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Entered according to the Act of Congrese in the year 1905, by 
In the Office of the Librarian of Congrew, at Washington. All rights reserved. 


• : ; .. •■ 





university), new YORK, 






Thf. very pratifyin^ reception acconled to the secoml edition 
of this work ha-s prompted me to make greater efforts to render 
the thiixl edition still more acceptable to the profession. To this 
end I have carefully gone over the whole text and have revbed, 
amplified, added to, and in many places mo<lified it. 

'Die snljject of sexual disorders in women has been more thor- 
on^hly treated and four new chapters have been added, namely, 
Pninliis (tf the Vnlva, Herpes Pro^enitalis in Women. <^ianprene 
of the \*ulva, and Injuries to the Female Genitals in Coitus. 

The chapter on the Anatomy and Physiology of the Sexual 
Apparatus has been very much amplifiwl and many new illus- 
trations have been added to it. 

In addition many new sections have been incorporated, notably 
the following: Florence's test for semen; composition of normal 
prostatic secretion ;orpanicstricture of the urethra and aspermatisni; 
Zohimbin; twisted penis; elephantiasis of the scrotum and penis; 
fibroid iutiltration into all the tissues of the penis; varices of th*' 
penis and urethra; sebaceous tumors of the penis; penis palmatus; 
fracture of penis; intertesticular anastomosis of the vns deferens 
for sterility; tuberculosis of testes and j-rnys; cancer of the j)enis 
and ar-rays and radium rays; corpora iimylacea and the prostate; 
imperative conceptions; vaginismus; spasm of the levator ani in 
female coitus; clitoris crisis and masturbation in women. Besides 
these vcr\' many interpolations have been added throughout the 
whole book. 

Much attention lias been paid to the matter of medical and 
surgical therapeutics in the direction of clearness of statement, 
of practicality, and of up-to-date fulness. 


Many new illustrations in monochrome and colors will be found 
in this edition, the majority of which are original. 

It is gratifying to record the fact of the publication of an Italian 
translation of the second edition of this work which has appeared 
at the hands of Dr. G. Salsotto, and has been issued by the 
Union Topogmfico Ediirice of Turin, 

It is therefore hoped that this volume will continue to merit 
the favor of practitioners and students of medicine bs a guide to 
the study and treatment of this important class of diseases. 

Robert W. Taylor. 

142 Webt Fobtt-eiohth Street, New York, 
AoousT, 1905. 






The Corpora Cavernosa. Mucous Secretion and the Follicles and 
Glands of the I'rethra. The Prostate Gland, the Prostatic Urethra, 
and the Bladder. The Seminal Vesicles. The Testes and the Vasa 
Deferentia 20 



The Mechanism of Erection. The Mechanism of Ejaculation . 68 



The Semen. The Composition of the Normal Prostatic Secretion . 73 








Peripheral Irritation. Chronic Bulbous Urethritis. Organic Stricture 
of the Urethra. Chronic Bulbous and Posterior Urethritis. Chronic 
Bulbous and Posterior I'rethritis with Prostatitis. Chronic Poste- 
rior Urethritis. Chronic Prostatitis. Inflammation of the Semi- 
nal Vesicles .......... 107 

CHAl'TER Vni. 






Absence of the Penis. Hypospadias and Epispadias, and Torsion of 
the Penis. Twisted Penis. Abnormalities in the Size of the Penis. 
Double Penis. Enlargement of the Dorsal Veins of the Penis 129 

^Kisir mfortxoB from obstruction of the intkgvment of thf, penis. 


«f the Integument of the Penis. Vegetations ol 
Growths of the Penis. Elephantiasis (tf tin- 

^lIvGUns Penis and Un^thra. Kil)roi<i Infiltra- 

1^ -4^ g^^Mt of the Penis. Varices of the Penis mid 
T'—OTi nf the Integument of the Penis. C'an- 
(£dema of the Penis. Stricture of 
Clwim. Preputial Calculi 142 





Ossification of the Penis. Fibroid Sclerosis of the Corpora Cavernosa. 
Syphilitic Nodes in the Corpora Cavernosa and Corpus Spongio- 
sum. Cur\'ature of the Penis. Penis Palmatus: Webbed Penis. 
Fracture of the Penis ........ 168 





Ectopia Testis. Changes in the Epididymis, Testis, and Vas Deferens 
due to Gonorrhoea. Changes in the Epididymis, Testis, and Vas 
Deferens due to Syphilis. Chronic Orchitis and Epididymitis. 
Orchitis and Epididymo-orchitis due to General Infective Processes. 
Orchitis due to Muscular Effort. Strangulation of the Testis and 
Epididymis from Torsion of the Cord. Tuberculosis of the Testis. 
Tuberculosis of the Prostate. Tuberculosis of the Seminal Vesi- 
cles. Atrophy of the Testis. AzoOspermatism and the x-rays . 190 



The Effects of Repeated and Excessive Coitus. Influence of the Pros- 
tatic Secretion. The Influence of General Morbid Conditions 229 



Lesions of the Seminal Vesicles and Deferential Ampullations. Lesions 
of the Ejaculatorj- Ducts. Stricture of the Urethra and Urethral 
Calculi, .\nomalous Cases of .Xspermatism .... 240 

xii CO.\TE\TS 





Chronic Inflammation of the Bulbous Urethra. Chronic Posterior 

Vrethritis 254 



Gonorrha?al Congestion of the Prostate. Chronic Inflammation of the 
Verumontanum and Prostatic Urethra. Chronic Catarrhal Inflam- 
mation of the Prostate. Prostatorrhcea. Hypertrophy of the 
Prostate 275 



Chronic Seminal Vesiculitis 312 














ONANISM ... 373 


PRIAPISM ..... 383 






VAGINISMUS ..... 403 























CHANCROIDS ..... 480 













It certainly can be stated, without fear of contradiction, that 
until recently the subject of se.xual disorflers liutl been treated in 
books and essays in a loose and impractical manner. This con- 
dition was due to the facts that the study of these affections was 
not thoroughly entered into and that the necessary groundwork 
of pathological anatomy had l>een entirely neglected. It thus 
came to pass that works on these subjects were unsatisfactory, 
unscienrilic, an<l largely basetl on unsound and visionary theories, 
and that clearly stated scientific facts were not advanced. Unwar- 
ranted and theoretical assumptions were indulge<l in and no real 
progress was attained. In looking over the various treatises one 
is struck with the entire absence of riefinite and rational state- 
ment and argument and the utter want of proper therapeutic 
deductions and indications. Heretofore the whole basis of medi- 
cal knowlalge of sexual ilisonlera might lie summed up in the 
recital of various ill-flefined symptoms, generally inclmled under 
the phrase loss of manhood » such as sexual debility and irrita- 
bility, seminal losses, spermatorrhrra, pollutions, and functional 
disturbances and sensory and motor neuroses of the genital sys- 
tem in the male. It can be readily understood that no author can 



approach toward doing justice to the stmiy of sexual disorders 
who allows himself to l)e fettereil and tranmielled by the study 
and elaboration of this unscientific conglomerntion of s^Tiiptoms. 

The tren<i of thought and study of seximl and genitourinary 
diseases among some authors within the last few years has been 
in the direction of acquiring knowle^lge of the intimate structure 
and functions of the various portions of the urinary and sexual 
apparatus and of the nature and course of the various morbid 
processes which attack this highly important system, and it is 
gratifying to be al>le to state that much useful infonnation has 
In-en gained. This spirit has dominated the writer in the prepa- 
ration of the present volume; and while hy classic custom it has 
become an author's duty to treat of the various forms of sexual 
debility prominently as symptoms, the underlying anatomical and 
physiological conditions have never Iwen lost sight of, and the 
light of pathology has been thrown on the picture as fully as our 
present experience will warrant. 

The endeavor lias been matle to fully descril>e the anatomy 
anil physiology of the whole sexual apparatus in a scientific and 
philosophical manner, and in so tloing the results of extended 
personal investigations have been incorporatetl. The importance 
of urethrnl inflammations as an underlying cause of sexual impair- 
ment has Ijeen duly emphasized. Much care has been bestowed 
on the description of chronic affections of the prastate (an organ, 
when damage<l, so often the cause of sexual debility), and in 
tlus chapter there is much that is new which has been developed , 
by the investigations of the author. The conditions of the seminal 
vesicles and their relation, when diseased, to sexual <lisorders have 
been fully elaborated, and much information based on personal 
investigation is here given. In fact, the basis of the study of 
genitourinary diseases will be foumi in this book. But so vast 
and intricate is the field of sexual disorders that more is required 
of one who wishes to thoroughly understand the subject than has 
thus far been mentioned. 

In the first place, well-grounded knowledge of physiology and 
of general medicine and a general understanding of the anatomy, 


physiology, and pathology of the nervous system are absolutely 
necessary. And, in addition, the surgeon needs a clear under- 
standing of the nature and course of syphilis, of the pathology 
of gonorrhceal infection, and of all acute and chronic infective 
processes. And, still further, to this long list of requirements 
the knowledge of the use of the microscope in the examination 
of the urine and of the various secretions of the body is absoluely 
essential. When studied on these broad lines diseases which in 
former years were vaguely if at all understood, and even shunned 
by medical men, can now be discussed on scientific and practical 
grounds; and whereas heretofore treatment was largely haphazard 
and empirical, and, as a rule, without benefit to the patient, 
to-day it can be entered upon on a scientific and satisfactory basb. 
The subject of sterility in women is considered in a general 
maimer, with the idea of conveying to the mind of the reader the 
conditions which tend to render a woman unfertile. The various 
forms of sexual disorders in women are also fully considered. 



The penis is a pendulous organ consisting of root, body, and 
glans, and through it three-fourths of the urethra runs. It is 
tlie orgjin of copulation and of urination, and is composal of two 
pandiel cylindrical bodies called the corpora cavernosa, which, 
lying side by si<ie, have a groove on their under surface in which 
is situateil tlie corpus spongiosum. These cylindrical bodies, with 
connective tissues, vessels, nerves, and lymphatics, together with 
the tegunientary investment sheath, form the penis. (See Plate 
I., Fig. 1.) 



Each corpus cavernusuni has a dense, quite thick, but very 
elastic fibrous investment, from which thin processes or trabeculse 
pass inwardly and form cavities, which are filled with erectile 
tissue. The inner surface of each cavernous baly is thick and 
complete in the proximal j>art of the penis; consequently, there 
is at that part a distinct septum formed by the fusion of these 
two inner surfaces. More anteriorly or distally there are only a 
number of vertical bands of fibrous tissue arrange<.l like the teeth 
of a comb, and hence called the septum pedinifornu. The corpora 
cavernosa are largely supplied by bloodvessels. This is well shown 
in Figs. 1 and 2, which depict a few twigs of the arterial supply. 
It is important to bear in mind the structure and relations of the 
cavernous bodies, as well as of the spongy borly, in operations 
on the penile urethra. The corpus spongiosum also consists of 
a firm, fibrous sheath, from which trabecular processes pass 



FIG. I. 

Transverse Section or the Penis. 

Shelving Corpora Cavernosa. Corpu* Spongiosum and Ureihru. ^vith 
Musculature of the Parti* 

FIO. 8. 


• flANCM 




Arteries of the Penis. (.Testut.) 


inward and form mesbes wluch contain erectile tissue. In the 
outer coat of the corpus spongiosum is a tliin layer of circular mus- 

Fio. 1 





'^^f'tfu^BftLJ ^ 


i^^SkSyci^^Ci c 




Arterial Iwig from tbe root of the corpora caTemo^a. 
Fig. 2 



1 ^^ 



^ ^^^^^^^^ 



Theitamo magnified twenty diameters. (Modified from Rouget ) 


cular fibres continuous with those of the bladder. A second layer 
of longitudinal muscular fibres is situated lietween the inner 
surFace of the corpus spongiosum and the miicous membrane of 
the urethra. 

Hie corpora cavernosa constitute the chief bulk of the penis, 
and each one begins in a tapering portion, the crus penw, which 
is attached along a groove in the rami of the ischium and os pubis. 
They are furtlier attached to the s^Tnphysis pubis by a strong, 
elastic suspensory ligament, the base of which is fused in their 
fibrous tbsue, and the apex is insertetl into the symphysis. Con- 
verging together at once at the root of the penis, these cylindrical 
botlies nm panillel side by side, and each ends in a bluntly rounded 
extremity whiHi Hts in a depression in the base of the glans penis. 

The Corpus Spongiosum. — The corpus spongiosum surrounds 
the lirelhra fruni the triiingulur ligament to the meatus unnarius. 
It liegins in the centre of the jjerineum in an expanded form 
called the bulbj which rests directly on the anterior surface of the 
triangular ligament. It then runs under the corpora cavernosa 
in the groove left for it, like a ramrod under a double-barrelled 
gun, and ends in an expandwl extremity — the glans penis — the 
apex of which corresponds to the meatus. 

The gliUKS penis is, therefore, the expanded distal portion of the 
corpus spongiosum, while the bulb is its proximal expamled por- 
tion. The glans is an obtusely conical, aconi-shaped bcwly, some- 
what flattene<I on its upper surface, and ending in a rounded, 
expanded portion called the corona, which rounds off abruptly 
and projects like a collar Ijeyond the bofly of the penis proper, 
and b<»hind it is seen, wheu tlie prepuce is retracted, a nearly 
circular gn>ove calle<i the coronal sulcus^ the balahi>j)reputial 
furrow, and the cervix. A little below the centre of the apex is 
the vertical slit-like opening of the urethra, called the meatus. 

The under surfac^e of the glans is flat and triangidar in shape, 
the apex of which usually ends in the inferior commissure of the 
meatus, and into it the fnenum of the prepuce is inserted. 

The arteries of the [>enis are derived from the external pudic 
and from the superlicial perineal and the tlorsal artery of the jx^iis. 




onrunATOR vriN 

Veins of the Penis. (Testui. 


which are branches of the external pudic. fSee Plate I., 
Fig. 2.) 

The veins of the penis converge from the prepuce and the three 
cavernous bodies and begin as a common canal at its dorsum, 
called the superficial dorsal vein. (See Plate II.) 

Nerves of the Penis. 

There are different classes of nerves in the penis concerned in 
erection and ejaculation. Those of the first order are the sensory 
nerves, which are most abundant in the glans penis; but they 
are also present in the integument of the organ, and transmit 
irritations, stimulation, and impressions backward to the sexual 
centre. In the second order, anatomically speaking, but more 
important, perhaps, in a physiological sense, are the excitor 

These nerves, called the nervi erigentes, or excitor nerves, are 
derived from the first and second and sometimes from the third 
sacral nerves. It is thought that these nerves originate in the 
sexual centre, which is supposed to be seated in the lumbosacral 
portion of the spinal column. Experiments on animals have 
shown that stimulation of these nerves causes erection of the penis, 
which is, therefore, essentially due to the vasodilator action upon 
the arterioles. 

The facts are well established that in the human subject mental 
impressions are transmitted down the spinal cord, probably in its 
lateral columns, to the sexual centre, which undergoes excitation, 
which is thereupon further transmitted through the nervi erigentes 
to the penis and accessory parts of the sexual apparatus. Periph- 
eral excitation of the sensoiy nerves in the glans penis and penis 
itself is conducted back by them to the spinal sexual centre, which, 
in turn, by reflex action through the nervi erigentes, acts upon the 
sexual sphere and induces erection. 

Certain facts derived from experimental physiology, and sup- 
ported by clinical observation, go to show that it is probable that 
besides the excitor nerves there are inhibitory nerves of erection 



which originate in the hrafn and pass down the lateral cohimns of 
the coni to the sexna! centre. As will be shown in subsequent 
sections, erection luay l>e inateria!ly niot]ified or extinguLshetl by 
mental impressions, and it is very probable that tiiis restraining 
effect is due to these inhibitory nerves. 

In the glans penis the nerve snpply is peculiarly exuberant, 
and many of the nerves end in Pacinian bo<Hes» while others 
have at their ends j>ecuHar bulb-like expansions. This rich 
ner\*e supply also exists in and about the fra'num, and it is to it 
that the excessive sensitiveness of these parts is ilue. 

The foregoing facts certainly warrant the opinion that the 
sensorium commune of the external male genitals Ls seated in 
the glans penis, which includes in its territory the regions of the 
fraMumi and of the fossa navicularis. 

It is chiimed by some that at tlie bulb of the urethra the nerve 
supply n^seml)les that of the glans. Certain it is that in this 
regit>n tlie bloi>d supj>ly is particularly copious. The iiitt-guinent 
of the penis^ the scrotum, and urethra are alsc> abundantly sup- 
plied by nervos. 

As might be expected fn>m the structure and function of the 
corpora cavernosa and corpus spongiosum these parts are freely 
supplied by fibres of the sympathetic nerves, which are derived 
from the pelvic or inferior hypogastric plexus. It is claimed by 
some investigators that the entire sympathetic nerve supply goes 
to these erectile bodies. 

In the consideration of the nerve supply to the penis particular 
attention should !«• paid t4> tlic vennnontjinum. In this structure, 
composed <»f mucous membrane, erectile tissue, and muscular 
tissue richly supplied by bImMlvessels, the nerve supply is par- 
ticularly abumhmt; hence, this part is usually ex(|uisite]y sensitive, 
is the seat of the pU-asurable sensations in coitus, ami in disease 
l)ecomes a factor of nuich im|}ortance and gravity. 

It will i»e thus seen that while there is an extenial sensorium 
c«mmmne of the sexual apparatus, seated at the distal part of the 
peuis, there is also an internal sensorium, seate<i in the middle of 
the prostatic urethra. 




The Interment of the Peois. 

The integument of the penis forms an investing sheath which 
retains its tubular form in the normal condition up to a little 
beyond the extremity of the glans penis. Then it Is reflected or 
folds on itself backward, in the form of a raucous membrane, and 
is insertetl by gradual merging into the whole length of the cor- 
onal sulcus. It is then reflected forward over the glans, to which 
it is finnly adherent, and ends at or a little within the orifice of 
the meatus^ with the uuicous membrane of which it is continuous. 
Thus it is that for a short distance (one-quarter to one inch or 
more) the mucous membrane of the urethra consists of sciuamous 
or pavement epithelium. 

That portion of the umler surface of the prepuce which is in 
the median line becomes tninsfoniiet! into a fibrous band which 
is called the frjenurn preputii, and which, as we have seen, is 
insertei! just umler the lower part of the meatus uriaarius. The 
prepuce, therefore, consists of two layers — the outer one integu- 
mentary and continuous with the skin of the penis, and the inner 
or reflected one formed of mucous membrane, which is covered 
with stratifie<i pavement epithelium, which extends, as already 
stated, into the meatus for a varying tlistance. 

The integument of the penis is very thin and extensible, and 
very readily movable over the cavernous and spong}' boilics by 
means of a very delicate, loose, and abundant connective tissue 
destitute of fat cells. 

The integument of the penis is plentifully supplied with seba- 
ceous and hair follicles, which frcijiieuLly become the seat of 
inflammatory processes anil of new-growtlis (milia and wens). 

The Prepuce. 

In the normal condition the prepuce, or foreskin, forms a tube 
of [juite unifnnn calibre, whicli is loose and roomy and readily 
admits of its retnu'tioii arnl rt^placemcnt over the glans penis. 
Usually it ends at or just beyon*l the meatus. In some cases, 
however, it b reduudaiit and extends more or less beyond the end 


of the penis. Then, again, it may be short, so as only to cover 
a portion of the plans, and in quite exceptional cases in the adult 
there is no prepuce at all. In this event it has bappeneil that as 
the penis developed the integumentary layer did not correspond- 
ingly increase, 

SoMjelinies the preputial orifice is verj' small, so that it will 
with fJifliciiUy allow the glans to emerge through it. Then, again, 
thb contraction may be so great that only a pin-siKe<l aperture is 
seen, in which event retraction is impossible, and very little of 
the glans or meuliis can l)e seen. In some ciLses the calibre of 
the prepuce is ilecidcilly too small for its easy retraction, and it 
then may exert injurious pressure upon the glans. IiMttlier cases 
the fnenuin is tr»n sfiurt (it is then nsnally a ratlu'r thick cord), 
and by the ct»u(rurtii>ti which it exerts upon the prepiii-e some 
deformity results. 

The penis is ryUndrical when flacciil, triangular in shape when 
turgid, unil, therefore, has three siiles, with corresponding rounde<l 
mftrgins. 'l*lie dorsal Hut surface is bromler than the lateral sur- 
faces are. 

The OUnduIar Structure of the Preptice. — It is widely stated 

that the mucous layer of the prepuce normally contains minute 

sebaceous glands C4illed by old writers glandidr Tyaonii CHloriJer(F. 

'ITiis, however, is erroneous. Whenever present, Tyson's gliuuls 

are situate<l externally on the |>enis, and are distributetl along the 

corona ghindis in the sulcus and on the reflection of the pn-puce 

and near the fnenum. In young children tl^ese glands are fairly 

ouinerous. but in iwlults they an* nmch more diflicult to find, as 

l\jev seem to become atrophied to a large extent. Tyson's glands 

awV\entical in ever)' resj)ect in structun* to the sebaceous glands 

«A Vbe «Wn or scalp, 'i'liey consist of two or more bag-like acini 

^^K VfQ^^watWiicuth the e])i<lcrmis. which ofXMt into a ccmimon duct, 

l^^^iiA tivc irWAo cvUular lining of the duct ami the glanil is con- 

^^^f''>">>K&V\\\\i\w> epithelium of the skin. (See Fig. 3.) 

I ^^^ Wq(i (AwwvAtimw show that the preputial nnicous mera- 

per* ^**«*\tmV. contaiiw no glandtilar stnictures whatever, but 

the I ^wtuunule invrfxions or invagitmtions of the mucous 


membrane in the form of diverticula, and longer and narrower 
ones found near the fraenum, which are calle<l ajMernrr frwnuli. 
The so-calletl glands are, therefore, simply reduplicatures or invag- 
inations of the membrane in the form of minute shallow or deep 

Fio. 3 

Showing a»erlion (much mn^nified) through one of Tyson's glands in llifl 
prepitcft of a voung cliild. (Drawn frora nature.) 

Certain clinical and pathological observations, however, seem 
to show that occasionally one or more Tyson's glands persist in 
later life. 

Preputial snift^niu, that wliitish coating of cheesy O4lor» is there- 
fore simply eiTcte epithelium, perhaps fonuetl in the crypts or on 
the mucous membrane itself. 

The Meatus. 

The meatus is normally a constricted part of the urethra. In 
structure it varies more or less in different individuals. In some 
its vertical lips arc thin and coapt with each other like the leaves 
of a book, forming a not prominent vertical slit. In other cases 


the lips are more or less rountled and the meatus has a rather 
expan<led, pouting appearance. Then, again, owing to the fact 
that llie mucous membrane is rather retlundant and loose, its Hps 
sometimes have an uneven, somewhat raammillated appearance. 
In some very rare cases the mucous membrane forms a cylinder 
of a line, or even a third of an inch, in length beyond the apex 
of the glans, constituting a membrunc»us extension of the urethra. 
In somewhat rare cases a thin septum is seen to extend horizon- 
tally across from one lip to the other, seemingly dividing the 
meatus into two parts. Scparatioti of the lips, however, shows 
that this septum simply forms a hliriil pocket which may be 
How or rather deep. In this condition the narrowing of the 
meatus is at its superior portion, and tlierefore the surgical indi- 
cation here is to n^lieve tlie trouble by cutting toward the roof 
of the urethra, while in almost all other cases the rule is to cut 
towanl its floor. 

In somewhat exceptional cases the meatus is very small, even 
of pinhead size. In this case it will generally be found, by pass- 
ing the tip of a probe inwanl and downward, that the abnormal 
smallness of the calibre is due to the fusion of the mucous mem- 
brane at the lower commissure. 

The Male Urethra. — ITie male urethra is a slit-like canal, re- 
ganleii by some as a close<l valve, which exteruls fnun the blaflder 
to the meatus urinarius. It is the venl-i)i|K' fur the urine and 
gives issue to the seminal flniil. It therefore has two functions, 
which must be kept in mind in order that its iHseases may be 
rly understootl. It is in direct relation with the kidneys, the 
R, antl the blatlder, and nuiy l>e the means of transmitting 
'fawc to these organs of the urinary system, or it, in turn, may 
Wome iKseased by the extensitjn of palhologiea! processes from 
WK*^ «tid structures. Then, again, pathological processes 
a^ the urethra may extend to all or to certain portions 
*• jjQeniUi ftYstem — namely, the testicles, the vasa deferentia, 
i^cscles, and the prostate and its cr}'pls and f4vllicle3. 
™ URtlire may he involved by the extension of dis- 
*■» «| theae structures and appendages, wiih which 



it is in direct anatomical relation. If the function of the urethra 
were simply that of transmitting tlie urine, a length of about two 
inches would be sufBcient, 

as it is in the female; but ' 

being also a part of the 
genital apparatus its length 
is necessarily much in- 
creased for purposes of in- 
tromission and fecundation 
of the female. This increase 
in length, as we have seen, 
is due to the existence of 
the cavernous and spongy 

The urethra is composed 
of three layers — a mucous 
layer, a submucous connec- 
tive-tissue layer, and a mus- 
cular layer. Its walb are 
always in contact, except 
during the passage of urine 
and semen, a period of three 
or four minutes during the 
day. The average length 
of the urethra is from seven 
to eight and a half inches, 
but it may l>e shorter or 
longer. It is increased in 
length during erection and 
in hypertrophy of the pros- 

When the urethra b .split 
longitudinally in its whole 
extent on its upper sur- 
face its course, with its S*'*^^*"^ '|'e"o™'^lureih™ opened longi- 

ttKlinftUy on its upper »UT(nc.e. (Drawn from 

varymg expansions, comes nature.) 


into view. (See Fig. 4.) At the meatus urinarius we find a nor- 
mal narrowing of the canalj which then expamis into a spindle- 
shapeil portion, wliich is called the fossa naviciilnm; hence this 
is called the navicular portion of the urethni. As thivS part 
emerges into the spongy or penile portion a slight constriction 
occurs. Tlie canal then expands, and we lind it of somewhat 
uniform calibre in its course through the corpus spongiosum for 
a distance of four or five inches. It then expands again, in con- 
formity with the bulbous expansion of the corpus spongiosum, 
and a spindle-shapetl canal is formed, which is from an inclj to 
an inch and a half in length, and which is called the sinus of the 
bulb or the bulbous portion of the urethra. Again, becoming con- 
tracted! at tlie anterior layer of the triangular ligament, it hiis a 
uniform calibre for a distance of alxait three-quarters of an inch, 
when, at the posterior layer of this ligament, it emerges to expand 
again into the prostiitic urethni. In its course through the trian- 
gidar ligintu'tit it is s(m|)ly a nicrnbranous canal scafcil about an 
inch beneath the sununit of the pubic arch and surrciunded by the 
compressor urethne nniscle. The prostatic urethra is the dirwt 
continuation of the membranous urethra. It also has a spindle 
shape, and is about an incli and a quarter in length. (See Fig. 4.) 
Thus, anatomically, there is a navicular, a spongy, ti bulbous, a 
membranous, and a prostatic portion of the urethra, making five 
divisions in all. The term "penile," or pendulous, urctfira is also 
appliefl to that portion which extends from the glans to the peno- 
scrotal angle. 

Clinically, in a general way, we speak of the anteru^r and 
posterior urethra, the former extending to the anterior layer of 
the triangular ligament, and the latter inchuling the portion 
beyond . 

Tlie mucous membrane of the urethra is smooth and shining 
and of a yellowish -pink color, which is deei>er at the first inch 
and at the bulbous portion. For a short distance — one-fourth to 
one inch within the meatus — the membrane is covered with flat 
pavement epitheliuui; l»eyond that part it is of the columnar 
variety as^far^as^the^vesical^orifice. 


Coarse of the Urethra. — The direction of the prostatic uretlira, 
which is in a fixed position, b downwartl and foru^ard until it 
reaches the posterior layer of the trian(;nlar lij^atnent. when it 
becomes the membranous urethn*, which pursues nearly the same 
direction^ with a sliglitly upward tendency. 

The Membranous Urethra.— The membranous urethra is from 
threeniuurters to an inch in length and of a calibre of 27 F,, and, 
owing to the fact that this segment of the canal forms a part of 
the subpubic curve of the urethra, its superior wall is somewhat 
shorter than the inferior wall. It is peculiar in the fact that it is 

Fio. 6 

Timatverae wction of the memhranoiiM iirethm, showing its anatomicftl fltnic- 
tare: 1, lumen of canal; 2, mucoiiA membrane with circumambient connective 
tuBUe ; 3, vuculnr layer; 4, loiigitudhml muBcutar fibres; 5, circular rooft- 
colar fibres composing the external sphlDcter of the urethra. (After TestuL ) 

composed wholly of mucous membrane, with a submucous con- 
nective-tissue coat and some unstriped muscular fibres. It is the 
least vascular part of the urethral canal, and has very few mucous 
glands and crypts. By reason of its anatomical structure it is not 
80 severely affected by the gonorrhoeal process as the other por- 
tions are; consequently, it is rarely, if ever, the seat of true stricture, 
except from extension of the process from the bulbous urethra. 
The membranous urethra is situated and held in a fixed position 
between the two layers of the triangular ligament — a knowletlge 
which is essential. 


The Triangular Ligament. — The triangular ligament, which is 
a portion of deep perineal fascia » consists of two layers — an an- 
terior an*I a posterior layer — between which is the compressor 
urethra; muscle. The anterior layer is a dense, fibrous membrane 
stretching from the posterior lip of the os pubis and ischium. 
This anterior layer is about an inch and a half in length, and, in 
accorti with the direction of the pubic bone, its base is directetl 

Firt. 4i 

tShowing the Milerior Isj^er nf the triangular ligament and of Henle's deep 
tnuuvene ligament of the pelvis, with openings for vessels and nerrea. 

hackwanl. About an inch below the s^inphysis pubis is the 
urethral orifice, the external tennination of the membranous 
urethra. The triangidar ligament extends upward towartl the 
symphysis to a distance just above the hole for the urethra, and 
alx)ve that is the dense, fibrous tissue calleil " Hcnie's deep trans- 
verse ligament of the pelvis," which is piercetl by the openings 
for the vessels and nerves. The triangular ligament and Henlc's 
ligament, therefore, close tliis part of the pelvic oudet. Around 
this orifice, as shown in Fig. 6, the fibrous membrane is seen» 



which is continueil forward over the bulbous portion of tlie urethra. 
Tlie triangular lipament extends upwani Ifiward the symphysis 
to a distance just above the hole for the urethra, as is shown in 
Fig. 6, as a curved line. 

The posterior layer ivf the triiin;^uliir iiji;ament is <lenve<l from 
the obturator fascia^ and from it a prolongation passes backwarr] 
and forms the outer capsule of tl»e prastate. Its upper portion, 
called Henle'a ligament, is pien-eil by the opening for the plexus 

Fin. 7 

Shuwing the posterior Inyer uf the trinngiilBr liguuient. 

venosits pMrtta impar, which cousisU of veins returning from the 
peuis and of the dorsal arteries. The triangular ligament proper 
is pierced by the membranous urethra, as shown in Fig. 7, which 
also shows the apex of the prostate and the external prostatic 
sphincter blending with the nierubmnous urethni. 

Th« OompreBSor UrethrsB Muscle. 

When the anterior layer f»f the triangular ligament is ilissected 
off, the compressor urethra? muscle is exposetl in the form of a 


firm, flat, muscular band, rather more than an inch wide, stretched 
between the pubic rami, hut not wholly covering the pelvic outlet 
at its apex, (See Plate III.) This muscle, also called the con- 
strictor urethne, the cut-off muscle^ is composed of transverse 
fibres of the stripetl variety, some of which pass directly over and 
some untlcr tiie urctlira, while others pass aroun<l and encircle it. 
This muscle is very powerful, and, being under the contrr>l of the 
will, it can at any time suddenly stop the flow of urine. Though 
the external prostatic sphincter consists of rings of unstripecJ 
muscular rd)a's at the apex of the prostate, the greater part of the 
true sphincteric action is perfonnetl by the compressor muscle. 
In the course of acute and chronic f^onorrha^a, and during irrita- 
tive processes in the prostate, seminal vesicles, and bladder, this 
muscle may undergo spasm an<] produce what is wrongly termed 
"spasmodic stricture." Under the influence of rough manipula- 
tion by instruments in the urethra, of colfl, and of very strong and 
irritating urethral injections, spasm may abo be pro<luced. Then, 
again, as a result of operations about the rectum, abdomen, lower 
limbs, etc., this muscle may be thrown into spasm, and retention of 
urine may result Some authors claim that this muscle is always 
in a state of rigid contraction, or tonus, so that the lumen of the 
urethra is of the fineness of a hair, and that this contraction tends 
to prevent the extension of the gonorrhccal process from the ante- 
rior into the posterior urethra, and also acts as a dam, preventing 
the secretions in the prostatic and membranous urethra escaping 
into the anterior uretlira. Tliis is far too sweeping a statement. 
AVhen the blathk-r is more or less full the compressor or constrictor 
urethne closes up the membranous urethra and prevents the escape 
of urine; but when the blad<ler is not full, even in cases of sub- 
acute inflannnation in any part of the urethra, bulbous or prostatic, 
there is not in the majority of cases any unusual tonus or spasm 
of this muscle. This fac*t can be rewlily demonstrated, as I have 
done hundrefls of times, by the gentle passage into the bladder 
of a soft catheter or bougie of a calibre of 12 or 14 F. This 
instmment, causing no irritation or nervous shock, glides easily 
first into the membranous urethra, then along the prostatic urtHhra 




Showing the Compressor Urethrse or Cul-off Muscle. 


into the bladder. The excessive tonus clHinie<l to be peculiar to 

this muscle in genenil occurs when rigi<l instnunents, particularly 
of large size and when not skilfully passed, are used, or when in- 
jections have been forcibly nmile. Then the nerves of the urethra 
are disturbetl and prompt reflex spasm of the muscle occurs. In 
the majority of persons the compressor muscle and the external 
prostatic sphincter keep the urethral canal mildly compressed — 
that is, its tonicity is such that the lumen of the canal is obHterated 
by the coaptation of the folds of membrane, but there is no spasm. 

Fio. 8 

Showing the normal contractions and expansions of the urethra from the 
meatoB to the blndder, with a Cowpcr's gland opening by its duct into the bulbous 
arethnu (Schematic, from nature.) 

Consequently, it occurs, as a rule, that the secretions of the 
prostatic urethra are kept from escaping into the anterior 

Though this may \ye stated us the law, it has exceptions in some 
cases of acute posterior urethritis, in some of prostatorrhcpa, and 
in some of suppuration of the seminal vesicles. 

On each side of the [nembrunous urethra, (piite near to It and 
seatefl in the substance of the compressor muscle, are Cowper's 
glands. (See Fig. 8.) 


The Bulbous Urethra. 

Ivvinf? just upon the anterior layer of the triangular ligament 
in the bull) of the corpus sponpiosura, containing the bullwus ex- 
pHiuion of the urotFira. Here the inetnbraiious urethra ends, and 
tJjr part is cjilleil tlie hulbomembranous jnuttion. Tlie urethra 
enters the bulbous exjninsion nearer its upper than its lower half; 
eorw»rc|uently the poiidi-Hke fiilatntiori of the urethra Ls greater 
on its lower surfiiee. It is this rorniition which sometimes causes 
trouble in the passage of sounds atul eatlieters, to obviate which 
it w necessary to keep the point of t})e instniment toward the roof 
of the nretlini, and to put the penis on stretch in order to efface 
the fKiiichy pocket as much as possible. 

Tlie bull>ous portion of the urethra or the sinus of the bulb is 
unuituully vascular, and its tissues are soft and succulent. Con- 
setpiently, the gonorrhieal process is often very acute anil severe 
at this part, and the disease shows a tendency to remain in a 
chronic comlition. As a result, we find the larger number of true 
strictures in this region. 

Tlie direction of the bulbous urethra is forward and upward, 
ami its calibre is from 33 to 36 F. The downwanl and for- 
ward direction of the prastatic urethra and the slightly upward 
direction of the niembrauous iirethm, with the decidedly upw^ard 
direction of the bulbous uri'thra, form what is called the subpubic 

The Penile Urethra. 

Continuous outwardly with the bulbous portion of the urethra 
is the spong}' penile or pendulous iiretlmi. It, like the bulbous 
portion, is containc*! in the corpus spongiosum. It is from six 
to six an<i a half inches (sometimes more) in length, and is sur- 
nnmde<l by ere<'tile tissue. The nuicous membrane crypts and 
follicles of this portion of the urethra will be de.scril>ed a little 
farther on. Hie calibre of the |)enile or pendulous urethra is -] 
usually from 27 to 30 F., but is often found to be greater 
than this measurement. The ]>enile urethra is susce|>(ihle of con- 
sidenible dilatability, but it must be remembered that the word 


"calibre" represents normal distention, such as is found by the 
raoflerately easy passage of instiniinents or by the stream of 
urine, while 'Milatahility" means a calibre profhiced by unusual 
or excessive distention of the canal by instniments. 

The distal portion of the urethra seated in the glans penis is 
called the fossa navicularis or the navicular portion nf the urethra. 
It is of spindle shape, and at its niii]<Ile portion its calibre is 
30 to 33 F. At its point of junction with the penile urethra the 
calibre is from about 2S to 30 F. Tlie calii>re of the meatus, 
the terminal point of the urethra externally, is from 21 to 28 F.; 
exceptionally, however, it is greater. A schematic representation 
of the urethra witli its normal contractions and expansions is given 
in Fig. 4. 

The degree of vwiriliiy of different portions of the urethra is 
chiefly influenced by the attachments of the neighboring fasciip. 
The anterior part of the penis is free, and capable, in a flaccid 
condition, of assuming almost any position; in its pasterior third, 
however, this organ is connecteil with the symphysis by means of 
the suspensory ligament, with the ischiatic and pubic rami by the 
crura of the corpora cavernosa, and with the anterior layer of the 
triangular ligament by means of tlie l»nlb; the spong}' urethra 
may, therefore, be said to be fixed in proportion as it approaches 
the membranous region. The membranous region is the least 
movable of all, owing to its firm connection with the pelvis by 
means of the two layers of the triangular ligament. The pros- 
tatic urethra is susceptible of some slight change of position, de- 
pemlent upon the action of the anterior fibres of the levator ani, 
the amount of urine in the blaxlder, and the passage of sounds or 

In a flaccid condition of the penis the urethra has two curves 
— the first confined to the anterior, the second to the deepest 
portion of the canal. The former is simply due to the dependent 
position of the anterior part of the organ, and is efface<l in a state 
of erection or when the |>enis is clcvateil to an angle of about 60 
degrees with the body. The hitter is called the subpubic cur\'e, from 
its position beneath the symphysis. Unless some degree of force be 


used to straighten the canal tliis curve is permanent, and a knowl- 
e<lge of its riirection is essential in determining the proper form 
of instruments an<l the manner of their intro*hiction. 

The subpubic curve commences an inch and a half anterior to 
the bulb in the penile urethra, attains its lowest point when the 
body is in tlie upright position nearly opposite the anterior layer 
of the triangular ligament, and finally ascends through the raem- 
branous and prostatic regions. 

It forms an arc of a circle three inches and a quarter in 
diameter, the cord of the arc being two inches and three- 
quartersj or less than one-third of the circumference. It is often 
found to be more acute in spare men, and in the corpulent 
more obtuse, and that traction of the abdominal muscles exercised 
through the suspensory ligament may also render it more abrupt; 
hence, the advantage of raising the shouUlers when performing 
catheterization upon patients in the recumbent posture. The 
elevation of the blmhler above the jnihes in children, and the 
enlargement of the prostate so common in oM men, also effect a 
change in the direction of the subpubic curve from its usual adult 
standani, ami require, therefore, a corresponding variation in 
the fonn of instruments. Swellings and abscesses about the lower 
extremity of the rectum, large hemorrhoidal tumors, and various* 
other conditions may also operate in a greater or less degree to 
cause some change in the direction of this curve. 

8hap« uid Conformation of the 0rethra.— The urethra is far from 
uniform as reganls its shape and conformati(m in its various posi- 
tions. This is well shown in Figs. 9 to 24, taken from sections ma<ie 
by me of the frozx^n penis between the end of the glans and the 
bladder. The canal is seen to be a vertical slit in Figs. 9 to 1 4. This 
vertical condition exists as far as the junction of the navicular with 
the penile urethra. In the i>enile urethra proi^er the canal becomes 
transverse, and so remains in its whole extent, as shown in Figs. 
15 to 20. At the bulb it becomes round, and so remains at 
the bul!>omend>ranou3 junction and in its membranous portion. 
At the apex of llie prostate it is somewhat changed, as shown in 
Fig. 21. lu the middle of the prostate the urethra looks like an 


mverted Y — thus, A (see Fig. 23) — between the arms of which is 
the verumontanutn, containing the sinus pocukris, or utricuhis 
masculinus. At the bladder the urethrovesical orifice is nearly 
round, the circle being impinged upon by the uvula vesica? at its 
lower segment. In Fig, 24 the very beginning of the urethra is 
shown in the depression in the centre of the base of the bladder. 

Fio. 9 

Fio. 10 

Fig. 11 

Through [»repuoe at hi 
of glana. 

Fia. 14 

Through prepuce and 
corona glaodis. 

Sections just behind the corona glindis, spongy 
and cavernous bodies weU shown. 

This is the posterior surface of the urethral orifice, its anterior 
surface, formed by the prostate, not l>eing shown in the section. 
The two ilots near the under surface of the prostate indicate the 
ejaculatory ducts, which run side by siile. 

By way of recapitulation it is well to rememl>er that the calibre 
of the urethra is nut unifonn, there Iniln^ physinh>gi4'n] contrac- 


Fin. 16 

Fir.. 16 

Fio. 17 

Fio. 18 

Pia. 19 

Fio. 20 

Figs. lA to 20 show t<«cLionR froui befnre backward through the penile urelhi 
j^he pectioifortn BC|>tum is complete except Fig. 16, whore corpora cavernosa are 
itlnuous with one another. 

Fia. 21 

Fio. 22 

Through bulboinembranoiiii junction, 
urethra Murroumled b/ some anterior 
Gbres of the oompi 

Through apex of proatate. 


Fig. 23 

Showing the pwUion of the ejaculator^r duels in I he middle of the proetale 
under the verumontnnum jvitit hpfore they turn upward and end in tJie pnwtatic 
urethra. The capsule of the prustate i» well &hown. 

