a file, the canula must then be returned into the closed instrument, which, after being oiled, may be passed down into the bladder, the patient being in bed or lying on a sofa; a surgeon at all in the habit of passing in- struments is able to distinguish when the instrument enters that viscus. The diseased part is at once known to the patient (so Lallemand states) by the in- strument causing some pain. This once ascertained, the surgeon will with- draw the outer canula to the extent of half an inch, and at the same time give a rotatory motion to the inner canula containing the caustic. By this means the diseased surface is slightly cauterized, eschars are not necessarily formed, nor are any passed in the urine, and the internal canula, being drawn within the external one, cauteiization is confined to the morbid structures only Kest in the horizontal position must be enjoined, and the patient desired not to make water for some hours. If pain comes on, a good dose of Laudanum, or an enema with Opium may be prescribed. For the few following days there is some pain in making water. The discharge increases, and is mixed with a little blood; but by attention to diet and rest, together with moderate doses of Copaiba or Oubeb capsules, these symptoms abate, and with them the emis- sions, although in some cases the cauterization may induce one or two escapes of semen during the following nights. Sexual intercourse must be strictly prohibited, and any cause which may originally have produced spermator- rhoea must be studiously avoided. In some cases it may be necessary to have recourse to a second or third application of the caustic; but at least ten days should elapse between each cauterization, and any accidents which may arise must be treated on general principles. The Reproductive Organs. 107 where there was marked and persistent irritation of the ure- thra not relieved by the remedies named.* I have also used % Cauterization.—In passing an instrument as above described, one of two conditions usually exists: either the instrument passes down to the veru-mon- tanum without pain, when all at once excessive sensibility is felt in one or more spots; or the urethra is found large, patulous, and insensible, hardly seeming to feel the presence of the instrument; the former condition is, how- ever, the one most frequently met with. Having explored the urethra, the surgeon should leave the patient quiet for that day, the only precaution taken being that of administering a mild aperient, and desiring him to abstain alto- ther from stimulants or coffee. The sufferer usually prefers that the operation be performed at the surgeon's residence, and I have never found any objec- tion to the patient returning home in a cab if the distance is not great. On the morning of the operation the patient may be allowed to eat a simple break- fast of bread, butter, or meat, but he must be strictly enjoined to abstain from fluid of any kind. Before proceeding to perform the operation, I desire the patient to com- pletely empty the bladder. I employ a syringe which is made entirely of stout glass, to obviate breakage, and to avoid all decomposition of the solu- tion of Nitrate of Silver. When put together and charged with fluid (con- taining a solution of ten grains of nitrate of silver to the ounce of distilled water), the instrument is passed down the urethra, the patient standing against the wall. No oil should be used, as it will interfere with the action of the caustic. The surgeon should take the precaution of folding a towel between the legs, in order to protect the trousers of the patient from being stained. The piston of the instrument is then to be forced down, at the same time that the finger and thumb of the operator's left hand compress the lips of the meatus firmly against the instrument, so as to prevent the fluid escap- ing from the urethra until the syringe is withdrawn, which is done as soon as the injection has been forced out of the instrument. I may mention here that the syringe usually holds about two or three drachms. The pressure of the fino-ers on the urethra is then withdrawn, and the whole of the injected fluid passes out into the vessel which is placed to receive it. The patient may now sit or lie down in an arm chair, and remain there a quarter of an hour. The first result of the operation is to produce a warm pricking sensation at the end of the penis, which soon, however, subsides, and usually in ten minutes disappears gradually. In some cases an urgent desire to make water may come on, but as the bladder has been previously emptied, this is a fictitious want, and rapidly passes off, the patient being told to restrain the desire as much as possible. As to the pain felt after the operation, I have been over and over again assured that the suffering consequent on the application of the' 108 The Reproductive Organs. with excellent results in these cases, a solution of Sulphate of Hydrastia, grs. iv. to Water, Sj. ; filling the urethra from the long tube, and holding the injection for some minutes. caustic has been much less than the patient anticipated, and in some instances it has been so slight that the patient doubts if any caustic can have reached the affected parts. Other patients say they have experienced none of that shock to the nervous system which interested individuals had led them to believe was sure to follow the injection of a solution of nitrate of silver, and which they had read that medical men had understated, in order to induce patients to submit to the operation. The first effect of the operation is to produce an oozing from the urethra, caused by the escape of a drop or two of caustic mixed with mucus, and hence a piece of linen or a folded handkerchief should be placed around the meatus to absorb the moisture, and protect the shirt from becoming stained. The patient within half an hour may be allowed to return home, but must not walk at ail that day, and should swallow a copaiba capsule directly, repeating it every eight hours. Too strict injunctions can not be given to abstain from drinking fluid of any kind until after making water, and not to pass urine until absolutely obliged. Some men can easily remain twelve hours without passing water; a space of time which allows the caustic solution to act on the mucous membrane. When the patient is no longer able to resist the desire of making water, say twelve hours after the operation, he may drink as much weak tea, soda-water, or diluents as he pleases Immedi- ately after the operation he may take his usual meals, abstaining, as before said, from fluid, and confining himself to an easy chair or sofa. During the few following hours some slight whitish discharge, like mucus, will flow from the urethra; but there will be little or no pain. When the patientfirst makes water there is some scalding, but the urine passes without difficulty. In some few cases, where I have reason to suppose there is an extra amount of irrita- bility of the bladder, I have prescribed opium after the operation, but this is very rarely necessary. When the patient has made water once, he may do so as often as he likes, and each time the slight scalding will diminish, until it wholly disappears. On the day following, a tinge of blood is sometimes noticed attending the last drops of urine, but this disappears in a day or two, the urine becoming again clear. On the second or third day the copaiba cap- Bules may be dispensed with, and the patient may commence a course of tonics with gymnastic exercises, sponging, etc. Violent exercise should not be indulged in for the first few days after the operation, but a moderate walk need not be interdicted. In from four to ten days the patient may take a little claret, and subsequently resume his usual mode of life, observing, how- ever, abstinence from tobacco or strong coffee.—Acton. The Reproductive Organs. 109 239. This urethral irritation is sometimes relieved by ex- ternal counter-irritation from a perpetual blister, irritating plaster, issue, or seton. In some cases we find it necessary to keep the penis sore in order to prevent erections, or in some exceptional cases to insure against self-pollution. 240. When lying on the back causes erection and nocturnal emission, Ave employ counter-irritation over the spine to pre- vent this, and also to relieve the spinal erythism which exists. The irritating plaster of our Dispensatory is the agent I pre- fer, and to the extent of two by six inches ; in the majority of cases it is applied over the sacro-vertebral articulation. 241. Where there is marked enfeeblement of the perineal structure, a well adjusted elastic perineal supporter is some- times of marked advantage, until by the use of electricity and passi\Te movement and kneading Ave can stimulate normal nutrition of these structures. 242. Pendulous scrotum and dragging testes, Avith or without varicocele, calls for a Avell adjusted suspensory band- age; and sometimes the local use of Pond's Hamamelis. 243. The truss Avorn for hernia may not only prove a cause of impotence, but also of spermatorrhoea. It should ■always be examined, and the pressure so arranged as to re- move the irritation as far as possible. In some cases it will not do to have any pressure upon the back, and then the simple strap with leaden ball Avill prove the best form. In others it is the inguinal pressure that causes the irritation, and we Avill employ the large soft pad for retention only. 244. Whilst in some cases Ave order the drinking of laro-e quantities of Avater, to dilute the urine, render it less acrid, and thereby remove irritation, in others Ave prohibit fluids, especially in the evening. In many cases the full bladder is the cause of sexual excitation, erection and nocturnal emission. In one ca^c under my care, the emission Avould occur in the day-time, under any circumstances, if the bladder was allowed to become largely distended. The patient is therefore charged to drink but little in the evening, pass water before going to 110 The Reproductive Organs. bed, form a habit of waking and passing Avater after mid- night, and of getting up, when first aAvaking in the morning. Not unfrequently this will give material aid in the arrest of nocturnal emissions. 245. I need hardly say in conclusion that the patient must break off from all vicious habits aud associates. Contact Avith the impure in thought and action is sometimes sufficient to continue the disease, despite the influence of medicine. A vicious literature is as bad as vicious associates, and our coun- try is flooded Avith it. It not only includes such vile sheets as the police journals, but the more popular Aveeklies filled Avith exciting love stories, mixed Avith blood and thunder. The parent who alloAvs such stuff to come into his house, is morally responsible for the debaucbment of his children. If the habit of self-abuse is not given up, Ave insist that it shall be, and if the sufferer lacks moral power, Ave make use of escharotics over the course of the urethra, to make handling the organ an impossibility. It is more difficult to manage the married than the single, and sometimes it is impossible to control them without sing-le beds. SPERMATORRHEA IN WOMEN. 246. Admitting that this is a misnomer, and that women can not have the disease according to our present nosology, any more than they can have prostatorrhcea, yet Avhen Ave study spermatorrhoea as but a symptom of a lesion of the re- productive function, Ave can readily see hoAv women may suffer similar lesions without this symptom. I am satisfied from a considerable experience that there are more cases in women than in men, and that the suffering and danger to mind and life is full as great in one as in the other. 247. The reproductive functions in man and woman are alike, though the organs differ. There is the same sexual The Rkimioih'ctivk Organs. Ill feeling, the same relatlm-diip with the emotions and the mind, the same connection Avith the spinal cord, and the same relations with all the vegetative functions through the sympa- thetic nervous system. 248. If Ave study the causes of the lesion Ave find that women are quite as much exposed to them as men. We have already seen that they suffer from self-abuse, not so frequently it is true, but quite as severely. And in the marital relation they suffer more frequently from excitation of* the sexual organs without gratification. Let this be repeated for years, and the wonder is, not that we meet with such cases, hut that they are not of more frequent occurrence. 249. Many of the nervous ills of woman, cloaked under the name nervousness, or hysteria, are due to this lesion of the reproductive function. Thousands of women have enjoyed ill health, and living a few years of a sickly wasted life, have died, without the nature of the lesion and its cause having been suspected. It is not always child-bearing and the com- mon household cares, that bring premature age and death. These are rarely the cause, as may be seen in the improved health of women when pregnant. Pregnancy, child-birth and nursing, are physiological functions, and nature responds to the call with alacrity. Perpetual gratification of the lust of a rutting man is unphysiological, and is the cause of the multi- tude of maladies attributed to natural function. 250. It is Avell to think and talk in plain English on this subject, for the lesions are so serious and destructive, and the cause so gross, that they should be brought fairly to view. It may be impossible to rectify the wrong in many cases, but it is possible in a large number, and Ave illy do our duty as phy- sicians if Ave do not use our influence in a right direction. 251. Though the lesions Ave propose studying here are principally nervous, it will do no harm to call attention to the fact that every form of local disease of the uterine organs may be grown from this cause. And, to the more important fact that this abuse must be stopped if Ave are to have successful 112 The Reproductive Organs. results from treatment. Indeed I have seen severe cases of ulceration of the cervix, that had resisted topical treatment, cured by continence and cleanliness alone. 252. The disease of the reproductive function Ave are studying in women may be divided into tAvo classes—one of hyperemia and increased sensibility of the nervous system and the sexual organs, the other of anaemia, and impaired sensibility. It isAvell to make this classification of cases, even though the majority may shoAV neither the one nor the other condition as a marked feature. When they do, however, the treatment will differ very materially. 253. In the one class of cases, the general expression of the body is of contraction—pinched. The features are sharp, the muscles of the face distinctly outlined, the orbicularis ovum and palpebrarum contracted, mouth retracted, eyelid? do not close, alse nasi drawn in, eyes dry, pupils immobile, hair harsh and dry, tongue contracted and incurved, etc. The appetite is variable, digestiou poor, bowels inclined to constipation, or constipation alternated with irritative diar- rhoea, nutrition impaired, skin parchment-like and dark, etc. You do not have to ask the patient if she suffers, the entire expression is one of suffering. You get a history of pain in back, intense pain in head, pain in every part of the body upon slight lesion, of broken rest, unpleasant sensation of dizziness, precordial oppression, and uneasiness in the pelvic region. But above all there is the impairment of conscious life alternating between undue excitation and the apathy of despair, which causes the most intense suffering, though it bears but little relationship to pain. 254. You make a vaginal exploration, and the touch sends an electric thrill over the person, and up the spine to the head, which is recognized at once as unpleasant. The exam- ination Avill frequently shoAV the character of the lesion in the change of the structures and their increased sensibility. 255. In the opposite cases, the body is expressionless, the movements languid, and the face apathetic. The eyelids are The Reproductive Organs. 113 full, dark lines around them, eyes dull, pupils dilated. The tongue is full, pale and slimy, the breath a peculiar SAveetish fetor, boAvels constipated, digestion and blood-making im- paired. She suffers from a sense of fullness and Aveight in the pel\ris, dragging sensations, difficult urination and defeca- tion, is easily exhausted, especially when obliged to be on the feet. This patient sometimes suffers intense pain, but it is the pain of exhaustion, as if nature, wearied Avith the struggle for life, was about to succumb. In this class Ave find atony of the sexual organs. The vulva has lost the fatty tissue, and is soft and relaxed, the vagina dilated, the uterus low, the cervix full, the os dilated and patulous, and from all the mucous surfaces there is an in- creased secretion. 256. We have a larger number of cases, in Avhich the symptoms are the same as described in the lesion of the male. There is marked impairment of the general health, but overshadowing this is the nervousness, the desire for seclusion and rest, the doAvncast look, unsteady eye, languid movement, with the fear of impending danger intensified by sensations of dizziness and precordial oppression. 257. These symptoms should excite attention, and a care- ful examination Avill lead to a correct diagnosis. It is some- times difficult to learn the facts, from the natural diffidence of woman, and her dislike to think of, much less talk upon these subjects. This is not mitigated by the common reputa- tion of many physicians, Avho more from indiscreet conversa- tion, than from impure lives, are looked upon Avith distrust— a fact which should lead physicians to be chaste in speech and in their professional relations, Avhatever they maybe out- side of this. 258. The prognosis is favorable when Ave can control the habits of the patient, and avoid sexual excitement. In some cases absolute continence and avoidance of all exciting causes are necessary. In others the cure progresses better Avith very moderate indulgence. 8 114 The Reproductive Organs. 259. Treatment.—In the first class of cases I usually com- mence the treatment Avith : Tfy Tincture Pulsatilla, Tincture Macrotys, aa. 5ss.; Water, §iv.; a teaspoonful four times a day. If the circulation shows fullness, I alternate with this : I$s Tincture Veratrum, gtts. x. to xx.; Water, 3iv. If it is small and shows hardness, Aconite is taken in preference. Not unfrequently there is a marked indication for the use of Acids, and we prescribe them internally and use Acid baths. Bromide of Potassium may be used where there is intense sexual excitement, and when the rest is broken. If the patient complains of persistent headache, Ave think of Iodide of Ammonium ; if there is an epileptic tendency shown by muscular twitchings, or periodic excitement Avith rigidity of muscles, we give Bromide of Ammonium. In some cases we use Veratrum and FoAvler's Solution of Arsenic, alternately or together, and sometimes associated Avith Cod Oil. Quinine inunction is frequently an excellent means, and gives the necessary stimulation to the nerve centers. 260. Demulcent vaginal enemata are sometimes of ad Aju- tage, and warm Flaxseed infusion may be taken as the type. Some cases are benefited by the wet-pack around the pelvis, others by the acid-pack, and still others by suppurative counter-irritation. The electric sponge-bath is also an efficient means. It may be used Avith the positive pole applied to the cervical spine, and the negative passed over the hips, peri- neum, back, and with a vaginal and uterine electrode through the reproductive organs. 261. The second class of cases will be benefited by the use of restoratives, good food, out-door exercise and sunshine. We prescribe here Pulsatilla and Macrotys, but alternate it Avith Nux Vomica and Iodine—the pill heretofore named is a good form. If there is excitement with free mucoid secre- tion, especially the glairy secretion from the cervix uteri we prescribe : fy, Tincture Staphysagria, 5j-; Water §iv. • a tea- spoonful four times a day. As an alternate we may use Tinct. The Reproductive Organs. 115 Phosphorus in the same proportion. Hamamelis is the remedy Avhere there is a tumid and doughy cervix, and full, protruding perineum, Collinsonia being reserved for the acute venous congestion. Coca may be employed in these cases where there is invol- untary excitement of the sexual organs, especially at night; Phosphate of Soda where the tissues are full, pallid, and lack elasticity. Belladonna and Ergot are occasionally useful Avhere there is dullness, hebetude, and a disposition to sleep. Zincum will be found an excellent remedy where there is a disposition to diarrhoea, aud impediments to chylous absorp- tion—the sixth decimal trituration is recommended, or small doses of Oxide of Zinc. Salt Avater frictions to spine, abdomen and perineum, Avith brisk rubbing Avith dry flannel will be found a good means in some cases. In others the dry flannel or silk friction is pre- ferable. And in still others we use electricity for its stimulant action—superficial faradization being the best. 262. The local applications, if any are used, should be stimulant as well as calculated to arrest the increased secre- tion. There are cases in which Nitrate of Silver, grs. v. to grs. x. to the ounce, makes the best injection. Sulphate of Zinc, 5ss.; Chlorate of Potash, 5ij., to the pint of water, is a good injection. The Tincture of Hamamelis, one part to two or three of water, is also a good remedy where an astrin- gent action is desired. 263. There is sometimes marked spinal irritation in these fcases, which must be recognized and relieved. It will be re- collected that we divide this lesion into two classes—hypere- mia and anemia of the cord, the nervous lesion being quite the same in both. The first is met by suppurative counter- irritation, the second by salt water frictions, rubefacient fric- tions, faradization, or the hot iron—firing. 116 The Reproductive Organs. DISEASES OF WOMAN INCIDENT TO PROSTI- TUTION. 264. Some public women seem to suffer but very little from their mode of living, but these are usually persons of peculiarly strong nervous systems, well developed bodies, and good digestive organs. They are also very careful in the care of the person, cleanly, regular in their habits, and the sexual excesses are thus counter-balanced by right living in other respects. But the larger number do suffer from acute dig. eases of the sexual organs, and finally from confirmed chronic disease. VULVITIS. 265. Inflammation of the vulva may be deep-seated or superficial, the last being by far the most common. In deep seated inflammation the parts are much SAvollen, red and painful. The patient suffers considerable constitu- tional disturbance, the pulse increased in frequency, the skin dry, bowels constipated, urine scanty, tongue coated, and the nervous system excited. In some cases the inflammation is very extensive, and involves the ischio-rectal fosse, and the patient sutlers intensely. It may be days before suppuration is so far advanced, that the pus points to the surface, and sometimes it is inclined to burrow deeply, instead of coming to the surface. 266. Superficial vulvitis is analogous to balanitis in the male, and is frequently the result of want of cleanliness, the secretion of the too frequently excited organs being acrid and irritating. In some cases there is an eczematous or herpetic eruption, and an intolerable pruritus, which induces scratching or rubbing the parts, only to make the trouble worse. Con- tinuing for some time, we have an eruption of small phleg- mons, very painful, and which sometimes repeat themselves for weeks or months. The Reproductive Organs. 117 267. Treatment. — In the deep-seated inflammation the patient is put upon the use of Veratrum or Aconite, as indi- cated, alternated with Phytolacca. The patient has a hot sitz-bath, a local application of Tincture of Veratrum to the inflamed part, followed by an emollient application, cold or Avarm, as may give the greatest relief. The boAvels are kept gently open with a saline cathartic, if necessary, and if the urine remains scant, a weak solution of Acetate of Potash is given as a drink. Though this is an outline of the treatment in ordinary cases, Ave do not forget that the successful administration of remedies is based upon special indications, and we follow them here as in other diseases. 268. If called in the early stage, Ave may expect resolu- tion, and if suppuration results Ave Avant to restrict it as much as possible. But when pus has formed, no advantage comes from gi\Ting it time to burroAv and break down sound tissue, and the abscess is opened early. If a proper general treat- ment has been pursued, and the secretions restored, the pro- cess of healing is rapid and good. But should it show tardi- ness in healing Ave may fear the formation of fistule, and Ave adopt the folloAving course. 269. Giving the patient a careful examination to deter- mine the general treatment—and this is a very important matter—we inject the abscess with such stimulant as may serve to restore the reparative process, and granulation from the bottom. I prefer our old-fashioned Sesqui-Carbonate of Potash, though sometimes the Sulphate of Zinc will do as Avell or better. The general means will be Cod-Oil, Lime Avater, Arsenic, Iron, the Hypophosphites, Phytolacca, Rhus, Iodide of Ammonium, or other special remedies as may be indicated. 270. In superficial vulvitis Avith excoriation, we sometimes find Colgate's best Glycerine Soap, well applied, an effectual remedy. The " Juniper Tar Soap " is also an excellent agent Avhere there is a constant disposition to this irritation. When 118 The Reproductive Organs. it is associated Avith pruritis, I prescribe Glycerole of Tar. In some cases, a solution of Permanganate of Potash, grs. v. to x. to Water, §iv., is a good local application, as is Carbolic Acid, grs. x. to Glycerine, Sij.; Rose Water, 5iv. The old remedy : R/ Morphia Sub, grs. x.; Sode Bi-Bo-as, 5j. ; Aque Rose, Syj. M. 271. In some cases the difficulty is dependent upon the irritant secretion of the parts alone, in some upon irritation of the rectum, from ascarides, constipation or hemorrhoids. When very persistent, we Avill ahvays find some general lesion, and even in acute cases, a single remedy, prescribed for a special indication, will give speedy relief. Then we use Rhus, when the vulva presents a shining, bright-red appear- ance, dry, Avith the characteristic pustular eruption. Apis, ilf the surface is mottled red and Avhite, like the eruption of " hi\Te," Avith some burning, or burning Avith itching. Phy- tolacca, if associated Avith fullness and sense of weight and dragging. When the irritation becomes chronic, we think of Arsenic and Cod Oil. 272. Chronic, deep-seated vulvitis is a very troublesome affection. There is a deposit of low albuminoid material, sometimes to a very considerable extent, and as the finger is passed over the surfaces the nodulated deposits resemble cystic or fibroid growths. These break down occasionally from local irritation or impairment of the general health, and suppuration occurring, sinuses form, burroAving in the cel- lular tissue of the part. After a time the formation of pus ceases, and the nodules of cacoplastic material are re-formed. In some of these cases, Lime-Avater is the remedy, associated with general restoratives, but in the majority permanent re- lief Avill only come from Cod-Oil, and Arsenic in small doses. urethritis. 273. In public women Ave are apt to regard inflammation of the urethra as specific, yet many cases of simple urethritis will be met with. It is usually associated Avith vaginal or vesical irritation, and sometimes with vaginitis or cystitis. The Reproductive Organs. 119 274. The patient complains of a frequent desire to pass water, and after a time the calls are every feAv minutes and can not be resisted. The urine is scanty, high colored and' acrid, and is passed with tenesmus and burning. The skin is dry, the pulse increased in frequency and hard, and the face shows suffering. 275. Treatment.—In the early stage of the disease the patient may be put upon the use of Veratrum and Gelsemi- num, Avith Avarm demulcent vaginal enemata. If indicated, a saline laxative may be administered, but frequently they will get along better Avithout it. Frequently the patient is mark- edly relieved in a few hours, and put upon the use of Aconite and Macrotys, makes a speedy recovery. In other cases it is tedious, and Ave folloAV with Cannabis Indica, Pulsatilla, Sta- physagria, as may be indicated. Persistent burning pain in the urethra is sometimes speedily relieved by Rhus and Aconite alternated. 276. In some cases local medication is of advantage, espe- cially if the disease is persistent. A bougie conveying a small portion of Carbolic Acid in Olive Oil, is good, so is an injec- tion of Sulphate of Zinc and Morphia, but Lprefer in most cases the solution of Sulphate of Hydrastia. irritable urethra. 277. In the last feAv years Ave have had many cases of irri- table urethra. It is not confined to public women, but is usually a result of sexual excesses. The patient complains of burning or scalding along the course of the urethra, frequent desire to pass Avater, and tenesmus. In some cases it is paroxysmal, the patient suffer- ing severely for a time, and then for some hours having relief. In some cases it is only felt during the day, and especially if she is much on her feet, but in others the patient has to pass water several times during the night and suffers constantly. Pretty soon you Avill see it Avearing upon the general health, 120 The Reproductive Organs. and as weeks go by, the patient has a worn and haggard ap- pearance, and complains of various functional lesions. 278. Treatment. — I have obtained the best results in these cases from the use of Rhus, Apis and Eryngium, ac- cording to the special indications heretofore named. I select the remedy, and use it in alternation Avith Aconite. Prof. King's prescription of Elaterinm AA'ill be found a specific in those cases in which there is inflammation of the base of the bladder with deep pain and tenesmus. Of a Tincture of Elaterinm, we would give twenty drops three times a day, until it acted upon the boAvels—then in doses of five drops. 279. If there is frequent micturition Avith pain and great tenesmus, extending to the bladder, I would recommend Stramonium as follows : fy Tincture Stramonium, .^ss.; Comp. Tincture Cardamom, giijss. ; from half to oneteaspooful every two or three hours. If the patient has been in the habit of using Opium, the dose will be larger. 280. When the disease is persistent, and resists the action of remedies, forcible dilatation of the urethra may be pro- posed as a radical cure. Usually the patient will have to be placed under the influence of Chloroform, when a large bono-ie or catheter may be passed, followed by one as large as the forefinger, or the finger well oiled may be passed quite as well. The patient is kept in a recumbent position, and full doses of Veratrum are given. The operation is repeated iu two or three days, usually without the Chloroform. VAGINITIS. 281. Acute vaginitis is not of unfrequent occurrence, and is sometimes a source of great suffering and annoyance. It is usually rapid in its development. Commencing with a sense of scalding in the canal, the parts soon become swollen, hot and painful. In some cases the natural secretion is ar- rested and the parts are dry, but in others the secretions are thin and acrid. Not unfrequently there is an unpleasant The Reproductive Organs. 121 tenesmus and bearing down, and despite the care of the patient her sufferings are increased by involuntary contrac- tion of the abdominal muscles. The constitutional disturb- ance is frequently marked. The skin is harsh and dry, urine scanty and acrid, boAvels constipated, pain in head and back, temperature elevated, 102° to 104°, and the circulation excited. 282. It is impossible to diagnose the simple from the spe- cific vaginitis further than this : that the simple comes up quicker, the symptoms are more active at first, and not nearly so severe in the second stage. The acute inflammation in simple vaginitis is sometimes folloAved by increased secretion of mucus or muco-pus, but the pain and uneasiness are relieved by the discharge, whilst in the specific disease it is increased by it. 283, Treatment.—I have treated these cases as I would an acute inflammation in other parts of the body. The pa- tient has a hot sitz-bath folloAved by hot fomentations, or a cold-pack, as may be deemed best, and is put upon full doses of Veratrum, Avith Gelseminum in some cases. If the bowels are locked up they are gently moved Avith a saline cathartic after the action of the sedative has been manifest. Noav con- tinuing the sedative we add Acetate of Potash with abun- dance of water, until the urinary secretion is free, and follow with Cannabis Indica, Pulsatilla, Macrotys, or Stayphysagria, as indicated. 284. In some cases, warm demulcent vaginal injections will be grateful at first, but sometimes they are not Avell borne. But after tAvo or three days, a weak solution of Chlorate of Potash to keep the parts thoroughly clean will be found im- portant. If secretion becomes too free, use an infusion of Hydrastis, or better, a solution of Sulphate of Hydrastia. CHRONIC VAGINITIS. 285. Sporting women do not suffer from vaginal leucor- rhcea as frequently as one would suppose. The strict atten- 122 The Reproductive Organs. tion to cleanliness, necessitated by their position, freeing the vagina from all secretions and discharges Avhich might un- dergo decomposition, is a safeguard. There is.no doubt but that want of cleanliness and care is a very common cause of this trouble Avith most women. In prostitutes, the vagina does not suffer from irritation like the vulve and cervix uteri, and if not exposed to the specific disease, and free from dis- ease above, there is little tendency to abnormal discharges from this surface. Following a badly treated gonorrhoea, or disease of the cervix uteri, Ave sometimes have a very un- pleasant form of the disease, and one Avhich at times Avill cause urethritis and balanitis in the male. 286. The symptoms are clear. There is an abundant muco-purulent discharge, varying in character, from a thiw ichor to a thick, flocculent yellow or greenish fluid. Tho woman complains of aching in the hips and back, sense of fullness and dragging in the pelvis, some difficulty in mictu- rition, tires easily, and suffers from menstrual irregularity. An examination discloses the increased secretion, and de- termines its chatacter. When the discharges are removed and the mucous membrane exposed, it is found thickened and discolored. In some cases it is unnaturally rugose, and every fold seems like a sponge furnishing the peculiar secre- tion. In others all the ruge seem to be effaced, and the mucous surface is unnaturally smooth, the vagina being very much dilated, especially in its upper portion. 287. This disease is not unfrequently associated Avith dis- eases of the rectum and bladder. There is constipation and difficult defecation, a hemorrhoidal condition, ulceration or fissure. And of the bladder, chronic inflammation, increased mucous secretion, deposits of the triple-phosphates, Avith oc- casionally prolapse. 288. Treatment.—In my experience a good o-eneral treat- ment is absolutely indispensable to success. A careful exam- ination determines the special remedies indicated, or if there The Reproductive Organs. 123 are no such indications we then institute means to increase waste and improve nutrition Avith the expectation of getting a better renewal of life, and with better tissues Ave may anti- cipate an improved condition of the diseased structures. 289. The remedies Avhich exert a special influence upon these structures Avill be thought of. Macrotys, if there is pain in hips, pelvis and legs. Hamamelis, if there is venous full- ness, tendency to varix, and relaxation of perineum. Staphy- sagria, if associated Avith involuntary sexual excitement. Pulsatilla, if the patient is nervous and depressed. Eryngium, if there is difficult micturition. Tincture Phosphorus, if in- creased mucous secretion from bladder. Even Copaiba and Cubebs may find a place in our therapeutics. 290. In old and stubborn cases, with depraved nutrition, I would always think of Cod Oil as an important remedy. And if the skin shoAved the peculiar dusky hue, Avith Avant of elasticity, Fowler's Solution of Arsenic. 291. The local remedies will necessarily vary very greatly. Take the thickened spongy vagina, seemingly secreting from every pore, and I would use an injection of Tincture of Iodine, Solution of Nitrate of Silver, Solution of Sulphate of Zinc, or of Permanganate of Potash, the strength of the solution proportioned to the change of tissue. This treatment neces- sitates confinement for a few days, and the free use of seda- tives, but it is sometimes tie only one that Avill reach the dif- ficulty. 292. In less severe cases I frequently prescribe : R/ Chlo- rate of Potash, 5ss.; Sulphate of Zinc, 5j-; Water, Oj. R/ Tincture Hamamelis, 5iv. ; Water, Oj. R Permanganate of Potash, 5j.; Water, O.j. R/ Solution of Carbolic Acid in Glycerine, (gj. to Si v.) r,ss. ; Water, Oj. R Infusion of aa. Alnus and Quercus Rubra. R Tannic Acid, Sj. ; Glycerine, Siv. ; Water, Oj. I need hardly say, that avc get along better when Ave study our cases Avell, and prescribe according to the condition of the case in hand, and not empirically. 124 The Reproductive Organs. acute metritis. 293. Inflammation of the uterus is of more frequent oc- currence than vaginitis, the loAver segment suffering especially. Whilst Ave may have a specific (gonorrhceal) inflammation of the cervical canal, the diagnosis is generally easily made be- cause it involves the parts below. 294. Whilst the symptoms are pretty clear if Ave look for them, the disease of the uterus is sometimes overlooked, be- cause the general symptoms are so pronounced. The patient complains of the general malaise preceding severe disease, has pain in the back, limbs and head, a chill, folloAved by febrile reaction. When Ave are called, she feels so sick, that she finds it difficult to locate the disease. She has unpleasant sensa- tions in the stomach Avith frequent nausea and vomiting, sometimes most persistent. The bowels are constipated, and she has an uneasiness and desire to go to stool, Avhich is inef- fectual, but painful. The skin is dry, urine scanty, and its passage frequent, the temperature is elevated, and the pulse small, hard and frequent. With such symptoms the disease may run on for days, like an ordinary fever, or it may be greatly intensified by bad medication, and develop peritoneal inflammation Avith typhoid symptoms. I recollect a case of this kind, Avhich ran a course of ten days, without being sus- pected by the attendant physician, yet post-mortem examina- tion showed suppurative inflammation of the uterine Avail, and recent peritoneal adhesions. 295. Treatment.—The treatment here is nearly a repeti- tion of that given for acute inflammation of other parts, yet there is no harm in repeating it. The patient must have entire rest, even from the tenesmus which is sometimes so annoying. Following a hot sitz-bath, with sometimes Chlo- roform applications to lower spine and over the hypogastrium, we use a rectal enema of starch -water and Tincture Opium, if necessary. Selecting the appropriate sedative, Veratrum when t>e pulse is full, Aconite when it is small, we give it in The Reproductive Organs. 125 the usual doses, every hour until con\Talescence. If the nervous system is excited, the eyes bright, pupils contracted, Ave add to it Gelseminum. If the patient is dull and somno- lent, Belladonna. If there is muscular pain, pain in the hips, and seemingly in the pelvic bones, or deep-seated in the pel- vis, Macrotys or Caulophyllum. The sharp, burning pain in pelvis, Avith erythematous flush of face, or surface elseAvhere, Rhus. In some cases the indication for the alkalies is marked, and a Salt of Soda is curative ; in the latter part of the dis- ease Acids are occasionally required. 296. If the inflammation has come on during or immedi- ately following the menstrual Aoav, or the result of abortion, (\vhich is always to be looked to),'the antiseptics become im- portant remedies. We are accustomed to say that Chlorate of Potash is the antiseptic in the diseases of the uterus, when absorption of putrescent material has occurred. Though this is the general rule, it will not do to take it for granted, and we select our remedy as Ave Avould in other cases. 297. If at the time of the menstrual Aoav, the discharge has been prematurely arrested, we follow the sedatives with : B/ Tincture Pulsatilla, Tincture Macrotys, aa. oss. ; Water, |iv.; a teaspoonful every tAvo hours. To be effectual, seda- tives must precede their administration. We never give the stimulant emmenagogues in such cases. 298. In the majority of cases the hot sitz-bath, folloAATed by fomentations and Chloroform counter-irritation, Avill give the most relief, especially if near the menstrual period. But in some cases, not at this time, the cold pack to the pelvis and perineum Avill do better. Occasionally benefit is had from Avarm enemata, of Chlorate of Potash, a weak salt water, or a demulcent; but in many cases the exertion and vaginal ir- ritation does more harm than the injection does good. CHRONIC METRITIS. 299. Chronic inflammation is not an uncommon disease in the advanced life of the sporting woman, as in her sisters who 126 The Reproductia'e Organs. have suffered sexual abuse under the marital cloak. The long continued excitement, frequent excesses, derangement of the menstrual function, and attacks of the acute disease, even- tually lead to it, aud Avhen these causes persist, the patient is with difficulty cured. 300. The previous history shows repeated attacks of ute- rine irritation, with attending unpleasant sensations. The patient may have had gonorrhoea, which is a not uncommon cause. She has suffered from back-ache, Aveak back, fullness and dragging in the pelvis, pain in the limbs, and leucorrhcea. Her general health is impaired, appetite variable, bowels ir- regular, some urinary trouble, and general malaise. Sexual intercourse may or may not be painful, but she is nearly always Avorse afterwards. 301. Examination by the touch shoAvs an enlarged uterus, sometimes to double its usual size. Elevating the organ upon the finger may not be painful, but Avheu pressure is made through the abdominal Avail above, it is ahvays productive of pain. The lower segment alone, or the entire organ maybe involved. The tumid tissue, tense yet yielding to the touch, with a sense of impaired elasticity, is characteristic. The os may be patulous and open, or tightly closed and rigid. In the first case the finger will readily dilate it and pass in to the first articulation. 302. If the disease is of the cervix principally, Ave will sometimes find an abundant secretion from the cervical canal of a glairy, tough mucus; or there may be erosion of the outer surface with abundant muco-puruleut secretion ; or Avell defined ulceration within or without, or both. 303. In some cases where the disease is of long duration. the cervix is very much enlarged, sometimes full, doughy, inelastic, at others nodulated, as if suffering from malignant disease. In other cases, and especially when the result of old gonorrhceal inflammation, the surface shows a granular sur- face, which bleeds on being- touched. 304. Almost ahvays there is displacement of the uterus The Reproductive Organs. 127 if the disease is of long duration. Most commonly there is prolapse, the cervix resting upon the recto-vaginal septum; and here the sense of Aveight and dragging is greatly in- creased, and all the symptoms intensified. In some there is anteversiou or retroversion, and the pressure upon the bladder aud rectum is the cause of very unpleasant symptoms. 305. Treatment.—It might seem unnecessary to study these diseases here, as they are studied in detail in the com- mon treatises on diseases of Avomen. But there are two reasons why I think it best: The first, that they may be asso- ciated in the mind with Avrongs of the sexual function. The second, that a simpler treatment may be presented. It really makes no difference Avhether this inflammation and its results are met Avith in the married or the prostitute, the causes are very similar, and the treatment Avill not differ materially. 306. Rest to the reproductive organs is an essential of a successful treatment. Absolute continence is not necessary in some cases, but it Avill be found the best in nearly all. Too much exercise upon the feet is to be avoided, and sometimes the recumbent position for a feAv days facilitates the cure. When there is much dragging and Aveight in the pelvis, the perineal supporter is an excellent aid, and Avill give marked re- ]ief. Any Avrong of boAvels or bladder causing tenesmus, must be relieved, as this seems to perpetuate the disease. 307. The general treatment is of great importance. In some cases there are marked indications for some one remedy, and we will find it curative. Thus I have cured cases with Macrotys, Rhus, Hamamelis, Nitric Acid, Thuja, Copper, Arsenic, alone, or as the internal treatment. The indications for a remedy not being distinct, Ave use those which influence the part, and in the direction opposite to the disease. In other cases, the general treatment will be directed to a renewal of life—such means as will increase Avaste and excretion, and such as will improve the appetite, blood-making, and nutri- tion. 128 The Reproductive Organs. 308. When Ave come to particular remedies, we may be guided by the folloAving : If menstruation is painful, and there is deep pelvic pain, or muscular pain, Macrotys and Pulsatilla. If there is fullness and relaxation of perineal tissues, Avith or without hemorrhoids, feebleness and Avant of elasticity of cervix uteri, Hamamelis; nodulated hardness of cervix, Iodide of Ammonium; Avith full leaden pallor of tongue, Iodide of Potassium; violet coloration of tongue, same color of cervix, Nitric Acid ; burning pain in upper vagina, or rec- tum, or bright erythematous redness of cervix, Rhus ; con- tracted os, or tense, resisting cervix, Avith brownish coloration of mucous membranes, Arsenic ; dilated os, and free, cervical secretion, Staphysagria, Tincture Phosphorus. 309. In some cases vaginal injections are used for cleanli- ness alone, in others for the topical action of the remedy upon the cervix. In the main Ave may be guided in their selection as in chronic vaginitis. There are cases in which a topical application of a saturated solution of Tannic Acid, or Per- sulphate of Iron will be beneficial in strengthening the blood- vessels, and diminishing the hypertrophied cervix. Others in Avhich there is abundant secretion from the eroded mucous membrane, in Avhich Permanganate of Potash or Carbolic Acid Avill be useful. 310. In the more common condition of localized ulceration I prefer the Nitric Acid to all. other remedies. Let the part be freely exposed with the speculum, using a good light re- flected. Have a pine stick of sufficient length, Avith the ex- tremity flattened, and adapted to reach all the ulcerated sur- face ; dip it in strong" Nitric Acid, ruhbing the free acid off on paper, aud apply it thoroughly to the parts. For the canal of the cervix, round the end of the stick, giving an ovoid ball termination, and the acid can be Avell applied to the cervi- cal canal. No application Avill be found so effectual in check- ing profuse secretion, or arresting the progress of ulceration; and promoting rapid healing as this, but it requires to be thoroughly used. The Reproductive Organs. 129 311. If the acid is applied to a large surface, or to a cervi- cal canal greatly diseased, or the structures are very irritable, the patient should be kept in a recumbent position, and the sedatives given every hour. If there is much pain from the application, Avhich is very rare, a sufficient dose of Morphine may be administered. OVARITIS. 312. Inflammation of the ovaries of a sub-acute character is frequently met with, acute inflammation more rarely. In some cases we find an unnatural irritability of these organs, and the patient suffers from local pain and sympathetic dis- ease of other parts, whenever she has been tempted to excess in eating, drinking, or sexual indulgence. 313. In acute inflammation the general symptoms are very similar to metritis. She suffers from general malaise, has pain in back and limbs, headache, loss of appetite, and following a chill, considerable febrile action. In some, cases she is not able to locate the pain, the entire lower abdomen and pelvis suffering with wandering pain. But eventually it localizes itself in one or other of the iliac regions, and deep pressure elicits tenderness. In some cases the peritoneum becomes very sensitive, especially when the attack comes on during or immediately folloAving the menstrual discharge. 314. It may continue for but a short time, or run a course of days. In rare cases it is followed by pelvic cellulitis, and the formation of deep abscesses, Avhich are especially un- pleasant Avhere the blood contains cacoplastic material or the patient suffers from constitutional syphilis. 315. In sub-acute inflammation there is little febrile action, yet the secretions are arrested, and the tongue is furred, and the appetite impaired. The patient suffers from pelvic pain, pointing in the iliac region, and less frequently a sense of Aveight and dragging, Avith back-ache and pain in the limbs. 316. Treatment.—The patient requires rest in either case, and Ave usually order a hot sitz-bath, followed bv Chloroform 9 130 The Reproductive Organs. counter-irritation over the ovaries, and this by a hot fomenta- tion. Hot applications, as a rule, are much more grateful than the cold pack, yet once in a while this Avill prove the best. If the bowels are irritated, either from the disease or the injudicious use of cathartics, great relief va ill folloAv from the use of an Opium suppository, or an enema of starch Avater and Tincture of Opium. There is no treatment so bad as the injudicious use of cathartics. 317. In the majority of cases Aconite Avill be the sedative, and Avhen there is a sense of fullness and Aveight with the pain, as is frequent, Ave add Belladonna. Our prescription is: R/ Tincture Aconite, gtts. x.; Tincture Belladonna, gtts. xx.; Water, §iv.; a teaspoonful every hour. The Belladonna may be advantageously replaced by the Macrotys the second day, or in some cases we will see cause to use it from the first. If, as the disease progresses, the patient suffers from " ner- vousness," we add Pulsatilla to the treatment, using it and Macrotys associated, alternated with the Aconite. 318. We control the rectal tenesmus Avith Opium and keep the bowels quiet, but sometimes we have difficult micturition with tenesmus. In most cases Eryngium will be the remedy, though in some it will be Gelseminum. The usual means are employed to establish secretion from skin and kidneys, as soon as the sedative action is obtained. The internal admin- istration of Opium, and especially of Chloral, to relieve pain, is to be deprecated. neuralgia. 319. Neuralgia is sometimes met with in its most stubborn form. The pain may be localized in the diseased part, as in ovaralgia, but most frequently it points at some distance from the part specially affected. Any undue irritation of ovaries, uterus, vagina, bladder or external parts, or of the sexual function in its entirety, may determine neuralgia. 320. When one suffers pain, he is apt to think it would be more easily borne in any other part than the one affected. If it was a toothache they would rather it would be a colic The Reproductive Organs. 131 or in the toes, but if in the toes, they would rather have it any Avhere else. Patients may not suffer more from neuralgia of the reproductive organs, in so far as the intensity of the pain is concerned, but there is no doubt but it exerts a much greater influence iu impairing the vegetative functions. 321. A very common place for this neuralgia to point, is in or near the anus. Sometimes she can cover the spot with her finger, but again, though located in this region, it is shift- ing. In one case of this kind dependent upon ulceration of the cervix, the pain Avas most intolerable, the contraction of the sphincter from irritation producing convulsions. The patient was chloroformed to relieve the suffering, a small hypodermic injection of Morphia used near the rectum, and the next day the ulcer was thoroughly cauterized with Nitric Acid, and there was no further return of the neuralgia. She had suffered from these attacks for some months. In a second case the pain seemed to point under the clitoris in the arch of the pubis, and was evidently the result of venereal excesses. The same treatment, followed by Pulsatilla and Macrotys, gave relief. 322. Treatment.