Fio. 24 

Showing the positiaa of Llie ejaculatory ducta in the lower pari of the problate 
and behind the urethra: 1, veHical orifice of the urethra; 2, ejacnlatory ducta. 
(All the secliooB drawo from nature.) 

tions and Jilutations. As a general average the following figu 
will be found to be correct: 


Meatus, 7 to & mm 

Foma naviculnrij4^ 10 to 11 mm. 

Middle of penduliiua portion, to 10 mm. 

Bulb, U to 12 mm. . 

Membranous urethra, 9 mm. 

At apex of prostate., 10 mm. 

Middle of proitate, 15 mm. 

Vesical end of proetaLe, 11 mm. 

21 to 28 F, 
30 to ;i3 F. 
27 to 30 F. 
33 to 3« F. 
27 F. 
30 F. 
46 R 
33 F. 

Otis claims that there ia a constant relation l>etween the circum- 
ferential measurement of the flaccid penis and the calibre of the 
urethra in the healthy condition. He say: *'Whea the circum- 
ference is 3 inchc-s the urethra has a normal calibre of at least 
30 R; if 3i, it will be 32 F.; if SJ = 34 F.; if 3j = 36 F.; if 
4 inches = 38 F. ; and if 4J «« 40 or more." 



In healthy individuab in moments of sexual excitement a 
few or many drops of a clear and mucous secretion escape from 
the meatus. In some fonns of sexual ill-health the secretion may 
become much more abundant than normal, and both in health 

Fig. 25 


One of the mucoiM gland* or folliclev of LiUre opening into the lumen af 
urethra: z y, lateral branches of main duct, with their most superficially flituated 
actoi * 1 1, oonlinuation of main duct, with deeply seated acini ; » «, trabccuheof the 
caTemoua tissue ; vus tunica albiiginca. (Drawn from nature, much magnified. ) 

and in ill-health it is sometimes the cause of much mental anjdety. 
It is necessary, therefore, to understand clearly the nature and 
origin of this mucous secretion. 

Into the anterior urethra, which includes that part of the canal 
in front of the triangular ligament, three orders of muciparous 


Fi«. 26 

\Jm uEmoM uBm 


Fio. 27 


f Rhowlng the lacuna magna and n deeper 

I valve-like pock(?l or crypt, and the orifices of 

j nninerous mucous glands or crTpU. (Drawn 

! from nature. ) 

glands open by means of ducts. 

These are the follicles of Littre, the 


lacunre or crypts of Morgagni, and 
Cowper's glands. All these glands 
are of the compound racemose type, 
consisting of acini which open into 
a common duct. (See Fig. 25.) 
The follicles of Littre are structur- 
ally the same as the crypts of Mor- 
gagni, but are smaller in dimensions. 
The lacuna magna in tht^ fossa 
navicularis is a good illustration of 
a tyf)ical Morgagni crypt. As shown 
in Fig. 26, it is a valve-like sti*uc- 
ture, at the bottom of which the 
duct of the glanil opens. There 
may be several of these crypts along 
the roof of the urethra, but they 
are usually not found deeper than 

Showing roof of the urethra, 
with bristles pK»«d into Littre'a 
foUidea. { Drawn from nature.) 


three inches. In Fig. 26 two of these valve-like pockets may be 

Littre's follicles are quite numerous, ami are seated mostly on 
the floor of the urethra and somctinie.s, though in less numbers, 
on its roof. The ducts of these ft>!lir!rs open oblitjuely forward 
towanl the meatus, ami by the tiaktnl eye or by the iiid of a mag- 
nifying glass may be seen as very minute depressions in the mucous 
menibrane. In Fig. 27 these follides itre indicated liy the many 
minute bristles wliich have been passed into tht-ir ducts. 

Cowjwr's glands are two compound racemose bo<]ies, seate<l just 
iM'hind the anterior layer of the triangular ligament in the suV>- 
.Htiint.'e of the compressor urellira' nuiscle. (See Fig. 35.) Their 
ductji are aljout three-rjuarters of an incli in length, and they pass 
obliquely forwanl tljrough the anterior layer of the triangular 
llgarncnt and open separately into the bulbous urethra on each 
iiii|<* of the mdian line. (See Fig. 29.) 

All thew? glands and follicles secrete a clear, viscid mucus of 
nllinlltie reaction which resembles glycerin in appearance. It is 
probable the Mccretion of Littrels follicles and Morgngni's crypts, 
Mfid i* rnoHt developed for the lubrication of the urcthml mucous 
frM^fMbrnnr, lint this fluid is also quite abundantly produced 
iltirinjC t\w Ncxual act. By some it is thought that the aci(]ity of 
111* urUw l«Tft ill the canal after micturition Is neutralized by these 
jMHrrwllonH, 'l*he .Hecretion of Cowper's glands is quite copious 
Mfut fffriillnr in chamcter to that just descri1>ed. It forms part of 
ihia Miiidnal dincliarge in coitus, and is frequently found in cases 
lif iii4«iml rM-ilrnient without orgasm. This secretion [jlays an 
|fM|Hirbiiii part in certain sexual disturbances to be considered 


TIlit pr(M(a(4i Klumi vn an accessory sexual organ of much im- 
piMlatti'it, whii'li aUi) iH crnployefl in urination. In order to obtain 
a I'limr lili'n iif lltin M*xual ^land it is necessary to study its siruc- 
(lirM initrrtMcupiuully in young subjects, both children ami animals^ 


^P and then to trace its development at later periods of life. Such 


and then to trace its development at later periods of life. 
stu<lies develop the following facts: 

The prostate is essentially a glandular organ, niul the chief func- 
tion of its other component tissues, luimcly, the fibrous coTuiective- 
tissue framework ami the unstri[>r(] muscular fibres, are (1 ) to form 
a niihis for the lodgement of the phinds^and (2) to tissist in tlieir 
normal uctioii. The glands are of the compound tubular U'pe, and 
end in short ducts wliicli open into the prostatic urethra. The 
ducts are merely fibrous tulH»s lijietl with columnar epithelium. 
The secreting portions of the glands are the tubules and the gland 
alveoli, which consist of longer or shorter, wavy, convoluted, 
branched tubes which terminate in saccular bliufl extremities. 
To some glands there are short Intend chib-sha]M.-d bnnichlets. 
The secreting portions of these glands are lined by long, slender 
cells which are surroundeirl by a delicate connective-tbsue base- 
ment membrane in which bloodvessels, lymphatics, and nerves 
are seatetl. Outsi<Ie the gland proper there are bumlles of un- 
striped nuiscular fibres, some of which arc circularly arranged, 
while others cross each other in various ilirections. By the con- 
traction of these muscular rings the secretion of these glands is 
thrown into the uivtiira. 

In the young normal pn»state the glands are grou()e<i in toler- 
ably wellHlelined loliules. This is well shown in Fig. 28, in which 
can be well imule out eleven distinct lobuhir groups of prostatic 
glands. In these lobules the tubular glands are inexplicably 
mbced up with each other very much as a bunch of earth-worms 
are, but all their ducts point towanl the urethra. In the figure 
the irregular s]>aees In white are the glands cut through, but there 
are very many long tubules shown, which in the section happen to 
have been cut in the continuity of the glands. 

There is no miiscular investment of the ducts of the glands, 
and it is probably owing to this condition that these outlets some- 
times become plugged up with amyloitl bodies, concretions, an*l 
calculi, which in all probability would Ije exiM'lled by circular 
muscular fibres if they wen* pnvsent. 

There is no reservoir in the prostate gland for storing up or 


retaining its secretion. Ilie laffer in the sexual act is very copi- 
ously eiuhnmtc*!, and is quickly thrown into the prr)sttttic urethra 
by means of the muscular mechanism which is ao admirably 
udiipted to that purpose, 

Fia. 28 

Showing st:<-tiuij .i.u.-. I. .^;.;^i.iUud) of normal prostate of a subject aged nioeteea 
years, made through miilrlle of verumontnnuro : ], urethra ; 2, Terumont&num ; 
3, HinuB poGuIaris; 4, ejaculaLory ducts; 5, prostatic glandft. (Drnwo fn^m the 
Kdinger projection apparatus.) 

The prostatic urethra is normally about an inch and a quarter 
or an inch and a half in length, and extends from the apex to tbft 
base of the prostate. It has a calibre of 30 1\ at the apex, 45 
in its midille portion, and 33 at its vesica! end. It tunnels the 
prostate gland one-third nearer its upper than its lower surface 
and its c]irection is iiownwanl and forward until it reaches 
membranous urethra.* 

* The Ufiaal anatomical defscriptiona of the prostatic urethra are bii<>eH on tK« 
{Kwition of the cannl as found in th« cadaver when it in laid tial un its hack. In 
atriet accuracy, the prost^nlic urethra in the living mule, aa he htand^ up, has ma. 
anterior and a poaterior wall which are nearly in ai-coni with the rertical &zis 
the body. 


When laid open on its upper surface the prostatic urethra is 
found to \yc of fusiform shape ami to present certain nnatoniical 
peculiarities. (See Fig. 29.) 

Fm, 2fl 

•Showing bUdder and urethra ofiened on the upper surface : I, the trigone and 
openings «f ureters; 2, profttale and prnstatic urethra: .1, buUi of the urethra^ 
with openingH of C'owper's glnndB; 4, veruranntaniim. with orifice of t*inUH |»ocii- 
laris; 5^ opeoiogs of ejaculatory ducts ; 6, linear series of o|)eninga of prostatic 
ducts: 7, groups of openings of prostatic ducts behind veruuiontanum. (Drawn 
from nature. ) 

The Verumontanum.—On its Hoor is a narrow, longitudinaK 
we<lge-.sha]>ed ridge called the verumontanum^ the caput gal- 



linaginis or crista gulli. This structure, which Ls from one-half 
to thret*-t|uartei*s of iin inch in Ipnglh, an<l one or two line.s in 
heiji^ht, is composed of erectile tissue and niusciihir fihres and 
many tubular fjlamls. all of which are covered witli a dense mucous 
membrane. At each si<le and at the base of the veniinontanum 
is a depression which is calle*! the prostatic sinus, and it is upon 
the surface of tliese sinuses, right and left, that In a tolerably 
re^dar linear arran^ment many proatalic ducts open, usually 
about twelve, and in some instances as many as twenty or thirty. 

The Sinos Pocularis.—On the summit of the verumontanum, 
sometimes at its fort*part ami sometimes about its middle, a slit- 
like depression may Ik* seen, winch leads to a cul-de-sac or flask- 
shaped pt>nt'h about oneH|uarter to fliree-fjuarters f»f an inch in 
lenf;th and of a calibre of about three millimetres, whicfi is directed 
upwani and Imckwanl in the axis of the prostatic gland. Th'\s\ 
cul-de-sac, which is called the uterus masculinus, or sinus pocu- 
laris, is really a separate structure and ilistiiK't from, but sur- 
rounded by, the prostate. It consists of a secreting surface of 
c*»hunnar epithelial cells surrounded by connective tissue and 
bloodvessels and circular layers of unstripecl muscular fibres. It^l 
may or may not have blind diverticula, ^B 

T\w function of the sinus pocularis is not known. It is thought 
by .some that by reason of its position Ijetween the ejaculatory^| 
flucts, its round shape, and its well-developt^d musculature, in 
Cfjitus it so contracts that it dniws upon the o[>em'ngs of the ejacu* 
latory ducts, and thus renders them so ])atuloiis that the semei 
reu<lily pjuHses through. 

The stnicture of the vennnontanum is well shown in Fig. 30^ 
On the left ,1 is representee! a vertical transverse section l^hind 
the openings of the ejaculatory ducts. In B is shown a section 
immediately Ix-hind the orifices of the ejaculator}' ducts and the 
sinus jx»cularis, while in C the general structure of the verumon- 
(anum anterior to the orifice of the sinus pocularis and to the 
orifices of the ejaculatory ducts, that b, in its proximal end, 
shown. In all these pictures the conformation of the ei 
tissues b well portra^-ed. 





The relations between the prostate and the bladder are so 
intimate that a knowledge of tlie latter orgjin is essential. 

The bladder is the musriiloinendifunons reservoir for the 
urine, and is seated in the pelvis beliind the pijl)es an4l in front 
of the rectum. When empty and contracted it is a small trian^uUir 
sac deeply seated in (he pelvis. When disten<led it Mssuuies a 
rounded form, partly fills the pelvis, and rises into the abdominal 
cavity. In many cases of retention oF urine it is so distendeti 
that its apex reaches the umbilicus. Its vertical Ls greater than 
its lateral diameter, and its lonp axis is oltlirpiely downward and 
backward, owing to the fact that it curves slightly toward the 

Fio. 30 

Anatomical titmcturc of tlie verumomannin: I, central column of the veru- 
montaniim ; 2, cavernoiin or ereclilo tiKHue ; 3, urethml muLfiua membnine; 
4, sinne pocularis; fi, cjaculatory ducU. (\fter Te-stut. modifiod from lienle.) 

abdomiiml wall. The apex of the bladder is romuleti and coii- 
nei'ted (o the umbilicus bv the irnichus. The front of the body 
of the liladder i.s not covet^^il with peritoneuni, and is in relation 
with the triangular ligament, the symphysis pubis, and the internal 
obturator muscles, 

Tlie peritoneum is reflected from tlie anterior surface of the 
rectum to the lowtr and back part of the bladder about an inch 
distant from the base of the prostate and just behind the points 
where the ureters pass into the bladder. It, however, in some 
cases comes down as low as the base of the prf>state. It then 
passes to the summit, ami from there is reflected upon the abdom- 


iiml Willi. As a rpsiilt of this arningpinent the [xTitoneuni sags 
down hehiml the pnl)es when the lihulcler i.s empty. As the viscus 
liccouieji distended its biiise extends towanl the perineum and it3 
summit comes in contact with the ahdununal walls. As it rises 
in the alM](»inen the prevesical peritoneal covering of the hlaihler 
gradually forms a pouch which, when the organ is much dis- 
tended, and particularly when the base of the bladder is elevate<l 
by a distended nibl>er bag in the rectum, Incomes more and 
more elevated above the pnl)es. and leaves a space of two or 
three inches of the anterior wall of the bhuider free from peri- 
toneum. This arrangement of the anterior bladder wall and of 
tlie [>critonet!m nujst be borne in mind in the oj>erations of aspira* 
tion and of suprapubic cystotomy. 

It is also necessary to l)e familiar with the space between the; 
pul>es and the anterior wall of the bladder^ called the prevesical. 
space of the cavity of RetKius. This cavity is pyrami<lal in shape, 
and Is formed by the ul4ic|ue positioji of the bkulder as it tilts 
forwanl towanl the alHloniinal wall. The prevesical space is 
formed by the transversalis fiusciii, which divides into two layers 
just aUne the pulies, the anterior layer passing down behiutl 
the pubes and thea^ l>ecomiiig mcrgetl, while the posterior one 
passes over and behind the bladder, merging with the pelvic] 
fascia. Thus there Ls a triangular space formei], the apex of 
vvfiicli correspouiis with the line of the fusion of the fascia alwve 
the pubc^s, while the base of it is Ixdiiml the pubes. In this space 
mon* or less fatty tissue untl blooilvessels are fonnrl, and it is 
through it that the incision is carritMl in the suprapubic operation. 

The mucous membmne <»f the bladder is of a pale yellowish- 
red or pale-rose color, and is covered by flat polyhetlral epithelium, 
unilemeatli which are chil>-shapc<l and siniple-shiiped cells. It 
has a few follicles, ami some small nicemose glands lined with 
columnar epithelium near its neck, which are seated in the sub-^ 
mucous connective-tissue coat. 

\Mien the bla<lder is o|>ene<I on its anterior surface, together' 
with the upper wall of the prtistate, it is seen to lx» thrown into^ 
folds or rugie. which for the mast part paas horizontally aroundj 




the visciis. Other rugre run longitudinally and oblitjuely, and 
as a result the membrane is divided up into more or less square 
ami irregular flat pininenres. Tins (jueer uppeamnce is due to 
the contraction of the muscular lihres aeling upon ihe mucous 
membrane and its submucous coat. It gradually di.sappears 
when the bladiler becomes distended. When in health the bladder 
is examintMl by means of the cystoscopy the membrane Is seen 
to t>e smooth and of light pink, sometimes with a yellowish tinge. 
It follows from what has been said that the mucous coat of the 
bladder is loosely attache<l to the muscular coats. This is the case 
in its whole extent except at its base. At this part we find the 
trigf^ne or triangular space, which is bounded on each side by a 
slight but well-marked ridge which corrc.spomls with the ptwition 
of the muscles of the ureters. These ridges l>egin ami form the 
af>ex of the trigone near the vesical orifice and uvula vesicfe, and 
nm outwani and backward about two inches. At its base the 
trigone is about tw4> inches wide, and at each angle fif it the orifice 
of a ureter opens into the bladder. From apex to base the trigone 
is about ouc and a half ijiches in lengtli. Tlie niuctms mem- 
brane of the trigone is of pale color, smooth, never wrinkleil, and 
firmly attached to the parts beneath. (S<v Fig. 29.) That [jor- 
tion of the bladder situated just liehind the trigone is called the 
post-trigonal space, and is of great surgical interest in the matter 
of pouches, residual urine, stones, ami tumors. 

When the bhidder is empty its walls, contracted into a rounded 
or triangular mass, are in coaptation. At this time the lumen of 
the prostatic urethra is effacexl by the contraction of the muscular 
fibres. The vesical end of the prostate Ls then in the form of a 
well-defined but not very resistant sphincter, which divitles the 
urethra sharj)ly from the biwlder. As the viscus gradually fills 
the pressure of the accumulating water overcomes the tonicity 
of the internal spliincter. Dilatation of the prostatic urethra 
then begins, and as this progresses it gradually loses its spin<lle 
shape and becomes decidedly funnel-shaped and directly con- 
tinuous with the bladder. Thus, when the Idadder is empty 
the prostatic urethra is essentially its neck, Init when it is quite 



fully distended the neck-like arraiigemeut becomes lost and thi 
bla<lder and prostatic urethra are coiitinuona without any barrier 
between them. It follows from what has been said that the urethral 
proper is longer when the bladder is only sUghtly full tlian it 
when it is quite fully distendefl. When the bladder is neari] 
empty it will he found that it is necessary to intnxhice the catheter' 
nearly an inch fartlier (han it is necessary to intro<luce it when it 
is full. The reason of this is obvious : with the bladder only slightly 
di-stended the internal sphincter is still contracted and the eye 
of the instrument must pass that part before urine is reached. «^ 
I^ter on, when the sphincter is nntch dilated and the prostaticfl 
urethra is transformed into a funnel-shaped cavity continuous 
with the lilndder, it is only necessary for the eye of the catheter 
to pass behind the external Hphincter, when it encounters urine. ^_ 
Finger is certainly right in his claims on this subject, ^M 

In this connection it is necessary to more fully call attention 
to the two sphincters of the prtxstate. Tlie internal prostatic 
sphincter is siluated at the [lohit of the junction of the prostate 
with the bla4lder, and is mergetl with the substance of the former. 
It is composed of smooth muscular tissue and elastic fibres arranged 
in the form of a ring, into the meshes of which muscular and 
clastic fibi-es from the bhidder enter at right angles. The internal 
prostatic sphincter therefore contains no voluntary muscular'^| 
fibres. The external prostatic or vesical sphincter is situated at ^^ 
the apex of the prostate, and is composed of smooth muscular 
fibres, together with a greater quantity of voluntary muscular 
fibres. The involuntary fibres are arranged in the form of a ring. 
The voluntary fibres at first (that is, in the portion toward the 
ap<rx of the prostate) form a transverse hand across the upper 
portion of the urethra, stretching from lobe to lobe. At the apex, 
however, they are quite numerous and form a distinct ring, which 
with the ring of involuntary fibres constitutes a very strong 
sphincter. It is this sphincter, when the bladder is full and the 
iutenial sphincter is much <lilateiU which remains firm, occludes 
the canal, and prevents the passage of the urine. The relation of 
the prostatic urethra and the sphincter to the bladder when 





empty ami full is well shown in Figs. 31 and 32, which are 
modified from Finger's pictures. In Fig. 31 the bladder is 
only partly full, and the well-defiiie<l vesical orifice is still intact 
by reason of the tonus of the internal sphincter. In Fig. 32 
the bladder is much tlisteiii!e<! and the prostatic urethra is 
obliterated, of a funnel-shape, an<l merges directly with the 
bladtler ca^nty. In tliis case the external vesica! or prostatic 
sphincter exerts its tonus and retains the urine. 

Fio. 31 

Fig. 32 



Showiog a pftrtially-fillcd blad- 
der separated from the prostatic 

Itladder much diHtended and fused 
with the prostatic urethra, which is 

Prostatic Tubules. — Upward and beynii<i thf^ venimontanum 
there is a small mass <>f ^land tissue enveloped in a connective- 
tissue stroma uinl covered with mucous membrane wliich is plen^ed 
by tlie orifices of many glaud-<lucts. This tissue-nuiss is seated 
between the two lateral lobes, ami it ends at the orifice of the 
bladtler. In some subjects the devt-lopment of this glandular 
area is very sparse, in others more luxuriant, while in a more 
limite<l class of subjects it is very exuberant. This mass of gland- 


ular tissue plays i\\\ important piirt in many youn^ and miHdle- 
ajred subjects in liein^ the seat of a low ^raile of ehronie influm- 
matory process, an4l in Ititer life it may uiulergo such marked 
hypeq^lasia that a third loh« of the prostate is formed, which,|^| 
l^comin^ investefl by a capsule derived from and continuous 
with that of the rest of the gland, offers more or less impediment^— 
to the passage of the urine. ^| 

It will thus be seen that some of the ducts of the prostate gland 
open on each side of the verumontanum in a linear manner, and 
tliat there is also a group of them clustered in the tissue beyond 
this structure as far as the vesical orifice. (See Fig. 29.) fl 

In tlie mncnns membrane Jying laterally beyond the region Just 
mentioncil we frequently find scattered here and there orifices of^ 
glanilwlucLs, but never in large numl^rs. ^ 

On each side of the orifice of the sinus pocularis, or uterus 
masculinus, in the vertical walls of the verumontanum, are the 
slit-like lipenings of the ejucniatory ihicts. In some ciuses (me or 
botli of these ducts opens into the cavity of the sinus prvcularis. fl 

In the anterior wall of the prostatic urethra, near its middle 
portion, are numerous venous channels, almost amounting to a 
plexus, which are su[>erficially seated in a dense submucous tissuel 
and covered only with mucous membrane- It is the injury of 
this plexus by careless sounding which sometimes gives rise toj 
severe hemorrhage. 

There are three layers of unstriped muscular fibres in the pros-l 
tatic urethra: fl) an internal circular hjyer inmicdiately beneath 
the mucous meinbnme; (2) a mid<lle loiigituilinal layer, which 
forms an imjierfect sheet of muscle; and {\\) an outer, annular 
coat, which is continuous with the circular muscular fibres of th^^| 
bladder. There are. in addition to (he foregoing, tlie external 
and intenial sphincters of unstnpe*! rnuscuhir iiba's of llenle,^ 
and in the capsule of the gland l>eneath the striped muscle is an^ 
iuilepemhMit thin layer of non-striped muscle, from which fasciculi 
piLss inwani and invest tlie ultimate groups of tubules. 

The arterial supply of the prostate is very coasidend>le, and 
ilerived from branches of the internal pudic. vesical, and henaoi 



rhoidnl arteries. The veins are correspondingly large, and they 
end in a ])le.\ns whic!i Ls situiil*'d at tlif sidt^ nnd hasr of (he j^limd, 
There is also an abundant dislrilmtion of Tne(hdluti.Hi and nnn- 
mediillated nerves to these parts, wlneh are deriveil from the 
pelvie plexns. 

In and about the venmionlanum tliere is an abun(hint .supply 
of nerves of jHH-uhur sensibility, and here it is thought that the 
seat of pleasure in the sexual act is centred. This part may be 
calle<l the internal seiiHorinni sexuale. 

The prostatic urethra in liealth en<is ul>ruptly at the vesical 
orifice, which is well shown in Fig. 'M. When the gland under- 
goes enlargonientf particularly when its thinl loiie is hyj^t^rt pop hied, 
and also In the lateral lobe, it begins to pass bey*)nd this vesical 
orifice, and may eventually extent] into the bladfJer cavity. 



The seminal vesicles aiv two elongated and lobulated mem- 
branous pouches situated at tlie base of the bladder just l>eyond 
the prost^'ite and in front of the iTctuui. Tlie seminal vesicles 
have been erroneously and variously described as convolulcil 
tubes, as little sacculale*! bUuMers, and as racemose glamls. 
Tliey are really blind-ending tubes with diverticula of various 

This can be seen from a study of Figs. 33 and 34. In Fig. 33 
the vesicle (1) is portrayed, divested of its loose connective tissue, 
and its three tulx*s an.' quite distinct to view. The ampullation 
of the vas deferens is also shown. In Fig. 34 the tulws are shown 
dissected apart. The iuner or first tube (2) is seen to have a 
ilecided distal enlargenieiit. The uiidflle or second tube f3) is 
seen to join the outer or third tube (1) at right angles. 'I^hese 
two tubes (the third and fourth) bear the same relation to each 
other that the blade of a jack-knife bears to its handle. The 
outer eidarged tulw*. of dog's-ear sliapc. is callei! the handle (»f the 
jack-knife, ami the middle tube is its blade. \Vhen filaceil in 
natural c(»aplation the knife-blade fits snugly In the e(»ucavity 


existing in the handle, and these lie side by side, all welded together 
by dense connective tissue with the first or inner tube. 

Fio. 33 

Fio. 34 

Showing the relation of the various parts of the (teminal vesicles to each other 
and the RmpiillntionB: 1, seminal veaicle; 2, inner tube; 3, 8econcl lube; 4, 
outer or third tube, or handle of the jack-knife. (Drawn from nature.) 

iND PHYSJOTx^or OF se: 

Each seminal vesicle measures two and a half inches in length, 
about half an inch (sometimes an inch) in hneadth, aiul a quarter 
to a third or half an iiichjn thickness. (See Fig. H5.) 


Under view of htnililer and sexual apparatiiB and of iirelhn. and pn»tale: 
1, nreter; 2, ampiillalion of vaa deferenu ; 3, seminal vesicle; 4, prostate; 
6, Cowper'n glandn ; G, bulb of urethra ; 7, metubranntis urethra; 8, crua penis. 
(Drawn from nature.) 

The anterior or pointed extremities of the seminal vesicle.s are 
situate^l, when the hhidder is empty, within u fingrer's breatlth of 
each other on each sifle of the median line just almve the hase of 
the prostate. In this inter%'al the arapulluted end of e^ch vas 



deferens joins the anterior pointed extremity or outlet duct of the 
seminal vesicle at a very acute an^le, and, merging together, they; 
form the ejaculatory duet. Thus there are two of these ducts- 
one on the rijjht of the nietliaii line auti one on the left — lying] 
very neiir to one another. These ejacidatory duets enter the pros- 
tate at lis hasp, tunnel its stnioture side hy siile (see Fijjs. 23 an<i 
24), pass downward and upward^ and enter the pmstatic urethrai 
eitlier on the sides of the sinns pocuhiris or inio its cavity. 

AUhon^h the senunal vesicles and \\n* atnpullutcd extreniitiej 
of the viisa deferentia lie very close to one another when thej 
l>Ia<lder is en^pty, when that viscns is nomially (iistcndeil these] 

Fio. 36 

Transverse section {»r tlie ba>e of the bladder just behind Ihe proHtate, aliowinK 
Ihc relation of the seminal veaiclett and the ampullalionH, wliioli are embedded 
in a den«e coiineeUvti-liinflue stroma: I nnd 2, cliambera of seminal vesicles; 3, 
ampullations of the vasa deferentia. 

structures are separated from each other so that they form the 
letter V on the outside of the vesical wall. (See Fig. 35.) On 
the inside of the hiadder at its hase a Wshiiped space, corre- 
sponding to the external one just descril)ed, exists, which is (uitleil 
the trigone. (See V'\^. 20.) It will l^e seen that in tlas figure, 
whicli is acctirately drawn, the orilicea of the ureters are unsym- 
metrically placetl. 

The seminal vesicles have the usual muscular, connective tissue, 
and mucous memhnuic coats. Each portion r»f the vesicles has 
a calihre varying from 10 to l-S of the French scale fand m 
some young and vig^mnis suhjects ;iO French), while its outlet 
duct has a calibre of about 4 to French and sometimes leas 
(See Figs. 37 ami 3H.) 




The epitheliiuu lining the vesicles is of the cohimnar and 

cuboidal varieties. The nuicous nienibrane, which is stiuhied 
witli the orifiees of munerous tuimliir ghiiuls, is thrown into folds 
by which its extent is greatly increaseth Thus the muscular 
layers form tral>eculpe. which produce many depressions and 
diverticula. (See Figs. ?il and 38.) In structure the seminal vesicles 
have thicker ami denser walls than the ampulhitetl i>arts of the 
vasa deferentia. They also have an idanidant nniscidature, by 
the contraction of which the seiTetifni is promptly expelled. 

Fio. 37 


Showing the internal structure of the seminal vesiclt^ ami of the ampultation of 
the vaH deferens, iiiir] the union of the two diictn whirh form ihe ejaculatory duota: 
1, interior of the Hetninal vehicle ; 2, interior of nrnpiiUa ; 3, junction of the ducUt 
forming the ejaculatory duct. (The nectjon \a taken in tninsverHe diameter of the 
prostate and in the long axis of the seminal vesicles and tos deferens. Drawn 
from the Kdinger projection apparatus.) 

The seminal vesicles are firmly welded to the prostate by tneans 
of dense, filirous connective tissue, which, liesidcs completely in- 
vesting the .sacs, so adjusts the anatomical relation of tlie parts 
that the normal position of the ejaculatory ducts is always pre- 
served, ami there i.s tiever dan^^er of their being accidentally bent, 
twistwl, or compressed. This condition of aifairs is nn>st impor- 
tant in coitus, since by it any hindrance to ejaculation is prevented. 


Fig. 38 

Showing Ihe inlvmal atruclure 
by longitudinal Ejection of the 
neniintil veuictes with th« large 
number of ampiiUic : 1, van de- 
ferens; 2, il8 terminal Rmpiilla- 
tiona ; U, the seminal ve«irles with 
their coni|)arlnionu ; 4. the ejacti- 
\tXory duct. (Afler Teatut,) 



Tliis perivascular connective tissue is also interesting in clinical 
pmctice, since in some cases inflammatory action extenils beyoml 
the vesicles themselves and involves it more or less extensively. fl 

The arterial and venous tlistrilnition of the seminal vesicles 
is ver^* rich, and is derived from t[ie middle aud the inferior 
vesical and middle hemorrhoidal tn^mks. 

The nerve supply is abundant, 
and is furnished by the pelvic 

The chief function of the seminal 
vesicles, liesirles acting as a store- 
house for the spermatozoa, is the 
elaboration of a |>ecnliur mucus in 
large quantity, which, in coitus, bj 
its volume and force, carries along 
with it without im|jedimentthe semi- 
nal fluid, which exists in much more 
sparing quantity in the ampuUatioiis 
of the vasa deferentia. 

In this connection it b well to 
call to mind the position and func- 
tion of the seminal vesicles an<l of 
the ampulhi*, their [n]medittte sur- 
roundings, and the conditions to 
which they are subjected in health, 
since stich annnderstaiiditig renders 
clear many pathological conditions 
which are now obscure. 

In health tlicse seminal reser\'oirs, 
when the man is in the erect posi- 
tion, are seate<l nearly in a vertical ]H>sition — that is, they are 
bags with their bo<iies high up and with their outlet ducts low 
down, looking downward and slightly forward. From tlicir posi- 
tion one might tlunk that iheir mucous contents miglil rea<lily 
escape in ol>cdience to the laws of gravitation. But we find that 
the secretion is retained in healtli in its reservoirs by wonderful 




provisions of nature. The healthy mucous secretion of these 
parts is very viscid, coiise(|iienlly it is not prone to leak out of 
the outlet ducts. In ill-liealtli it is more Hnid, and then it tends 
to escape. Then we must consider the interior strncture of tliese 
receptacles. Tliey are not simply cavities like an egg-shell, but 
are compose<l of intricately Hrmnged chambers Avitli »iecidedly 
deep tral^eculae and diverticula, all of which tend to keep the 
secretion pent up until discharged by the functional activity of 
the parts. Then at the orifices of the outlet duct such is the 
compactness of the structure of the circular muscular fibres that 
they possess a certain tonus which prevents the escape of the 
contained secretion. It is probable, also, that in a measure the 
normal action of the musculature of the ejaculatory ducts so 
compresses these tubes that escape of secretion througii them is 
prevented- The redupUcaiures of the mucous membrane also 
help to stop up these tubes. Therefore, we see that the condi- 
tions inherent in tlie .Hecretions theuiselves and of the parts which 
hok! theui remly for disclmrge all lend to keep tliem well stored 
up until they are thrown out in ejaculution. In disease all this is 
changed, anti tonus is replaced by lack of normal contra^ctile power, 
and a general ilabbiness and iiiertness of the parts are present. 
Then, with secretions less viscid than normal, and with lass of 

tonus and functional activitv in the reservoirs and their outlet 


ducts, it is readily seen why these secretions escape. 

We must further fully consider the various influences to wliich 
the semial vesicles and ampullae are constantly subjecte<l. Welded 
as they are to the base of the bladder, they undergo more or less 
expansion and contraction, according as that viscus is full or 
empty. In tlu* net of urination, when the size of the l)ladder 
diminishes until it becomes a mere ball, there must be some 
pressure exerted upon these seminal ap[)endages; but in health, 
as a genenil rule, no expression of their contents is produced. 
Then, again, we must remember that the bladder and all struc- 
tures connected with it are necessarily more or less acted upon 
by intra-abdominal pressure (the weight of the intestines and 
their distention after eating, the distention of the rectum by gas 


or by feces. an<l abdominal fat), which in health does not, with 
very few exceptions ^ pnxhice any change either in the vesicles or 
the ampulla'. Kiirther than Ibis, in the expulsive and contractile 
efforts of the rectum, whicli lies immediately l»ehind thcni, in iJefe- 
cation, particularly if the fecal mass is lar^ and firm, consider- 
able pn\ssure must be exerted upon these intimately connecte*! 
parts, particularly when there Is stnmg contmction <>f the levator 
ani mascle. Even with all these surruitudin^ and nei^hbormg 
forces acting upon the vesicles anil iinipulUc, they, as a rule, 
remain unalTected, and their seciTtion h not in any way al>nor- 
mally disturbed, TOien these facts are fully understood much 
advance is ma<le toward a clear and scientific comprehension of 
the nature and extent of seminal losses. 

The Ampullations of the Vasa Deferentia and the Ejaculatory Ducts. 

The umpullated ends of the vasa (h^ferfutia are really expan- 
sions develope*! in these true spermatic canals at fheir point of 
juncture with the inner or first tulx* of the seminal vesicles at the 
niche in the base of the j)rostate. They have the same histo- 
logical structure and (he same glandular sup]>ly as the seminal 
vesicles, except (hat their fibrous and muscular tissues are rather 
less copious; Imt they are, nevertheless, finn and strong. The 
calibre of the ani[)nllations of the vnsa tk'feri'nlia varies l>etween 
fi un<] \0 French* but in vigomua yuung mt-n it may 1>e much 
larger. The internal stnicture of these dilated extremities of the 
spermatic canals is tral>eculated Hke that of the vesicles, by which 
arrangement a greater amount of secreting surface is produced. 
(See Fig. 37.) There are present tnimcrous tubular muciparous 
glands thn^ughout their extent. These ampulla* l>ecome narrowed 
just at the base of the prostate, and the*y then form a tul)e into 
which a bristle or a knitting-nee<lle will pass without the use of 
much force. Amund the orifices of these (hicts the muscular 
tissue is somewhat increased in quantity, so that a not very well 
ileveloped sphincter is formed. This duct is then joineil by a 
duct of similar calibre, which is the prostatic end of the inner or 
first seminal vesicle tube. (See Fig. 37.) In this manner are 





formecl the ejaculatory ducts, which are aVw)Ut three-cjuarters of 
an inch in lenj^th an<l liave a calihi-e of a1>out two millimetres. 
'riiey run, as has already l>een statc<!, through the prostate down- 
ward and upward and o])tMi on each si<le of the verunion- 
tanuni. (See Figs. 23 and 24.) The mucous membrane of the 
ejaculatory ducts contains tubular ^lanils, is somewhat tra!>ecu- 
lated, atui from it numerous diverticula and duplicatuR's are 

Microscopic stiKly of the structure of the ejaculatory ducts 
shows that their fihroiis coat Ls not ver)' thick, heavy, or con- 
ilensetij and Ihat their tnuNcnlar coat Ls correspondingly sparse 
and weak. A careful examination of the^e structures will con- 
\-ince the obsen'er, I think, (hat their role in ejaculation is cither 
passive or their function Ls to contract moderately after the ejacu- 
late has passed through them. There are no such firmness and 
<lensity of structure of the ejaculatory ducts as there are in the 
vesicles and ampulla', expulsive power is very great, owing 
to the preponder.iliiig anu»unt of unstripeil muscular tissue. In 
the rhythmical process of ejaculation the secretion passes from 
above through the ejaculatory ducts, which then remain [mtulous, 
and it enters the priKstatic uivthra, and as this cK-curs the 
pnxstate contracts tpiickly, limily, and synchronously. The ejacu- 
lator)' ducLs then contract as strongly a,s their ftn-hle structure will 
allow them. Tims tfie ejacnlak' is thn)wn forwanl. 

The chief function of the ejaculatory ducts, however, seems to 
be secondary to that of the orifices of the seminal ve-sicle and 
ampulhe. The sphincteric action of these orifices is i:|uite power- 
ful, owing to t!»e goodly (pmntity of circular muscular fibres. 
Now, addeil to this wc have the secondary sphincteric action of 
the ejaculatory ducts, which closely compresses the lumen of these 
canals. It must lie remembered that there is no fibrous and firm 
tube to occlude, but there are so many trabeculations and redu- 
plications in the mucous membrane of these ducts that by their 
coaptation alone the lumen is occluded, and by this condition, 
aide<l by moflerate muscular contraction, they may be said to 
t>ecome nonnally plugged up, and thus offer a bar to the escape 


of secretions from above. In disease these parts liccome Habbj 
anil their musciiKir tonus is more or less lost. 

The Intrinsic and Extrinsic MuscLes of the Sexual Apparatus. 

In the performance of the sexual function a number of corre- 
lated groups of muscles ami muscular structures are concerned in 
the process of ejaculation, which are calleil intrinsic and extrinsic 

The intrinsic muscles, which are of the unslriped, involuntary^ 
variety, consist, first, of the musculature of tiie prostate and pros-»fl 
tatic urethra, second, of the muscular fibres seate<l in the walls 
of the seminal vesicles, of the ampuUations, aiul of the ejacula- 
tory ducts, antl those of the circular and longitudinal muscular 
tibn-s connected with the corpus spongiosum. ^| 

Tiie extrinsic nniscles an* of the striped or vohiiitary variety, 
and ihey consist of scane of the muscles of (he male |>erineumj 
antl of the aual region, and of some which belong to the peni 
proper. These are all well shown in Plate IV. 

It Ls unnecessary to fully and technically describe these variousi 
muscles, since all the facts can be rea<lily ascertained by ctmsult-i 
ing any text-book on anatomy. These muscles are as follows: 
the bulbocavernous or accelerator urina^ muscle, which surrounds 
the bulb and extends over the corpus spongiosum and on to the 
side of the corpora cavernosa for a length of fully two inches and 
perhaps more. These muscles compress the corpus spongiosum 
and bulb. Secondly, the ischiocavernous muscles, also called 
erectores penis, which are tiUached to the ramns of the iscliiuni, 
and are inserted on each side into the cms penis, and by their 
action compress the parts and maintain erection. Thirdly, the 
transversus perinei, the external sphincter ani, and the levator 
ani, which give strength and firmness of support, and by thei 
combined powerful contractions aid ejaculation of the semen, 
(Sec sections on the Mechanism of P^juculation in the next] 


Intrinsic and Extrinsic Muscles, of the Sexual Apparatus. 

1. Corpu* Spongiosum 2. Bulbo-caveriious M Li«ele 8. t«cl)io-caverutjui 

Muscle A TransveraitB Porinoi Muscle 6. ExiernaJ Sphineter Ani 

Muscle. 6. l^evator Am Muacle. 



It is imnecessar}- in this work to jjive an elaborate ami tech- 
nical description of the niimite structure of the testes, l>ut certiiin 
general facta concerning these glands shouUi !)e emphasised. In 
tlie glamlular portion of tjiesc organs we find the conical-shape<:l 
lobules whose apices emi in the mediastinum testis. These lobules 
are formed of convoluted neminifertms iubules^ in which are ilevel- 
oped the seminal cells and the s|wnnatoblasts. (See Fig. 39.) 

Fio. 39 

Tunica f'air'»afM. 


7\tnica Ait/ugintu. 
It 9 Septa 

Showing intimate structure of Che testis. (From Oraj's Anatomy.) 


Each lobide is enclosed in fibrous tissue, winch forms the frame- 
work of the gland, iLs outer coat Iwirig the dense tunica albiiginea, 
and its irnicr portion, less dense, being tlie mediastinum testis, 
through which the seminiferous tubes pass, turn upward at right 
angles, a.ud [lerforate the upper inner portion of the tunica albu- 
ginea. Here they become much enlarged and ctmvolute*], and 



fonii the globus ninjor or head of the epidiflymis. All these 
uiinule seminal tulniles then mer^ into one tuln*, which becomes 
much convokitetJ on itself nnd forms the body of the epididymis^ 
which i.s the nnrrowed ]H>rti()n just hchnv (he globus major. Iliis 
convoluted (ui»c then forms a large mass, which i.s culled the globus 
minor or tail of the epidi<KTnis. From the globus minor the tube 
ascends, growing less and less convoluti^d, and then forms the 

Ftn. 40 

Sclieomlii: repreMeiilalioii of tlie t'titiri: ^uiilu! apiiamtiKS uf a man (un right 
Hide) : Af bliuMer ; H, prowtalic urt-llira ; V, i»enibranou» urelhm ; D^ »\>ongY or 
buUiuuN tir«thni ; 1, rij^hl iKKt'w\e ; 2, epidiiiyriiiH ; it, van dertfunH; 3', iini|HilU, 
of van (Icfcren!); 4, f^Miiiniil vwicle ; Tj, ejiiciilniurv iltiel vmliiig in ihe veriJinun< 
Uniiiii; (>, TowjierV kIaiuI with iU excretory duel; 7, ni»ening in the biilbousi 
urelhra. ( Afl»«r Tchlut.) 

nearly ^straight tuU'— the vas defercn.s--whicli, with tlie vessels, 
lymphaticjj, and nerves, and its connective-tissue sheath, consti- 
tutes the spermatic cord, which l>egins at the tail of the e]>ididyTnis] 
ami ends at the internal alMloininal ring. (S<t Tlatc V.) 

It is well to remendM»r that in healHi the spermatic veil 
coining from the Iwick of the testes l)ecome convolute*! an<l foi 
the jmrnpiniform plexus. In disease this tortuosity of the veins 


H ~ IH^^^^I 

^^^^^^H 'H ' - '^^^^^^^^^^^^^^^^^^^^^^^^^^^^^1 

^m ■' ^ ^1 

^H ^^H 

PLATE V. ^^ 


^^W^I^^V JUHCTlOM ^^^^^H 

^PB ^^^B U'RICTAL ^^^^^H 

• ^ftl '^^^M AtO WMCERAL ^^^^^H 

OBH^^H LAVCHftOr ^^^^H 

^HV^^^^H TLJMICA tfAOl- ^^^^^H 

K ^^Il^^^^h ^b ^^^^^^^1 

^^^^^^^d^^B iM ^^^^^^^1 


'■■ rV V ^^^^H 


B W ^ ^1 M ^^^^^^^1 


w H ¥V /^ JH ( ^^^^^^1 


^^^^ \ 

vB^^Hi ^1 

M r * u ^^^^^^1 

^ ^irnuO" -I- ^^ 



|jK "v ^ ^H 


n^^ln ' ]|fey^LO«U« ^^^^H 


^^HJt' )LiiL^- 7.JH ^^H 


^^^^_ JUM*^ ^^J^y UPPCR CNO ^^^^H 

^^^■v vjujij^^^ '^^^Rkt" Of ^^^^H 


^^^n J^^^P ^^V^HTDATID ^^^^H 


^^^■1 f^^^^^^t^ '^^^t^^F ^^^^^^^1 


^^p HJ^^^r '^^^^V ^^^^^^1 


^v ^^HTv ^\I^^^R ^^^^H 


^P I^^V'^V "''V J^^^l/ ^^^^H 


I^V *' ^^^^F uH^^^^^^Kf ^^^^^^^1 


l^n ' ^^V^ n ' l^^^^^^^^nF ^^^^^^^^1 


\i\/ ^^^^^^^v ^^^H 


^S^^HT ' '^^B^^^^^^By ^^^^^^1 


^^^IbH^ ^H 

. ,^^ii^^^^B^^PAItlCTAL UIVtN ^^^^1 



^K Right Testicl< 

3, iis External Surface. (Testut.) ^^H 



more or less increased, and we have the condition known as 

At the internal abdominal ring the vas deferens turns and 
descends into the pelvis, crosses the external iliac artery, curves 
around the bladder on the outer side of the epigastric artery and 
inner side of the ureter, backward and downward to its base, 
where it becomes ampuUated, as we have already seen. 

A survey of the structure of the testes shows that pathological 
changes which destroy the tubules and the lobules may give rise 
to sterility. In such an event, however, it would be necessary 
that all the glandular tissues of the organs should be destroyed. 
But it will be seen that the more vulnerable points are the medi- 
astinum testis, and the head, body, and tail of the epididymis. 
In these parts such infiltration and compression may take place 
that the efferent ducts are obliterated, and thus no spermatic cells 
or spermatozoa can escape from the testes. 

By way of a general risumS of the subject it is worth while 
to study the features shown in Fig, 40. 



IIavino a<X|ui[vii n clear kno\vle<l^e of tiie anatomy and struc- 
ture of the sexual apparatus it is now necessary to study in detail 
the pliysinlogy of the sexual function. To this end it is necessary 
to *lesf*ri^H' in a luciil and concise manner the mechanism of erec- 
tion, tlic mechanism of ejaculation, and the nature and composi 
tion of the seminal fluid. 


In order to understand the mechanism of erection, or that state 
of rij^idily of the penis necessary for intromission and copulation,fl 

the facts connected with the anatomy and pliysioloj^y of the gen- 
ital apparatus already hrougiit out should l>e recalled to mind. 
Concisely stated, diis condition of erection may be induced b 
psychical or tactile influences, or by the combination of both. 

Scxiial impulses, as we have seen, originate in a sexual centre 
which is seated in the lower lumbar part of the spinal cord. This 
centre is stimulated into functional activity by impressions or sen- 
sations whi<h originate in tite brain, and arc tran.sinittM through 
the [khIuucuH cercl^ri ant] the [»yus do\\7i the spina! cord to it, and 
also by excitation and frictional influences which are applied to 
some part of the j^enis — t. e., glans, fncnum, fossa na\*icularis 
or integument. In the first place the mental excitation thn^w 
the genital centre into a condition of erethism which immcdiatel 
acts ui>on the penis and its accessor}' sexual organs by means 
the nervi erigentes and caus<'s its rigid condition. Tn the sccon 
place the peripheral nerve irritation is transmitted backward 



I the sexual centre bj means of the sensory nerves, which throws 
B the centre into a condition of excitation, which ia reflected or 
' carried outward to the penis by the nervi erigentes, and erection 

It is thought by some authors that besides the sexual centre 
which governs erection there is also a centre for ejaculation. 
Iliis view is mainly ba^ed on the not very common occurrence 
of erection without ejaculation. In many cases in which coitus 
is thus interrupted some inhibitive influence is undoubtedly trans- 
mitted from tlie brain, and in these cases at least there seems to 
• be no necessity for snpjjosing that there is an ejaculatory centre 
the function of which is disturbed. 

Thus we see that the re<:|uircnients for erection are: first, a 
healthy and stable condition of the genital centre; second, a 
perfect comp<'tence on the part of tlie nerves which originate 
in the brain and of the erigentes and sensory nerves to transmit 
the influences of excitation which are communicated to them. 
H Stimulation of the sexual centres with resulting erection may 
V also occur tlirough influences brought to Ix^ar upon the prostatic 
urethra. Thus friction of tliis point by instruments and appli- 
ances passed down the urethral canal, cither by the surgeon or 
by the individual himself for erotic puqioses, excites the genital 
centre, which reacts through tlie nervi erigentes ujjon the penis. 
Calculi in the prostatic urethra and distention of the canal by 
urine also produce a similar effect. 
I Tlien, again, injury or disease of the lower part of the spinal 

B cord may cause erections by means of the irritation transmitted 
from the sexual centre to the penis. 

• The physiological actions involved in erection of the penis are 
very instructive and interesting. Under the influence of stimu- 
lation of the nervi erigentes, derived, as we have seen, from the 
sexual centre in the lumbar part of the spinal cord, a vasodilator 
action takes place in all the erectile tissues of tlic penis. Coin- 
cidently witli the nervous excitation and vasodilator action, relax- 
ation of the muscular bundles and fibres of the tralx^culie of the 
cavernous and spongy Ixxiies occurs, and thus the full distention 


of the blood and cavities is rendcre<l possible. In propor- 
tion, therefoiv^ jls ilie alTlux 4>f hlootj from the arterial capillaries is 
abundant and liie inuscnlar relaxation is complete, so is the erec- 
tion moderate or very firm. 

Although little is sai<l tin the snhject by authors, it is possible 
that the synipatheHie nerves of the erectile tissues play an impor- 
tant part in the production of erections. The functions of these 
sympathetic nerves is in immediate reciprocal relation with that 
of the cerebrospinal nerves. The former iiuluce relaxation of ^ 
tissues and vascular dilatation, while the latter, the excitor nerves, ™ 
are concerned in the pnmipt and full supply of blood to the 
tral>ecula?. If, however, the condition of the b!(x»d supply were 
not safeguarded, and if an imp)ediment wen.* not provided against 
immediate esea]«? and return of that (iuicj to the lK>dy by the 
veins, erections would in all eases be alx>rtive or of very short 
duration. Hut |X'rfeet stnbilily is ensured and nuiirifained by cer- 
tain anattiuiieal coTuiitions. With the filling of the trabeculw 
tfien? naturally occurs an engorgement of the venous sinuses, 
which, in its turn, so compresses the large longitudinal veins of 
the jH'nis that decided stasis occurs, and thus the volume of dis- 
tention (»f the (jenis is materially increased ami maintained until 
orgasm or ejaculation has occurred. 

Further than this, the engorgement of the penis is also mate- 
rially enhanced by t lie direct action of various extrinsic muscles, 
namely, the bullM>cavernou5 muscle, which compresses the erec- 
tile tissue of the bulb as well as the dorsal vein of the penis, and 
of the erector penis and tlie transversus }>erinei, which compress 
the crus j>enis and retani the return supply of blood. The levator 
ani also acts as a powerful extrinsic compressor of the parts. (Sec 
Plate IV.) 

The mechanism of erection, tlnrefon', depends on a peculiar 
nervous stimulation which n\suUs in a well-defined temporary 
bloo4i eng<jrgement of the penis. 



The cumhintMl physiological pmcesses wliich tuke place in the 
prxxluction of erection am preparatory to tlie completion of the 
sexual act, which culminates, in coitus, with emis8if>n or ejacula- 
tion. The emission of semen is produceirl by a series of complex 
butcorrt^lated a^'iicies [nvolvin^^ the whole sexual sphere*- Whether 
L^ there is a special sexual centre for ejaculation, as has l)een stated 
^P before, is donbtful. With the development of the erotic impres- 
sion and the erection of the pienis the testicles are, in all prob- 
al^ility, thrown into a condition of increascil functional activity. 
The first visible evidence of the jiarticipation of these ^^laiids In 
copulation or sexual erethism is the stwjng aetiim of the cn-nmster 
muscles, which ilnnvsthcni *|ni(e tjf^htly up to (he inti*rnal abtlom- 
tiial rin^. Synehnnionsly siMiien eseu[)*\s froin the eoni vitsciihisi 
i>f the epididymis and n-aches the vasa deferenlia. Arrived in 
these tid>es, the strong circnlar muscular Kbres contract power- 
fully and rhythn\ieally, and the fluid is fi>reefl up to the ani])ul- 
hitions of these tulx\s, which tlien Ux-omc very much disiendeib 
At tliis moment the seminal vesicles l>eeonie functionally active, 
and they contract an<l expel part of th^-ir contents synchronously 
with a similar action of the ampullations of the vasa deferentia. 
The seminal fluid in relatively small quantity is thus mingled 
with the copious ejaculate of the seminal vesicles, and the mix- 
ture thus pn»duced is thrown through the ejacuhitory ducts, the 
nmcous membranes of which take on functional activity and add 
their quota of mucous Huid, by strong muscular action, into the 
pnistatie urethra. While this part of the function has l)een K*^)ing 
on the follicles of the [jrostate and the sriuis |Micularis have lieen 
active in the elalKiration and expulsion of their secretions into tlu* 
!■ prostatic urethra. At this moment t!»e caput ^allinaginis iK'comes 
swollen and en*ct» and it so atljnsts itself that in the nonnal state 
the seminal fluid must go forward thn>ugh the now patulous 
orifices of the ejaculatory ducts, and cannot pass backward. At 
this time the compressor urethra* muscle is so n^laxed that it offers 



no im|K'iliinc'nt to the escape of the semen, which is thmwn out of 
the prostatic iiretlira hy means of the complex but powerful mus- 
culaluro of this ^iuiul. At this crisis it is believed that the pecu- 
liar sensation of the sexual orgasm is experienced. The combiued 
secretion of the ampiillatious, nf the vasa defcrentia, of the semi- 
nal vesicles, of the prostate, of the sinus pocularis, antJ of the 
ejaculatory ducts then flows into and distends the bullx)us urethra, 
being there mixed with the secretion of Cowper's glands. Theti 
llie circular juusculiir fibrtvs of this p<)rtion of tlie urethra contract 
forcibly, and at the same linic (lie accelerator urina' muscles con- 
tract upon the bulljous urethra, and thus the ejaculate is quite 
forcibly thrown along the urethra and out of the meatus. In its M 
passage througli the penile iirt^thra the ejaculation of the seminal ™ 
fluid is further accelerated by the rhythmical contraction of the 
circular muscular fibres of the corpus spongiosum. The s<?cretion ■ 
i>f LiUrc's fitllicles and Morgagni's crypts lubricates the urtHhral 
canal and adds somewhat to the volume of the ejaculate. In the 
act of ejaculation it can be seen that unstriped muscular fibres. I 
the intrinsic muscular tissue of the sexual apparatus, play a verj- 
important part; but the completion of the act is largely aided by 
the powerful contraction of (lie extrinsic muscles, the levator ani, 
the external sphiiu'tcr of Hctile, the ischim-avernosus muscle, and ■ 
the transvcrsiis [HTituM. As stated by Foster;* "A contraction 
In^gius in the exteruul sphincter ani, extends to the levator ani, 
anil then passes to the other muscles, pn)gressing in a wave-like 
manner from iK-hind forwartl, and is repeated in a more or less 
distinctly rhytlntiic manner until all the semen is ejected from the 

* A Text-book of Hhymolojrt-. lAmdcm, 1.S9I, Pari IV., p. 373. 



The proper performance of tlie sexiial function in the human 
?, the natural outcome of which is the propagation of the specieg, 
requires not only tlic intt'grity of the r4>inpo.sitt' nu'chanism of 
the st»xual apparatus, hut also tlie rlahuration of henltliy seminal 
fluid in normal <juaultty. A dear knowledge of the nature and 
coinpiKsition *>r this sltti'Lioii hi liealtli is absolutely necessary to 
the uaderstandiug of the clian]y;es wliich take place in it as a result 
of disease. 


The semen is a composite liquid of a whitish, opaline color, 
somewhat resembling starch-paste, alkaline in redaction, and viscid 
and ropy in consistence. It emits a |x,'culiar odor, like that of 
sawed bone. It is the combined secretion of the testicles, of the 
seminal vesicles, of the prostate gland, of Cowper's glands, and of 
the mucipannis glands of the urethra. According to Miescher/ 
whose conclusions have been accepted by the best authorities, 
the composition of semen is as follows: water, S2 to (X) per cent., 
the remainder compoMrd of serum albumin, alkali albuminate, 
hemialbuminose, nuclein, lecithin, guanin. hypoxanthin, protoniin, 
fat, cholesterin, inorganic salts, phosphoric acid, muriatic acid 
in combiDation with inorganic salts, and organic bases. 

When semen is examined imderthe microscope we find sperma- 
tozoa, seminal bodies, and very fine seminal granules, with per- 

* Verhandl. der Naturfor. UeselUch. id Basel, 1874, Band rt., Heft 21, p. 138. 


Imps a few epithelial cells and crystals of phosphates, chiefly of 
magnesia ami Hme. 

Spennatogenesia. — It is important here to call to mind the 
CHSi-ntial facts concerning spcnnatogenesis. Upon the endothe- 
lioiJ bu-scincnt membrane of tiie convoluted seminifenjus tuhules 
the nucleated parietal cells are seated, the outermost layer of which 

Fid. 41 

Rhowlng tnnMverae »«ction of human serainiferoun tubule: 1, membrana pm- 
prill ; 2. Tonr of pnrietal cellr< ; 3, mother-L'ellB undergoing division ; 4, imrtiiillr 
d«valoptHl «ii«rituiiocoa ; 5, rnreloping cunneotive tiAsne. (After pMiniol.) 

18 eomiHiseil of sustentnculur cells, which an* not concerned in pro- 
ducing s|K»nnatic elements. Inside and on the foregoing layer are 
the sjM'nnatogenctic cells, of which the outer ones are the longer 
or mother-cells, and the inner ones the smaller or daughter-cells. 
From the nuclei of the latter cells s|)ermatohlasts are developed 
anil from tl) structures the sjxTmatozoa are dirvctly formed. 
(Sm Fig. 41.) 

The s]>enuAtohla5t5 are eli»s«*ly packe<l t<»gether. side hy sulc, 
in II finely granular scmigelatinous suhstance. They gradually 


becdinc cloiij^ntcd and iM-aii-shajKnl, and finally arr elalKirated 
into fully dpwlopftl sperriintozoa. Pearsol ami others state tliat 
each spt'rma1i>KO(Hi is developed from the mieleus of a spermato- 

The secretinf^ portion nf the testes Is confined to the eonvolnted 
seminiferous tubules. From this part of the organ the spenna- 

Fio. 42 

Showing fipclion nf r liilmleof the human epididymis: 1, memhranft propria; 
2, coliioinar ccIIh crowned with, 3, lonR cilia ; 4, layur tt( non-striped niiutoular 
BbreH ; 6, iatortuhular conneclive tiHsiie; 6, maattea of spermatozoa in the lumen 
of the tube. (After Pearsol.) 

Itozoa enter the straight tute or canals, pass into the vasa ofTer- 
entia, a!id from there through all the manifohl eonvolutions of the 
cpi<Iid}Tiiis until they reach the vas deferens, whieh they traverse 
until they arrive at the deferential ampullations and seminal vesi- 
cleSj where they remain until cjmnilatioii occurs, "^rhe migration 
of spermatozoa, pn>l)al)iy, is eilected by their own vihratih* niove- 
B ments, but there are certain delicate vital and meehauical aids 
which speed them on their journey. From the begitiiu*ng of tlie 


Straight tubules up to the ampullated expansions the seminal 
canals are line<l witli ciliated columnar epithelium and surrounded 
by circular layers of unstriped muscular fibres, so tliat, in addition 
to their own motility, these bodies receive propulsion from the 
motion of the cilia, and also by the rh}1:hmical contraction of 
the muscular rings. (Sec Fig. 42.) It will thus be seen that the 
process of spermatogenesis is a most delicate and elaborate one, 
and that the m^'chanism of transportation of these vitalized bodies 
is wonderfully intricate* and eiTf^ctive. 

The spennatozoa are highly vitalized elements composed of a 
liead and a cilium or tail, and in their shape resemble tadpoles. 
The head viewed on its broati surface is oval in shaj)e, but when 
examined on its si<ie it appears somewhat triangular or wedge- 
shaped. Tlie lengtli of a spermatozoon is 5U to G0/(, of which 
the head is 3 to 5/-*, while the rest consists of the thin, tapering 
tail. The seminal bodies or cells are of considerable size, have a 
well-defined outline ami granular appearance, am! contain nuclei. 
The smaller cells are about four times the size of pus corpuscles, 
and contain a large nucleus and much granular protoplasm. The 
large cells are oval or irregular in shape, and they may contain 
several nuclei. Under high powers seminal cells show a fibrous 
structure. In my examinations I have most encountered the 
seminal cells in the semen of young men and in those of early 
middle age. It is liot, I think, common to observe them in the 
semen of men past fifty years of age. In such subjects we usually 
fuid spermatozoa and seminal granules. 

The seminal granules are extremely minute and fine, sometimes 
presenting a yellowish color, again having a gn'iisy upiK'arance. 
They have a much less refractive capacity than amorphous phos- 
phates and carbonates, are very much smaller, and are scattered 
evenly over the microscopic picture. 

When healthy semen is allowed to stand in a test-tube the 
tissue-elements slowly settle to the bottom, and in about twelve 
hours we find that it presents two layers of ecjual bulk, an upper 
one, whicb is of the consistence of semen, and may be slightly 
turbid or perfectly clear, and a lower one, which is opaque, and 




looks like starch or tragacanth paste. The lower layer is com- 
posed almost wholly of spermatozoa/ 

According to M<fhu,* healthy semen should on evaporation 
yield 10 per cent, of its wieght in organic and inorganic matters. 
With the change in the composition of the fluid due to, 
local or general, this quantity is proportionately lowered. In 
azoaspermatous semen the solid constituents are diminished alK)ut 
one-half in quantity. 

The microscopic j>icture of fresh, healthy semen presents a 
bewildenng appearance. It looks, as Ultzmana says, "as if an 
ant-hill had been stirred up with a stick." Tlie spermatozoa 


' Flokence's Test kor Semen. — Dr. Man has made an exhaustive study of 
this subject and has reached the following concluHions: 

"1. The addition of Florence's reagent to seminal fluid obtained directly from 
the epididjmes of animals does not give rise to the formation uf crystals. 2. 
Seminal Hluins from the epididymis of tlie ox, when moistenud with water, give 
Florence's reaction in every instance. The same experimpnl gives negative 
resutttt in the horse and cat, and positive reaults in exceptional instances in hogs, 
dogs, and guinea-pigs, even when the staintt are twenty-four hours old. 3. 
Aqueous extracts of epididymes of animals always give the reaction, even in 
uoospermio. •!. The presence of puF germ» in the aqueouti extract, or in the 
iolution obtained after <i»aking Bcmiiial mains in water, inhibit<i the reaction. 5. 
Freshly ejaculated hiiiuan ^nemen gives the same reaction as dried semen in stains. 
6. Stains with semen of man and of oxen give a piwitive reaction, even if kept 
indefinitely, provided the fabric is kept in a dry place. 7. Florence's crystals are 
formed mure distinctly if the drop to be examined in not mixed .with the drop u( 
reagent, but only brought into contact with the latter. 8. Florence's reagent 
must contain not le^s than 1.27 gm. of itxline, 1-65 gm. of iK>ta«sium iodide, and 
30 gm. of water. It is better to u^e more concentrated Molutinnii hiKumae the iodine 
evaporates in CO unte of time. 9. A<]ueouB extracts; made from the semen which 
w pre»ed out of the epididymis of an animal <in<efl not give Florence's reaction. 
10. Care must be taken not to mix any of the crystaU obtained in previous ex- 
periments with the lliiidn to \*& tested. IL Th« human semen resembles that of 
the ox more than that of any other animal. Yet the latter i« distinguished from 
the former in that it does not give the ivaclion in the fresh slate. 12. The view 
of Wyalt Johnston that the semen of animals gives a ' [»scuilorcaclion ' is erro- 
neou.<», Florence's test consists in adding a drop of iodiiie-|H)lasBium iodide 
solution to the fluid obtained by soaking a seminal stain in water. At the [loint 
of contact of the two drops, some dark-brown needle-t^haped or rhoraboidal 
crystals will form, which resemble the crystals of Inimin " 

' Bemarques sur les variations de lu composition du sperme dann <juelqucs cas 
pathologiques. Annules de Mai. des Org. Utjn.-urin., Tome t. pp. 30^$ et seq. 


squirm about in the most lively manner, and there being so tnaxiy 
of thffn, 1111(1 all i>f llicTii |,''»iTiK in zigzjigs, the eye may become 
confii.s(:*(l by the siglit. 'I'lu'ir |Ht>]H]lsive power is sometimes 
well shown when they easily push crystals of inorganic salts 
several times their size, and scattered over tlie field, out of their 

As a rule, it may be stated that in spermatozoa which have died 
after ejaculation the tail is well outstretched or slightly Ijent at 
the eml, whereas wiien they have l>een discharged dead the tail is 

I-^G. 43 

8liowiag ii|wrmatuz(m nm) oeuiinHl celU. 

\m\\y curled up or much twi.strd. In Fig. 43 spermatozoa are 
nlMfWM II* lliry appear untler the microscope in life. The sj>eci- 
IfMfli from which Ihis figure was nm<le was st^Mired from a sjht- 
Hfnli'' cyitt ill a vigonjus yuuug man. The heut applied to the 
iibjj'ii-^ltiifi in the drying ne(*essary tii staining suddenly 
blllod ihi' wi<>»|MTni» when they wen* wriggling in a very lively 
llianiM'i' nviT llie field. 'Hicsc spennatozou, which ait' very large 
Mild liui^*t very long tails, are goo<l examples of these bodies iu 


Fig. 44 


Un<ler high magnifyiug power the minutp aiiatinnical structure 
of the s|xTriiatozoa is clearly bmu^ht out us shown in Fig. 44. 

In vvcjik ana-mic persons anil in old men .sfHTinatoxtia may he 
sinulUn' than iK^niial. having strikingly sinull and tliin lieads and 
short tails and showing tnucli less vigor of motion. On the other 
hand, in some young and ruhust men they may be of exceptional 
size and very vigorous in their niovetiients. In water, spennatozoa 
S(Km Im-couics inotioidi'ss. but in alka- 
line or salt solutions, as well as in 
thosi* ctjiitaining sugar, allnnnin. and 
urea» they seem very vigomus. ('old» 
acids, and sohdions of metallic salts 
quickly kill these bodies. In the 
vagina the r<mtlilit)ns M'cm]* favor- 
able for the life of spennatozoa, and 
It is stated that they have been 
found in the cervical canal seven 
days after coitus. 

Up to pulx'rty llu' seminal (hiid 
contains seminal granules, but no 
s(K*nnatos!oa, and from that jK-niul 
until the agi» of fifty years, and even 
l)eyond in well-preserve* I subjects, 
these bodies are healthv and abun- 
dant. TowanI sixty decn^ase in size, 

!nvimber, and vital energy is usually 
liote^l in spermatozoa, 
'riiough autfientie eases have iK'cn reported in which sjH^nna- 
tosu>a were found in the semeti of men of seventy and eighty years, 
and even lK*yonil these advanced ages, and tdthongh men over 
Itinoty years old have ^M*en known to procreate children, such 
ot-enrrences cannot be taken to constitute a nile, and they must 
Ik* looked up(m as very excvptitmal. A fair avi-ragi', 1 think, of 
the limit of nuiny men's virility in general is between sixty 
and seventy or even seventy-five years, though there an* many 
men whose scxmd powei-s and dcsin*s cease much earlier. It 



Ilucufin fii>enuiiioc(ta- The 
right uiiu is seen in prutile. 





must he n*inrrnhorpd that although spemmtozoa may V>e found in 
th^ semen of aged men it does not f^>ll^^w that they jx>ssess tl 
vilal energy necessary to tlie fruetifieation of the female o\'TiIe. 

The number of spennatozoa, aa well a.s their structure ani 
virility, varies areorUing to the eonstitution of the producer. In" 
vigorous, robust men they are found in ahundanee in a healthj^ 
condition* ^M 

Lode,* by computation, estimates that at each noniial ejacula- 
tion a man discharges two hundred and twenty-five million sper- 
matozoa. Guelliot,^ however, think-s that this eMimate is too. 
small^ and claims that in his researches tlie figures reached wei 
four hundred and twelve tnillion five hundred thousand sperms 

In less robust persons these bodies are less abundant anti ha^*c 
less vital energy, while in weak and debilitated indiWduals the] 
an* usually small in i[uardi(y and feeble in vitality. In somel 
p»rsons they are after ejac!ilatif)n nipidly n^phired by a new crop^ 
while in others their generation is slow and meagre. During 
acute illness of various kinds (he function of the testicle is not 
performed, and in elironic diseases the tlevelopinent of spermatozoa^ 
is slow, intermittent, and slightly pn)ductive. H 

Extendeil post-mortem studies made under my direction cleurly 
show that the more nearly uonnal the sexual organs and funetioDj 
are at the time of death the greater is the number of spermato; 
in the seminal vesicles and the ampulla^ of the vas deferens. 

In one case of miliary tuberculosis, in a patient aged fifty-five 
years, the seminal vesicles were found contracted, their caviticsj 
closed and entirely devoid of sperniatowja. In a case of tubei 
culous peritonitis and in one of chronic unemia no spcrmatozoi 
were found in either ampulla or vesicle. All of these cases had 
been in very low general condition for from two to four weeks, 
l>efore death. 

' Ueb«r Hpermaprmluction beim MeuHchen iind Hunde. Wicn. klin. Wochi 
Kbrift, 1891, Band iv. p. 907. 

* L« oumcrfttion den iiperniiktozoii'de«. Aimalesdea Mai. des Org. Gt^a.-ai 
1893, Tome x. pp. 77 ei K«q. * 







lu two cases of piu-urrionia ihore wrre iiistinctly mure sjHrma- 
tozoa in the atnpullu' tfmii in the seminal vesicles, 

III fivf casrs tin* spcninilowm iti iht'^ arn|jijl]ii' nnd vcsicli's were 
very numemu.s ami nrarly tM|ual in miiiilKT. 'I'hese t-nsvs nwlinlv: 
fracture of the skull, a^fd twenty-two years; ccrchral hemorrhage, 
age<l fifty years; acute urremia, agcfi nineteen years; acute purulent 
arthritis, aged thirty-<'ight years; acute bronchopneumonia, aged 
forty-five years. WitJi the exception of the case of pundent 
arthritis terminating in septicirmia, all of the subjects died after a 
short illness ari.sing during a period of comparatively good health. 

It is very probable that in the first coitu?^ of a healthy subject, 
continent for several days, the numl)er of spermatozoa ejaculated 
is quite large, and that in successive rt*pctitions of the at*t these 
bodies )HM"<JU»e more Kiid more sparse in the ejaculate, until i\\ry 
can nc) tongiT Ik* finiml. Liegois* well-known observatinn tm 
this point is worthy uf reiuenibrance: The semen of a student 
who had had tlirt^e or four conneetions daily for ten successive 
days was carefully exann'nedj and oo sp<*nnatozoa eouki be dis- 
coveretl; but several mouths later, after three weeks of continence, 
these botlies were found in enormous nnml)er. 

No <fefinite statcnieut can Im- ruiulr as tt* tlie aincMuit (»f semen 
discharged at cacli ejaculation. (_)u an avcrugt*. in healthy young 
men. two drachms is about the f|uantity emitted, but it may 
\ye more, or even less. In rniddle-agetl men, with some excep- 
tions, the tjuantity is usiudly aU^ut a drjichni, or perhaps mon*. 
In old meu it may amount to a drachm, nr even less. Exception- 
ally the (piantity discharge<l is very copious, since in some well- 
observed cases it was from ff>ur to six draelirns, and in a case 
reported by Ult/.mauu^ it was found to W over thirty-five grams 
(about eight and tliree-<|uartets drachms). In such instances as 
those just related, while thcR* may l>e a larger discharge of s{>erma- 
tozoa than the average, the bulk of the ejaculation is comi>osed of 
the secretions of the seminal vesicles, prostate ghiml, and tlie 
muciparous glands. 

■ The Neurivw of the Genitourinary System in the Male, 1889, p. 60 et req. 




Urine which contains seminal fluid has a whitish, cloudy, 
opalescent appearance, and in it small, dimly shining flakes usuall 
may l^e seen. Such urine l>ecoines clear very slowly, since the 
cellular elements, being very light in structure, float as a cloud for. 
several hours before settling at the lx>ttora of the glass. 

Semen dnVs upon linen in patches of irregular shape with' 
anfractuous l»orders. It causes the fabric to lHNX)me stiffened and 
to assume a dull-gray color. 

A few cases are on recoiti wliose histories seem to show that in 
some men the pnjduetion of spermatojMja by the testicle does not J 
take place. This condition, called aspennatisui, however, is a veir ■ 
rare one. Obliteration of the ejaculatory ducts is sometimes the 
cause of a mechauica! aspennatism. Semen may in some cases 
have a red or reddish-brown or a color, due to 
the admixture of blixxl derived from some deep part of the sexual 

A yellow tinge is not infrecpiently imparted to the secretion 
from contamination with pus, secreted eitlier hy the seminal 
vesicles, the ejaculatory ducts, the prostate gland, or the nrcthra. 

Indigo rnixf'd with the semen gives it either a violaceous or a 
blue tint. 

According to Ultzniarm,' such abnonnalities in the shape and 
development of spermatozoa as the following may be found: (1) 
the heads of these Iwdies may be hydrocephalic; (2) they may 
have two heads; and (3) they may liave two tails. These anomalies 
may be found among normally shapt*d zoiisperras. 

It is now necessary to consider the other secretions which go to 
make up the seminal ejaculate. 

The Secretion of the Seminal Vesicles. 

This secretion constitutes the major part of the seminal fluid. 
It is an iniKlorous, mucous, viscid, and gplalinous liquid, of a ^ 
grayish or a light-brownish tint, of alkaline reaction and high ■ 
specific gravity. It is secreted by the tubular glands of the 

* Op. ciL, p. 185. 


vcsicIcSj and is formed of a globuliti .substance, whk'h, upon the 
addition of a stronji^ alkalirir si^hition (soda or potash), is con- 
verttMl into a tough, white nia-ss. 

Wien the secn-tion of the soniiiial vesicles is examined under 
the tnicn>.sco}>e it is found to present a very striking picture. (See 
Fig. 45.) The greater part of the field is covered with large, 
medium-sized, and small globular iniusses of mucus, which, when 
once recogniy^d, will afterwartl be readily detected. Tliese globu- 
lar masses are well shown in Fig. 45. It can be seen that they 

Fia. 45 

Nonnal secretion of ihe seminal vesicles. 

have no structure, and tliey may l>e mistaken for globules of oil 
or air-bubbles. They are less n*fraetive of light than air or oil, 
and sometimes they have a whitish tint, like that of moon-stones. 
They may be nf oval or of irregular shapes. They are surnnmdeti 
by small qnantittes of granular phosphates, and spermatozoa may 
be seen intermingled with them. It is important to have a clear 
idea of the composition of this secretion in health, in onler to 
compare it with the appearances found in disease. 

The secretion of tiie seminal vesicles is relatively quite copious, 


and by its viscidity, large quantity, and the force of its propul^ 
sion in coitus it carries the spermatozoa along in the rushii]|H 
current towanl the prostatic urethra. Besides this function, thb 
secretion serves as a very efficient dihiting agent in the setuinj 

Even in health, hut usually as the result of a chronic inflamma- 
tory process, we may find calcareous concretions and certain little 
yellowish masses, presuiuahly of organic or inorganic origin, com- j 
posed probably of phosphates and mucus, which are called sym^f 
pcxia. Blood corpuscles also may be noted as an accidental ad- * 
mixture. In some instances, under the microscope, epitlielial cells 
of the columnar variety may be found. No ciliated epithelial 
cells arc found in any part of the seminal vesicles. 

The Secretion of the Prostate Gland. 

The secretion of the prostate gland in a state of health is a thin 
licpiid of alkaline reaction and milky color, and from it the odor 
of the semen is derived. It serves tr) dilute and render less viscid 
the secretion 4»f the ampullations and sernijuil vesicles, and to exert^ 
a lUJtritional inHuentv on tiic spennatoswa. When laken by aspi- 
ration and with cai*e tliat there be no foreign admixtures from 
perfef'tly healthy prostate i»f a recently dead individual, the li(|ui< 
has the appearance just f|escril>ed, and under the microseojjc it is 
found to contain cylindrical cells and some granular phosphates. 
Tlje amount of mucus in the scen^'tion is not great so long as thi 
organ is in a normal conditittii. In Fig. 4i} the niicToseopie pic-' 
ture of the prostatic fluid taken immediately after the sudden 
death of a young man whose gland was in a state of [>erfect heall 
is well shown. Many examinations have convinced me that this" 
is a tj-pical microscopic picture of the normal pmstatic secretion. 
In health the granular phosphates are seen to be not very copious 
in the secretion under tlie microscope, but in disease these granules 
become very copious. (See Fig. 4C, also sections on AlTcctioi 
of the Prostate.) 

The prostate has no apparatus for storing its seert^don, thei 
fore the latter is elaborated in [>eriod3 of functional activity ai 



of sexual excitement. There is usually a very moderate amount 
,of secretion in the tubules in the f|UJescent state, and this can he 
obtained in small (]iiaii<ities aftrr death, pmvidcd preat care is 
takrn in the ri'tiiuval (»f the m-xiiuI orj^aiis fnnn the prlvrc cavity. 
It is claimed hy a numhrr of writers that the prostatic secre- 
tion contains an orj^anic ha-se, which, when acted upon by a 
cliciriical .solution, Ik-coiucs coiivcrttMl into what arc known as 
Btittclicr's s|xTiua-cry.staIs. 

Fjo. 46 

Showing normal proeiatic eecrelioD of a jroung man. 

Bottcher'a Spenna-crystals. — These crystals are interesting 
curiosities mthcr than valuable dia^jnostic indices. They are 
obtained by mixing about ctiual parts of azoospermatous semen 
and a 1 per cent, watery solution (»f phosphate of ammonium. 
In this condiination these crystals i|uile ijuickly form in ^ri'at 
ninnbcrs. When normal semen is mixed witfi the phosphate of 
ammonium solution these crystals form rpnte slowly and may be 
sinnewhat smaller in size. It is not nnconmion to look in vain 
ifor them in this combination, since they are not invarialjly formed. 


Sperma-crystals are colorless, very transparent, and of quite 
large size. The dominating forms of these crystals (see Fig. 47) 
are in the shape of daggers or of cuttle-fish. In the first there is 
a median elevation, or ridge, which slopes gradually to the sides 
of the crystals; in the second the surface is moderately convex. 
In many crystals the dagger point is broken off, and in others 
it does not exist, as each end of the crystal is cut off at an oblique 
angle. These crystals are sometimes so long that their whole 
length cannot be viewed in one microscopic field. In some crys- 
tals a very fine longitudinal striation can be made out. When 

Fia. 47 

Hr>ttcher*8 spernia-cryslalH. 

fractured tlicsc long crystals sometimes have jagged ends, like a 
broken piece of wood. There is a marked tendency of the crys- 
tals to gn)up together, to lie si(i<^ by side and upon and across one 
anotlier, and they sometimes appear to pierce and fuse with each 
other, and without break or fissure to form a cross. It is not 
uneonunon to find a rosette-like arrangement of crystals which 
is very pretty. 'J^icn, aj^ain, we may find rhoml)oi<hd forms, and 
even thick, square ervstals. Although sperma-crystals suggest to 
the ey<' the appearance (tf aininonio-magnesian ])!iosphate, a little 
examination will sliow soon that t!»ey arc rather less translucent 
and brilliant an<l mon' uniformly dagger-shaped. 



The interest in these crystals centres in the fact that they are 
supposed to be the result of a combination of an organic base 
with an ammonio-phosphate salt. The organic base is thought 
by Biittcher, Schrciner, and Poehl to be derive* I from the semi- 
nal fluid, and is called by the latter spermia. Furbrini^r claims 
that this organic base exists only in the prostatic flui<l; therefore, 
when these crystals are forme<l after the a*ldition of tlie ammonio- 
phosphate solution to a secretion derives! from the sexual tract 
that secretion must have come from the prostate. On the other 
hand, the more recent olxscrvations of l^nbarseh' have roovineed 
him that Inirbringer is wrong, and that these crystals have as 
their organic base the epithelial eells of the testicles. 

Seeing that we now have rchjiblc descriptions and facts as to 
the micnt.seoj>ic appearance* of the secretion of the seinitial veSieles, 
of the ampnlhe, and of the prostate, it is no longt^ necessary to en- 
deavor to fortify the diagnosis by the development and discovery of 
Bottcher's crystals, d»e op|K)rtnnity of winch very often fails, while 
the experiment in many instances comes to naught. It may l>e of 
interest here to state the fact that the crj'stals depicted in Fig. 47 
were found in the azocispermatous semen of a man, aged thirty- 
four, treated in the usual way by me, which secretion, when tm- 
mixed with the chemical, contained very many seminal cells, all 
of which disapjieared with the development of Hi>ttcher*s crystals. 
This, th<nigh a single, well-studitnl observation, is in striking 
support of Lubarsch*s contention. 


^P Very little has hitherto l>een known of the intimate composi- 
tion of the sccR'tion of the prostate gland. Much light has recently 
iKTn shed on the subject by the investigations arnl writings of H. 
.*^teni, Furbringer, J/)Iinstein, Pusncr an<l others. The subject 
is so new and so imjmrtant that I deem it wise to incorporate 

' DeuL med. Wochenflchrtft, 1896, No. -17. 


the main tacts hrouglit out Uy Stem.' His contribution certain! 
ilcserves a greater dignity thiii» is alFonle^t liy a riie<lieal journal 

The n(»rmal juice of the prostate gland, even when pnx-ured 
under the utmost precaution, is never entirely free from su 
stances secreted by adjacent glands. 

The physical characters of normal ]>rostatic secretion which h 
iM't-n ohtaiiifd by expirssing tlie gland p(*r rcctinn, ami after 
micturition, may vary greatly in different individuals, and ai 
ih'ffen-nt pcHiKls in the same inijividnal. 

QiANTiTY.— 'I'iiis is dependent upon age, glandular stimula- 
tion, fnH|uency of ejaculation* habits, time of the day, and season. 
On eerlaiii occasions it may Ik- abstnil a]C*>g(*t]ier, but it may 
aniouTil to .'j e.c. or more withoiM exhibiting {jnalltative nmdifiea 

Color. — Norma! prostatic f]ui4l may pivscnt various sha<l 
of color. Most commonly it ap|>ears grayish-while; occasionally. 
however, it is yellow or bhie-hued; In rare instances it prt^sents 
a greenish histre. The color of the semen is almost entirely depen- 
dent U|M>n the color of the prostatic .secretion. 

Transparkncv. — The pitistatjc si-cn'tion always displays a 
more or less pronounced milky turbidness, which, to the greater 
extent is <lue to the presence of lecithin globules. 

OiJOK.— The characteristic oflor of semen acconling to Fu 
bringep is due in part at least to cnmpf^unds (of Schrtnncr's base) 
ecnitaiued in the pi*ostatic se<Tetit)n. The hittiT substance v. 
pnibably identical with ethylenimin (dieljiylendiamin). Th< 
ixlor nniy U* likened to that emanating from withering bjossoi 
of the horscH'hestnut. 

CoNRi8TE\cv. — Normal freshly expressed secretion of th< 
prostate gland is aqueous and occasionally slightly xnsciil. Ai 
eventual t<'nacity, howev<r. may 1k» tauscd by the admixture oi 
seereti*)ns fmm neighl>oring glands. 

Spkcific Gravity.— The density of normal prostatic fluid it 
little higher than that of water, as the secretion c-ontains but oni 

' Arnerii-nn Journal of the Meilir;il S<'iom*«», Angitst, 1903. 
> Z«iidchrift f. kliii. Med., 1881, vol. iii. p. 310. 



or, at the utmost, 2 per cent, of solic] matter- It is therefore con- 
siderably lighter than nomial urine, which contains on the average 
alH)u( l^'j por cent, of water. 

The compofljtion uf normal exprcsseil lii^uor prostaticus is 
depemlent upon the same factors as is its physical condition. 
Within narrow limits it fluctuates in (lifTcrcnt indivirliials and at 
<lifTerent ]>crio<ls. 

Reaction. — Normal prostatic fluid reacts mostly faintly alkaline; 
not infnv]ucntly it lichavcs neutral. In some instances the secre- 
tion reacted anipliotcncnlly. Wlicn not admixed with other 
secretions to any degtvc pri*statir jni^'c hardly ever exhibits an 
ahsi)liite]y acid rt^action. 