—After what has been said, I need hardly call the reader's attention to the necessity of a careful exami- tion to determine the cause. In the majority of cases, point- ing at a distance, the location of the pain is calculated to mis- bad. A singular case may serve as an example: Mrs. C---- lias suffered for some ten years with coccygeal pain, to such an extent that she has been forced to maintain a recumbent position for weeks at a time. In addition to various internal remedies, and local applications, she has had the sphincter ani divided, and an incision made thence to the coccyx, and a small portion removed. I came to the conclusion that the wrong Avas of the sexual function, and associated Avith a dys- menorrhoea, from which the patient had suffered for years. Whether the diagnosis was correct or not, she recovered by 132 The Reproductive Organs. the use of Pulsatilla and Macrotys, followed by minute doses of Arsenic. 323. The relationship between local disease and neuralgia is best seen in cases of ulceration. Hence the cure of the ulcer stops the neuralgia. 324. But in addition to determining the cause, Ave find it advantageous to recognize the ordinary classification—with predominant affection of the part Avhere the pain is found ; Avith predominant affection of the brain, which receives the impression—and secondly, with hyperemia; with anemia. 325. In some cases the treatment will be almost entirely local, and Avhen the disease of the part is removed, the neu ralgia is permanently cured. In others the treatment will bu general, and especially directed to the nerve centers, and m the increased susceptibility to impressions is gotten rid o/, the neuralgia is cured. 326. In the condition of hyperemia, whether of the part or brain, we put the patient upon the use of the sedatives Avith Gelseminum, and follow them with saline laxatives and diuretics. In the condition of anemia we employ small doses of Aconite and Belladonna, Quinine, Iron, and the restoratives. The hypodermic injection of Morphia becomes an impor- tant means of temporary relief, and many times of a radical cure. As a rule I prefer to use it as near the place AA^here the pain points as possible. The quantity will vary, usually \ to \ grain is sufficient; the strength of the solutiou being grs. x. to water, Sj.; the dose would be ten to thirty drops. In some cases the influence of Atropia with Morphia is better than the Morphia alone—Atropia, gr. \ to gr. j. ; Morphia, grs. x.; Water, Sj- Sometimes we use the agent endermi- cally. Take a thimble closed at the top, put a lock of cotton in it, and drop in a feAv drops of strong Aqua Ammonia, and apply quickly to the part. In about one minute the epithe- lium is loosened, and may be rubbed off with the finger. Dress the part Avith a paste of Morphia, and the influence is the same as from the hypodermic injection. The Reproductive Organs. 133 GONORRHEA. 327. It Avill be advantageous to study venereal diseases of women separately from those of men, at least so far as the primary or local lesion is concerned. The parts affected are different, the diseases present different symptoms, and the methods of treatment vary to a certain extent. Especially is this the case with gonorrhoea, Avhich in the male is confined to the urethra, but in the female may involve vulva, urethra, vagina, the canal of the cervix, and even the cavity of the uterus. 328. We will study the specific character of the venereal poisons, when Ave come to a full consideration of the subject, and will find good evidence to believe that they are three in number—gonorrhceal, multiple or soft chancre, and syphilis proper. We will probably reach the conclusion that each is distinct, always reproducing itself in kind, never producing the others, and so far as Ave know, at this day never arising de novo. It may be that Ave wi 11 find the differential diagnosis difficult in some cases, but in the majority it will be readily made, if sufficient care is used. 329. Contact Avith the gonorrhceal virus gi\*es rise to a peculiarly malignant inflammation of mucous membranes; not necessarily of the urethra alone, for one mucous mem- brane is as susceptible as another. In the extensive mucous l'.ning of the female reproductive organs, the part first suffers Avhich has received the virus. It may be confined to this part, or extend itself by continuity of structure, or the secretion of gonorrhceal virus Avhich is brought in contact with the surface. 330. Thus we will sometimes find the disease confined almost wholly to the vulva, or the urethra, lower part of vagina, or the upper portion of Angina and cervix uteri. It is singular, in some cases, hoAv the disease can remain local- ized in a small portion of this mucous surface ; as it is sin- 134 The Reproductive Organs. gular in others how rapidly it will spread, until the entire mucous lining is involved in disease. 331. There is also very great difference in the intensity of the disease. Whilst in some it is so mild that they are hardly aware there is anything wrong, in others the inflammation is extensive and extremely intense, with considerable constitu- tional disturbance. I have known cases Avhere the woman was diseased for weeks, and only became aAvare of it by in- oculating her male associates. 3-32. There is also very great difference in its persistence. In some cases it will get well of itself in a feAv weeks, or is readily cured by simple means, and not a trace of trouble is left. In others it seems almost impossible to effect a cure, the contagion lurking in the folds of the vulve, urethra, ruge of vagina, around the cervix uteri, or in the cervical canal. 333. In the severer cases the symptoms are very distinct. From tAvo to six days after connection, she feels a sense of heat in the vulve or vagina, and if the urethra is affected, 3calding on passing urine. In twelve to twenty-four hours, this sense of burning has become very unpleasant, and is asso- ciated Avith SAvelling and dryness of the parts, pelvic pain, scanty urine, desire to evacuate the bowels, and some febrile action. By the second or third day secretion is established, and soon becomes abundant, a yelloAvish or general muco- pus, very unlike the secretion in any other acute disease of the parts. 334. In the less severe cases there is some burning, the parts being somewhat SAVollen. The discharge is not so free, and there is less irritation in adjacent organs, and no febrile action. 335. The progress of the disease is very variable. In some the local inflammatory symptoms are lessened as the discharge increases, but in the majority they remain quite as severe, or are intensified for some days. Usually the acute symptoms are lessened by the end of the first week, have nearly disap- The Reproductive Organs. 135 peared by the fourteenth day, and by the the tAventy-first the discharge has almost or quite stopped. 336. Mention has already been made of the rectal and vesical tenesmus, Avhich is sometimes the cause of the severest suffering. The uterus may sympathize in the inflammation, and if a menstrual period should occur during the progress of the gonorrhoea, the sufferings may be greatly intensified. In some cases the ovaries are involved as Avell, and rarely there is pelvic cellulitis or even peritonitis. 337. The symptoms pointing to disease of the sexual organs will cause an examination even in the mild cases. The touch shows parts SAvollen and hot, smooth and elastic in the first hours, bathed in secretion after the second day. If we use the speculum Ave will have ocular evidence of the inflam- matory process. Frequently Ave have no occasion for the speculum, in fact could not use it Avithout very great suffer- ing, the piarts being so swollen and painful. The woman being exposed, the vulva is shown tense, swollen and red, and as it is pressed open by the finger, the condition may be seen upAvards as far as the commencement of the vagina. The nymphe are sometimes so SAvollen as to project beyond the labia, and the entrance of the ATagina shows like a red ring of SAvollen tissue inside. When the urethra is involved, the meatus is prominent, reddened and tender to the touch, and the SAATollen urethra is prominent in the anterior vaginal Avail. 338. Whilst the majority of women recover readily from a gonorrhoea, some never get well ; the specific character of the disease may be lost, after some months, so that they can not transmit the contagion, but they suffer for life from the results of the inflammation. In some the mucous membrane of the vagina is thickened and spongy, secreting muco-pus. In others there is chronic disease of the cervix uteri, especially of the cervical canal ; in others chronic cystitis, Avith occa- sional attacks of urethritis ; in others diseases of the rectum ; and in still others, and more intractable than any, a tendency to inflammation of the pelvic connective tissue, Avith a Ioav 136 The Reproductive Organs. grade of deposits Avhich frequently break down, and some- times from fistule in various parts of the perineum. 339. Treatment.—In the ordinary cases of gonorrhoea in women, the treatment is quite easy if they are so situated that they can follow directions. Rest and cleanliness are two essential elements. Rest means the recumbent position and quiet until the active inflammation has passed off, if this is possible. To relieve the inflammation and for cleanliness, Ave order a Avarm sitz-bath, (sometimes a cold sitz-bath is more grateful), the diseased parts being thoroughly Avashed with glycerine soap Avhilst taking the bath. This bath may be re- peated two, three, or four times a day, at first, and Avhen there is no further occasion for the bath, a large bowl of water is so placed that the patient sitting over it can Avash thoroughly. Sometimes a Aveak salt-Avater is less irritant than simple water: sometimes it is a weak solution of Chlorate of Potash, Borax, or Acetate of Lead. If the upper vagina is involved, an in- jection pipe Avill be required, but AAThen the disease is princi- pally at the outlet, simple washing will answer. 340. If there is tenesmus, Ave order an Opium suppository. Moving the boAvels every second day Avith a saline laxative— Prof. HoAve's Crab Orchard Salts and Sulphur does very Avell, with a small portion of Cubebs after the first Aveek. 341. Put the patient upon the use of: B/ Tincture Vera- trum, gtts. xx.; Tincture Gelseminum, 5ss. to 5ij.; Water, Siv.; a teaspoonful every hour. With this give a simple diuretic as Althea, Hair Cap Moss, an infusion of Melon Seed, until the urine becomes moderately free, and then Ace- tate of Potash, with an abundance of diluents to maintain the action. Usually a twenty-four or forty-eight hours of this treatment gives marked relief, and Ave hoav add Canabis Indica, Macrotys, Pulsatilla or Staphysagria, as may be in- dicated. 342. When the disease is confined to the urethra, I Avould risk the abortive treatment. Nicely round the pine stick to The Reproductive Organs. 137 the size of a catheter, the end being made very smooth, dip it in the Nitric Acid, Avipe dry, and after a minute, introduce it as you Avould a catheter. Of course it burns, though the burning does not persist as one Avould suppose, and is soon succeeded by a feeling of relief. The same means may be used at any part where the disease is localized and can be reached in this way. I am sure it offers the only certain cure for gonorrhoea of the cervical canal. 343. Following these sharp applications, the patient is kept quiet, put upon the use of the sedatives, and has a hot sitz- bath, or an Opium suppository if necessary. 344. When the discharge has become profuse, I have ob- tained more benefit from Macrotys, Cannabis, Staphysagria and Pulsatilla, then other remedies. Sometimes the old pre- scription of Copaiba is very good, but very offensive. Cubebs is much pleasanter, and may be used in poAvder when we Avant a stimulant action. 345. For a Avash when the discharge is abundant Ave may prescribe Chlorate of Potash, Sulphate of Zinc, Permanga- nate of Potash, Carbolic Acid, or Avhat I prefer to all, a solu- tion of Sulphate of Hydrastia, grs. iv. to Water Sj. It should be used after the parts are A\rell cleansed, and held in contact with them for sometime. In some cases more benefit seems to come from keeping the mucous surfaces apart than from the medicine. A piece of soft cotton cloth or lint, of proper width, folded upon itself, and Avetted Avith Mucilage of Elm, medicated with Acetate of Lead and Morphia, carried' up with the finger, a spatula or something of this kind, Avill be found to give very great relief. I have also employed the remedies named in this way. Or in place of this, Ave may use our remedies in the form of suppository, introducing them into the vagina. 346. In chronic cases where the mucous membrane is thickened and spongy, I use a local application of Nitric Acid, a strong solution of Permanganate of Potash, Sulphate of Zinc or Carbolic Acid, as may seem best adapted, but in 138 The Reproductive Organs. either case so as to change the condition of the part and the secretion. With a good general treatment and improved nutrition these patients will frequently make a good recovery. SYPHILIS. We might omit the study of syphilis in Avomen, as the treatment is very nearly the same, yet there are some points connected with it that deserve attention, and they may be better studied in this connection. 347. As heretofore named, Ave recognize three venereal contagions—gonorrhoea, soft chancre or chancroid, and hard chancre or syphilis proper, and we Avill study these more fully further on. Here Ave want to call attention to the important fact that the soft chancre is almost ahvays multiple, the hard chancre a single sore. In women, at least, this is the only safe guide, as the true syphilitic ulcer will frequently present but little induration, OAving to the character of the tissues. As an additional means of diagnosis Ave recollect that in chan- croid the lymphatic glands are enlarged earlier and suppura- tion is a very common result; in hard chancre or true syphilis there is induration of the glands, but rarely suppuration. 348. This seems plain enough—if there is but one sore, and engorgement of the inguinal or femoral lymphatic glands, without suppuration, it is true syphilis. But if there is more than one sore, especially if inclined to spread, and the glands suppurate, it is chancroid. In the first there Avill be constitu- tional symptoms, no matter Avhat plan of treatment is adopted. In the second there are no secondary symptoms, the disease being purely local. Notwithstanding Ave can state the general facts thus explicitly, and the diagnostic distinc- tions are Avell defined, still errors in diagnosis are made by the most experienced: A single ulcer may be chancroid, and the The Reproductive Organs. 139 glands may not suppurate ; the ulcer may also, from local in- flammation, have a degree of induration. So also we will oc- casionally find the true syphilitic ulcer multiple, and the glands may suppurate. In the one case Ave congratulate our- selves on the success of a treatment Avhich seems to have neu- tralized the syphilitic poison, and effected a radical cure. In the other we are surprised to find a syphilitic eruption and other symptoms following a local disease which seemed to be soft chancre. Such mistakes should not occur often, but they Avill happen sometimes to the best. 349. The examination for chancre must be very thorough, else the ulcer may escape our notice. I prefer to make it with reflected light, having a good lamp set by the side of the patient and using a concave hand mirror. The first inspec- tion Avill be of the vulva, and every fold should be effaced and thoroughly inspected. The obscure places are the special sites of venereal ulcers, because they escape the Avashing that fol- lows impure connection. The sore may be in a fold of the nymphce, in the superior commissure, in the fossa uavicularis, between the carunculce, by the side of the clitoris, hid by a full meatus, or just Avithin the urethra. Using the speculum, the examination must be very thorough of the outer surface of the cervix. The little ulcer may be at the junction of vaginal wall and cervix, and Avith an ordinary examination may not be exposed. It is still more difficult to detect it, if located on the posterior surface of the cervix. It may be just Avithin the os, and the sAvelling of the part may have so closed the open- ing that we only suspect the part by its localized hardness, and the unyielding character of this lip of the cervix. Chan- cre of the vaginal Avail is more rare, yet the sore Avill some- times be found hid aAvay in one of the ruge, small indeed, but a continued fountain of infection. 350. Whilst the venereal contagion is propagated by sexual intercourse, there are very rare cases in which it may be communicated othenvise. Thus there are cases on record, in which chancre of the lip Avas communicated by a kiss 140 The Reproductive Organs. chancre of the breast by nursing an infected child, and I have seen one case of chancre of the nates, communicated from an infected water closet. Chancre of the hands are not uncom- mon, from handling dressings, or Avashing the clothes of the infected. 351. Thus chancre may be developed upon any part of the skin or mucous membrane, by contact with the virus. A number of cases are on record of chancre of the rectum in Avomen, produced by attempted intercourse post-venereal, under the mistaken notion that the disease could only be communicated to the genital organs. Similar cases of chan- cre of the mons Veneris, and outside of labia, have been met Avith. 352. Sometimes the local symptoms may be so slight, that a woman Avill carry a venereal ulcer for months Avithout being aware of it, until from communicating the contagion, she is forced to have an examination made. A hard chancre may thus be allowed to lapse into a chronic form, and shows so little of the character of a sore, that it may escape notice, unless the examination is very carefully conducted. The chancroid usually presents the severest local symptoms, and forces attention until cured. True syphilis may thus lurk in the genitals of a woman, in the character of an old and indu- rated ulcer, or Avhat seems to be a warty growth, and be com- municated for months, possibly for years. 353. Both hard and soft chancre may be present together, and Avhat seems singular, one person may contract the one, and another person the other. Both have had connection with the same woman, no other exposure, one has chancroid without constitutional syphilis, the other has true chancre, folloAved by secondary symptoms in the usual time. It has been claimed that a woman might carry the three contagions, and Avhilst one of her friends Avouldhave gonorrhoea, a second Avould have chancroid, and a third true syphilis—hence the idea with some that there Avas but one syphilitic poison, pro- ducing the three forms of disease, according to the peculiar The Reproductive Organs. 141 condition of the one exposed. If true, this would have been a fair example of idiosyncrasy. 354. Treatment.—As a general rule the treatment of chancre in women is more satisfactory than in men, if one knoAvs what to do, and hoAV to do it. In the treatment of the venereal we want a clear knoAvledge of the varying conditions of the local and general disease, cultivated senses to recog- nize them, and a steady hand to carry out the plan deemed best. 355. In soft chancre, and in true chancre not very much indurated, I prefer cauterization Avith Nitric Acid. No half- way Avork will answer the purpose. Have the part thor- oughly exposed, one or more pine-pencils, thoroughly satu- rated with the strong Acid, Aviped dry, and apply them thor- oughly to every part of the sore or sores. It is not superficial cauterization that we Avant—simply making the surface white; but the pencil should reach the bottom, and folloAv every sin- uosity, especially of the borders of the ulcer. Many physi- cians have a very light hand Avhen they use an escharotic, they are afraid of burning too much—it is "a lick and a promise." This kind of practice Avon't do, Avhat needs to be done, needs doing at once and thoroughly. It is juet as bad practice to use the pine-pencil Avith a drop of free acid adher- ing, for this only reaches the surface, and runs off on to adja- cent sound tissue, and not unfrequently serves as a cause for spreading the disease. Make a note of this—cauterization must be thorough and deep. 356. But it don't do any good, in the majority of cases, to use Nitric Acid on an indurated chancre, still less good to use Nitrate of Silver. Indeed, many times Ave Avill see the chan- cre harden under the application, and a sore that might have been cured in one or tAvo Aveeks, is made to last for many months. Complete destruction, rapidly effected, is the object, if we use means for the destruction of the chancre. 357. If the chancre is so situated that it can be Avholly 142 The Reproductive Organs. excised, this is the quickest method of removal. Cleanse it thoroughly, grasp the tissue Avith serrated forceps, or the or- dinary dressing forceps, lift it the length of the connective tissue, and snip it out Avith the scissors; slightly apply the Nitric Acid to the surface, and use a simple Avater dressing. 358. If Ave use an escharotic, it Avill be Potasse Fusa or Chloride of Zinc. In using the stick of Caustic Potash, Ave protect adjacent parts with lint wetted in vinegar, and the pencil is carried to the complete destruction of the entire in- duration. The Chloride of Zinc is used in the form of a paste—B/ Chloride of Zinc, (crystals), Gum Arabic, aa.; water to form a paste; spread it upon leather the proper size, and apply until the diseased structure is entirely removed. These remedies are not selected, unless there is marked induration, and they wil 1 not ahvays give satisfaction. You think you have used your escharotic thoroughly, and yet yon find the wound left shoAvs hardness, and presently the characteristics of chancre, and you have gained nothing. The disease is constitutional, and the local disease can not be cured, except with general treatment. 359. In very many cases, a good Mayer's ointment (made strictly according to the formula) will be the best dressing after cauterization. It is sufficiently tenacious to remain where placed, protects *the part thoroughly, and gives the necessary stimulation. The sore heals by granulation, and the part needs rest and protection. 360. In some cases an astringent and stimulant application is necessary, and then we think of the old-fashioned dressing of Port Wine and Tannin— fy Port Wine, Syj.; Tannic Acid, 5ij-; apply with lint. I should use this application when the part Avas spongy and deep colored. A solution of Permanga- nate of Potash Avill also be found a good dressing in some of these cases; and once in a while a weak solution of Carbolic Acid. 361. Sometimes Ave find that a dry dressing ansAvers a better purpose ; most usually in cases Avhere there is a free and The Reproductive Organs. 143 somewhat ichorous secretion. If the part is tumid and pallid, I Avould use Sub-Nitrate of Bismuth ; if pallid but spongy, Oxide of Zinc. Dry Calomel has been very highly recom- mended as a dressing for some chancres, but I doubt whether it possesses any advantages over those named. Once in a while a case Avill present, in Avhich the chancre is spongy, secretes profusely, and is very irritable, when Oxide of Lead (poAvdered White Lead) will, serve our purpose best. 362. If we conclude not to cauterize the hard chancre, Ave Avill keep steadily in vie\v the fact that it Avill be best removed by suppuration, and anything that Avill favor free suppuration, without producing irritation and determination of blood, will serve our purpose as a dressing. The Mayer's Ointment spoken of above, is a favorite remedy of mine, and I fre- quently dress the sore from first to last Avith Jhis alone. Where the chancre was a nodule of induration, like the half of a split pea, secreting but very little, and shoAving no irri- tability, I haA7e dressed it Avith the irritating plaster until it suppurated freely, then Avith the Mayer's Ointment. 363. But the constitutional treatment should be closely looked after here, as sometimes the local disease will not yield until Ave have made an impression through the blood. It is all romance to talk of a single plan of treatment, or a single Siiiti-syphilitic, for all cases. Just as foolish to expect that " Compound Syrup of Stillingia and Iodide of Potash " will prove a cure-all, as that Proto-Iodide of Mercury is a cure- .(tll. The physician Avho has an "invariable prescription" will fail here as Avell as elseAvhere. We find cases that need Veratrum, Quinine, remedies that increase Avaste and elimina- tion, remedies that give an appetite and favor blood-making, restoratives, Alkalies, Acids, Iodide of Potassium, Iodide of Ammonium, etc. It is hardly Avorth Avhile to describe the indications for these here, as Ave will be obliged to take them up in detail hereafter. 144 The Reproductive Organs. ^ DISEASES OF THE MALE ORGANS OF GENE- RATION. INFLAMMATION of the penis. 364. Whilst there are rare cases of simple inflammation of the penis, the majority of cases are .erysipelatous in character. It is not,a common disease, but an unpleasant one to manage, as there is a constant tendency to destruction of tissue. 365. The inflammation here commences with the usual symptoms. The part is SAvollen, hot, red and painful, and with these local symptoms there is considerable constitutional disturbance. In the majority of cases the erysipelatous char- acter of the disease shows itself in the erythematous rednesu of skin, and effusion into the cellular tissues. Sometimes, within twenty-four hours, the SAvelling of the subcutaneous tissue is almost sufficient to strangulate the organ. In one case the prepuce draAvn back Avas so SAvollen as to cause liv- idity of the glans, and free incisions Avere required to prevent sloughing. 366. The disease runs the usual course of such inflamma- tions. The appetite is lost, the boAvels irregular, the tongue shoAvs blood-poisoning, and the nervous system the influence of the zymotic disease. In some cases the skin vesicates, and large blebs form, which discharging gives relief. In others suppuration of the cellular tissue occurs, and when opened there is a discharge of a thin unpleasant pus. The inflam- mation may extend to the abdomen, perineum, scrotum, or may involve the tissues of the corpora cavernosa and spon- giosum. 367. Treatment.—Let the patient understand at once that absolute quiet is necessary to a successful treatment. With a good bath for cleanliness, and a hot foot-bath, put the patient to bed. Select the proper sedative, and give it in the usual way. In some of these cases—where the part shoAvs the The Reproductive Organs. 145 bright redness of arterial blood, and the pulse is full—Vera- trum is specific. If the pulse is small with sharp stroke, Aconite Avith Rhus—as : Py Tinct. Aconite, gtts. x.; Tinct. Rhus, gtts. v.; Water, giv.; a teaspoonful every hour. If erysipelatous in character Ave select the proper antiseptic by the appearance of the tongue. True, we may give Tincture of Iron empirically, and hit it in three-fourths of the cases, but I think it better to start with a correct diagnosis. Iron is the remedy where the redness is not vivid, and especially if there is a tinge of blueness. The indications for Veratrum have been noticed already. Sulphite of Soda is the remedy Avhere the mucous membranes are pallid, and the tongue covered Avith a pasty-white coat. Sulphurous Acid where the mucous membranes have a normal color, but the coating is thick, pasty and dirty. Rhus Toxicodendron is the remedy if the part is tense, glistening, and vividly red. 368. The local treatment will vary in different cases. In simple inflammation the part is painted Avith Veratrum, and a Avet dressing applied, either cold or hot, as may be most agreeable. In sthenic erythematous erysipelas Ave use Vera- trum as the local remedy, painting the part Avith the strong tincture. When Ave give Tincture of Iron internally, Ave Avould use it as a local application, either of full strength, or diluted with Glycerine or Avater. In phlegmonous erysipelas, after the first day, a solution of Permanganate of Potash is usually the best remedy; the strength being from 5ss. to 5ij- to Water, Oj. Carbolic Acid is also a good remedy in some cases, especially Avhere pus has formed and a tendency to sloughing is manifest. It should not be forgotten that if the infiltration and swelling of the cellular tissue impairs the cir- culation, and there is a gangrenous tendency, free incisions are necessary to ensure safety. BALANITIS, POSTHITIS. 369. Superficial inflammation of the mucous membranes covering the glans and lining the prepuce, takes these names, 10 146 The Reproductive Organs. and either or both, Avhen secretion has been profuse, has been knoAvn as gonorrhoea spuria, or balanorrhoea. In some cases it is undoubtedly caused by an impure connection, the female oreans suffering from a similar disease, or from an irritant leucorrhoeal discharge. In many it is a sequel of venereal diseases-^the sufferer has had gonorrhoea, chancroid, or true syphilis, and ever after has tenderness of these parts, and is obliged to look after them carefully to prevent irritation. Still in the majority of cases, the inflammation is the result of a Avant of cleanliness, the secretion from the glands of the parts being retained become acrid and irritant. 370. The patient Icuoavs he has a sore penis and tells the story clearly. If the prepuce can be retracted, Ave can see the exact condition of the organ. In balanitis there is superficial excoriation, and the surface denuded of epithelium secretes pus freely. Sometimes the excretions are very irregular, and the surface dark red and velvety in appearance : sometimes the redness is vivid, or there are vivid red granulations shoAving upon the surface. In posthitis we frequently find an irritated mucous membrane, and a number of small superficial ulcers, almost as clearly defined as chancroid. In many cases we see them in every stage, from the minute red spot, the vesicle, the complete ulcer, and the erosion. The follicles of the corona glandis, are frequently enlarged, and secrete abundantly. 371. When the prepuce is long and narrow, phymosis oc- curs early, and the diagnosis is someAvhat obscure. The ex- tremity of the penis is swollen and painful, there is a more #r less free discharge of a yellow purulent matter from the open- ing of the prepuce, and there may be difficulty, pain and burning in micturition. Sometimes it is almost impossible to tell where the discharge comes from, the prepuce being so contracted that Ave can see the meatus with difficulty. It is quite as difficult sometimes to diagnose it from soft chancre. Usually, hoAvever, the enlargement of the inguinal glands, and suppuration in the last comes in to help our diagnosis. 372. If the prepuce is short and retracted, it may become The Reproductive Organs. 147 cedematous, or a state of paraphimosis induced. Some of these cases are very unpleasant and persistent. The swollen pre- puce interferes \vith the freedom of the circulation, and cov- ering up the fosse of the corone glandis, ulceration may go on there, hidden aAvay from ordinary applications. 373. Treatment. — Prof. Blackman was in the habit of saying, " that no man should have a penis unless he thought enough of the organ to keep it decently clean," and so say Ave all. This means "soap and water " freely used. Some men will find, that they can not get along comfortably with- out the use of soap and water, to keep the parts free from acrid secretions. We prescribe soap and water in every case as the basis of good treatment. There is a choice in soap, and it is well to say " Colgate's best Glycerine Soap," with soft Avater. Turn the prepuce well back, and dipping the cake of soap in the water, rub it thoroughly into the part, and then wash clean. 374. If the prepuce is in a condition of phimosis, a piece of the soap may be cut so that it can be introduced through the contracted opening and brought in contact Avith the dis- eased surface. Or it may be used Avith a thick camel's hair pencil, or a strong soap suds may be used with a syringe. In either case the part should be thoroughly rinsed in clear water. 375. If this does not seem sufficient Ave use in addition : ty Permanganate of Potash, grs. v. to grs. x.; Water, Siv. ; to be applied tAvo or three times a day. If there is much pru- ritus, Glycerole of Tar is an excellent application. If there is an erosive eczematous eruption, resisting the means named, Ave Avould think of Citrine Ointment, one part, to simple Cerate, three to five parts; apply morning and night. 376. The only trouble with the local treatment in minor cases is, that it cures too quickly, and patients do not like to pay for " soap and water." In such cases a placebo always goes Avith the treatment—" to purify the blood," and act on 148 The Reproductive Organs. the patient's imagination. It is not worth Avhile to give any- thing nasty, or any of the " Compound Syrups," at the ex- pense of the doctor's pocket. 377. But there are cases, in which an internal treatment is necessary to a cure. Sometimes the patient will Avant Iodide of Ammonium for a few weeks; or a cooling purgative, as Crab Orchard Salts and Sulphur. Sometimes Sulphur alone or Sulphurous Acid, etc. When the disease has been of long duration, and is very stubborn, Ave frequently find an indica- tion for Arsenic, and give Fowler's Solution in doses of tAvo to three drops, three times a day. VERUCCA. 378. Warts may appear upon any part of the genitalia, either of the skin or mucous membrane. They may be non- venereal, and arise from irritation of the surfaces, or from the obscure and unknown causes, that change nutrition, and give rise to these growths in other parts. They sometimes follow the irritation of balanitis and posthitis, or pruritus. Or they may be venereal, either a sequel of the disease Avhich has run its course in the person, or contracted by intercourse Avith one having these \Tegetations. 379. Gonorrhoea is a not unfrequent cause of verruca, and Avhat is singular, these warts are sometimes as contagious as the primary disease, and they are propagated by intercourse. They are of less frequent occurrence after chancroid, yet sometimes they will secrete a contagious pus, which Avill pro- duce soft chancre in some, verruca in others. They may folloAV hard chancre, growing from the site of induration, and continue to secrete an inoculable virus. Or they may follow the primary disease, being induced probably by the local irri- tation, and possess none of the characteristics of syphilis. The Reproductive Organs. 149 Or they may folloAV as a secondary symptom, associated Avith mucous tubercle. 380. In the male, the most common seat is immediately behind, or upon the corona glandis, though they may appear upon the prepuce, glans, or at the meatus. Varying in size from a small point to a groAvth as large as a straAvberry, there may be but one, or they may cover the entire extremity of the organ Avith their red, granulated surface. In the female, the most common situation is at the entrance of the vagina, though Ave may find them in every portion of the organs. 381. In both sexes, they give rise to irritation of adjacent surfaces, increasing secretion from the mucous follicles, and sometimes causing erosion and secretion of pus. It is suffi- cient to say they are ahvays unpleasant companions, and should be gotten rid of. 382. Treatment.—A great many methods of removal have been advised, but the most of them are Avorthless. Powder- ing the surfaces Avith powdered Savin or Alum, don't amount to anything, unless the warts are ready to leave of their oavu accord. You can snip them off Avith the scissors, or cut them off with a scalpel, or strangulate them Avith a ligature, but in a feAv days they are back as bright and ATigorous as ever, and you Avill be lucky if you don't find that others have come to attend the funeral, and concluded to stay. It is very much the same Avith the use of the common escharotics. You may burn them off, but it only serves like good cultivation—they groAv more vigorously afterwards. 383. There are three methods which will give success, and one of the three I advise. If the wart is rather loose in its structure, not very flaccid, or a rapid groAver-, use Nitric Acid. Shape your pencils to suit the groAvth—ahvays pointed; satu- rate them Avith the strong Acid, and carry them thoroughly doAvn to the base in every interstice of tissue, and take time enough to do the work thoroughly. Superficial cauterization will not answer, and Ave Avant no free Acid upon the surface. 150 The Reproductive Organs. Chromic Acid probably stands first in destructive power. It will destroy the warts, but it is difficult to circumscribe its action, and it Avould quite as soon burn sound as morbid tissue. Unless used with care, it is very apt to burn where you don't want it, and not enough where you do Avant it. The best meaus of applying it is with a pointed glass rod, not using too much free Acid, but Avorkiug it well down to the base of the growths. It is especially the remedy for syphilitic verruca. My favorite remedy is the irritating plaster, (Emplastrum Picis Compound of our Dispensatory). Take a piece of sufficient size to cover the Avart, put it on the end of a probe, and hold it to the fire or lamp until soft, and apply to the Avart; and repeat the dressing Avith fresh plaster eveiy day, until the growth is gone. I hardly knoAV how it acts, but one thing is certain, the wart goes, and goes quickly, and is so disgusted Avith the treatment that it never returns. 384. In some cases constitutional means are necessary. It may be the evidence of depravation of the blood, and asso- ciated Avith impaired nutrition in other parts, and will require means to promote Avaste and restoratives. When gonorrhceal, and the Avarts are very persistent, it is Avell to suspect the con- tinuance of the gonorrhceal virus, and employ the proper remedies for it. In my early practice I saAv a case cured Avith Copaiba and Cubebs, that had resisted ordinary means for a tAvelvemonth. If syphilitic, of course an anti-syphilitic treatment will be necessary to a cure. PHIMOSIS. 385. Phimosis may be congenital or acquired. Up. to the age of ten or fourteen the prepuce covers the glans, and can not be retracted. Noav in the development of the organ, the foreskin is shortened in proportion to the entire length, and the opening becomes so dilated that it can be retracted. In The Reproductive Organs. 151 some cases Ave find that this infantile condition persists, the prepuce being long aud narrow, aud the glans is never ex- posed, or exposed with difficulty. In other cases it is nar- roAved, and slight irritation is sufficient to cause the contrac- tion of phimosis. 386. In many cases of chancre, especially the multiple or soft chancre of the prepuce, it becomes so SAvollen that it can not be retracted, and the parts distended with the secretion, become very unpleasant. We may have phimosis from hard chancre, but it is not of such frequent occurrence. We have already seen that in balanitis and posthitis, phimosis might occur, and sometimes gives rise to considerable trouble. 387. Treatment.—Whilst an operation gives the speediest relief, it is not ahvays the best plan of treatment. Indeed, in some eases it should not be resorted to if it is possible to avoid it. These are especially the cases of soft chancre, in which the disease almost always appears in the incisions, and makes the case very unpleasant. 388. In the majority, careful attention to cleanliness, using soap and water as heretofore directed, Avith the camel's-hair brush or syringe, Avill be sufficient to remove the irritation of the mucous membranes. Painting the part with Veratrum Avill remove acute inflammatory action, and the application of a solution of Alum, or Pond's Hamamelis, will strengthen the tissues and relieve the swelling. 389. When there is oedema of the prepuce, the adminis- tration of a hydragogue cathartic, folloAved by a diuretic, Avill frequently give speedy relief. Or in place of this Ave may give: R/ Tincture Apocynum, 5ss. ; Water, siv. ; a teaspoon- ful every two hours. 390. If there is necessity for operative interference the surgical procedure is very simple. Introduce a grooved director under the upper part, and cut the prepuce upon it, the entire length of the constricted portion, so that it may be freely retracted. Now apply an adhesive strap, so that 152 The Reproductive Organs. the wound is kept open to its full extent, and apply a water- dressing:. It has been recommended to make several of these incisions to free the prepuce, but I think when more than one is required, circumcision is the better operation. CIRCUMCISION* 391. It is Avell in this place to study briefly the ordinance of circumcision, and its relation to the reproductive function. If of Divine ordination, it must have had an important use in *Advantages or Circumcision from a Surgical Point of Vikw.—Dr. Cadell read a paper on this subject before the Medico-Chirurgical Society of Edinburgh. He considered it in four aspects: 1. In infancy. 2 In boy- hood. 3. In adult life. 4. In old age. He described : 1. The local and constitutional disturbance which may be set up by a long prepuce in infancy, and showed how these might be immediately relieved by circumcision. He read notes of a case, and also referred to those of Mr. Bryant, illustrating the effects of an adherent prepuce on the urinary organs, and the relief obtained by circumcision. 2. In boyhood, he believed that a long prepuce, by imprisoning the secre- tion from the glans, might be an exciting cause of masturbation; and if there was an hereditary disposition to nervous affections, epilepsy and insanity might be thereby induced. 3. In adult life, circumcision would facilitate cleanliness, diminish the se- cretion from the glans, so that the great cause of non-venereal excoriation would be removed, and thus render the mucous surface less susceptible to the venereal poison. 4. In old age, he cited Mr. Hey's opinion, that a congenital phimosis was an exciting cause of cancer in the penis. In conclusion, Dr. Cadell remarked that he would strongly recommend cir- cumcision in boys between infancy and puberty, whenever a congenital phi- mosis caused them the slightest inconvenience. Prof. Lister said the cases alluded to by Dr. Cadell, of irritation caused by adherent prepuce, must be admitted to be of great interest. They knew that where adhesion existed there was often an accumulation of secretion, and they could understand that to be a cause of irritation. He should like to have it clearly brought out how far the symptoms in these cases were attributable tc The Reproductive Organs. 153 the Avorld, and it is possible that in neglecting it, Ave have neglected a wise proA7ision for health. 392. The social laAvs and observances of the Jews were certainly conducive to physical Avell being; of Avhich Ave have the evidence in their existence as a people through so long a period of time, their poAver to endure persecution and oppres- sion, their health as a people, and especially their exemption from the diseases Ave are now studying. 393. The elongated prepuce keeps the covering of the glans delicate and sensith^e, and as we have already seen, this might be a cause of sexual irritation and spermatorrhoea. The extremely sensitive glans makes copulation brief, and ihat cause, as distinguished from mere length of the prepuce. Though all would allow that cases of phimosis ought to be subjected to operation, it ought to be considered whether circumcision was the best that could be done. The object could be obtained without mutilation. Mr. Jordan, of Birmingham, has written an interesting paper on the subject, showing that a perfectly natural condition of things might be obtained by the simple means of notching the ring of skin to the requisite extent, and then dividing the mucous membrane up to the coronaglandis, and, avoiding all use of stitches, simply have the part drawn backward and forward twice every day. As regards the question of malignant disease, he might have been unfortunate, but he had now seen a large number of cases of cancer of the penis, not one of which was associated with the phimosis. Dr. J. Bell said his experience in regard to circumcision was in cases of long standing, and perfectly incurable nocturnal enuresis by small children who Avere in the habit of wetting the bed. In as many as four or five cases he had succeeded in effecting a perfect cure, by simply removing the redun- dant portion of the prepuce. In one case, a very bad case, a poor little fellow made his water first in the prepuce, which was like an orange at the end, and then he got rid of the water by squeezing it with his hand, the water coming out by a small aperture. That case was in George Watson's Hospital, and it became a question with the managers how to provide the necessary bedding for the boy. The operation performed was very simple, and was a complete cure. He (Dr. Bell) had very little experience of adherent prepuce; cases of adhesion of the prepuce were not so common as those of long prepuce. Dr. Halliday Douclas said, that several years ago he Avas waited upon by a gentleman who had been married a few days before, and who had failed tc effect connection. He was laboring under a very tight phimosis. He had 154 The Reproductive Organs. though the venereal orgasm is perfect in the man, it is more rarely experienced by the woman. This Ave have seen is sometimes a cause of disease. The elongated prepuce and tender structures offer a better field for the venereal disease, and Ave find here one element of free contagion. 394. So far as recommending circumcision, I am free to say this, that it is especially applicable Avhere the penis is ex- tremely sensitive; Avhen a person from this suffers nocturnal never experienced any inconvenience during his life of twenty-five or twenty- eight years. He (Dr. Douglas) transferred him to Mr. Syme's hands, and, within twelve months, there were twins born to him. Another curious fact in this gentleman's history was this: In early life his brother had been re- lieved of phimosis, and three of his children, nephews of the first gentleman, had required to have the operation performed. Dr. "Watson was glad that the conclusion to which Dr. Cadell had arrived ■was, that where an elongated prepuce was a source of annoyance, it was right to relieve the person by removing it. As regarded the question of the com- parative frequency of venereal complaints among persons who had been cir. cumcised and those who had not, he might refer Dr. Cadell to a paper which appeared in the Medical Times and Gazette, 1st of December, 1855, by Mr. J. Hutchinson, in which it was shown that at the Metropolitan Free Hospital, situated in the Jews' quarter, in London, in the year 1854, the proportion of Jews to Christians among the out-patients was as one to three—at the same time, the proportion of cases of syphilis in the former to the latter was only as one to fifteen. Yet, that this was not the result of any higher decree of morality on the part of the Jewish population was obvious, because fully one- half of the cases of gonorrhoea occurred in Jews. This preventive influence of circumcision, as regards chancrous infection, led to hereditary syphilis being rarer among the children of Jews than of Christians.....He was surprised that Dr. Cadell did not quote that greatest of all authorities on such matters, viz., Dr. Kicord, who had said, in one of his published clinical lectures: "The prepuce is an appendix to the genital organs, the object of which I could never divine; instead of being of use, it leads to a great deal of inconvenience, and the Jews have acted kindly in circumcising their chil- dren, as it renders them free from one at least of the ills to which flesh is heir. The prepuce is, in fact, a superfluous piece of skin and mucous membrane, which serves no other purpose than as a reservoir for the collection of filth. especially when individuals are inattentive to cleanliness." This was very strongly confirmatory of Dr. Cadell's views, though it appeared to Dr Watson a little extreme.— Edinburgh Medical Journal. The Reproductive Organs. 155 emissions, over-sexual excitement, neiwous irritation, sperma- torrhoea and prostatorrhcea ; or where there is continued dis- ease from its closeness. 395. The operation of Gross is the simplest: " With this vieAv, the redundant parts, steadied with a pair of slender forceps, applied just in front of the head of the penis, are cut off with one SAveep of a long bistoury from above downwards and from behind forwards. The contracted and tightened membrane is then, if necessary, divided with the scissors. Any little arteries that may bleed are secured with fine liga- tures, when the muco-cutaneous edges of the Avound are ap- proximated by four sutures, placed at equi-distant intervals. Elevation of the penis, Avith cold-water dressing, recumbency, light diet, and a purgative the morning after the operation, constitute the after treatment. The sutures are removed at the end of the third day." PARAPHIMOSIS. 39o In paraphimosis Ave have a contracted prepuce, but it is diawn back and strangulates the glans. We sometimes find cases of this kind in boys, Avho having Avorked the pre- puce over the head of the penis, find that they can not get it back. We Avili also see some rare cases of this in the adult. In the majority, hoAvever, the opening of the prepuce has been contracted by disease, usually posthitis, but sometimes soft or hard chancre, and it being retracted Avhilst the organ is very flaccid, it can not be returned on account of the swell- ing. It may also be caused by a rapidly induced inflamma- tion of the prepuce. I saw a case of this kind, in which it followed the irritation of connection, there never having been any previous difficulty. In some rare cases it will follow erection, the glans not losing its state of turgescence. 156 The Reproductive Organs. 397. The symptoms are very clear, and usually very un- pleasant, if the constriction is severe. The contracted pre- puce has prevented the flow of blood from, though it does not prevent the admission of blood into the head of the organ. The glans is very much swollen and discolored, and in the majority of cases there is some pain. Pain, however, is a good symptom, for where there is pain, there is life ; absence- of pain and Avant of sensibility are precursors of gangrene. If the strangulation is severe aud protracted, a Ioav grade of inflammatory action may folloAV, or the glans may slough in part or the Avhole. 398. Treatment.—In the minor cases, relief is speedily given by the local application of cold to the part. We may use pounded ice, or even suspending the organ in ice-waterv or cold Avell or spring Avater Avill ansAver. If the case is still more serious, Ave use a cold, sitz-bath, a good sized tub of water being preferable to a small quantity. 399. Should this not be sufficient, or if from the appear- ance of the organ, Ave deem there is imminent danger to the tissues Ave relieve the constriction with the scalpel. I do not think it is essential to Avork a grooved director under the con- tracted prepuce, though if this can be done it is well enough, and will give the ordinary practitioner confidence in the use of the knife. In the severer cases, the director can not be used. Take the head of the penis betAveen the thumb and finger, bending it sharply dowinvards, have the patient or an assistant retract the prepuce as much as possible, and with a sharp scalpel sever the constricted portion from above doAvn- Avards. There is but very little danger of cutting the body of the organ—none at all if the knife is held steadily. 400. Dress the part with an ordinary water-dressing, add- ing a small portion of Tincture of Aconite and Camphor if the constriction has been of some hours duration, or use a weak solution of Sulphate of Zinc, if there is danger of sloughing. The Reproductive Organs. 157 URETHRITIS. 401. Inflammation of the urethra in the male, may result from various causes, but in a majority of cases it follows con- nection Avith a woman suffering from vaginitis, leucorrhcea, or during the menstrual period. There are times Avhen the secretions from the va'gina become very acrid, and give rise to urethritis, balanitis, or posthitis. It is rarely the case, hoAv- ever, that these affections can be transmitted from the male to the female. Women suffering from secondary syphilis, and having inflammation of these organs, or leucorrhcea, Avill sometimes communicate local diseases of a very severe char- acter, not, however, specific. 402. Symptoms.—The symptoms of urethritis resemble to some extent those of gonorrhoea, though not usually so seA^ere nor persistent. At first a feeling of fullness, tension, or con- striction along the urethra, Avith frequent desire to urinate, is followed in a couple of days by burning in passing Avater, sense of soreness afterward, and a milky-Avhite discharge. In the majority of cases, the ardor urinse commences to decline by the fourth or fifth day, there is no chordee, and the dis- charge ceases, or becomes yellowish and creamy. 