I^)hnstein,* on the other hant], found in 542 examinations of 
prostatic secretion derived from SO patients iiffccted with clirtMUc 
pn*slatitis (lie ivaction a<'iil in 404, neutral in 30, and alkaline in 
108 instances. Apart fn)m the fact that these ol>servations were 
not made with secivtimiH of normal [irustatcs and the [M>ssihihty 
of ailmixtnre of prostatic fluid and excretion urine in a niimlH-r 
of the 542 sp<^'cinieiKs obtaine4l for examination, the umisually 
high pei-ccntagi* of acid liquor prostaticus scoms due to the em- 
ployment of pjienolphthnh^in as an indicati>r. Tlir vari4>us chem- 
ical indicators ptssess divci's affinities and degrees of sensitive- 
ness. Stem has seen pheimlphthalcin imiicating an acic! condi- 
tion of the prostatic fluid when litmus cither redacted not at all 
or pointerl It) an alkaline state; however, in a few instances the 
reverse con<htion wils present, when, on the addition of a single 
drop of 0.1 prr emt. alcoholic phenolphthalein solution the pros- 
tatic M'crction turned red. while lilmns behaved like in an acid 
me<iium. The CDutrary l)eluivior of these two indicators is de- 
penilent U}>on (juantity ami quality of [ibo.sphoric acid compounds 
contained in the prostatic Huifl. 

Salts of Hydrochloric Acid. — Sodium chlcjride occurs in normal 
pnwtatic secretion in greater anK^mt than any other single con- 

* Uvherdio Ilt>nkiioDdc!i ProsUUhekivtea bi'i c*lin>niM.4i«r ProsUtilUund ihrvii 
Eiotlum aufdic I^t3ensraehif;keU der SpermntoKOen. Dcutache med. Wochen., 
1900, i>i». 841-^44. 


stituent. It is usually present in from 0.5 to 1 per cent. Calcium 
chloride is always present in approtuiMe <|uantities; potassium 
and magnesium chloride occur normally in traces only. 

Salts of Sulphuric Acid. — In tlic^ normal prostatic fluid calcium 
as well iLs inM^ncsitini sulphate oerur in minute quantities. 

Sftltfl of Fhospbonc Acid, — Pho.sphoric acid is found in normal 
prostatic secretion in corabiuation with sodium, calcium, and 
magnesium, with which It iiiidonhtedly forms various salts. An 
eventual acidity of tlie secretion may l)e due to its contents of 
Ca(HjPO,)3lIjO. NalljPOj, which combinations, however, may 
have been derivt'd from other sources than the pmstate gland. 

Albmninous Substances. — Normal prostatic fluid ctmtains from 
0.35 to 0.7o per cent, of albuminous material, the principal among 
which seems to be nucleoprotcids, fibrinogen, and mucin (muoinoitJ 

BnjEyme. — A specific prostatic ferment, causing coagulation 
of the contents of the seminal veuiclea, was describeil by Camus 
and (iley.' They (jbserved that eh)tting ensued in the semifluid 
neutral contents of the seminal vesicles of nnleiits on the atklition 
of u drop of prostatic secretion. This eougulatiou is not produced 
by rennet, fibriii ferment, or blood-serum; organo extracts, a-s 
those from the testicles, suj)rar<Mial capsule, kidney, liver, and 
pancreas, give rise to morc or less pronounced agglutination of 
the contents of the seminal glands, but do not call forth their 
coagidntion. The secretion of the prostate, on the other hand, 
does not produce alterations in either the blood or in milk. The 
authors, who applied Vrn^ name "vesiculase" to the enzyme, found 
its activity still unimpaired in liqimr pmstaticus from guinea- 
pigs aseptically preserved for a whole year. The enzyme is not 
dc3ln>yc<i after the residue of the desiccated litjuor has been sub- 
jected to a temperature of 14tP C. 

Lecithin and Gholin. — The fatty nitrogen and phosphorus con- 
taining substance known as lecithin, a constituent of every cell, 
animal and vegetable, also enters into the composition of pn>s- 

* CoDipltt-reDJui de U Socit^U'* dc hiulogie, toI. xlvUi. pp. 787, 788, and roL 
xlix. pp. 787-700. 



\i the latter is due, 



tatic juice. The milky opacity ot me Jaiter is aue, as we 
already seen, tu the presence of lecitliiri glohules. Tbey are of 
various sizes, the larger possessing alwut iuiif the diameter of 
erjihrocytes. They are often found euiliedded tii the amyloid 
substance of the secretion. The occurrence in the expressed 
normal prostatic flui^l of the only drcomposltion product of 
lecithin (cholin) was dcinonstratctj by Stern in smwv instances. 
If, as aaserted by Richter, and later by Bocarius, the production 
of Florence's crystals is due to the presence of cholin, then this 
reaction is not the exclusive indication of the presence of spenna» 
but oci'urs in all secretions in wliicli choHn is contained. Whether 
prostatic lecithin Is to he considered merely a priwIiHt of waste 
or a jKitent runstitncnt r>f seinen is still an open question. 

Morpbolo^cal Elements: Epithelium. — ^Tlie eolumnar variety, 
lining the canals as well as in the terminal prostatic vesicles, is 
most frequently distinguished in expressed normal prostatic fluid, 
S<(uamous e}»itlirlium also occurs in the normal secretion of the 
prustatc, but it is not S() common as the cylindrical type. Round 
epithelia appearing in the prostatic fluid resemble very much 
tliose f^>niiiifr from the ureters. Tliey art* most always finely 
granulated and frequently possess two or more nuclei; however, 
they appear but rarely in the normal secretion. 

Leukocytes. — A few leukocytes, mostly p>lynuclear, are found 
in the normal juice of the prostate. 

Erythrocytes. — Erythrocytes are not invariably present, but 
some Tcd corpuscles occasionally occur in the normal secretion. 

Hyaline Material. ^vSome globules of hyaline material, ])er- 
fci'tly clear and frequently of considerable iliameter, an» con- 
tained in normal licpior prostaticus. 

The constitution anti complexity of the prostatic secretion at 
once prechide its pIrysioUigical indifference and Inactivity, and 
make it apjX'ar as an im[x>rtant factor of anil in the seminal Huid, 
Recognition of the pr»tency of prostatic juice relegate^i to the rear 
the former assumption tluit (he prostate was ntlher a part of the 
urinary than of the sexual ajijiaratus, and furthermore tends to 
draw the attention of the internist to an organ which the genito- 


urinary surgeon since time immemorial has been wont to acc^C 
as his exclusive domHin. 

Kraus already maintained that the spennatozoa cannot pre- 
serve tlieir vitality in the uterine mucosa in the absence of prostatic 
secretion, hut tliat in its presence they rt^tain their physiologieal 
potency often lonf];er than thirty-six hours, Steinach and others ■ 
found that in white rats, after tlie extirpation of the prostate anrj 
seminul vesicles, impregnation of the ova will not occur although 
thr sjM'rniatozoa continue to l>e discharged. 

All ohser\'ers practically a^^ree: 

L That the nurleus of the s|x*rmatoi5oon is the fcrtilisdng 

2. That the spennat()zi>rui is eniihled to maintain its active 
motion in a .snitahir nieflium tinly. 

3. That sueh a mf<liuni is furnished by the secretion of the 
accessory glands, mainly by that of the prostate and seminal 

4. That the secretion of the accessory glands may perform 
other inijM>rtant functions. 

It is as yet impossible to single out the specific importance of 
the prostatic fluid. Perhaps it is due to its enzyme exhibiting 
coagulating pn)perties; pcrhaj>s to the phosphorus containing 
leeithin, whicli oceurs in abiindunt amounts; perhaps to some of 
the nuclet)proteids whost» raiaon d*cfre hius still to he det<*rrnined; 
again to a eond>inrd action of any or all constituents, or to 
another factor altugettier. 

On the other hand, there can be no doubt as to the phyjficai 
impi>rtaiice of the prostatic secretiim. It serves as a vehicle for 
the sus|>ension, pnttection, and preservation of tlie spermatozoa. 
The pmslatie flnid by cnvc-loping. so to speak, the sp*Tinatozo«in, 
protects it from external influences, as contact with air and such 
pliysiologieal or pathological dischargt\s which are detrimental 
to its vitality. The secnHions of the other accessory organs, of 
CMiurse, contribute in proportion towan] the protecting and pro- 
.serving medium. 

Dilution of the seminal flnid bv water calls forth cessation of 




movement, loss of fccimdatinn; qiialitios, anil <lisiiitegratio» of 
the spemiatozoa. Artificial inipre^^nation of dogs and otlier 
animals has been effected, however, hy injecting into the vagina 
spermatozoa obtained din-rtty from tlie canal of the epidiilyrni.s 
which were sus|x'tKled in a U.5 per cent, .solution of sodiunt 
carbtjnate. These experiments conducted by Iwanoff do not at 
all negate the essentiality of prostatic secretion in the process 
of fecinidatioiK On the contrary, the necessity of prostatic fluid 
ap[wars in a new light; the facts, namely, that the addition of 
juire water to the seminal fluid destroys the spermatossoa while 
they retain their vitality in a weak solution 4>f sodinin carlMuiaie, 
clearly evince that pure water is a poison; that is to say, that it 
is h}'potonic and that a 0.5 per cent, sodium carlx)nate solution 
is isotonic (or hypertonic) to tlie speruiatozoa. The osmotic con- 
ditions in the seminal flui*! or in normal pnxstatic juice alone 
must be similar to those in a 0.5 per cent. solutii»n of sodium 
carlx}nate. We will, therefore, not be very far from the truth in 
assuming that a[)art from an eventual specific chcmicfj-eui'.ymic 
potency the sccR'tioa of the prostate gland is of importance in 
overcoming the quiescence of the spermatozrm, and in elFecting 
that state of osmosis in the seminal Muiil which is essential to 

The secretion of the ejaculatory ducts and of the sinus jxtcu- 
laris is in all pmhability simple mucus, and is not very copiously 

The Secretion of Littre's Follicles, of the Crypts of Morgagni, 
and of Oowpei*B Glands. 

In periods of sexual excitement Littre's follicles, Morgagni's 
crypts, and Cowper's glaiuls give forth a quite abundant secretion 
of clear, viscid, threa<Iy, alkaline mucus which loolcs like tlie 
white of an vgg (unl)oiled) or glycerin. This secretion differs 
markedly from the seci'etion furnished by the deeper parts of the 
sexual apparatus. It is thrown into the urethra anterior to the 
triangular ligament, and is very frequently found without any 
admixture of secretion from the deeper parts. This secretion 




seems to be concerned in the dilution of the semen. Its chief 
fuiictioin however, is to neutralize tin* anterior urethra, which is 
usually rendered acid by tlie passage of urine. It also acts iu i 
an efHeient lubricant in preparing the urethra for the transmissioa ■ 
of the seminal <iischarges. A p>rtion at least of the secretion of 
the glands under consideration appears during erection and before 
ejaculation in the shape of one or two clear drops, which are seen 
at the orifice of the meatus. 

Un<Ier the niitroscope we fiiul In this sccrt^tion strings of mucin, 
flat or cylindrical epithelial cells, and perhaps a few coffin-shaped 
crystals of phosphate of magnesia or lime. This secretion, which 
is Imown when abundant umlerthe name urethrorrha'a ex libidinct^ 
is usually of no significance whatever. It is founil, a.s a rule, in 
cases of sexual excitement, especially when it is great and pro- 
longed. It may also l>e observed in cases of excessive sexual 
irnlulgL'iK'e and <>f umsturliatiou in yffuiig men, and is seen in 
cases in whicl* inca» fur various reasons, injuriously and frequently 
press the glans penis between the tfiundi and forefinger. 

This secretion first appears as a thin cloud in the urine, andl 
then slowly settles to the bottom of the glas.**, from which it ma? 
be securetl for microscopic exaniinullon, by means of tl»e pipette, 
as a small, clear, gelatinous mass. ■ 

If the man has had a recent seminal emission or has indulged 
in coitus within a few hours, some spennatozoa may have been left 
in the urethra and have Ix'come entangled in this secretion. This 
accidental occurrence may |>erhaps not be recognized by the micro- 
scope, and erroneous ideius a.s to tlie naturt^ of the secretions are 
liable then to be formed. This fact thould be remembered, 
clinical practice. 





By the tcnn impotence is understood a diminution or complete 
loss of power to perform normal coitus. In the .sexual act the 
most essential factors are the natural desire and a state of erection 
of the peni.s, without which intmmission is impossible. 

Normal sexual intercourse varies very greatly in tlifferent indi- 
viduals. In some men a e«mdition of marked virility exists^ while 
in others the sexual appetite and power are much less fully devel- 
oped. As a broad, general rule men having stron/;, rohust consti- 
tutions are .sexually very jM>tent, and in prtjptirtiim us tlie general 
standard of health is lessened so are the sexual appetite and power 
diminished. Ivveeptions to this general average are sometimes 
.seen in neurotic aiui lustful persons, who, tliough not physically 
strong, have a constant desire for .sexual iutkilgenee. In these 
cases, however, decline sets in sooner or later, and impotence in 
varying degrees may then be present. 

Sexual vigor, therefore, is a relative term, since what might be 
called full virility in one man would feebly compare with the 
marked sexual capacity in another. In order to understand the 
various features of .sexual impotence in the male, it is necessary, 
as has already been said, for the reader to have a clear knowledge 
of the anatomy and physiology of the sexual organs, of the 
mechanism of the sexual act, and of the nature of the seminal 

By the term impotence a number of closely connected condi- 
tions and functions are included which demand a systematic 
recital. In the first place, the controlling influence or sexual 
desire must be present, and this requirement can only be fulfilled 
when the brain is undisturbed and when the environments of the 
pfttJeQt are calm and satisfactory. The second essential is the erec- 



tion, which <lepen(Is upon the integrity of the hrain and the sexiiftl 
system am] n|MJU tin' haniumiims working of i\\v vascular ami ner- 
vous systems. When th^-se intri<'Hle \u\i\ e4>rn'hi1e(I ('on(htif)n.s are in 
acconl the mniation of the sexua! act in orgasm and ejaeu- 
lation (ake.s place, ami the nuin may he saiil to he sexually jK>teut. 

Impuirment of sexmt! desire nniy Rvsult fixini causes and condi- 
tions soon to Ix' considered, IinjMTfect erections may Ix* <lue to 
mental causes or to a numher of physical eonditious, which even 
with erection may intei-fere with the sexual H<-t and rendor it pre- 
mature, weak, or even prevent its consummation. When itnpo- J 
tence in the male is considered in detail it is found that: (1) tfacicfll 
may be absence or impairment of desire; (2) absence of tlie power 
of erection and intromission; (3] absence or diminution of iht 
power of ejaculating the senu'iiiil thud; and (4) a lowered standard 
of or an entire absence of orgasm. 

In most cases of tnjile impotence the fertility f>f the semeQ 
remains intact, and iinpn^gruitii)!! of the female is reasonabl 
prtjbable if the male organ is sirfhciently potent to diseliargif it 
in the pmper place. In ttic event of [jartial intromission, ev 
when tjf slmrt duratiun. irnpregnutiou of the fenude may occur; 
but when inlnnuission \s inipossildc a man naturally I>eeomcs 
sterile, although his semen may Ix* fertile. 

When the whole sid)ject of nuile imiK)tenee is cuR-fully gone^fl 
over it is found that the varicius (* may l)e conveniently sul>-^ 
flivided and arrangeil in four distinct groupvS. To the first, id 
which brain impressions play a prominent part, we may apply the 
term Psychical Inipotetice. The second class of ca-ses, in whicli^ 
some rlamage, hmited to one or mnre jnulion-s i»f the sexual sphere,™ 
is the underlying cause, and the imjM>tenec a symptom thereof, the 
term Symf)tomatic Inif^Kitenec is appMtable. ^Vhen impotence i^| 
due to impairment of the sexually controlling parts of the ner\'ouS^ 
system, owing to various depre.s,%ing causes, it may very properiv 
be designate*! Atonic Impotence. And, fourthly, when any struc- 
tural defect or disease so disturl»s or cripples the penis that intro- 
mission is interfered with or remlercd impcxssible, the conditioi 
may be termed Organic Impotence. 



The term psychical impotence is appliftl to rvrtaiji ron<litions 
of st^ximl wpiikfu's.s or iria!>ility in wlsich im-ntal iniprt\ssiinis inter- 
fere more or It'ns witli .sexiiul tlesirt' Jiiul with envtion urul ejacula- 
tion. In many eases of this form of iinp[>tenee the sexual i»rgaiis 
are ?n a perfectly normal condition; In others there may be some 
mild abnonnality. but the doiniimting cause in all arises in the 
brain and in tlie impressions wliieli it conveys. Whatever may 
be the condition operating; on the mind, an inhibitory effect is pro- 
<luced upon t!ie sexual centre, which impairs or paralyzes its 
action and (hat of the nervi erigentes. 

Cases of psychical im|x>tencc arc not uncommon, and are found 
more frequently in young men al>out the date of puberty, and 
much less conimonly in men up to the fiftieth year. 

These cases present very many and witJcly dilferent clinical 
pictures, while the one underlying symptom is the sexual weak- 
ness or impotence. 

It is not uncommon for young men who have lived clia.ste lives 
to find that at the tirst coitus tliey become so much excited that 
the penis does not become erect, and that it may even shrivel up. 
In some of these cases there may Im* partial erection and even a 
dribbling ejaculation. The result of this dismal failure varies in 
different imlividuals. Some men look at the matter calmly and 
philosophically, reason with themselves that they are sexually 
impetuous, and they wait and try again. Others (and they are 
in the majority) become very much depn'sscd in mind and go 
post-haste to the surgeon. In all these eases it is usually found 
that a little pKxl advi<'e and wholesome common-sense will put 
the man's mind at, sn that he can soon perform the function 



satisfactorily. But in many ea^s a sciisc of timidity or fear is 
indiKTfi, whic'h, for a long ornlinrt tinu*. renders the man sexually 
weak or imjwtciit. Such ejise.s, if projH'rly treated, can l>e eurpd. 

Some timid men of a rellrini^ disjK>.siti(m remain for long peri 
al).S4»lutidy eontinent, and tlieii fear that their penis is not projjerl 
deve[o|>eii, or tliat tlieir testicles are iruK'tive, iuu] as a result thef 
U'coine psychically inipoteul. 

Amither elas.s of c-a.seH of supposed inijHitence is fuiiml amor 
ycnni^ men who constantly sif and ftindle their ftanri'fjt, an<l who 
naturally U'come sexually excited. A.s a result, such a perstin 
notiees that a few drops of clear mucu.s escape from the meatus, 
and that he may have queer hut mild sensations in the {K*ni.s an 
testes. In many of these cases the mind is not at all <listurl)ed, 
hut in inntu' sneh is the sexual e!*ethtsm and the impaired mental 
state that the man is imfitte<l for husiness and knows no comfort 
or plciLsure. }]v feels certain that he is losini; semen, an<l as * 
result of his worry, his erections, which usnally oceurr<'d in the 
morninj; and in times of lovn'ng ilalliancc, arc no lon^r pre,*«enl 
hut the so-called spcrmatorrluea, which is only an escape 
normal niiiftjus se'cretion {urrihrurrhtni (\r ///jfWfV/c), keeps up. Fn' 
this state of mind lie dreads the thought of irmrriage, and fwU 
certain that he cannot perform the sexual aet, Jn many ci 
when ihe ecmrtsliip is pn4ongc(l, and the courting -sra/icf* an* frr- 
tjuent and ]>rolracted, tlie lot of these yoimg men is a very unhappy 
i»ne. ^riiey arc constantly and rt^gularly expxsod to a sexual 
erethism for which there is no legitimate relief at liantl. After 
a time erections may not occiir when in the com|)any of his 
trothed, and they may or may not occur at other times. As 
general rule, though erections are not exjx*rienced, the escape 
mucus occurs at each loving interview, anfi there may Ix* pollu* 
ti(ms at night. Many young men thus tricfl remain steadfast ami 
loval, and hy the help of the surg*'un (and somi'times hy- the 
patiencv and tact of the wife) soon after nuirriagc lose their fe 
arul enter into normal sexual life. Others, however, are le; 
s(*nipidous, and essay coitus with public women. In many c 
that I have known these men have found relief, and have h 






practiff conviiict'<l thcmst'lves tliat they are potent^ ami they 
become corrcsporuliji^ly happy. Many of these hackslidirif; men 
I have known to liecome faithful and uxorious husbands and 
happy fathers of healtliy childrtMi. Other men rnay have a less 
fortuitous experience, Tliey re.solve to test their .sexuiil capacity 
with some other female, and when tlie critical moment arrives 
their morbid fear» increased, [K'rlm])s^ liy feelings of shame or 
remorse at their imfaitlifuhiess, so [)n*ys on their mind that sexual 
desire is absent and 4"reelion thtvs not ttecur. The residt is that tlie 
man is still more unhappy, and his fear troubles him incessantly. 
In many of these cases men have sexual desin^ anr] erections anrl 
jMLThaps emissions wlien away from their prospective l>rides. To 
some tliis evidence of sexual activity is very reassuring, but to 
others the irregularity and abnonnality of the condition are a 
source of even greater dejection, Uruler the stinuilus of kindly 
encouragement and by the aid (jf judicious uilvice these men 
sooner or later may enter into a happy matrimonial state. 

Many young men who have had nntre or less fn'f|uent and 
normal coitus lx.'fore marriage, during courtship, become fearful 
that they may not be ix>tcut in the nutrriage-beel. They very 
often go with their doubts to the surgeon, who should always 
advise them to entertain no fear in their mine], and sliould jx>si- 
tively assure them that, n(»twiths(iinding they may have a few 
initial failures in their new relations, they will he competent. In 
some of these cases tonics and hygienic influences very often play 
a very useful part. 

We sometimes see cases in whieji nervous overscnsitiveness or 
religious scruples so act upon a man's mind that when he attempts 
coitus with a fenude he loses all desire nnd n-tires in disgust. 
Then, again, some young men are so fastirlious, ami perhaps so 
scrupulous, that they cannot associate, much less have sexual 
intercourse, with public women. In genenil these cases in time 
right themselves, but in some instances an aliiding fear of sexual 
weakness or imjxjtence is left which may pn^vent a man from 
contracting matrimony. In none of these cases is there anything 
seriously wrong, and a happy outcome can be induced if the 


patient be properly advised and judiciously comforted. As a rule, 
marriage to a congenial helpmate soon leads to normal sexual 

A goodly number of cases of sexual impotence are observed in 
young and even middle-aged invn who nni submitted to severe 
mental strain. In these dlscs then' is u.sually an evidence of 
general ill-hcaltb, even of neurasthenia. Such men may be ovcr- 
taxetl in their professional duties (lawyers, civil engineers, mathe- 
maticians, etc.), or they, in their eager efforts to make monev 
cjiiiikly, are continually in a state of excitement and doubt, which 
disturbs their whole economy. As a result they may lose all 
sexual desire, and if they force themselves to coitus they experi- 
ence failure, or tliey may simply bt-come sexually weak, an<I coitus 
is with them unsatisfactory and feeble in cliaracter. In cases iu 
which the sexual organs were previously healthy this temporarr . 
disability ceases after a time, anti the pati<*nt again becomes virile. ■ 
When, however, the .sexual tract has Iwcn the seat of inflammation " 
(posterior urethra, prostate, ampidlations, and seminal vesicles) 
the return to the normal state may be slow and halting. A lai^ 
contingent of impotent young men is composed of those who have 
lieen addicted to long-continneil masturbation and sexual excesses. 

The impjtence wliieh follows in the course of masturbation is 
sometimes very difficult to cure, and amounts to what may be 
tcrtui'd irritable weakness. These patients have so lon^ practi.sed 
this si*litarY vice that it is often dittieult to (as one may sav) 
swit<'h tlieni oil into natural habits. Not only do they, in many 
instances, become averse to intimate rt^lations with a wonmn, but 
lliev exiK-rience a sense of shame, and arc very fearful that they 
will fail in coitus. Such men frequently have UDetunia! |h>1Iu- 
tious, which have a very damaging effect upon them mentally. In 
{\w^ cast's there is very frefpiently more or less trouble in tlu- iht^p 
I parts, and as a result the disability is more ]>n)nounctHl. 
I . many castas of impotence incalculable hurm is done the 

it bv the 'mendacious exaggerations of quacks; but this bad 



iallv well-n^Jirked in psychically impotent men wh< 

^[^:ii»d masturbation. 




Sexual excesses naturally lead to reaction in which the sexual 
desire is much less keen than formerly. This concHtion wry often 
preys on the patieiit^s mind, and he fears tliat he has lost his 

It is natural in these cases for a condition of sexual inertia to 
ensue, but except in very bad cases sexual power is not wholly 
destroyed. Rest and general hygiene usually bring these men out 
of their slongh of desjxind. 

Men apparently vigorous in mind and body and of more advanced 
age sometimes consult the surgeon for very insufReicul n-asons. 
They have hud one or several attacks of gtmorHni'ji, jK'rhaps, many 
years before^ which in their cases have left no damage to the un^thra 
and prostate, but lately they had convinced themselves that tlieir 
sexual capacity was less vigorous tluin formerly, and (hut it must 
be due to their old trouble. In many of these cases the real con- 
dition is one of less keen sexual appetite and vigor, caused, in 
many cases, by mental an<I pliysical overtaxing, than was pos- 
sesseil in earlier years. 

The psychical effects of varicocele in inducing impotence are 
described elsewhere. 

As a rule, most men sirffer from psychical impotence at some 
period of their life for a longer or shorter time. Seeing that the 
mind exerts such a far-n'a<*hiug antl controlling inHucnce on the 
sexual act, it can be readily tmderstotx! that in the multiplicity 
of <!istnrbing causes which may operate on the l>rain a temporary 
irn|Mjtenc<* may l>e induce<i. Pletisant eomlilions and surrt)undings 
are absolutely necessary for normal sexual contact, and when in 
any manner these are disturbed the function is eitlier interfered 
with or liehl wholly in check. Thus, a man may l>e tlinturbed 
by oniini>us soundsj by unpleasant odors, by the necessity for 
haste, and by fear of discovery. Certain physical defects in the 
woman may abort all sexual ilcsirc. There may be a flabby vulva, 
or a very large vagina, laceration of the periueiun, or great red- 
ness of the vulva, or the presence of a purulent discharge. Ex- 
cessive obe-sity in the female in many instances has been known 
to cause irremediable impotence of the male consort. Warts or 


retl or ccsicmatous patches in and alwut the Ial>ia inajora and 
minora have Ix'en known to a sudden inhibitory effect. The _ 
fear of contracting a venereal disease often puts an end to tbeV 
attempt of a man at coitus with a public woman. Then, ag^n< 
a man may be intiifferent or may feel a repujtjnance to a woman, ■ 
or a htisharul may entertain a suspicion jus to the fidelity of his V 
wife. All these conditions may pniduee a disturbing effect on the 
brain aiul sexual centre. 



In S4>nie causes the loss of a beloved wife or mistress so preys 
on a man's mind that for a time he has an aversion to the female 
sex^ and he may lx> tein[>orariIy imp<itent. Cases have been ■ 
iv|x>rted [n wliirh men, in or<ler to perform vigorous coitus with 
a woman to whom they were rather iiidilTcri'nt, have had to fix 
their minds during the act upon the vohiptuousness of another 
and highly prized consort. Many men are very vigorous with 
some women and can have only nnsatisfuetory coitus with others. 
Alcoholics, as a rule, slimuhite the brain and st»xual centre, and 
in cases of psychical im])otence they (as we may say) "help many ■ 
a lam4' dog over the sfilr." A^ however, has been reported 
in which a drunken man fuile<l to copulate with a woman of the 
town, and when informed of the fact he was so depressed that for 
a time he was impotent. A curious case is on record of a man who M 
had normal coitus with otiier %vomen, but could only o^habit with 
his wife when he was much enraged. Many women have little 
sexual desire; to some s**xual contact is unpleasant and even ■ 
revoking; wliile others reUntanlly consent to it, and w<»nder at 
their husband's canial lust. Such frigidity on the part of the 
wife naturally reacts powerfully on the husband, who may become 
sexually weak or even impitent. 

Some men have a predilection for certain women: one likes a 
blonde, another a brunette, while sliil others yearn for a fiery 
auburn consort, and none of these mejj run have full and satis- 
factory sexual intereoiirM' uuU'ss eongenially nial*Mb 

We iM'casiunully meet with cases in which diere exists whnt 
may Ik* term***! sexual apathy, due, perha|xs, to s<jme ctiiiditirm of 
the brain and sexual centn*. In all of cases (and I have 




seen fullv a dozen) the virility of the man has never heen up to 
the statuknl of normal devflopinent. As boys they may or may 
not havi' mastiirbaUHl for a few times and generally at long lEiter- 
vals, and veiy often as a result of curiosity inspii*ed by wlher 
boys. At and after pulx^rty they may have infrequent sexual 
intercourse, which gives them little or no pleasure; then the sexual 
desire ceases, and they Iwther themselves no longer with the 
matter. In most of these cases the patients are hard workers 
mentally or physically, or in Ixjth directions, but they never 
become mclanchoiie. 

A ninnber of very intercstinfj rases of psychical impotence 
have been pnblished in medif^a! literature. A (X'cnliar case is 
reported of a ^'ntleman who, while an a visit to the country, was 
seducetl by a lady in full walking <'i»stunie. Dnrin^ n [HTind of 
one year he continuerl to c<»liabit with the same wonmn, under 
similar conditions. He later on married an estimable and healthy 
woman, and though in the full exercise of all his nu'tilal and phys- 
ii'al ptfwers, he was unable to Ix^gin or even to complete the act, 
I lis previous intercourse with a woman in full dress had disturbed 
his equilibrium so much that he could not perfonn the act until 
his wife had her clothes on. 

In striking contrast with the foregoing case is that of a man 
who for years had hod coitus successfully when in the seclusion 
of his l>ed-<'hamber and without the accompaniment of <lress. On 
several cKvnsions fu' cndenvonnl to [jerfonn the act both with a 
mistress antl later with his wife when dresscfl, and he failed dis- 
mally every time. 

A remarkable example of psychical impotence was observed 
in the case of a prt)minent mathematician who married a lady 
congenially suited to him. Both were in perfect health and de- 
sired chililren, yet at every attempt to complete intercourse some 
abstrus*' pn)blem wotjld force itself into the miti<l of the professor 
and desthiv at once all capacity for the perfonnancc of th<' act, so 
that he was c<3nipelled to give up the attempt. Again and again 
the same accident necurred. It seemed utterly impossible for liirn 
to contrtjl his mind In the matter of madiematical |)rol>lems suHi- 


cieiitly lonj^ to accomplisli anything. Tlie fuinily physifiaii fiimlly 
cuuiiselk'tl hitii to ^H jnirtially uikIct the iiifluentv of alc-oliol an<i 
then to ivy. He took the luixice, ami was enabletl to reach ihe 
desired goal without any further trouble. 

A case is on nx-onl of a man who was much enamored witlj A 
lady whose right log had been ainputatcfl at the thigh. lie always 
had satisfactory coitus with this person, but was entirely impotent 
with jverfectly formed women. I^ater on in Hfe it was alv^*ay5 
necessary to his sexual gratification that he should have a consort 
who had only one leg. 

It is a matter of history that a man, at other times perfectly 
virili\ who fiad In'en a nieinlicr of the vohinteer fire clepartnient. 
was never abk' to have coitus at night, for tlie reasini tliat when- 
ever he went to bed it was w^ith the expectation that he would 
have to go to a fire. 

On this subject Howe* says; "Even in persons of vigorous 
hialdi, psychical impoteiiee may result from fear. Impotence' 
has l»een produced in a healthy man by a friend's recital of hia 
own surprising failure. The thouglit of the accident that befell 
the friend occurreil at the time of intercourse, anti he, too, failed, 
A married patient of mine, a lawyer, with excellent physique, the 
father of two chiklren, l)ccame temporarily incapacitated in this 
way: Heading in a medical journa! that impotence might attack 
healtliy jx^rsons. temperate in all things^ and without notice, he 
became impressed with the fear that a similar accident might 
Ix^fnll himself. Curiously enough, the next time he attempted 
intercourse the fear took ctjuiplete [Mjssession of him, and be 
Ijccame tem|Kirarily impfitent." 

Finally, there is a class of cases of men who are temporarily 
impotent for the reason that they have got out of practice. Thus, 
a husband is away for a long jx-riod from or loses a Ijeloved wife, 
and for a time so cherishes her memory that his sexuality is dor- 
mant. Or a man may U>se a very congenial mistress, and for a 
time sexual desire seems extinct. Then, again, for various causes, 


Kxcewive Venerj, etc, p. 8fi et s^\. 



some men suddenly cease to have sexual intercourse, and for a 
longer or shorter time are much ocriipiet! mentally or are greatly 
worried. In eases very often a feehng of doubt anti timidity 
is developed, and the man refrains from sexual intereourse. Ac- 
cording to my observation, in the course of time most of these 
men, when not very old, find congenial females as wives or eon- 
sorts^ and then the supposed sexual incapacity s<H>n gives way 
to gratifying vigor. 

The prognosis in these cases is gtiod. 

Treataik-NT." — In all causes of psychical impotence the surgeon 
should seek out the cause and then give directions as to its removal. 
Patients thus affected need kitnlly advice, encouragement, and a 
plain statement of the exact facts in their case. They should he 
firmly assured that they arc* in no danger of losing their virile 
power, ami that they must under no circumstances give way to 
doubts and dreads. 

Ill the cases of men who become much exeitci! and have a 
mucous discharge while near or fondling \v<micn. si>eedy marriage 
should be rccommendfd. It is always most important that ex- 
cesses in coitus should not be indulged in, and that when the act 
is p>erfonned the surroundings should be pleasant and satisfactory. 

GrtxKl hygiene, avoidance of exfwsure to sexual excitement, 
plenty of fresh air, out-door exercise, and wholesome food, will 
contribute largely to the patient's well-being. In many cases 
relief from all business cares and occupations, with entire relax- 
ation, is productive of great benefit. According to indications, 
massage, cold douches, salt-water bathing, electricity, and stupes 
may be employed. 

Iron, tjuininc, coca, kola, urscnic, and tlu' animal extracts may 
be used when the neces.sity for them is indicated. In some cases 
tincture of cantharides (10 to 15 dn>ps three or four times a day) 
has seemed to be ver}' beneficial. With due n*siraiut as to inor- 
dinate alcoholic indulgence, it may on occasions be necessary to 
stimulate a man's Hagging energy by means of whiskey, brandy, 
champagne, or Burgundy. 

In all cases it is incumbent on the surgeon to carefully explore 


the whole genital tract, in order to ascertain whether any part is 
in a morbid condition. This examination should be very thorough 
and the condition of the meatus, urethra, prostate, seminal vesicles, 
and ampullations should be clearly ascertained. In addition, a 
thorough examination of the bladder, anus, and rectum should 
be made. 






In a consuleralilc proportion of ca-scs of Impotence certain 
morbul comlilions of the end of the petiis, of the hall^ius urethra, 
of the prostatic urethra, ninl prostate gland, and perhaps of the 
j-aetnina] vesicles^ so react rin the sexual sphere that a condition of 
diraiiushcd vitality and function is induced. I'nfortunately, in 
these coses we possess no facts tierived from the post-mortem 
study of the conditions <if the sensory sexual nerves or of the 
sexual centres 

Our knowled^a' of the morbid changes in the .sexual tract is 
quite full and tolerably clear, but how these changes operate 
on the nerves and the .spinal cord centre, and what structural 
conditii»n.s they produce, are mysteries to u,s. 

\Mmtever the morbid change may Ik* the effects in many cases 
are very apparent, and the thought suggets itself that some tem- 
porary datnage has Iwcn done to the stnisory nerves or the sexual 
centrt* by which their function is more or less impaired. 

Impotence being s}^llptomatic of the above-mentioned well- 
defined morbid conditions of the sexual tract, it seems to me 
more nattiral to designate this disability as s}Tnptomatic impo- 
tence rather than as at<mic im|K)tence — the term wliich is used 
by several authors. 

We are certain as to (he symptoms, hut we do not know al)ont 
Uie atony. A clear and systematic presentation of this subject 
can only l>e given by adopting an anatomical basis by which the 
various sources of irritation may be studied seriatim, and their 
effects may then be lucidly traced. 



case I 


Tinpairnieiil of (he stwiial fumtina, cvlmi to t!ie extent of 
ciiitid iinpotcuoo, iiiay h<' due in congenital and acquired malfor 
matioBS of the prepuce and glans penis. The following case 
presents interesting features: 

A man, aged twenty-six years, who had never had gonorrh 
and who had [)ractised masturbation very slightly, was married 
to a very attractive and congenial lady of his own age. During a 
period of six months the man hatl many times indulged in coitus, 
which on no occasion was satisfactory. His erecti<jns were at first 
nearly normal, but ejaculation was always premature, ami the 
sexual act was never cftmplcte<L This state of affairs went on 
until just b<*foPi- tlie pati<'nt consulted tne. He was then verv 
nuK^h w(»rried, and phy.sirally was l>elow par. Examination of the 
urethra, prostate, and seminal vesicles slH»we<l these parts to be in 
normal condition. But the condition of the distal part of the 
penis demonstrated the cause of the trouble. The prepuce v;&s 
long and tight, and its orifice, which was very much reildcned, 
was abnormally sumll. When by some force the prepuce wmsS 
retracted a reddcni-d, ptaiting condition of the meatus was found, 
wliich extended into the UR'thra. The glans pMiis was red and 
very tender. The diagnosis of extreme peripheral irritation of 
the penis was made, and ciixumcision was, with the patient's con- t 
sent, performed. Within six weeks erection Ix^caTne normal and 
coitus was satisfactorily indulged in. In this case there was not 
any .subsequent impairment of the sexual power. ■ 

I have seen several cases in which erections were flabby and 
ejaculations were premature, which rcsultcil from adherence of 
the prepuce, which hatl existe<i fmm birth and which gave rise 
to venous sta.sis of the prepuce and glans. 

Tn like manner I have .several times seen a short, fibrous TwP 
nura, Mitli long, light prepuce, give rise to .symptoms wliich con- 
vinced tlie patient that he was impotent. Smallness of the meatus, 
both congenital and acquire<l, from chancroidal orsyjihilitic ulcera- 




tioti, ni)t Infre(|iient!y, in iny fXf>erienoe, has caused such Impair- 
ment in the commenct'rnent of the sexual iict that its full per- 
rominrK-e liecame impossible. In this coiiuection it is well to add 
thiU hi tlif case of a nervous yauii^ man who ha^l a halo of soft, 
small ve^tations in the coronal sulcus, such was their tenderness 
that on intromission of the penis the erections instantly ceased 
and ejaculations took place at once. 

As a nile, cases of partial or complete impotence, due to these 
malformations of the penis, are promptly curetl by operation, and 
the probable existence of these causes siiows how important it is 
in every rase to carefully t^xamiiie the virile organ. 

In these eases just consiilered there may Ix: little or no mental 
suffering, or the patient's condition may give him serious concern. 
Hut, as a rule, operation ;^ves such }>rom|)t and ih-iMded ivlicf 
that mental depression is so<mi disjHi'lleil. 

Ur»fortunately, in some of these cases of irritation of the pre- 
puce and the ^hms there is a history of early, energetic, and long- 
continued masturbation, which has caused chnxnit; c{»iigestn>n in 
the posterior urethra, together with emissions and imperfect erec- 
tions. In these cases relief is sometimes st»mewhat slow in coming 
on, uiKJ, besides operations on the prepuce and glans, careful 
treatment of the urethra Is necessary. 

It happens, though quite rarely, in some of these cases that a 
condition of morbid fear remains for some time, which prevents 
normal coitus; hut cheering and comforting advice, supplemented 
by tonics, fresh air, and sea and cold baths, generally tend to 
restore the confi<h'nce and virility t>f the patient. 


Chronic inHummation of the bulbous urethra alone furnishes 
fjuite a large contingent of sexually weak and im[)otent men. 
These patients may or may mit have Ix^en adcHcted to nntsturba- 
tion and sexual exc<»sses. They usually give a history of an early 
and severe attack of gon(trrli(ea, followed by a more or less per- 
sistent gleet, and perhaps other atttu'ks of goiiorrha-a. They are 


usually luen l>etween thirty and fifty yrars of aj^, and they pn*^ 
sent themselves with a history of waning erections, premaiurt 
ejaculations, and lessened desire. Many of these men say that 
their attention was first called to the disturbed sexual funetioa 
by their iniibilitv tn promptly produce nonual ejaculations, 'llie 
sexual act in tlnvsc ciiscs is at first somcwhiit pn)lun)^Ml, and this 
dilatoriness gradually IxH.'onies more pronounced. 'Fhen deficiency 
in (*r»M*fiiui is ntjticc^d, together witfi fcelilc, Hubby* an<l {H*rhap9 
pn-nialiirc, cjaculatioris and very i>fien nocturnal einIss»Jons. 
have many times ]>ccn mucli surprised at die patience and e<|ua 
nimity with which these patients regarded their disability. lu mj 
expi'rience in this parli<'nlar chiss of cases mental worry is not 
often observc<l, and sexual ncnrasthcniii is very exceptional indce<l. 

In many of these cases we find submucous cell-infiltration 
around the liullwus urethra, which may ix' contracted to 25 or 
even 20 of tlie French scale. In siuue cases the new c-ell-forma- 
tion is soft and succulent; in uthers it is more dense. 1 have 
very many times caivfully examined these coses as to the condi- 
tion of the anterior and [HKstcrior urethra, iind found that the 
njorbid process was localized in the bullx>us urethrUj and that the 
prostate and seminal vesicles were healthy. 

As a rule, these patients can be benefited and cureii if they wilt 
refrain from s<'xual excitement and excesses in other directions 
than coitus, but not otherwise. 

A more pninoimeed class 4>f cases is seen in men who have true 
stric-tnrr of tht^ bidh. The less seven- <'lass of cases is found, as a 
rule, in men about thirty to thirty-five years of age, in which the 
stricture tissue is not, as yet, very firm and flense. The severe 
form inchulcs tlnKst* cases in which much fibroid infiltration, even 
to the extent of nodnlatlon, is present. 