403. There is no possible means of determining between a specific and non-specific urethritis, other than that the symptoms of the last are much milder, as would appear by the description. It usually runs its course in a Aveek or ten days, though it may be protracted for months, or give a great amount of trouble by continually recurring upon slight ex- citing causes. 404. We occasionally see cases in Avhich the inflammation runs higher than in gonorrhoea, but these are quite rare. In gonorrhoea the favorite seat of the disease is the lacunse of the navicular fossa ; in simple urethritis the disease involves the entire urethra, and is severest Avhen it principally affects 158 The Reproductive Organs. the membranous and prostatic portions, and especially AArhen it extends to the bas-fond of the bladder. In the latter case, there is deep-seated, burning pain, Avith an almost constant desire to pass urine, and great tenesmus—so much so at times that the patient passes blood Avith each discharge. 405. Treatment.—In the majority qf cases a very simple treatment gives excellent results. Put the patient upon the use of Veratrum and Gelseminum, in the proportion of—R Tinct. Veratrum, gtts. xx.; Tinct. Gelseminum, 5ij. ; Water, 5iv.; a teaspoonful every hour. If the bowels are constipated use a saline laxative, as a Seidlitz powder, Bitartrate of Potash, or Crab Orchard Salts and Sulphur. Give diluents freely, sometimes an infusion of the milder diuretics, usually a weak solution of Acetate of Potash. 406. This treatment gives relief in tAventy-four hours, and it may be all that is necessary. Usually, when the acute symptoms pass off, we follow Avith: 1^ Tinct. Cannabis Indica, gtts. x. ; Water, ?>iv.; or Avith small doses of Pulsatilla, Sta- physagria or Macrotys. 407. When the upper portion of the urethra is principally involved, Ave have the patient use a hot sitz-bath, until the tenesmus is relieved, go to bed, and have an enema of starch and Laudanum, or Tinctures of Opium and Lobelia, or an Opium suppository. The boAvels maybe relieved before these are used, as named above, but afterAvards should be kept confined. The sedatives should be given as in the less severe cases, and the after treatment will be the same. HEMORRHAGE FROM THE URETHRA. 408. Hemorrhage from the urethra may occur as the re- sult of injury to the parts, especially Avhen the penis is in a state of erection. It may also result from over-excitation The Reproductive Organs. 159 during sexual intercourse, or in some rare cases of chordee. I recollect a case of hemorrhage in a man aged some forty- five years, Avhich Avas caused by great venereal excitement and connection Avith a woman under the influence of liquor. The Aoav of blood Avas profuse, and the sufferer Avas almost exsanguined before it Avas arrested ; in this case it Avas from the bulb of the urethra. In another case the hemorrhage Avas caused by a kick from a prostitute, and it Avas months before the sufferer could have an erection without some bleeding. 409. The diagnosis is easy, a stream of bright blood wells out of the meatus, and if an attempt is made to arrest it by compressing the head of the penis, the urethra becomes dis- tended, and presently involuntary contraction ensues, and the blood is forcibly expelled. The locality of the ruptured ves- sels may sometimes be determined by the uneasiness in the part. 410. Treatment.—Suspending the penis in ice-cold Avater, or the application of pounded ice "will suffice in a majority of cases. But if the locality of the ruptured vessels can be de- termined, compression can be made to the urethra over the part, and the patient kept still until the vessels are closed. When the hemorrhage is persistent, I should use a large sized bougie, with moderate compression and the application of tiold. URETHRAL CALCULI. 411. Occasionally we meet cases in which small calculi formed in the bladder or in the kidneys, pass into the urethra with the stream of water, and either from their size, or from irritation then lodge there, and the sufferer can get them neither forward nor back. In some of these cases the suffer- ing is extreme. The Aoav of water is suddenly stopped, and 160 The Reproductive Organs. the desire to micturate becomes very pressing, and is attended with tenesmus and forcible expulsion. The angular or sharp projections of the stone irritate the urethra, which contracts against the further advance, and as the stone progresses it tears the tissue, causing severe pain and hemorrhage. Calculi have thus remained in the urethra for many hours. 412. Treatment.—Surgical authorities have recommended the extraction of calculi from the urethra Avith forceps, which is all Avell enough if the stone is near enough the meatus to be readily reached and grasped. Even then its removal is attended Avith severe pain. But in the majority of cases, the forceps will not reach it, and the patient must suffer intensely until it has Avorked its Avay sufficiently forward. Here my treatment will be found especially applicable — Introduce a large bougie or catheter back as far as the stone, and gently press it backward so as to dislodge it; hold the parts quieli for a feAv moments until the involuntary contraction ceases, and then sloAvly withdraAving the instrument have the patient make the effort to pass urine. The stone folloAvs immediately behind the instrument, Avhich dilates the urethra, and it is passed Avithout difficulty or pain. STRICTURE OF THE URETHRA. BY PROF. EDWIN FREEMAN, M. D. 413. A stricture of the urethra may be defined to be an organic contraction of that canal, at some particular part. This interferes Avith the passage of the urine, and becomes more and more serious, according to the degree and perma- nency of the contraction. Strictures are essentially of tAvo kinds : transitory and permanent. 414. Transitory strictures consist of tAvo well defined kinds, spasmodic, and congestive or inflammatory. In spasmodic The Reproductive Organs. 161 stricture, there is involuntary contraction of the circular mus- cular fibres of the urethra, in some part, or of the compressor urethra? muscle, which may be associated with some degree of irritability of the mucous membrane at that point. In con- gestive or inflammatory stricture, there is usually chronic con- gestion, or inflammation of the mucous membrane of large tracks of the urethra, principally the prostatic, membranous, and bulbous, Avhich from various causes, is suddenly increased to an acute condition, with swelling or thickening of the mucous membrane and narroAving of the canal. This condi- tion may be, and frequently is associated Avith a spasmodic action of the muscular fibres just referred to, the tAvo causes acting temporarily to completely occlude the urethra. 415. The exciting causes may be, errors of diet in dyspep- ,tic and irritable persons, or the effects of cold, suppressing the secretions of the skin, or the intemperate use of liquors, and other like causes, increasing the acidity of the urine, and as a consequence, the irritability and inflammation of the urethral canal. The congestive form is especially liable to occur in persons of a rheumatic or gouty diathesis ; and the spasmodic form in those given to excesses in drinking and in venereal indulgences, or in those afflicted with piles, ascarides, fissure, stone in bladder, etc. Symptoms of spasmodic stric- ture are : Inability to pass the urine, resulting suddenly, and quickly passing aAvay. It may be accompanied Avith some heaviness in the perineum, and as the bladder fills up there are expulsive pains in the hypogastric region, Avhich increase in severity if the urine does not pass. 416. Treatment.—These attacks are usually quickly re- lieved by a saline cathartic; the free use of Acetate of Potassa Avith Gelseminum and Hyosciamus ; or Avith Sweet Spirits of Nitre, Avith Opium and mild mucilaginous diuretics, as the Marsh.MalloAvs, etc. The hot hip bath, with a Dover's poAvder internally, may be the only thing necessary to give relief in some cases. It may be necessary to introduce a 11 162 The Reproductive Organs. bougie or catheter in some cases, before relief can be ob- tained. 417. Congestive Stricture.—The symptoms are : Inability tc pass the urine, with great heaviness and pain in the perineum, occurring as the result of cold or dissipation, etc., in persons having a persisting inflammation or congestion of the urethra. There is also extreme sensation of burning if a feAv drops of urine escape; pain in hypogastrium extending frequently to back and hips; eversion and redness, Avith sometimes gleety discharge at the meatus, Avith other indications of acute ure- thritis. On testing the urine, the blue litmus paper Avill usually turn a bright red if the urine be highly acid. 418. Treatment.—Subdue the inflammation by the use of Aconite, Sweet Spirits of Nitre, Hyosciamus and Gelseminum internally. Use fomentations of Hops and Stramonium to the perineum and hypogastric region, covering the external genitals. Give freely of Acetate of Potassa or Bicarbonate of Soda if the urine be found to be acid. Administer freely infusions of Marsh MalloAvs and Flax Seed, and by injections and mild cathartics get the boAvels into a soluble condition. It may be necessary to introduce a bougie or catheter, if the urine can not be made to pass otherAvise, but it should be done with great care, lest the inflamed and swollen urethra be injured and increase the difficulty. In the after treatment it may be necessary to pass a bougie occasionally, of as full size as possible, and also to use mild injections of infusion of Hydrastis Canadensis, in Avhich a little Borax has been dis- solved, or the infusion alone Avill be sometimes most grateful. Sometimes Iodide of Potassium in large doses, alone or com- bined Avith other antilithics, have the best results, while in other cases in persons suffering from malarial influences, anti- periodics, such as Quinine, etc., must be given before much relief can be obtained. 419. Permanent or Organic Stricture.—In this form, the contraction remains permanently, and is only removed by in- strumental interference. It may be the result of chronic in- The Reproductive Organs. 163 flammation, leading to plastic deposits in the mucous mem- brane at some part of the urethra, or in the sub-mucous tis- sues, or else ultimately extending to them and the corpus spongiosum. In the initiatory stages, it is probable that there is some muscular contraction resulting from the frequent passing of the urine over an inflamed and slightly thickened mucous membrane, and this occurring at the time that the plastic deposit is becoming organized, results in the formation of a more or less Avide circular band around the urethra, nar- rowing its canal. The persistence of the cause, and the addi- tional cause resulting from the narroAving of the passage, the extension of the inflammation and deposit into the sub- mucous tissues, and possibly the effects of careless instru- mental interference, ultimately result in so close a contraction of this band, and such an indurated condition of it and adja- cent tissues, that urine can no longer be expelled, excepting after long waiting, much effort, and then only in a very small twisted or divided stream, or in very bad cases only in a feAv drops at a time. 420. Another definition of the causes of stricture is, that it is the result of a proliferation of the elements of the sub- mucous cellular tissue. According to Rokitansky, there is sometimes found at the site of the stricture, and deposited upon the walls of the urethra, a copious secretion of pasty mucus, the result of chronic inflammation. It " may or may not be attended with an exuberant formation of epithelium, and in which accordingly the epithelium is either rapidly throAvn off from an almost bare, and, as it seems, excoriated mucous membrane, or accumulates over the whole or parts of the surface, and thus forms a complete laminated covering for it, or patches of various thickness here and there upon it." He also describes a croupy deposit upon the mucous mem- brane without any external contraction—the result of acute inflammation. Sir Henry Thompson has only found three cases in a large number of examinations, and tAvo of these he thinks OAve their appearance to dilated lacuna?. 164 The Reproductive Organs. 421. Age.—Stricture of the urethra seldom occurs before puberty. It usually takes its origin between the ages of twenty-five and forty, and may continue for an indefinite period. It has, according to Mr. Erichsen, been known to occur as early as fourteen years of age, and a case of trau- matic stricture at eleven years of age is reported by Dr. Chas. C. Lea, in the American Journal of Medical Sciences, July, 1862. 422. Seat.—On this subject much might be written, as eminent surgeons have remarkably differed. But examina- tions on the living subjects are, from various causes, liable to be inaccurate, Avhile post-mortem examinations, carefully ami honestly made, must necessarily be determined to be decisive*. Sir Henry Thompson has made a careful examination of more than three hundred preparations of stricture, in the museums of Paris, London and Edinburgh. His statement is this : That part of the urethra which is most frequently affected Avith stricture, is the portion comprised in the niche anterior to the junction,." (of the membranous and spongy portions), " that is, the posterior or bulbous part of the spongy portion. The liability of this part to stricture appears to diminish as it approaches the junction, where it is less common ; while be- hind it ns very rare. Most rarely is a stricture found so far back as the posterior part of the membranous portion." The strictures occurring in all this region just mentioned amount to sixty-seven per cent, of the entire number. The next most frequent seat of stricture is that part of the urethra included betAveen the meatus urinarius and two and a half inches Avithin that orifice, the number being seventeen per cent. The central portion, including the part betAveen the tAvo portions above mentioned, has a ratio of sixteen per cent. Examina- tions by other surgeons fully sustain these decisions. Mr. Thompson, however, has not seen a case of stricture in the prostatic portion of the urethra. Yet Mr. Walsh describes a preparation in the Museum of the Royal College of Surgeons in Dublin. Other surgeons have also described other cases. The Reproductive Organs. 165 423. Number and Character.—In the largest number of cases there is only one stricture, but often there are more. Mr. Thompson never met with more than three or four in one person, while Mr. Hunter has met with six; and Colot with eight. Sometimes the stricture is a simple fold of the linino- membrane containing the constricting fibres; a narrow annular stricture, called by Mr. Thompson the "linear stricture," the " pack-thread " or " bridle " or " valvular" stricture of other writers. This fold is sometimes oblique, or may extend only part of the way around the urethra. It has sometimes been perforated by instruments, and forms bridles or frona, stretch- ing from one side to another. The "elongated annular" stricture may occupy a considerable part of the urethra, being closely contracted at the beginning and ending and less in the centre. When the course of the passage through an elongated stricture differs from its normal direction, it is called " irreg- ular or tortuous." 424. Degree of Contraction .—Cases present themselves of all degrees of closeness of constriction. Many are rigid, others are readily dilatable, but as quickly contract. These are usually situated in the bulbous and spongy portion of the urethra, and are called by Mr. Syme the " resilient strictures." In some the Avails are indurated and firm like cartilage, allow- ing the urine to escape only drop by drop, in many cases allowing the passage of only the finest instrument after long and tedious effort, and sometimes entirely preventing the passage of any instrument through them. A stricture that is strictly impermeable to urine probably does not occur, ex- cepting as a "traumatic" stricture, the result of injury and possibly sloughing of the urethra, in Avhich a urinary fistula would be present, through Avhich all the urine passed. 425. Results of Stricture.—The principal changes in the genito-nrinary track are found posterior to the seat of stric- ture. The urethra may be largely dilated, even forming a true pouch, Avhich may present itself in the perineum as a fluctuating tumor. The Avails of the bladder, from the effort 166 The Reproductive Organs. to expel the urine, may become thickened and fasciculated. The ureters may become dilated, and even the kidneys irri tated and congested and structurally changed, and their func- tions materially interfered Avith. The ejaculatory ducts may be dilated, and the testicle may become irritable and inflamed. The patient, in severe cases, may become hypochondriacal from the remote effects upon the nervous system of incom- plete depuration of the blood through kidneys. He may also become dyspeptic and be subject to chilliness and Avandering pains in back, limbs and thighs. 426. Symptoms.—These are a greater or less delay in th'j evacuation of the urine or AA7aiting for it to appear, and after it has passed, the retention of a few drops which afterward escape. The stream of urine is small, often tAvisted or forked, scattered, fan-like or passing in two currents, one forward and the other directly downwards. There is often a sensation of pain or aching in the perineum in passing the urine. This becomes almost constant and severe in bad cases. Often in such cases there is over-distension of the bladder and a con- stant dribbling of decomposed urine, loaded Avith mucus and triple-phosphates. The severe straining to expel it sometimes gives rise to hernia, hemorrhoids, prolapsus ani, or severe irri- tation about the rectum. There is often also a gleety dis- charge from the meatus, often quite profuse, \vhich arises from the mucous surface around the stricture, and is the re- sult of chronic inflammation. It is especially so when the stricture is the sequel of gonorrhoea. One of the effects of straining in a severe stricture is a slight rupture of the mucous membrane behind the stricture, the insinuation of a little urine through the fissure, which gives rise to inflammation and the formation of abscess and fistula. Blood sometimes appears in the urine, but it is not common. 427. Causes.—In two hundred aud twenty cases, according to Mr. Thompson, twenty-eight strictures were from " injury The Reproductive Organs. 167 to perineum," eight Ave re true " inflammatory," seven were true " spasmodic," six Avere from " congenital " causes, seven from various other causes, as phagecloena, cicatrization of chancre or chancroids, lithotrity, masturbation, etc., and one hundred and sixty-four Avere from gonorrhceal inflammation. Of these latter, ninety were from chronic inflammation or gleet. 428. Diagnosis.—As many of the symptoms of stricture are found in other diseases, as sub-acute inflammation of the prostate gland, and urethral neuralgia and hyperesthesia, it is necessary to make a careful exploration of the urethral canal. This may be performed with steel sounds, solid or flexible catheters or Avith certain bougies. The instrument should always be large enough to well fill the urethra, and should be passed in \vith a firm and careful hand, until the obstruction is reached, and fairly recognized. Smaller sizes may then be passed until one passes through to the bladder. In this man- ner the seat and degree of the stricture may be pretty accu- rately determined. In certain slight strictures Avhere there is doubt, it is best to pass a bougie of sufficient size with an acorn point, " bougie a boule." This maybe readily passed through, but being AvithdraAvn, the shoulders of the point are restricted by the fold of the stricture and thus determine it. 429. Treatment. — There are four principal methods of treatment, viz. : Dilatation, Rupture, Incision, Caustics. 430. Dilatation maybe performed in three Avays : gradual, continuous, over-distension or rapid dilatation. 431. Gradual dilatation is the usual method and a very successful one of treating ordinary strictures. In this method instruments that can be closely crowded through the stricture are used daily, or every two or three days, always increasing the size, and the pressure from within, besides enlarging the canal, causes an activity of the absorbents that soon results in the lessening and removal of the indurated material of which 168 The Reproductive Organs. the stricture is composed. The instruments by which this may be accomplished are : 1st. Steel sounds well polished in oil or nickel plated. The curve should, according to Thomp- son, be made to correspond to the sub-pubic curvature of the urethra, which is an arc of a circle three and a quarter inches in diameter. 2d. Silver or gum elastic catheters of similar size and shape may also be used, and sometimes it is an ad- vantage to use them, where there is accumulation of urine in the bladder. A bell Avire may be bent upon itself, and then given the proper curve and used as a catheter in case of emergency. 3d. Bougies of lead, wax, elastic, catgut or whalebone, may be.used, and they are made of various sizes and shapes. The English mahogany colored, and the French black bougies are most used. The latter are the most prefer- able, on account of their flexibility and adaptability to the canal. They are also furnished with olive shaped points which prevent their being caught in the lacuna? of the mucous membrane, or catching in and penetrating the folds of the stricture, which' is possible with the sharp pointed ones. They readily engage themselves in the opening through the stricture, and are more easily insinuated through it. The English bougies are stiff, and in those furnished with an olive point, the neck beyond the point is so slender and brittle, as to be easily broken on slight pressure. Filliform bougies, either of gum elastic or Avhalebone, are indispensable in the treatment of very tight and close stric- tures. These are made with the acorn point, or Avith variously twisted points to suit the various conditions. The large ex- tremity of the gum elastic filliform bougie may have a metallic cap securely fastened to it, by Avhich it may be screAved on to an instrument for over-distension, rupture, or internal urethral incision. The finest Avhalebone filliform bougies are of great use in first passing an almost impermeable stricture, even AAThere the gum elastic filliform can not be made to pass. When at last the latter can be got through, if there is to be forcible enlargement or incision, the instrument may be at The Reproductive Organs. 169 once attached and passed in, the bougie acting as a guide through the stricture, and coiling up in the bladder, Avhence it is withdrawn after the operation is completed. It is safe to attach a fine strand of strong silk to the bougie, near the metal cap, previous to passing it into the bladder, lest by acci- dent it become detached from the cap, and left in the bladder when the instrument is withdrawn. In such a case the silk will guide the end of the bougie into the urethra, and draw it out of the bladder, thus saving much trouble and danger. 432. Introduction of the Instrument.—This may be accom- plished Avith the patieut either standing or lying down. If standing, the surgeon stoops or sits in front; if reclining on his back, he places himself on his left side. The instrument being Avell oiled, he grasps the penis near the head, betAveen the ring and middle fingers of the left hand, the thumb and forefinger being left free to retract the prepuce and open the meatus. The instrument is seized Avith the right, and by the thumb and fore and middle fingers, lightly like a pen. If it be a bougie it passes in Avith slight manipulation and pressure. If a sound or catheter, etc., Avith a fixed curve, it must enter the meatus, Avith the shaft parallel to the surface of the abdo- men or left groin. The penis should be Avell drawn up, so as to put the mucous membrane on the stretch, and the point of the instrument should be made to follow the course of the upper Avail of the urethra, as it passes under the pubes to the bladder. In this operation the handle of the instrument is, at first, raised to a perpendicular, and then depressed betAveen the thighs, the instrument being pressed firmly in the direc- tion towards the point if there be much resistance. In some cases Avhere there is difficulty in the introduction of an in- strument, besides oiling it well, the injection of oil into the urethra opens and lubricates the canal, and facilitates the pas- sage of the instrument. When it has passed into the bladder it should be retained from one to three or five minutes, or it may be immediately withdraAvn. In one or tAvo days a larger one may be attempted, and this course should be persevered 170 The Reproductive Organs. in until a Xo. 26 to 30 French scale, or 16 to 19 English scale, is passed. This large instrument should then be passed once a week, once a month, or once in three months, and perse- vered in for a long time, to prevent further contraction. During this course proper attention should be paid to the general condition of the system and the urine, and such mea- sures taken to allay any irritation produced by the instru- ments. The urine should be rendered as bland as possible ; and the general condition improved by proper tonics, etc. Sometimes a stricture can not be dilated by this method be- yond a certain size, and resists further efforts. For these cases and all others in which Ave wish to hasten the cure, the following methods are adapted : 433. Continuous Dilatation.—In this method the catheter is retained for several days in succession, producing ulceration at the point of stricture, and a free discharge. The urethra becoming enlarged, a larger catheter is inserted, and so on. Care should be taken not to allow it to remain so long that incrustations form around it. This method is allowable Avhen there are false passages, or Avhen, the catheter being inserted, if withdraAvn it Avould be very difficult to again pass it in. The disadvantages and dangers attending this mode of treat- ment, and the more frequent recurrence of contraction, pre- vent its being often resorted to. 434. Over-Distension or Rapid Dilatation.—This operation is performed by an instrument of two blades, united at their points, and separable in the curve, by the working of a screAV between them. It allows of distension at the stricture, greater than an instrument of the size of the meatus could produce. The distension proceeds slowly, requiring from seven to ten minutes to complete it. A full sized gum catheter is then passed, and alloAved to remain twenty-four hours, and then withdrawn, and on the third day a large sound maybe passed and occasionally afterward repeated. 435. Rupture.—This method has come much into use chiefly through the exertions of Mr. Holt of the Westminster The Reproductive Organs. 171 Hospital, London. An instrument invented by him, "Holt's dilator," consists of t\vo blades with a handle, and united at the point, which is somewhat tapering. A wire passes through the handle and to the point between the blades. Upon the wire, cylinders of various sizes are made to slide, the rod guiding them while they separate the blades. The point of the instrument may be removable, so that the metal- lic cap attached to the filliform bougie may be screAved upon it. In very close strictures the filliform-bougie should be in- troduced first, and then the instrument being attached it Avill follow the bougie through the stricture, until its Avidest part becomes engaged in it. In an open stricture, the instrument may be used without the bougie. The proper slide is then placed in position, and firmly pushed doAvn to its place. The rupture of the stricture is sudden and complete, yet the mucous membrane may not be injured much, excepting the stricture Avas very close, or the slide a very large one. If there be some hemorrhage, it is readily arrested by the appli- cation of cold cloths, and the internal use of Hamamelis or other astringents. Fomentations may be used for several days, and such other treatment as may be necessary to reduce the inflammation. At the end of three or five days, a No. 8 or 10 English, 14 or 18 French bougie may be passed, and rapidly increased daily to the largest size. This should then be introduced occasionally for several months or a year. Voillemier's rupture instrument is on the same principle, ex- cepting that in that the central slide is grooved and the blades are made to slide in them. In Thebaud's instrument, the blades are made to separate at the end, Avhich Avhen they are closed is blunt, and can only be used on a stricture Avhich is quite open. The blades are separated by a screAv working in the handle. 436. Incision.—There are two methods of incision : In- ternal urethrotomy and external urethrotomy. Internal ure- throtomy is performed from before backwards ; or from be- hind forwards. In the former method a groo\Ted staff is in- 172 The Reproductive Organs. serted, guided by a filliform-bougie through the urethra, and a triangular blade sharpened at the edges before and behind,- bnt blunt at the apex, is pushed doAvn the groove of the staff. The blunt apex protects the urethra, Avhile the stricture is en- countered and cut through by the sharp edge of the blade. This is Maisoneuve's instrument, Avhich has been modified by Voillemier, by furnishing the blade Avith a sheath until it reaches the stricture, and then withdraAving it. The stricture is incised from behind forwards, by an instrument (Civiale's) in which the blade is concealed in a terminal bulb, of the size of No. 7 or 8 of the English scale, and can only be used Avhen a stricture is dilated to that size. It is passed through the stricture, the blades are projected during its Avithdrawal, and it cuts its Avay through. The blades are sheathed and the in- strument is withdraAvn. The after treatment in either case is essentially the same as in rupture. In stricture of the spongy portion of the urethra, nearest the meatus, the lanceted catheter may be used, or Avhen close to the meatus, Civiale's concealed bistoury or a probe-pointed bistoury. 437. External urethrotomy may be performed in certain forms of stricture, in which the cure is not possible by either of the other methods. This operation may be performed in certain forms of permeable strictures, and in the imperme- able ones. Permeable strictures accompanied Avith extreme sensibility of the urethra, preventing the use of instruments, and resilient strictures under similar conditions, may require external urethrotomy, although in most cases it will be possi- ble to use the urethrotome or to rupture, the sensitiveness being overcome by the use of an anaesthetic. Slightly per- meable and impermeable strictures Avith fistulas, may need ex- ternal urethrotomy. If the stricture exist in the spongy ure- thra near the meatus it may be incised upon a grooved director. If, hoAvever, it be situated more deeply in the peri- neum, the operation is more severe. If a guide can be passed through it, to be cut upon, it is called " Syme's operation," or perineal diATision. If no instrument can be passed through The Reproductive Organs. 173 it, the operation is called especially " perineal section," and " external urethrotomy," or " external perineal urethrotomy." In the first case the operation is performed upon a Syme's staff. This is a steel staff of proper size, terminating at the extremity in a grooved probe of smaller size, and joined to the staff" by a distinct shoulder. This is passed into the urethra, the probe passing through the stricture and the shoulder engaging against it. The patient is secured as in the operation for lithotomy, and an incision an inch in length is made in the median line, behind the scrotum and in front of the anus. Penetrating carefully, so as to avoid the rectum, and keeping Avell in the median line, the grooved probe is felt in the urethra Avithin the stricture, the kuife is made to enter the groove behind the stricture, and it is opened from behind fonvard, the edge of the knife being kept forward, so as to avoid opening the deep perineal fascia. After making certain that the stricture is entirely relieved, a catheter may be in- serted, and guided into the bladder. It is then AvithdraAvn the patient placed in a natural position, Avith the bed Avell protected, and the urine is allowed to pass out of the Avound, which it Avill for a time, until the perineal orifice closes, Avhen it Avill pass out of the urethra. In impermeable stricture the incision is made upon a staff, or catheter, Avhich is passed as far as the stricture. It may then be possible to pass a fine probe or even a bristle through the incision and stricture, as guide for the urethra. If so, it will not be very difficult to find that canal behind the stricture. But if the canal is en- tirely obliterated, as it sometimes is, the difficulty becomes vastly increased. It is then necessary to work carefully back- Avards, in the median line, from the point of the staff, until the healthy urethra is reached. It will sometimes be dilated, and present itself in the incision as a fluctuating tumor, and must be opened, and from this point to that of starting, the urethra can be traced. The catheter will then be guided into the bladder and AvithdraAvn, and the after treatment pursued as before. 174 The Reproductive Organs. 438. Caustics.—This method is so entirely superseded by those already described, being so harsh and dangerous, and liable to produce fresh and greater complications, that but little need be said of it. The exact distance of the stricture behind the meatus is ascertained, and marked upon a bougie. A depression is made in the extremity of it, and a piece of lunar caustic or caustic potassa is firmly fitted into it. It is then passed doAvn rapidly to the stricture, and pressed firmly against it, and AvithdraAvn. A gleety discharge is the result, but the application must be renewed every two or three days, until a bougie of the proper size can be passed, and the dila- tation Avill then be continued with the bougies. 439. Consequences of Operations upon Stricture.—Frequently, in sensitive patients, rigors "will folloAV the insertion of an in- strument, Avhich soon pass off. In more severe cases, the patient is suddenly seized with 'a chill, vomiting, acceleration of the pulse, and often Avith delirium and great prostration, seemingly the result of a partial shock to the nervous system. This must be met \vith the administration of stimulants and opiates, and Quinine if necessary, also with sinapisms to the back, abdomen and extremities, and hot foot-baths and bottles of hot water to the feet and sides, and such other measures as Avill restore the equilibrium. 440. Retention of Urine.—A person suffering from a tight stricture may, from cold or some imprudence, have super- added a spasmodic condition, Avhich will suddenly and com- pletely close the urethra. The bladder fills up, rises above the pubes, and expulsive efforts become serious, Avith no re- sulting discharge of urine. Eventually the urethra behind the stricture Avill give way, and extrawasation of urine occur, if by some means relief be not obtained. Care should be ex- ercised by the surgeon not to Avait too long, before giving re- lief, lest permanent injury be sustained by the kidneys from the pressure upon the delicate glandular structure, through the pressure of the urine through the ureters. The Reproductive Organs. 175 441. Treatment.—In most cases by placing the system thoroughly under the influence of opiates and relaxants, the hot bath, fomentations, etc., and effecting an evacuation of the boAvels if necessary, the urine may pass or a catheter of small size, or Thompson's probe-pointed catheter, may be passed. If not, the patient should be placed under the influ- ence of an anaesthetic, and the attempt made, Avith care and perseverance, to pass the instrument. It is sometimes the case that a small acorn-pointed French bougie or an acorn- pointed filliform whalebone bougie may be made to pass through the stricture, after injecting oil, and the effect of the withdrawal may sometimes be a partial or complete evacua- tion of the bladder. What is called forcible catheterism should not be resorted to, for in the attempt to reach the blad- der at all hazards, the urethra may be punctured, and the in- strument pursue an uncertain course betAveen the rectum and bladder. If, hoAvever, it should find its way into the bladder, it Avould be by making a false passage, which Avould very ma- terially complicate the treatment of the case. 442. If relief can not be obtained by such methods, and if the condition of the patient and the surroundings Avarrant it, the operation of external perineal urethrotomy should be per- formed, which will at once remove the striefure, as well as i;ive relief to the patient's more immediate symptoms. This operation, called opening the urethra beyond the stricture, may be performed in the manner already described, by cut- Ving down upon a catheter in the urethra; or by plunging a bistoury into the perineum, just in front of the anus, the cut- ting edge forward, and with the finger in the rectum guiding it, cutting forward one or tAvo inches. The bulging urethra can soon be felt in the Avound and opened, giving relief to the urine, Avhich would escape Avith some force. The stricture can then be severed upon a director. A director should folloAV the knife into the bladder, to facilitate the passage of a catheter afterwards. 176 The Reproductive Organs. 443. Puncture of the bladder through the rectum is an- other method of relief in an extreme case. In this method the boAATel being evacuated, the finger, well oiled, is passed into the rectum, and guides the trochar and canula to a point beyond the posterior border of the prostate gland, directly in the median line, to a triangular portion of the bladder not covered by the peritoneum, and bounded laterally by the vesiculse seminales. In its passage the trochar is slightly AvithdraAvn into the canula, and at the point named, firm pressure is made toward the interior of the bladder, counter pressure being made from the hypogastric region. The tro- char is withdraAvn, and the urine escapes through the canula, Avhich is then fastened in Avith tapes for several days, until relief of the stricture can be obtained. 444. Puncture above the pubes is a simple operation, in lean persons, when the bladder is fully distended, but no'l under other circumstances, and is especially dangerous if the peritoneum be wounded, or if infiltration of urine occur. This operation is especially applicable in those cases in Avhich there co-exists an enlarged prostate-gland, rendering perineal section dangerous, and puncture of the rectum impossible, from the finger not being long enough to reach beyond it. An incision is made in the median line above the pubes, about tAvo inches in length, and the bladder felt for between the recti and pyramidales muscles. Its position being ascer- tained, the trochar and canula should be passed into it, in a direction doAvmvards and backAvards, the trochar withdrawn, and the urine e\7acuatecl. The canula should be fastened in for several days until the wound closes around it, and care should be taken to guard against urinary infiltration. The stricture to be treated as in the other methods. 445. Puncture through the symphysis is another method of relief, in which the trochar is forced by a rotatory motion, Avith or without a previous incision, betAveen the pubic bones and into the bladder. A flexible catheter is inserted through the canula. The Reproductive Organs. 177 446. Extravasation of Urine is a very serious consequence of retention of urine from stricture. After great distension of the bladder and severe expulsive pains, there comes a sense of relief, after a feeling of something giAnng way in the peri- neum, folloAved after a time, by throbbing and pain, and a sensation of SAvelling and fullness in the same region. This usually extends fonvard to scrotum, thighs and penis, and is soon folloAved by a dingy red coloring of the skin, increased to a dusky red and purple color. The parts become often enormously distended, with a crackling feel, cedematous and emphysematous. It is confined to this region by the deep perineal fascia, Avhich also prevents the extravasation extend- ing backwards and into the pelvis. If relief be not early obtained, they quickly become gangrenous, and the testes and cords become denuded, the sloughing involving all the parts affected by the infiltration, until the patient sinks from ex- haustion. 447. Treatment.—If not much urine has escaped, and the bladder be still distended, make "a deep incision in the median line and enter the urethra at the point of rupture, in the manner described for entering it behind the stricture. In all cases free incisions should be made, Avherever the appearances indicate the presence of urine in the areolar tissues, to alloAV its escape. The patient should be put on sustaining treat- ment, using lotions and injections as much as possible, of solutions of Sulphate of Zinc or Carbolic Acid, Daharrague's solution, Avith charcoal and yeast poultices to the parts. 448. Urinary Abscess may occur in the perineum, external to the urethra, and not communicating Avith it primarily, being the result of irritation produced by passing of instru- ments or from other causes. Pus is formed, becomes circum- scribed by a dense Avail of plastic deposit, and ultimately opens into the urethra. Or a few drops of urine may escape from the urethra, as the result of stricture and severe strain- 12 178 The Reproductia^e Organs. ing in urinating, and an abscess be formed, communicating primarily Avith the urethra. 449. Symptoms.—The appearance in the perineum, under such circumstances, of a hard, someAvhat circumscribed and painful tumor, with a sensation of Aveight and throbbing. There may be fluctuation if in the neighborhood of the scrotum. 450. Treatment.—It should be laid open by deep incision, and treated according to the indications. 451. Urinary Fistulce form in the perineum and scrotum, commonly as the result of abscess. They may appear in the groin, thighs or anterior abdominal Avail, and usually commu- nicate with the bulbous or membranous portions of the uro- th ra. Their external orifices may be quite numerous and some of them may be quite small, Avhile others are large. They may sometimes communicate Avith large cloacae or cavi- ties beneath the surface. The tissues, in which they have burroAved, become indurated almost like cartilage. Fre- quently nearly all the urine passes through them, but little passing through the meatus. Fistula may occur in the ante- rior portion of the urethra, and is usually single. 452. Treatment.—If there be stricture, the relief of that once accomplished, the fistulae Avill usually close themselves. Either of the methods, by rupture or urethrotomy, may be resorted to. Where there are many external openings and much induration, perineal section will produce the best re- sults. The patient should be instructed hoAv to draAV off the urine himself Avith the catheter, or the catheter may be fas- tened in and a rubber tube attached to the external extremity, so that the urine may be continuously passed off Avithout dis- tending the bladder, thus keeping it out of the fistulae. If they do not entirely close up, a fine Avooden probe may be dipped in Nitric Acid, or some caustic solution, and passed into them, cauterizing their sides. This repeated occasionally The Reproductive Organs. 179 will usually cause them to close. Sometimes scrotal fistula? require to be laid open to the bottom of cavities Avith which they communicate, and to be healed from the bottom. Some- times the edges may be pared, and brought together by the quilled suture, Avith free lateral incisions. 453. Penile Fistula?, situated in the anterior part of the urethra, often require the operation of urethroplasty for their cure. De Gros Clark's method is essentially this : Pare the edges of the fistula, after introducing a catheter into the bladder, and securing it. Make a transverse cut through the integuments of the penis, about an inch in length, above and beloAv the fistula. Dissect up the skin subcutaueously. Unite the edges of the skin at the borders of the fistula by means of clamps or the quilled suture. By this operation a Avide, raw surface from each side is brought into contact, Avith con- sequently a greater chance of a successful union resulting ft The rubber tube should be attached to the catheter, so that, by keeping the bladder emptied, the danger will be avoided, of a drop or two of urine being forced by the side of the catheter, and through the fistula, Avhich might be the result of an effort to evacuate the bladder. ACUTE PROSTATITIS. 454. The prostate gland is but a small organ, and seems to serve an unimportant function, yet its diseases are among the most severe and stubborn that we are called to treat. This is to be attributed in great part to its situation and rela- tion to the bladder and urethra. As the neck of the bladder terminates in it, and the urethra is excavrated through it, any cause producing enlargement will alter the position of the bladder so as to cause retention and difficult expulsion of urine; and diminishing the size of urethra and changing its 180 The Reproductive Organs. course, will cause difficulty in its passage. It seems also to be freely supplied Avith nerves from the hypogastric plexus, and also from the spermatic, hence all the pelvic viscera sympa- thize in a marked degree. 455. Acute inflammation of the prostate may arise from the ordinary causes of inflammation, being excited by a blow or other injury of the part, but more frequently by sitting on something wet or cold—the perineal structures being thor- oughly chilled. It may also be caused by an extension of gonorrhoea, by the use of irritant injections, and occasionally by the use of irritant diuretics. 456. Symptoms.—The patient complains of a sense cf Aveighu and tension in the perineum, with deep, tensive pain. There is a frequent desire to pass Avater, difficulty in its pas- sage, and an increase of pain at the time and aftenvards'. Movement increases the suffering so much sometimes, that the patient is confined to his bed, and can hardly change hts position. Deep pressure also produces pain. 457. There is usually considerable constitutional disturb- ance. In some cases there is marked febrile action for two or three days; in all there is more than usual irritation of the nervous system. 458. When the disease is very serious, the difficulty in passing urine becomes very great, and the patient suffers in- tolerably at these times. Indeed, I have seen cases in which it could only be passed after an injection of Opium per rec- tum, and in a hot sitz bath. 459. The duration of the disease is variable. Terminating in resolution, the inflammation may subside in two or three days, or it may continue a week or more. It is very rare for it to terminate in suppuration. Occasionally a case Avill pre- sent, in which the inflammation extends to the cellular tissues adjacent, and an abscess forms in this, finally opening in the perineum, and inclined to terminate in fistula. The Reproductive Organs. 181 460. Diagnosis.—The location of the symptoms will call our attention to the organs situated at the outlet of the pelvis, aud an examination will readily determine the character of the lesion. The pain points just beloAv the scrotum, and an examination at the point elicits deep tenderness. If a catheter or bougie Avere passed up to the prostatic portion of the urethra, it Avould meet Avith obstruction and cause great pain. (I do not advise this method of examination). If not satis- fied, a linger passed into the rectum will determine the en- larged prostate very tender to the touch. 461. Prognosis.—We can generally procure relief within forty-eight hours, and an entire removal of the disease. If the person has suffered from previous attacks, Ave will be gov- erned by the history of the disease. 462. Treatment.—It is a rule in the practice of medicine, that no matter Iioav small the structure involved in inflamma- tion, the treatment will be just as active as if a larger part or organ Avas affected. Especially is this the case Avith the spe- cific means Ave use. 463. We put the patient upon the use of Veratrum and O'relseminum in full doses, and continue it until the hardness and frequency of pulse has passed away, and the secretions established ; then in smaller doses. Cathartics are always in- jarious, indeed Ave are careful that the boAvels shall not be opened until the acute inflammation has passed by. After the influeuce of the sedative, the patient should take the Citrate or Acetate of Potash to the extent of tAvo or three drachms daily, largely diluted with water. 464. To relieve the local suffering, Ave may employ the hypodermic injection of Morphia over the gland. Or in place of this, Ave may use an injection into the rectum of: fy Tinc- ture of Opium, 5ss.; Tincture of Lobelia, 5j. ; Warm Water, 5ij. M. The hot sitz-bath may be used for thirty minutes to an hour at a time, if the pain is severe; or a hot fomenta- 182 The Reproductive Organs. tion may be employed in its place. I prefer a hot brick Avrapped in flannel Avith Tincture of Opium and Lobelia in Avater, and placed between the thighs near the perineum, to either the bath or fomentation. 465. In sub-acute cases, Ave will occasionally succeed AATell, with the use of Hamamelis alternated Avith Staphysagria. Of the distilled Extract of Hamamelis, I give twenty drops every three hours; of the Tincture of Staphysagria, 5j- to Water, Siv.; a teaspoonful every four hours. These may be also given during convalescence. It will rarely, if ever, be neces- sary to attempt to clraAv the urine Avith a catheter. The in- jections of Opium and Lobelia, the hot sitz-bath, and the in- ternal administration of Gelseminum being sufficient. CHRONIC PROSTATITIS. 466. Chronic prostatitis is a disease of advanced life, very rarely occurring before the age of forty, and from that to sixty years. Whilst it is more frequently found in good livers, persons avIio have indulged freely in the pleasures of life, Ave will occasionally see cases Avhere the person has lived a very regular and temperate life. 467. It is difficult to determine the cause in many cases. It may result from an acute attack, or from a badly managed or frequently repeated gonorrhoea. But in the majority, it is developed slowly, and conies on like haemorrhoids, or other sloAvly progressing diseases. 468. Symptoms.—The disease pursues a very irregular course. There is all the time an unpleasant sense of fullness and Aveight in the perineum, and more or less difficulty in micturition. When the patient has been on his feet for some time, or undergoes unusual exertion, these symptoms are in- creased. The Reproductive Organs. 183 409. Then there are violent outbreaks in the disease, aris- ing from over exertion, from injury, or from cold. The pros- tate increases in size, becomes very tender, the seat of a deep, tensive, aching pain, with occasional lancinating pain, like a toothache. There is a feeling of tenesmus, with desire to go to stool and pass water frequently. But the passage of urine is tardy, very difficult, and attended with much suffering. In some cases it is almost impossible for the patient to void urine, and for many hours none is passed. In some cases, the bladder being dilated to its greatest extent, the urine dribbles away involuntarily. Such a paroxysm may continue but oue or tAvo days, or it may last for as many Aveeks. The sufferer sloAvly recovers his usual health, and continues to suffer in moderate degree until the next paroxysm. 470. Diagnosis.—The symptoms point to the urinary ap- paratus, as the seat of disease. On examination, Ave find ten- derness on deep pressure just below the scrotum, and in per- sons thin in flesh, Ave can detect the enlargement through the perineum. An examination per rectum is necessary, Iioav- ever, to determine the extent of the disease. The finger can be passed over the entire gland, determining its size, position, and degree of tenderness. 471. Prognosis.—Chronic prostatitis has been deemed in- curable by most writers, and treatment was confined to palli- atives. I think, hoAvever, Ave may succeed in curing the clis- d.isease in quite a number of cases, and giving very marked relief in nearly all. 472. Treatment.—If called during such paroxysm as de- scribed, Ave Avould adopt the treatment named for the acute disease. The difficulty in passing urine and its retention Avill be oA-ercome by the administration of Veratrum and Gelsemi- num, the enema of Opium and Lobelia, and the hot applica- tion. In some of the severe cases I Avould use the hypodermic injection of Morphia. 184 The Reproductia'e Organs. 