In many of these cases, liefore the dilTiculty in nrination is ex 
pc'rienced, or when it is very sUght anrl mild, the [)atients begin 
t<i i'xjM'riKnce the same sexual ilebility that .sufTerers from ehn>nic 
bulUuis urethritis complain of, as we have aln'ady seen. In this 
conilition gnuhud dilatation is iu4licated, and, if well lM>rne, with 
the iucn»a^ng size of the canal improvement in sexual desire and 


ixnvcr IS uu 




a surprising negree 



in some 

nun, [>nrticularly those in whom the sexual nppetite has never 
been very aetiw, tlie desire iui<l |xt\ver in rf>itus re* 

nni s 


unil vvitli halting intervals. When tlte sirieture is xrry dense 
an<l tight the return of sexual aetivity inuy be (|iiite sluw; but, 
in general, a gimnleilly favondile j)rogn(isls nniy Iw ventured. 



One of the most eommnn eauses of organic irnputenee, and in 
some instanees of aw»6spermatism» is nochilur strietnre of the 
urethra. In such eases there is very frequently, prinnirily, impo- 
tence due to tile jjeripbi-ral ctMiditiiin caused by the strictun^ as 
stated in the text. But in very pronounced cases, such as the one 
|H>rtrayed tn Figs. -IS anil 4S), it is imjjossible for the ejaculates 
tu R-aeh the vagina uf the wonum. 

In some cases the semen is <lischarged and h*aks backward 
into the bladder. This occurs especially in the rather excep- 
tional cases in which tlie membranous and prostatic u:ethra have 
become nuich stenosed (see Fig. .">0). In other cases in which 
the stricture is in the pendulous urethra and the deeper parts 
comparatively frtv, the ejaculate is thrown int<f the diuniigcd 
prostatic uretlira and then oows into the mendiranous and hnl- 
Ixjus uri'thra and is stopfwd in the p-ndulous uretlira, from which 
it may back uy into the l)huidcr, or after coitus may dri!>hle 
through the nn'thra or meatus. In none of these cases is fecun- 
dation protlnced. 


Chronic inflaiunialion of the bulbous and |>osteri(»r urcthni is 
a not unconnnon cause <»f sexual weakness and impotence. Tliis 
condition is well shown In the following cast*: 

A man. aged thirty-two years, tlnn, ncrvotis, and s*nncwhat 
worricil, had masturbated from his seventeenth year until shortly 

Fig. 48 

tShnwing firm fibrous stricture in 
middle of pendtiloiM urethra, dilata- 
tion of can A I b«hind it, inndulnr fttrii-- 
lure at bulb, Ab(k*c»« of pronm^e, liypcr- 
lr«|ihy of l)la«Ider, und dilatfllion of 
orifirCHof uret«r8. ( From the museum 
of tb« CoDcffe of rhyRicians and Sur- 
geooB, New York.) 

S}inwinj{ denre fibrnuft stricture of j 
the urethra just beyond the peDo-j 
Nc^rotal nnj^le, with rlllntation of tb« 
hulhoii*;, nK-mbriiiioua, nnd prcMlatie 
urt.-tlii'H. The i^^tftutuloufl urethrm is 
kIho inurh thirkened and intiltmt«il. 
Walla of btndderniuch hyiierlrophicdt 
orific» ofiiretcrH dilated. (From Ch< 
MuMMitu of the Cotleire of Physicli 
niul Surgeons, New York.) 



before his marriage, two years previously, having had gcinorrluea 
in a rail<l form and of short duration when he was twenty-four 
years old. Several months l)efnre the eeremony he began to suffer 
fn)m emissions, whieh oeciirrtMl several times a week. lie found 
coitus im|M>ss!ljle, th(mgh he luid jmrtial ereetions in the morning. 
Physieal examination showed intense eongestion of tiie bullious 
and pmstatie uri'thra. with eon.siiierahh' thiekening of the fiinner 
and a scanty uuicopiirulent secretion. Rectal examination of the 
prostate gave no results. By the careful use of nuMlerate-sizA'd 
sounds, beginning with one of calibre 24, French scale, chilhMl in 
ice-water, and nitrate of silver instilliUions, togctlier willi hygiene 
and tonics, this unpmmising case slowly improved. At first the 
erections were not ]>erfect and were of short duration, hut later 
on they Ix'came normal. 

As a rule, cases of sexual il<'bility like the foregoing, in which 
the bulbous and posterior urethra is involved, are quite n'fractory 
to treatment, and they demand much care and attention from 
the surgeon. 



A more advanced class of (»ajies is sometimes ol>served in which 

the Ijulbons and |Htstcrior urethra, as well tus the prostate, is in- 
volved. This combiiuilion and its elTects aif well shown in the 
following case: 

A mam aged thirty-two, of good physique and .sound mind, 
ha<l indulgeil freely, anti at times excessively, in sexual inter- 
course since his eighteenth year. lie had mild gunorrha^a when 
twenty years old, and again when twenty-eight. For two years 
prior to his first visit to mc he had noticed a small uiuci>puru- 
Icnt globule at the meatus every morning, and hiul felt an uneasy, 
dull, burning pain in the perineum and near the anus. There were 
increased fn^quency of urination and moderate discomfort at the 
end of the act. His sexual desire antl activity had l>een going 


t'ruHi \im\ to worse for a year. The first jet of urine contained 

tlirtjuls of pus, nuR'iis, aiid <.'j)illH'!iiim. Examination of the 
urethru ri'veiiltMl gu-at ton<lcriifs.s in tbe bulbous and prostatic 
|X>rtioiis, with so much thickening of the walls as to hug quite 
finuly a bougie a honle. No. 25, French scale. Tlie prostate ■wa5 
.sonicsvhiU cnlar^f'd and tender in all directions, particularly on 
the left sitl*', lunl after massage a milky, unicoid Huiil |>eculiar to 
chronic tubular prostatitis cs<'a|)cd from the meatus. In this cai« 
coid sounds of increasing size, with nitrate of silver instillations. 
alternating with moderate lavage of the posterior urethra \y\\\\ & 
solution of ])ermanganate nf potassium (1:1'(.K)0), cured the local 
process, and coincidently the sexual function l>ecanie more vigoi^ 
ous until (lie normal standard was n^nelu'd. 

In llie foregoing ease there was only ii moderate amount of 
mental uneasiness regarding the ni-ethral and sexual trouble.s. In 
souTc of these cases, however, the mental trouble is quite severe, 
an<l in exceptional instances sexual neurasthenia is observed. 


Cases of sexual debility and (jf impotence are sometimes observetl 
in which the underlying nuirhid pr^^cess is seated in the posterior 
un/thra, iwxA in which the prostate itself is not involvcfj. Pijst- 
morteiti examinations have clearly shown that gonorrlueal inflam- 
mation may lie strictly limited to the epithelium ami the submucous 
comieetivc-t issue layer of the |M)stt*riin* urethra — notably that imit- 
titui covering the verumontauuni. I have carefully examined the 
urethra and the urine of very many cases in which all signs j>ointed 
to posterior urethral involvement alone, and the must thiimugh 
examination of the prostate l>y the aid of the finger in the rectum 
failed to rt*veal any eviiienee of disease. To further conftnu the 
diagnosis, the urine pa^ed after the prostatic massage was rnicro- 
s<:opically examined, ami the characteristic tissue elements and 
phospiialic salts wen* not found. I am thus emphatic and precise 
in details, for the reason that there b a tendency on the part of 






(me writers to ascribe all cases of symptomatic {or, us ihey tiTin 
it, atonif) impotence to lesions of the prostate, aiul to dewy to 
posterior urethritis any pathogenic infhiciice. 

Cases of sexual tlebilitv and impotence in which chronic jx)ste- 
rior urethritis is found as the probable morbid factor prt^sent, as 
a rule, the symptoms peculiar tfi that disease. Such patients give 
a history of gr>norrh<ea which has left in its wake a tendency to 
frequent micturition, witii, perhaps, more or less uneasiness at the 
end of the act. In some cases there is, besides, a history of recur- 
rent slight luematuria; in others, of a sensation of deep pelvic 
and rectal uneasiness. Some of these patients have noticed that 
their urine, particularly that which is first paased in the morning, 
contained gonorrlia-al threads. In these cases the develojmient 
of the sexual debility is usually slow, and it begins with feeble 
erections, protracted sexual act, and dribbling, and jierhaps pre- 
mature ejaculations, without or with a diniinutioti in the iniensily 
of the customary orgasm. Beginning in this manner the disability 
becomes more or less pronounced until an in][>otent stale is 
reached. Patients who suffer from this form of impotence art* 
usually mtni of thirty years and beyond — even to fifty years. It is 
sometimes sixu in men between the ages of twenty and thirty. 

As a rule, this form of impotence is more or less promptly 
relieved by treatment; ami although some men suffering from it 
become worried and dejected^ and even neurasthenic, in my ex- 
j)erience they, in general, regard tlie matter (piietly and philo- 
sophically, and ai<l the surgeon in bis efforts to cure them. 

Many of these patients liave been guilty of st^vual excess<*s, and 
such subjects should Ijc made to clearly understand that a return 
to their old practices will Ik' followed by more permanent impotence. 

Knowing, as we do, that so many sensorj* nerves end in the 
verumontanum, and that this jvnrt is so constantly anrl severely 
involved in chroiue posterior urethritis, the question suggests 
itself: Wliether this form of inqM>tence is caused by the irritation 
of the ends of tfiese nerves, which is conveyed backward to the 
sexual centre, and then-, after a period of excilati 
a condition of sedation? 





A ver)' large proportion of tiic cases of symptomatic impotencp 
are fouml in men who an* suffering from clironic pn,ist«titis. In 
almost ull of these cases the disease of tlie prostate has been causcti 
by early and loiig-coutiniicd masturbation, by sexual excesses, by 
sexual excitement without natural K'lief, by coitus reservatus, and 
as a result of gonorrha'a. 

Tlie patient siifferiiig from this form <jf iinfiotcnce may be 
young (and they are in the nuijority), middle-aged, or old. They 
e4>in[)hiiii of various conditions 4*f disability- — namely, of lack of 
desire (and in sonu! impetuons desin*), of imperfect erections or 
absolute want of erections, of feeble and protracted coitus, or nl 
pivinature ejaculations, niey often Lave nocturnal emissions, 
and some have fairly j^^ood erections when they are not near 
women, but these usually fail them when they conic to close 

Young men in partieidar who are tlius affected constitute the 
large arrny of sufferers from so-called spt^rniatorrLcea. 'ITiey 
complain that their semen escaj>es either after urination and 
defecation, and during severe physical exercise, or involuntarily. 
In many of the-sc cases, particularly in young and luiddle-jigeil 
sul>ji*cts, tiicix^ are observed incntul worry, hypochotulrijisis. ami 
even uenrasthenia. 

Many of these cases are very ameiuible to treatment, otlicrs 
yield less rea<]ily, while not a few are very refractory. In some 
cases intense sexual eretliism is very jKTsistcnt and damaging , 
in its effects. Such patients may endeavor to force themselves ■ 
to coitus, and usually fail, or they may suViject tlu^msclves to 
sexual excitement, or to unnatural practices, and always with 
had effect. 

It is only necessary here to give this general outline of what we 
may call prostatic im|M)tence. an<! to refer the reader to the chapter 
on Chronic Prostatitis for more uiinute details as to the varieties 
of cases and their symptoms. 








There is a tendency nowaxlays on the part of a few surgeons 
to ascrilx' many cases of sexual weakness anil impotence to in- 
flaninmtioa of the seminal vesicles, and to deny that the pms- 
tate is in any way a pathogenic factor. In order to ^'ain true 
and clear views a-s to the probahlc influence <if -spcnnalorystitis 
on the sexual functions^ I have made many ohservutiinis and 
examinations, and have supplemented them })y long-(H)ntinued 
and extended micmseupic stntiy of tht* urine, of the semen, 
and of ahnornud dischiir^j^es from tlie nn'tbra in these cases. 
These studies have Ixvn nidiinsed hy any tiicory, anil liave not 
been prejudiced by any peculiar ideas or views; my aim has been 
not to theorize, but to put a prrtper interpretation on the facts 
carefully elicited and the appearances presented. As a result of 
extended observations and close studv, 1 am leil to Ix'lieve that 


disease in the seminal vesicles is rather rare in younger subjects, 
and that seminal vesiculitis ]>lays a subsidiary role in the pro- 
duction of impotence. It is rather unconmion Uy find any trouble 
Ijeyond the prt>state in young and impotent men, piirticularly in 
masturbators and those who have not suffered from chronic 
gonorrhoea; and if the seminal vesicles seem involved, it is only as 
a concomitant, or, p-rhaps we may say, a complication of chronic 
prostatitis. In a number of middle-aged men, am! in some past 
fifty years of age, who have suffered from iinjHitencc. 1 have 
f*mnd direct e\nflence of chronic intfammation of the scniinnl 
vesicles; but in every case there was unmistakable evidence, 
either on rectal palpatitm or in the microscopic cxaminatiou of 
the expressed secretion, that the prostate was jilsn the seal cjf 
disease. In the light of my present experience I am led to think 
that in some {not numerous) eases of masturbation and gonor- 
rhoea in young ini[iotent men the prostate and seminal vesicles an* 
involved, but that in general this s\'mptom-complex is ftiund in 
men of forty years of age and lieyond, who have Ix^en mastur- 
bators, have had chronic posterior urethritis, and who through- 


out life have been very vigorous sexually or have indulged to 
excess and perhaps abnormally. In this restricted manner I am 
disposed to look upon seminal vesiculitis as a cause or factor Id 
the development of symptomatic impotence. 

It must be remembered that in this chapter only a general 
survey of the subject of symptomatic impotence is given, but 
that it is further fully elalxjrated in the matter of clinical histoiy 
in later chapters. 





Sexual weakness anil even impotence ure not uneonnnonly 
eonaplained of I13' |)atients who have .sulferetl fnun varioii.s ady- 
iianiic ilisea-ses unil l>y tlio^ie ufflieted with brain or spinal eunl 
diseases, antl they are sakl by some authors to l>e more or less 
rtMiiotely L'aiise<! by tfit' aetion of a nuiulHT of ilrii^s. 

This fonn of impotence ha.s l>een <k\senlHMi by sonic authors as 
symptomatic impotence, but I think the term atonic Impotence 
is more correct, for the reason that in these cases tliere are im- 
paired nervons function am! stimuhis, due to devitalizing causes, 
brain and spinal cord lesions, utnl the depressing actions of drugs. 
In all cases the underlying cause is the atonic state of the brain, 
spinal conl, and sexual centre. 

In the various form.s of ana»mia such ia the general lowered 
standanl of the vital processes and of metal)olism that the func- 
tion of no organ is perfectly performed, and with the resulting 
depression to the cerebrospinal system the sexual function is 
more or less torpiil, and it may even be leiniH»rarily exlinguisiied. 
In neurasthenia the supply of nervous force required for the essen- 
tial vital functions (chiefly circulation, respiration, and alimenta- 
tion) is so nmch drawn upon tbat none is left for a function tike 
that of copulation, which is only occasionally called into use, and 
can, without detriment to the patient, be absent or in abeyance for 
varying periods. After diphtheria, en'sipelas, influenza, typlioid 
fever, pneumonia, rlieumalic fever, and in the course of malaria 
and urtemia, sexual weakness, more or less pronounced, is often 
observed, and the question suggests itself to one's mind whether 
the underlying cause is the impaired or depressed nutrition of the 
nervous centres or whether the toxjemic condition incident to these 
diseases is the essential cause? 


Many persons wlio suffer severely from gastric and gastrrv 
intestinal disor<_ler3 are not infrequently weak sexually, ami their 
iTn|x>tent conrlition is iTa*lily oxplaine<I by the malnutrition, which 
prtxlncos nervous atony, which in itself is increased by the worn 
iiu'icleiil to those affections. 

In sotne cases of (hahetcs a well-marked and even permanent 
state of sexual impotence maybe pHMhiced, Ijeing sometinies h 
first and ]>iv!noriiton" syin[)foTn, caused, in all pmbability, by the 
general bad state of iiutrititJii of tiie patient. In soim; of these 
cases, coinciding with the diminution in the amount of sugar in 
the urine and the general improvement in health (when it occurs) 
the sexual function nuiy Ix^come more or less active. Witli the 
st'vere development of the general systemic disorrler this func-tion 
soon becomes less active, and then perhaps extinct. 

In many functional and organic affections of the brain a more 
or le.Hs complete am! (x'rmanent form of im|>t>tence is sometimes 
seen. In cases of cerebral excitement and exhaustion from various 
causes, of spinal irritation, cerebrospinal meningitis, spinal meoin- 
gitis, syphilis of the brain aiul spinal cord, myelitis and lo<'omotor 
ataxia, the aliatement of sexual [lower is soon si'cn. sometinies after 
a period of girat erethism, and in the course of time it is entirely 

Sexual excess, and particularly the indulgence in abnormal 
coitus, very often produees atonic impotence by their damage to 
the general nervous system and the sexual centre. Tlic same 
may Ik* said of excessive nias(iir}>ation. 

It is not uiK'ounnon to observe patients who sutler from atonic 
impotence who may be said to l>e sexually woni-out. Such 
patients may or may not have had gonorrhoea or syphilis, but 
were in their early ilays virile and pt'rsistent in sexual intercourse, 
reiving, as they usually tlo, a fast life, they keep late hours, drink 
and smoke to excess, and are in many instances immoderately 
given to sexnal exce&ses in unnatural metho<ls (chiefly aniujt ah ore\ 
and also naturally. Toward forty-five and fifty years of age 
(and sometimes earlier) these men l>egin to decline in sexual 
power (in some the retrograde process is slow, in others rapid), 




and, as a rule, in spite of careful treatment and general reforma- 
tion, they lose tlesire and power nntil the end is reached In utterly 
incurable irnf)otence. 

An old, persistent syphilitic dyscrasia, in combination with 
alrolioli,sni and the indulf^cnce in sexual excesses, leads in many 
instant'es to pennancnt imjKitence and often to tabes an<! paresis. 

It is Sfud that in the Eiist Indies there is scarcely a %'irile man 
over twenty-hve years nf age. The sexual decay in these men is 
due to the practice of long-protracted coitus. Wiile in the act 
they keep ready at each hand a basin of cold water or some cold 
object, with which they constantly cool their hands just before tlie 
orgasm comes on. fn this way tliey greatly pmlouj^ the sexual 
act, and in so doing wear out their sexual centre am! perhaps 
damage other parts of the nervous system. 

In America the unnatural prtjlongation of coitus (for the alleged 
reason of greater gratification to the female) is very often the cause 
of a more or less persistent fonn of atonic impotence, and also of 

In chronic moryihine addiction and npium addictif)n in any 
form, loss of sexual desiit? and [xjwer is an early result, and it 
remains as long as the use of the dnig is continued. 

Prolonged indolence in the use of absinthe has been known 
to be the cause of sexual decay. 

Bromide of potiissium has Ix'cn claimed as a frequent cause of 
sexual weakness and decay, but onr knowledge of its action in 
this direction docs not rest on a Si*\U\ basis. Cases undoubtedly 
have occurred in which it seemed probalxle that tlu* long-ctjniiiuied 
use of the drug had impaired the sexual function, but suHicient 
prominence has not been given to the morbiil conditions for which 
the therajieutic agent was administered and to the probable 
anaphrodisiac iivlhjcnce of these morbid states. It is ver}^ prob- 
able that decline in the sexual functi*>n may follow the long- 
continued use of this drug in a heidtliy in<liviilual, for the reason 
that it acts as a sedative to the sexual organs, but on this point 
we have no reliable information. 

Large and long-continueii 4loses of iodide of potassium are said 


to cause atrophy of the testes ami sexual impotence. Hen\ ago 
no distinction is made Itetwcen the action of the drug and iIk' 
aiTection for which it is administered- While, therefore, it b 
probahle that ioditle of potassium may, when used for long period*, 
cause diminiitiou in a man's virility, we liave not to-day siifficieni 
trustworthy cvitlencc to prove the point. 

Alcijholic excesses at first the sexual desire, but Uter 
on tliis stimulant ceases to stimulate, and it produces an obtiind- 
ing auil devitalizing effect on the nerves of generation. 

In ciin>nic U'a4l-]>ois4»ning sexual iuipotemv is said to lie a quitf 
constant and prominent symptom. The use of camphor and tur- 
pentine is said to produce an lUuiphnMlisiac effect. It is clainiPtl 
that excessive use of ttjljacco and cigaivttes may cause sexu)d 
torpor and inability, and if it does, it is by reason of the depws*- 
ing effect of the poison on the nervous centres. 

The excessive use of coffee aniJ tea, particularly in persons 
emphiyed as samplers uf these articles, luis Ix'en cited as a cauac 
of impotence, but it should be rememl>ered that when such clainu 
are niiide full d<'tails of the alleged cases are absolutely neces- 

Nervous impreasions transmitted to the sexual centre from the 
testes undoubtedly have much influence upon the sexual function, 
although our knowledge of its iu-tion is very limited. Structural 
affections of the testes and the vasa ileferentiu nuiy lea«l to azoc- 
spTUiatisra, and it is very probable that when mild or severe 
ni**rhid changes takes place in these organs a depressing effect iis 
produced in the spinal iXM\\ and the sensory nerves. In cfuscs of 
cxliaustion, of overwork, an<l of adynamic disease the structural 
vitality of the testes is much interfered with, and it is pn^bable 
that the nerve impressions conveyed to the Ixidy under these 
circumstances in a greater or less degree prodvicc a condition of 
sexual torpor or impotence. This point is worthy of careful 
thought. We have l>eeome so accustomed to lf>ok for causes of 
impotence in the sexual tract itself that we really pay little beeil 
to the j>robable depressing effects of testicular troubles upon the 
ci'ntral nervous system. 





In the newly proj)ose(l operation of castration for prostatic 
hypertrophy the fact has kwen clearly brought out that in some 
cases the removal of the testes is followed by mental depression 
and unbalancing, as if a nonnal stimulus had been su<ldcnly 
withdrawn. This fact suggests to us that very probably in healthy 
condititjus some indeterminate impressions arc conveyei! from the 
testes to the central nervous system wliich are necessary to its 
full integrity. 

Sexual vigor usually grows less at-tive with the advaiuing age 
of the patient, in Sf>me men earlier than in others. Such ciises are 
generally due to sexual inertia, particularly to grmlual exhaustion 
of the sexual centn*. They are really cases of senile atonic impo- 

Treatment. — As atonic impcjtence is only one of many symp- 
toms incident to aniemia ami various other a<lyniimic conditions, 
brain affections, and chronic systemic poisoning, the first in<lica- 
tion is to determine what is the morbid factor, and when discov- 
ered to treat it on general medical principles. In many cases 
constipation is a constant c<nulition, and its existence slmnld be 
regularly inquired into. It is always most i!npr)rtant that a free 
movement of the bowels shouUl occur at least once a day. This 
fact should be clearly brought to the mind of the patient, and 
such measures should be instituted or such drugs taken as will 
bring ulM>ut the dcsin-d result. 

In some of these cases much mental and perhaps some physical 
benefit may follow the judicious instillation of strong nitrate of 
silver .solutions (of strengths varying from 1 to 5 jxt cent.) into 
the prostatic urethra. Likewise, the passage of a warmed or a 
cold sound once a week or more frequently may be of benefit. 

Damiana has failed to prove a uniformly efficient aphrodisiac 
remedy, and cantharides is so irritating to the stomach and the 
urinary tract that, as a rule, it often cannot be given in sufficiently 
large doses to excite the sexual centre. In some cases, however, 
it seems to act beneficially on the sexual centre. 

In some cases much l>enefit is produced by the ingestion of a 
combination of atropine and strychnine. The initial dose of 


atropine is one-one-hinulrodth of a grain in water three times i 
(lay. and that may Ix' infn*as<'d to one-sixtieth or oiie-Iiflieth of* 

TTie usual dose of strychnine is one-thirtieth of a gnun, which 
may be gradually and continuously increased to one-twentieth of 
a grain. 

Quinine in three-grain doses, given three times a day, pu^ 
ticularly in combination with strychnine, and in very atonic cmso 
with atropine, is sometimes of markedly l:K»neficial effect. An 
excellent preparation is the following: 

H — Ferri et quinioiu , . . • 3*j. 

Fl. «t cooe ,5ij. 

Tr. g«nuiu)w cr>iDp 3>H* 

Tr. nucid vomicae ..... jftl. ccc 

Ai]i>it' 388. — M. 

One teupnonful in a wineglan of wiUr ihree timei a day one hour after m**\*. 

And the following prescription, taken in the same rlose .-ml 
manner, mav Ik' administered: 

U — l^uiniiup sulph. 
Tr. ferri muriat. 
Tr. nijcia vomitw 
S.Tr. vimpl. 

. gr. Ixi» to xciri. 
. glL ooczz. 
irtt. coc. 

q. *. ad ,^iT. — M, 


A preparation composed of various animal extracts, known ms. 
phosphoalimmin, acts as a decided sexual tonic in some c 
In my expericnct* little if any relianre can be placed on the mu 
advertised and patented spermin, though astonishing clai 
have been made for it as an aphrodisiac. In some cases benefit 
has l>een profluceti by the a«lministnition of th\Toid extract in 
tablet form, llic usual <lose is one tablet (five grains) three times 
a day. It is well to use this remetly for one or two weeks and then 
allow an interval of n'|M)se Ix'fore its rt»newal. 

Chlori<le of gold and sodium, administered in the form of pill 
in doses of one-twentieth of a grain three times a day, bav( 
vaunted by several authors as having marked aphrodisiac powe 


Phosphorus proves to be in many cases of anaemia and atonic 
sexual exhaustion a most effective remedy. It is best given in 
gelatin-coated pill form, the initial dose being one-one-hundredth 
of a grain three times a day, and the dose may be gradually and 
cautiously increased to one-twentieth of a grain. Care as to the 
condition of the stomach must be exercised in cases where this 
drug is taken. 

Phosphide of zinc, in doses of one-tenth of a grain three times 
a day, maybe given. The latest novelty in the treatment of atonic 
impotence and in sexual neurasthenia is Zohimbin, which has been 
much vaunted of late, particularly in Germany. It is preferably 
given by the mouth in tablet form in one-twelfth grain doses, 
three times a day, or the same quantity may Ix* used in watery 
solution in the same dose twice daily. At present no striking 
or convincing statements can be made as to the efficiency of this 
drug. Time and experience will settle the question of its value. 
In a personal communication to me Dr. T. W. Williams and Dr. 
W. S. Bennett recommend the use of the fluid extract of the bark 
of the tree of Zohimbehe, from which the alkaloid is obtained. 
These gentlemen think that the fluid extract of this bark is much 
more efficacious in sexual incompetence than the alkaloid, and 
that it is a decided sexual tonic and stimulant. It is also used 
locally, about ten minims being dropped on the retracted prepuce, 
and the distal part of the penis then well rubbed with the tip of 
the finger. Grcneral turgescence of this organ is then said to be 
produced together with gratifying erections. In some cases it is 
necessary to use in addition spermin nuclein and phosphorus 
preparations. It will be interesting to leani the opinion of these 
gentlemen after further and prolonged experience with this agent. 

Nutritious and easily digested food should be taken, together 
with a moderate amount of Burgundy or claret. 

Many local remedies act well as general and local stimulants 
in atonic impotence. Cold sitz baths and cold affusions to the 
penis, testes, and lumbar region, carefully administered or used, 
may often prove very invigorating. Systematic cold bathing and 
salt-water bathing in combination with active internal medication 


shouUl be emploved in all cases. Mental relaxation, physical 
fresh air, change of scene, together with niotlerate out-<Joor exej 
cise, shoiiUl Ix* insisted upon, proviiieil they are practical 
Horseback exercise is excellent, but it must not be indulged 
when the genitoiirinan' tract is in an almorraal condition. Loci 
and general faradization may |jrodnce excellent stimulant effecl 

If any affection of the meatus^ urethra, prostate, seminal \'esicli'S>l 
or testicles be present it shoidd rewivc proper attention. Care- 
fully gra<Uiated ina-ssage is a therapeutic niea-sure of much imjwr- 
tance. Zabludowski^ recommends its systematic empIovTiicn! in 
certain parte of the genital regions followed by massage of smaJler 
and hirger jM>rtie>nH of the eiiliiT iKidy. The object is to stimulate 
the entire vasomotor system and to increase the tone of the blix^d- 
vessels. The self-reliance of the patient is also favorably in- 
fluenced by this treatment. The technique is as follows; Tht- 
patient, lying on his back, hiis each of his testicles gently manipu- 
lated by the operator. Care must be exercised never to grasp either 
testicle at opposite points, for in that case pain is caused. Tlifii 
the manipulation gradually extends along the spermatic conl 
and also along towanl the bulb of the urt^thra and the perineum. 
Finally, the iruier surface of the thighs is massaged. In varioui^ 
positions of the patient — i. e., while lying on his side or on his 
alxlomen, all these processes are carried nut. Then follows 
nuLssage of the Umd)ar and sacral n'gious (*arrietl out i>y meaa*' 
of kneading with the fist, although not too severely. Then pressure 
and massage* along the occipital, cervical, and intercostal nenT 
shouKI follow. In all these m!ini|>uluiious the most time anil 
care are necessary where painful areas are loeaU'iL It luis l»eeii 
found that after the simplest i>alpation in the genital regi<»n.% 
carried on thn^ugh a few sittings the sensitive areas become 
greatly diminished, and that the atonic condition of the skiu, 
which had easily broken out in clammy perspiration before, 
became sounder and more elastic. The resisting power of thcj 
muscles likewise is increase<l. During treatment it is ad\-i5able 

Berlin, klin. Woch«uchrtfl, August 13, 1900 


for the patient to abstain from attempts at coitus for about 
six to eight weeks. The patient may take exercise by walking, 
wheeling, swimming, and riding on horseback, unless contra- 
indicated by local conditions. When great nervousness is com- 
bined with loss of weight, a short sojourn in bed is advantageous. 
Change of scene is also advisable. Douches every morning with 
water at the temperature of the room keep the skin in good, 
active condition. In cases of nocturnal pollution it is also advis- 
able to change the hour of the evening meal and also decrease 
the quantity of fluids taken before retiring. In-door exercise also 
is very often beneficial. 

Boxing is excellent, as it calls info play all the muscles of the 
body. It tends to make the mind alert at the same time the 
muscles are actively called into play. Dumb-bells and Indian 
clubs are also excellent means of hygienic exercise. They may be 
used several times a day, care being taken that exhaustion is not 



Many cases of impotence depi^n^l on certain stnic-tural defects, 

anomalies, changes, anJ <lLstortions of the penis, which are of 
congoiiitiil or ac([uirt*<l origin. 

In many case-s of malformation of the penis <'oitus is imp*>- 
siple; in others, intnuni.ssion is more or less interfercri with; while 
in still others the nrt^thra is so misplac<*<i backward that fccundsr 
tion cannot Im? accomphsht'd. In tliis division arc tnchuled cases 
of ahsencc of tho jHMiis, hypospadias antl e|)ispadia.s, ahnomiHli- 
ties in size, and douhle penis. 

Ulcerative and other tlestriH'tive jirocesse.s in some cases 5n 
damage and distort the puis that a man may hecome actnaltv 
impotent as a result. Then, again, the size, slrnetiire, aii<] shair 
of the organ may Im:' rendered so abormal by l>enign hj^xTplastic 
processes and by malignant new-growths and preputial cah-iili 
that coitus cannot be performeii. In tliis morbid catcgi>ry belong 
cases of destructive lesions of the skin of the penis and of the whole 
organ, exuberant vegetations, homy growtjis, lymphoid coniiecd\^ 
tissue hyperplasia, and cancer of the penis. 

In another class of cases of organic impotence wc find degen- 
erative and hyjierplastie changes in the corpora cavernosa, and 
morbid eomHticms of these structures t\\\v to eurvature ami frac- 
ture of the penis. 



A MAN may l>e rendered impotent by certain organic and con- 
genital conditions of the penis which impede or wholly prevent 
intromission nml ffcnndution. He is, Itowever, not necessarily 
sterile, since the functional arlivity of the testes may not V)e at all 
impaire<i. He therefore preserves the procreative power (poicntia 
gentrandi), while he lacks the faculty and power of perfonntng 
coitus (potcnfia cfvitndi). 

In this form of organic impotence arc classified cases of absence 
of the penis, h)'pospa<!ias ami epispadias, abnormaKties in the size 
of the organ, and some cases of double penis. Some men having 
two [>enes, however, are perfectly able to ]>rrfMrm cr>itns, in some 
instances with both organs seriatim. 


This anomaly, when congenital, is very rare, while cases of 
nifiirnetar}' penis of the infantile type are not especially uncom- 

GoschlerV case of congenital absence of the penis is very inter- 
esting. The patient was a well and otherwise fnlly developt^d man 
of twenty-seven years of age. Tlie scnitum was well furnied, and 
the testes and eonls were normal (the left testis was at time of 
observation inHamed), Xo trace of the penis could be discovered, 
but on the anterior wall of the rectum, alx)ut four inches above 

* VierUljahrcMchrift fiir prmkl. Heilkuiide. Prague, 1857, vol. Iiiii. p. 
«t teq. 


tlie anus in the medittn line, was a rounded orifice from wl 
urine esea]H*d. A mjiiiu! iiitnuluced into llu* rectum cfHiKI 
passed thrtui^h a urethra one an*! a half inclies long into tl 
bladder. In front of the anus was a fold of skin which consist* 
largely of ereetile tissue, and wliich IxHame turgid in scxiial 
citenient. There was no ineonthienee of urine in this ca^e. 

R<5volat*s' case wa.s that of a newborn ehild in vhom th 
were no external genitalia, 'riiere were spina bifida and umliilii 
hernia, l)o]ow which the urine ami meconium escaped through 
transverse opening. 

Fia. 50 

Absence of penis due to syphilitic pbagedena. 

X^aton' has re|H>rted a cjise of a iliihl, two years old, in 
there was no jx'nis, ihougii the scrotum and testes were p] 
nie urine was passed through the rectum. Cases similar to 
have also been refwrted. 

' Joumnl rie S^Millnt, vul. xxxii. p. 370. 

' Demaitjuay. Maladies Cliinirg. du I'enits 1877, p. 539. 



Cases of apparent absence of the penis have Ixien reported. 
Boiiteillcr's cast^ t)k' penis couV! not U* s(*en. though on 
palpation a small, worm-like body was felt l>cncath the skin, wU 
dissection showed was a small penis. Murphey' records a 
what similar case in which there was a well-formed scrotum 

Fig. 53 

a 5od 



Double hydrocele with invagmation of the p«nu. 


apparently no penis, the urine eseaping from tlie lower part 
abdomen. Deep pressure revealed a Ixxly which, when dissc 
out, prove<l to be a small penis, for which tlie re[H)rter vent 

* British Medical Jonmal, 1885, rul. ii. p, 62. 



entertain the hope that it wouUl later on be equal to all retjuire- 

Ahsfuce of the ptiiis may result from (lie plm^nlcna of hard 
and soft chancres (see Fig. 50) and from gangrene (sec Fig. 51). 
In cancer of the penis more or less of its continuity is removed 
by amputation (see Fig. 52). Slrangnlation of the penis by 
self-inflicted ligature has been known to produce absence of the 

In some cases of enormous Iiydroeele (see Fig. 53) and of 
scrotal hernia, and in some cases of enormous enlargement of the 

Fio. 54 

haiitiatiU or the tcroUim (end leg) wilh inva^iriaiiun uf the penis. 

testes, the penis is forced backward and appears U\ he absent. 
In some of these cases the organ is so enveUjjjcd that even in 
erection intn>mis.sion is rendered im|K)ssil>1e. This rendition also 
obtains in elephantiasis of the scrotum (see Fig. 54!. 




These rare malformations will not here be described in full, 
but will be ronsideix'H only in tlu'ir relation to the sexual act. 

H}^ regally consists of a greater or less deficiency nf 
the corpus spongiosum and of tlie urctltra. \\l»en the urethra 
ends at the biLse of or in the glans the eontlition is called baliuij^ 

Fia. 55 ™ 

PtiritieuHci'uUl ItypoepatiiuM. (After Oolbeaa.) 

LSiwliiv-*** l'> *^'''^ 1 cMiditiun the semen may Vh? dis<'harged into 
^VHjpim iind impn'f,MuUion may result. 

\\1 'H lU»' "itHlira ends in the course of tixe penis, piT>vi«led it 

. (j^P (,rtek, the condition, which is called penile hypos- 

^^^ V not pw'Venl fructification of the fenutle ovule, as the 

T^"^^ liven tlis*'^"^''K*''' '"^" ^'^'"' ^'**K'"'»i- Wien it ends ipnif 

\ k iW win**" c-HfaiH"^ ^^^'^^r the external i;enituls. U^his aldo 



occurs in penoscrotal hypospatlias, in which the urethral orifice is 
seated at the an^le formed Iw (iie jH*nis iirui scrotum. 

In scnital anil perineoHcrolal hy^xispatlias the semen (huvs not 
eonie near the genitals of the woman, hence it has no opportunity 
for fnit'tificatioii. Men thus affected are necessarily sterile. (See 
Fig. 55.) 

In epispadias the urethra opens on the upper svirf ace of a mal- 
formed penis» either in its glandular portion, in the inyitinuity of 

Fio. 56 

Epiapadiafl of gUm and corpiu spoagioeiim. (Afler T)uU»eau. ^ 

the organ, or just at the symphysis puhis. (See Fig. ofl.) In 
(mses of glamlular epispadias impregnation of the female may 
fK'cur, hut the chances of this t'vetit iHroiue nion^ remote in pro- 
portion as the opening of the urethra occurs at points farther 
back. \Mien the urethra opens at the symphysis ])uhis the seuivn 
is thrown outside the vulva, and jus a fecundating Huid it is lost. 
Total absence of the uretlira is a very rare malformation. Occlu- 


sion of the canal when it occurs near the glatis Ls generally reme- 
diable by operation, and even when seated farther hack the caliJin* 
of the canal may l)e so ^^sto^ed that on introniLssioii fecumladyii 
of the female ovule may result. 

Torsion of the penis is a very rare condition, compltcatiiig 
hypospadias and epispadias, and by it the organ is so twisted im 
its axis that the unahral orifice is abnormally placed. 


This condition is very rare. It sometimes accompanies hypos- 
padias and epispadias, but may occur without this combination. 

Fio. 67 

Twisted p^nia. ( A ftcr Morris. ) 

The penis may he twisted on its own axis or tlic iin'tbra may 
wind .spirally around the corpf>ra cavrniosa, :ls shown in Fig. 57. 
The jMmis in this case was that of a child, and wjus of largo size 
and l>ent with the wnvexity to the right and twisteil a quarter of' 


Hudimeniary Penis with CrypLorchism. 


"Two months later he reported himself well, mentally and 
physically; his sexual appetite had returned, and since the opera- 
tion his power of maintaining erections had been as good as ever." 

It is well to lay emphasis on the fact that this procedure has 
not been thoroughly tested, and that it has not as yet received 
authoritative indorsement, though several years have passed and 
no further cases have^been reported. 




'^llie intcg^iment of tlu' |>pnis may, in coiisofiuenpc of disease 
<ir Iraiiniatisni, Im* so iinicli ilt'strf>V('(l tluit wlicn cicntrizjition is 
complete intromission of the organ may be either much impaired 
or wholly prevented. 

Ohancroidal Ulceration. 

Chaneroidal ukvration may be so severe iiiul extensive that 
mucli of the It'gnuu'titary sheath of the penis is destroyed. In 
Fig. 59 is portrayeil a [kmiis which ha<l lx*en the seat of several 
large chancroids. After healing, the organ was so curved down- 
ward and twisted at its end that coitus was practically inij)ossible. 
I have seen many instances of this kind, some of which were more 
pronounced than the one here mentioned. 

Phagedena in Syphilis. 

Phagedena may allaek the iiiitnil lesion when seated on the 
penis, anil so destn»y or distort tliat organ that coitus is n*ndered 
impossible. In gcneraK the destructive action mcnrs in the gluns 
penis or in the prepuce, and the process is arrested before serious 
damage is prochu-cd. It sometimes happens, parflctilarly in cases 
of phimosis, that a suhpivputial initial lesion Ite^vmes attacked 
by phagedena, and, owing to want of care, or poor care, more or 
less of the organ is destroyed. In these days of strict antisepsis 


>hage(ipim is not a common cninplieatinn of jjriniarv s>'y)hilitic 
'sions, and in the event of its offurpenep it is ninrli nuire ]>rnmptly 
rheckctl tlmt it was twenty years ago. 

Via, 69 

Cicfttrixatinn of interment of the jieni.x fuDowing chancroids. 

PhagetU'iui has Ix-eti kiKtwn to attack the urethra and to run 

\\a\ tlie canal fur short or long tlistances, even to llie ])enoserotal 

jle. In these rare eases, of which I have seen several, organic 


impotence was pn»<hK'etl. I have several times l)een al>lc to a\Ti 
this process before It ha«l extended ninch beyond the meatus, h 
these latter eases a dense fibrous stricture is usually produced. 

Oan^ene of the Penis. 

It usuully lia]>[>ens that gangrene primarily attacks ami desti 
some part nf the integnment of the penis and also the glai 
with perhaps some of the tissue beyond. Ilic result of gan^ 

Km. CO 

Gnngrene of tlie iotegumenl of Itie penis. 

of the penis is well shown in Fig. r>0, in which tlie gn*ater poi 
tion of tlie skin of the organ, beginning near the preputial orifice 
and extending almost to the abdomen, was destroyed. When full 
healing had taken place in this ca^e tlie penis was so pushed back- 
ward to the alHluiucn by the sclerosing cicatrization that erections^ 
were abortive and penetration was rendered impossible. I have 



ler instances in which gangrene of the jjenis Nvas followed h\ such 
leforuiity that coitus became tlifficnlt, incomplete, or impossible. 


Injury to the integument of llu- penis, Iwyond mere bruises, is 
lot very common. Laceration i>f these parts is of very infrequent 

Fio. 01 

Showing dmraction of the intei^iiment of the penis resuUing rmm irnunjatiitni. 

In Fig. 61 is shown an example of a hicerated wound of the 
'penis of much extent atid severity. As a result of his iM'ing stnick 
by a revolving wheel, the penis of this patient was nearlv dtinided 
of its integument in its whole circumference. Id cases like this 



the rtvsultinjc citatrix is so dense and firm that the organ beconii 
somewltat tuisted, and nn erection it is so distorted that inl 
mission is either verv diHieult, piiinfiil, or impossible. 

In most of these cases the affectetl surfaces are so studdetl wil 
luicm-organism.s t!uit skin-f^rafts will fail to take root. Then, a|pui 
tlie m4)l)ile eoudilictii of tfie penis is siieh that a perfect resuh 
n-ndereil almost impossible. 


Vegetations are papillary new-gT(jwths, due to hyperplasia of 
the connective tissue ami of llie epidermis. They are developi'd 
on the mncoLis tncnibrane of the penis arul at its junction with tl» 
skin, in consei|ueuce of the irritation pHwlncetl hy de<?omposii 
secretions and liy pus. The hy|K'nemia left by chancres and chai 
croids (m the ^lans or prepuce rnay lead to the development 

These lesions begin as little red spots, which soon become satieul 
and fn^m a |Ki]>ular condition they ^row rapidly and cxuljcranth 
until papillomatous or cauliH4>wcr-like gnjwths are prixlucefi. 
Tliey may Ix* rounded antl sessile, or pedunculated or Indian- , 
club-shape*]. They f<irm masses like strawberries, and larjzieS 
aggregations of them very niucli resendjle caulifltiwvr ^^rowlh;*. " 
In color tliey nuiy Ik* very re<l, or eif a [liiik or even gra\nsh linl 

The sites nion^ fretpiently attacked by vegetations are the col 
onul sulcus, the inner surface of tlio prepuce, the region of 
fnenum, and the lips 4>f the meatus. 

When small ( lesions may not cause im|>edinient to coitus; 
but when they become large, and con.stitiite fuiigating masses 
and eaulillowcr excrescences, they render itdriMuis.siiMi impossilile. 

In cases of long and tight prepuce tliey often lead to phimosis, 
which may end in perforatitMi of that appendage and to gan| 
and hemorrhage. 

In Fig. 62 vegetations of the coronal sulcus, the whole of the mu- 
cous layer of the prepuce and of the meatus are clearly shown. l\ 
this case coitus was impossible and urination was much himiei 






I have several times seen cases in which men were unfitted and 
Incapable of fructifying coitus with their wives by reason of nearly 
complete stenosis of the preputial orifice Ijy rea'ion of its natural 
smallne^ss and of the blocking up of the penis by vegetations. 

Vui. fig 

Vegetations of the glans and prepuce. 

lis condition is well shown in Fig. 63. In this case after circum- 
cision the man's wife promptly became pregnant. 
A The diapiosis of warts is nsiuilly very readily made. In some 
^ises of ron<Iyloniata lata papillomatous exuberance may occur, 
and the lesions may look like simple vegetations. Since condylo- 


inata lata art- nsinilly foiinil alxnit und araiind tiic anu*) and the 
inner snrfatv of the tliighs and on lh<* si'mtum, it is well when 
large, flat wurl.s are found on these sites to inquirt* into the hJstorj 
of tlic case iu order to detennine whetlicr syphilis may be prcse; 
a.s a morhiil faetor. 

Tiie prognosis of warts of the penis is nsually goocl^ pro 
iulellij^nt treatment is instituted. In old subjects, both mi 
and female, the oecurrencc of warts about the genitals shoul 

Fw. 63 

VegeUiloD6 of the preputial orilice, ciiUbing nlmoAt cooiplclestenoiM. 

alwaj's suggi\st to the mind of the surgeon the predispoalion oT 
these lesions to nia1ic:^ant degeneration, antl their removal 
t)e promptly aceompli.siied. 

Treatment. — The treatment of warts of the penis when 
an' small is very simple. The penis should Ik* thorougldy clean 
and ana*sthetize<l with cocaine and the lesions removed with the 
curette or small cur\e<l scissors. Absolute cleanliness and dryni 




the penis are necessary to prevent a relapse. Destructive can- 

•rization by the acid nitnitc of mercury, tincture of iodine, solu- 

ions of chloride or suhsulphatc of in>n, chlon>acctic or luetic 

'id may l)e employed when tlie warts are very small m\i\ sharply 

lUzed, particularly when patients are very nervous and fidgety 

to operations. 

WTienever possible tlie curette should Ijc used; but when the 
iions are large, hard, and densely hypertrophied it may be 

Fig. 64 

Homy growtiiH uf llie p^ni?. ( After D©ni:irtiu«y.) 

unfavorable to remove thcin witfi the c-iirrttr, and in this event 
the galvanocautery acts very efficiently, and if carefully and 
slowly operateil no hemorrhage follows. 

\Mien tiie meatus is the scat of warts care should l)e taken that 
die Ups be not damaged, since stenosis may follow. After removal 
it is necessary to use dry powders, such as zinc oxide, nosophen, 
and dennatol, and to keep the parts covered with absorbent 




This fonri of new-growtlis on the penis is very rare, 
existence always pmvcs it Imr to i'oilus. 

Horns of the penis lake their origin on the corona in the con 
sulcus and on the iniuT juspect of the prepuce, particularly 1 
the fra-num. Tlieso honis arc usually devcloptHl from 

Fiu. 05 

Honu of the penis. ( Afler Pick. ) 

persons in whom there has IxH^n some chronic irritative procei 

the prepuce or glans. \ 

Fig. 64 is an a^hnirahle inustration of corneous veget 

which began in the classical seat, the corona glandis, asi 




In rather rare cases keloid and sclercHlenna attack the ^lans penis 
id fossa naviciilaris aiul in most instances sueli is the inveteracy 
the process and the resistance to operative treatment that organic 
ipotenoe is practically established. It maybe possible to render 

F!<i. 69 

I>enae fibroid intiltration into the integument of the peniH and into all the 
coraponcnt Btrncturea of the penis. 

e urethra patulotis for a time by internal urethrotomy; but in 
neral recontraction Ivegins very promptly and the passage of 
men apain be<'omes barn*d. 
In Fig. <>N keloid of tiie glans penis and fossa navicularis is 


well shown in a case which was under my care. As far as expkwi 
tory procedure would admit nf oj^inlon it seemed to me that tli 
tissues in this case were inliltrated as far down as the bulb. 


This condition is very rare and is productive of organic impo 
tence. (See Fig. 09.) In ihis case, wliicli was observenl bv 

Flo. 70 

Vahcuse condition of the integument of the penis. 

thca' was absolutely no history {x>inting to cause or etio] 
all that could Ik learneii from the patient, aged thirty-two 



'as that the banlness and coiukiisatlon U'gan when he was a 
ly, aiu] as the |x^nis ^rew in size the ahiKinmil contlition In- 
sasetl in intensity. Tlie patient never hinl an ejjiculutiini to 
lis knowledget and lie had never masturbated. He had Httle 

[if any sexual desire. Owing to tlio eomlitioii of the penis no 

■relief could be obtained Ijy operation, 


Organic impotence may l)e due to the very rare condition of 
lenlargement of the veins an<l ]x>ssihly ifie lympliatlcs of the penis. 

Varicose cundition of Uie meatus and foaaa uavicularift. 

In Fig. 70 the varicose condition of the integument of the penis 
and of tlie fossa navicularis is well .sho^vn. 

In Fig. 71 varicx)se conditions of llie meatus, fossa navicularis, 
and urethra are very striking. 


In these cases the ejaculate is flHinmed back in the penile 
urethra an<l at ooilus is not projected into the vajB^tna, but laler 
on esottpt's l>y <lrops. 

These conditions may be amenable to operative relief. 


^rhese tumors are not at all uncommon in the scrotum, but 
they are rather rare on the penis, where they may cause oi^ganic 
im|xiteiR'e until the parts arc reliovetl by operation. In Fig. 72 
a large wen is strikingly sho\\7i. 



















Sebaceous tumor of the integunieat of Uie \iea\9* 


Cancer of the penis, as a rule, is an affection peculiar to advanced 

life, hut less frequently Is found in men lH*t\veen the ages of twenty 
ami fifty. Lk^twccu tlie fortieth and fiftieth vears it is far from 


Cancer of the p-MUs usually In^gins in au inMif^niHcant manner, 
[fts a little wart» a thickened patcli r>f epithcliutn, and as a small 
[chronic ulctryr fissure. ^Vs a ri»K\ the primary lesion is so devoid 

►f symptoms that it causes no mental or physiea] uneasiness, and 

Its (levelopment is usually very slow. 

Fio. 73 • 

Showiajg epilheiiomatoUH deg«neratiun n^ the glnnn penis barating through 
the prepuc«, which wb« phiniotic 

It he^ins either in the coronal sulcus or on the eonma near the 

ffrivnuin, on the iiuier surface of the prt*|Hice, antl vvvy exceptitin- 

illy in the urt^hra. When the pre|>tice is lung theiv may l>e milil 

►ruritus or a sensation of heat, due to the irritation of the secre- 


tions of the partes. Usually after a chronic period of iiuiescencf 
Uixiiriatit growth occurs and the penis lKx*omcs much enlargwl 
and (listorleil toward its entl l»y fleshy masses and exuWrant 
cauliflower-like tumors. As a result, deformities and distortions 
of varying apiH'aranre are pnnluced (si'e Figs. 73 and 74), coitus 
becomes impossible, and urination is much impeded. 

When epithelioma of the penis becomes fully developed, land 
nating and persistent pains are complained of and hemorrhage, 

Fio. 74 

Showlog the under surface of cnse Hhawn in Fig. 73, with new-growlh Bod 
stenoued pi^puiial orifice. 

more or less severe, may occur. As time goes on the general 
health is underminerJ and the patient dies of marasmus, or, very 
rarely, of metastasis into some of the viscera. As the lesion of 
the f)enis progresses implication ikf tlic inguinal ganglia occurs, 
and palpation shows these organs to l>e large, hard, painless, and 

^I'he diagnosis of cancer of the penis when fully developed is 
usually verj' easy. Any chronic nodule or ulcer with hard and 



Thaps exuberantly <levclo[)eiI or surrr>nn<iinf;s, partunilarly 
nn men over forty years of ag*^% shoiiKl l>i- ri'^ardnl witli murh 
mspicioii, carefully watched, and treated early. It is necessary 

rememljer that in younger ineu the initial lesion may be very 
[exulK^ranl^ dense in structUR\ and perhaps more or less fungating 
[on its surface, and that it mav !>e mistaken for ranrer. 

The piT>gnosis of eancer of the penis depends entirely on the 
ifact of its early recognition and thorough removal, together with 
^all the ganglia in the groins and perhaps in llie thighs. 

The treatment of cancer of the penis, acconling to the extent 
and severity of the lesion, consists in either amputation or extir- 
[pation, with the removal of the lymphatic ganglia. (For a full 
[account of the treatment of this affeetion. s(»e my work .1 Practical 
Trcatvte on Geniiourinary and VeneretU Diseases and Syphilis. 
Philadelphia. U)04.) 

It is too s<Hjn to speak with reasonable certainty as to the eti'ects 
»f the j"-rays and radium rays on cancer, and particularly on 
i-caneer of the penis. Seeing that several reliable surgeons are 
disposed to eonsider the .r-rays and radium rays as valuable and 
lefTieieiit tlu'ra]>eutic agents in eancer it is well to 1m* on tlie alert 
and up-t(wiate. It will take time to decide the question. 

In one of my eases the x-rays or radium rays certainly caused 
tlie rather prompt involution of ihr fungating superfieies of the 
[penis cancer, but it failed utterly to relieve the [niin and to stop 
'the new-growth from extending, therefore it was necessan*^ to resort 
:to amputation. These rays seem to have a decidrdly good effect 
on supi'rHcial fungating portions of the caneer, but 1 susj^eet that 
they will fail to cure the deeper, more indurate*! portion. 


Indurating tedema of the penis is a s*uiiewhat exceptional com- 
plieation of hard ehnncn^ of this organ, and owing to its chronieity 
and its hyiM-rpIastic tcn<leney it may in some eases lead to per- 
manent deformity and to organic im|X)tence. 

Induratuig trtlema begins in a slow, painlesj^ manner aroimd the 



niurffln of tin* initial lesion or lesions of syphilis. It 
tlitil ihe lissucs I>egin to swt-ll ami present a ilull-retl or pnrptij 
hue, and the density of structure a little less compact than thi 
of It typiral hard chanere. LLsually the hard chancre is seated c 
tiie prepuce or tlie pivpiiee and ^'lans^ and from these foci tl 
bvperplastic proeess may ^nidually creep upward, an<l in 
cases involve the whole penis (see Fig. 75), and exccptioi 
rnay involve the penis ami the semtum (see Fig. 77). In 

Fio. 76 

IlliliirHlitig (Klema oT the penia wUh bard chancre on ihe tinier layer of tht 
prepuce, (ireat enlargeioeal of the organ. ^H 

run* I'liwiH when tlie hard chancre iK'giiis on the cutuneoii.s enveloi 
Iff llie iNMiiN (luH indurating (M>mphcati()n may o(»curin the«te wmxi 
nnd llirn il ninally first travels dt)vvnwiird to the preputial repc 
liitd Hlmrtl) iif(rr\vard n|tward toward the piihis (see Fij 
In iiiOMl eiuM*N want of proper and prompt treatment of 
rhuiicn*. hijiiriniiN luul Inttnnpernteeauterixution, and iinch 



the causes of irritation of the initial syphilitic lesion. It is gen- 
illy observed that wheti active raea-sures are promptly adopted 
►r the cure of tlie iruhirating process before much tissue has been 
ivaded, rt\solutioii may ([uite speedily srt in; but that when the 
'atment has been {lelayed (particularly if the parts are irritated) 
id the lesiftn is well under way its tetnlcucy to further extend is 
!ry great and its resolution is long iklaycd. 

Hard chancre with very cxlciisive (edema of the |>emH. Great enlargement 

of the org&ii. 

It is this slu^ffish chnMiieity fif the lesion of the penis which 
ra<is to tlu* great liyix'rtropliy of the or^iin an*l its frecpient and 
lore or less permanent distortion. 

Under vigorous treatment resolution nuiy occur in even severe 
;s in several or many months, and during this |)eriod coitus is 

lally impracticable. In some caseii such an elephantine hyper- 


trophy of the pt^nis is produced that the patient is rendercci oi;gi 
ically impotent. ■ 

Treatment. — In (hf\se cases active intenvnl and l*K*a1 treaiffl 
is impcnitively denumilrii. After eanfiil antiseptic clcan.singi 
organ must be kept envelo|i*'*l in strong mercurial ointment, fm 
spread on lint, whicli is to he hold in place by gutta-percha ilssi 

Fi... 77 


(Ic'inu of ilio [tenis uiui KTulum froru hard eliancre of tlie ii 
layer of the prejiace. 

Ititenmlly an cuer^-tic and eflkient inunction course shoulH I 
adopteil, and in the event of prompt resolution not being obseni 
rest)rt should U- had to the ingestion of the mixe<l treatment in{ 



Uanl chancre *»f (hi- mnUiis not infrc(|uently leatls to si 
of llieso |>iirt5. This (*on<litiun is strikingly showij in 


rbich was taken from one of my patients. This form of stricture 
[is peculiarly reliellious to operation, iiiul iinlrss the greatest care is 

Fig, 78 

Stricture of the meatud following liBrd ctiancre. 

taken by the putit^nl it is very prone to rec-ontraet. In in<»st eases 
orga[iic impotence is produced. For a time sexual intercourse may 
the decitlciUy competent. 

Fio. 79 

Preputial calciiU. (Natural size.) 

Treatment. — Incisioii into tin* meatus witli snlisecpieut dilata- 
ion kept up for a long period is the oidv reme^ly which offers any 




A peculiar form of (li.slortibn of the p<'nis, which, when w 
marked, pro<luoes organic impotence, is cause*! Ky the prpsra 

Fio. 80 

Prepulial cmiculi. (After I'emarquay. ) 

of calculi in the preptitinl sa<*. There niuv he one, two, or 
or more calculi present, ami the distortion of the organ vt 


according to their numl)er and size. As a rule, intromission of 
the penis becomes impossible and coitus so painful that it is 
usually not indulged in by these sufferers. 

Preputial calculi may be seated side by side, and may then be 
symmetrically faceted to each other, or one stone may be seated 
on the top of the other in a concavity in which the convex base 
of its upper fellow is smoothly placed. It is said that preputial 
calculi are not very uncommon in China, particularly in the per- 
sons of the natives. In Fig. 79 are well shown two preputial 
calculi which were removed from a Chinaman in Canton, China, 
by my friend Dr. J. A. Andrews. 

I have seen two instances in which such a large quantity of 
dried smegma was present in cases of phimotic prepuce that 
intromission was difficult or impossible. 



I.v tins category are included ossification of the penis, fibroid 
sclerosis, syphilitic nodes, together with curvature and fracture of 
the organ. 


This affection is very rare, and is denominated calcification bv 
some authors. It occurs in middle-aged and old men; hence, as 
a rule, it does not cause much mental disturbance, though it mar 
interfere with ami even entirely prevent coitus. The parts in- 
volved are the sheaths of the coqx>ra cavernosa and the septum 
pectinifonne. The bony growth may Ik* in plates, as it is usually 
found in tlie superfices of the cor[M)ra cavernosa, or in rcKl-shape 
when the septum pectinifonne is attacked. 

Ossification of the penis, which is always partial, takes plaa' 
very insidiously and withoiit pain, and the patient first becomes 
aware of its existence by the impediment it offers to coitus or the 
curvature wliich it causes to the organ. Jn a case reportetl by 
MacClennau/ in which thcr<' was so nuich distortion of the penis 
that urination was accomplished with the greatest difficulty, the 
whole length of the septum was ossified, and coitus was rendered 
impossible. Hiis l>ony mass was dissected out and a fairly goad 
result was obtained in remedying the curvature and restoring the 
function of the organ. In Fig. SI is well shown an example of 
longituthnal bony growth in the median line of the penis, which 
wjis observed by Denuirciuay' in the Pathological Museum of 
Vienna. No facts concerning the Ciuse were obtained. 

' Philadelphia Monthly Journal of Medicine and Surgery, 1827, p. 256. 
* Op. cit., p. 363. 


The curvature produced by ossification of the penis may be 
sither upward or downwanl. In this affection erections are pain- 
ful, manipulation <jf the penis causes suffering, and in its quiescent 
eStale the organ is more than normally sensitive. 

Fio. SI 

Bony growth of the penis, shown as white banHs in middle of doi>um. 
( After I>Qiiiarq^uay. ) 

According to l>cnuiri|nay, there is a cast* on rcconl in whieli an 
oxdriver hiu! a [M'nis which was wholly ossified, always in erec- 
tion, and the of great sulFering to his wife, llie same 
.author mentions a case observed l>y Velpcau, in which a liony 
growth sprang fn»in tlie pubie l)<Mie and inva<led the left side of 
the jx'nis for a distance of fifteen Uncs. 


Treatment.- Xothinj; hut n-moviil hy nirans of the kmfe b 
intli*'iiU«l in tlu^sc m.s«*.s, ami it i.s pn)UaliU' thiit the cicatrix itsull- 
in;; rr'<un iiw wouiul nuiv lead to hiul <listorti<in t>f the penis. TV 
iinVrfitiii is pnu-tirnlly tiit'urahU'. 

Iti Slum- of these cases, whi-n the plates are superficial an«l th» 
hony iikmIihii eonls aecesslhle to the knife, removal may l»e effectoi 
hv n|>ern.lion. and im|)i»veT>U'nt of the patient's c()n<lition mi^ 
n-siilt. Internal or exteral niedicatiou is worse than us<']e&s. 


TIiIm iilffrlion lias licretohjre Iwcii dcscnU'<l under the titlc»rf 
chnMiie eirrunjserilM"<l inflanimntion of tin* et>rpopa cavernosa, an 
ohvioiiM inistumier, sinee no rmc hjis vvor ohserveij any inflamma- 
(nry coriiiition conniM-ted uilli it. 

ThiM a(Vet'tioii Ix-^ns slowly, jminlfssly, anil insiiHously, ami, as 
M rule, i.H (irsl irci)pii/,nl hy (lie jiiUitMit as a httle Ix-Hn-like hinip 
or nliile of tissue in thr (ia'cu of tlit* njrponi cavernosa, which 
iniiv I"' ^I'K'*''^ painful i»ii pressure or ihiriuj: erection. 

In t'weptional 1 have n<fte<l that the patient (roinplainrr] 
of itnh» Ml Ihi' |KMus, pailirnlarly on ereciion. wlven on can*fiil pat- 
iMillMU IM* ehanp' in ihr corjiora eav<' couKl \h^ made out, evra 
nfit f neveral examinations. In thtse cases the only evidt*nces uf 
lt>«|iMi Wt*^* l*«* tendeney of thr penis to curve ujiwanl and 
lUeMit****' "' P*"" whcMi an attempt wa-s nnnle to straigliien ll 
luiU'tl MftfMii- I" 'l**^'^* cases the fihroi<l prohfcration w, 
lliul^**' WrtVi '•"* '* ^""' ""* bi'cnnK' stiflieieutly compact to 
%{w\\ i\ »'lnnti«' 1" *!'<* tissiies as to Ik- prnvptihh- to ihi^ fiiipcrs. 

A« H rilll*t 1^"' ''<*^''<'**^'^ *^ toliTahly well aUvaneed when 
i|IU#tUI IM i'*Mi«Mlleil. and he fituls a hard, firm plate of tisswr 
Hn» mV I^M Im ilii»'ki»e^^. iwrhajis thr size of one's thnmh-nail or 
( ^(|.(| In til*' sti|M'riieinl portion of the corpora cavtrnosi. 

, lit. nH cacli '^i'l** "'^ ''^'' ii'<'*'i^i>k Vuiv, hki' a sa4ldU\ lu 
n t t|(i»||y •har|)ly defin<Mi and n»gular, or they may ei- 

, I illuiVlMi, "IIk'^'I'^' inufuliitrd, and jM^fKips thickened. 
lUl ,\;:iUI pMklo MH*. f*" " rule, fn-r fi-oni (lu- disease, hut excep- 

as «i 





tionally we find that the innrliid process has exteiulei! downward 
inte) the trul»eculji\ ''Ilif luduriitltm i»f tlie |jlate is viiriablf; in 
the early stages it is iisimlly not very densej bnt in ohler eases it 
may be of cartilaginous hardness. Usually these plates have a 
kind of elasticity which gives to the finger a sensation <|nite <lif- 
fereiit from that offered hy the Ikhiv and eartJlaginou.s plates 
sonTctiines fomu! here. As. however, these plates gnjw old, they 
may become very dense and wholly inelastic. 

The lesion nniy occupy one e<*rpus cavernosuni, or lioth; hut 
It almost always st-eins to U'^in on the dorsum of the penis, par- 
ticiihirly near the mcilian line. I have recently seen f(»ur eases in 
which the plates began )>n the sides on the penis near thr line of 
apposition »)f the rorpora eav(Tnf)sa with tlie eor]>iis spongiiHjun. 
In two eases syninietrical plates over an inch long were foniid, 
one on each side of the penis. In a third case there wa*s a large, 
firm plate on one side, ancl a smaller ami more elastic one on the 
other side of the jK'nis. In the fourth case there was Vmt one 
small plate on the left siile of tlie penis, in all these eases the 
curvature of the penis was well marked and <lownward in direction. 

In general, these plates are found to Iw (he shape of a saddle, 
usually symmetrically placed over the cavernous lw)4lies and well 
welded together in the median line. While this arrangement is 
the one most eommoidy found, I have seen two exceptional eases, 
in which there seemed ti> be a little sulcus directly in the mi4ldle 
line oF (he penis, wfiere the two plates met but did urjt join to- 
gether. This depresst^d line seemed to l>e composed of muiffeeted 
tissue, and it acted as ii hing*' upon wiiieh i'ither of the two plates 
could Ih' slightly movcil or tilled upward or (kiwnwurd. 

'llic smaller plates are ovoid, and Ihey have l>een found as long 
&s two and even thri'c inches and as small as half an iiicfi. As a 
rule, tlie selen>sis attacks the corpora cavernosa, but tpiitc exce[)- 
tionally it involves the corpus sjwjngiosum. This is sho\>n in 
Fig. 82, which is a schematic representation of a case once under 
my care, in which on each side of the ]K'nis there wits an o+fshoot 
extending around X%> the fneniun along the course of tfie lym- 


In some rare cases in which the lesion is unilaterally <levelope 
its inner e<lge usually inipingt'S on tlie meflian dorsal line of til 

As a rule, we find but one siuLlle-like plate, but in some instanci 
I have seen two, one just behin<i the glans pcMiis, and the otk 
farther up the orp;an. near its nK>t. Another anomalous form i 
(Ins aflVrtion consists in the usual satMle-likr lesion witli one o 
two small phi(|ues seateil on one nr lioih sides of the eorpon 

'riiesr phites may grow in all the ilirei'tionsof their margin, bnl 
usually to a givater extent in un anteroposterior direction. Tlie; 

Fia. 82 

Klbroiil Bcleroatifl of llie coqiora cmTerikOMU 

I 4iitivuuenlly remain stationary for a long period, but usuallj 

uAH'Kil M*"^'* !*lnwly anil insidiously. M 

t, i)m' MinjoHly of ea.s4>s the lesion runs its course in the Hf 

>ay\i\\ nuuuKT just descrilx-d; but in some instances thr 

iK Ktiwii l*H*e»*'*-'' rxtentls deeper into the tral)eeulated tissue d 

4ku tfci^^HI MkVern<WB (""* produces nodular masses uf varying 

I'kl. rt^hi^^**** in(erfen*H more or less with erection, according to 

. , ^j^j, nhupie. H this is small it may cause but slight 

. ,,„ iM»ni«; but as it grows larger it so interferes witb 

\i\\\\ »»f <1*'* organ that it is bent exceptionally aij 



Ho a right angle, Imt usually iipwar^l and towarfi tlic atfrcted side, 
or it may be somewhat twisted. In most cases the erectile tissue 
imilerlying the lesion in the whole length of the organ Ijeeomes 
hard and firm during erection. Wlien, however, the traliec-ulatetl 
tissues have been attacked by these selenitic infiltrations, the ])enis 
beyond theui is not at all eongeste<l, while the erection in the 
proximal part Ls complete. In tliis event the organ may resemble 
a flail, the firm part near the body f>eing the handle, and the 
distal part or swingle hanging flaeei<l, pephiips nearly at a right 

In general, patients liaving plates in the dorsum of the penis 
complain thai when erect ihc end <if tlu- organ stands so n<'ar the 
alKhnniual wall tliat intrtuuission is nMulered impossible, and any 
attempt at straightening it out is attende*! with severe pain. This 
feature is shown in tlie schematic drawing made by a patient of 
his own [)enis when erect. (See Fig. S3.) In this a very 
curious and exceptional condition existed — namely, the organ 
became distended and erect in its distal ami unaffected four-fifths, 
-whereas at its proximal sclerotic [>ortion near the l>o<ly it heeanie 
much less distended and was somewhat limber. In this condi- 
tion intromission was only ]>ossible (and then \^'ilh much difficulty) 
when the vagina was very large and moist. 

The appearances presented by another exceptional case are 
shown in Fig. <S-1, which is taken from ii drawing furnislicd by 
the patient of his penis in n state of erection. The distal thinl 
of the cur[)ora cavernosa iM'liiud the glans was the scut of two 
long plates, wlucli giratly reduced the si/c of the penis and guve 
it a decided upward curvature. The unaffected part behind be- 
came normally enlargetl, but engorgement never took place in the 
glans penis. In his dcs(Tiptit»n of bis case this patient said that 
his peuis when rigi<l resembled a plucked turkey, the head being 
the glans, the affected portion the neck, an<l the botly l)eing the 
pnjximal part of the penis, which swelled out during erection. 
In this case intercourse was painful and unsatisfactory. In some 
cases the glans and the penis itself may feel cold, and the glans 
may be so amesthetic that there is no vigor in coitus, and as a 

Fibroid scIertMiB of the corpora cavenioea- 

'riiLs niTcction is peculiar to tho.m» of middle ami lulvanccd a 
I have seen it once ut tliirty^ in another ciise at thirty-five, and 



'veral cases at tht- fortieth year. As a rule, these patients prc- 
rnt tliemselvcH when ahout fifty years oU\, ami fniin that time 
to sixty or seventy years. 
Etiology. — Wo have no preeise knowletij;^^ as to the cause of 
lis attVction. By some it is thouglit to be the result of a fjouty 
fmlitioiu and hy others that it is canwHl hy itialietes. Notwith- 
tanding that Wrneiiil aiu! 'I\iHier' in twenty-vsix ea.sps found 
ift(vn patients to Ik* ^>uty and eU-veii to In* iliahetic. it does not 
follow that these conditions wen' tnu- etiolo^ieal factors. I have 
•n so many cases of this affection in alisolnlely lieuUhy men, 

Fig. 84 

Fibroid scleitMis of the corpora nivcrnosa. 

rho were not |;onty aiul whose nrine ilid nut contain sii^ar, that 1 

very skeptical as to the influenee of a diathesis in prodnring 

Nit peculiar sclenising process. In all prohahility the origin is 

local, '^riie euphernistic dia^jnosis of gont in the p-nis is very 

[ratifying to some old men. 

Close intern>^ali(ni of intelligent patients thus affeete<l usually 
wrings out no facts as to it.s origin. In some exceptional cases 

* AoD&Ies des Mai. ties Org. Gtfn.-orin., 1885, p. 401 ol seq. 


there is a vagiie rccf>llectioii of traumatism, but, as a rule, nothi 
can l>e leunie<l froTn the patient a.<^ to the cause of his IrouWr. 

Pathology. — Acconlinjj to Tuffier and Leioir. these noiiule* 
reseinlile mi(T<>s<opi(any keloid, there iRMiig a fibrous network of 
tissue like that of sears, with few vessels and islets of emhrvoiiic 
cells, showing a tendency to fibrous transformation. In short, 
the process in a ehronie fil)n>id sclerosis. The statement that tliis 
iitTertiini is eaiiseti by ihronilKJsis of the venous spaces is not SHp- 
jHirted \i\ any scientific evidence. 

Two eases have l>een reported in which, after the exsection 
plnte-like nutsses from the penis maeroseopically similar to fihm 
.sclcn)sis, the luicroscopic (hagnosis wassaid to be tiiat of a mal 
nant new-growth calleii endothelioma. As these cases weiv 
critically studied and the full facts concerning them have 
Ik'co published, it wouhl he unwise at this time to elnini th 
(ibroit! si'lemsis is of a lualiguaiil nature. I have oL»servetl \xrf 
many such cases over a long stn*tch of years, and I have nev 
seen in them at any time whatever any evidence of nitdigriaut 
degeneration. It is in»[)ortant that this point should lx» clearly 
rememlKTed in order tluit unnecessary operations and mutilatioa? 
shall nut l>c performed on one suffering from fibroid sclerosis of 
the corpi^ra cavernosa. 

Prognosis. — 'I'he prognosis of this affection is very unsatisfac- 
tory. There is no case on record in which this sclerosis has dis- 
appeared. It has l)een stated thnt in sonu* cases the affection 
crept backward, and then interfered less with crection.s than it 
did when it wa.s more distally placed. In tiie very inanv cases 
I liave seen aful studied no snch auspicious turn of affairs took 
(>Uice. As this trouble is juruliar to men who are growing oM, 
and who are in general no longer eager for sexual activity, it is 
in most cases complacently borne, and the patients do the best 
they can in their crippled condition. 

Treatment-— Little can l>e done for this affection. Most patients 
desire at least to make an effort to remove tiieir disability. lu 
this spirit mild l>listers, mercurial inunctions, applications of 
iodine, ichthvol ointment, and the use of the constant ciurent 




lay Ik' tried, ami for a time iodide of potassium may be given 

Lntcrnally. Siirli. however, is th** iiiiretiHUity of ultimale favor- 
tl)l<^ nvsults tluit oiu' is not warranted iu causing these patients 
jnconvenieuce or suffering. 


Ill til*' tertiary, ami very exceptionally in tlie secondary, period 
►f syphilis the erectile tissues cjF tlie |X'nis may l>e attacked \]y 
IcK'aHzed gummatous intiltrations. The parts attacked are the 
irjMjra cavernosa and the corpus spongiosiun. The involvement 
if these stnH'tnres hy syphilis is \ery rare, and one part is attacked 
,Im)uI as fnH|Uf'tit!y as the others. 
When the corjxjra cavernosa are attacked usually one of the 
KJies is the seat of the h'sion, and very excej>tionally two are 
|iivolve<i. As a rule, the patient cx|)crien<rs no pain, uiul he hnds 
►y accident a nodule the size of a pea or a nutmeg, or even of 
irger <limensions, in the meshes of the erectile tissue. These 
lodules are sharply defined, of roundish shape, of firm consist- 
tnce, and they niav even reveal a finite dense hardness, Usuallv, 
In this, as we may term it, syphilitic cavernitis the theca of the 
parts is !»ot invoKed, an*) the nodule can Ik* fcU as a deep-seated 
tumor. Kxceptirmally, I have seen such a nodule lulhcreiit to a 
goodly sized phu|ue in the theca, and still more exceptionally I 
have seen a Hat, gunnnatous inliltialiiin into the theca, with pro- 
gressive involvement of tin' iire<>he of th<' cavernous tissue. 

Pea-sized or nutmeg-siKed jiodules of the corpus s[>ongiosutii, 
in most cases involving the whole of the circumference, and 
cxceptioually limited to the up|)er or lower wall^ are also some- 
what rarely seen. These lesions are quite firm, hut not cartil- 
aginous in consistence, and their outline can ustially Ije quite 
sliarply dedned by the fingers. 

All these lesions run an indolent course, and, as a rule, do not 

►flen anti form abscesses. They cause trouble and disquietude 

patients by reason of the curvature of the pci»is wliich they 



produce, which may be upward or downward or to the sides. 
Thus interference with coitus may be produced, and in manj 
instances intromission may l^e rendered impossible. 

Tliese lesions of the corpora cavcnwsa nui an indolent coi 
with little tendency to involution. In some cases they soften 
are i^nuhiHlly al)sorl)ed, ami llu-n distinct loss of tissue is 
In other ca.scs the breuking-dowu of the tumor leads to an absces^ 
which may he slow in healing. In cither of these events loss of 
tissue and curA'ature of the penis result. If the case is seen earIjA 
and vigorous treatment is instituted these noihjlos promptly sho»" 
siffiis of resolution, and they tnay disappear without perceptiUe 
damage to the part. In some cases a slight fibroid thickening 
may Ix' felt. 

Syphilitic nodules of (he corpus sjM»ngiosuni nm a similar coui 
to those of the cavernous Ixxlies. In the event of sjx>ntaneoi 
resolution, of softening, or of abscess formation, there is danger 
of the ffMinaliou of a ilense nUroid stricture of the uretlira. \U 
huwL'viT, the case is seen early, the treatment may promptly cau* 
the absorption of the infihnUion» and little, if any, damage to the 
urethra and spongy l>ody may be left. In some cases slight tltick- 
eninp of tiie urethral wall is produced. 

DiagnoBiB. — In general, the deep-seated nodular form of syphil- 
itic infiltration in the corpora cavernosa is so well markeil thai 
no mistake in diagnosis will cxTur. AVhen there is a plaijue-Iikr 
infiltration of the theca of the cavernous bodies the existence of^J 
fibroid sclerosis may be suspected. In all cases of doubt we ouist^H 
depend on the history and on the results of an ti syphilitic tieat- 
mcnt, which is usually |>ron»ptly curative in the specific afTection 
and powerless in that of .simple origin. '^Tlie nodules of the corpus 
spongiosum, as a rule, readily disappear under treatment. 

Prognosis. — AXlien these syphilitic nodules arc seen early and 
are vigorously treated they will promptly undergo resolution, and 
perhaps leave little damage. In old, neglected cases the integrity 
of the tissues is more or less impaired. 

Treatment. — An active mixeil treatment should be admini?^ 
tered internally, and merc^urial ointment or plaster .-ihould be kept 



>ver the site of the lesion. In some cases hypodermic injections 
[of bichloride of mercury may be tried. 


This condition is snnielimes found in patients whose organ has 
not Imvu injimnl. In sunn* cnses tlie ciii'vatun' is slight and 
J u[>\vanl; in otliers, TnoderaU'ly dtnvnward, while in some there 
^Hs a decided twist of the organ » usually to the left. In none of 
^Bttiese cases is there any material iiiterferiMRV with eoitiis. I have 
BVeen deeided lateral twists in the penis in eunlinru'd jnastnrbators, 
which were probably <iue to the abuse to which tlie organ had 
^^been subjected. 
^^ Various abnormalities of the penis may be aeeompanied by 

I curvature of the organ. The most e(»minon cause of slight curva- 
ture is shortness of the frienum, which, as a rule, is reachiy rcUeved 
Ijy operation. 
In some rare ejises the septum of the eorpora eavernosa forms 
a distinct string or cord just above the cnq>us spongiosum, and it 
draws down the penis towanl the scrotum. 'I'liis condition also 
may he relicveti by operation. 
I Hypi>spa<has, with adhesion to the .scrotum, is a rare condition, 

^fcbnd is usually complieated v^Hth eurvattire of the penis, dur in 
some to the cim!-likc condition of the septum nf the eor(H)ra 
cavernosa. This condition may Ir' much impnivcd or relieve<l by 
I plastic operation, 

^h Gmgenital adhesion of the penis without hy[)ospa<Has is some- 
^^ times found. In this state the penis is either wholly enveloj>ed 
I by the scrotal tissue or it is attached by its inferior surface to the 
^■bag by means of a wcbljed banfi of integument. The glans is 
usually free, and from the meatus the urine dribbles downward. 

kThe penis lK*iug thus (>ound do^^^l, when it lwc<^mes erect it is 
curved df»wnward, and intromission is inipi>sslble. (See F'ig. 86.) 
I Curvature of the penis from shortness of the corpus sptmgiosum 
IS quite ran*. A dense and inelastic condition of the spongy body, 
^ther congenital or the result of gtmorrhieal innajumation, insome 


rare cases leatls to down wani curvature, which cannot l>e thorotij 

relieved hy opTatioii. 

Injury to the corpora cavernosa frt>n» abscess, ^iin 
infiltration, partial or complete fracture, and thrombo! 
result in curvature of tlie penis. In fiitroid sclerosis and ossil 
tion of these structures tlijs defonnity is a permanent st 

Fj.i. K5 

Congenitfil ciirvALiire of ihe iteni« and Bdhe»iun tn scrotum. {After 

Teinponify curvature of the jhmus iimy occur during phii 
and purapliimosis aiul from chordce. 

Within the past twenty years, in which extrtMucly large incluq 
into and ovenh'latation of the urethra have been so extensive 
practised, it hiLs not Ix-en uncommon to see many distressing ca( 
of curvutuR' of the jn-nis, in some of which Inlrumissioi 



iniprjssible, while in others coitus could Ix* indulged in with ji[reat 
jdifficulty and discomfort. In many of these eases the distress of 
the patient wa-s increased I>y the resulting sexual debility, which 
in some cases amounted to inipotcjice. As a rule, curvature of 
le [M^nisj tlie result of intemperate instrunientation, is penuanent 
ffind wluflly refrartory to nvcdical and surgical trcatuuMit. 

Fin. Rt3 

Peiiii puImutiiH: Webbed pei)i.H. (After UupliLy aiid Kvcturi ) 


This ittntlitiiin, ealli'd hy the French |>euis paluu''' fsee Fig. SG), 
lilTers from tlmt tlescrilu'd in the previous seetion (see page 171*) 


in the fact that tlie adherence of the scrotum is confined to the 
lower Iwrder of the penis. In some cases the adhesion of tht 
.scrotum only involves the integument of the f>enis, but in 

others there is stnirtiipul involvement of the corpus spi>ngiosuitt 
in a<,ldition. In some hypospadias complicates the case. 
Ill the latter event the cnrvafure of tlie peni.s is more pronounced 
than wlien simply the serotum iin*^ intepmient are involved. In 
any ease pcrfe<'t <'oilus is imjHJssihle; in most, organic impotencr 
is pnMlij<'e<L In these cases of included |x;nes more or less reUef 
muy jHMiiup.s hr attained by operation liy means of incisions 
iiud (laps. In most eases, liowever, givater or lesi* curvature of 
llir [K'u'is may l>e confidently expected. 


'Phis accident is (juite mK-oiiunon. and generally occurs in cohu"; 
aiwl exceptionally during .sleep. It may l)e complete, in which 
ca-si' the cavernous Ik-hIIcs and s|>ongy l>ody are totally Wroken m i 
incomplete, in which con<lition one cavernous liody or the spongfll 
\itu\\ aloni' may he fractured. " 

'riu- lirsl .symptom is a snihlen .stabbing pain, and then swelling 
of the organ rapirlly su|)crvenes. \Yhen tlie corjxjra eavcmo*a 
are involved the swelling is on the dorsum and sides of tho penis^| 
and, acconiing to the anunint of extraviLsatitm of blood, is lafjC^f 
or snuill. Pain, distention, anil uiiwiehliness are pronuneiii 
symptoms. In some cases the fractured ends have been rouiul, 
and on motion crepitation was pro<hiced. 

A nnmlKT of very inlcn-sting ciLses are n'porte<l in incilical 
litcratun* which sliow several pluLscs *)f this subject. 

V'eazie' reports the case of a young man wlio while liannj; 
eonnectiiMi with a woman, the latter in her excitement drew haik. 
and tlie man's |*enis, thus I>ecoming free, iinpingtNl violently a4;ain^ 
the pelvic bone. He exjierienced a sense of severe injury, 
jjreat pain, and luinurrhage from the urethra. Tlie penis l»egan tll^ 
swell and n'tenlion set in. Veazie fouml a complete separation ol 

■ N«w Url«an» MimI. and Surg. Journal, 1S84-5, xii. p. 321. 




ith navpmosa and spongiosum ^ nne ant! a half inches bark of the 
comna. Urine was drawn by eatheter and external ineisinns were 
made for the eseape oE bloiul, etr. Nevertheless fever oecurred, 
followed by patches of sloughing of the sisie of a half-*lollar or less. 
Recovery followed tlie use of antiseptics and the constant intro- 
duction of a catheter. Six months later there was no return of 
erectile power in the distal portion of the penis. It is said that 
complete functional recovery eventually occurred. The penis had 
been quite normal prior to the time of the injury. 

Carter' re]x>rts tlie case of a man aged twenty-seven years who 
after coitus with his wife fell asleep at once. Upon waking in the 
morning he found the betiding saturated with blood, and blood 
clots were lodged Ix^twcen his legs. .Vfter using cold applications, 
he went to business, but hemorrhage persisted and he sought a 
surgeon at noon. His clothes below the waist were saturated with 
blood, and there were clots in his Ivoots. The propnce was much 
swollen, and blood oovx^d Ihcrcfrotn. Ketniction was diflicult, lint 
the fnvnnm was found to l>e completely ruptured; the artery was 
torn; bleetling occurred from lK>th ends. Ligation was practised, 
followeil eventually by circumcision. 