473. In the general treatment, if the health was impaired, such means should be employed as would restore it. In the majority of cases Ave will find it of advantage to stimulate the skin, kidneys and bowels, so as to get increased Avaste. Then by the use of bitter tonics and restoratives, and a nutri- tious diet, get an active nutrition and reneAval of tissue. We will sometimes find, as in other forms of chronic disease, that this is the most important part of the treatment; indeed, that it Avill accomplish the object Avithout specific means. 474. The special remedies that I have relied on in these cases are, the Hamamelis, Staphysagria, Colliusonia and Phos- phorus. Of the first I use the distilled extract (Pond's), in doses of twenty to thirty drops, four times a day. Of the Tincture of Staphysagria, oj-to Water, 5iv.; a teaspoonful four times a day. Of the Fluid Extract of Collinsonia, 5ij. ; Water, giv. ; a teaspoonful four times a day. Of the Tincture of Phosphorus, 5\j- ; Water, 5iv. ; a teaspoonful four times a day. These may be given singly, or may be alternated ; and changed sufficiently often to continue the good effect. As a local application, I prefer a small seton, as being less annoy- ance than any other means of counter-irritation. 475. When there is considerable urethral irritation, the prostate offering an obstruction to the passage of a bougie, Ave A\ill sometimes find advantage from injections. The solu- tion of Sulphate of Hydrastia acts very kindly, as does a weak solution of Carbolic Acid. The injection is used Avith an Acton's long-tube syringe. PROSTATORRHCEA. 476. Associated Avith spermatorrhoea Ave not unfrequently find an excitation of the prostatic and Cowpers glands, and possibly of the vesiculse seminales. These glandular struc- tures furnish an increased secretion, having a mucoid appear- The Reproductive Organs. 185 ance, and slightly resembling seminal fluid, which is passed Avith the urine, on going to stool, on lifting or straining, and in some cases, when profuse, there is an almost constant oozing. The patient's mind having been excited by what he has been told by designing persons, calling themselves physi- cians, or the private circulars he has received from the same source, he is constantly on the look-out for the discharge, and is excessively troubled by it, so much so that he is not unfre- quently on the verge of insanity. 477. Not only do Ave find this discharge in those who truly have spermatorrhoea, but quite as frequently where that dis- ease does not exist, the prostatorrhcea being the only trouble. The sufferer has, however, been told that he is suffering from the former affection, and religiously believes it, the influence on the mind being such as to frequently impair the general health. It is useless in these cases to attempt to persuade them of the mistake in the nature of the disease, and when we arrest the discharge Ave invariably get credit for curing a ease of spermatorrhoea. 478. In rare cases the bladder is the principal seat of the disease, giving rise to irritation of adjacent parts. Generally, the chronic inflammation is confined to the trigone vesicae, giving rise to but few of the common symptoms of cystitis, though there is an increased secretion of mucus, and fre- quently copious deposits of the triple phosphates. 479. Treatment.—What treatment can Ave adopt in these cases, that will relieve this irritation, and arrest this dis- charge? Upon this will frequently depend the success of our treatment for spermatorrhoea. If Ave are to successfully manage this affection we must gain the confidence of our patient, and cause him to believe that Ave can cure him. If this prostatic discharge continues, Ave can not attain this end ; if Ave arrest it, he has visible assurance of the efficacy of our medicines. Spermatorrhoea is, to a considerable extent, a 186 The Reproductive Organs. mental disease, and unless the mind can be favorably influ- enced, there is but little prospect of a favorable result. 480. Those Avho have had much to do Avith these affec- tions will bear me out in saying that nothing favorable may be expected from injections into the urethra, no matter what their character, and in many cases most serious results have folloAved their use. Where there is irritation of the prostatic portion of the urethra, marked by burning or pain on passing water, Lallemand's porte caustique may sometimes be used Avith advantage, othenvise all irritant local applications are useless. If there is much excitement of the genital organs, with frequent erections, nocturnal emissions or masturbation, this must be controlled, and may be very readily by any irri- tant material applied to the penis, that will make it so sore that erection is impossible. I usually use the Spanish-fly plaster, sometimes Croton Oil, at others Potassa Fusa. There should be no hesitation in the use of these means, and to such an extent as to accomplish the object, 481. As to internal measures, I have used all that have been recommended, but have not attained the success Avith the common means that I was led to expect. Agrimonia, Hydrangea and Collinsonia seem to have some influence, but not sufficient for a cure. Buchu and Uva Ursi are inferior to the first named. Pareira Brava has, in some cases, a decided influence, as has also Cubebs, Hydrastis and Carbonate of Iron, aa. The remedies upon Avhich I depend now are three in number, and their use is empirical. I am inclined to be- lieve the first one is almost or quite a specific. They are, the Staphysagria, Apis Mellifica, and Phosphorus. I use the Tincture of each, oj. to 5iv. of water, a teaspoonful four times a day. I place more dependence on the first one named, Avhich, by the way, is Avorth studying, as it possesses marked medicinal properties. The Reproductive Organs. 187 CHRONIC CYSTITIS. 482. Chronic inflammation of the bladder is of more fre- quent occurrence than the acute. It is almost ahvays con- fined to the mucous coat, giving rise to the various changes of structure noticed during chronic inflammation, as thicken- ing of the mucous membrane, enlargement of the follicles, ulceration, etc. Its causes are various; it may arise from cold, injuries, irritating diuretics or injections, the presence of calculi, irritation from disease of the kidneys, extension of disease from the urethra, as in gonorrhoea, and from extension of disease from adjacent organs. 483. Persons suffering from chronic cystitis usually com- plain of a sense of weight in the hypogastrium and perineum, Avith a dull, dragging pain. There is also tenderness on deep pressure over the hypogastrium. More or less difficulty is experienced in passing urine, sometimes on account of the increased mucous secretion, and at others, from the seeming acridity of the urine. The patient frequently complains of pain in the neck of the bladder, extending the entire length of the urethra, and sometimes of a sensation of scalding or burning referred to the region of the bladder. In severer cases, Avhen complicated Avith disease of the prostate, or Avhen ulceration has occurred, the pain and beat in the bladder is >/ery severe, the call to urinate urgent, and attended by vio- ,ent tenesmus and straining. 484. The general health becomes markedly affected Avhen the disease is severe ; the boAvels are constipated ; the appetite impaired; the skin dry, harsh and sallow ; and considerable loss of flesh and strength. The urine varies greatly; in the milder cases it seems nearly natural, but in the more severe cases, it contains mucus, pus, and the phosphates. Sometimes it is so thick by the presence of these materials that it is voided Avith difficulty. 188 The Reproductive Organs. 485. In some cases, Avhen of long duration, Ave find the symptoms very severe. The urine is passed frequently both night and day, and Avith great tenesmus. There is no resist- ing the inclination to its passage, and if resisted, the tenesmus only becomes greater. In some cases it starts Avith difficulty, and the patient suffers intense agony for some minutes before the stream starts. In other cases, it starts freely, but is sud- denly arrested, either by the contraction of the circular fibres, or by a forcing down of the mucous membrane from undue contraction of the detrusor urince, and in still others from the passage of mucus. In some cases, the tenesmus is such that prolapse of the bowel occurs during micturition. 486. Chronic cystitis is determined by the location of the pains and tenderness, and its association with difficulty in passing water, and alteration in the urine dependent upon the changed secretions of the bladder. Mucus in urine may be determined by its action on litmus paper, by its particles coagulating into a thin, semi-opaque membrane, on the addi- tion of Nitric Acid, and by its soon undergoing putrefactive decomposition,becoming ammoniacal. Pus in urine generally falls to the bottom when alloAved to stand ; Acetic Acid has no effect on it, but if agitated Avith Liquor Potassae it forms a dense, translucent, gelatinous mass. If the urine contains phosphatic deposits it is often very foetid, sometimes pale, at others greenish, and viscid from abundance of mucus. On placing some of the mucus beneath the microscope, abundant crystals of the triple phosphate are found entangled in it. Dr. Bird remarks that: " One point must be borne in mind in forming a prognosis from the state of the urine, viz., not to regard it as ammoniacal because the odor is offensive, and not to consider the deposit as purulent because it looks so. A piece of litmus paper will often shoAV it to be neutial, and even sometimes acid, while microscopic inspection often proves the puriform appearance of the urine to be an admixture of the phosphates with mucus. For want of these precautions, I have seen some cases regarded as almost hopeless which The Reproductive Organs. 189 afterward yielded to judicious treatment. It is quite certain that the mucous membraue of the bladder may, under the in- fluence of chronic inflammation, secrete so much of theearthy phosphates and unhealthy mucus, as to render the urine puri- form aud offensive Avithout having necessarily undergone any structural change." 487. Post-Mortem Examination.—In the milder forms of this affection, we find the mucous membrane thickened, in- iected and discolored, and its follicles enlarged. It is fre- quently softened so as to separate from the muscular coat with considerable readiness. In a still more advanced stage the entire coats are thickened and contracted, the mucous follicles enlarged ; and more or less ulceration, sometimes regular and well defined, and at others irregular and sloughy. According to Copland, " When the ulceration is extensive, the hypertrophied muscular fibres appear, and resemble the columine carnea of the heart, presenting a purplish-red color, the mucous coat betAveen the columns thus formed being pale, soft and SAvollen. Pouches or sacks generally co-exist, with dilated ureters, betAveen these muscular columns, and are formed by the contraction of the bladder and of the abdomi- nal muscles in expelling the urine, forcing the mucous coat in places betAveen the muscular fibres. These pouches are lined with a diseased mucous coat, which secretes an alkaline mucus, and are sometimes the receptacles of a mortar-like matter, and finally of calculi, consisting generally of Phos- phate of Lime. As the disease progresses, it frequently ex- tends to the ureters, pelvis of the kidney, and at last so in- volves its structure as to occasion death." 488. Treatment.—The treatment of these cases Avill vary o-reatlv, and here as elseAvhere, Ave Avill find that success comes from a careful study of our cases, and the employment of "specific" remedies so far as possible. I do not know that there is greater variation in these cases, than in disease of other organs, but very surely the variation is more marked. 190 The Reproductive Organs. 489. It will be Avell to study the special means seriatim. pointing out so far as possible, the special indication for each remedy. Of course these are not peculiar to a disease of the bladder and its therapeutics, but are quite as applicable in any other form of disease. 490. Where there is an irritable bladder, Avith burning pain, and scalding in passing water, a tendency to erysipela- tous inflammation of the skin, or simple erythema with burn- ing, I Avould prescribe Rhus. 491. If there Avas irritation of bladder, frequent micturi- tion, and a severe burning Avith pruritus, acute formication of surface, Apis. 492. If there Avas difficult micturition, Avith sense of full- ness and Aveight at the neck of the bladder and perineum, Eryngium. 493. Where there was difficulty in starting the Aoav of urine, and tendency to retention, Santonine. 494. If Avith the disease of the bladder, there was undue nervousness, and unpleasant forebodings Avith regard to the termination of the disease, the tissues being- someAvhat tense and contracted, Pulsatilla. 495. If associated Avith deep pelvic and perineal pain, lumbago, muscular pain in every portion of the body, deep sense of soreness in the bladder, especially Avhen called into contraction, Macrotys. 496. Frequent desire to urinate, but a very small stream, passed with difficulty, and great excitation of the nervous system, Gelseminum. 497. Increased mucous secretion, Avith sense of fullness and Aveight, Staphysagria, Phosphorus. 498. Impaired venous circulation, feebleness and relaxa- tion of pelvic tissues, protrusion of perineum, atonic hemor- rhoids, varix, Pond's Hamamelis. 499. Frequent desire to urinate, with pain if the urine is retained for a short time after the desire is manifested, and a The Reproductive Organs. 191 severe, cramp-like, aching pain in the region of the neck of the bladder, Elaterinm* * Specific for Chronic Inflammation of the Neck of the Bladder.—Prof . J. M. Scuddkr— Dear Sir: As you are at this time engaged in preparing a list of specific remedies for the readers of your Journal, I now present you with one, from which I have derived success in every instance where it has been em- ployed. I will state in advance that as far as I have been able to learn, the agent, to which I here refer, Elaterium, has never been employed for this puipose. All the writers who have written upon this article, view it merely as a drastic purgative, from Pliny to the present time. In a Dispensatory I have, which is 111 years of age, it is spoken of as a dangerous drastic purga- tive. Nor have I been any more successful with Homoeopathic writers, whose provings have never led them to view it as a remedy in the disease under consideration, or for its symptoms. Though, I have no doubt, since I now mention it, that they will soon solve the matter, as they did with the honey- bee, after I had first made its value in urinary difficulties known to the classes to whom I lectured. I, therefore, claim the right to the discovery of Elate- rium as a specifie in chronic inflammation of the neck of the bladder, until some other party can show a distinct and definite priority. I have used this remedy since 1849, and during that time have treated about 45 cases, (some of whom were patients of other physicians), and with invari- able success. The symptoms among these patients were more or less severe, and nearly of a similar character; they may be summed up as follows: fre- quent desire to urinate, with pain if the urine was retained for a short time after the desire manifested itself; one or more urinations during the night; urine frequently voided with pain and difficulty; with some, during urina- tions, "it seemed as though the urine was poured into the urethra;" a con- stant sense of weight or pain in the region of the neck of the bladder, fre- quently increased upon standing, or walking; with some, standing occasioned a paralytic sensation and uneasiness in one or both thighs. In the worst cases, a "severe indescribable, cramp-like, aching pain " in the region of the neck of the bladder, and in the perineum, was experienced immediately after urinating, which sensation frequently extended, with more or less violence, over the whole of the lower region of the pelvis, and low down into the thigh; the region of the neck of the bladder was distended, and painful to the touch as well as on standing or sitting With a few, in whom the disease had been of long standing there were also present, cold feet, swollen feet, hectic fever, colliquative perspiration, cough, etc. In the more severe cases, I have usually commenced by giving half a fluid drachm of the Tincture of Elaterium, one, two, or three times a day, until it acted upon the bowels; and afterward continue its use in doses of from 5 to 10 192 The Reproductive Organs. 500. If there is some tenesmus, with spasmodic contrac- tion of the pelvic and perineal muscles, Avith expulsive pain, Stramonium is the remedy. It may be given in doses suffi- cient to give relief, the usual proportion being: ty, Tincture of Stramonium, §j. ; Compound Tincture of Cardamom, gij. ; Syrup, Sj.; a teaspoonful every three hours. 501. If there is a tendency to emission without the evi- dence of vesical contraction, Belladonna would be suggested. 502. If the bladder is emptied Avith difficulty, and the perineum has to be elevated Avith the hand, that the last por- tion may be passed, Ergot or Strychnia would be suggested. 503. If the tongue has a violet coloration, the urine being strongly ammoniacal, Ave Avould give Nitric Acid. drops, gradually increasing it as it could be borne. Great relief has always followed in these cases, as soon as the purgative effect came on from the first large doses, and that too, in cases where other purgatives had been frequently taken without any relief whatever. In less severe cases I commence with 0 or 8 drops three times a day, gradually increasing it as could be borne, and being very careful to avoid giving it in doses to act upon the bowels This action I have only deemed necessary at the commencement of treatment in the more severe and obstinate cases. A great difference will be found among different persons as to the closes they can bear; while some can take from 6 to 12 drops three times daily for weeks without any unpleasantness arising therefrom, others will be found who can not bear more than l or 2 drops for a dose, on which account, some care and attention is required on commencing the treatment As the agent is apt to excite nausea and vomiting, I have generally ad- ministered each dose of it in a teaspoonful or two of syrup. Sarsaparilla syrup, or Compound Yellow Dock syrup, etc. In cases of cold feet, general sensa- tion of cold or chilliness, Tincture of Prickly Ash Bark may be added to each dose; if the liver is torpid, Tincture of Apocynum Androsaemifolium, etc., etc. Gastric acidity, constipation, nervous irritability, anaemia, etc., when present, require the usual treatment for their relief or removal. I prepare the Tincture by adding one drachm of pulverized Elaterium to one pint of Alcohol, 95 per cent.; allowing it to stand two or three weeks, Avith frequent agitation. I will here remark, that I have likewise found this remedy very beneficial in chronic gastritis, and other chronic inflammations of mucous tissues. In procuring the Elaterium, be very careful that it is good, as there is much in the market that is worthless.—Prof. John King in E. M. Journal, 18 70. The Reproductive Organs. 193 504. If the urine is markedly acid, Ave would use Alkalies; if markedly alkaline, Acids. 505. These are special agents, and in addition we have the large class of tonic diuretics, Uva Ursi, Buchu, Chimaphilla, Agrimonia, etc., which may be occasionally employed, though the common treatment Avith these agents has not been very successful. 506. A general restorative treatment is sometimes neces- sary to a cure. Take a patient who has suffered long from these urinary troubles, and has had his vital poAver impaired, and Avaste and nutrition enfeebled, and a cure will only follow improvement of the general health. Relieve the local irrita- tion and give rest to the parts, and Ave find by the use of the usual means there is a rapid improvement in the general health. 507. ' The measures aboA^e named answer very Avell in the milder cases, and though Ave use them in the severer forms of the disease, Ave do not depend upon them. In such cases Ave resort to injections to remove morbid accumulations, and for their topical action. It is surprising to see the benefit that will result from simply Avashing out the bladder Avith tepid Avater, in cases of phosphatic urine Avith increased raucous secretion ; the distressing tenesmus and burning pain and dif- ficulty of passing Avater, all disappear, but return Avhen this material again accumulates. In some cases the use of simple tepid water is all that is necessary, but in others Ave medicate the injection. If there is much irritability of the bladder, Ave might employ equal parts of Glycerine and Rose-Avater after the tepid injection; or: R Chlorate of Potash, 5ss.; Glyce- rine, Rose Water, aa. oij. M. Use one ounce as an injec- tion ; or: 1^ Zinci Sulphas, grs. x.; Morphia Sulphas, grs. iij. ; Glycerine, Aqua Rosse, aa. 5ij. M. One ounce to be used as an injection, after washing the bladder out Avith tepid Avater, and if it produces too much burning, to be folloAved bv the injection of more Avater to Avash it out. Chloride of Zinc may be used as an injection in the proportion of one, or 13 194 The Reproductive Organs. at farthest two grains to the ounce of .Avater. A decoction of Hydrastis or Cornus Florida have been used Avith success in many cases. 508. Formerly I employed counter-irritation extensively, and would not think of treating a case without the irritating plaster over the hypogastrium, or sacrum, or an issue in the perineum. ISToav I use the acid pack at night with a thorough Avashing with water in the morning. Usually a flannel ten inches in Aviclth, Avrung out of good vinegar, passed around the pelvis, and a dry towel over all Avill answer; but if the case is a serious one, I Avould use Avater acidulated with Muriatic Acid. ORCHITIS. 509. Inflammation of the testicle maybe produced by any of the ordinary causes of inflammation, and we occasionally meet with cases, in which there has been no special cause. Usually, hoAvever, it Avill have been excited by an injury of some kind in the simple form of the disease, or by the vene- real poison in gonorrhoea and syphilis. 510. The symptoms of orchitis do not differ materially, whether it has arisen from ordinary causes, or from gonor- rhoea. The patient first complains of a sensation of Aveight and dragging in the scrotum, and pain on any sudden move- ment or jar. In a feAv hours these symptoms have become more marked, and the patient finds that all movement is painful ; and at last has to assume the recumbent position, and keep the part supported. 511. As these symptoms develop, the testicle increases in size, until finally it attains a diameter of a couple of inches, and a length of three, or sometimes four inches. It is quite sensitive to the touch, and Avhen alloAved to drag upon the cord, is very painful. Sometimes there is considerable heat The Reproductive Organs. 195 of the part, and the scrotum is reddened. The pain in the organ is of a tensive character, Avith occasional lancinating pains ; sometimes they are of a throbbing character, and are very severe. 512. The disease runs a variable course ; sometimes coming up rapidly, the organ attaining its greatest size in one or tAvo days, at others sloAvly increasing for a Aveek. It will some- times pass aAvay, under appropriate treatment, in forty-eight hours, but in others may last for days. 513. Gonorrhceal orchitis is usually developed coetaneous with the suppression of the discharge from the urethra. Many have thought that such arrest Avas the cause of the in- flammation—that the orchitis was a metastasis. This opinion is strengthened by the fact, that with the subsidence of the disease of the testes the discharge reappears—or, as others would state it, Avith the re-appearance of the clap, the orchitis abates. There is no doubt but there is an intimate relation betAveen the t\vo, and a treatment that looks to the sudden suppression of a gonorrhceal discharge will frequently be fol- loAved by the inflamed testes. The constitutional disturbance varies in different cases. In some there is marked febrile action and arrest of secretion, in-others but little disturbance. 514. The diagnosis of orchitis is readily made. No one making a careful examination would fail to determine the solidity of the testicle in inflammation, from a distension of the scrotum from serum, blood, or the pressure of the intes- tine in hernia. 515. It has been deemed more difficult to determine whether it Avas simple or specific. An examination of the penis Avill give the necessary information. In simple inflam- mation there is no eAddence of recent disease of the prepuce and glans, or of the urethra. In gouorrhoeal orchitis, though the discharge has usually ceased, the mucous membrane is tumid, dusky or livid, and irritable. If syphilitic, the disease has developed slowly, there are evidences of previous 196 The Reproductive Organs. chancre, and almost invariably a cutaneous eruption of the syphilidse. 616. With proper treatment, we may safely promise speedy relief, in a large majority of cases. Once in a while, we Avill meet Avith a very stubborn case, continuing until both patient and physician are discouraged. Gonorrhceal orchitis, as a general rule, is most readily managed; and syphilitic or- chitis the most stubborn. 517. Treatment.—If the inflammation is of an acute char- acter, I usually prescribe: Jfy Tincture of Veratrum, 5ss.; Tincture of Gelseminum, 5ij-; Water, §iv. M. A teaspoon ■ ful every hour. If, hoAvever, there is a sluggish circulation, 1 prefer Aconite and Belladonna in the usual doses. The patient's boAvels are moved Avith a Seidlitz PoAvder, or somo mild cathartic. 518. If it has arisen from gonorrhoea, the use of means to check the discharge should be stopped, and nothing used but a mild lead Avash or a solution of Sulphate of Hydrastia, as an injection. 519. Rather than use local applications, I prefer support- ing the testicle by means of adhesive straps. Let the patient lie down, and cut the hair from the pubes and perineum, Avhere it is necessary to attach the straps. Cut the adhesive plaster in strips over an inch broad, the width of the roll. Have the person support the testicle on the abdomen, and Avith the straps well heated, apply them from the perineum upward on the abdomen, and from side to side around the testicle cross- wise. The object is to bind it firmly to the abdominal Avail, giving it uniform support and compression. 520. Prof. Howe employs the adhesive straps in a differ- ent Avay. The testicle being suspended in its natural position, he applies the straps spirally, so as to give uniform compres- sion, and finally attaches them to the abdomen so as to take the weight off the cord. The Reproductive Organs. 197 521. If Ave do not employ the adhesive straps, the testicle should be supported in a suspensory bandage, or by a sling, which may be easily continued. As a local application, I prefer painting the part with Tincture of Veratrum, or Aconite and cold water, or occasionally Belladonna. A hypo- dermic injection will give speedy relief to the suffering, and will sometimes effect a cure. I prefer to use it at the affected part, raising the skin of the scrotum. CHRONIC ORCHITIS. 522. Chronic inflammation of the testicle is occasionally developed from the ordinary causes, but in the majority of cases it Avill be found to be the result of gonorrhoea or syphi- lis. Occurring in persons avIio have lived fast, we have no hesitation in asking such questions as will determine this fact. True, it will make little difference in the treatment, whether it has been produced by repeated attacks of gonorrhoea, but it would make a difference if it could be traced to syphilis. 523. The patient describes having an enlarged testicle, which is a source of annoyance from its size, its Aveight, and unpleasant sensations of fullness, dragging, and occasionally aching. The enlarged organ is in the way, and is constantly getting hurt. When Ave examine it, we find the testicle three or four times its natural size, sometimes as large as a goose egg, hard, and sensitive to pressure. In some cases the enlarge- ment will be almost Avholly of the body of the testicle; in others it will be in part of the epididymis. Occasionally it is associated Avith hemorrhoids, at other times with an irritable bladder or urethra. I have seen cases in Avhich the general health was markedly affected, but usually there is nothing of this to attract attention, 198 The Reproductive Organs. If syphilitic, Ave Avill have the evidence of the lesion in some other form. Whilst Ave may have acute orchitis Avith the syphilidse, the chronic inflammation is usually one of the last of the secondary symptoms, and is associated Avith macu- lae, ulceration and nodes 524. Though it is easy to determine the enlarged testes, it is not ahvays so easy to say that it is simple inflammation. The diagnosis betAveen an orchitis and enlargement from fluid in the tunica vaginalis is readily determined, as it is from scrotal hernia. Cystic disease may frequently be determined by the uneasiness and variable degree of hardness. Malig- nant disease may be determined by the irregular form, un- equal consistence, and nodulated character of the groAvth, The diagnosis is confirmed by the cancerous cachexia, Avhich is ahvays soon developed in cancerous testes. 525. In the majority of cases we may promise a cure, though in most of these cases it Avill require time and patience. Of course there are some cases that can not be cured. Old syphilitic orchitis has been deemed peculiarly in- tractable, but even this can be cured. 526. Treatment.—If the general health is good, our treat- ment Aviil be confined to such special remedies as influence the testicle, and to local applications. If it is impaired, we will adopt the appropriate means to restore health, Avaste and excretion, and good nutrition. 527. In some cases, Avhere there has been considerable de- posit, good results will occasionally folloAV the use of the vegetable alteratives and the saline diuretics to stimulate ab- sorption. 528. I have used the Hamamelis with excellent effect; the distilled extract is preferred. This is alternated with small doses of Veratrum, Tincture of Phosphorus, and small doses of Collinsonia. 529. In irritable testes Bromide of Potassium will some- times exert a good influence. It may be given in doses of ten The Reproductive Organs. 199 grains, three or four times a day. I have also used the Sta- physagria aud Pulsatilla in the same cases. 530. The local application Avill vary in different cases. When the scrotum, is dense, aud will bear it, I prefer a solu- tion of Iodide of Ammonium, used in this way : Py Tincture of Iodine (strong), Aqua Ammonia, aa. Let them stand until decolorized, and apply with a camel's hair brush. 531. Occasionally a dressing of Mayer's Ointment, Black Salve, or Ointment of Stramonium, will serve a good purpose. A lotion of Iodide of Potash lias also been employed with advantage, as has the Belladonna. 532. Whatever application Ave may use in this way, the testicle should be well supported with a suspensory bandage. In some cases the continued use of a Avater dressing, Avith such support, will answer the purpose. In some cases, com- pression by means of the adhesive straps, as ad\dsed in the acute form, will give the speediest cure. 533. If the cause is syphilitic, the patient should also re- ceive the appropriate treatment for this. It is true, that a general antisyphilitic treatment will not cure the testes, but it is equally true that they will not get Avell without this. (See Syphilitic Orchitis.) STRUCTURAL DISEASE OF THE TESTES AND SCROTUM. 534. We may briefly notice a number of structural lesions of the testes and scrotum, more especially to point out their differential diagnosis. They are not of very common occur- rence, and yet the testes suffer more frequently than some other portions of the body. strumous disease of the testes. 535. When irritation of the testes, from injury or other causes, is set up in a person Avho has a Ioav grade of albumi- 200 The Reproductive Organs. noid material in the blood, it wi 11 be deposited in these organs, as it Avould be elsevvhere under similar circumstances. Tavo conditions are represented in tuberculosis—the presence of a Ioav grade of albuminoid material in the blood, and a local irritation Avith determination of blood to a part. In this case these organs may suffer without any fault of the patient, but many times the irritation that causes the deposit has been in- duced by sexual excesses and abuse. 536. The disease announces itself Avith a sense of uneasi- ness and weight in the scrotum, especially on prolonged exer- cise, and the patient gets relief by supporting them Avith the hand or the clothing. At a further stage, he notices that they are really enlarged, and that the increase in size is con- tinuous; there is also greater Aveight and uneasiness, Avith sometimes dragging pains in the scrotum. In this Avay it may go on for months or even years, before the tubercular material loses its life and breaks doAvn. 537. On examination Ave find the body of the testes irreg- ular in form, and many times the tubercular nodules can be distinctly felt, especially in the epididymis. At a later stage, the enlarged organ forms attachments to the scrotum, Avhich assumes a livid hue, ulceration occurs, and the matter is dis- charged Avith but little inflammatory action. In this case un- pleasant fistulas are formed, Avhich discharge a thin serous pus, and continue for a long time. 538. In other cases, acute inflammation results from the deposit, presenting the usual symptoms of orchitis, but run- ning on to suppuration, and the formation of an abscess, dis- charging through the scrotum. Abscess of the scrotum is very rare, except from strumous disease, or severe injury. 539. Treatment.—Two indications of cure are here prom- inently presented. The one looks to the removal of irritation of the affected organ, and its proper support and rest, to re- move the tendency to local deposit; the other, to getting rid The Reproductive Organs. 201 of the imperfect material in the blood, and its replacement by a Avell elaborated albumen. 540. If there is considerable irritation Avhen the case is severe, Ave order rest, a Avell adjusted suspensory bandage, and the local use of Veratrum, or Aconite. If the irritation is not so acute, Ave may prescribe Hamamelis, Belladonna, a solution of Iodide of Ammonium, or an infusion of Alnus and Quercus Rubra. If the testes are irritable with neuralgic pain, Camphor Chloral will be a good remedy. 541. The general treatment will be varied to suit the par- ticular case in hand. We determine carefully what needs be done to facilitate retrograde metamorphosis, and increase secretion from skin, kidneys and boAvels, bearing in mind that great over-activity can not be maintained, and will be fol- loAved by corresponding depression. This is but one-half of the treatment for a " renewal of a better life." The diges- tive organs must be put in good condition to receive food and make it into blood, and the necessary restoratives must be given. Sometimes the one half, sometimes the other half, of this treatment will preponderate, but neither must be for- gotten. degeneration op the testes. 542. Degeneration of the testes is a rare form of disease, but still it is met Avith in all of its variations, fibrous, cartilagi- nous, osseous, fatty and granular. The causes Avhich give rise to it are obscure, but probably there is ahvays the general tendency to degeneration, and the local manifestation is due to causes Avhich debilitate these organs. I think in all degen- erations Ave find these two factors. There is an impairment of the blood, and a Avant of formative power, and locally the organ or part has been over-Avorked, and its poAA^er of renewal impaired. 543. In all cases of degeneration, the size of the organ is increased. It Avill frequently affect but one testicle at first, and involves the other only after some months or years. In some cases there is deep pain at times, but in the majority, 202 The Reproductive Organs. there is simply a feeling of discomfort from the enlargement, and the dragging upon the cord. At first it may increase sexual excitement, but gradually as the structure of the testes is lost, especially if both are involved, venereal passion and poAver are lost. 544. Treatment.—Though treatment has not proven very successful, Ave Avould adopt the rational plan in this as in other cases. The organ affected needs rest, and gentle stimulation ; especially does it need support. Whilst the general treat- ment should look to a better reneAval of life. In the early stage of the disease, I Avould think it possible to arrest its progress ; of course, the tissues lost would never be replaced, yet if but one testicle was saved, it Avould Avell repay the ne- cessary care. 545. As degeneration, like other chronic structural dis- eases, involves but one of the testicles at first, and commences in the second Avhen the first is destroyed, Ave may Avell con- sider Avhether the removal of the diseased organ may not be necessary to the preservation of the sound one. Here, as in structural disease of the eye, I am satisfied that the disease of one affects the other sympathetically, as Avell as by their close relationship and arterial and nervous supply. In other words, that the presence of the diseased organ will frequently prove a cause of disease in the other. Hence the importance of removing the affected testicle Avhen it is a source of irritation, and if the disease in it can not be controlled. CYSTIC DISEASE OF THE TESTICLE. 546. Cysts may form in the testicle, and eventually destroy its structure. They may be large or small, from the size of a pin's head to a pigeon's-egg, and number from one or two, to many hundred. Cystic disease usually occurs in early life, from the age of sixteen to thirty. 547. As a rule, the patient suffers little pain or uneasiness. except possibly a sense of fullness and Aveight as the organ The Reproductive Organs. 208 enlarges, until sometimes attaining a very large size, it be- comes very inconvenient from its bulk. 548. The only remedy is excision, Avhich should be per- formed sufficiently early to save the other organ, Avhen but one has suffered from the disease at first. CANCER OF THE TESTICLE. 549. The testes suffer from malignant degeneration, though not so frequently as might be expected from their structure and exposed situation. Encephaloid is the most common form of the disease, and it usually occurs in young persons, and runs its course rapidly. Scirrhus is less common and occurs in advanced life, running its course sloAvly. 550. If Ave find that the testicle has enlarged rapidly, with little suffering at first, but afterwards Avith deep tensive pain, in addition to sharp pains radiating from a centre, and passing up the spermatic cords, to the groins, back and thighs, Ave Avill suspect encephaloid. The diagnosis will he confirmed by finding an irregular and nodulated growth, of unequal elas- ticity, enlargement of the blood-vessels in the vicinity, and eventually attachment to and discoloration of the skin. The evidence of a cancerous cachexia is soon shown in the gen- eral appearance. 551. Scirrhus progresses very slowly. The testicle is en- larged, hard, nodulated, and is the seat of a severe, tense, burning pain, Avith the occasional radiating, lancinating pain spoken of above. The patient bears in his general appearance the evidence of severe suffering, and impairment of nutrition. 552. In both cases the attachment of the skin is the pre- cursor of ulceration, and the symptom of open cancer. En- cephaloid hoav runs its course quickly, the patient being ex- hausted by severe hemorrhages. Scirrhus runs its course still slowly, and may involve much of the perineal tissue before death results. 553. Treatment.—The treatment of cancer is not yet very successful, and though the testes seem favorably located for 204 The Reproductive Organs. removal, operative means have not been folloAved by the good results expected. One reason for this is found in the tenacity with Avhich a man clings to his testicles. He can not bear the thought of losing them, and postpones the time until attach- ment is formed to the skin, or the lymphatic glands have become diseased. There is but one chance of success here, and that is in early excision. If the diseased structure is ex- tirpated before the lymphatics suffer, and the patient is then put upon a treatment Avhich will improve waste and nutri- tion, he may be cured, or it will be many years before the disease returns. VARICOCELE. 554. Varix of the spermatic veins is a disease frequently met with. In many cases it is slight and increases slowly, or not at all, giving rise to but very little disturbance. In others the vessels become much enlarged from causes which disturb the organs, and then shrink aAvay when they are at rest. And in still others, the enlargement of the veins con- tinually increases, until from their size they become a source of constant annoyance. 555. Any cause that unduly excites, or debilitates the sexual apparatus may be a cause of varicocele. Thus it is in- duced by onanism, by sexual excess, or by injury of the organs by much horseback riding. But it only occurs in those Avho have an enfeebled venous system, and a tendency to varicose veins, and is thus frequently associated with varix of the legs, or hemorrhoids, or as it occurs in early life, it maybe the precursor of these. 556. It is usually slow in its progress, and at first gives rise to but little disturbance, except a feeling of weight and dragging in the groin. As the veins enlarge, however, the patient suffers aching and dragging pains in the parts, much The Reproductive Organs. 205 increased by being upon the feet, by Avalking, or riding. In some rare cases it causes venereal excitement, but in the ma- jority it lessens it, and may finally prove a cause of impotence. 557. An examination shows a marked enlargement of the spermatic cord, forming an elongated conical tumor, the en- larged veins giving a sensation very much like a bundle of earth Avorms. 558. Treatment.—In the early stage of the disease, the patient may be very much relieved, sometimes cured, Avithout an operation. We order a Avell fitted suspensory bandage for the day time, a linen band to retain a compress at night. The scrotum is Avetted with Pond's Hamamelis, morning and night, and for a time a compress wetted Avith the same, may be used at night. If there are acute attacks, Avith determina- tion of blood, and venous enlargement from this, I should prescribe: R Tincture of Collinsonia, oss.; Water, *iv.; a teaspoonful every tAvo or three hours. But if it Avas purely from venous atony, the prescription would be Pond's Hama- melis, gtts. x. to gtts. xx.; three times a day. 559. Prof. HoAve has permitted me to extract from his surgical papers what he says in reference to operative means for the radical cure of varicocele : " Surgical treatises usually contain descriptions of several operative methods for the radical cure of varicocele, yet none of them are devoid of danger from erysipelas, phlebitis, teta- nus, or pyaemia—accidents Avhich generally arise from the puncture-nature of the Avounds inflicted, and from the subcu- taneous strangulation of the veins. A ligature—even if it be made of virgin silver—tAvisted tightly around A7essels beneath the skin, will produce irritation enough to call out fluids AAdiich have no means of escape except through the opening in the integument occupied by the ligature. Therefore, it is my opinion that a subcutaneous strangulation of the enlarged veins is more hazardous than ligation applied through a free incision in the integument. But fatal consequences haATe fob 206 The Reproductive Organs. loAved all kinds of straugulation of the spermatic veins, though the degree of danger is diminished by an open inci- sion at the point of constriction. " To shun the risk incurred by all of the Avell-knoAvn ope- rative procedures, I have excised a segment of the A-aricose veins, and used no ligatures or sutures. I make an incision an inch in length along the course of the cord about half way between the external abdominal ring and the bulge in the scrotum produced by the testicle. The hair is snipped off before the incision is made. A fold of the loose integument is raised by the thumb and finger along the course of the spermatic cord, and the crest of the fold is incised, including 7 O skin, dartos and Avhatever fascia is grasped. The Avound is then spread with the fingers, and the true spermatic fascia seized and incised. The dilated veins may now be separated from the vas deferens, nerves, arteries, and other structures of the cord. After the varicose plexus has been Avell isolated and brought out of the incision, scissors are used to excise a segment of the veins, by dividing the vessels in two places, each a half inch from the other. The operation is not attended Avith excruciating pain, and the hemorrhage is never profuse. In fact, the size of the dilated veins has little influ- ence over the amount of blood passing through them. Be- sides, vessels cut Avith scissors do not bleed so persistently as Avhen divided Avith a knife. " If the divided veins do exhibit a disposition to bleed, the bleeding ends may be compressed Avith the thumb and finger for a feAv minutes, or until the hemorrhage ceases. I can assure the most timid that there is no danger of exhausting hemorrhage. " After the operation is performed, and the hemorrhage, if there be any, has ceased, the edges of the Avound are to be laid together, and a Avet compress applied. If Chloroform has been used, as it may be Avith irritable and apprehensive patients, the reaction from its effects may start afresh a hemor- rhage Avhich has been checked, therefore the surgeon is not The Reproductive Organs. 207 to leave his patient too soon, lest he be re-called to arrest what the patient and attendants may consider a dangerous bleeding. " The patient should keep the recumbent posture for three or four days, Avhen, if everything be favorable, he may be dressed and take moderate exercise. Of course, the scrotum should be supported by some kind of a suspensory apparatus, Avhen the patient assumes the upright attitude. The Avound Avill suppurate moderately, and heal by granulation. So sutures being used, the traumatic condition is rather simple ; and the wound being open there is little danger of pus bur- rowing in the scrotum. After the healing process is com- plete, a suspensory netting should be worn to afford comfort, and to prevent, as far as may be, the dilatation of other veins. It is not to be supposed that all the veins in the spermatic cord become varicose, therefore Avhen one set is obliterated or occluded, enough are left to convey the blood, and even to reproduce the original difficulty. Occasionally a patient radi- cally cured, may, some years after, need a second operation. " I have operated four times in the manner described, each case proving a satisfactory success, and no untoward circum- stance interfered with the healing process. In the rare cases of varicocele needing an operation, I feel like commending the plan described. The operation is easily performed, and there is no danger of seriously disturbing vessels or struc- tures proximate to the varicose veins. The excision oblite- rates the dilated vessels as circulating media, and does not in- terfere with the functions of the testicle or spermatic cord. The wound is too unimportant to admit of dangerous compli- cations ; and is attended Avith less pain and shock, than other operative procedures designed to accomplish the same result. An anodyne maybe needed the first night to ensure rest, but, after a day or two, the patient considers the operation an in- significant affair." 208 The Reproductive Organs. HYDROCELE. 560. The tunica vaginalis is arranged like all serous mem- branes lining cavities, having a visceral layer investing the testes, and a reflected layer lining the scrotum, and secretes sufficient moisture for the lubrication of these surfaces. Like other serous membranes, it may be so changed by disease that it Avill secrete considerable quantities of fluid, and dropsy re- sults. The more common causes are such as cause irritation and subsequent enfeeblement of the serous membranes. The fluid is generally of a specific gravity of 1010 to 1020, but sometimes becomes quite thick and contains considerable floc- culent material, or may even be purulent. 561. The SAvelling commences in the loAver portion of the scrotum, and as the fluid increases gradually extends up to the abdominal ring, pressure does not produce pain, except it is brought to bear upon the testicle, and then there is pain with a sense of faintness. The tumor is pyinform in shape, and gives the sensation of a bladder filled with Avater, Avith some- times distinct, sometimes obscure fluctuation. If there is doubt in the diagnosis, the room may be darkened, and a light placed behind the scrotum Avill shoAV a degree of translucence and determine its character. 562. Treatment.—In the early stage of the disease Ave may sometimes effect a radical cure without an operation, but Avhen of considerable duration Ave would not attempt it. Keep the patient's bowels moderately open with a saline cathartic and Sulphur, and apply a compress, wetted with a solution of Hydrochlorate of Ammonia, or Pond's Extract of Hamamelis. A fine elastic suspensory bandage is necessary to success. In some cases, firm strapping to the abdomen with adhesive strips, as recommended in orchitis, is an excel- lent means, and Avill sometimes effect a cure alone. 563. The operation is a very simple one. The scrotum is punctured Avith a trocar, and the perforator being withdrawn, The Reproductive Organs. 209 the canula is pushed into the sac and all the fluid drawn off. It is necessary to be careful about this, and the position of the canula Avill sometimes need changing, and the scrotum pressed in order to remove the last portion of fluid. Noav a stimulating injection is thrown into the sac through the canula, in order to set up adhesive inflammation. The injec- tion commonly used is Tincture of Iodine, one part to two, three, or four of Alcohol, bringing it in contact Avith the en- tire surface by movements of the scrotum, and pressing out all the free fluid. The canula is now withdrawn, and the scrotum supported by a well adjusted bandage. In old cases, or where the operation has been previously unsuccessful, the scrotum should be firmly strapped to the abdominal Avail, as in cases of orchitis. 564. If acute inflammation folloAvs the operation, Ave would apply a lotion of Aconite, Aconite and Camphor, or Veratrum. Keep the patient quiet in bed, and give the sedatives inter- nally. 565. In the hydrocele of children, a cure can almost ahvays be effected Avithout an operation. The local application of the Hamamelis or a solution of Hydrochlorate of Ammonia, proper support, and the internal administration of small doses of Apocynum Canabinum, soon removes the effusion. HEMATOCELE. 566. Hematocele, or an effusion of blood into the tunica vaginalis, is usually the result of an injury, though some- times the patient may not be able to account for it. It usually comes up quickly, though the distension may be to the full capacity of the scrotum. 567. Not only does the swelling come up quickly, but then it has more solidity, no fluctuation, or very obscure, is dark 14 210 The Reproductive Organs. in color, and not translucent. The history of the case, and the fact of an injury, aid the diagnosis. 568. Treatment.—The object of treatment is to prevent inflammation, and promote absorption. Following an injury the part should be dressed Avith a lotion of: Py Tincture of Aconite, §ss. ; Tincture of Camphor, 3j.; Water, Oj.; until all excitement had passed aAvay. Then Avith a compress Avet- ted Avith Pond's Hamamelis. The patient might have small doses of the sedatives, followed by an alkaline diuretic. 569. If inflammation should ensue, and we fail to control it by these means, and suppuration is likely to occur, an inci- sion is made, the blood turned out, and the part healed by granulation. TUMOR OF THE SCROTUM. 570. Occasionally fibroid tumors are developed within the tunica vaginalis, and may attain considerable size. They are annoying from their weight, and especially Avhen they press upon the testicle, sometimes give rise to severe suffering. Usually the diagnosis is easy. The fingers can trace the sper- matic cord and testicle, and separate them from the enlarge- ment ; the tumor maybe above or beloAv the testicle,growing from the scrotum, or may be attached to and grow from the testes, though this is rare. 571. If the groAvth is annoying, the operation for its re- moval is quite simple. Make an incision into the tunica vaginalis of sufficient size to remove the growth. Separate it Avith the finger nail from its attachment, and close the part with silver ligatures. Keep the patient quiet for a few days, using the sedative lotion named above. 