It may Ix' remernlx'red that rupture of the fra^num is not un- 
common, but it is seldom accompanied by severe hemorrhage. 

Watson* reports the case of a man who had coitus with his 
wife eti vachf while drunk. He had severe pain in the penis, 
followed by hemorrhage and slight oozing for two days. 

It was then found that a swelling had appeared about the 
urethra, and had reached from the |jerineum to one inch from 
the meatus. Micturition was progressively <litiicult, and retention 
became t*omplete. r'atheterizati^jn seemed to show that a flap 
of niptun'd nmcosa caused the nn^thral ol>stniction. There 
was a purulent discharge. A rt'^tention catlieter was u.sed for 
twenty-six days. When the patient removed it, as a result, reten- 
tion occurred, witlk evidences of septic infection. External 
uretlimtorny w»is jmrformed, with the evacuation of fetid pus. 

' Lanoet, 1893, ii. p. 9*28. 

■ Boston Med. and Surg. Journal, 18d5, No. 20, p. 463. 


Riipturp of the iiivthni was rendered visible two inches Ix-liind the 
rnf^atiis, Hie wounds healed, hut left a traumatic stricture. 

A casr is re|W)r1e(J liy Iliii^juier* of a man aged thirty-sev<*n 
years who inid Uh^ii hlistere*! over t hi* mastoid for an ear atfci-tion. 
This Mister appeared to l>e the cause of priapism, and tlie patient 
wjus warned utruinst eoitns. lie disolieyed orders, and on uttenipl- 
in^ coitus with liis wife mmle a false movement in his excitement, 
sinking the perineum or thijjh. As a result violent pain followeil: 
the penis assumed a reddish-violet hue, and the patient was unaUf* 
lo iirinat*'. \n\\\ alti-tripts at eiiflu'terizatiou wen» fnllowtnl hv 

In the hospital ttie penis was found swollen and hiack, (left>nnwl 
n\\\\ extri'tnely soft, the i>repnee was ledenuitous, and the s<TOtum 
an*l perineum showed signs of swelling and exlravivsation. Ilnguirr 
»-inilii not introduce a catheter. 'I'he diaji^nosis was rupture of 
l!ie urethra. A little urine escaped spontaneously during ihp 
evrninp. <F;inprrnr dcvelope<l in situ and after ten or eleven ilay> 
death occurriMl, evidently caused l>y urinary infection. The lesion 
was found to have Ijeen complete rupture of the corpus spongio- 
HUTU, with apparent loss of substance in the c4>rpora cavernosa. 

JiornctV case was that of a man. aged foi-ty-tw<i years, wlwr* 
while nuiking vain attempts to effect penetration in ct>itus fell a 
nharp pain. Ejaculation, however, occurre^l and was free fnjm 
liliMiil, Next day the penis was swollen, and the pn'piic^^ wa.*- 
«wolh-n and infiltrated with hlooih 'I'hen^ wjls no pain or obstnie- 
tlnn to iirituiflou. Some eight days later he noticed an induration 
til Ihr ri^;lit ami towanl the middle of tlie |H*nis. Fiftet?n days after 
ihe accident he essayed coitus, hut fimtui this was impossible, jw 
(he orKim when erect lK'<'a!ne twisted, almost forming a right angle. 

Ihxiri examination, ertclion was found limited to the left corpii 
envernoMum and lower part of the right. When flaccid, u sms 
Ihduradon was felt towanl the nwt of the right corpus. 

Ill all prohahility in thi.s ca-ne there was bUKxl efTusion ii 
Ihn tliraiMm of the eorpiis .s[xmgiosum and one of the rawrni 

' null. H«c. Cliirurg. de Paris 1862-3, iii. y. 614. 




Roseuherger* reports a case in whicli severe urinary infiltra- 
tion occurred. A healthy man, aged twenty-six years, seven weeks 
married, wliilc attempting coitus with his wife struck his jwnis 
against the symphysis pul>is with great violence. The organ Ijent 
nt tlie n>ot, but without pain. Swelling l>egan and increased, so 
that in four or five ihiys there was urinary i-etention. Swelliug 
extended to the scM>tuni, thigh^» etc., and l>y the tenth day a catheter 
could no longer Ik* introthiced. Urinary infiltration was relieved 
h\ scrriltil incjsinns. (_iangn»ne of the scrotnin uiul urinary infec- 
tion developed. Pn^fuse su]>|ninition of gangn^nous areas tfccunvd, 
which extended over most of the thighs in front and over the abdo- 
men to the navel. The case ended in sponluneoiis n*eovery, hut 
with loss of most of the .scrotum (testicles exposed), and of *S em. 
of the un*thra. I^osses were repaired f)Y plastic ojM^ration. Relative 
recovery. The patient tlid not lose power of erection. 

Menschel* rf']Mn1s a ease of severt* urinary infiltration fnllnwed 
by death. A man, aged thirty-seven years, was accustomed^ after 
prolonged abstinence, to indulge violently in coitus. On one 
such occasion be missed the introitus vaginsc, and his penis, 
rigidly en*ct, impinged against the puhie arch, l>ending suddenly 
upon itself jit \\\v posterior piirtioii. amidst severe pain. Hlood 
escaped from tlie urethra. iTination soon Ix'came <liiii<-ult, as 
the penis and smitum brgau to swell. No relief was atrorded 
by treatment, and by the next ilay abundant evidence of urinary 
infiltrati<»n and infe<*tion with In-ginuing gangrene of the genitals 
was observed. His condition was further eomplicateil by erysipelas 
and peritonitis. Tie patient «Herl about five days after irtjury. 

(iangrene in thi-s ease ap|H'ars to have lx*en prt'cipitateil by 
the rapid swelling of the parts, which soon attained an enormous 

Fracture of the corpus spongiostim may occur as the result of 
a filow on the p'nls when curved in chortlee; it more commoidy» 
however, is tlie result of violent efforts in coitus, sometimes in the 
liridal 1m**!, but g<*nerally as an incident iti a drunken debauch. 

' Aroh. fiir klin. ('hirtirKie, I8Kr>, ixxii. p. s:h. 

' ZeitAt^hr. fiir Med., Cliirurgle iind GebMrlshuire, 1855, ix. |i. 305. 


In the case of fracture of the spongy body the parts rapidly sweB, 
owing to the escape of blood, and, unless prevented by the prompt 
use of the catheter, extravasation of urine occurs, in which even 
the penis is greatly swollen from the base to the glans. In cases 
of urethral rupture retention of urine is a frequent and trouble- 
some symptom. The retention may occur as the result of swelling 
and the resulting pressure on the canal, or it may be due to the 
valve-like action of the toni mucous membrane. 

'Die local disturbance and the consecutive symptonis vary in 
different cases. In all there is more or less hemorrhage, and 
when the urethra is involved there may be, in addition, as just 
stated, extravasation of urine. Fever is usually present in a pro- 
nounced form, and in some cases pyeemia, even so severe as to 
cause death, supervenes. As local effects, abscess, destructive 
ulceration of the tissues, and gangrene may occur, in which events 
urinary or uretliral fistuhe may Ik? left. 

Fracture of the penis is observed in young and old subjects. In 
atlvanced life the sheath of the corpt>ra cavernosa is sometimes 
moR? condensed and hritth* than nonnal, and it is more liable to 
frac^ture. I saw such a case in tlie person of a very old man, who, 
(hiring sleep, rolled over on a very erect penis and broke the 
c(>r}H)rii cavernosa as sharply its if they liad been cut with a ktiife. 

The prognosis of fractun* of the penis varies according to the 
extent un<l seat of tlie injury. ^Vhen the cavernous lK>dies, one 
or both, are fractured the parts may heal and erections may 
thereafter Vh* perfect, or erection may occur only in the proximal 
part of the penis, while the distal part remains flaccid. 

The outcome in ciu^cs of ru])tnre of the corpus sjwngiosum is 
usually a traumatic stricture* *»f rapid growth and much density. 

Treatment. — In mild <'ases n'st in the recuml>ent position and 
the application of cooling lotions or ice-water may be all that is 
necessary, except the introduction of a soft catheter to empty the 
bladder. In the seven; ordtT of cases, when the extravasation of 
blood is extensive, it may Iw necessary to make a free incision 
and then perform external uii'throtoiny and establish bladder 
drainage. Ulceration and gangrene of the parts should be treated 


on the regular surgical lines. All collection of pus should be 
incised and the parts well irrigated and antiseptically dressed. 

Rupture of the corpus spongiosum usually requires the regular 
passage of a catheter, and perhaps its retention for a longer or 
shorter period. Free incisions should be made when extravasa- 
tions of urine have occurred, and when blood extravasation is 
extensive, particularly when it exerts injurious pressure. As the 
swelling in these cases is usually so great that the urethra cannot 
be reached and promptly stitched, it is necessary to await events, 
and when the stricture is fonning to endeavor to restore the urethral 
calibre by the introduction of sounds, and, in the failure of this 
effort, to resort to internal urethrotomy. 



It Is only within the past twenty-five yean that the subject of 
sterility in men has been carefully studied and that clear ideis 
liave been entertained concerning it. In earlier years unfruitful 
marriages were generally, by common consent, ascribed to the 
fault of the wife, who in many instances was enei]getica!ly and 
needlessly submitted to much gynecological treatment, discomfort, 
and trouble. In those earlier days, if a man seemed well devel- 
oped sexually, if he was able to copulate properiyj and if he had 
what seemed to he normal ejaculations, he was deemed potent, and 
if he was married and without issue, the fault was not laid at his 
door. But with the advance in medical science, the condition of 
the semen and of the seminal tracts has been carefully studied, 
with the result of proving that in many cases, although to the 
unaided eye this secretion seemed normal, yet by the aid of the 
miorosco|)e it wjis found to contain unfertile spermatozoa or no 
spermatoza at all, although all the other constituents of the secre- 
tion miglit be present. As a net result of the observations of many 
investigators, it may be stato<l, in general, that in cases of unfruit- 
ful marriages the husband is the sterile partner about one time in 

Two conditions have IxH^n found to be the cause of sterility in 
the male. The first is called azodspennatism, in which, although 
the man can pn)perly perform the st\xual act, his semen is unfer- 
tile, for the reasons: (1) that it is lacking in spermatoasoa; (2) that 
these highly vitalized IkwHcs are of imperfect development; or 
(3) that they cannot n^ach the sexual tnwt. When the cause of 
this condition is investigated it is found to reside in some struc- 
tural change in the testes and tiie epididymes, by which the secre- 
tory function of these glands is either destroyed, or temporarily 


impaired, or that an impediment is offered to the escape of the 
spermatozoa, either in the epididymes or in some part of the vasa 

The second condition producing sterility in the male is called 
aspermatism, in which, although the power of normal coitus exists, 
there is no ejaculation of semen, or the quantity of semen is de- 
ficient, or its emission is imperfect or impeded. Aspermatism is 
caused by a blocking up of the sexual tract in some part between 
the seminal vesicles and the ampullae and the meatus urinarius or 
the preputial orifice. 



The term a?Atdspcrmatism is applied to that comlition in which 
a maij retains the power of eojuilatioii. while in his ejacula- 
tions sperTnatozf>a arc either wholly absent or present in small 
(jnantity, or they are so poorly develojnil, t)r functionally inactivT, 
or unfertile, that he is nf necessity sterile. Azoosponuatous ro^a 
may, therefore, possess the potentia rceundi and lack the potentici 
ffcnerandi. In a'/*oospormatisni the ahsence of sperinatowia is dur 
(o some abnonnalily of the testes or to some blocking up of the 
vasa deferentia as far up as their ampullation. AzoosjxTinatLsnip 
thert^fore, differs 4k'ri4ie4lly frf>m aspermatism, in which condition 
the obstructive chanp;»*s take place in the seminal tract lx*twrm 
till' seminal vesicles ami deferciilial ampnllatlous and the meatus 

Azoos|H*nmi(ism results fnun a variety i>f aliiiornud and morbid 
condititui.s nf the testes, hi tJio fi'ont rank of abuonnal states are 
the various forms of testicular luisplaetMuent and of al»sencc of 
the testes or some part of their exci*ptory canals, Gonorrhmd 
inflainmation plays an in][>ortant part in this form of di.sonlcr hv 
the stenosiug an<l destnuHivc lesions which it pmduces in ihr 
epiflidymes, testes, and vasa deferentia. True azoospermatism is 
induced when the organs of each sirle art* involved; but in the 
event of the trouble Iwlng unilateral it then constitutes a menace 
to the man's future^ virility, since he has but one testis left, and 
the fiuiction of this one may 1k' and is very frctjuently destroyed. 

Syphilis is very often an im|Mirtant factor in this condition, since 
it may attack any or all portions of the testis or cord. i 

Chronic testicular inflammation, due to some lesion of the gen* 
ital tract or to some infective process^ is very often the underhing 
cause of a man's sterility, which may also result from orchitis due 






to muscular effort or strangulation of tlie cord and gangrene of 
the testis. 

The functional activity of the testes may Iv so in pal re J, or 
even destroyed, by the existence of hydrocele or hn^matocele that 
a man is temporarily or permanently azoospermutous. 

Tnb»Tcnlosis of the testis is a not uiiconinion cause of dcstnic- 
tion of the organ, while inulcr various cireutustances and in dif- 
ferent conditions atrophy of these glands may result in tlie loss 
of their function. Tuberculosis of the prostate aud of the seminal 
vesicles and arapiiUations may so alter or pois(jn the seca'tions of 
these organs that the spermatozoa are killed. 

\Vhile it is true that many of the conditions thus outlined may 
attack but one testis, in which event a man is not aKoanpermatous, 
there is ahvays a h'ability that the second organ may become in- 
volved, either by the original morbid process or by one of different 
nature and origin, lliese considerations have convinced me that 
the subject of uzofispermatism can Ix'st l>e satisfactorily presented 
by a dear and i-onciso description of all abnormal states and 
morbid conditions which may Icail to the impairment or destruction 
of the functions of the testes and of their canals. 



It is necessary to recall to mind that in cases of abnormal |M»si- 
tion of the testis, kiu^wii under the general term ectopia, the organ 
is either retained in the abilominal ca\nty or it becomes misplaced 
in its descent. This conihtiou is also called cr}*ptorchism, espe- 
cially when both testicles are misplaced, and tfic bearers of this 
deformity are called cryptorchids. 

Thus we find the testes in abdominal ectopia either near the 
posterior wall of the abdomen or in one of the iliac fossa*. In 
cases of imperfect descent it may l>e retained: (1) in the inguinal 
canal; (2) in the fold between the scrotum and the thigh; or (3) it 
may pass under Poupart's ligament through the crura! ring and 
become lodged in the thigh; or (4) it may down and Ix'cnme 
fixed in the perineum in fn'jnt uiul to the sifle of the anus. 


*riit\sc inis])Ia('cd testes, all of which are usually ahiioniuillv 
^ihmII, Heeiii to W ratlKT pn»ne to uiwlrri?*) ninlt^iaiit <leg«'neraru 

Mrlopia testis lias l»een l>y siHue authors e(»nsiil«'n'<l t<j l>t' 
iin(linil>te<l eatise of sterility, assuming that the function of 
other or free testis has lieen <lainaj:^'il. Curling^ reports sevei 
eiii«eH ill wliifh no sperniatozoa were foiiiul in the somen a1 
very cun'rnl iiii^niseopie exaniinatioti. The facts iif tlie ease 
however, as stated hy Moncnl am! Terrillon^ and by !Mi>n«Ml 
Ai'tliMinl.^ Ill early years the speniiiitoifeiietie |Kiwer (»f the 
IhIIMmI or iois|jUw*ed or^an is uiiin)]>aired, hut jus tiuK- g»U's \m 
lUmirit either decay hy fatty degeneration (»r by fil>nn<l infiltrati 
and ihe function of the gland is then <lestroyed. 

10 tit[»iji <'f the testis, therefore, niiiy lead to such fli^orgimi] 
Hon of iIh' gland that spermatozoa are no longer tlevel<i|H*d in 
If In Hill h a case the other testis is in any way disea^cnl or 
Nllityed the Ihiliyt is sterile. This point is well hrought ont hr 
H late re[H>rteil hy (iodard/ in which a man having un mule* 
«i>|tnd) -d Icslis hail a child liy a mistress, an<i who, after an ait^k 
llf n|tididyino-orchi(is on the o[)jw>site side, was twice marne<] and 
hiol ito |iri»gi'ny. ^hmy years after this man\s semen waa fou 
(ii |h> dc'tdtute of s|K']inato/oa. 

Ill (lit* nire eases of congenital absence of the testes, orof pan 
ll( IIh' VM»a dcfcr<'ntia. the subject is azo(is|H'rinatous. 

TUiiinoi)^* This consists in cutting dt»wn on the inispl] 
ll'jih* if iurr:^.iil>le,and in anchoring it by sutures in the Mrruti 

t TlilKf* (li*i MitlHilimdu Testiculet etc., Fiir^ I88{», |i. 45etsrq. 

• rmilOlindtiM <*» rKOitle lies Alterntions dii Twiiieiile Ectopiqiie, elc 

* I'.iittlKN *iii In MiHiorcliidie et In CrxplureUidie otieii rhotnme. M^m. de 





Oonoirhoeal Epididymitis. 

As a result of the gonorrha^al process in some cases certain 
Structural changes take place, principally in the epididymis, and 
Iso in the vas deferens^ which either temporarily or ]>ernianently 
prevent the escape of spermatozoa from the testis. In these cases 
sterility may result if both epididymcs are attacked, or if the 
afTection is unilateral and the other one is otherwise damage<l. 

The most important post-mortem studies and microscopic 
examinations into the testicular stnictures anil into the condition 
of the semen in cases [ire^senting these lesions have l>een made by 
Gosselin,* li^gois^^ and Terrillon/ and their essays furnish a basis 
for the study of this subject. 

Gonorriueal inllamiuation usually attacks the lower part or tail 
of the epididymis or globus minor, and less commonly the head 
or globus major, and gives rise to an indurated mass which may 
obliterate the efferent canal, which at this part of the organ con- 
sists of one very mncli convoluted tube. When this condition is 
produced no spermatozoa can pass into the vas deferens so long as 
it lasts. If the head of the epididymis is attacked with indurating 
hyperplasia there is a chance that some of the numerous vasa 
efferentia may not be involved, in which event the escape of sper- 
matozoa may not wholly be* prevented. For these reasons, there- 
fore, induration of the tail of the epididymis is a much more 
serious matter than implication of its head. 

In cases where obliteration of the spermatic canal has occurred, 
even when Ixith sides are attacked, no perceptible change seems 
to take place in the testes. 

* XouTelle* KtudeH sur I'obliteration des Voies Spermntlques et sur la Sterility 
coDeecutivc A I'^pididymite bil&temle. Arch. G^n. de M^., September, 1853. 

' Influence des Maladies du Tesliciile el de IVpididyme but la compoellion da 
Sperme. Annales de Dermat. el de Syphiligr., 1869, p. 410 et ueq. 

* Des alteraliona du Sperme dans iVpidid/mite blennorrhagique. Ibid., 2d 
Seriee, Tome i. p. 439 et seq. 



In cast\s where lx>th cpididymes arc attacked patients seem to be 
sexually miaffecteti, l)eing capable of coitus and having complete 
erections and ejaculations. The semen, however, is destitute of 
sjx*nnatozoa, and, therefore, is unfertile. 

In the early stagt* of this form of testicular trouble the semen 
is less viscid than normally, and it has a yellowish or yellowish- 
green tint, due to the admixture of pus cells and granular globules, 
the origin of which is not known. 

Tcrrillon ohst^rved this yellow tint of the semen in a case of 
unilateral in<Jurati(>ii of the sjHTmatic canal, and when this fluid 
was examined under the micn>scope spermatozoa were seen vigor- 
ously wriggling around among pus cells. 

As the iiKlurution in hihiteral cases grows ohler and necessarily 
iH'comcs more stenosing the pus cells gradually disappear, Iwt 
the sjHTmato7x>a do not reappear. ITic man, therefore, though 
capable of coitus, is sterile. When, however, one testicle has 
renuiincd unaffected the In^anT jM)sscsses the power of fecunda- 

It has Ix'cn cluinied by some authors that g«)norrhcral, tuber- 
culous, and otl\(T morbid affe<-tions of one testicle or cp!di(h*nii> 
may in sonic occuh way so afVcct its fellow that it also bectunes 
incapable of |)r(>during spcrinatozoa, aiul that as a result the man 
becomes sterile. There is, however, no scientific evidence to sup 
])<»rt tin's contention, wliieli |>rolmbiy is the *mtcome of faulty 
elinieal investigatiftn and dednetion. 

l,ieg<>is has verv clearly shown by his studies that in pn)jx)rlion 
as the induration <>f the jjjlobus minor softens an<l tlisapjH'ars 
spermatozDa show tlu-niselves in the s^'uien in increasing numl»er 
until tiu' normal condition of that Ihiid is reached, lliis author, 
amt>ng three hnndnMl <'ms4's of epididymitis, <hd not observe a 
single east^ of gemiine atrophy of the t<'stis, although he olxser\'ed 
a slight diminution in vohnne in six or st*ven instances. In only 
eight eases did he note loss of virih' power, while in several it was 
notably in<reased. 

'riie eonelusions. therefore, warranted by tlu* foregoing consid- 
erations arc as follows: 1. In all cases of unilateral epididymitis 



[ireatiiiHnt shouki not cease with the decline of the acute sttige, but 
'tive measures shoiihi W taken to cause the absorptiou of the 

induration. 2. When l>ihileral ejjididymitis exists, even if of pro- 

[longe<i duration, energetic and loiig-<*nntitujed tix-atinent should 
adopted, with the hope of dissipating the Induration. 3. In 

[cases of recent involvement much hope miiy Ik* cntertaine<l of 
rrfect cure. 

My experience has convinced me that the existence of chronic 
onorrhccal epidid>Tnitis, unilateral or l^iluteral, even with imfer- 

tile senirn, may in iniiny instances Iw so rnucb rrlievct! that virility 

IIS restored to the man. 
Luckily for the human race, the tendency in most cases of gon- 
orrlural epiilidyinitis is towanl resolution, at any rate, to the 
degree of reudcriii^ the spcnuatic canal patulous. 
Post-mortem investigations in cases of gonorrha^al induration 
of tlie epididymis have confirmed the facts brought out by clinical 
observation. Hardy endeavore<l to force an injection Ruid through 
the tail of an indurated epididymis, and faileil.^ In like manner 
Delaporte* was unsuccessful in a case of epididymitis which had 
only existed five weeks. 

Treatment. — In the <leclining and even in the chronic stage of 
epididymitis with more or less induration it is well to keep up 
vigorous measures to cause absorption. When (he parts are still 
tender it is well to apply continuously an ointment composed as 


R— Pulr. opii, 

^H PuIt. amyti hA ^ss. 

^H Ext. Mladonnie 3ij. 

Ext. l>elladonni 
Ung. tJ\. roMB 



In rather more advanced cases ichlhyol ointment. 5ij-Sj of 
cold cream, may be«l. Whatever application is employed or 
whatever measures are adopted it is always well to envelope the 
scrotum with absorbent cotton anil over this place a layer of 

' i-^tudes Kur rinflmnoiBtion du tetttcule et principalemcnt sar I'^pididymita 
et rnrchite bleiiiiorrhagiqiie. Th^t>c de Pirb), ISHO, p. 15. 

' De I'orchite aigue biennorrhagicjue. Th^ae da Parit, 186ti, p. 12. 


giitta-pcroha tissue. The parts are then covered with a nirfK 
fitting suspensory bandage- Under no circumstances should 
the testicle he stra[)ppd, since by that pnwediire compression of 
the iesticuhir canuls and even other alterations may he producfd. 
Gentle and persistent massage is very lieneficial. In some cases 
the frequent applications of a scjhition of nitrate of silver, 5j or 5ij 
to water Sj, may be nsefl every few days. The guarded an^I 
repeated use of the Paquelin cautery over the tliickencd cpi- 
didynies may be of decided V>encfit; it may also be alternated with 
the application of the precedinfj measures. It is alwavs well lii 
bear in mind the use of iodide of lead ointment and in severe and 
obstinate cases the application of strong mercurial ointment mar 
be employed over a considerable space of time. Strong tincture 
of icKline may also be used. In very obstinate cases it mav U 
well to mirainister iodide of potassium in good-sized doses. It L* 
also a good practice to fully test the efficacy of a prolonged courw 
with the mixed treatment even if there is no history of svphiliiif 

Treatment of Sterility due to Obstruction in the Epididymis froo 
Gonorrhoea. — in the event of the failurt» of tlie treatment alre&dv 
given it may be necessary to resort to radical measures. r>r. 
Edward Martin' has used successfully in one case an o[>eratioa 
devised by him of which he gives the following details, which br 
reason of their novelty I deem worthy of full (juutation. \\t 
says: "I demonstrated in dogs that after cutting the \hs a short 
distance from its origin in the cpidid\Tnis and forming an anasto- 
mosis of this divided vas end with the head of the epidid^mi^. 
subsef|uent ejaculations of the dog would Ik* found to contain » 
normal numlHT t>f motile and appan^ntly healthy spermatozos. 
Some animals, under observation for months, apparently showed 
that there was no tendency toward closure of this arti6citl 

*'A morphological study of the human s^>crmatozoid taken 
from the rete testis, the upper part of the epididymis, and ibc 

* New York M«dical Jountal, October 10, 1903. 



as seemed to show that these spermatozoa underwent a devel- 

pmenfal change in their progress through the epididymis, sug- 
sting tliut even though this method of anastomosis might be 

ppUcabk; to men sterile because of obliteration of the epididjinis 
it <lid not necessarily follow that the spermatozoa thus short- 

ircuited would be necessarily fertile, 

Tlie method of pro\'ing wliether or not such spermatozoids 
■would be fertile lay in a clinical application of the knowledge 
ined by experimental research; therefore we operated Deccml^er 
2» UK)1, on a man whose childless marriage apparently was 
absolutely dependent upon azoospermatism consequent upon a 
double obliterating epididymitis. He was most anxious for chil- 
dren, as wa.H also his wife. She had Wvw subjeeti'd to thlatation 
and curettement before it was discoveretl that her husband was 
sterile. In the fall of 1897 he suffered from gleet, having had two 
attacks of acute urethritis, one twelve years antt one four years 
before. Both attacki* were severe. The first was couiplicate<i by 
rheumatism, the second by bilateral epididymitis. There was a 
large stricture in tlie bulbous urethra, with ulceration behind it. 
There was also some follicular prostatitis. 

" Gradual dilatation, irrigation, and massage cured the gleet. 
In the spring of 1808 it was discovered that the semen contained 
no spermatozoa. There was no nodulation of the tails of the 
epididymes. The right testis was the larger of the two. The 
patient was directed to wear a sweating suspensory bandage, 
and was ordered testicular massage. A prolonged course of 
internal medication supposed to Ix* helpful in causing the absorp- 
tion of inHammatory fibn>i<ls material proved unavaihng. 

"Repeated examinations failed to show the presence of sper- 
matozoids until March, 1SK)1, when, on careful search, two or 
three ill-formeil oru^s vvertr found in each ct»ver-ghus.s prepara- 
tion. In the fall of HWl a most thumngh st^arch failed (o show 
the preseuee of a single spermatozoid. On December 10, 1901, 
examination of specimens about six hours old was made, which 
showed the presence of a few wliite blood cells ami amyloid 
corpuscles of great variety of shapes. As the cellular elements 


were so few and the accurate detennination of the presence or 
absence of the spermatozoids was most important the material vu 
diluted with thirteen times its volume of an 0,8 per cent, soludon 
of sodium chlomle and was then centrifuged. Spiermatozoa veif 
not found. 

" The patient was etherized on the evening of December 24th. 
The vas of the left side was freed at about the level of the top of 
the testis, and, by means of a sharp-pointed pair of scissors, a 
slender bistoury, and a grooved director, such as are used bv 
ophthalmologists, its lumen was opened by a longitudinal cut 
a (juarter of an inch long. The epididymis was then approadied 
from the outer side and its entire length was exposed. An inci- 
sion into the tail failc<l to show the presence of a railky fluid, 
though cover-glass preparations subsequently examined demon- 
strated a few spermatozoids in the expressed fluid. A portion 
of the head was then picked up in a toothed forceps and excised. 
A few minute, whitisli drops at once appeared on the resulting 
cut surface, nuule up in the main of spermatozoids, some of 
which, when examined fifteen minutes later, were motile. Into 
the woun*! of the epididymis the vas was implanted by means of 
fine silver wire ciirricd on small face needles from the outer sur- 
face of the vas into its lumen, then from the cut surface of the 
opening ma<le into the epi(li*lymis through its Rbrous tunic. A 
suture was pljieed ut either en<l of the vas incision, and the latter 
was held open by two other sutures, one on either side, llie 
skin was closed by <-jitgut. The dressing slipped the next day, 
ex|K>sing the wonml, wliich Ix-eanu' infected and suppurated 

" Semen twelve hours old sent for examination Januarv 11th 
showe<i the presence of spernuitozoids not so plentiful as usual, 
but very actively motile. A diil'er<Mitial count showed that 50 
|K»r cent, of the <*ells present had either a much enlarged middle 
piece or one showing a protuberance somewhere along it. In 
nearly all of thcni were the nu<ldle pieces more marked than is 
usually observed, this point <*()uung out no matter which method 
of staining w;us used. These cells corresponded in type to those 



onservc*l in tho epididymis of the liiiman testis roinoveil after 
death mul suhjet-ted to jin exuTuiiiation. 

*' On Jannury *.hli this patient resumed marital relations, and 
on Octotjer 17, two hundred tind eighty-one days later, his wife 
was delivered f>f a iiomial ^irl hahy, cxhihititi^ an almost luilierous 
resemblance to her father. This completes the demonstration as 
to the value of an anastomosis l>etween the vas and the e]3ididymis 
in case of sterility due to obliterating lesions in the tail of the 
i*pidid\Tnis, apparently pro\nnj^ that even thon^h certain forma- 
tive ehan)^\s do occur in tfie sperruatozoids during their course 
through the epidid>'mis, tliese changes are not crippling in so far 
as the procreative power of the spermatoz4>a is coacemed." 

It is well to eniphasi'/e tlie fact that this operation, having 
only been successfully perforinixl once, is really in its early 
pxj>erimental stage. In this connection it is well to rememl>er 
that TosniT and Cohen* comment on the faiUm* of most 
naHhods for dt'terniiniri|f tlie pn^scnce of living sjHTUUilozoa 
where more or less obliterali<ni of the seminal pa.ssages has taken 
place as u i^esult of gonorrhoea. Furbringer has pn>pos*'d an 
operative measure by whieh the testicle is laid open and Its con- 
tentJi examined. Tliis is rather im extreme procedure, and in 
place of this the writers have employcil puncture of the testicle 
by means of a hypodmnic syringe. The advantages of sucli a 
procedui'e art* painlessness, no necessity for an amesthetic, or 
confinement to U'd. \Mien the material thus secured is found 
to be free from spermatozoa, and consists of fatty cells and <le- 
tritus. it is useless to attempt anvthing more. The ((uestion is 
what to do when spemiutozoa are foun<L In six cases tlie authors 
have implanted the cut end of the vas deferens dirtx'tly into the 
opened cannis 4>f the head of the epididymis, nfter the pro- 
cewlure of Martin, or have made an anastomosis by appn^xima- 
ting and carefully suturing tlie e^lges of openings made in the 
wall of the vas and the epiilidyniis. Thus far, however, no 
positive results have Ih'cii ol>tained. 

' Deiitwh. med. Wochenschrifl, July 14, 1904. 


QonorrhoBal Orchitis. 

Though its occurrence is denied by some authors, there can U 
no doubt that in some cases of gonorrhoea! epididymitis there L« 
true inflammation of the testis proper. In the majority of c»sei. 
however, of so-called gonorrhoea! epididyiuo-orchitis there is 
simply a hypersemic and quasi-inflammatory condition analogous A 
to the congestion of the prostate, which niaj occur in acute gon-T 
orrhccal posterior urethritis. 

As a rule, testicular involvement in gonorrhcea! epididymitis 
quicldy disappears, and the gland seems [lorma! upon palpation. 

In some cases, however, chronic parenchymatous orchitis is 
fleveloped, which may lead to the disorganization of the glaud. 
The essentia! change is cell-proliferation into tlie connective tissue 
amuiid tlie seminal tubules, as a result of which the developraent 
of spermatozoa ceases and the tubules become filled with granular 
matter and cliolesterin crystals. VMiile at first the gland is more 
or less increased in size, as the degenerative changes grow old, 
condensation ami utrt>phy occur even to the extent of destroying 
all evidence of glandular structure and transforming the org&o 
into a mass of dense fibrous tissue. I have seen two vi'eli-marked 
examples of atrophy of the testis from acute gonorrhoea, and Rona' 
has published the historj' of a very interesting case. 


Gononhceal Funiculitls, or Deferentitis. 

In some cases the gonorrhoea! process does not reacli the epidid 
ymis, but centres it^^lf in a segment of the vas deferens, usually 
near the testis, or at any part up to the external abdominal ring. 
In such cases a goodly sized round or oval tumor is formed, which 
is the seat of pain. After the inflammation subsides a hard nodule 
is left, which may block up the ealilire tif the canal, and if the 
resulting stenosis is permnnent s|M'rmat()Zou cannot pass from the 
testis. TOien tliis condition exists in the course of both vasa 
deferentia the bearer is sterile. Such cases, however, are very rare 



^ Monauhefte fur pnik. Dermat, 18$6, Band v. pp. 300 et seq. 



The vas deferens may be attacked within the pelvis, and more 
or less damage to its lumen may follow. Instances of this affec- 
tion are very un(!ommon. 

Treatment. — Active efforts should be made to cause the absorp- 
tion of the cellular infiltration, wherever it may be. In some cases 
repeated small blisters with eantliaridal collodion art* Ixineficial. 
Applications of mercurial ointment, of iodine ointment, of iodide 
of lead ointment (one drachm to one oance of cerate), or of ichthyol 
ointment (one drachm to two drachms of cerate) may be tried, 
and their use should be persisted in. These preparations may 
be spread on layers of absorbent cotton, which are placed over 
the scrotum, over which is one thickness of gutta-percha tissue, 
and the whole held up snugly by a suspensory bandage. 

Iodide of posassium may be given internally. 

In every case the condition of the urethra should be ascertained, 
and if chronic inflammation be present it should be thoroughly 


Syphilitic Epididymitis. 

Syphilis may attack the epididymis, both in its early and late 
stages. In the early months of the infection it is not uncommon 
to find the globus major, and less frequently the globus minor, of 
the testis to Ix' swollen, hard, and moderately painful, especially 
when compressed. This condition also occurs at any time during 
the first and second years of the disease. 

The size of the tumor, which has a smooth surface and firm 
consistency, varies between that of a i>ca and a hickory-nut. Un- 
influenced by treatment, this indurated nodule will remain in an 
indolent condition for a long period, and will ultimately produce 
disorganization of the head of the epididymis. But if local and 
general treatment is promptly adopted, resolution soon follows, 
and the integrity of the parts restored. 


In some cases both epididymes are attacked, either simultaafl 
ously, or, as more commonly occurs, after a longer or slmrtrr 

It sometimes happens that an epulidymis previously indnral 
by gonorrhanil intlanimation lieomrs attacked by syphilis, 
which event resolution may Ik* very slo\v» and in the end soi 
corulensation of tissue may reniain. 

ITie diagnostic poin( that ^>norrhcra attacks the tail of 
epididymis, and tliat syphilis is more prone to invade the head. 
may Im* oUserved in the greater nuuil)er of eases, ^ 

In late secondary and in tertiary syphilis the epidid\-mis q| 
sometimes jittueked in a slow, painless way by n chronic infiUre- 
tive process, winch l4'juls (o a snuHith r)r nt»(hilar bi)nx>u.s expan- 
sion of the aireetcd sef^ment, nsiiiilly the heail of the appendajje.^ 

ITiis late form of syphilitic epididymitis is usually iinilateraljH 
hut it may Ik- bilateral. Tertiary sy]>hilitic inflaniniution mav 
attack ati epididymis the s<*at of <,'onorrlneal induration, imd then 
stenosis of the >|H'nnati<' eaual is to l>e feannl, I^tt- .svphililir 
epididymitis does not yield to treatment us promptly a.s the earlv 
fttnn does; then»fore. it is important that me<lieation slionhl be | 
commenced as early as possible, ami pusheil with care and vi^r. 

In very rare cases syphilitic notlules form in the vas defefvas, 
in the scrotum, and they may, if left alone, lead to stenosis of ihil 

When occlusion of one spermatic canal is produced by llie f 
^ling processes a man's virility is not destroyed, pro^nded tli 
other testis is eomjM'tent; hut if ]K'rTnuijrnt stenosis of lx>th sper- 
matic canals is developed, steriUly inevitably follows. In these 
cases much ho|)e can Ix' entertained, hence treatment should not 
lie precipitately abandoned. 

Sypbihtic Orchitis. 

I^te in the secondary and during the tertiary period the bod] 
of the testis may Ix'fMime attackeil by a slow, painless, and in- 
sitlious fibroid or jjinnnuitous infiltration. The <»r^an biHM)mes 
uniformly swollen, hard, lirm, less scMisitivc than nonnul, amtj 


usually smooth on its urface. In some cases large nodular masses 
may be found in the organ as a result of gummatous infiltration. 
As a niif, the testis at first retains its nonniil .shape, hut as 
time goes on it enlarges very eonsiclcraljly, even to the size of a 
hig fist, and l)eromes of a deeiilodly pear-shape, or ovoid or glob- 
ular, r.sually one testis, Init n[)l infn'([uently l>oth glantls, are 

involved. (See Fig. 87.) 

Fio. 87 


Double RyphiliLic orchitis, or saroocele. 

This form of nreliitis, or sareoeele, a.s it is railed, nms a ehronic, 
unewntfu! rour.s4' if left to itself; but it will yi<'ld iti a surprising 
manner if treatment is instituted early. Hu' danger in tlu' affee- 
tion is thai the seminal lobules will Lh- destroyed by the fibroid or 
gummatous tissue which develops in the fibrous stmma iu which 
they lie. When this occurs the development of spermatoisoa in- 
evitably comes to an end. In addition^ the efferent tubules may 


be destroyed by fibroid stenosis or ilcgeneration, l^erefow, ihi 
affection is a very serious one, as it tends from the first to destroj 
the spermatogenetic capacity. Degenerative changes may 
and abscess may be produced, or the testis may be transformed^ 
into a fungating inass^ungus testis. 

In exceptional e!ises tlie testis in tertiary syphilis bceomes sud- 
denly swollen and painful, and presents points of resemblance to 
gonorrhueal epididymo-imilvitis, except that the epididymis is vri 
rarely attacked. Tliis syphilitic orchitis* of brusque invasion 
usually attended with pain in the groins and loins. Tlie acutf 
ness and severity of the symptoms may last a week or two, axi< 
then the process gradually subsides until the typical indolent con< 
dition is observed. In these acute cases involvetneut of both' 
glands is to be very much feared. Effusion of fiuid into the tunict 
vaginalis is sometimes to be found in cases of this testicular lesion.fl 

Tliis form of orchitis is very likely to lead to destruction of one ™ 
or both testes and to partial or total sterility. 

Nearly all patients suffering from syphilitic sareocele become 
very anxious and apprehensive, fearing that as a result they may 
become sterile. When but one testis is attacked the patient'5 
ejaculation will contain fertile spermatozoa, provided the other 
gland is unaffected and competent. Even when both glands are 
attacked it is often surprising to see how promptly resolutioo 
occurs and how soon the semen again becomes fertile. I have 
seen many such cases, in which, after bilateral syphilitic sareocele, 
a cure has been produced and the man has begotten healthy chil- 
dren. In these cases, therefore, it is well to be very hopeful, and 
to press the treatment as vigorously as possible, since a perfect 
cure and restored virility may occur even when the case appears 
desj>erate. It seems remarkable that the seminiferous tubes may 
be so profoundly and chronically affecteil, and yet they may regain 

^ Broca haH published an interesting caao of this kiml (Syphilis testicuhuN 
bilal^rale i) <l^bul bru^qtiB et doulaiirt^iix : Oiuetle Hebdom., 1883, Tome x. p. IHl 
et sw].), and Tarsi ne h»w publi^lied a number of cases (011 ^fa^ooc<*le Syphilitiqoe 
& d^but inflAmmatoire et douloureux^ Th^ de Parts, 1S86), in which the testic- 
ular lesion was accompanied by severe secondary manifestations. 




their function perfectly. However, when syphilitic sarcocele has 
existed for very long periotJs, such as one or several years, there 
is danger of the destniction of the function of the organ, and that 
on resolution atrophy may result. 

In all cases in w^hich syphilitic sarcocele is complicated with 
exuberant fungoid development the spermatic function of the 
gland is destroyed. 

There is a class of quite rare cases, to which attention was first 
directed by Tvaroyenne,' of syphilitic men who, without perceptible 
lesion of the testes, are sterile. In the^e cases there is no history 
of testicular iuvolvement, nor arc there any symptoms pointing to 
disturl)ance in the gland. I have examined the semen in several 
of these cases, and have lieen stnick by the entire absence of sper- 
matozoa in that fluid. This aKo6s|)ermati,sm may l)c seen in persons 
in the secondary stage of syphilis and in those in whom the infec- 
tion had not shown any e\'idence for a few or many years. Laroy- 
enne thinks that in these cases syphilitic cell infiltration of a mild 
degree has so compressed the tubules that the function of sperma- 
togenesis is destroyed. This view is also entertained by Bryson,' 
who, in a series of cases, found absence of spermatozoa in the 
seminal fiuifl. 

As a nde, in this fonn of syphilitic azo6s|>ennatism treatment 
fails to afford any relief; but in one case I was surprised and 
pleased at the reappearance of s(KTmatozoa after an absence of 
three years, in consequence of a prolongetl and vigorous course of 

Syphilitic Fnnicolitis or DefeientitiB. 

Syphilitic infiltration in ami around the vas deferens is >*ery 
rare, and shows itself as nodular or moniliform swellings of indo- 
lent course. If left to themselves these lesions undergo degen- 
eration and the lumen of the canal is occluded. 

* Lc riiifeoondil^d'arigine syphilitique. Lyon M^icale, 1875, No. 4. 
' Syphitiiic Asoofipermidm. St. Lonia Courier of Medicine, 18S2, rol. vU. p. 
495 et 86(1. 