572. Occasionally Ave meet Avith sebaceous tumors of the scrotum, evideutly arising from disease of one or more of the The Reproductive Organs. 211 sebaceous glands. Sometimes it attains considerable size, is painful, and has been mistaken for malignant disease. 573. Most usually, when it possesses the character of a groAvth, it can be readily turned out with the finger after a first incision is made with the knife. But Avhen it is asso- ciated Avith hypertrophy of the skin, it is the safest method to apply the Chloride of Zinc paste, establish free suppuration until the groAvth is removed, and then dress Avith some simple ointment. EPITHELIOMA OF SCROTUM. 574. In the olden time, chimney-sAveepers or "soot- cancers " of the scrotum, Avere among the most common of the epithelioma. There was probably nothing in the soot, further than as it and the occupation caused irritation of the scrotum, and consequent depraved nutrition. But outside of this cause I am inclined to believe that the scrotum is a favorite seat of epithelial cancer, and it will probably be met with here more frequently than in any other situation, the fntce excepted. 575. Paget thus describes the groAvth : " Among the ex- amples of the superficial epithelial cancer, the greater part derive a peculiar character from the share which the papillae of the skin or mucous membrane take in the disease. These being enlarged, and variously deformed and clustered, give a condylomatous appearance to the morbid structures, which has led to their being called papillary or Avarty cancers, and Avhich renders it sometimes difficult to distinguish them from common warty growths. According to the changes in the papillae, numerous varieties of external appearance may be presented; I shall here describe only the chief of them. " In the most ordinary examples of epithelial cancer of the loAver lip, or of a labium, or of the scrotum in the soot- 212 The Reproductive Organs. cancers, if they be examined previous to ulceration, one cai: feel an outspread SAvelling, and an unnatural firmness or hard- ness of the affected skin. The width and length of the swell- ing are much greater than its thickness. The diseased part is enlarged; the lip, for example, pouts, and projects like one overgroAvn; and the SAvelling is slightly elevated, rising gradu- ally or abruptly from its borders, and having a round or oval or sinuous outline. Its surface, previous to ulceration, may be nearly smooth, but more often is coarsely granulated, or tuberculated, or loAvly warty, like the surface of a syphilitic condyloma, deriving this character usually from the enlarged and closely clustered papillae. The surface is generally moist Avith ichorous discharge, or covered Avith a scab, or Avith it soft material formed of detached epidermal scales. The firm- ness or hardness of the diseased part is various in degree in different instances : it is very seldom extreme ; the part, how- ever firm, is usually flexible and pliant, and feels moderately tense and resilient on pressure. Commonly, it is morbidly sensitive, and the seat of increased afflux of blood. Its ex- tent is, of course, various; but, before ulceration, the disease makes more progress in length and breadth than in depth; so that when, for example, it occupies the Avhole border of a lip or of a labium, it may not exceed the third of an inch in thickness. "In the form of epithelial cancer just described there may be no considerable enlargement of papillae, or it may only appear when the groAvth is* cut through. But, in many in- stances (especially, I think, in the epithelial cancers of the prepuce, glands, and integuments of the extremities), the changes of the papillae are much more evident. In some, as in the adjacent sketch, one sees a great extent of surface covered with croAvds and clusters of enlarged papillae set on a level or slightly elevated portion of the cutis. Singly (Avhen the ichor and loose scales that fill their intervals are washed aAvay), they appear cylindriform, flask-shaped, pyriform, or conical; clustered, they make nodulated and narrow-stemmed The Reproductive Organs. 213 masses. They may be in one or in many groups ; or groups of them may be scattered around some large central ulcer, They appear very vascular, and their surface, thinly covered Avith opaque-Avhite cuticle, has a pink, or vermilion, or brightly florid hue. " In other instances, or in other parts, a large mass is formed, the surface of Avhich, when exposed by Avashing aAvay the loose epidermoid cells AA-hich fill up its inequalities, is largely granulated or tuberculated, and is planned out into lobes by deeper clefts. Such groAvths are upraised, caulifloAver-like; and, with this likeness, may be broken through the clefts, into narrow-stemmed masses, formed each of one or more close-packed groups of enlarged, tuberous, and clavate papil- lae. The surface of such a groAvth shoAvs, usually, its full vas- cularity ; for if it be Avashed, it appears bare, and, like the surface of common granulations, has no covering layer of cuticle. It may be florid, bleeding on slight contact, but, more often, it presents a dull or rusty vermilion tint, rather than the brighter crimson or pink of common granulations, or of such Avarts as one commonly sees on the prepuce or glans penis. " Occasionally, Ave meet with an epithelial cancer having the shape of a sharply bordered circular or oval disk, upraised from one to three lines above the level of the adjacent skin or mucous membrane, and imbedded in about the same depth beloAv it. The surfaces of such disk-shaped cancers are usually flat, or slightly concave, granulated, spongy, or irreg- ularly cleft; their margins are bordered by the healthy in- teguments, raised and often slightly everted by their groAvth. Such shapes are not unfrequent among the epithelial cancers of the tongue, of the lining of the prepuce, and of the scro- tum. I removed such a one also from the perineum, aud have seen one in the vagina." 576. It may maintain these appearances for months, before involving deep seated tissues, and during this time the patient suffers only from a superficial burning pain, Avhich only be- 214 The Reproductive Organs. comes very troublesome when the part is irritated. But after a time the skin and cellular tissue are markedly thickened, and nodules of cacoplastic material are deposited. The ulceration becomes deeper by the softening and breaking down of this, and finally we have complete destruction of the skin and an extension of the disease to the testes, perineum, or penis, and the patient presents very much the symptoms of open scirrhus. 577. Treatment.—Whilst we do not profess to cure cancer in general, at least after the lymphatic glands are involved, this variety is usually amenable to treatment. In some casea, the epithelial disease is scarcely malignant, and though the ulceration is corroding, and destroys tissue after tissue, it doos not cause constitutional infection. 578. In these less severe cases, the progress of the disease may be sometimes arrested by the use of Carbolic Acid din- solved in Glycerine, (5j. to 5iv.); or by a dressing of Tilden's " Bromo-Chloralum," or by the use of a strong Tincture of Iodine. 579. But in the majority I would prefer to use the Arseni- cal paste, prepared as follows : Take of the Hydrated Sesqui- oxide of Iron a sufficient quantity, throw it on a filter to drain off the Avater, until it has the consistence of a paste ; add to this one part of Lard to three or four parts of Iron, thor- oughly mix. In this we have the basis of the ointment, and to it Ave add Arsenious Acid in the proportion of 5j- to .">iv. to oiv.; usually the weaker preparation ghres the best results, though it requires more time. It is spread on soft cotton cloth, and applied once or tAvice daily, until the malignant character of the disease is removed, and the tissues seem soft and healthy, when we use the simple Iron dressing until the parts are healed. 580. In some cases the Chloride of Zinc will be the prefer- able remedy, as in other forms of cancer. If deemed best. it will be used in the usual manner. The Reproductive Organs. 215 PEDICULUS PUBIS. 581. The capilli or hair covering the external organs, oc- casionally suffers from disease, but it is rarely of much moment, It is, hoAvever, the habitat of a parasite, the pediculus pubis, Avhich is occasionally a source of great annoyance, and sometimes of quite severe disease 582. A patient complains of persistent pruritus of the parts covered by hair, that is not relieved by scratching. It has been a source of uneasiness for some time, but they have not yet determined the cause ; in such cases an inspection will frequently detect the louse. Remaining for some time, they spread to other parts of the body where there are short hairs : about the anus, the hair of breast, abdomen and axillae, the hair of the neck, the eyebroAVS, etc. In some cases they give rise to severe irritation of the skin,-which, increased by scratching, causes ulceration. In the female they sometimes cause seA^ere leucorrhcea. 583. This louse Avill be recognized by its broAvnish color, and its close adherence to the skin and the hairs with its fore legs. " It has a shield shape and a much broader body in proportion to its size than either of the other forms of lice; and there does not appear to be any distinct separation be- tween its thorax and abdomen. It does not run about like other lice, but grasps the stems of the hairs Avith its fore legs, and adheres so firmly that it is difficult to remove it Avithout pulling out the hair. The nits or egg-capsules are attached to the hairs in the same Avay as on the head. Pruriginous or eczematous eruptions, Avhich may become pustular, are the results of their existence," (Anderson.) 584. They are propagated by contact, like other lice, and though frequently in veneris, yet quite as commonly from male to male by sleeping in the same heel. A husband may catch them innocently by occupying a strange bed, and transmit them to the Avife, and both may suffer long and severely 216 The Reproductive Organs. before they know what is the matter, and if the wife choose to be jealous, she may have grave suspicions of her husband on finding out the character of the disease, but which will be dissipated by the explanation of the physician. 585. Treatment.—It has been proposed to destroy these parasites with Sulphur, infusion of Tobacco, Staphysagria, and Mercury. As a general rule the Sulphur Ointment will be found insufficient as well as filthy. A solution of Potassae Sulphuretum has been recommended, but it is not very certain. The strong decoction of Tobacco is both unpleasant and un- certain. Staphysagria is more likely to irritate the skin than kill the lice, aud to the common Mercurial Ointment Ave have the objection that it is sometimes absorbed and causes saliva- tion. When Mercurial Ointments are used, it is generally the " red or white precipitate." 586. I prefer Prof. King's treatment—a thorough applica- tion of a good Cologne; two or three applications are usually sufficient to destroy the pests. Should it fail, and Mercury become a necessity, the solution of the Bichloride, three or four grains to the ounce of water and Alcohol, will be found decidedly the best. The application should be especially to the hair, and very thorough, once or twice a day for a week, reaching every part affected. Venereal Diseases. 217 VENEREAL DISEASES. 587. As a result of venereal excesses men suffer from cer- tain infectious diseases of the reproductive organs. They are propagated by contact of the virus with a mucous or some- times cutaneous surface, and so far as Ave know, at the present time, are never produced de nova. As Ave have already seen in the brief discussion of prostitution, the origin of these dis- eases dates back to very early periods in man's history, as Ave have evidence of it iu the earliest preserved writings. Hoav the diseases Avere originated we know not, but have reason to believe that they Avere the result of intense animalism in the early periods of the race. 588. We have already noticed the fact that there are epi- demic cycles, in Avhich contagious diseases are greatly inten- sified, as there are periods when the contagious virus loses a portion of its virulence. This Ave find to be the case in all diseases produced by a specific contagion, as has been noticed and described in such common affections as variola, rubeola, and scarlatina. We do not knoAV what peculiar conditions intensify these diseases at regular intervals of some years, but the fact is well established. 589. This is also true of the venereal virus, aud one need but to read its history to be satisfied of this. It will account for the sudden outbreak and spread of the venereal at certain periods, as at the siege of ISTaples, as it will also account to some extent for the discrepancies between authors. 590. This variation of the disease in epidemic cycles is not only in its intensity, but also to some extent in its character, and Avill account for the differences in treatment. I am quite ? 218 Venereal Diseases. sure that these, like other affections, do not present such uni- form lesions, that a stereotyped treatment can be successfully employed in all cases. Even the diseases of a single year will sIioav a diversity of pathological peculiarities, and demand skilled diagnosis and therapeutics. 591. It is hardly Avorth while at this day to discuss the unity, duality, or triality of the venereal poison, and adduce the arguments pro and con, for the best observers have determined that there are three distinct venereal diseases—gonorrhoea, chancroid, and syphilis. This vieAv agrees with all Ave have seen of the disease, and is the only one that will explain itr phenomena, and offers a classification that will be intelligible to the student. 592. Each of these has its peculiar virus, is propagated d;y direct contact, and produces its oAvn specific poison. Thij gonorrhceal virus always produces gonorrhoea, and never chancre or chancroid ; chancroid produces chancroid and never gonorrhoea or true chancre ; and true chancre repro- duces itself, and never either of the other diseases. 593. It is true, as already noticed, that a person, the woman especially, may have tAvo, or e\7en three of these dis- eases, at the one time, and that free connection may inocu- late one Avith chancre, another Avith chancroid, and a third Avith syphilis. These cases are rare, but they have been relied upon to prove the unity of the ATenereal poison. As a general rule the three diseases are distinct, and their history very clear. 594. We Avill find that whilst this is a true classification, there are cases in which our diagnosis may be at fault. We can not ahvays tell from the appearance of the local disease Avhether Ave have chancre or chancroid, and Ave are obliged to make the diagnosis by the appearance, or non-appearance of constitutional symptoms. Just as in some cases Ave can not distinguish betAveen a specific urethritis—gonorrhoea, and a simple inflammation of the urethra. So there are cases of concealed chancre—of the urethra for instance, Avhich, causing Venereal Diseases. 219 a free muco-puruleut secretion, simulates gonorrhoea. Or a concealed true chancre, Avith outer chancroid, and secondary symptoms result, though the physician has only the evidence of the disease Avhich produces no constitutional infection. 595. Here as elseAvhere Ave must learn not to give credence to exceptional phenomena, at least not to form theories from isolated cases. The habit of superficial observation is so in- grained in the majority of physicians, that the wonder is not that they make mistakes in diagnosis, but that they are not more frequent. Theories are very frequently formed from the superficial observation of a feAv cases, possibly from a single one, and then all facts are bent to its support. 596. These three specific contagions are very much alike in their origin and propagation. They are each produced in the course of the disease in the form of a specific pus, that does not materially differ from ordinary pus formation, Avhether Ave examine it chemically or under the microscope. They are each propagated by contact—the specific virus, Avhatever it may be, possessing the poAver to change the life of the tissues, and produce the characteristic local disease. If Ave Avanted a theory to account for this, Ave could probably find it in Beale's bioplasm, the secretion of thediseased surface or ulcer containing a peculiarly diseased material of this char- acter, possessing the poAver of reproducing itself in a pro- toplasm. 597. In diseases produced by contact Avith a contagious material, the only absolute safety is in avoidance of the danger; in the case of the venereal it is, " touch not." These contagions ma}' be and are found outside of prostitution, but outside of prostitution there is very little danger. It is illicit intercourse Avith unknoAvn persons that usually transmits the disease, for even the confirmed prostitute will be careful not to endanger her personal friends, if she is aAvare of the dis- ease, lam sorry to say that the male prostitute has not so much honor, and will sometimes out of pure maliciousness disease those Avith Avhom he has been friendly. The Avoman, 220 Venereal Diseases. as a rule, degraded though she may be by these associations, is far more honorable than the man. 598. When one risks infection by intercourse \vith persons knoAvn to live such lives that they may contract these dis- eases, they take a Avell knoAvn risk, for Avhich there is no pro- tection except cleanliness. Some men might and do have intercourse Avith diseased Avomen and not be infected. It may depend upon a Avell developed epithelial tissue, the immunity being natural, or upon thorough washing Avith soap and Avater immediately after the act. The public woman ahvays pro- tects herself by free ablution, especially of the external geni- tals, Avhich are more likely to suffer than the internal organs. 599. In this description of the venereal virus, Ave have only studied the propagation of the primary or local disease. True syphilis, as Ave Avill see hereafter, may be produced in other Avays. Very certainly certain forms of secondary syphilis may be inoculated. The lesion is hereditary to a cer- tain extent, and both mother and child may be diseased from the male germ, the one from its inception, the other through the placental circulation. 600. It might be asked hoAv one suffering from these local diseases could be induced to have sexual intercourse ? Look- ing at the fully developed disease, we Avould think a man or woman suffering from gonorrhoea, chancroid or chancre, Avould find it a source of discomfort and pain rather than pleasure. So they may from the fully developed disease as frequently seen, but we find it in an obscure form in a large number of cases, and its only influence may be to increase sexual excitement. One thing is very certain, that the infec- tious material is produced in all these before there is much local disturbance, and .a slight secretion may retain its infec- tious character when the patient seems to have recovered. A man will frequently disease his Avife with gonorrhoea before he has felt the first symptom of urethral irritation, or feel it first or immediately after such intercourse. He may transmit a soft chancre from a sore not noticed, or that seems little Venereal Diseases. 221 more than an erosion ; and true syphilis from the secretion of the diseased membrane before the chancre has formed. In Avoman, these unconscious sources of disease are far more common, for it may lurk in her genitalia, Avithout producing sensible irritation, the secretion being but little if any changed. She may convey the contagion in this Avay for months, Avithout being aAvare that there is anything Avrong. 601. As a rule, Avhen a person has venereal disease, Ave may conclude that they have contracted it in the natural Avay. Modest persons are frequently very much surprised when they learn the character of the disease, and feel inclined to blame Avater-closets or prh7y-seats. It is all Avell enough, and makes no difference in the therapeutics, and we have charity in such cases. GONORRHOEA. 602, As Ave have already seen, gonorrhoea is a specific in- flammation of mucous membranes, produced by contact Avith gonorrhceal virus. Whilst confined to the urethra in the male, and the external and internal organs of generation in the female, in the majority of instances, it may affect any mucous surface in the body. Whilst the disease is caused by contact Avith gonorrhceal virus, in its progress it reproduces the same, which may serve as a center for further infection. 603. As regards the gonorrhceal virus itself Ave know but little, further than it is a muco-pus, produced during the gonorrhceal inflammation. In its physical properties, it does not differ materially from the products of simple inflamma- tion, further than it is usually in large quantity. 604. As the disease is dependent upon a specific virus, contact with this is essential to its production. This usually occurs during sexual congress with a person diseased; and Ave may take it for granted, in a large majority of cases, that the 2i!2 Venereal Diseases. disease is thus contracted. Of course there are exceptions : in one out of a thousand cases a man may contract a gonor- rhoea from sitting on a privy-seat used by a person having the disease, sleeping in a bed occupied by such person, or occa- sionally by using clothing, cloths, toAvels, etc., contaminated by the virus. The eyes are diseased by carrying the virus to them with the hands or cloths. The nose in the same man- ner, the rectum by want of cleanliness, and the bladder by a gradual extension of the inflammation from the urethra. 605. A period of incubation, of longer or shorter duration, ensues after exposure. The closest observers claim that this is from thirty-four hours to three days; but we find many patients who contend that a Aveek, ten clays, or even two or three Aveeks have elapsed before they experienced any symp- toms. While I am of the opinion that the disease manifests itself before the fourth day, in a majority of cases, I must still believe there are cases in Avhich the virus remains dor- mant for a considerable time. 606. Sexual intercourse with one suffering from gonorrhoea is said to produce peculiar sensations, by Avhich danger may be suspected. Among these is a sense of pungent heat and burning, sometimes associated with an intense erotic excite- ment. These sensations are someAvhat persistent, and the organs may not lose them until the disease is fully announced. 607. In the male, the first symptoms of gonorrhoea are—a feeling of pricking and itching in the urethra and at the meatus, which soon becomes so intense as to be very un- pleasant ; the patient, also, feels a sensation of fullness, and as if there was something foreign there, and a desire to uri- nate and evacuate it. By the end of the second day these symptoms have become real pain, the urethra is dry, with frequent desire to urinate, and a scalding sensation when the urine passes the urethra. The discharge noAv commences having a miiky-Avhite appearance. 608. By the fourth or fifth day the disease is fully devel- oped. The desire to urinate is very frequent, Avith sharp, Venereal Diseases. 223 pricking pains previous to the passage of Avater, and scalding Avhile it is passing. The pain is usually more severe after the bladder is emptied, and toAvard the last the urine passes in drops Avith much tenesmus. There is a constant sensation of fullness, tension, and soreness, Avhich is very unpleasant. The discharge has uoav become free, and is a yellowish, someAvhat creamy muco-pus, its fluidity varying in different cases; sometimes it possesses a peculiar unpleasant odor. 609. If the penis is uoav examined the meatus will be found red, slightly everted or pouting, and on separating it the mucous membrane Avill be observed red and SAvollen. The part of the urethra diseased is SAvollen and hard, and pressure produces pain. In a majority of cases the disease is located, at first, about an inch and a half from the meatus, Avhere there are numerous large lacunae, but as time passes it gradu- ally extends to other portions. 610. Painful erection, or chordee, makes its appearance uoav in many cases. These erections occur when the patient gets Avarm in bed—sometimes several times in a night—and prove a source of very great annoyance. In consequence of the inflammation, complete distension of the corpus spongio- sum is impossible, or the urethra fails to attain the length necessary in erection, hence the dowmvard curvature of the penis, the pain being consequent upon traction upon the in- flamed structure. 611. When the case is left to itself the discharge usually increases for a Aveek or ten days, remains stationary for the same length of time, and then decreases until nothing re- mains but a slight gleet. During the first period the suffering is greatest, but the pain and scalding in passing Avater, grad- ually diminish during the second, and at last become so miti- gated as to give but little trouble. 612. In some cases the prepuce becomes much SAvollen from serous exudation, and phymosis is the result. These are usually troublesome cases, and sometimes complicated Avith balanitis, or posthitis. 224 Venereal Diseases. 613. Though from the symptoms enumerated we might suppose there Avould be little difficulty in diagnosis, and in a majority of cases a simple inspection of the penis tells the story, there are cases Avhich require a very careful examina- tion, and even then we are sometimes left in the dark. I have already described simple urethritis, having no relation to the gonorrhceal virus, as a disease so similar that the best observers might be mistaken. Numerous cases are on record in Avhich the husband Avas informed by the surgeon that he had gonorrhoea, and he Avell knoAving that he could have con- tracted it from but one source accused his Avife of unchastity. But an examination of the Avife revealed no disease. These facts should cause us to be very careful in giving an opinion, when there is any doubt. 614. Chancre of the urethra sometimes simulates a gonorrhoea in all its symptoms, though there is not usually near so great a discharge. I have, myself, been deceived in this case, though I use much care in examination. One case came to my notice in AA-liich the patient Avas said to have an intractable gonorrhoea, ha\ring lasted for months ; careful ex- amination detected an indurated chancre about half an inch Avithin the meatus. 615. Treatment.—Persons suffering from gonorrhoea are extremely anxious for a speedy cure, and Avith very good reason, for the disease is not only painful but extremely filthy, and thus annoying to a person accustomed to cleanliness. In many cases the mental suftering is more intense than the bodily, and the chagrin and loss of self-respect is sometimes sufficient to impair the general health. Some persons, of course, get used to it, and some are so constituted as to bear it stoically as a boy Avould a Avhipping, but in all the first question is, as to a speedy cure. 616. Speedy cures do not come from internal remedies, and in the abortive plan that Ave are about to study the treat- ment is often wholly local. It is a mooted question Avhether Venereal Diseases. 225 the risk in the abortive treatment does not more than balance the prospect of speedy cure, and this will require considera- tion in each individual case, and the answer will depend someAvhat upon the peculiarities of the patient, and the char- acter of the disease. 617. It is Avell to understand that the disease is self-lim- ited, and Avill run its course in a majority of cases in from three to six Aveeks. Still there are some in Avhich the gonor- rhceal virus is reproduced for a long period, though the local symptoms are but slight. This is the case even Avhere the disease is treated with the ordinary remedies.* *"For the satisfaction of the reader, I append my treatment, as found in Hill's Surgery: "The treatment of gonorrhoea is almost entirely empirical, and hence we have an abundance of means recommended, and such marked drft'erence in its management by different practitioners. It might properly be divided into two parts, the abortive and symptomatic; in the first remedies be- ing used for the immediate arrest of the disease, and in the second the symp- toms met as they arise. " In the first stage of gonorrhoea, the disease being still confined to the fossa navieularis, the inflammation not being too acute, the abortive plan may be employed with success. This consists in substituting a common inflammation for the specific one, by the use of caustic injections. I might premise the de- scription of the means employed by saying that in order to prove successful, the injection should come in contact with the entire surface affected, for if but the smallest portion escapes, the gonorrhoea again extends. "The injections employed should be used by the physician in most cases, the syringe working accurately, a rubber one being the best. Have the patient place his finger upon the urethra above the disease, then insert the pipe of the syringe well up, pressing the glans with the fingers to prevent the escape of the fluid, and completely fill the urethra. The injection should be used soon after urinating, and retained for from two to five minutes. After using it, the penis may be held in a vessel of water as hot as can be borne, which relieves the pain to a very considerable extent. " Nitrate of Silver has been most extensively employed as an abortive, and when used with the precautions above named, rarely produces any unpleasant consequences. The strength of the solution used varies in different cases, from fifteen to forty grains of the crystallized nitrate to the ounce of water, being the usual quantity. I have employed it of a strength of from twenty to thirty s from the gleet, and probably may suffer for years. But the case Avas not Avell selected, the young man being spare, anae- mic, and of relaxed tissue; it Avould be better adapted to the full blooded, Avith sthenic inflammation. 638. Cold applications externally are a very common means, and Avill sometimes giATe marked relief. The Avater may be used in the form of a penis bath, or Avet dressings may be applied, especially at night. But as Ave have already seen, hot applications are to be preferred in other cases, and I have no doubt that "warm water injections will sometimes be found preferable to those which are medicated. 639. Glycerine, one part, Rose Water, three to five parts, sometimes forms a pleasant injection, and gives marked relief; 640. Sulphate of Zinc, grs. v.; Acetate of Lead, grs. v. ; Water, oiv. ; is a vovy common injection, and Avas a favorite of Pi cord. In some cases the strength may be decreased Avith advantage. 641. A solution of Tannin in Claret Wine makes a most excellent injection, and Avas a favorite remedy of Niemeyer. The solution may be of the strength of oss. to Syj., and should be repeated two or three times a day.* ■The best therapeutic results are to be obtained in a perfectly recent gonor- rhoea before the symptoms have become severe, as it then generally can be 232 Venereal Diseases. 642. My preference in ordinary cases, after the acute symptoms have been relieved is: B/ Sulphate of Hydrastia, grs. iv. ; Warm Water, Sj. Use it two or three times a day, and continue once a day for a Aveek after the discharge is checked. 643. Within the past four years it has been claimed, that the use of remedies in the form of a suppository, would give better results than their use as an injection. The great diffi- cured in a few days. In order that the number of tractable cases of this kind maybe increased—for it is only now and then that we see one—we should make all our patients aware that the disease is continually increasing in ex- tent and violence, so that each day of delay only makes it Avorse. Such opin- ions, delivered by physicians who have the confidence of that portion of the public among whom gonorrhoea is most common, have marked effect. It is scarcely credible how coolly and with what cynicism these people talk of their debaucheries and their consequences, what an extensive knowledge of the sub- ject is shown by some of the laity, and how much one can learn from them. For instance, in Magdeburg, where the innumerable commercial travelers of the various mercantile houses meet annually at the hotels, report is ahvays made as to whose pox has relapsed, and who remained cured, and what injec- tions have answered the best for gonorrhoea, etc. Only a short time after I had begun to prescribe injections of Tannin in recent claps, Avhere the symp- toms were still trifling (and I had been very successful with this treatment), the number of recent gonorrhoeas which sought my aid multiplied consider- ably. I usually ordered three powders, each of which contained half a drachm of Tannin. One of these was to be dissolved in a half pint of red wine, and the solution was to be used as an injection. If the result was unsatisfactory, the two other powders were to be put into the same quantity of wine, and the injection to be continued with this doubly-strong solution. It has repeatedly happened to me that a patient has pulled one of these very powders out of his pocket which I was about to prescribe for him, and which he had ob- tained from a friend, and has asked whether he might try that first. In order that these injections may be of service, we must give them once or twice ourselves, or let a skilled assistant give them. If we neglect this precaution, it often happens that the liquid does not enter the urethra at all, or perhaps is merely thrown under the prepuce, and flows back past the syringe. Gonor- rhoea syringes must be so small that they will not hold more liquid than the urethra is capable of containing. It is then unnecessary to compress the pos- terior end of the canal. The best plan is to have a supply of suitable syringes at some particular instrument maker's, and to give them some unobjectionable Venereal Diseases. 233 culty Avith an injection is to bring it in contact with the dis- eased surfaee, and to maintain the contact long enough to be of advantage. This is claimed to be accomplished by the in- troduction of a suppository, Avhich distending the parts brings the remedy in contact Avith the entire affected surface, and maintains it for a sufficient length of time. 644. " Dr. Schuster, of Aix-la-Chapelle, describes a method of treating gonorrhoea and gleet, to Avhich he Avas led by observing the results of a similar plan in uterine catarrh. Tannin, Avhen mixed Aviih Glycerine, forms a Avaxy mass, Avhich soon becomes smooth, hard, and broAvn, but readily dissolves under a gentle heat. He makes rods, three or four inches long, consisting of Tannic Acid, two parts, poAvdered Opium, 0.12 part, Avith a sufficiency of Glycerine. These are soft in Summer, but very brittle in the Winter. The rod, moistened Avith hot AArater, is introduced into the urethra, and a piece about an inch and a half long is left in : it melts down and forms a whitish mass Avith the mucus of the canal. The rod may, after remaining from five to ten minutes, either be removed by the finger, or be expelled by the stream of urine. The remedy is applied twice or thrice daily." 645. In this case, the remedy gives a consistent supposi- name, since many patients, feeling too much embarrassed to ask for a "penis syringe." £jet an "ear-syringe," or other unsuitable article instead. I have cut short a large number of recent virulent gonorrhoeas in two or three days ty injection of Tannin. Even where the disease is not quite recent, but where the inflammation is not very violent, I have often used the Tannin, and ob- tained excellent results, although the cure was less rapid. I have no idea of claiming especial qualities and merits for Tannin; but I have employed this article much more often than Nitrate of Silver, Sulphate of Zinc, Sugar of Lead, and other astringents. I have never had occasion to prescribe the strong solution of Nitrate of Silver (grs. ten to fifteen to one ounce), for its effects can hardly be better than those obtained from Tannin, and since even its introducers admit that it sometimes causes severe and even violent symp- toms, such as I have never seen in my treatment. "When the inflammation is very severe, it is well to wait for its abatement before resorting to injections. —Niemcyera Practice of Medicine. 234 Venereal Diseases. tory Avhich may readily be introduced. Other agents can not be used so easily, as the ordinary suppository has not suffi- cient consistence. Yet with a little care, I think it would be possible to use any agent heretofore uamed. A very good method is to make the suppository about one-half inch in length, aud cutting an ordinary gum catheter, press the suppository upon the open end, and carry it up to the affected part; slight pressure Avith the finger, as the instrument is withdrawn, retains the suppository. 646. Internal Remedies. — Whilst some rely exclusively upon a local treatment, or only prescribe internal medicines to amuse the patient, others rely wholly upon internal reme- dies for the cure of the disease. The first claim a shorter time for the cure, the latter a more uniform success, less trouble and danger of infecting other parts, and an entire avoidance of the unpleasant sequelae that sometimes Avill follow local means. Still a third class employ the tAvo together, adapting them to the particular case in hand. 647. Veratrum and Gelseminum are the remedies for the acute gonorrhceal inflammation. If the passage of urine is free Ave prescribe the first alone ; if there is scanty urine, aud difficult passage, the two together. We prescribe them in the usual way : B/ Tincture of Veratrum, gtts, x. ; Tincture of Gelseminum, 5j. ; Water, siv. ; a teaspoonful every hour. 648. When the disease is less acute, or its intensity has been modified as above, Cannabis Indica is an excellent remedy, as: B/ Tincture of Cannabis, gtts. x. to gtts. xx. ; Water, §iv.; a teaspoonful every two or three hours. 649. Macrotys is the remedy where there is soreness or stiffness of the muscles, or muscular pain. We usually pre- scribe it with Aconite, especially if the pulse is small: B Tincture of Macrotys, gtts. xxv. ; Tincture of Aconite, gtts. v. ; Water, 5'iv.; a teaspoonful every hour. 650. If the patient suffers unpleasant dragging pains in the perineum or urethra, I prescribe Staphysagria, 5ss.; Water, 5iv.; a teaspoonful every three or four hours. Venereal Diseases. 235 651. With general nervousness, and sense of formication along the urethra, Pulsatilla Avould be the remedy. 652. If the tongue shoAvs a violet coloration, and the lips of the meatus are full, and sIioav the same color Avhen opened, Nitric Acid, gtts. xx.; Water, Syrup, aa. rij. ; a teaspoonful every three hours. 653. Copaiba and Cubebs may be used Avhen there is a sense of fullness and aveight in the course of the urethra, Avith abundant yellowish muco-pus. I prefer Copaiba in cap- sules, and Cubebs in poAvder. I use Cubebs especially Avhen the disease is prolonged, Avith a free discharge, the stimula- tion aiding the local remedies in checking the discharge, and lessening the intumescence of the mucous follicles and lacunae. 654. We might supplement this by saying, that any remedy, markedly indicated by special symptoms, may be a remedy in gonorrhoea. In some cases Ave find need of, and marked benefit from a cathartic, a saline being preferable in some cases, the more active vegetable remedies in others. I have treated gonorrhoea Avith Podophyllin alone, Avith marked success, and yet I think if the patients had to choose they would prefer the gonorrhoea to the medicine. One case comes to mind, in my early practice, in which the near approach of the marriage day, made a speedy cure a matter of necessity— one grain of Podophyllin and tAvo of Extract of Hyosciamns iivery four hours, as long as the patient could stand the rem- edy, effected a cure in forty-eight hours. 655. The urine becomes scanty in all cases, and in propor- tion as it is scanty it is acrid and irritating to the inflamed mucous membrane. Hence the benefit that folloAvs the free use of diluents, Avhether of the simpler diuretics, or Avater. In some cases an abundant use of Avater Avith tAvo or three drachms of Acetate of Potash during the day, gives relief. 656. Frequent micturition is a source of great annoyance and suffering, and intensifies the disease. The patient should be requested to make Avater at as long intervals as possible, 236 Venereal Diseases. and In many cases Avill be able to control the desire. If not, and there is much tenesmus we Avill use an Opium suppository or injection into the rectum, or a hypodermic injection of Morphia. CHORDEE. 657. The irritation of gonorrhoea not unfrequently causes sexual excitation, and involuntary erection, especially at night. This in consequence of the inflammation of the urethra, is quite painful, as it is impossible for the corpus spongiosum to become fully distended, or to take the length of the corpus cavernosum. Many crude theories have been held with re- gard to this unpleasantness. It has been claimed to result from over-distension of the corpora-cavernosa, they not being antagonized by the spongy body ; or by an imperfect disten- sion of the spongy body, owing to the inflammation. The true cause, inflammatory exudation into the structures of the urethra, seems to have been overlooked. 658. As is the intensity of the inflammation so is the severity of the chordee, at least in the majority of cases. Yet AAre find many times that the inflammation, is very acute, and there is certainly much structural change in the urethra, and yet there is not chordee, for the simple reason there are no erections. In some persons the sexual function is very much excited, and erections will occur even in the day time. They will also come on frequently at night, Avakiug the patient out of a sound sleep, with a pain so intense as to cause him to spring up on the floor. In some cases the erection speedily passes off Avhen the patient is aroused, or by a cold applica- tion, but in others it persists for a considerable time. I have known cases of chordee so extreme that the patient Avould cry out in his agony, and the tension on the urethra Avould be so great as to cause hemorrhage. 659. Treatment.—In the olden time when Copaiba and Cubebs were prescribed for every case of gonorrhoea, chordee was a more constant attendant and required special means. Venereal Diseases. 237 With a carefully selected treatment, as heretofore named, es- pecially the internal remedies, it will give but little trouble. I should say, in any case, if there is severe and persistent chordee, the treatment is Avrong—get a right treatment, and you Avill have the speediest relief from this unpleasant symp- tom. Since I have been careful in selecting my internal rem- edies, I have had no trouble from chordee. 660. If it requires means additional to those named, I should advise an injection (per rectum) of Tincture of Lobelia, Tincture of Opium, aa. oss.; Starch Water, .vs.; at bedtime. If it Avas still more severe, a hypodermic injection of Morphia will give speedy, and sometimes permanent relief. If Ave select internal remedies they Avill be Pulsatilla, Macrotys, or Staphysagria, as specific to the condition ; or a pill of Opium and Camphor, aa. gr. j., as a palliative. PHYMOSIS 661. As already mentioned, the prepuce occasionally be- comes infiltrated with serum to such an extent as to produce phymosis. Usually I order a lotion of Acetate of Lead, the usual strength, keeping the parts Avell cleansed Avith soap and Avater. A strong decoction of Hydrastis, adding a small por- tion of Alum, does Avell. If it should be very perverse, it is recommended to make several incisions into the prepuce to permit the escape of the fluid. hemorrhage. 662. Hemorrhage from the urethra occasionally occurs as the result of chordee. Usually but little blood passes, but I have seen copious hemorrhage. Ligation of the penis tempo- rarily arrests the Aoav ; it may also be checked by the appli- cation of ice, or injections of ice Avater. If it persists and is severe, employ an injection of Persulphate of Iron, or of Alum. ABSCESS. 663. Abscesses occasionally form along the urethra, and if alloAved to run their course, sometimes terminate in urinary 238 Venereal Diseases. abscess and fistula. If symptoms of such inflammation pre- sent, the part should be painted with equal parts of Tincture of Iodine and Tincture of Aconite; and if the abscess forms, it should be opened early. Occasionally the lymphatics of the groin become engorged, and inflammation ensues. In this case, the treatment will be that named hereafter for bubo. UNPLEASANT SENSATIONS. 664. Unpleasant sensations of itching or pricking, or the feeling as if there Avas a drop of urine in the urethra, some- times continues for a considerable time after the disease is arrested, causing uneasiness on the part of the patient. I usually order a Tincture of Pulsatilla, 5j- to Water, Siv.; a teaspoonful four times a day. If it is persistent, the occa- sional passage of a bougie will prove serviceable. ENURESIS. 665. Occasionally Ave find a case in Avhich the gonorrhoea is attended Avith greater or less incontinence of urine. Thi.j is a very troublesome complication, as the continued passage of Avater keeps up a constant irritation. In addition to other treatment, I have obtained marked advantage from the use of Belladonna. I usually order it as folloAvs : B/ Fl. Extract of Belladonna, gtts. x.; Water, §iv. ; a teaspoonful every three hours. The Tincture of Ergot may be used for the same pur- pose, in doses of half a drachm. ISCHURIA. 666. Retention of urine during gonorrhoea is most usually caused by spasmodic stricture, and is met with most fre- quently in those who have previously had a diseased urethra, Though not often met with, it is a most troublesome symptom, and requires prompt treatment. It is of but little use to try to pass a catheter in some of these cases, though in others it passes Avithout great difficulty. We will, however, have to depend principally upon medicines. A very good plan of treatment is to have the patient take a hot sitz-bath, and Venereal Diseases. 239 drink freely of an infusion of Polygonum Punctatum ; 01 Tincture of Gelseminum and Tincture of Lobelia in the usual doses may be given with good results. Or an enema of: Py Tincture of Gelseminum, Tincture of Opium, aa. oij. may be used. These measures are very effectual, and Avill not fail once in a hundred times. 667. Suppression of Urine occasionally occurs during gonorrhoea, but is rarely complete. The usual symptoms ensue, at first nervous irritability, then uraemic coma. It is a very grave occurrence, and is caused most frequently by irri- tating diuretics, though in one case I Avas called in to see, under the care of a Homoeopath, it Avas the result of the dis- ease. In the treatment of these cases, I have the boAvels moved Avith a brisk purgative, hot applications applied con- tinuously across the loins, and give internally Tinctnre of Gelseminum in the usual doses, Tincture of Veratrum in small doses. In a few hours mild, unirritating diuretics may be employed. PROSTATITIS. 668. Gonorrhceal prostatitis is not of very frequent occur- rence, but Avhen the disease does extend to this gland, the symptoms are frequently severe. The patient complains of a dull, grinding or throbbing pain in the perineum, with sensa- tion of fullness, desire to urinate, but the urine passes sloAvly and Avith shooting pain in the part. When the disease is severe the pain is intense, shooting to the anus, the back, and doAvn the thighs, and the passage of Avater almost occasions spasms. If the part be examined, the prostate -will be found swollen and tender on pressure. 669. In the treatment of this complication I would direct four or five leeches to the perineum, or active counter-irrita- tion. For the latter the folloAving Avill prove an excellent plan : Py Chloroform, Alcohol, aa. oj. ; Benzine, 5'j- ; wet a piece of lint in hot water, pour this liquid upon it, and pres-; it firmly to the part. The burning is intense, far greater than Avould be produced Avith a hot iron, and of course the coun- 240 Venereal Diseases. ter-irritation is proportionately efficient. After evacuating the bowels, I employ injections of a warm infusion of Lobelia, sometimes adding Opium or Gelseminum. Internally I prefer small doses of the Tincture of Staphysagria, or of Cannabis Indica, to all other means. In place of these, we would stimulate secretion from the skin, use relaxants and mild, diuretics. CYSTITIS. 670. Rarely an acute gonorrhoea extends to the bladder but frequently chronic cystitis results. I have Avitnessed acute gonorrhceal cystitis, the symptoms being those usually de- scribed in the books. For symptoms and treatment the reader is referred to page 189. ORCHITIS. 671. Gonorrhceal inflammation of the testicle, or epididy- mitis, is one of the most frequent complications of the dis- ease. It does not differ materially from that heretofore de- scribed, yet the treatment will bear some relation to the dis- ease of Avhich it is an attendant. It has not yet been settled how the inflammation reaches the testicle. Some contend, that passing to the prostatic portion of the urethra, it makes its way along the mucous lining of the vas deferens. I am satisfied that this may occasionally be the case, as I have in tAvo or three instances observed perineal pain, Avith tender- ness and pain in the course of the spermatic cord, previous to the SAvelling of the testicle. But I have been just as well satisfied, in other cases, that there Avas no such extension of the disease, the gonorrhoea being confined to the anterior por- tion of the penis. In this case the orchitis Avas the result of abnormal innervation. 672. The symptoms of commencing orchitis are usually Avell marked. The patient feels a dragging pain in the scro- tum and spermatic cord, with a sensation of tension and aching in the testicle. It sometimes enlarges rapidly, attain- ing the size of a goose egg in a couple of days, but in other cases the swelling is more gradual. Frequently the pain is Venereal Diseases. 241 intense, resembling that caused by a blow on the testicle, but at other times it is only Avhen unsupported that it is thus painful, there being a constant dull aching and soreness at other times. The disease runs a very variable course, some- times continuing for four or five Aveeks, if allowed to have its way, and occasionally terminating in suppuration and de- struction of the testicle. 673. In some cases the inflammation and swelling declines, but does not entirely cease. There are dragging, unpleasant sensations, occasional soreness and pain, and the diseased tes- ticle is larger than its fellow. In others, in addition to these unpleasant symptoms, the testicle seems to get injured fre- quently, the slightest Woav or pressure producing pain. With this there may be a Ioav grade of inflammation and gradual change in the structure of the organs. This might be called " irritable testis." In other cases the testicle remains perma- nently enlarged, and from its bulk annoys the patient. 674. Some writers seem to have thought that swelled tes- ticle was a metastasis of the disease, and always associated Avith a more or less complete arrest of the gonorrhceal dis- charge. With these vieAvs they have urged the importance of re-establishing the discharge as a means of cure. I do not think that the premises are correct, at least my experience does not bear it out. 675. . Treatment.—The most successful treatment in many cases is the judicious use of compression. For this purpose I employ the adhesive plaster, strapping the testicle firmly to the abdomen, as named under the head of orchitis previously. Dr. Howe straps the testicle and scrotum by itself, carrying the adhesive plaster around it like a roller. In either plan the straps must be applied equably, so as to produce equal compression, and renewed as often as they become loose. I have often seen a patient, after the application of the straps, get up and go about his business, when before he could hardly move Avithout excruciating pain. If the case pro- 16 242 Venereal Diseases. gresses favorably, Ave Avill observe the testicle getting smaller day by day until cured. 676. Though strapping answers, in a majority of cases, there are some that will not bear it. Here, in addition to the usual internal means, we use narcotics and sedates locally. Equal parts of Tinctures of Belladonna, Stramonium, and Aconite, is an excellent local application ; though other com- binations may prove as efficient. Steaming the inflamed organ Avith a decoction of Tansy or Hops gives great relief, as does the application of hot fomentations. A poultice of pounded Peach leaves Avet Avith water, is highly recommended. Occasionally the application of ice-water will give relief Avhen warm applications increase the difficulty. 677. Internally, I prefer the use of the special sedatives, in small doses, associated with the use of the bath, and an oc- casional mild cathartic. If Copaiba and Cubebs have been used, they should be suspended, and the milder injections employed. In addition I would give a combination of: Py Ext. Conium, Iodide of Potassium, aa. 5j. ; Tinct. Macrotys, §ss.; Simple Syrup, giijss.; a teaspoonful every three hours. 678. The treatment of irritative testes is a matter of con- siderable difficulty, as we haA^e no remedies that act directly. Sometimes Ave Avill be successful by keeping the testicle Avell supported in an elastic suspensory bandage, and using a local application of one part of Pond's Extract of Hamamelis to three of water. The use of equal parts of Tincture of Iodine and Tincture of Muriate of Iron, applied locally over the spermatic cord and around the scrotum, is sometimes advan- tageous. Internally I prefer the Compound Tincture of Corydalis Avith Bromide of Potassium. GONORRHCEAL OPHTHALMIA. 679. Gonorrhceal ophthalmia is never a metastasis of the disease, as some of the older physicians supposed, but is caused by bringing the virus in contact with the conjunctiva. It is strange, not that it should occur, but that its occurrence Venereal Diseases. 243 is so seldom, witnessing as Ave do the Avant of care and disre- gard of cleanliness upon the part of persons affected with the disease. Statistics show that it only occurs once in about six hundred and tAventy-eight. cases ; still it is a very formidable affection Avhen met Avith. 680. Within twenty-four hours after the introduction of the virus, the patient will complain of a sensation of itching and burning in the eye, and feel a constant disposition to rub or wipe it. Succeeding this is a feeling as if sand Avasin the eye, Avith irritation AA'hen the lids are moved, accompanied by a flow of tears, and some intolerance of light. As the disease progresses rapidly, there Avill be a free secretion of muco-pus by the end of the second day, and by the third the disease is fully established. Noav the patient can not bear the least light, the lids are swollen, there is a hot, burning sensation Avithin the orbit, and circumorbital pains. The discharge of muco-pus is noAV abundant, and the eyelids glued together. 681. If Ave examine the eye—Avhich Ave do by using Avarm water with a soft sponge to loosen the adhesions—Ave Avill find the conjunctiAra uniformly red and swollen. When the affection is severe the conjunctiva surrounding the cornea is so SAvollen as almost to occlude it, and in some cases the eye is not visible at all—nothing but a fiery-red mass being seen AArhen the lids are opened ; this SAvelling surrounding the cornea is termed chemosis. 682. Progressing still further, ulceration of the conjunc- tiva occurs, and in other cases, phlyctenula of the cornea, which terminate in ulceration and sometimes perforation. In some cases the chemosis is so great as to strangulate the cornea, and it sloughs, discharging the contents of the eye. In others the cornea becomes weakened from imperfect nutri- tion, and possibly from ulceration, and the fluids of the eye pressing upon it causes it to project, forming staphyloma. 683. Treatment.—It is yet a matter of doubt Avhich is the better plan of treatment—that looking to a removal of the 244 Venereal Diseases. inflammatory action by the ordinary means, or the stronger local applications for the abortion of the disease. I will give the twTo plans, and the reader can adapt them to special cases. 684. If the disease is seen in the early stage, the patient should be put upon the use of the proper sedatives, Veratrum or Aconite, with Gelseminum or Belladonna, if indicated. The necessity of rest in a darkened room should be insisted upon, as well as frequent bathing in warm water to Avhich a small portion of common salt, or Chlorate of Potash, has been added. Paint the lids with Tincture of Veratrum, and if necessary, keep the pupil dilated wnth a solution of Atropia. The boAvels may be gently moved once a day, if thought necessary, and in some cases the alkaline diuretics Avill be cf adA'antage. 685. In some cases I am satisfied that Rhus will be founl an admirable remedy, as it is in purulent ophthalmia Avitiii phlyctenular, the sensation of burning being extreme. I would prescribe it Avith Aconite, as : B/ Tincture of Rhuis, gtts. v.; Tincture of Aconite, gtts. x.; Water, §iv.; a tea,- spoonful every hour. 686. As a local application use a solution of Tannic Acid, grs. x. ; Glycerine, gss.; Rose Water, Sjss.; or : Py Chloride of Zinc, grs. j. ; Water, Sj. ; adding Atropia, Morphia, or Gelseminum, Avhen indicated. If Ave use the first it is usually in the proportion of one-half grain to the ounce; the second two to four grains to the ounce; and of the third, gtts. xx. to 3ij. to the ounce. 687- Counter-irritation amounts to but very little, if any- thing, in these cases, and it is not worth while wasting our time with it. 688. In the other plan of treatment we propose making a sharp impression, and destroy the specific character of the disease at once. In one of the two cases of the disease I have seen, I adopted Prof. Hill's treatment—the lids were everted and the eye filled with strong Tincture of Capsicum; the relief Avas speedy and permanent, and the pain was not so Venereal Diseases. 245 severe as might have been expected, and in ten minutes the eyes were in a more comfortable condition than before using. The danger in this form of conjunctivitis is from arrest of circulation and sloughing, a want of stimulus, and the stimu- lation of Tincture of Capsicum or Myrrh can not be harmful. 689. Gross claims that a solution of the Bichloride of Mercury, is by far the most reliable remedy in these cases, especially where the disease is running a rapid course. He prescribed: B/ Bichloride of Mercury, gr. J; Solution of Opium, grs. ij.; Water, 3j. I have seen it used in one case, in the practice of an acquaintance, Avith excellent results. Though my prejudices are very strong, if the question Avas put to me—Mercury or eyes, which ? I should say, put iu the Bichloride. 690. Chloride of Zinc, if it could be safely used of suffi- cient strength would be a good remedy, but when we increase the proportion beyond gr. j. to the ounce, and can not guide the application there is danger. Sulphate of Zinc may be employed of the strength of grs. v. to Water,' Sj.; Carbolic Acid, grs. v. to Glycerine and Water, aa. Sss. 691. Whatever is used, it is necessary that it should be thoroughly applied. The eye is extremely sensitive, and the su'elling and involuntary contraction of the lids make the or- dinary use of a collyriuin impossible. Hence it is best to em- ploy them Avith a syringe, carefully throwing the fluid under the lids from the outer and inner canthus. Before using the stronger fluids, the eye should be thoroughly washed with tepid water, or milk and water. 692. The SAvelling of the conjunctiva (chemosis) is what endangers the structure of the eye, and may cause sloughing of the cornea in a single day. A free use of the bistoury, Avill obviate this, and give marked relief, and should not be neglected. 693. As before remarked, counter-irritation does very little good in the acute stage, yet Avhen the eyelids are enormously SAvollen, the disease running a sIoav course, the application of 246 Venereal Diseases. a fly-blister to the lids is said to give relief. Gross gives it his recommendation, Avith the caution " that the surface be Avell protected Avith gauze, to prevent the fly falling into the eye." In a «more advanced stage, benefit is sometimes experienced from the application of Oil of Amber around the orbit. 694. When the acute stage has passed, leaving a some- what chronic purulent conjunctivitis, 1 should think of the solution of Sulphate of Hydrastia as likely to meet the indi- cations. If the lids showTed granulations, or there Avas cor- neal opacity, Prof. HoAve's use of Nitric Acid, Avould probably prove best. He shapes his pine pencil Avith a smooth flat surface, dips it in the strong Nitric Acid, wipes it on paper, and passes it over the part. If the cornea is touched it is very rapid. GONORRHCEAL INFLAMMATION OF THE NOSE. 695. I have seen a ATery severe form of inflammation of the mucous membrane of the nose, produced by the gonor- rhceal virus. It may be confined to one side, or involve the entire nose, causing great suffering. At first the symptoms resemble, to some extent, a bad cold. The nose is drv, stops up, there is a feeling of itching and irritation, and some pain. Soon a discharge of muco-pus occurs, Avhich in a day or tAvo becomes profuse. There is pain ^aud uneasiness, stopping of the nose, a feeling of fullness, and dull, aching pain in the forehead, and shooting pains in the face. The disease may go on in this way for tAvo or three Aveeks, and finally decliue into a chronic ozaena. 696. Treatment.—In this case Ave would adopt the consti- tutional treatment recommended in gonorrhceal ophthalmia. As a local application Ave will find the following to be effi- cient: Py Chlorate of Potash, 5ij ; Common Salt, 5ij.; Gly- cerine, Sij.; Water, Oj.; M. Py Permanganate of Potash, 5_i " of the pituitary membrane - 1 " of the eyelid ------__i " of the fingers -----___ \ " of the leg ------__. l Total .... 471 832. As we have already seen the typical chancre makes its appearance as a papule or tubercle, and not as a vesicle or pustule. This nodular engorgement may sometimes be noticed before ulceration, but usually Avhen the patient pre- sents himself for treatment, there is erosion of the epithe- lium, and secretion of pus. This sore runs a very sIoav course, does not secrete freely, is not very sensitive, and occasions but iittle uneasiness. The induration is Avithin the skin or mucous membrane, and rarely iiiATohTes the connective tissue, hence the ulcer and induration are freely movable upon the tissues below. Chancres INDflAATED OR HUNTERIAN CHANCRE. 133. The inth.yavion is distinct from the adjacent tissues, in whioh it seems imbedded, in shape and size very much like a split pea, and is somewhat elastic like cartilage. If upon the pr&puoe, it may be grasped and moved in any direction, seeming more like a tubeicle than anything else. In a majority of cases it assumes a circular form, is very rarely irregular, and its cavity is CYip~.maped, with smooth edges, 19 290 Venereal Diseases. sometimes slightly overhanging. It secretes but little pus ; in many cases the bottom of the ulcer is covered Avith a grayish, plastic matter, but in others the entire surface is smooth, and Avith scarcely any secretion. The edges are sloping, hard and elastic. In one form of the disease the chancre seems raised above the adjacent tissues, ulcus elevatum. According to Vidal, " the base is raised by a kind of vegetation of the form of a rounded or oval basin, of a fungous nature. They occur fre- quently upon the edge of a prepuce, furnish a sero-purulent matter, generally not painful, and their borders and base but little painful." 834. The quotation from Mr. Erichsen* describes a major- ity of chancres met Avith. They are not the typical indurated chancre, and yet there is some induration, Avhich is manifest after the sixth day. They do not furnish the abundant secre- *" When chancres are caught in connection, they usually commence with a small excoriation, which appears to have been directly inoculated with the specific poison. In other cases, again, though more rarely, they may be seen at first in the shape of a small pointed pustule, which speedily breaks, leaving an ulcer of a specific character in its site. Very generally, hoAvever, this pustule escapes observation, and the disease is presented in the first instance as an ulcer. The chancrous ulcer, whatever form it assumes, seldom makes its appearance until a few days—five or six—after connection. In some cases, however, I have observed it, evidently from the infection of a fissure or crack, on the day following impure intercourse, and occasionally, in rare in- stances, it does not occur until a much later period than that which has been mentioned. " Whatever may be the appearances presented by a chancre, there can no longer be any doubt that the disease arises from one kind of virus only, the modifications in the sore depending on its situation, the constitution of the patient, and occasionally on that of the individual who communicates the in- fection. That this is so, is evident from the fact that any chancre, when in- oculated, reverts to one typical form, and that, however much chancres may ultimately differ, they all present the same characters during their early stages. The progress of a chancre that has been artificially inoculated on any part of the cutaneous surface is as follows, and its study will serve to elucidate what takes place under other circumstances. During the first twenty-four Venereal Diseases. 291 tion of soft chancre, and yet are constantly bathed in pus, Avhich is not the case in the typical chancres above described. 835. The hard chancre almost ahvays leaves some indura- tion after it has healed, marking its situation for months, sometimes for years. The common form in which the indu- ration is less marked, may or may not leave induration, de- pending someAvhat upon the treatment. The chancroid rarely if ever leaves induration. 836. It might seem from what has been said that the diagnosis of chancre is easy, and so it is to the expert who has made the disease a special study. But to others it is sometimes a matter of much difficulty. Ulceration simulat- ing chancre sometimes occurs in balano-posthitis, and occa- sionally ulceration of the follicles back of the corona, re- sembles it. If, hoAvever, the part be closely examined, bear- ing in mind the description of the disease as above given, a hours after the introduction of the specific pus into the skin on the point of a lancet, we find that some inflammation is set up around the puncture, which becomes hot, red, and itchy. About the third or fourth day, a pointed pustule is produced, which is at first deep-set, but becomes on the following day more superficial, with some depression in the center, resembling pretty closely a smallpox pustule; on close examination this will be found not to be a true pustule, but rather a mass of epithelial scales and pus not included in a dis- tinct wall. On the fifth day it has become hard at the base, apparently from the infiltration of plastic matter, and on the sixth, it has usually dried, form- ing a small round scab, and leaving an ulcer, which presents the typical characters of a true chancre, being circular and depressed, with a foul, gray- ish surface that can not be cleansed, sharp cut edges, a hard base, and an angry looking red areola around it. This is the typical chancre, and these are the appearances that every true syphilitic sore on the skin will present, about the fifth or sixth day after inoculation; from this time it may diverge more or less completely from these characters, but will yet, if inoculated at any time during the poisonous stage, produce an ulcer that will run the specific course up to the same period, after which it may in its turn again deviate into one or other of the special forms that chancres occasionally assume. When in- oculated on a mucous surface, chancres do not so early assume on indurated character around their base." 292 Venereal Diseases. mistake can not occur. To avoid error, it is best to treat all suspicious sores upon the genitals, as if they were syphilitic. Secondary syphilitic ulceration may be determined by the ex- istence of other symptoms of constitutional infection. 837. In urethral chancres mistakes are frequently made, as the disease simulates gonorrhoea. Yet in this case it will be noticed that many of the symptoms of gonorrhoea are absent, the discharge is not so great, and close examination will de- tect induration. In other, though rare cases, a chancre of the lip, hand, or anus, may not be recognized, for the simple reason that the disease is not looked for in those places. 838. Occasionally a case will present itself in which th« patient has decided secondary symptoms, Avithout ever having been aware of having had the primary disease. In some e present in a patient suffering with local ulcers also Venereal Diseases. 295 * Avhich such local abortive treatment will prove successful, is from tAvo to eight days. For my own part I believe there is constitutional infection from the day of exposure, if the per- son is infected, and though an early arrest of the local disease is desirable, it will not prevent secondary symptoms. 843. Treatment.—If there is but one chancre—and this is small and situated on the prepuce—the simplest and best plau is to remove it by excision. Cleansing the chancre thoroughly Avith soap and Avater and clean towel, grasp it with the finger and thumb nail beloAV the induration, and ex- cise it with a sharp bistoury. Of course strict attention must and the pus of those ulcers might be inoculable, notwithstanding the presence of general syphilis. Secondly, the thin discharge of the ulcerated papule of syphilis is not inoculable on its bearer; nevertheless, if the papule is made to suppurate by any kind of irritation, the pus from it sometimes becomes freely inoculable. The test is therefore considered useless as a guide in diagnosis. 3. The indurated sore of syphilis—non-suppurating chancre—Hunterian chancre d/lcus vallalum). Induration is the primary lesion, first as a papule, over which a crust may form, and underneath this crust a cup-shaped ulcer of l reater or less depth rapidly develops itself. It is indolent in its progress, iind having the appearance of being scooped out; it presents raised and rounded edges, a glossy iridescent surface, a base generally grayish or larda- oeous-like, bathed with a serous or Avatery-like secretion, not reinoculable, and not pus. This is the most characteristic lesion of commencing syphilis. The indura- tion, which forms the bed of the lesion and base of the ulcer, extends beyond its circumference, and has been compared to the half of a dried pea for hardness. It is elastic, resistent, and cartilage-like, quite different from cica- tricial hardness or oedema. This condition of ulcer lasts about three to six weeks, when the'edges pf the chancre begin to empty themselves and collapse. The granular particles which covered its base become eliminated or absorbed. At any rate the false membrane-like surface disappears, granulations form, and cicatrization commences from circumference to centre. The resulting cicatrix is round and slightly depressed, and is the seat of induration, sometimes persistent. For a long time it is of a dark-brown or bronze color, and finally all color disappears, and an unnatural whiteness takes its place. Aitken. 296 Venereal Diseases. be paid to cleansing the parts, for if the minutest portion of virus comes in contact Avith the excised surface, the chancre would be reproduced in a much more severe form. But Avhen done according to direction it must succeed, and the wound heals as speedily as any other clean incision. 844. Escharotics are the means usually made use of to abort the disease, and to accomplish this they must be em- ployed before absorption takes place, and entirely destroy the specific character of the sore. It is most absurd to be con- tinually using caustics after the second Aveek, or Avhen en- largement of the glands is felt, unless it is done for the pur- pose of more speedily healing the ulcer; and yet we find such practice frequently extending over a period of mouths. If a first thorough cauterization does not remove the indura- tion, and change the chancre to a simple ulcer, it will not usually be accomplished by repetition. 845. In these cases I prefer one of the three following- remedies: Chloride of Zinc Paste, Potassa-cum-Calce, or Nitric Acid. They are used as directed for chancroid, carry- ing their action so far as to entirely destroy chancre and in- duration. It is bad practice to half cauterize these chancres, as the specific sore is not destroyed, but rendered more per- verse and less amenable to remedies, the induration beino- in- creased. It Avill sometimes require more than one application to accomplish the purpose, but if it is well used, one will generally suffice. 846. A water-dressing, or a poultice, may be employed while the slough is separating, or the sore may be dressed with Mayer's Ointment. After this, we treat it as has been named for soft chancre. Some cases get along better with the use of the wine lotions, others require dry dressings, with Bismuth, and still others heal rapidly under the application of Mayer's Ointment. If cicatrization progresses slowly, and the circulation is sluggish, or the granulations too large', the occasional use of the stick Nitrate of Silver will be^found useful. Venereal Diseases. 297 84T. In the elevated chancre I employ the Chloride of Zinc paste, to thoroughly destroy it, and then dress it with Mayer's Ointment, occasionally using the solution of Carbolic Acid, or Permanganate of Potash. In the serpiginous form, the solu- tion of Persulphate of Iron, or Tincture of Muriate of Iron, Avill be found good, and as a common dressing a solutiou of Potassio-Tartrate of Iron, 5v., to Water, Oj. Tincture of Iodine sometimes proves useful in these cases, or Ave may combine it with an equal part of Tincture of Iron. Especial attention to the general health is necessary in this form, Qui- nine, Iron, and a nutritious diet being indispensable. 848. General Treatment.— While Ave did not consider special medication necessary in soft chancre, in this form of the disease Ave consider it of prime importance. We have already seen that the constitution becomes affected at least by the eighth day, and that after this the abortive treatment is useless. If this is so, and it can not be disputed, Ave have something more to do, than simply heal the chancre, as many imagine. We must stimulate the removal of the virus from the system, or destroy it Avithin ; the first can be readily ac- accomplished, but Ave have no specific that Avill effect the second. 849. Medical men like a treatment that requires no thought, and will adapt itself to every condition. Our Old School friends, many of them, are loth to believe that Mercury is not a specific for syphilis, it wras so easy to administer the remedy, Avhich Avas adapted to all cases, and Avould grapple Avith the disease in any part of the body. Those Avho reject Mercury, replace it Avith the class of alteratives Avhich they suppose will find the poison and remove it in some inexpli- cable manner. 850. If Ave are to succeed in the treatment of syphilis, Ave must have some well defined plan of action, and give reme- dies for the accomplishment of certain results. We have no just grounds to look upon any remedy in our Materia Medica 298 Venereal Diseases. as a specific to the poison of syphilis, and the sooner Ave re- alize this fact the better for our practice. What then are the indications, aud hoAv may Ave best fulfill them ? 851. Like all other animal poisons the virus of syphilis is removed by the excretory organs, and as in analogous cases the poison affects those tissues, the vitality of which is im- paired, rapid metamorphosis of tissue should be stimulated that these parts may be removed, and replaced by new mate- rial. All the evidence that has accumulated on the subject of syphilis goes to prove the truth of these propositions, and they are acted upon by the most successful practitioners in this disease. 852. To accomplish the objects named, I Avould put th<> patient upon the use of a pill composed of: Iy> Podophyllin, grs. x.; Hydrastin, grs. xx. ; Quinine, grs. v.; Extract Nun Vomica, grs. iij.; Vallett's Mass., 5ss. Make twenty pills, ol which one may be taken tvAO, three, or four times a day, so aa to give a couple of actions from the bowels daily. Let thj patient take a daily bath, using soap and Avater AA-ith brisk friction, and if this is not sufficient to get good action fronj. the skin, use the vapor bath tAvo or three times Aveekly. II! the kidneys act well, this will be sufficient; if not, give .>ss, Acetate of Potash in a tumbler of cold Avater three times a day. In some cases the pills will have to be suspended from time to time, and the patient placed on the use of the Resto- rative Wine Bitters, Avith Iron, or Nichols' Elixir of Peruvian Bark and Iron. 853. Under this treatment the patient should have in- creased appetite and power of digestion, and to replace the rapid waste, a highly nutritious diet should be advised, of beefsteak broiled, roast beef, mutton chops, soft boiled eiru's, milk, etc. We intend to renew the body as rapidly as pos- sible, and to obtain as high a degree of health as is possible, and by the time the chancres are healed, the patient will be in vigorous condition, and the syphilitic poison thoroughly removed. Venereal Diseases. 299 854. I Avish it understood, that I object decidedly to the use of alterative syrups and Iodide of Potassium in this stage of the disease, as inefficient to effect the objects named, and a Avaste of invaluable time to the patient. They Avill, hoAvever, be recommended hereafter in their proper places. SECONDARY OR CONSTITUTIONAL SYPHILIS. 855. Syphilis, as Ave have already seen, is, in a majority of cases, a constitutional disease from the first; if not, in a longer or shorter time, the virus is absorbed by the lymphatics or bloodvessels, and the entire system becomes infected. It is sometimes difficult to account for it, as parties protest that they never had chancre, and no marks of it can be found. Yet if Ave bear in mind, that many times the infecting chan- cre is small, superficial, and causes no uneasiness, we may readily see that it may have escaped the person's notice, or have been regarded as a simple abrasion. Many cases of chancre get well in a feAv days without treatment, or they may continue as a slight indurated sore for months, Avithout secretion, or causing the person any uneasiness, and, Avhen unacquainted Avith the affection, any thought of syphilis. In other cases the primary sore is concealed, situated within the urethra, or a fold of the vulva or anus, or in some situation where it Avould not be suspected, as upon the lip, hand, etc.; in such cases it may run a regular course Avithout suspicion. 856. The evidence, hoAvever, is growing stronger, that secondary symptoms may be transmitted from one to another, under peculiar circumstances. Thus it is uoav claimed that a party having the constitutional infection may have intercourse Avith another for a long period without injury, but that some local irritation of the parts from other causes Avill so concen- trate the syphilitic infection that it will be contagious. Thus Vidal remarks : " As to the transmissibility of the secondary accidents, aside from hereditary descent, the doctrine is proved by the fact of the infection of the nurse by the child affected Avith consecutive tubercles, and the contagiousness of 300 Venereal Diseases. the mucous tubercle in the adult; it has been proved by the experiments of M. Cazenave. Wallace, Walter, M. Bouley, M. Richett, M. Litthman, by my oavu, and by those of other experimenters. Under the head of mucous tubercles, experi- ments have already been mentioned, and AAdien we come to treat of the pustular syphilida we shall find certain facts Avhich leave no doubt on the subject. The distinction, there- fore, betAveen the primary and secondary accidents, Avhich rest on their transmissibility—a distinction to Avhich so much importance has been attached—is destroyed both by experi- ment and clinical observation. Both primary and secondary accidents are inoculable." 857. The virus of syphilis, like other contagious diseases, has a period of incubation in which some of its effects are manifested. If no general treatment has been employed, the first of the secondary symptoms occur, at a someAvhat regular period, the mean being about fifty days. In fifty-tAvo cases recorded by Diday, the earliest symptoms appeared in twenty - five days; the greatest length of time elapsing Avas one hun- dred and five days. In one hundred and seven cases reported by Bassereau, fourteen occurred betAveen twenty and thirty days, sixty-six betAveen thirty and forty, twenty-three betAveen sixty and ninety, three between ninety and one hundred and tAventy, and one in the fifth mouth. 858. General treatment modifies the disease so much in some cases that this period is greatly protracted, sometimes to months, at others to years. The first symptoms are some- times so slight and evanescent that they are not recognized by the patient, and this is also a source of error. The folloAv- ing table compiled by Mr. Martin, will shoAV the usual devel- opment of the more common syphilitic lesions • Venereal Diseases. 301 Date of usual development. Date of earl'at development Date of latest development. Roseola ------ Papular eruption - Mucous patches .... {Secondary affections of the fauces Vesicular eruption .... Pustular eruption - •- Rupia ----._ Iritis ------- Syphilitic sarcocele - - - - Periostitis -.-.-. Tubercular eruption ... Serpiginous eruption ... Gummy tumors - - - - Onychia ------ True exostosis ----- Ostitis, changes in the hones and cartilages. Perforation or destruction of velum palati. 45th day. 65th " 70th " 70th " 90th " 80th " 2 years. 6th month. 12th " 6th " 3 to 5 years 3 to 5 " 4 to 6 " 4 to 6 " 4 to 6 " 3 to 4 " 3 to 4 " 25th day. 28th " 30th " 50th " 55th " 45th " 7th month 60th day. 6th month, 4th " 3 years. 3 " 4 " 3 " 2 " 2 '■ 2 " 12th month 12th " 18th " 18th " 6th " 4 years 4. " 13th month 34th " 2 years. 20 " 20 " 15 " 22 " 20 " 41 " 20 " 859. Diagnosis.—The different manifestations of secondary syphilis Avill be considered in detail hereafter, and we noAV Avish to consider only the general characteristics of the dis- ease. In a large majority of cases, the first manifestation of it is in the form of an exanthematous eruption upon the skin, frequently as an erythema or roseola, Avhich may be attended with fever. This eruption fades in the course of from two to six clays, and leaves the skin dingy, dusky, or dirty. Follow- ing this are macula?, at first dusky red, but assuming soon more or less coppery discoloration. They appear first upon the cheeks, nose, forehead, inside of the arms and thighs, and upon the back. Shortly they are associated with lesion of the mucous membrane, as sore throat, passing to ulceration, small excoriations of the lips and edges of the tongue. At a later stage, the hair commences to fall—alopecia, and other of the accidents hereafter named. Dr. Tilbury Fox gives the folloAving points as aids to diagnosis : 860. " The syphilitic poison once introduced into the sys- tem is apt to be folloAved by certain eruptive manifestations : these are only the naked-eye evidences of a deep-seated change in the system at large. The functions of various organs are deranged, the blood is charged Avith a poisonous principle, and all the organs and structures supplied Avith that blood suffer to a greater or less extent. The brain evinces its 302 Venereal Diseases suffering by mental dejection ; the nerves by a general feeling of prostration and debility .... there is often a neu- ralgia (nocturnal) . . . the pulse is quickened . . . the tongue coated, Avhite, broad, and indented by the teeth. The fauces are more or less congested, the tonsils and soft palate being frequently SAvollen ; there is irritation of the larynx, producing a mucous cough and often nausea . . . the conjunctiva is congested and muddy, and the Avhole skin remarkable for its yelloAvish and dirty appearance, looking as if saturated Avith impure and discolored humors. 861. " Syphilitic eruptions have certain peculiarities : " 1. There is a history of syphilitic inoculation, Avhich tells iti tale by the numerous symptoms (due to the circulation of tho poison,), noticed at the opening of this chapter: and, in addi,. tion, by the presence of cicatrices, indurations, scars, anil stains about the penis and groin. " 2. Their color.—It is described as copper colored ; in reality ' a reddish-yellow brown ' (Wilson). It is dull red at first, and becomes coppery after aAvhile, and as the eruptions vanish, a dull red or yelloAvish dirty stain remains for a varying length of time. In the early stages of disease the tint may be violet, but this soon becomes replaced by the coppery hue. " 3. Their form, which is peculiarly circular. This feature is not perhaps of much moment, per se, but in conjunction with other points is of some aid in a diagnostic sense. It may be destroyed or prevented by the confluence of other patches, but even then the typical form can be recognized in the component parts of the patch of disease. Syphilitic scaly eruptions are composed usually of small circular spots. Scales or squama? are thin, oftentimes very fine, gray, and a few in number; fewer and lighter than in the typical aspects of eruption. Crusts are thick, greenish, or black, and firmly adherent. Vesicles are flattish, and do not readily rupture. Ulceration is a common feature; the ulcerated surface is ashy gray, covered with a pultaceous substance, and bounded by sharply cut edges. Cicatrices are whitish ancl reticulated, or Venereal Diseases. .303 dull and broAvnish, leaving in their place on disappearance a yelloAvish stain. Fissuring is marked in the squamous forms. "4. The Absence of Pain or Itching.— With the exception of mucous tubercles and some forms (moist) of infantile syphilis, pyphilodermata are generally unaccompanied by heat or pru- ritis during their existence. In their tubercular forms, just prior to ulceration, a process of softening, apparently de- pending upon a Ioav kind of inflammation, goes on, and the tubercles may be painful and tender. "5. Their Polymorphism. — This is very characteristic of syphilitic disease. Several different kinds of eruption may co-exist, and this is a rule of general applicability, if Ave ex- cept the squamous class of eruption. It is no unusual thing to see papules, pustules and squamas co-existent on the same syphilitic subject."—Dr. Fox on Skin Diseases, p. 267. 862. Prognosis.—The most important question in the con- sideration of secondary syphilis is, whether the poison can be entirely removed from the system, so as to leave the person without a taint. Some Avriters claim that this can not be ac- complished; that the present symptoms may be cured, but that sooner or later they Avill reappear, or at least the system will remain contaminated. 1 admit that under a mercurial treatment this is the case, for Mercury acts as a mordaunt and fixes the disease in the system, sometimes beyond the possibility of removal. But under the treatment that I shall name, 1 am satisfied that the virus can be entirely removed, and the patient Avill be as well as before contracting the disease. It is even claimed by good observers, that the natural poAv- ers of the system, if not interfered Avith, are sufficient to effect the removal of syphilis. Thus Dr. Bennett says : " For my oavii part, I believe that the virus of syphilis, if left to it- self, and if the health of the patient be attended to, will generally wear itself out. Unfortunately Ave are only com- mencing to obseiwe the natural progress of syphilis, and con- 304 Venereal Diseases. sequently Ave are unable to determine how long, under ordi- nary circumstances, it takes to accomplish this." 863. General Treatment.—We take up the constitutional treatment of the disease here, because it will be nearly the same for all syphilitic lesions, and in considering these sepa- rately we will notice the necessary modification of it, and the local means to be employed. 864. The poison of syphilis continually reproduces itself, and affects those parts, the molecular life of Avhich is feeble. Thus those persons are most severely affected Avhose health is impaired, and Avho contain the largest amount of Avorn out or devitalized material. We may then claim that it can be re*- moved by getting rid of these old materials, Avhich form il/a nidus, and replacing them Avith neAV and highly vitalized material. Experience proves that resistance to diseased ac- tion is directly proportionate to the vitality of tissue. 865. The reader 'will find an explanation of many phe- nomena of syphilis in my Principles of Medicine, p. 208. lit is a disease that involves the nutrition of the entire body, and must therefore be associated Avith blood making. The germs of the blood are furnished by the lymph, and as is this pro- duct so Avill be the blood and the tissues. " The syphilitic poison ahvays gains entrance through the lymphatics, and some of the earlier and more constant phe- nomena are of this system of vessels and glands. I claim that the reason Avhy the disease is so general, so obstinate, and causes such varied and sometimes fearful lesions of nutri- tion is, because it is a disease of the lymphatic system, and poisons the fountain from Avhich the blood is draAvn. I have made a number of examinations upon the cadaver in persons Avho Avere suffering from constitutional syphilis, and in every case I found perceptible lesions of the lymphatic glands. In one severe case, in Avhich there Avas ulceration, nodes, and syphilitic psoriasis, there Avas not a sound lymphatic gland in the body. This person had died of the syphilitic cachexia. Venereal Diseases. 305 So confident am I of the correctness of these statements, that I will risk my reputation that no case of secondary or consti- tutional syphilis can be found in which disease of the lym- phatic system is not present. " If Ave examine the matter closely, Ave will see that there is no other Avay in Avhich Ave can rationally account for the continuance of the disease as a permanent part of the life of the individual. The ordinary supposition that it is a morbid material in the blood, and governed by the same laAvs that control other animal miasms, is untenable; for it Avould be an exception to the rule, that after a longer or shorter time they are always removed by the excretory organs. On the contrary, Ave find that remedies that simply increase secretion do not influence this virus, but, on the contrary, it requires remedies that influence the lymphatic system. So true is it that the lymphatic system is the seat of the disease, that many physicians at once examine certain parts of the body, to de- termine the condition of the glands, Avhenever a uoav case presents. A friend of mine claims that in a very extensive experience, extending over many years, he has never seen a case in Avhich there Avas not enlargement of the occipital lym- phatic glands." 866. The indications of cure in secondary syphilis are, then : 1st, To stimulate the excretory organs to increased ac- tivity, and promote the removal of Avorn-out tissues, the seat of the syphilitic poison ; and 2d, To replace this material by other products of a high degree of vitality and Avell formed. As Chambers Avell remarks, " It is a renewal of life." Bearing in mind these principles, we will consider sepa- rately the various agencies employed in the treatment of the disease. mercury. 867. From the days of Paracelsus it has been claimed that Mercury is an antidote to the poison of syphilis, and the only remedy that can be depended upon for the removal of the poison. Different practitioners have employed different pre- 20 306 Venereal Diseases. parations of the mineral; thus some use the Bichloride, others the Iodide or Proto-lodide, some soluble Mercury, some Calomel; it is employed by mouth, by inunction, and as a fumigation. We object decidedly to the employment of mer- curials in any case, though admitting that certain symptoms yield speedily to their influence. We ground our objections on the facts : 1st, That it is uoav clearly proven that Mercury Avill not cure syphilis ; 2d, That it tends to fix the syphilitic poison in the system, and prevents its removal by other rem- edies ; and, 3d, It produces symptoms far Avorse and more permanent than the disease for Avhich it is given. I might give pages of evidence from Old School men in proof of these propositions, if space Avould permit, but I Avill only make a quotation from Dr. Bennett: 868. " The idea that Mercury is a specific for syphilitic poison, and the incalculable mischief it has occasioned, Avill constitute a curious episode in the history of medicine at some future day. It is now well knoAvn that the poison of Mercury produces a cachectic disease and secondary sores iu the body, which have been to a great extent mistaken foi those of syphilis. It consequently has happened that Mer- cury, given to cure primary sores, has produced a constitu- tional disorder closely resembling that of syphilis; more Mercury has then been administered, increasing the mischief, and so the disease has been perpetuated. The real fact, Iioav- ever, is, that the syphilitic poison is no exception to the pery-reddish color. They appear most frequently upon the back, shoulders and neck, though they may be found on any portion of the body. They are usually preceded by some de- rangement of the system, as loss of appetite, arrest of secre- tion, headache, etc. The eruption frequently does not con- tinue more than tAvo or three weeks, and passing off, leaves slight blotches, and desquamation of the cuticle. A broad papular eruption is sometimes seen, thus described by Vidal : " Sometimes Ave observe them of a firm consistence, very prominent, and of a decided copper color; at another point, we find little elevations already faded, less prominent, of softer consistence, and of a paler tint; on one side are yelloAv- ish spots, Avith a rosy tint, which are in process of being con- verted into papules; on the other,they are of a grayish shade, more depressed than the latter, and the marks left by the papules which have disappeared. They are separated by in- tervals, at Avhich the skin is of a peculiar earthy color, giving to the whole a very characteristic aspect. SQUAM.E. 946. Of syphilitic squamse wre have three varieties—lepra, pityriasis, and psoriasis. It may be remarked that all syphil- itic skin diseases are scaly to some extent, this being a char- acteristic symptom ; but these possess the features of the diseases named, in fact are the same diseases modified by the syphilitic poison. 947. Lepra appears in the form of small, coppery-red, shining spots, a little elevated above the skin. In a short time they lose their smooth appearance, and become covered with thin scales, which are constantly falling oft" and being renewed. They increase in size, maintaining a circular form, until they are tAvo or three inches in diameter, and the skin becoming thick and hard, movements of the part are impeded and painful. In some cases ulceration occurs, the result being 330 Venereal Disease? the formation of very unpleasant sores. The disease may be confined to the extremities and about the joints, but in some cases it extends to every part of the body. 948. Pityriasis is most usually confined to the scalp. It makes its appearance in the form of coppery-red discolora- tious, Avith but little change in the skin, but continued exfo- liation of the epidermis. It may or may not be attended Avith the falling of the hair. 949. Psoriasis may appear in four forms. First, in the form of small coppery or dusky-red patches, irregularly rounded, and elevated above the adjacent skin. These soon become covered Avith thin scales, which are continually cast off. In other cases it occurs in the form of flat, angular, irregular patches, Avhich, as the disease progresses, form con- tinuous surfaces, covered Avith thick, dirty-Avhite, and pretty adherent scaly incrustations. The margins of these spots have the characteristic dirty-yelloAv or coppery color, and when the incrustations are removed, the part presents a livid appearance. In the severer cases the skin becomes thick, hard, hypertrophied, and fissured in various directions. On pinching up the skin it is found to be much altered in struc- ture, rough, hard and uneven. The disease occasionally appears about the eyes, and gives rise to much irritation, and about the lips, Avhich are dry and present fissures Avhich are irritable and painful. The most frequent form is psoriasis palmaris. It makes its appearance in the form of one or more red blotches or papules, exfoliation of the epidermis occurs, leaving a coppery-red and tender surface. At a later stage these become tender, crack, and Avhen used, frequently bleed. Sooner or later the disease involves the tips of the fingers passing under the edges of the nails, and may cause their entire removal. 950. In the treatment of this form of the disease 1 employ the vegetable alteratives in infusion, using them freely, and bathing the surface Avith the same. If the patient's health is not much broken doAvn, give Iodide of Ammonium or Potas Venereal Diseases. 331 sium, and after tAvo or three Aveeks, put the patient upon the use of Tonics and Iron. These are the cases in which Arsenic has been employed with such marked benefit, both internally and locally, but I Avould only recommend it where the skin is dry and harsh, and has lost its tonicity ; then it proves a A*alu- able stimulant. 951. In addition to the means named, Ave will frequently derive much benefit from vapor baths, followed with fumiga- tions of Sulphur, or Iodine. Sulphite of Soda, Sij. to Water, Siij- ; Glyceriue, Sj-; is an excellent local application. Or: 1^ Glycerine, Sj-; Beuzoic Acid, o\j.; Oxide of Zinc, 5j.; Water, Sij- M. My favorite local application in this, as Avell as some other of these affections, is : 1^ Iodide of Ammonium, 5j.; Water, Siv.; Glycerine, 3j. I have also employed the Glycerole of Tar with very good results. VESICUL.E. 952. Syphilodermata rarely appears in the vesicular form, and when it is met Avith it is an early symptom. It most fre- quently takes the form of simple eczema, appearing upon the back, face and extremities. In many severe cases it ansAvers the character of eczema impetignodes, the skin being swollen, /he vesicles large, which when ruptured form a scab, which is east off and renewed for several Aveeks, leaving coppery dis- eolorations or cicatrices. BULLAE. 953. Of this Ave have tAvo varieties, pemphigus and rupia, the first being of rare occurrence, while the second is a quite frequent form of syphilitic skin disease. Pemphigus is most usually seen in congenital syphilis, and is evidence of grave impairment of vitality. It makes its appearance in the form of large blebs or blisters, ovoid in form, situate on a violet-colored base, and filled with a straw colored fluid. When they rupture, thin, broAvnish crusts form, Avhich may- be renewed for some time. 332 Venereal Diseases. 954. Rupia is one of the later symptoms of constitutional syphilis, and is almost invariably associated with poverty of the blood, and enfeebled vitality. It commences by the for- mation of large vesicles, upon a reddish base, sometimes filled with a yellowish serum, at others the fluid is bloody. By the third to the sixth day its contents dessicate and form a scab, covering a superficial ulcer, Avhich is violet in its color Avhen the scab is removed. The constant secretion of purulent matter adds to the under surface of the scab, and it becomes more and more prominent, until it is half an inch or more in thickness. The scab is yelloAvish brown, or almost black, and the skin surrounding it presents a coppery-red areola. 955. The treatment for these forms will be similar to that directed for the squama?, especial attention being paid to the digestive organs, and the administration of Bitter Tonics and Iron. The Compound Tincture of Corydalis proves a good remedy iu this case, associated with Hydrastis and Iodide of Iron. An infusion of Corydalis or of equal parts of Cory- dalis, Alnus and Rumex is also an efficient treatment. 956. As a local application, Ave will find equal parts of Tincture of Muriate of Iron and Glycerine to answer well in some cases. The Hydrated Oxide of Iron, Avith an equal part of Lard, is good, as is the Glycerine and Oxide of Zinc, pre- viously mentioned. In quite severe cases I have obtained good results from an application of a strong decoction of Alnus, Rumex and Cornus. If single points of rupia are very persistent, I sometimes apply the Chloride of Zinc Paste to produce a slight slough, and then dress the sore Avith Mayer's or Mild Zinc Ointment, PUSTULE. 957. Pustular eruption is a frequent form of syphilitic skin disease, Avheu the poison has thoroughly impregnated the system. We recognize three varieties — ecthyma, im- petigo, and acne, each of which possesses many of the char- acteristics of the non-syphilitic affection. Venereal Diseases. 333 Vesiculo-Pustular Syphilida. 958. Ecthyma is of most frequent occurrence. It makes its appearance as small, red, indurated spots, which soon sup- purate, and a pustule is formed in the center. When severe, the skin is much inflamed, swol- len, and of a dark color, and the pustule is blackish aud infiltrated with blood. In the first form, Avhen the pustule ruptures, a broAvnish scab is formed, Avhich maybe reneAved for some time; the surface, Avhen it is removed, has a coppery-red color, aud when healed it leaves a slight cicatrix. In the second form, a thick, dark scab results, Avhich is very adherent; progress- ing further, a process of ulceration is set up, Avhich increases its size, and at last terminates in the formation of an open ulcer. 959. Impetigo appears as slightly raised, red patches, upon Avhich soon appear numerous pustules, flat, and of variable size, manifesting a tendency to run. together. The fluid is abundant and soon dries, forming thick, yellow incrustations, and when throAvn off, the pit is coppery-red and tender. The eruption extending by neAv eruptions of pustules, may extend over a considerable portion of the body. The disease is occa- Pustulo-Crustaceous Syphilida. sionally very severe, especially about the mouth and nose, the pustules being large, and forming thick, yellowish-green or broAvn crusts. In a later stage of the disease, the pustules arrange themselves in circles, and the crusts are thick, yellow- ish broAvn, and cover considerable surfaces. The cicatrices left are of a dull Avhite color, and permanent. 334 Venereal Diseases. 960. In syphilitic acne, the pustules are of small size, situated upon red indurations; remaining stationary for some time, they become covered Avith a thin scab, which when re- moved leaves a slight coppery redness. In other cases, the disease assumes the indurated form. It commences as livid, red, indurated tumors, which are painful when pressed upon. Suppuration proceeds sloAvly,and small scabs are formed upon the surface; in some cases the cellular tissue is involved, and the induration remains for some Aveeks. 961. The treatment in these cases will not differ materially from that recommended for rupia. Sulphite of Soda some- times ansAvers an excellent purpose, in closes of tAventy grains four times a day, and a strong solution may be employed as a wash. Syphilitic Rupia. TUBERCUL^E. 962. " Syphilitic tubercles," says Langston Parker, " are deep-seated, solid, circumscribed elevations, containing neither lymph nor pus; they differ from the papulae in their size, being much larger, more prominent, and better defined. Syphilitic tubercles are either isolated or grouped, of a shining red, livid or broAvn color, surrounded by an areola of a dark- red or coppery appearance. These tubercles are prone to become ulcerated, and form excavated sores with thick and elevated edges, and a foul surface, secreting an offensive pus, which, drying up, is transformed into gray or dark colored scales or crusts. The syphilitic tubercle forms the connecting link betAveen the secondary and tertiary symptoms of M. Ricord : it is the first of that class of syphilitic diseases in which the virus appears to have penetrated more deeply into the economy, and to have produced a disorganization in tis- Venereal Diseases. 335 sues, Avhich those forms hitherto considered have left un- touched. 963. " The flat tubercle of M. Cullerier, or the tubercu- lous pustules of Alibert, sometimes occurs as a primitive affec- tion, but more commonly as a symptom ot constitutional syphilis; in the former instance it is obseiwed on the scrotum, the labia, the vicinity of the anus, or the mammte. The sur- face of these tubercles is smooth and flat, of a deep red or copper color, varying from the size of a sixpence to that of a shilling; they are not so much disposed to ulcerate as the other varieties. 964. "The more common forms of tubercles are conical, or round eleA'ations, dispersed here and there over the skin, or assembled in groups or clusters, which are also irregularly distributed. The size of these varies from that of a pea to that of a large hazel nut or filbert; they are more commonly situated on the anterior surface of the chest, or the abdomen, or the neck, or the internal part of the arms. 965. " Another variety of tubercle is situated more com- monly on the alse or lobule of the nose, or on the forehead ; frequently, also, upon the neck of the uterus, or upon the tongue, Avhen they may be mistaken for cancerous affections. These tubercles are commonly assembled in circular groups of variable size ; they are so prone to ulcerate, that this ter- mination appears to be one of their natural characters ; Avhen in this condition, they are frequently described under the name of syphilitic lupus. The tubercular syphilida are com- monly complicated Avith a scrofulous, scorbutic, or herpetic tendency or diathesis ; their progress is sIoav, and generally Avithout pain ; they gradually increase in size till they termi- nate in softening or ulceration. They are the most formi- dable of all the forms of constitutional syphilis, producing great deformity in all the parts invaded by ulceration, and exceedingly difficult to cure." 966. In the treatment of syphilitic pustules, the remedies should be carefully selected. If Iodide of Potash is indicated 336 Venereal Diseases. as heretofore named, it will sometimes effect a speedy cure, and the same is the case Avith Nitric Acid, Arsenic and Cod- Oil, The vapor bath every other day, Avith Sulphur, proves a valuable aid to the treatment 967. If the tubercles become painful, and shoAV a tendency to suppuration, Ave may employ emollient applications, or sedatives and narcotics. I like the action of the folloAving : I$j Extract of Conium, Sss. ; Extract of Aconite, 5ij. ; Glyce- riue sufficient to form a paste. In some cases an application of equal parts of Tincture of Iodine and Tincture of Muriate of Iron Avill prove serviceable, or they may be covered Avith the Collodion or Gutta Percha mentioned under the head of Bubo. When they are indolent, Ave sometimes obtain good results from a continuous application of Mayer's Ointment. ULCERS. 968. Ulceration may be the result of the vesicular, pustulse. or tubereulee, as already described, or it may even occur from. the long continuance of the papula? or squamse. These ulcers possess all the characteristics of those arising from other causes — being irritable, indolent, corroding, etc. They also vary greatly in size, from that less in size than a three cent piece to one that covers a surface as large as the hand. When arising from the vesiculse or pustulse, there is usually a con- stant tendency to incrustation, no matter what their size; but Avhen caused by suppuration of tubercles or gummy tumors they are usually open. 969. We will find them presenting every variety of form__ round, oval, and irregular—at times superficial and Avithout effusion into adjacent tissues, at others deep and surrounded by a Avail of adventitious tissue. Whatever may be their shape or size, there is the coppery discoloration around them, or in the cicatrices of former ulcers, Avhich gives their history. 970. The treatment will not differ from that already laid doAvn, as the open ulcer is but a continuance of the prior dis- ease. I believe it is the experience of all practitioners, that Venereal Diseases. 337 syphilitic ulceration heals as readily as the simple, Avhen the constitutional affection is removed. They may be healed before this, by the use of the local applications that have been named, if the general health is good. If there is general de- bility and impoverishment of the blood, they will sometimes heal rapidly under the use of tonics, Iron and nutritious diet. 971. Mayer's Ointment, made strictly according to the Dispensatory, is an excellent dressing, as is the Ointment of Elder, the Ointment of Baptisia, and the Ointment of Nitric Acid. The decoction of Alnus, Rumex and Cornus—hereto- fore named—proves useful Avhen the ulcers are indolent. If the secretion is profuse, Ave may use a decoction of equal parts of Baptisia and Cornus, or a Solution of Permanganate of Potash, one or tAvo grains to the ounce of Water, or of Car- bolic Acid one part to forty parts of Water; or, what is better: 1^ Carbolic Acid, 5ss. ; Glycerine, Siv. If the ulcers are sluggish and Avill not heal under these applications, Ave sometimes apply the Chloride of Zinc Paste to destroy the imperfect structure of their edges and base, Avhen they heal as simple ulcers. The Ointment of Iron—made by precipi- tating the Solution of Persulphate with Ammonia, and com- bining Avith half a part of Lard—ansAvers a good purpose in the same cases. MUCOUS TUBERCLE. 972. Mucous patches may be an early or late symptom of syphilis, occurring as early as the tAventieth day, or not for two or three years. It is even claimed that they may be a primary symptom, taking the place of a chancre, and trans- mitting the primary disease by their secretion. 1 am satisfied that Avhen appearing thus early, that they have their origin from aii irritation of the surface produced by the syphilitic virus, or as Ave have seen, from the chancre itself, and in such cases the secretion is the specific virus. 973. They are also transmissible Avhen really secondary symptoms, aud not only will the groAvth spring up, but the constitution av'iII be infected. They may be propagated from 338 Venereal Diseases. point to point of the same person by contact with the virus, and this is probably the means of their extensive distribution in some cases. 974. Mucous tubercles most usually make their appearance at points Avhere the mucous membrane joins the skin, though they will be found on the mucous membrane proper, or upon the skin, as the scrotum, perineum, groin, axillae, between the toes, the inside of the thighs, etc. They most frequently pre- sent themselves at the margin of the anus, or just behind the corona-glandis, and in the female upon the vulva; and from these parts they may extend so as to involve a considerable portion of the genital organs, and the perineal fissure. They may also be found at the lips, the inside of the cheeks, tonsils, the nose, etc. 975. They first appear as one or more red spots, slightly elevated above the surface. Their groAvth is usually rapid, so that in a short time they are one-fourth or one-half inch in height. When grouped together they resemble a bunch of red raspberries. Their color is a bright vivid red, and they bleed freely Avhen their covering is ruptured. The secretion is usually thin and muco-purulent, but if from friction or other cause ulceration occurs, it is purulent and abundant. At times the secretion from them becomes so ichorous as to excoriate adjacent parts. When situated on the skin, their color is brownish-red, and when upon the mucous membrane of the mouth, a blanched white, like the eschar of Nitrate of Silver. 976. As in other forms of constitutional syphilis, Ave ex- pect to remove this symptom, by eradicating the general dis- ease upon which it depends. And although local treatment will effect their removal in some cases, Avithout internal rem- edies, it should always be held subservient to the latter. 977. Various local means have been employed in this case, sometimes with and at others without success. I have seen the strongest escharotic used for their removal, and the re-ap- pearance of the mucous tubercles before the part had healed. Venereal Diseases. 339 So I have seen the hot iron applied to the entire perineal fis- sure until the patient could not be seen for the smoke pro- duced by the burning, and in tAvo weeks they were as abun- dant and prominent as ever. If this teaches us anything, it should cause us to rely upon constitutional measures. 978. I have obtained good results from cauterization Avith Chromic Acid, as named under the head of gonorrhceal vege- tations, but I would only employ it when the patches were small. A strong solution of Permanganate of Potash has also answered a good purpose. And I am informed that Carbolic Acid has been successfully used. Dusting the patches with equal parts of Sub-Nitrate of Bismuth and Oxide of Zinc, being careful to separate the folds and apply the powder betAveen, is a very good plan. In other cases we may use a saturated solution of Tannin, freely applied. The extract of Red Clover has also been recommended. GUMMY TUMORS. 979. Gummy tumor is a late symptom of syphilis, not usually appearing for tAvo or three years or more. They are generally found in the cellular tissue under the skin, but the same development may take place in the muscles, or even in tendinous structures. They make their appearance as hard- ened masses, freely movable under the skin, from the size of a cherry to a hen's egg. They frequently remain Avithout change for mouths, giving the patient but little uneasiness, further than the sensation of an adventitious body. At last they become tender on pressure, form adhesions to the skin, Avhich become dark-red, or livid and coppery, aud at last thinned and ulcerated, discharging an ichorous pus. Suppu- ration usually commences at their center, and as it progresses a large foul ulcer is formed. No tendency to healing is man- ifest until alb the formation has been removed, Avith subse- quent adA-entitious deposit, and at last when healed a perma- nent cicatrix of a dull Avhite color remains. 340 Venereal Diseases. 980. The treatment will not vary from that heretofore de- scribed, but it needs to be very thorough, as the presence of these tumors is evidence of grave syphilitic cachexia. ALOPECIA. 981. Falling of the hair is an early symptom of constitu- tional syphilis, and will usually be found associated Avith the exanthemata, and w7ith redness of the fauces. At its com- mencement it seems a minor affair, the hair coming out in small quantities, but as it progresses the hair has so frail a tenure that it comes out in quantities on slight traction. Thus if it progresses the patient will become nearly or quit* bald, and in some cases will lose the eyebrows and eyelashes also, giving him a very singular and uncomfortable appear- ance. Usually there is but little apparent disease of the scalp ; occasionally there is pityriasis, and again the pustules and scabs of impetigo. 982. Caused by the syphilitic infection of the system, the constitutional treatment is mainly to be depended upon, and Avhen the person is brought under the influence of the proper remedies, the hair ceases to fall out. To gratify the patient, Ave usually prescribe local remedies, which to some extent check the falling of the hair. The following formula will be found as good as any : 1^ Tincture of Cantharides, fSj. ; Cas- tor Oil, fSiv. ; Alcohol, fSxij.; Oil of Bergamot, Oil of Lemon, Oil of Lavender, aa. 5ij. Mix. Let it be applied with slight friction once or twice daily. Dupuytren's Pomade is fre- quently used : fy Medullae Ossium Bovis, Sj. ; Tincture of Cantharidis, Sj- Add: Plumbi Acetatis, gj. ; Bal. Pernviani, Siij.; Olei Carophylli, Olei Canellas, aa. gtts. xv. Mix. ONYCHIA. 983. Not only does the skin suffer in its nutrition, inde- pendent of the eruptive diseases named, but as Ave have seen its appendages become diseased. Affections of the hair are far more common than of the nails, but in protracted syphilig Venereal Diseases. 341 Ave will ahvays find these presenting some evidences of disease. 984. In the majority of cases, the nails have lost their bright, fresh appearance, and look dull and opaque. They are inclined to incurve, become brittle, break and scale off. Becoming more diseased, we find that the matrix and edges of the skin surrounding them become swollen and tender, the nail grows thick, rough, opaque, and dark colored, looking someAvhat like the crust of rupia prominens. After a time the matrix and edges ulcerate, and the entire nail may be thrown oft' by this process. As would be supposed, it is a very unpleasant and painful manifestation of the disease. 985. The general treatmant will be, of course, for the constitutional infection, and if anything is suggested here it will be the use of Cod Oil and Arsenic, or in some cases, Phosphorus or Sulphur. The local means will vary. In some Permanganate of Potash will be the best local applica- tion, in others Carbolic Acid. Whenever the eruption at the edges of the nail is eczematous, I Avould advise the Brown Citrine Ointment, at first of full strength, afterwards one part to three of Simple Cerate. DISEASES OF THE RESPIRATORY APPARATUS. AFFECTIONS OF THE NASAL CAVITIES. 986. Disease of the nose is usually a late symptom, though <.ve may observe erythema Avith catarrhal symptoms, associated Avith the disease of the throat. It commences Avith the symp- toms of catarrh, and continuing for a time, Ave Avill find the mucous membrane SAvollen, dusky red, and at last presenting points of ulceration. At first there is diminished secretion, but after a time, masses of inspissated mucus, Avith blood and pus, are, from time to time, discharged. Progressing still further, this secretion becomes more abundant, the patient complains of a fullness, sense of tension, and aching in the nose, Avhich is frequently someAvhat SAvollen at the loAver mar- 342 Venereal Diseases. gin of the nasal bones. The ulceration progressing further, the bones become affected, and there is frequent discharge of fetid muco-pus, scabs, inspissated mucus, and the debris of bone. 987. Points of ulceration may be visible to the eye, Avhen they present the same appearances as those described in the throat. But the middle and posterior parts of the nose seem to be the favorite locality, and it there commits its greatest ravages. The turbinated bones are frequently affected, and are first cast off. The vomer becoming involved, the support of the outer nose is destroyed, and Ave have that peculiar sinking of it so characteristic of syphilis, or it may continue to the destruction of the cartilaginous septum, the nose be- coming flat. Passing upward it destroys the superior turbi- nated Avith the lateral masses of the ethmoid, and backAvard it erodes the soft palate, and at last destroys more or less of the palatine arch. We thus find in some cases that the mouth and nose is but one cavity, all the superior structures as far as the orbits, and base of the cranium, having been re- moved by the ulcerative process. 988. In the earlier stages, the disease yields readily to treatment, but Avhen the bones become involved much care is required to arrest it. Select internal remedies, so as to re- move the constitutional affection Avithout producing debility or impoverishing the blood. Iodide of Ammonium with the vegetable alteratives, and the employment of Bitter Tonics and Iron to improve digestion and assimilation, Avill be the best treatment. The prolonged use of Iodide of Potassium frequently does much harm. 989. Local means are of much importance. Thev are used to best advantage in the fluid form, either Avith syringe or the new method of hydrostatic pressure. In either case they should be used in considerable quantity, to clear the cavities of accumulated secretions, and to thoroughly reach the affected parts. It has been shown that- if the patient breathes through the mouth exclusively during their use, the Venereal Diseases. 343 soft palate closes the posterior nares, so that a fluid thrown into one nostril Avill pass out at the other. If a syringe is used, it should contain four to six ounces, Avork easily, and have a large nozzle; having filled it, let the fluid be forced slowly into the nose until it is thoroughly Avashed out. In the other method, ajar or funnel, resembling a bottle with its bottom removed, is placed on a retort stand. To the small loAver extremity a piece of rubber tubing, three or four feet long, is attached. Now filling the jar, which is higher than the patient's head, the tube is inserted into one nostril and the fluid floAvs through and out at the other. Any amount of fluid may be thus used. 990. To Avash the nose out, Ave may use a solution of Common Salt, Sss. to Water, Oj. ; or of Permanganate of Potash, 5j. to Water, Oj. A very good lotion for relieving irritation is composed of: ty Chlorate of Potash, 5ij.; Gly- cerine, f'Siv.; Water, f^xij. We may sometimes substitute, with advantage, a decoction of equal parts of Alnus, Rumex and Cornus, Avith or Avithout a portion of Glycerine. A solu- tion of the Permanganate of Potash, alternated with the in- fusion just named, is the remedy I have obtained the best results from. 991. I have used the inhaling apparatus, or atomizer, of Dr. Seigle, in these cases, as Avell as in syphilitic sore throat, aud laryngitis, Avith marked advantage. The instrument consists of a copper boiler, resting on a tin frame Avork, which also incloses the spirit lamp by Avhich the boiler is heated ; passing from the top of the boiler is a glass tube, bent at a right angle and terminating in a small opening, and at right angles to this a similar one, which pusses into a small cup holding the medicated fluid. The instrument Avorks Avell, is automatic, and not liable to get out of order. 992. In using it, fill the boiler half full of water, light the alcohol lamp, and in three minutes a jet of steam will pass out of the glass tube. Place the fluid to be inhaled in the small glass cup, and as the jet of steam passes over the small 344 Venereal Diseases. tube leading from the cup, a vacuum is formed in it, and the medicated fluid rises and is carried off in the current. With the vaporization of one drachm of water in the boiler, two drachms of the medicated fluid will be atomized and carried off. 993. Any remedy in solution may thus be carried to the part affected. I use decoctions of Chamomile, Hydrastis, Baptisia, etc., and solutions of Chlorate of Potash, Perman- ganate of Potash, Sulphite of Soda, Chlorinated Soda, and Nitrate of Silver. SYPHILITIC LARYNGITIS. 994. Among the serious lesions of syphilis, disease of the larynx occupies a prominent place, and is one of the most common causes of death. Chronic laryngitis is at all times an unpleasant affection, but especially so Avhen it goes on to ulceration. Intractable and Avith difficulty arrested in ordi- nary cases, this difficulty is greatly increased in the specific form of the disease by the depraved condition of the blood. 995. In the early stages of secondary syphilis, Avith throat disease, Ave will frequently observe a roughening of the voice, and a disposition to a short cough to clear the throat. This usually passes away Avithout special treatment, as the general disease yields. 996. In a further stage of the disease, the voice is rough- ened, and the patient finds it someAvhat difficult at times to control it as he wishes, and the throat requires frequent clear- ing in speaking. The cough is especially for the removal of increased secretion, and becomes Avorse Avhen this increases, better when it decreases. As yet there is no evidence of ulceration, but there is secretion of mucus or muco-pus. 997. With commencing ulceration the patient suffers from local pain in the larynx, and considerable irritation. There is not unfrequently some difficulty in breathing, from con- traction of the intrinsic muscles, the result of the irritation. If the ulceration is upon or near the vocal cords, the voice is markedly changed, and its use becomes very painful. The Venereal Diseases. 345 sputa is uoav characteristic, at least in many cases. The secre- tion of the ulcer remains for a time, sometimes partially des- sicates, and is then brought up in a mass, its surface being tinged Avith blood. 998. At a still more advanced stage of the disease, the patient suffers continuously and severely Avith his throat, There is no time that he breathes with ease, and when the larynx becomes irritated he suffers as a child Avould with croup. The voice is rough and hoarse, and he can talk but little without causing severe irritation. The matter expec- torated is an unpleasant, greenish pus, and is sometimes dis- charged in large quantities. Hemorrhage is also of frequent occurrence. 999. The impairment of the general health keeps pace with the local disease. With the first symptoms it is distinct, and as the local disease runs its course as above named, Ave find the patient losing flesh and strength, until in the latter stages he presents the appearance of one in the advanced stages of phthisis, and 'has hectic fever, night SAveats, colli- quative diarrhoea, etc. 1000. Post-mortem examination shows all phases of dis- ease, from simple thickening of the mucous membrane, to ulceration involving and destroying the mucous membrane, vocal cords, and even the cartilages of the larynx. 1001. Treatment in the early stage of the disease will, in the majority of cases, prove very satisfactory. If the irrita- tion is marked, and acute, Avith erythematous redness of the fauces, I Avould prescribe : 1^ Tincture of Aconite, gtts. v. to gtts. x.; Water, Siv.; a teaspoonful every t\vo hours; the Avet vinegar pack to the throat at night, and cold sponging in the morning. In very severe cases the use of Aconite Avith the spray apparatus, will give speediest results ; either the steam apparatus, or the air bulbs, may be employed. If the throat sIioavs the peculiar fibrinous exudation, covering it like a film, or in streaks or patches, especially if diphtheritic, I would prefer Phytolacca, as : 1^ Tinctnre of Phytolacca, 346 Venereal Diseases. (green root), oss.; Water, Siv.; a teaspoonful every two hours. If the disease is more slowly developed, with rough- ening of the voice, I Avould advise Collinsonia, in the usual dose: Jfy Tincture of Collinsonia, 5j ; Simple Sirup, Siij.; a teaspoonful four times a day. 1002. The wet pack at night, and cold sponging in the morning, will be found markedly beneficial in the majority of eases. But in some it does harm rather than good, and in these I Avould use the perpetual blister on each side of the larynx, covering a spot from the size of a dime to that of a twenty-five cent piece. 1003. In the more advanced stages of the disease we use local applications, principally with a spray apparatus, of Iodine, Iodoform, Carbolic Acid, Tannic Acid, Nitrate of Silver, etc., but further than palliating the disease, I have never seen them do much good. 1004. Very much will depend upon the careful selection of remedies for the constitutional disease in these grave cases. If we persist in giving Iodide of Potash, when not indicated, defibrinizing the blood Avith it, and impairing nutrition, we Avill see our patient groAv Avorse rapidly. In the majority of these cases, especially the more advanced, a restorative treatment is of the utmost importance, and should not be neglected. In some it Avill consist of the Bitter Tonics, as the Triple Phos- phate of Quinine, Strychnine and Iron, (Compound Tonic Mixture) ; in others of the Hypophosphites ; in others of Cod- Oil; in others of Arsenic; in all of an abundance of good, nutritious food. 1005. There is an occasional case of these grave lesions, marked by a small, incurved tongue, Avith prominent roil papilla, in which I should give small doses of Donovan's Solution, say gtts. ij. to gtts. iij., three or four times daily; to be followed after three or four days, with Cod-Oil Venereal Diseases. 347 syphilitic disease of bronchle and lungs. 1006. Among the rare syphilitic diseases may be named ulceration of the bronchial tubes, Avith the symptoms of chronic bronchitis, and of the lungs, Avith symptoms simulat- ing phthisis. A very clear decription of these lesions is given by Aitkin, Avhich 1 quote. 1007. " The folloAving are the kinds of lesions Avhich pre- dominate : 1. " Evidences of Inflammation of the Mucous Membrane of the Bronchial Tubes.—In such cases bronchial irritation, Avith fever in many cases, precedes the skin lesions, and may disappear Avholly or partially Avhen the skin lesions are established. On the other hand, if the syphilitic eruption suddenly disappears, bronchitis may ensue. Walsbe records Avell-marked instances of this ; and it is a circumstance to be looked for amongst soldiers especially, Avho, having recovered from a primary syphilitic sore, are apt to be exposed to the risk of bronchitis Avhen mounting: guard soon after being discharged to duty. Secondary symptoms and pulmonic lesions are then apt to date their commencement; and all the general symptoms of phthisis may supervene, and yet no tubercle in the lung may be developed; but chronic bronchitis remains persistent. On this point Dr. Walsbe observes, that in the persistence of the general symptoms there 'is assuredly enough to create a strong suspicion of the existence of tubercle in the lungs, taken in conjunction Avith the indubitable tendency of syphilis plus Mercury to induce the outbreak of phthisis in a person having 'the requisite constitutional aptitude. How are the cases to be distinguished? By the total want of accordance betAveen the physical signs and the constitutional symptoms : the patient with syphilitic bronchitis has neitherconsolidation signs nor, a fortiori, the evidences of excavation. But there is a curious source of difficulty which sometimes starts up in these cases, and renders doubt imperative,—the infra-clavicu- lar ribs and clavicle thicken from periostitis, and produce 348 Venereal Diseases. dullness under percussion, which can not Avith positiveness be distinguished from that of tubercle Avithin the lung. Here the observer must wait for events to clear up the diagnosis.' (Diseases of the Lungs, p. 233.) 2. lk The Occurrence of Gummatous Nodules in the Pulmonary Substance.—These are, in the first instance, of the same histo- logical constitution as the well-knoAvn node of the shin, or the subcutaneous product described by Ricord, Barensprung, VirchoAV, and McCarthy. They form especially toAvard the periphery and bases of the lungs. In the former site they resemble nodules of lobular pneumonia. They may soften and be eliminated much iu the manner of tubercle, although they may have at first a consistence like scirrhus. It is con- cerning those Avhich soften in this Avay that Ricord gives the warning ' not to confound suppuration of a feAv syphilitic nodules of the lungs with phthisis.' Regarding those gum- matous nodules Dr. Walshe observes : ' I can find no positive ansAver to the query, Do these gummata ever form inde- pendently of other tertiary evidences of syphilis in the bones and cellular tissue ? If they do. their diagnosis must be infi- nitely difficult—difficult, indeed, under all circumstances; for the physical signs can be none other than those of solidifica- tion, folloAved by softening and excavation, Avhile the local aud general symptoms closely simulate those of phthisis." (Diseases of the Lungs, p. 431). 3. " The Occurrence of Gummatous Nodules in. various Stages of Growth and Degeneration, associated with the Miliary Deposit of Tubercle.—In such cases the history of events in the illnesses of the patient may be found to correspond more or less closely with the appearances seen in the lungs—appearances which distinctly indicate the formation of lesions commenced at dif- ferent dates—appearances which denote the occurrence of lesions in crops, or as a succession of events Avhich may be illustrated by the history of the symptoms during life. "The minute structure of these gummatous nodules has been closely examined by many observers. They consist of a Venereal Diseases. 349 growth of elements Avhich leads to the development of an elastic tumor composed of a well-defined tissue, and the ele- ments of Avhich are extremely minute. The tumor takes origin from the connective tissue, or the analogues of such ; and hence the universality of the site of syphilitic lesions. When these are sufficiently large to attract attention—as in the form of a node on the shin-bone, or on some part of the true skin—they are small, solid, pale knots, like a hard kernel, about the size of a pea. They are generally first seen on some part of the true skin or subcutaneous or submucous tissue ; and when the tissue in Avhich they happen to grow is sufficiently lax, they groAv to a considerable size, and convey to the touch a sensation as if they Ave re filled Avith gum. Re- peated examinations of this groAvth sIioav that in its gelatin- ous or soft state it arises from a proliferation of nuclei amongst the elemeuts of the connective tissue, not unlike the formation of granulations in a Avound. The component cell- elements appear as round, oval, or oat-shaped particles im- bedded in a'matrix of fine connective tissue of a granular character, and tending to fibrillation. The cell-elements are a little larger than blood-globules, and are distinctly granular in their interior when mature. In the groAving part of the node, aud immediately in its vicinity, where growth is abnor- mally active, the minute cell-elements are seen to be devel- oped in groups within the elongated and enlarged corpuscles of the connective tissue. In form, therefore, the node or gummatous nodule resembles a tubercle; aud by fatty de- generation or tuberculization may not be capable eventually of being distinguished from tubercular deposit. Hoav, then, are Ave to recognize the specific nature of such gummatous nodules? There is nothing in them so specifically and ana- tomically distinct that, apart from their history, they can be recognized. The history of the syphilitic case during life is the great guide. The nodes on the shin-bone, or clavicles, have long been recognized as the product of syphilis. It may almost be said that they have been seen to groAv under the 350 Venereal Diseases. eyes of the patient and the observer; and their anatomical characters are found to be such as compose the gummatous nodules just described. In a case of inveterate syphilis, therefore, whose history is fully known, in Avhom the node on the shin or other bones is characteristic, and has been seen to groAv, and in whom also Ave find similar nodules in the lungs, or in the liver, or in the testicles—symmetrically growing in these latter organs, and consisting of minute cell-elements exactly the same as the node on the shin—it is impossible to overlook the fact, or not to be impressed Avith the belief, that all of these lesions acknoAvledge one and the same cause of development—namely, the syphilitic poison—of which they are the expression. The progress of the node is also charac- teristic and suggestive. Growths of a similar form Avhich re- sult from idiopathic inflammation generally proceed to the formation of an abscess, or to the hypertrophy of fibrous tissue. Abscesses are recognized by their pus; fibrous tumors or hypertrophies, by the fibre-elements which com- pose them. " GroAvths of a form similar to the node, which result from cancer, are in general to be recognized by the juice expressed from them. In the gummatous nodule Ave haA-e no juice, and the cell-elements seen in cancer are generally so diversified in their form and mode of growth as not to be easily mis- taken. The gummatous nodule is uniform as to the size and form of its cell-elements, and forms a growth less highly sup- plied with bloodvessels than a cancer. Cancers tend to infil- trate and involve neighboring textures; the gummatous nodule remains isolated and distinct. " % way °f" elimination, therefore, and by duly observing the history of the case, Ave are generally able to recognize the nature of such growths, and to assign to them their proper place in pathology. " The gummatous nodule has now been recognized and de- scribed in almost all the solid viscera of the body. Symmet- rical development is a most constant characteristic. If a node Venereal Diseases. 351 grows on one shin, it is probably also to be found adATanciuo" on the other; if found in one testicle, it is extremely probable that it Avill be seen in the same relative spot in the other. Numerous examples of this symmetrical development may be seen preserved in the Pathological Museum of the Army Medical Department at Netley. During the growth of the nodule, proliferation advances sloAvly, and gluey-like material forms, which constitutes the inner cell-material of the nodule. If near the surface, such a nodule is apt to melt down, soften, open, and ulcerate; and such a result seems to be associated with other evidence of active constitutional disease, such as exists Avith a predisposition to tubercle, or with its actual ex- istence. The tumor, however, continues gelatinous and cohe- rent if it is inclosed in a dense part, or is deeply seated, as in gummata of the periosteum, scalp, brain, liver, testicle, lungs, and heart, if constitutional disease remains latent or inactive. Fatty degeneration may also eventually occur in the gumma- tous nodule, and eventually lead to its absorption ; or its ab- sorption takes place as a natural process of cure, the changes of which are not exactly known. We know only that the node on the shin-bone not seldom disappears from view, and does not return. "For reasons already stated, phthisis must be regarded in many cases as the product of syphilis; and I Avould fully in- dorse the statement of Dr. Balfour, from what I have seen in the post-mortem rooms, when he says that a great cause of pulmonary disease among the Guards is the amount of syphilis which prevails amongst the men, which he has not the least doubt is a very fertile cause of its being called into active operation. The influence of syphilis on the health of the soldier is indeed poAverful for evil throughout the Avhole army." 1008. The treatment of these lesions Avill require much care, and should be carefully directed to conserve vital power. It Avould be difficult here, Avithout occupying too much space, to give the means in detail, but they may be classed in three 352 Venereal Diseases. groups—1st, those that influence the respiratory apparatus, removing irritation, giving rest, and stimulating the impaired mucous membranes; 2d, those that improve the vegetative function, increasing digestion, blood-making, and nutrition; 3d, those directed to the removal of the specific disease. 1009. Among the first, I may call attention to Veratrum, Sauguinaria aud Lobelia. The first is par excellence the remedy to relieve irritation of the circulatory and respiratory apparatus, and Ave employ it quite frequently in the treatment of all forms of syphilitic disease. It may be associated Avith Cod-Oil, Arsenic, the Iodides, or other means, and in propor- tion as it gives a better circulation of blood it will be found beneficial. I like the action of small doses of Sauguinaria upon the respiratory mucous passages, and in the single case of syphilitic disease of these structures that I have seen, marked benefit attended its use. I prefer the Nitrate of Sau- guinaria, grs. ij. to Syrup, Siv. ; in doses of half to one tea- spoonful four times a day. Lobelia is also used in small doses, gtts. x. of the Tincture to Water, Siv. ; a teaspoonful every three or four hours. 1010 Much Avill depend upon the proper selection and use of the second class. In the rarer cases, the Bitter Tonics will prove useful. In a larger number, the bitter Avill take the form of a nerve stimulant, as in the Triple Phosphates of Quinine, Strychnine and Iron, in some cases Nitric Acid; in some the Hypophosphites; but in the larger number more benefit will be had from the use of Cod-Oil, and small doses of Arsenic. The third class of remedies will be selected as in other Byphilitic manifestations. Venereal Diseases. 353 syphilitic affections of the digestive organs. affections of the mouth and throat. 1011. Erythema of the throat is an early symptom, as we have already noticed. It may pass away soon, or re-appear several times, before the parts become permanently diseased. The disease makes its appear- ance in the mouth, in the form of small ulcers, usually situated on the edges of the tongue, in- side of the lips, or upon the cheeks. The parts adjacent to the inflammation are reddened and tender, Avhile the ulcer is more or less painful. It will vary in size from a grain of wheat to the size of a dime, rounded, oval, or irregular in form, Avith sharply cut edges, and its base covered with a coppery-yellow or gray material. Sometimes they remain stationary, but at others they mani- fest a tendency to spread and involve adjacent parts. We Avill occasionally find them remaining unchanged in size and appearance for months. When healed a cicatrix is left, and the part retains a peculiar hardness for some time. 1012. Ulceration of the throat commences in a similar manner, in many cases, the ulcer being the cause of the sore- ness. At others, the throat becomes inflamed, giving rise to uneasiness and pain in deglutition. On examination it is found of a dusky red, the mucous membrane thickened, and the follicles enlarged. The ulcers are usually of a circular form, the edges Avell defined, and covered Avith a dirty yelloAv or Avhite, pultaceous material. As in the mouth, they mani- fest a tendency to enlarge, but at other times attaining the size of a three or five cent piece they remain stationary. 1013. In addition to the general treatment heretofore de- scribed, Ave may use the folloAving local means: Frequently 23 354 Venereal Diseases. the ulcers of the mouth are benefited, or heal rapidly by free cauterization Avith Nitrate of Silver, a mouth Avash of a strong decoction of Hydrastis or Baptisia being employed. Hydras- tin one part, to Chlorate of Potash five parts, is sometimes a very good application, as is a solution of Permanganate of Potash, one or tAvo grains to the ounce of Avater. 1014. For the disease of the throat Ave employ a gargle of a decoction of Baptisia Avith Chlorate of Potash, or instead a lotion of Iodide of Ammonium in Glycerine and Avater. The solution of Permanganate of Potash Avill be found an excel- cellent remedy, using it three or four times a day. The ulcers may be touched occasionally Avith Muriated Tincture of Iron, or with Nitrate of Silver, which assists in removing them. TUBERCLE OF THE TONGUE. 1015. Iii the advanced stages of syphilis Ave sometimes find well defined nodules of aplastic material deposited in the tongue. This may be a cause of soreness, usually of difficult movement, but sometimes will continue for a long time Avith- out suffering. Finally this material breaks down, ulcers are formed, and it is discharged. This is usually associated Avith a low grade of inflammatory action. 1016. Fissures of the tongue are usually symptomatic of inflammatory lesions of the kidneys, and will ahvays suggest great care in the use of remedies. The deep fissures, with ulceration, observed in old cases of syphilitic disease, may be dependent upon the deposit of tubercle. GUMMATA. 1017. The gummy deposit (aplastic) of syphilis, presents itself in the pillars of the fauces, the soft palate, and adja- cent structures, and is frequently the origin of the destructive ulceration of these parts. 1018. The first symptoms are of soreness, and uneasiness in deglutition, with a feeling of fullness or constriction of the parts. A careful examination shows at first a discoloration Venereal Diseases. 355 aud localized engorgement, Avhich after a time gives evidence of a Ioav grade of inflammation terminating in ulceration. These ulcers are remarkable for their depth, and in many cases soon perforate the structures. Thus we will find them perforating the pillars of the fauces, sometimes showing the ulceration in front, but in others upon the posterior surface. A very common and unpleasant location is about the middle of the soft palate, Avhich may be first noticed as an elongated ovoid ulcer, covered with a grayish-yelloAv slough. This thrown off, and the perforating character of the ulcer is clearly seen, and sometimes passes through the tissues in a feAv days. Similar points of ulceration, evidently from gummy deposit, may be seen at the point of attachment between the soft and hard palates, and in the roof of the mouth, at any point between this and the alveolar process. It is singular that they appear so constantly on the mesial line, and retain the ovoid character. 1019. These points of ulceration may progress only to the size, and for the removal of the deposit, and will then heal kindly. But in other cases the ulcerative process once set up, seems to groAv in intensity as it progresses, until the tissues seem to soften and break doAvn before it. Or possiblv the majority of these would be better described by saying, that the inflammation Avhich attends them causes a continuous infiltration of adjacent tissue with aplastic material, destroy- ing the resisting poAver of the structures. 1020. This destructiA^e process once set up, and all tissues yield before it, mucous membrane, connective tissue, fibrous tissue, muscles, cartilage and bone. It may perforate and de- stroy the soft palate, the hard palate, the roof of the mouth, or the structures of the fauces. Commencing in these parts it may progress upwards, attacking the structures of the nasal cavities, destroying structure after structure, until mouth, throat and nose become one cavity, or the drain upon the economy is so severe that life is lost. 356 Venereal Diseases. 1021. The general treatment of these lesions will not differ from that heretofore named. The reader will see the import- ance of conserving the life of the patient, and the life of the tissues affected, and as far as possible making the treatment restorative. This is one of the cases in Avhich Cod-Oil and Arsenic come into prominence as restoratives, and may arrest the local destruction. '1022. In the early stage of ulceration, I would advise the local use of Nitric Acid with the pine pencil, and the usual local applications. The use of Sulphurous Acid, Avith the spray apparatus, may be suggested, as giving excellent results in some of these cases. Of the vegetable remedies I have ob- tained better results from the Alnus, Scrofnlaria aud Rumex, than any others. I employ them in infusion, both internally and as a local application. 1023. All operative interference Avith the bones of mouth or nose should be avoided. Ea^ii Avhen a sequestrum seems loose, much force should not be used in taking it away. As a local application to diseased parts, to facilitate the removal of that Avhich is dead, and to stimulate the tissues against the destructive process, I Iciioav of nothing so good as our old- fashioned Sesipiicarbonate of Potash. 1024. The (Esophagus is rarely the seat of syphilitic disease, though sometimes the ulcerative process extends to it from the pharynx. Cases are on record, in which the cicatrization of such ulcers produced permanent stricture and death. In the majority of cases, dysphagia is nervous, and does not ensue from stricture. In some it is due to irritation of the nerves of the oesophagus, from ulceration of the throat. In others it is a symptom of disease of the brain, and probably one of the most common and distinctive symptoms Ave meet with. 1025. Nervous dysphagia is treated with Pulsatilla, Bro- mide of Ammonium, or Lobelia, as may be indicated. The first is especially useful, Avhen there is dizziness, want of power to control the voluntary muscles, and fear of impend- Venereal Diseases. 357 iug danger. The second, Avhen the attacks are epiliptiform. And the third Avhere there is precordial oppression. 1026. The stomach sIioavs the influence of the syphilitic poison upon its function, as Ave have already noticed in " syphilitic feA'er," and Ave Avill find cases in which this im- pairment is very marked and persistent. But this func- tional wrong is about the only one Ave have to notice, as this viscus seems to be exempt from the specific ulcerative process, or the deposit of aplastic material. 1027. The liver has been found diseased in secondary syphilis, but it is difficult to determine whether this is to be attributed to the syphilitic virus or to the over-stimulation of mercurials given for its cure. In my opinion the latter is best supported by evidence. 1028. We can see how this organ, directly and continu- ously influenced by mercurials, with its circulation deranged, and its function interfered Avith, should suffer from Ioav grades of inflammation, and be the seat of tubercular or gummy de- posits. So far as my experience goes, and so far as I can trace the history of the non-mercurial treatment, no such lesions attend it. 1029. The intestinal canal suffers from over-medication and the abuse of cathartics, but until Ave reach the rectum, Ave find little evidence of the specific disease. Lanceaux says : " That tx'he facts seem to prove that the intestines are not ahvays ex- empt from the attacks of syphilis, for although the cases are lare in which this canal is affected, it is none the less true that the multiple and rounded ulcerations, penetrating to a greater or less depth and circumscribed by fibrous tissue, of Avhich it is sometimes the seat, are probably only the sequence of gummy deposits, or, in other words, the result of the de- generation Avhich these deposits have undergone." 1030. The rectum suffers from syphilitic disease more rarely than Ave Avould suppose. Even ulceration just Avithin the sphincter though occasionally met Avith, is a rare form of the disease. Syphilitic fissures have been spoken of, but these 358 Venereal Diseases. are probably simple, and the result of other causes, in the majority of cases. 1031. Mucous tubercle of the anus is quite common, prob- ably the most frequent seat of the lesion, and is sometimes very unpleasant. The patient thinks, probably, that he is troubled w7ith hemorrhoids, and frequently is treated for this disease. Finally an examination reveals the mucous tuber- cles, and the treatment heretofore named soon removes them. DISEASES OF THE NEKVOUS SYSTEM. MUSCULAR PAINS. 1032. Muscular pains frequently accompany the earlier symptoms, though they may attend all stages of the disease. These pains are sometimes attended Avith a sense of stiffness and soreness, as if caused by over exertion, but at others they are more of the nature of cramp, and are relived by pressure. The addition of Conium to the remedies employed is usually required to remove them. If they are located in the fibrous structures near the joints, Macrotys Avill also prove useful ; if there is oedema, give Apocynum. NEURALGIA. 1033. Among the later symptoms of syphilis is a most in- tense and persistent neuralgia, not associated Avith nodes, or other structural lesions. Intense pain may, in some cases, be dependent upon disease in the course of the nerves, as in a; case of ulnar neuralgia I witnessed from disease of the hume- rus, but this will be readily detected. The disease Ave Avisb to describe is associated Avith marked impairment of the vege- tative functions, and some of the lesions classed a3 tertiary. 1034. In the majority of cases the pain is of the extremi- ties, and seems to be in or about the denser fibrous tissues, and in these situations is sometimes most intense. In a re- cent case it Avas located in the feet, seemingly in the plantar fasciae, and for six Aveeks the patient suffered beyond all de- Venereal Diseases. 359 scription. It Avas associated here Avith a very sore mouth, the tongue being fissured, and bleeding on the slightest pressure, Both hands had been badly diseased for some months, Avith syphilitic psoriasis, so that the patient Avas incapacitated from Avork. The sore mouth and skin disease Ave re cured Avith Rhus, the neuralgia yielded to Iodide of Potassium as soon as the digestive organs Avould tolerate the drug in sufficient quantities. DISEASES OF THE BRAIN. 1035. Syphilitic lesions of the brain are also among the later symptoms, and though very serious and frequently fatal, are often overlooked. The lesions sIioavii after death are very distinct, and it is a Avonder sometimes, not that death should have resulted, but that life Avas maintained so long. 1036. Gummata of the brain is probably the most common lesion. Obscure in its course, there is a slow deposit of im- perfect albuminoid material in the substance of the brain, or its meninges, or sometimes in the connective tissue betAveen the dura-mater and bones of the cranium. For a time the organism accommodates itself to the changed condition and process, with the development of one after the other of the symptoms hereafter described, until finally death results from compression, or from the .breaking cIoavu of the deposit. This condition is described by Ricord, as syphilitic tubercle of the brain. 1037. Degeneration of the nerve substance may result from impaired nutrition Avithout any syphilitic deposit, pre- senting the ordinary symptoms of cerebral softening. In other cases the cerebral vessels suffer from syphilitic disease, aud atheromatous patches, aneurismal dilatations, and the presence of a loose cicatrical tissue, are the evidences of its progress. 1038. Wilks remarks, with reference to some of these cases, that, "a quantity of tough, yellow, fibrous tissue B60 Venereal Diseases. unites together the surface of the brain Avith the adjacent membrane, and this again is adherent to the bone. The cor- tical substance of the brain at the affected spot is often partly destroyed, and the adventitious material occupies its place. The question has still to be solved as to what structure is pri- marily affected. Many have given the authority of their names to the opinion that the disease commences first in the bone, but simply for the reason that the osseous system is that which has so long been recognized as liable to be affected. But since Ave noAv knoAV that other structures may be similarly attacked, Ave are prepared to look for its commencement in other parts, and even in the brain structure itself. . . The cases Avhich are so frequently met Avith are those where the deposit involves both sides of the dura mater, and includes in it the bone on one side and the brain on the other. The probabilities are in favor of its occurring in the dura mater first, as it arises in the periosteum on the exterior of the cranium." (Wilks in Med: Times and Gaz., Oct. 25, 1862.) 1039. The symptoms in these cases, at first obscure, be- come gradually more pronounced. In many cases, the patient will first complain of a sense of fullness or sometimes lightness of the head, Avith dizziness and want of command over the voluntary muscles. There may be impairment of hearing, with tinnitus aurium, impairment of vision with muscse volitantes, ptosis, or other local lesion depending upon the situation of the lesion in the brain. A verv common symptom is an impediment in Avalking, a "dragoino- oait " usually more marked in one side than the other. 3040. Following these symptoms, the patient Avill some- times suffer acute pain in the head, which may continue in rare cases for days or weeks. This is the precursor of paraly- sis in some of its forms, or sometimes of the softening and breaking down of the gummatous or tubercular deposit. 1041. The situation and degree of paralysis vary greatly in different cases. In the majority it is never complete, and Venereal Diseases. 361 is not constant, being uoav better, uoav worse, for mouths 01 even years. 1042. The treatment of these lesions is sometimes quite successful, but only when the right antisyphilitic is selected. If Iodide of Potassium is the remedy, we will find that pain, dizziness, paralysis, and the series of symptoms will rapidly fade out before it, and this is the case with other remedies employed in the disease. If Ave do not find such remedy, the disease Avill run its course, and Ave can only palliate the symptoms. IRITIS. 1043. Inflammation of the iris is one of the most serious lesions of syphilis, involving as it does so important an organ, and if not arrested, causing the destruction of the eye. It most generally makes its appearance from six to fourteen months after the primary disease, being associated Avith papulae, alopecia, and sore throat. It does not differ mate- rially in its symptoms from nou-syphilitic iritis, and can only he diagnosed from it bv its association with other lesions. 1044. Dimness of sight and fatigue in using the eye is r.sually the first symptom, and may continue for several days before the disease is developed. Soon the globe becomes sore Avhen pressed upon or when moved, and injection of the circum-corneal vessels is noticed. The pain soon becomes severe, with a feeling of extreme distension of the eyeball, said dull pain extending to the orbit and forehead. There is much intolerance of light, Avith increased secretion of tears, when the eye is exposed, and dimness of vision and haziness become prominent at this time. If Ave examine the eye, Ave will notice a redness situated beneath the conjunctiva, which is formed by vessels passing in radii toAvard the cornea. The pupil is contracted and looks dull, and the motion of the iris is impaired, its color is also changed, becoming yellowish- green if the person had blue eyes, and dusky red if they were dark. Some writers base a distinction betAveen common and syphilitic iritis, by the scattered and furuncular appearance 362 Venereal Diseases. of the redness for some time, and upon the rusty color of the iris near its pupillary margin Avhich is observed in the last. 1045. If the disease is alloAved to progress, the iris bulges forward toAvard the cornea, the pupil is irregular in form, and at last becomes obliterated, and the exterior half of the eye and cornea become more convex ; myopia, hardness of the eye and amaurosis folloAV more or less promptly. 1046. Though a severe affection, the treatment is com- paratively simple, and very successful. Open the patient's boAvels and keep them regular with the Podophyllin pill heretofore named, and give a solution of Iodide of Ammo- nium in ordinary doses. Keep the stomach and digestive organs in good condition by the use of tonics and small por- tions of Quinine. At first use the spirit vapor bath, with cold sponging daily, afterward a simple bath Avill be sufficient. 1047. The most important part of the treatment is to keep the pupil dilated with Belladonna. If this is done, im- pairment of the structure of the eye need not be feared. I prefer a solution of Atropia, from one to five grains, to the ounce of distilled water, and dropped into the eye every four to six hours. The same object may be accomplished by the use of the Extract of Belladonna around the eye and to the lids, or by a collyrium of: R Fluid Extract of Belladonna, 5j-; Watir, 5j. No other local means should be employed, as it avouId interfere Avith the above and lead to bad results. Keep the patient quiet, in a darkened but Avell ven- tilated room, until the pain and intolerance of light has en- tirely disappeared. SYPHILITIC DISEASE OF THE BONES. 1048. Disease of the bones is among the latest symptoms of constitutional syphilis, and is included in the tertiary form of the disease, when this division is made. It is very difficult at this day to determine what part in the causation of these aft'ectious the virus of syphilis plays, as it is well known and Venereal Diseases. 363 noAv admitted by most Avriters, that Mercury will give rise to all the phases of them noticed. It is my belief that they are Avholly due to mercurialization, and that syphilis has nothing to do Avith them. We will notice some authorities upon this subject. 1049. Mr. Parker Avrites, " We may naturally inquire Avhether Mercury has anything to do Avith the production of nodes. I confess that I am disposed to think that a great deal of mischief is due to a mercurial cure." "It is a fact," says Mr. Carmichiel, " that in those cases of syphilis treated Avithout Mercury, the secondary symptoms are particularly mild, and the bones are seldom or never affected." Dr. Chas. A. Lee, in a note to Copland's Dictionary of Medicine, re- marks: "The symptoms folloAving mercurial treatment are more severe aud difficult to remove than those folloAving pri- mary sores not treated Avith Mercury ; and Avhen relapses do occur in the secondary stage, they are far more readily re- moved in those cases Avhere no Mercury has been given. Mercury, when given incautiously, or in too large quantities, especially in syphilitic diseases, tends to undermine the con- stitution, to predispose to and aggravate constitutional affec- tions, to increase general irritability, to induce inflammation and ulceration in, and destroy the mucous textures, to pro- mote morbid absorption and removal of the fatty, fibrinous Mid osseous substance of the system, and to induce synovial, albuminous, and serous accumulations. The extent and in- jury to the soft and bony parts of the system produced by Mercury, are more to be dreaded than any primary or secondary effects of venereal poisons." nodes. 1050. Nodes are hardened elevations upon the bones, caused by exudation between the periosteum and bone, the result of a Ioav grade of inflammation. In other cases the material throAvn out resembles the provisional cartilage in fracture, and occasionally deposits of bony material takes 364 Venereal Diseases. place within it, giving it almost an ivory hardness. In some cases this groAvth progresses to considerable size Avithout any unpleasant symptoms, but in others there is more or less pain, usually deep-seated, tensive and aching. 1051. Nodes may form upon any of the bones, but are more frequently met Avith where they are superficial. The tibia is a favorite location, as is the bones of the cranium, and in these situations they are ahvays unpleasant and pain- ful. In some cases nodes of the cranial bones give rise to ex- cessive pain, Avhich is not relieved until suppuration occurs, or the tension is removed by the use of the knife. 1052. Nodes terminate in a variety of Avays. Resolution frequently results under appropriate internal treatment, the enlargement gradually passing away, though almost ahvays leaving a roughness or unevenness that remains for life. In other cases, inflammation of the bones occurs, folloAved bv suppuration and caries. 1053. In addition to the general means, Avhich should be carefully selected, Ave sometimes employ local applications with advantage. Penciling the surface with Collodion will sometimes relieve pain, and by its contraction cause absorp- tion of the effused material. A saturated solution of Iodide of Ammonium is a favorite local application. It may be im- proved by combining equal parts of a strong Tincture of Iodine and Aqua Ammonia ; if allowed to stand for a feAV days it is decolorized. Conium, Aconite, Veratrum and Bel- ladonna have been employed in some cases with advantage, but unless specially indicated they frequently fail. 1054. If the pain is excessive, and is not relieved by the local means named, and the internal treatment is slow in its influence, Ave may employ the hypodermic injection, or resort to free incision. We use the common solution of Morphia, (grs. x. to 5j.) with or without the solution of Atropia (grs. j. to Sj.) throwing it under the skin as near the point of dLase as possible. This always gives temporary relief, and will sometimes be followed by the, disappearance of the node. It Venereal Diseases. 365 is bad treatment, however, to persist in the use of Morphia hypodermically, merely for temporary relief. A better prac- tice is, to make a free incision through the distended perios- teum to the bone, giving exit to the glairy deposit under- neath. This is almost ahvays followed by relief, and the dis- appearance of the disease at this point. NOCTURNAL PAINS. 1055. Are almost ahvays associated with nodes, and are sometimes so severe that they prevent sleep and cause much nervous exhaustion. These pains may also occur Avithout apparent disease of the bones, in each case being deep-seated and aching, or as if there was a foreign body in the part that should be removed. 1056. In some cases the suffering is most intense, prevent- ing rest, and finally impairing the nutritive processes. The patient may suffer but very little :f any during the clay, and examination shoAvs no structural cause for the severe pain, yet as soon as he lies cIoavh, the pain commences, or he is aAvakened out of his sleep by the pain. 1057. We may employ the usual means for temporary re- lief, but no permanent benefit need be expected except from the general antisyphilitic treatment. The administration of Opiates either by mouth or hypodermic injection, Avill gener- ally interfere Avith, or may Avholly prevent the action of proper remedies. SYPHILITIC PERIOSTITIS. 1058. The superficial bones are those most commonly affected, though once in a Avhile the deeper seated will suffer. Commencing as a node, the periosteum and adjacent bone become more vascular, a peculiar viscid material is deposited, and finally inflammation results. This runs a variable course, sometimes acute, at. others very sIoav, not unfrequently termi- nating in suppuration, and caries of the bone. 1059. The disease of the bones thus set up is in some cases very destructive. As we have already seen, it may de- 366 Venereal Diseases. stroy the bones of the nose, aud those forming the roof of the mouth, producing great deformity. Commencing in the bones of the legs, especially the tibia, it may continue for months or years, each succeeding outbreak confining the patient to his room for days or Aveeks. Affecting the bones of the feet, the disease is very painful, and is frequently pro- longed, aud results in permanent disability. Affecting the former, the inflammation is deep seated, and involves the Syphilitic Hypertrophy. superimposed parts, producing extensive abscess and great exhaustion. In the bones of the cranium, the disease is espe- cially painful, as Ave have already seen, and frequently o^oes on to the destruction of the external table of the skull, and in some rare cases to the entire destruction of the bones, and exposure of the brain. 1060. The upper extremities suffer like the lower. The disease may attack the clavicles, and be followed by caries or necrosis, and by contiguity the deeper structures, and even the lungs may be implicated. Disease of the arm or forearm is almost always followed by deformity, and impaired func- tion. The ribs and the cartilages suffer, and disease of the sternum has been observed, going on to its destruction and the exposure of the organs beneath. 1061. As no part of the osseous system is exempt, so Ave will find every form of bone disease, from the simple osteo- periostitis, which terminates in resolution, to caries and ex- tensive necrosis. 1062. Permanent cures may be expected in many cases, but in some, the bones once affected there is successive out- Venereal Diseases. 367 breaks as long as the patient lives. In these the bones be come thickened and rough ; the tissues above show abundant cicatrices of former ulcerations; sinuses leading to diseased bones persist, and discharge continuously, and sometimes sequestra are carried for years. 1063. The treatment of these cases will be the same as in simple periostitis and osteitis, except in so far as it is directed against the syphilitic poison. A cure is ahvays sIoav, and if we can make it permanent, it is with months of careful attention. SYPHILITIC ORCHITIS. 1064. Syphilitic orchitis has been classed by some Avriters with the secondary symptoms, by others with the tertiary. It rarely comes during the first year, yet it has been seen as early as the sixth month. In some cases it is purely inflam- matory, in others the enlargement is from gummy deposit, and there may be but little inflammatory action. 1065. In the majority of cases the enlargement is quite slow, and the patient is only aAvare that there is disease of the testes by the dragging sensation upon the cord. As the enlargement continues, there is occasionally tensive pain, associated Avith a feeling of great Aveight and dragging upon the cord, Avhen the organs are not supported. Exercise Avill frequently increase this so much, that the sufferer is forced to keep quiet. 1066. In some cases there is never any pain, and the organ is not sensitive to pressure, the only discomfort the patient experiences being from the increased weight of the testes. These are said to be the typical cases, and that when Ave find the enlarged organs, Avithout pain or even ordinary sensitiveness, the patient having had syphilis, Ave may con- clude it is syphilitic orchitis. This, hoAvever, has not been my experience. 1067. The treatment Avill not differ from other similar lesions. In many cases Iodide of Potassium aviII be found 368 Venereal Diseases. the internal remedy, as a solution of Iodide of Ammonium is the best external application. But in this as in other cases, the treatment must be adapted to the case in hand. A friend of mine suffered from syphilitic orchitis for many months, and after exhausting all the common means, cured himself with small doses of Proto-lodide of Mercury, and the use of electricity. It was suggested that probably the galvanic cur- rent might have removed the disease alone (?) I think in many of these cases it will be found a useful remedy. 1068. The Phytolacca will prove a good remedy when the disease is acute, and may be employed as a local application as well as internally. The Iris Versicolor has also given good results, using a Tinctnre of the fresh root. INFANTILE SYPHILIS. 1069. Secondary syphilis may be transmitted from either parent to the child, Avhich Avill be born impregnated Avith the poison. The disease either sIioavs itself at birth or a few months after, though in rare cases several years may elapse. The most common affections of the child is the squamse, and pustular skin diseases, though occasionally the mucous mem- branes are affected. There is almost ahvays contraction of the jaws, and deformity of the teeth, and this is looked upon as evidence of syphilitic parentage, even when no other symptoms present. The folloAving are the propositions laid down by M. Ricord regarding the transmission of syphilis : " 1. The father and mother may transmit the disease to their child indifferently, if either or both of them be affected. " 2. Transmission may occur from the parents to the child, Avhen they are affected Avith constitutional symptoms, or when a concealed syphilitic diathesis exists in them. " 3. The absence or existence of constitutional symptoms in parents at the moment of impregnation and conception exerts no influence on the form of the disease, Avhich may after- ward appear in the child. The distinction established by M Venereal Diseases. 369 Cazenave betAveen congenital and hereditary syphilis, and Avhich is based on the absence of constitutional symptoms in the parents at the moment of generation, or Avhich have been developed in the mother during gestation, is totally errone- ous; and indeed M. Cazenave confesses that his opportuni- ties of observing have not been ample. " 4. The character and period of the manifestation of the symptoms in the child are governed by the stage to which the disease had advanced in the parents at the moment of generation. The treatment to Avhich the parents Avere sub- jected may also retard, prevent, or modify its appearance in the child. " 5. If the parents are both healthy at the time of genera- tion, and the mother contracts syphilis during gestation, she may transmit the disease to her child. Of this I have seen several examples at various periods of pregnancy, even to the seventh month inclusive. " 6. When the venereal poison is transmitted from the mother to the child during pregnancy, infection takes place through the medium of the placenta, and in this case, appears to occur after the fourth month of utero-gestation. " If the father alone be diseased at the moment of genera- tion, an abortion may occur at any period of pregnancy. If the mother alone be diseased at the time of conception, the abortion will not take place until after the fourth month. '• 7. Children born of a father or mother affected Avith syphilis may escape infection ; for a certaiu disposition to re- ceive constitutional disease is necessary for the child as Avell as the adult, and this may be absent. "8. Observations made as accurately as possible seem to prove that constitutional syphilis may be transmitted from the child to the mother during utero-gestation." 24 370 Venereal Diseases. SYPHILIZATIOK 1070. The minds of syphilographers are uoav agitated with the question, can the constitutional disposition to syph- ilis be so entirely removed that the person will be no more affected by it than he would be by smallpox, if he had pre- viously had the disease? This question is not only answered in the affirmative, but Prof. Boeck, of Christiana, Sweden, claims that continued inoculation will also remove the consti- tutional disease when all other means fail. Other surgeons have tested his views Avith fiworable results. As it is a neAv subject, it will be better to let Prof. Boeck speak for himself, and I Avill quote from a lecture delivered before the physicians of Dublin : " By syphilizatiou I understand the mode_of treatment by which, by repeated inoculations of syphilitic matter, taken from primary sores, 1 bring the body into the condition that it is no longer susceptible of the action of the syphilitic virus. "It will, perhaps, be agreeable to you, gentlemen, before I proceed further, that I should lay before you a short resume of the history of this mode of treatment. Auzias-Turenne, of Paris, performed inoculations of syphilitic matter upon animals in order to see whether this virus could be trans- ferred to them, Avhich up to that time had been denied. In this he was at length successful, and it was chiefly apes which could with the greatest facility be inoculated. After chancres had been repeatedly produced in the same ape, a great many skeptical fmysicians Avished to see his inoculation, and a meeting was appointed in the Jardin des Plantes; the old ape was inoculated, and a still greater crowd assembled a few days later to see the result. But when the ape was brought in nothing was to be seen. It may easily be imagined how the result was received, and that Auzias-Turenne was ridi- culed, but he did not on that account give up the method • Venereal Diseases. 371 he continued his inoculations, found that the old ape wras not susceptible of fresh inoculations, but that a second ape after inoculation got chancres, though this ape also, after a series of inoculations, became unsusceptible. "Auzias-Turenne uoav saAv clearly that he had here a natural laAv, in itself resembling that Avhich your immortal Jenner bad discovered in the inoculation of vaccine matter, and Ave shall not upbraid him uoav that his French blood car- ried him aAvay, and that his first idea was to employ the in- oculation of syphilitic matter like that of A/accine matter—as a prophylactic. We can not gainsay him that his train of ideas is logically correct, but it is not practically correct, for the great rule is, that he only gets syphilis avIio himself will have it. " As the result of this idea of employing syphilization as a prophylactic, my friend Auzias Avished at the time to syphi- lize all public girls, seamen, and soldiers, and he Avould wil- lingly have syphilized us all. No Avonder, then, that such an idea met Avith all the opposition it deserved; but it was not long until Auzias renounced his error, and at the same time there appeared au Italian, Sperino, of Turin, who shoAved, by a series of experiments, that the syphilitic disease Avas cured during these inoculations, Avhich Auzias, too, at the same time demonstrated. Still, this failed to reconcile physicians to the new method; such a prejudice had been raised against it, that both the Academie de Medicine of Paris and the Academy of Turin condemned it Avithout having the neces- sary materials before them for passing any judgment; the paradox invoked in this method appeared to all so enormous as to render proofs of its absurdity unnecessary. " Lecturing in the University of Christiana upon syphilis, and having a section of the hospital devoted to this disease, I carefully investigated all that Avas adA^anced upon this sub- ject, and ascertained that there must be some truth in it. I had, through a period of very many years, found that our treatment Avith Mercury is highly unsatisfactory ; I therefore 372 Venereal Diseases. considered that, from my position, it was my duty to give a trial to this neAV method, although it appeared to me as para- doxical as it did to all the world, and notAvithstanding that it had been condemned by iavo academies. But before-1 began, I laid down for myself certain limits, to Avhich I still adhere. It will be at once observed that I will not speak of the method as a prophylactic : this Avould be immoral; but neither am I at liberty to employ it in every case of syphilis; it is only when syphilis has become constitutional—Avhen the syphilitic virus floAvs Avith every drop of blood through the system— that I allow myself also to inoculate it upon the skin. "The next question is, whether I shall employ syphiliza tion in every case of constitutional syphilis ? " By a fortunate coincidence it happened that of the two individuals Avhom I first took under treatment by syphiliza- tion, the one had not been treated for syphilis, Avhile the other had been the subject of all the resources of our art. In the first the inoculations proceeded Avithout difficulty, the symp- toms gradually disappeared—in a word, I found myself upon the beaten path. In the other case all was irregular. I could effect no order at all, and Avhen my first patient was Avell, the phenomena in the second Ave re still in full bloom. I imme- diately began to suspect that it was to the medicines pre- viously given that this result was attributable, and on subse- quently investigating this opinion, its truth has been most completely confirmed, so that I have made it a general rule to syphilize only those Avho have not previously been treated Avith Mercury, whether this has been employed for primary or constitutional symptoms. But if 1 be asked whether syphilization has not some effect in these cases, I can ansAver decidedly in the affirmative—it often acts incredibly. Dr. Simpson, of Edinburgh, has recently described tAvo such cases, which Avere sent over to me by Prof. Simpson ; what is there stated corresponds precisely to Avhat I have myself noted, and of which any one may satisfy himself. But the reason why I do not undertake the treatment of such indi- Venereal Diseases. 373 viduals is to avoid having relapses, Avhich in these cases are apt to occur. " Noav, in order to make my usual mode of proceeding as plain as possible, I shall suppose that a person laboring under primary syphilis consults me. In this case I treat the primary sore as a simple ulcer—I prescribe a weak solution of Sul- phate of Zinc or such like, and occasionally employ a slight cauterization of Nitrate of Silver. I give no internal medi- cine, but make the patient come to me once or tAvice a Aveek, that I may observe Avhen the constitutional symptoms break out, for the earlier syphilization can be commenced the better. So soon as I perceive the first constitutional signs, I com- mence the treatment by taking matter from an indurated chancre or from an artificial pustule in a patient under treat- ment by syphilization. I inoculate first on both sides of the chest, and make three punctures Avith a lancet, precisely in the mode adopted in vaccinating. After three days pustules are developed, and then I inoculate again in the sides, taking the matter from the pustules produced by the first inoculation, observing carefully to make the second inoculation at a dis- tance from the first, so that the sores may not become con- fluent. At the end of three days 1 make the third inocula- tion, taking the matter from the pustules of the second in- oculation ; and 1 uoav continue to inoculate on both sides every third day, ahvays taking the matter for the fresh inocu- lation from the pustules last formed, so long as this matter continues to afford a positive result. When it no longer takes, I procure neAV matter in the same mode as for the first inoculation, and continue Avith this as with the first. This second matter will yield smaller sores and a shorter series than the first, and Avhen it no longer takes 1 procure a third and proceed in the same manner. This third matter will produce very little effect, and I therefore pass to the upper arm, Avhere I proceed in precisely the same mode as in the sides ; and Avhen no effect is any longer visible in the upper arm 1 remove to the thighs, and continue there in the same 374 Venereal Diseases. way as in the tAvo preceding places. By the time the inocu- lations are here brought to an end, from three to three and a half or four months have probably elapsed; the symptoms Avhich manifested themselves from the commencement have disappeared, or if some slight symptom has remained this disappears spontaneously. It often happens that during the treatment a fresh outbreak takes place, and be Avho is not ac- quainted with the method believes that some other plan must noAv be adopted; another infers that syphilization is of no avail. But, let them not be deterred by an} symptom, not even by the most severe iritis, which never requires anything but the instillation of a little Atropia. But, happen Avhat may, let them shut their eyes to it, and continue the inocula- tions. The patient aaIio, during the Avhole treatment can attend to his business, feels, after it is completed, perfectly well, and may immediately expose himself to any hardships. He can endure Avet, cold—in a Avord, everything Avhich after mercurial treatment Avould render him liable to life-long ill- ness. It is probable that I may uow be asked as to the result at a later period for these individuals, and I shall speak first of the relapses. On the Avhole, I ha\7e treated 429 individuals, and of these 45 have come back, making about 10J per cent.; but, as Ave may calculate that some of those treated durino- the last year will return, I will assume that the relapses will amount to 12 or 13 per cent. But, let us uoav examine more closely what is called a relapse after syphilization. In many instances a single mucous tubercle, a small white spot on the tongue or in the throat—symptoms for Avhich nothing more than external means is employed, and for which the patients are treated only for a few days in hospital. So far as I at this moment remember, thirteen were taken again under treatment with syphilization, and two with Iodide of Potas- sium. " You will next ask whether tertiary symptoms have been developed in any of them. This has been the case, I believe, Avith three; but at the same time these individuals have been Venereal Diseases. 375 perfectly well — their general health has not, as so often happens after mercurial treatment, been broken down, and in those who have had relapses it has been good, as it is evident that in those who have had no relapse it has been particularly good. " We come uoav to the children of those who have been syphilized. Here Ave are not much better off than after the mercurial treatment; Ave see the same rule to prevail as after this last method, namely—that wheu the mother has been syphilitic, the first child or children is or are syphilitic; that they are healthy is the exception. If the father has been syphilitic, the children are, in general, healthy ; that they are syphilitic is the exception. " You Avill next propose to me the question how I treat syphilitic children. I treat them precisely as I do adults; and it is interesting to see that the sores in these little ones bear in size a proportion to that of the child, and that the patients suffer less, and not more, than adults. The results of syphilization in children Avith hereditary syphilis have not been brilliant; of forty-two children, twenty-two died, but I have taken under treatment every case that I have met with, and every one knows that in such children there are very often affections of the internal organs which lie beyond our power to cure. I can not at this moment say how many little children Avith acquired syphilis I have syphilized, but they are not few, and of these only one died, the cause of death in that instance being croup after I had performed tracheotomy. Of adults, two died—an old woman of dysen- tery, and a young woman of puerperal fever. This latter case 1 forgot to include in the resume I have given in the British Medical Journal. " Noav, in order to give you a definite idea of the confi- dence I have in this method after having practiced it daily for thirteen years, I shall say only that if I myself, or any of mine, were so unfortunate as to get syphilis, I should employ no other means than syphilization. 376 Venereal Diseases. " Still, a feAv words in conclusion, gentlemen. Vaccination has for many years stood alone ; syphilization now comes to join it. Shall we stop here? I believe not. Vaccine and the syphilitic matter are both animal viruses ; we see them contained under a similar law. May not also the other animal poisons be referred to a similar law? We see that nature is simple in her diversity : should this not also here be the case? Should not glanders, hydrophobia, etc., some time be curable ? Let us all seek to clear up this dark point in our science, and let us not, as hitherto, Avith respect to syph- ilization, seek only to extinguish the rising gleam." The majority of observers noAv unite in condemning the practice of syphilization. It not only requires a long period of time, but is as unpleasant and disgusting as it is tedious. And as the old methods are dispensed Avith, the disease is found more tractable, and even if syphilization Avas successful, it will be found unnecessary. Plate I 0 * I C - "m_ 5 '4* J. ^ - 9r • XH.i: - :.r' EXPLANATION OF PLATE I. Fig. 1.—ShoAvs the result of the inoculation two hours after the matter was inserted by the lancet; already may be marked a tumefaction of the tissues, and in the center is seen the puncture made by the lancet, surrounded by a reddish areola of small extent, almost confined to the projecting parts. Fig. 2.—DraAving six hours and a half after inoculation. The inoculation is still more elevated. The areola is of a deeper color. Fig. 3.—Drawing twenty-four hours after inoculation. The projecting parts appear clearly defined, and their base is of a deep-red hue. On the summit is seen a grayish point, corresponding to the incision of the lancet. The inflammatory areola has comparatively greatly extended. Fig. 4.—Drawing in thirty-one hours. The pustule is formed. The grayish point of the morning has become completely black, and forms a small gangrenous eschar, around Avhich the epidermis is elevated by the pus. Fig. 5.—Drawing forty-eight hours after inoculation. All the elements of the pustule are progressing. (377) 378 Venereal Diseases. Fig. 6.—Drawing three days after inoculation. General pro- gress. We remark an irregularity in the periphery of the pustule, Avhich during the night discharged some pus, and in the center of Avhich the gangrenous eschar is de- pressed, and appears to be adherent to the subjacent parts. Fig. 7.—DraAving four days after inoculation. General pro- gress. The pustule is lacerated at several points, and appears to be free from pus. Fig. 8.—DraAving five days after inoculation. General pro- gress with the exception of the inflammatory areola, which appears less intense. The irregular eschar, cover- ing the Avound made by inoculation, Avas removed, and beneath it is seen a roseate base studded Avith yellow spots. On the edges Avhich are scarcely'separated, is seen a whitish border formed by the epidermis. Fig. 9.—Chancroid of posterior lip of the cervix. It has assumed a slight phagedenic character, and has lo3t its circular appearance. Plate II w n EXPLANATION OF PLATE II. Fig. 10. Mucous papulae of the vulva. Secondary symp- toms in the third month from single ulcer—chancre. Fig. 11.—Polymorphous vegetations. Fig. 12.—Secondary syphilitic ulceration of os uteri, with rose-colored granulations of anterior lip. Fig. 13.—Secondary syphilitic granulations of cervix, with chronic inflammation. (379) n Plate ILL 15 16 1Z n ty EXPLANATION OF PLATE III. Fig. 14.—SAvelling of the prepuce attending chancroid— paraphimosis. Fig. 15.—Chancroid, with paraphimosis. Fig. 16.—Suppurating bubo, following chancroid. Fig. 17.—Single chancroid, which has destroyed a portion of the glans, prepuce and fraenum. Circumcision has been performed, aud the sore is healing. Fig. 18.—Chancroid of vulva. (381) PlatejT 19 22 EXPLANATION OF PLATE IV. Fig. 19.—Chancre of the prepuce just behind the glans. Fig. 20.—Non-indurated ulcer of the fraenum—perforating, (chancroid). It Avas folloAved by suppurating buboes— virulent; no constitutional infection. Fig. 21.—Chancre of the fraenum—the sore healing. Fig. 22.—Chancre of the thumb. This Avas associated Avith the ulcers on the penis, all indurated. The disease Avas followed by constitutional infection. (383) * PlateV 23 ^^ J^S*/*:' W- '#•« w J- y ■'• *i<% - it 25 £" ^ ri^i^i %--f:>i j-'Nk \r\f '%,-^r k ■.. ..J,:^-;.-.,,. S^ .'•../'•......'^' <$k EXPLANATION OF PLATE V. Fig. 23.—Pustular syphilide—impetigo. Fig. 24.—Papular syphilide. Fig. 25.—Syphilitic litchen. Fig. 26.—Gummata of the forearm. In one ulceration has occurred. (385) 25 PlateVl 30 EXPLANATION OF PLATE VI. Fig. 27.—Onychia of thumb and forefinger, in the form ot mucous patches affecting the matrix of the nails. Fig. 28.—Syphilitic ulceration of the tongue. Fig. 29.—Syphilitic iritis. •Tig. 30.—Syphilitic ulcer of the soft palate. (387) 1 INDEX. A Action of the male....................... 35 of the female........................ 38 Act, duration of........................... 45 immediate effect of................ 47 repetition........................... 47 Acute metritis............................124 ovaritis................................129 prostatitis............................ 179 orchitis............................... 194 Abortive treatment of gonorrhoea... 226 Abscess urinary ..........................177 from gonorrhosa..................237 Ammonia, iodide of....................311 Alteratives, vegetable......... .........313 Arsenic..................................319 Affections of the skin..................328 Acne..........................................334 Alopecia....................................340 Anus, mucous tubercle of...............358 B Brain, innervation from............... 25 Boys, masturbation in.................. 50 Balanitis...................................145 Bladder, inflammation of............187 gonorrhceal disease of............240 Bubo .....................................280 virulent........................ ......282 indurated ...........................290 Baths ......................................323 medicated............ ..............323 .Blood, disease of...........................324 Sullse.........................................331 Bronchia, disease of.....................347 Brain, disease of.........................359 gummata of.........................359 degenoration of......................359 Bones, diseases of........................362 mercury on...........................363 c Christ, teaching of....................... 19 Children, training of..........•......21, 27 Corpora cavernosa....................... 28 Corpus spongiosum....................... 28 Clitoris.................................... 30 Coition...................................... 35 act of the male..................... 35 act of the female................... :^8 duration of........ ................. 45 effect of................................ 47 repetition of.......................... 47 Chronic vaginitis.........................121 metritis................................125 prostatitis.............................182 cystitis.................................187 orchitis.................................194 Circumcision..............................152 Calculi, urethral................... ......159 Congestive stricture..................... 162 Continuous dilatation...................170 Caustics in stricture.....................174 in chancre..........................296 Cystic disease of testes.................202 Cancer of the testicle..................203 of the scrotum ...................... 211 Contagion, specific.......................219 Chordee.....................................236 Cystitis, gonorrhceal.....................240 chronic.................................187 Chaiicre and chancroid................267 Chancroid.................................269 inoculation of,.....................270 situation of......... ................ 271 inflammatory.......................272 phagedenic...........................273 serpiginous...............».......... 274 treatment of.........................274 bubo in................................280 Chancre.....................................288 390 Index. Chancre, Hunterian.....................289 induration after healing .........291 excision of...........................295 escharotics for......................296 general treatment of...............297 Compound tonic mixture...............318 Chloride of gold and soda..............321 Classification of syphilitic lesions...324 D Duration of coitus........................ 45 Diseases of women incident to pros- titution............................116 Diseases of the male organs............144 Dilatation of stricture..................170 of stricture, rapid...................170 Degeneration of testes..................201 Diagnosis of gonorrhoea................222 of syphilis...... ......................260 Development of syphilis...............301 Disease of the blood.....................324 of the respiratory apparatus...341 of the nasal cavities...............341 of the bronchise and lungs......347 of the digestive organs............353 of the mouth and throat..........353 of the stomach......................357 of the liver..........................357 of the intestinal canal............357 of the rectum......................357 of the nervous system............358 of the brain...........................359 of the bones........................362 Dysphagia, nervous.....................356 E Excesses, marital......................... 59 venereal.............................. 89 Extravasation of urine..................177 Elaterium in cystitis.....................191 Epithelioma of scrotum................211 Enuresis in gonorrhoea..................238 Excision of chancre......................295 Escharotics in chancre..................296 in stricture............................174 Ecthyma ..................................333 Erythema.................................328 F Fallopian tubes........................... 33 Female, impotence in.................. 81 masturbation in.................... 56 Female, diseases of.....................116 spermatorrhoea in..................110 gonorrhoea of........................133 syphilis of...........................138 Fistulae, urinary..........................178 penile..................................179 Fever, syphilitic......................328 hectic...............................328 Fissure of tongue...................... 354 G Good morals..........'..................... 18 Generation................................ 33 Gonorrhoea in women.................133 Gonorrhoea in the male.......... ......221 treatment of........................224 abortiA'e treatment of.............226 treatment with suppositories...233 internal remedies in...............234 chordee in.............................236 phymosis in.........................237 hemorrhage in......................237 unpleasant sensations from......238 abscess in.............................237 enuresis in...........................238 ischuria in.......................... 238 prostatitis in.......................239 cystitis in..............................240 orchitis from.........................240 Gonorrhceal ophthalmia...............242 inflammation of nose...........246 disease of rectum....................247 rheumatism..........................249 sequelae................................256 G'eet.......................................252 Gummy tumors. ,.,.......................339 Gummata of throat......................354 of brain ..............................359 H Hunterian chancre.....................289 Hemorrhage from urethra............158 Hydrocele..................................208 Hematocele...............................20-9 Hemorrhage in gonorrhoea............237 Hectic Fever..............................328 I Innervation of the sexual organs... 21 from the sympathetic............. 22 spinal................................. 23 from the brain..................... 25 Index. 391 Instinct, reproductive................... 26 Impotence in the male.................. 74 from undue excitation,........... 75 from impaired innervation...... 76 from structural impediments... 78 in the female......................... 81 Irritable urethra.........................119 Ischuria from gonorrhoea...............238 Inoculation of syphilis.................270 Indurated chancre......................289 Iodine......................................310 Iodide of potassium......................311 of Ammonium.......................311 of starch, lime, soda...............312 Impetigo...................................333 Impairment of health..................345 Iritis ........................................361 Influence of mercury..................363 Infantile syphilis ........................368 J JeAvish law................................. 20 L Labia majora.............................. 30 Labia minora............................. 30 Lesions of secondary syphilis.........324 Lepra.......... .............................329 Liver, disease of...........................357 Laryngitis..................................344 M Monogamy................................ 18 Moses, law of............................... 19 Mons veneris............................... 28 Meatus urinarius........................ 30 Masturbation.............................. 49 in young children.................. 49 in boys................................. 50 after puberty....................... 51 in women.....,................ ...... 56 Marital excesses............. ........... 59 Male organs, disease of..................144 Mercury.....................................325 Mucous tubercle...........................337 tubercle of anus.................358 Muscular pains.................. .........358 N Nymphae.................................... 30 Neuralgia.................................130 Nymphomania........................... 90 Nervous dysphagia......................356 Nasal cavities................. ............341 ulceration of.......................342 Neuralgia................................. 358 Nodes...................................... 363 Nocturnal pains...........................365 O Organs, sexual............................. 28 Ovaries............................... _ 33 Onanism..................................... 49 Ovaritis........ .............................129 Orchitis..................................... 194 chronic........................... .....197 gonorrhceal...........................240 syphilitic .............................367 Onychia ....... ............................340 (Esophagus, disease of...................356 P Polygamy................................... 18 Physiology the best guide............. 20 Penis....................................... 28 Prepuce ................... ................. 28 Prostate gland............................. 29 Prostitution................................. 63 the cause of venereal diseases... 69 Prevention of disease................. 73 Prostitution, diseases incident to....116 Penis, inflammation of..................144 Posthitis...................................145 Phimosis....................................159 Paraphimosis ..... ......................155 Penile Fistulae.................,.........179 Prostatitis, acute ........................179 chronic...............................132 Prostatorrhoea.............................184 Pediculus pubis...........................215 Poisons, venereal.........................218 Prostatitis in gonorrhoea............. 239 Primary syphilis.........................259 Phagedenic chancre.....................273 Pathology of syphilis................. 324 Pityriasis...................................330 Psoriasis....................................330 Hustulae......................................332 Pain in the head.........................360 Paralysis....................................360 Pains, nocturnal...........................365 Periostitis....................................365 K Reproductive function.................. 17 Religion, influence of..............., .. 19 392 Index. Reproductive instinct.................. 26 right use of.......................... 26 Rupture of Stricture.....................170 Rheumatism gonorrhceal..............249 Rupia.......................................332 Respiratory apparatus..................341 Rectum, disease of........................357 S Sympathetic innervation............... 22 Spinal innervation....................... 23 Sexual organs, male................... 28 organs, female........................ 30 Structural impediments................ 78 Salacitas................................... 88 Satyriasis................................... 89 Spermatorrhoea............................ 96 treatment of.........................101 in women..............................110 Syphilisin women .......................138 Stricture of the urethra............... 160 transitory............................160 spasmodic.............................160 congestive.............................162 organic............................... 162 seat of..................................164 number of.............................165 degree of contraction.............165 results of..............................165 treatment of..........................167 continuous dilatation..............170 rapid dilatation....................170 rupture ................................170 incision................................171 urethrotomy........................ 172 caustics................................174 consequences of operations......174 extravasation of urine............177 urinary abscess in.................177 urinary fistulae from...............178 penile fistulae from..................179 Structural disease of testes..........199 Strumous disease of testes..............199 Scrotum, disease of......................210 tumor of..............................210 epithelioma of.......................211 Siege of Naples...........................217 Specific contagion........................219 Sequelae of gonorrhoea..................256 Syphilis............... ......................258 primary...............................259 diagnosis of...........................260 Syphilis, usual development of.......301 inoculation of....................... 265 vegetations...........................286 secondary. ...........................299 peculiarities of eruptions.........302 general treatment..................304 mercury in...........................305 iodine................................310 saline diuretics......................312 the water cure......................312 vegetable alteratives..............313 tonics and restoratives............315 nitric acid............................319 arsenic.................................319 chloride of gold.....................321 serpiginous chancroid.............274 Secondary syphilis, lesions of.........324 classification.........................324 pathology............................324 Syphilitic fever..........................328 Special remedies..........................327 Skin, affections of........................328 erythema..............................328 papulae.................................329 squamae...............................329 lepra...................................329 pityriasis...............................330 psoriasis............................. 330 vesiculae................................331 bulla?...................................331 rupia...................................332 pustulae................................332 ecthyma...............................333 impetigo .............................333 acne....................................334 tuberculae.............................334 ulceration.............................336 Syphilitic disease of respiratory ap- paratus............................341 laryngitis............ ,.....!.........344 of bronchiae and lungs............347 of the mouth and throat.........353 of the digestive organs...........353 of the brain..........................359 of the bones..........................362 iritis....................................361 periostitis..............................365 orchitis.................................194 Syphilis, infantile.......................368 Syphilization..............................370 Index. 393 T Training children....................... 21 Testes......................................... 29 structural disease of...............199 strumous disease of................199 degeneration of....................201 cystic disease of.....................202 cancer of.............................203 Tumor of scrotum........................210 Three venereal poisons.................218 Tonics iu syphilis........................315 Temperature, increase of...............325 Tuberculae...................................334 Tubercle, mucous.......................337 of tongue..............................334 of anus ......................,.........358 Tongue, fissure of........................354 Throat, gummata of....................354 U Uterus...................................... 32 Urethritis..................................118 Urethra, irritable........................119 Urethritis in the male..................157 Urethral calculi...........................159 Urethra, hemorrhage from............158 stricture of...........................160 Urinary abscess...........................177 fistulae..................................178 Urine, retention of.......................174 extravasation of....................177 Urethrotomy...............................172 Ulcers........................................336 Ulceration of nose........................342 of larynx.............................344 of throat..............................345 destructive...........................336 V Vesiculae seminales-..................... 29 Vagina....................................... 31 Venereal diseases, cause of............ 69 Vulvitis........:.............................116 Vaginitis....................................120 chronic.................................121 Verucca......................................148 Varicocele..................................204 operation for.........................205 Venereal diseases........................217 Venereal poisons.........................218 Virulent bubo.............................282 Vegetations syphilitic.................286 Vegetable alteratives....................313 Vesiculae....................................331 W Wrong education......................... 27 Woman, masturbation in............. 56 impotence in......................... 81 spermatorrhoea in..................110 diseases of.............................116 gonorrhoea in........................133 syphilis in.............................138 Water cure.................................312 ^ COMPLETE DESCRIPTION and PRICE LIST OF MEDICAL BOOKS PUBLISHED AND FOR SALE BY JOHN M. SCUDDER, 228 COURT STREET, CINCINNATI, O. 1888. Any book in this list sent post-paid on receipt of price. " -----*§*§*----- S a school of medicine we profess to have a distinctive practice, unlike either our old school or homeopathic neighbors. We claim to use differ- ent remedies, or in different form and dose, and for different effects. We boldly claim a more successful practice than either of our competitors, and this claim can only be based upon different principles, a different therapeutics, and a different materia medica. We must, therefore, have distinctive books which clearly state our methods of practice. Old-school works will not serve this purpose, neither will homeo- pathic. With the pretensions we make, if we can not show that we have such works, and depend upon them, we are frauds of the first magnitude. In the early days of Eclecticism, the need of text-books was clearly seen, and great sacrifices were made to furnish them. The writers toiled without pay, and'to publish the earlier works they practiced the most rigid economy for years to command the money. By. these means we had Beach's works, Jones and Morrow's Practice, King's Dispensatory, and some others. The making of books was not an easy nor a profitable job. Now we have a full list of text-books, or books of reference, and by frequent revision thev are kept fully up to our practice of to-day. They have been very successful, more so than any American books in the market, and this is the best evidence of their value. They are bought by all schools of medicine, and when bought they are brought into active use. M T 1-f F**" ECLECTIC PRACTICE OF MEDICINE, By JOHN M. SCUDDER, M. D. The best recommendation of this work comes in the statement, "tuclfth edi- tion." It is the authority of our school of medicine, and thousands of sick are daily treated according to it. Thus far it has proven sufficient, and it has given a success that others have failed to obtain. Twelfth edition, revised : s mo., sir, pp., Sheep : $7.00 post-paid ; $(>.00 post-paid to Journal Subscribers. T H E Principles of Medicine. By JOHN M. SC UDDER, M. D. Thi> is a study of the elements of disease and the principles of cure. It is the basis of our practice, and, a^ we think, of the practice of the future. It gives a rational basis for medical practice. Fifth edition ; s mo., :>VJ pp., Sheep; post-paid. $4.00. ■np j t 'pp ffiLECTlg PRACTISE IN DISEASES OF CHILDREN. By JOHN M. SCUDDER, M. D. If there is one thing more than another that we take pride in, it is our suc- cess in the treatment of children. The teaching of pleasant remedies, in >mall doses, for direct effect, has relieved thousands of children from the horrors of "regular" medicine. Fifth edition ; 8 mo., 186 pp., Sheep ; post-paid, $5.00. A PRACTICAL Treatise on the Diseases of Women, ILLUSTRATED BY Colored Plates and Numerous Wood Engravings. By JOHN M. SCUDDER, M. I). With a Paper on the Diseases of the Breast, by Robert S. Newton, M. D. Late Professor of Surgery in the Eclectic Medirai Institute of Cincinnati. This work has stood the test of twenty years, and as revised it gives our treatment of to-day. Fourteenth edition, revised ; 8 mo., ">:>l pp.. Sheep ; post-paid, $4.00. Specific Medication and Specific Medicines By jo::ix M. S( udder, m. d. Eleventh edition, fourth revision : 12 mo., i:;j pp., Cloth ; Price, $2.50. SPECIFIC DIAGNOSIS. By JOHN M. Sl'I'DDEK, M. I). Seventh edition ; 12 mo., :;ss pp., Cloth ; Price, $-.50. These companion volumes have had a larger sale than any other medical works in this country. They appeal to the feeling every thinking physician cherishes that there must be something certain in medicine, if it can be dis- covered. 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