Rtnditaiy RypUUi of tt« 

In syphilitic infants and young chibben the testicle mmj 
indolently and painlessly swollen to the aifle of a jageon's egg or 
of a walnut. The epididymis may also be qrnduxiiioiuly attadoed, 
and in veiy rare instances the vas deferens is enlazged to a gmter 
or less extent, lliese testicular alterations, due to hcieditiij 
syphilis, may, if promptly treated, end in full veaohition. b 
some cases, however, atrophy, necrons, absoeaSy and fungoid de- 
generation lead to the incompetence of the gland as a factor is 
the sexual function. In these cases a round or irr^ular nodafe 
of fibrous tissue remains, and the virility of the person, should 
he reach puberty, depends upon the integrity of the remaimng 
t^s. Unfortunately, in heredita^ syphilis both testes frequently 
may be attacked, and with their destruction the ultimate sterifi^ 
of the patient is inevitable. In some cases of syphilitic ordiitis in 
the young subject tuberculous infection attacks the a.fliw?tpd tissue 
and thus adds a factor of malignancy to the case. 

Lewin^ reports the case of a lad, eighteen years old, who was 
puenle in demeanor and very boyish-looking, whose testicles woe 
of the size of those of an infant, as a result of hereditary OTphilis 
in infancy. R^-lus^ s})eaks of the case of a patient (age not given), 
considered hy Purn)t an<l Founuer to be the victim of her^taiy 
syphilis, in whom a testis of the size of a small nut, and of great 
firmness, was present. I have seen a case in which the gland 
was reduced to a small mass of fibrous tissue. When we find 
such a sequela in an adult the suspicion of antecedent hereditaiy 
syphilis of the testicle is warrante<l. 

Treatment. — In all cases of syphilis of the testis and e|Hdidymis 
an energetic and prolonged treatment by mercury and iodide of 
potassium shouUl be adopted. In these cases the local use of 
mercury in the form of blue ointment should be instituted at once 
and persisted in. It is a good rule to begin with goodly doaes of 
the iodide of potassium (10 to 30 grains tcr in die), and to increase 

* Berl. klin. Wochens., 1876, Noe. 2 and 3. 

* De la S/philis du Testicule. Paris, 1382, p. 149 et Mq. 


the f|uaiitity until two or three drarhms are taken throe or four 
times a day. This drug may also Ix* given in eomltinntifin with 
biniodide of mercury ^the siwalled mixed treatment. In obstinate 
leases it is well to use hy|M>dennie injections into the liuttocks for 
ra considerahle period of time. The injections may be made 
(every five, s*'ven, or ten ihiys. The sohition should Ik* }nelilr)ride 
[of mereury dissolve<l in sterile water^ beginning with one-eighth 
lin in ten minims of water. This may be gradually increased 
until one-quarter of a grain (lissolved in fifteen minims of water 
are used al each injertion. It may Ix- IxMiefirial to administer at 
the same time {(^hde of jHUassium in the doses already desigiuited. 
'Testicular lesions in infants should be treated in the same manner, 
except that smaller doses should lie given. Many brilliantly suc- 
iCessful results follow active treatment. 


The testis and the epididymis are liable to be attacked by such 
■A degree of chronic inftammatt(ni in young, middle-aged, and old 
subjects thiit the finiction of the gland nuiy h*' destroyeil by the 
indurating and atr(»pfiie processi^s which su|K'rvene. In many of 
these eases tliere has existe<l as a starting (M>int gouorrlueal epi- 
didymitis or epididymo-orchitis; in s<inie, however, the gland 
had previously Im^cu healthy. 

In some cases *>f chronic [M^sterior urethritis and of stricture of 
the urethra, usually in careless sexually irKhdgent snlijects, the 
epididymis is attacked Ivy a mihl form of iiitianunation, which 
does not cause the patient tn go to IkvI or the epi<liclyniis to Ix?- 
come much swollen or painful. Such an attack usually soon 
subsides, am! is followeil at a greater or less interval of time by 
a recrudesi'cnee, which in its turn is ftjllowed by another attack, 
and so the case contiinies for yt'ars. Some relapses are more severe 
and inflammatory than others. WTien examined, such an epidid- 
ymis is found to l)e enlarged usually in its whole length, the swell- 
ing l>eing ipiitc uiiiFonn and dii^Fuse, and not nodulated at any 
point. Thus is produi*ed a hanl, iirrn, perhaps painless, sclerotic 


crescent, which is attached to the back and upper and lower pan 
of the gland. ITic lesion not being of a tuberculous nature, degen- 
erative changes, such as abscesses and necrosis, are not obsen-ed, 
but as time goes on the sclerosis gradually destroys the efferent 
spermatic tulies and produces azoospermatisni of one and not in- 
frequently of both sides. Tlie testis may become rather lai^o^ 
than normal or it may decrease in size. As a rule, patients tiinflj 
afftvted being young and well, and obserWng for a long period 
no diminution in their sexual desires and in their ability for copu- 
lation, pay little heed to their testicular trouble. Later on, in casc^l 
of double epididymitis or epididymo-orchitis, the sexual appetitfl 
and the rapacity for coitus may lx*gin to wane, and the affectioD 
hecnmes a source of anxiety and apprehension. In the case 
unilateral involvement there may be no functional impainni 
unless the unalfected testis becomes diseased from any cause 

Tliis form of chronic epiilidvTtio-on'hitis beinpj so persiste 
so liable to undergo exacerbation, and so rebellions to treatment^' 
is really a serious affair, and it calls for careful local and urethral 

The clinical picture above portrayed will apply to oase^ of 
young and old subjects usually having chronic gonorrhoea or 
stricture of the urethra, in whom it is necessary to pa.s5 for Ion, 
periods of time urethral instruments; also the cases in whidi 
lithotrity, Htholapaxy, ami lithotomy have been performed. In 
these cases, however, abscess of the testis may occur. 

In some old men having hypertrophy of the prostate, cystitis, 
and that low-grade form of chronic urethritis which is not un- 
common, a slow, usually painless fibroid enlargement of the 
whole epididymis, and perhaps of the testis, may not uncom- 
monly be observed. When double, this afTection soon extinguishes 
the process of spennatogenesis, and coincidently the sexual desire 
may become less keen. When the trouble is unilateral there may 
be DO perceptible impairment of the sexual function for a long 

The tendency of this affection is to produce permanent sclerosis 
of the parts attacked. 






Testicular inflammation is not uncommonlv observed as a com- 
plication of a tnnnlxT tjf infective |>, and it niav lead to 
such structural changes that the integrity of the testis, of the 
epidiilymis, or of Ixjth. may he destroyed. These infective testic- 
ular lesions, as a nile, attack hut one fj^Jand, hut it is not uncom- 
on to see both glands afTeclcd. As a rule, the testis is the part 
ttacked, and with it the epidi4lyTnis may be involved. It is not 
common to find infective epididymitis w'ith*>ut involvement of the 

Mump Orchitis. 

During the course of mumps the testicle, esf)ecially in young 
subjects, may be attacked by severe inflammation, and the clinical 
picture of lilennorrhaglc einihdynio-orchiLis inuy then be counter- 
feited. The invasion of this affection is brusque and its course 
rapid. Occasionally, the two testes are attacke*!. Full resolu- 
tion may occur, but it is not at n!l uncommon to observe total 
atrophy of the gland, and, ext^eptionally, of both glands. Many 
men become sterile owing to the destruction of one testis by 
mumps and of the other by some other morbid change. The 

Iree'iprocui rehition l>etween the testes and the parotid glantls is 
shown in certain rare cases, in which, after the removal of these 
glands, the parotids become acutely swollen and inflamed. 

Tonsillar Orchitis. 

This condition may occur during the course of tonsillitis, with 
acute invasion and usually with prompt resolution. Abscess may 
destroy the testis. 

Variola Orchitis. 

In some cases of smallpox the testis, epididymis, and tunica 

vaginalis may l>ecome rapi<!ly and severely inHametl. Rcsohition 
usually occurs, but in .some cases atrophy or abscess of cither or 
all of these structures ensues. 


Scarlatina Orchitis. 

This fonn of orchitis may octur in chihlren and ailole^^nb 
and it is usually of an active type. Resolution may take plaw. 
but atrophy may result. 

Malarial Orchitis. 

During the course of malaria the testis may become inflamei]. 
even in subjects who have not had gonorrha-a an<l its testicular 
tmulile. In the cases thus far reported it has Ijceij noted lliar 
excepti(Mmlly atrophy (>f the testis and in<luratioii of the epiiiicl- 
ymis have followed this malarial phlegnia^sia. 

Grip Orchitis. 

Involvement of a testis which previously had been healthy, or 
v;hieh liad l>een the seat of gonorrhneal inftainmation, has l>era 
ol>served in (piite a nunilx-r of instances. Resolution usiiallr 
oeeurs, but atrophy, epididymal induration, and gangrene ait 
lia!)le to follow. 

During f!ie course of whooptn^-eoujiifh, pneumonia, t\pht»i<l 
fever, |>yix'mia, anil of j^rave phlegmonous intiammation of hoDt^. 
the testis ami |)erhaps the epididymis may become the seat of ii>- 
fiammation. In such cases resolution may take place or degen- 
eration of the testis or of the epijlidyniis may be produced. 

'I'he *iangiT of these infectious testicular idlliinunation^ lies in 
the fact that tliey occur chiefly in young subjects, and that wlu-fi 
they Hre severe dcstructujii of the gland is complete. Should ihr 
nnairected testis later on become invitlved by one «jf the m»M 
morbid conditions which are liable to attack it, the result is slc^ 
ility in its bearer. 

The treatment is that used for gonorrhceal epiilidynio-orehiris 


'llils fonn of traumatic orchitis is nuMlerately common, h 
may l>e a simple and ephemeral condition, or such changes taa^ 



be prxxluced by the injury that the epididymis may be much 

^knlarged and indurattMl, ur the testis may be so disorganized tliat 

^Mtrophy may rcsuU. In either of these events unilateral azo6s|>er- 

^HDatism may follow the injury to the epididymis or the testis. 

^P The cliniea! picture of orchitis from muscular effort is that of 

goiiorrhteal epididytnoorehiti.s, usually with a preponderance of 

the testicular trouble. Under the influence of rest and suitable 

local applications resolution usually occurs quite promptly, but 

the testis mav remain tender an<l somewhat swollen for some time, 


Terrilhjn' reports a eiusc of this form of orchitis in wliich atrophy 
LTurred, and this process was attended hv so luueli pain that 
lastration was resorteii to. 

In all probability orchitis from muscular effort is due primarily 
sudtlen and stmng abdominal pressure upon the spemialie 
►lexus of veins in persons who have lifteil heavy weights, who 
lave slipped with violence, or who by any means have been ruilely 
ihaken, as in jumping a great distance, or even hurriedly alighting 
from acar in motion. Tenuity of the walls of (he veins may be the 
tnderlying condition favorable to tlie development of this accident. 

It is only in severe eases that this traiinuitisni may cause degen- 

sration of the testicle, which of itself wrjidd nr»t lead to sterility 

If the other testis l>e sound. The lesion pro(hice<l in the testis 

tnd epididymis is, first, effusion of blood, and^ second, the changes 

inxhicfMl by tlu' cornpressufn thus exerted. 

Treatment.- -In all cases of chronie 4>rehitis and epi<lidymitisy 

the orchitis of infectious origin> and in the orchitis due to mus- 
!ular effort it is importunt to fi)l!t)\v the *lirections laid down for 
the treatment of chronic (^jiididymitis. (See p. 195 d »eq.) 


lliis forra of traumatism is very uncommon, ami occurs in 
subjects (mostly yt»ung ones) wlu)se testictdar apparatus is some- 
what malfonned. Then* is usually a history or evidence of uu- 

< Annates des Mai. deti Org. G<?n.-uriD., 1886, Tome iii. p. 239. 


(losoendod or iiiiperfe<'tly desoended testiH; conse<juently. a.* a 
rule, tho swelling is found in the inguinal canal or just within the 
upfXT part of the scTutuni. 'llien* are present localized swelling, 
(iHlema, and redness, and such subjective syinptoins as may point 
to strangulated hernia, traumatism, or appendicitis. The pa^tioa 
and (|uite sharp localization of the tumor, the altsence of the testis 
from ttx' scn>tum and the history of the casc^ uill usually point 
to its natun\ 'I'he diagnosis, however, is, as a nde, (X)niirmed 
when an exploratory incision has Ikhm) made. Then the testis 
and e])itlidyniis ar<» found to Ix' swollen, of a «le<'p blue or even 
black <'olor, an<l sometimes th<»y an* gangrenous. In most case? 
the testis is entirely destnmMl. 

In some cases cxc(\ssive and violent strain (*aiiscs a twisting of 
the cord, wliich ]>roduces this tmublc. In others no exciting caiisf 
<an l>e aseertain<Ml. The twist of the conl may Ik» partial or com- 
plete, or tiie cord may Ik* twisted several turns. The essential 
and niulerlyiiig cause of torsion of the conl is (listurl)an(*e in thf 
d<'velopnu*nt of the vaginal protrss of the jx*ritoneum, in whidi 
the niesorchium is eitlier too slender or too long, and hence does 
not give the testis the rw-eessary amount of fixation. The mesor- 
chiinn then allows greater movement than normal, and the testis 
may, as a result, encoiiiiter difficnhy in entering the ingtiinal eanal 
and im|)(Mliment in traversing it. When it is in the inguinal canal 
the flat (•(►ndition of the testis militates against its replacement 
and H'liders iliis imjxissiblc when inflanunation has Ihh'u estal»- 
lished. Ill the s<rutiun the tnrsittn may Ix* ntliice*!. I'saalk 
sneli a testis rcipiires pnniipi extirpation. Pmvided the otlier 
testicle is coiiiprteiit. the sterility 4)f the man is not lost. 


In some ('as<'S(>f old hydroct^le such ])ressure is exertwl up"D 
the testis and the epididymis that the spermatogenetic function b 
nuieh imi)airiMl, and it is even temporarily su.s|HMided. In some 
old eases in wlueh the tunica alhuginea and the epididymi.-* aie 
much thickened ainl citntracted by iit)rous hypi»rplasia, fertile 
spernial*»zoa are no longer pHKluced. 


AZofisPERMA TlS^f 2l3 

I^niielongiie* and Marimon' have in cases of old and volimii- 
'noiis hydn>oele faund such iilteralions in the stnicture of the opi- 
!did}7nis and the efferent tubes soinjiirionsly eompressed that the 
iescape of semen was profoundly interfered with. A very impor- 
tant faet has l>een noted by RonhantP in the case of a youn^ man 
Tvho had very lar^e double hyriroeele. He was then strrile, und 
no spermatozoa were found in his semen. After j>unetijre of the 
[two saes .sfwrmatoKou reappeared in the semen, disappeared when 
ley Ijeeame lilled and distended a^aiti. utnl irajvpeared after a 
»cond tapping of the two hydmeele.'i. 

Out of twenty-three cases of hydrocele in which the semen was 
ixamineil by I>annelongue no spermatozoa were found in five. 
Desmaroux' reports thv case of a man, ap-d fifty-seven years, 
ho hinl doul>le hydn>cele and was .sterile, but who Ix'came potent 
[after puncture and iodine injection of the tunica vaj^nalis. It is 
rell, therefore, not to for^t that hydrocele may l>e at least a tem- 
porary and, exceptionally, a |KTnianent cans*' of sterility. 

Treatment. — Palliative measures consist of tapping the vaginal 
ravity as often as it l^ecomes full. In all cases, especially where 
:he function of the testis is impairi'd by hydrocele, the Uvst pro- 
'(^lure Is to |>erfonn von Bcrf^ninnn's ojM'ration, in which idl the 
larietal layer of the tunica viigiintlis is cut away. 


In severe o{ lieniatocele such damage is inflicted u|K>n 
the testicle and such injury is pnxlueed by the effusion of bkn)d 
and the subscijuent changt*s tliat th<* function of the gland may l>e 
destroyed. If its mute, however, is competent, sterility <loes not 

Inece.ssuriiy folli>w, but in case it i.s damaged the Liearer is .sterile. 
Kocher* has shown that the seminiferous tubules may be altered 
* Bulletin de 1> Soc. de Cliiruixi«. 1873, Sd S^rie, Tome ii. p. 421. 
* Recherchea sur I'Aoiilomie pathologtqiie des groaaes Hydroi^'les. Tbdse de 
Parits 1874. 
■ Traits de I'lmtniisKMnce, etc., lH7ti, p. 676. 
*G«zeUedes IlApimux, 1883, Tome Ivi. p. 762. 

* Die Kraiikheiten der Mannlichen Ueaclileclitsorgane. Stuttgart, 1S87, p. 
^00 et seq. 



and even obliteratetl by h^'pcrplasia of Hbroiis tissue, and thai 
the whole glnn<l may undergo Hbroid degeneration after ^enu- 
tocele. Filliel' has clearly shown that the sclerosis begins in ihr 
tunica albuginea, and spreads inward and invades the ctwts of (bf 
lul>es and vessels, and thus tiestroys the glandular slructuir. 
It is well, ihert^fon', to Ix-ar in niiTi<i that l>esi<les lieinp a ^ ■ 
fif pain anti aiu»<iyance heniatfM'dc may, if left untreate^J, Ir 
such damage of the testis that its function will be wholly lost 

Treatment.— In recent acute cases rest in l>ed, suspension of 
the scmlum, and the application of ct;M>ling lotions are n<*cev'-'r- 
When Htictiiatiou can !«• distinctly discove«;d it is well to i 
the part (after proper surgical prejMiration) and then to pack it 
with iodfvfonn gauze. It is always well not to operate until ihr 
indications therefor an' very clear. 

In chronic cases compression may be tried and mercurial or 
ichthyol ointment may Ije employed, ^^'hen the tumor remaiK^ 
unchanged and uninflueneeil by treatment it may l>e necessary in 
rt\sort to Volknuum's <»peration for hydrocele. \Mifn the tumor 
is of very large size or when testicular liisorgunization is evidf-m. 
it may l)e necessary to remove the organ. 


Tulierculous inlUtnitiou is one of the most eominon afTeetiaos 
which attacks the testis and destmys its function. It is olxservwl 
chiefly at and duriug pul>erty and in adult life, but may i)c found 
in infants, an^l much less frequently in middle-aged and eldedv 

In all probability, tuk-rcle of the testis is developed second- 
arily to some other more or less remote foeus of infection of the 
Ixjdy, and it is chiefly noted as l)eiug found in association witli 
tulHTCulosis of the prt>state, seminal vesicles, and bladder and 
ureters and kidneys. Though stjme cases, fnmi a clinical staml- 

* Nolesiir I'^Ut du Teslicule Hans rtT^rimiitoele Vagiimle. Compt. rend, do 
Soc de Biolugie^ 1887, SeriM 8, Tome iv- p. 3*d!4 et iwq. 


300 PASTcUR , . 

^ry OF 



rtnt, seem to be instances of priniar}' testicular tul>erculosis, it 

not well to venture such a (iiagnosis with much positiveness, 

ince lurking and perhaps dormant foci of infection may exist in 

»me part of the hotJy which can only be detectCil by post-mortem 


As to the avenues hy which the testis is invaded, it may l>o stated 

int clinical^ anutomicat, and pathological facts point to the hlood- 

re.ssels as the carriers of the infective material. 

There is no seientifie evidencv at hauf! In favor of the view 
that infection thnjugh the urethral caiinl may occur and lead to 
■sticular invasion. 

lliere is ^mkI reason for supposing that infection of the seminal 

resides and [>rf>s1atc may occur thr^nit^h the vesicorectal peri- 

'ueal fold fnmi tulKTcnlosis of the peritoneum. 

In clinical practice we fitul two quite clearly marked forms of 

tul)ercle of the testis — namely, the acute and the chronic forms. 

Besides these forms we find mixed varieties, in which acuity and 

L chronicily are blen<led. 

B "^ITie acute form of tulx^rculosis of the testis presents somewhat 
the same clinical pictun* as is offered hy acute fjnnijrrlHral epidid- 
ymitis. The patient may have given evidence of tnl>tTcu!osis in 
J some other and perhsi|)s remote or^an; he may or may not have 
^komplained of bladder, pmstate, or urethral disonler; an<l he may 
or may Tn>t have suflfered fn)m giMiorrliu'jd epididynun)rehitis. 
He may have previously enjoyed gooil or fairly good health, or 
the testicular lesion may appear as the only local evi<ieiice of dis- 
ease in a man who is pale, weak, and sickly, and who, perhaps. 
has within a short time lost flesh. In many cases traumatism 
seems to lie the exciting cause, 
^b Usually the first symptom is pain seated in the head or the lail 
of the epidi<!ymis. ami very soon the segment involved swells to a 
considerable size. In some galloping cases the whole epididymis 
is much swollen in all directions, is either spontaneously painful 
on slight pressure, and is covereil with an acutely inflamed area 
of s<'nital tissue in a day or two. In other ca.scs several days, 
or even two or three weeks, elapse liefort^ such an lu'ute condition 


is reached. In these oases there is usually more or less fever and 

When palpated in this state the epididymis usually does not 
present any diagnostie points, and the conclusion may be reached, 
if then* is any evidence of urethral discharge, that the case is 
one of fjonorrho'al epi<ii<lynio-orchitis in the declining or chronic 
stage. When the entire absence of any urethral discharge or 
affection is HMKienvi clear the suspicion of tuberculous invasion 
may Ih» entertained. 

In a few <hiys, or in a week or two, upon the subsidence of the 
severe iiiflununatory reaction (in cases in which an abscess has not 
Ix'en forine<i, and in which vaginalitis has not developed), the 
surgeon can carefully examine the organ, and then, or perhaps 
later, a nodular or lK)ssy condition of the head and tail and per- 
haps of the iMxiy of the epididymis may be clearly ma<ie out. 
At this time the testis may appear uninvolved, but later on it 
may iM'come more or less enlarged, and on its surface small or 
large iiodulations. just as if small shot or split peas were seated 
in the tissue, can l»e felt. 

It sometimes happens that the seminal fluid becomes of a rose 
color from Mood admixture, probably derived from some part of 
the testis. 

Al)s<'css may sooner or later develop, usually at the head of ihe 
epi<lidyniis, and also at the tail. When the tail of the epididymis 
is attacked it is not uncommon to find a mass of suppurating tissue 
alM>ut an inch or less from it an<l coimected by a fibrous strand in 
the loose scrotal tissue. These cxtraepididynial abscesses -seeni 
to Ih' due to infecting |>ns whicli escapes from the involved epi- 

Al)sc4'ss is the direct outcome of the caseation and softening of 
the tuberculous inflanunation. The non-vascular cellular nodules 
produced by the infective process, and the infiltration which sur- 
i*ounds, compresses, aii<l destroys the seminal tubules and leads to 
a chronic diffuse orchitis, break down and give issue through one 
or several Hstuhe to a thin fluid streaked with pus and small 
gnunous nuisses. The scrotal wall U'comes of a deep red, even 



of a hluish-re<i color, and the orifices of the fistulie look very 

unhealthy. In the cases thus briefly descrihefl there is usually 
more or less destniction of the testis proper, but the function of 
the gland is promptly destroyed by the deadly infective invasion 
which attacks it in its centre and on lK»th flanks. The develop- 
ment of tuberculosis of the epididymis is well shown in Fig. SS, 
and its extensive invasiiui of the testis pnipcr is adiiumbly por- 

Fki. 88 

Tabercn!<wi« of llie teiiliri. The larger portion of the epididvmia lies on the 
right side: a. ehe&>v epididymis; b, wliiiinh mass oociipyinfc ihe mediuriiinum ; 
Cj ivolaled tubercle with ehe«8y centre; </, siuall cyst at ihe »»i)inmit of k^'^^us 
tnajor; <:, larger and smaller opaque apolfi scattered over the surface of ihe 

trayed in Fi^, <S9. (>iu» testis muy Ijc thus attacked^ but not very 
infreijueiitly the other one is .sooner or later involved. 

In the chronic form of tuberculosis of the testis many clinical 
pictures are presented. h\ some cases, in apparently healthy or 
in sickly l<H»king subjects, witli or without coexisting nretliral, 
prostatic, and vesicular involvement, the epidiilymis (tail or head) 
swells painlessly, an<l the patient by accident discovers a small, 
pea-sized or hickorviiut-sized noilule of irregular outline. This 
condition may slowly increase, and as it (Joes the intittratioa 

iKM'Dincvs more rugose upon its surface, and it may extend to the 

wh<»l(' epididymis, converting it into a fihroiis mass. In this 
painless, indolent state it may remain for a lonp time — months 
or years — or caseation, softening, and fluctuation may be discov- 
ered, or abscess or fistula may develop. On removal of such a 
testis the epidid\*niis is fontu! to l>e very tou^li and fibrous, with 
lit'if add there cavities in winch <legerieration has occurred. Vtrv 
often no evi<lence of invasion of the testis can be found. 

In other chronic cfuses theiv may be aynchmiiously observed 
Hepani*<^ nodules of small or hir^ si'/e in the head and tail of 

Fui. 89 

'riitwrciilrMb of the keftlis. Tlie testicle is cut w> that tlie lar^r part of the 
v|ili)i(iymjii llm in t^e Hght half: a, Hwallen and clieeHy epididytnU ; h, mam ii( 
iHiiilliiont ItibercleM nl llie uit'diiulinum, exlenrjing ouLwaiii inU) the tevlicle toil 
linllail ftbovb witli the gluttus mujor; c, larger aod Bmaller tuberclea, «ome with 
oIlMKJf Ottilrm, in the tesiicie lusues. 

(lie rpidiflymis, with what is then niost common, the invcilvemenl 
of the whole mediastinum testis. In tliese cases the disease may 
reiimiii latent and indolent for varying ])erio<is (often quite long 
liliri)i t>r rxaeerlmtions may occur, and the case in its course may 
ihen n^HiMidile (hose of acute developinetit. In ^neral, however, 
ila* iidcitive process goes on, the chronic epidiilymo-orchitis keeps 
on 111 «nir»«», and then we find a much enlarged epididymis, which 
In Imril, knohhy. and irregular. In some cases the lesion in the 
f«ptdldvMii« pn'ponch'rates, an<l then that appemiage is very large 
Indi'tMl. and the us yet uninvaded testis forms but a small portion 


i4 t 




of the raorhid tumor. Then, again, the growth in the testis keeps 
pare with the process in tlie opididynii.s, ami a hirge mass is pr<>- 

Hvilmeele is observed in al>out one-third of the eases of tubercle 
of ttie testis. Tn Sf>ine exeeptional rjt'^e.s tnberculijsis of the testis 
(one or Iwith) presents the same eliiiieal pietun* as is ofTen^d by 
syphilitic sarcocvle. By slow tle^rees, with some or little piiin, 
the testis ami epidiilytnis cnlargi' ami form an ovoid or |x*ar- 
shaped tumor, which has a snunjth surface and hard, firm ctjnsist- 
ence, nud winch mayljc mistaken fur syphiHtic sarcocele or cystic 
sarcoma of the testis. These tul>erculous testes may l>e as large as 
a good-sized pear or a large fist. They may remain intact for a 
long perio*!, and they may become the seat of abscess and fistula 
and of fungoid development. In some of these cases I have 
observed small and large roundcil nodulations on the surface of 
the testis. It is always difficult and often impossible in this form 
of tulw^rculosis of the testis to discover the epididymis (»r to settle 
in one*s mind how much it (rontributcs to the general swelling, 
since the parts are so intimately merged together. 

The life-history of [Hiticiits sidl'enng from tulxTcle of the testis 
is that of tuberculosis in general. In some cases the patients hve 
for years after the extirpation of the organ or organs; in others 
<leatli follows sooner or later from extension of the disease to vital 

IJesides the strikingly well-marked features presented by the 
affected testis, there is, in most cases, evidence of prostatic involve- 
ment in the sha|X} of enlargement and large and small nodulations, 
an<l j>erhapsof irregular infiltrations in the ampullated ends of the 
vasa deferentia and of the seminal vesicles, which may l>e ascer- 
tained by digital examination in the rectum. 

In many cases of tulKTculous testis the scmtal [)art i^f the vas 
deferens is more or less attacked. There may Ih' slight thicken- 
ing and enlargement, circuraserilx^d or diffuse, or the tube may he 
so no(iulati'f! that it h'cls like a string of U^ads of various sizes. 
A testis attacked by tulK^rculosis soon ceases to possess the sper- 
matogenic function. 


In all probability. tulxTCulous invasion of the epiclidj^Twis 
testis destroys the function of the ^'lun<l much sot»nvr an<l mn 
frequently than we have heretofore thought. It must be reme 
Ix'fed that even in mild and indolent eases the development 
toxins oeeura in association with the morbid tissue changes, t 
(hesf* poisons [>ermeate the structures of the testis and <iostmy t 
(Jeheute arrangL'Uieut by which the spernialogenic function is 
formei]. hi very acute cases the extensive swellinfc and hv 
iernia are, undniibtedly, hir^ely due to the diffusion of the 
thruu^h tlie wli4»le ^hiiid. It is fair to assume that this (*i>nditio] 
destniys tlie function cjf tlie testis at once. Then, in addition i<i 
this ditrnsil)le poison, the cell changes so destroy the integrity i*( 
the gland that it soon becomes useless as a producer of apemii- 

Involvement of the two gland.s carries with it sterilitv. ITw 
foregoing considerations show what a widely deleterious influeoc^|| 
tul>erculosis exerts n\nn\ the sexual function. 

Treatment. — 'i'he most inijwirtant ptiiiit in the management of 
oases of tulxrculou.s testes, and in which other organs and tissues 
(lungs, kidney, bladder, prostale, vesicle, etc.) are attacked, i.s th^ 
removal of the patieril to a suitable climate which is hig-h, dr? 
and sunshiny — the AdiroiidacLs, Southern Californiu, an<l (V*! 
rudo. In all cases it must be rememlx'red that climate is the chi 
<Mirative fsu'tor, aiul that t!ie actluii tjf drugs is only secondarv 
Bencht, however, nuiy result from tlie us** of cod-liver oil. tlv 
hypophosphites, creosote, iodide of iron, and tonics, all of whicfai 
should Ix; judiciously employed. The adoption of surgi(*al meas- 
ures dejHL'uils wholly u[k>!i the extent an<t sent of the tulx*n*uk>us 

If there are indurated masses in the epi<lidymis or in the tester 
these (M>ints should l)e incise<l, thoroughly st-raped, anil piu-ked 
with iodoform gauze. 

If lhe«» are sinuses leading into the epi^lidymis or testes 
nhould be enlarg»'d, scra]M'd, mid packed with abH4)rbent ^tize 
iodoform ointment. 

\N hen the entire testis is extensively involved and broken do 




it is necessary to resort to castration ; but in these cases the necessity 
of climatic change should he forcibly imprcsse<l on the patient. 

It is interesting to note that in the hands of Dr. L)e Garmo' 
a tuberculous testis was submitted to a?-ray treatment, with 
flecided fx*nefit. The patient was fifty-six years old and had 
had one testis removed for tuberculasis. The second one was 
attacked later on, and De Garmo says that on examination 
there was a clear history of ttiberculasis of the testicle, which was 
confirrnefi hy the clinical appearance. The testicle was swollen 
to several times its normal size and was hard, painful, and 
quite tender on pressure. One huntlred and twenty-six treat- 
ment:* of ten minutos each were given f)y means of a medium 
ttibe, which was used at a distance of about ten inclies. The 
first application relieved the pain. The swelling and tetiderness 
also gradually subsided until at the time of the last treatment 
the testicle was apparently of normal size and in normal 

If the x-ray will accomplish, even in a small number of cases, 
what it has seemed to accomplish in the one just narrated, it is 
of extreme importance that all of those who are liable to meet 
with these casps should be quite familiar with the facts. 

The treatment was employed for ten months, and more than 
a year has elapsed since the supposed cure was effected. 


The (>n)statc is inv<>ivrd in the majority of cases of (uImtcuIosis 
of tlic giMiitourinary trad. Its development may U* primary or 
secondary to infecting foci in adjacent or remote parts. It is 
mostly observeti at puberty and in early life. 

Tuberculosis of the pn>state may cause azoospermatisni by the 
obliteration of the ejaeulatory ducts. 

The course of tuberculosis of the prostate may be acute, sub- 
acute, or chronic. 

> Medical KeconJ, April 15, 1905. 


In the majority of cases the disease begins in the urethra, hut 

il is aIs<> fmiml in the siihstance of the glaiul and on its periphery, 
iwrtitMilaHy near the rectum. 

In eases of iinMhral involvement the symptoms are complained 
of quite eariy. ''I'he most prominent s>Tiiptom is pain, particiiladt 
on urination, which may l>e very urgent, and it may be eitlier 
i-ontiniions or iiitcniuttent. Invasion of the prostate is usually 
followed <|nite promptly by extension to the bladder, with its 
custumary gnmp of s^7nplonis. 

In cjuie.s of pmstatic tul)ercnlosis there is usually a more or less 
pri)fuH«' mucopurulent discharge', which may escape spontaneouilj 
or on dcffcalion. Wlien the tu!>erculous nodules are seated in tbe 
narrnehynui of the pro.state they may not give rise to pronouneetl 
svmptoius for some time. This is particularly the case when the 
o>ur?«* i** >''*0* chronic. When the tuV>erculous nodules are seated 
li»\sftt>l the periphery of the organ they may occasion few, if any, 
.H>nn|>ton»s. hut when they art^ very sui)erficinlly seated, particularly 
lienV llw* ni'tuui, they may cause pain ami in those |>arts. 

On nH'lal examination the finger-tip may not encounter anj 
*<M*<«1»«^*^^* ^^'^1^" ^^^ urethral j)art of the ]>rostate i.s attacked, 
NMhM* the utMlulcs an* seated in the parenchyma of tlic or^n andj 
iK%^\ hrtxv Iw^'onje c|uite hirge. or when several have eoalescc'd hm 
iVl^^V*< ^*" ^^^^ snirface, their presence may be determinetl by pal- 
u^Si^^\ \\{\\\ till' Hnger iu the rectum. 

W s^hMtt***^'* **^ prostatic tulx-rculosis may be made by exam- 

tiMi^U^w *vC *he mt»rhi<l secretion or of the urine. Hut in maiif | 

*W^ i^^niiiinations fail to reveal the bacillus tul>erculasi«| 

lire Inis i>een Immfjlil to bear on tlie gland and 


.^1 TulMTi'iilosis involving the urethral canal maf 
\ m>wtali<' and bladder irrigations of warm solutioi 
a« ineivury (1:3(M)0 or 1 : SOOO). In the event oi 
^ v^M"ii>tf V*^^^^ ^'*'^ urethral irritation it will be 
>«uthtvic it. In some cases iodoform and sweetS 
m the form itf injections, have seemetl of lienefil 
..„^v%wu( »l»'' "rellira. 


Tuberculous abscesses of tlic prostate near the rectum may be 
reachotl by a crcsccntic incision made au inch in front of the anus 
l»etweeii the prostate and the rectum; they are then incised, 
scrapeii, and packed with iodoform gauze. 

Change of climate (see section on Tul)erculosis of the Testis, 
p. 220) is the main indication in these cases, whicli are usually 
those of more or leas extensive distribution of the tuberculous 


This condition is rarely, if ever, of primary development, but 
is usually found synchronously with tuI>erculous prostatitis and 
cystitis. It is a disease of early life^ and very frequently coexists 
with tuberculous infiltrations of other organs more or less remote. 

By rectal examination with the fin<^*r a nmlular swelling is 
found continuous w'ith and just aljove the prostate. The tissues 
can be felt to be much infiltrated and quite ^^oggy. 

In many cases the ampuHations of the vasa deferentia are 
involved, and they feel hke brawny, insensitive swellings. 

Wlicn the seminal vesicles are involved by the tnl)erculous 
process their respective ducts are generally involved simulta- 
neously, and fnjtn foci the morbid process may extend and 
attack the ejaculutory ducts. 

\Mienever the seminal vesicles and the ampuUw are the seat of 
tuberculosis, a mucopurulent discharge, mixed with grumous 
masses and sometimes with blood, forms within them, which while 
the ducts remain patulous may esea]>e through the urethra. 

When these seminal sacs and the ampuHations are the seat of 
tul)erculosis, sexual erethism may Ijc complained of at first, but 
later on impotence is observed. Wicn in these conditions the 
morbid tissue products l>ecome mixed with the normal secretions 
of the parts, the spermatozoa are destroyed. 

It is very probable that when tuberculosis attacks the vasa 
deferentia the sprmatozoa arc killed as they pass upward from 
the testes. 


Treatment. — ^The remarks already made on the necessity of 

climatic treatment (see p. 220) ho!<l ^>o{\ in ease.s of tu!»ercu- 
loiis s()ennatoeystitis. Care as to hygiene, diet, and si 
therapeutic measures should also lje exercised. 

Such is the extent of tulxTcuIous infection in most cases 
surgical operations on tlie seminal vesicles alone are not indicate 
Abscess of these parts may Ik? reached l>y a creseenfir incisii 
about an inch in front of the anus and carried down l^etween the 
prostate and vesicles and the rectum. The parts are, after carefol 
irrigation, packed with iodofonn gauze, which is held in pliut- 
by a retentive dressing. Excision of the vesicles may he accom- 
plished by means of Kraske's or Zuckerkandl's incision. 


As has been shown in some of the foregoing sections, atrophr 
the testis is very coinmoii, and it is due tu a great variety of caus 

III the yinui^ .siiliject the jjland may Ijccome dwarfed hy reasoi 
of altnoruuil ri'tcniioii and of nialpositiou or ectopia. In old sul 
jects, senile changes begin earlier in the testis than in other pn< 
of the lx)dy, and the organ may be reduced to a mere mass of 
fibrous tissue without any trace of glandular stnictnre. 

Arthaud' has sfiown that in the testes of men Wyond fifty years 
of age atrophic changes usually l)ecome established. The essen- 
tial lesion is a j>t"ritid)ular sclerosis, which leads to the ^a<hjiil 
disappearance of the epithelium. As a result the seminiferous 
tubules are destroyed, and sometimes cysts are developefl. ITw 
underlying causes are vascular interference and insufficient nutri- 
tion of the glands. 

Desnos^ lias further shown that in old men the periepi<hd\-tnal 
veins become much dilated, and that this process slowly goes on 
until the veins of the parenchyma of the epididymis are invDh*ed. 

' iCtudc Hur le tetiicule senile. Th^ de I'arU, 1886. 

* B«chercheH nur t'npp&reil genital dw Vieillardfi. Annftlm den Mai d«» Urf. 
Qto urin., ISStf, Touie iv. i>. 72 et 8«q. 




te result of this pressure is the merhaniral obliteration of the 

efferent seminal vessels and the transformation of these strnrtures 

into dense, fihrous tissue. Desnos further claims that iiydrocele, 

hich is not uneommonly found in old men* causes hy its com- 

iression atrophy of the testis. 

By way of recapitulation we may hriefly refer to the following 

facts, and also call attention to several rather infreqiicnl causes 

(f atrophy of the testis. An a complication in the course of a 

umber of infectious diseases the testis is not infrfMjiJ4'n(ly in- 

Lvolved, and the outcome is very often atrophy or structnnil degen- 


GonorrhtT'H uuiy, in rn.ther exceptional cases, end in testicular 
atrophy, hut its (ianger to (he sexual capacity resides in its ten- 
dency to occlude the spermatic tul>es. 

Syphilis is a potent and frequent factor in the production of 
;trophy e)f the testis and of the epididymiR, and occupies a prom- 
inent place in the category of causes of sexual impairment and 

Hydrocele and hematocele may lead to moderate and temporary 
or permanent aKoos|5ermatism by reason of the structural changes 
which they produce in the testis and epididymis. 

It is doubtful whether varicocele produces true atrophy of the 
testis, except in very rare instances. 

In a certain number of cases of elephantiasis of the scrotum 
true atrophy of the testis has been obserA'cd. In some forms of 
hemiplegia, general paresis, and in some cases of traumatism of 
the skull, brain, ccrel>ellum, medulla oblongata, and spinal cord, 
wasting of the testes is observed. In tliese cases the spinal sexual 
centre is so affecteil that its function is destroyed. The long-<on- 
tinued use of iodide and bromide of potassium and belladonna 
has been stated to be the cause of atrophy of the testes. 


In January, HK15, at the New York Academy of Medicine, Dr. 
fp Tilden Brown made the follownng startling statement: "He 



had to announce that men by their mere presence in an JMar 
atmosphere, incidental to ra^lioi^fraphy or the therapciiliV uses n( 
the rays, after a perio(i of time — a-s yet undetermined — will be ren- 
dered sterile. In tiie last few days ten individuals who have dcvotn! 
more or less time to the work during the past three years — none 
of whom have had any venon-al diM^jtse or tniinnatisui invoKin^ 
the j^enital tract— have Ix^en found to be the subjects of alisolutf 
azoospTriia, None of the lunnlurr are conscious, however, of 
any change or deterioration in regard to their potency." 

'lliis condition hud developefl without any waniinja;; then* \\Mi 

Ik^pu no symptom of lack of sexual potency, and the disrown 

was almost by accident. It seems that in some cases the sptr- 

inutozoa were wholly absent, while in others there wa** more or 

' U'ss (k'struction of their l>odie3; some had no heads, others 

no tails, and all seemed to be in a disorganized con<iition. In 

one reported case a patient treated by the x-rays for pniritus 

uni was known to have active spermatozoa before exposure to 

the x-rays, but these disappeare*! after the treatment, and fc 

ivverul months no signs of spermatozoa could be found. 

wfts. however, after some three months, a gradual return to 

normal, and active spermatozoa eould again Ik* discovered. 

U'«rned editor of the Medical Sewn in {-ommentinf^ on this 

of ntTairs says: "This effect of the x-rays may seem surprisi 

111 lha**e who are unfamiliar with some of tiie biological efff 

lh*t have Ix'en known to occur as the n^sult of the ex|>osurr 

kiWT-r organisms of various kinds to the action of these ratiiatioi 

<f«ls for instance, exjKised for even a few hours to the ac*tion of 

lh» j-ravs lose something of their ability to grow, and if plant 

, jrsul'o "^ con*ri>l seeds which have not Ix^en expensed, 

Shoots to which they gWe rise may l>e readily picked out, beeai 

. lowness with which tin y increase in size. On the 
ViMsid exposun^ for a number of hours is likely to kill the 

. \_ I iN-neral, the longer the exposure the more cioes 
^^^ , ^ gg^ suifer. I'urthennore, a senes of appurcnl 
' ins h»vt' In^en made upon insects which usuj 
metamorphosis in their ordinary- life c' 


the larvre of some beetles be exposed to the .r-rays for a short 
'time they are not killed, but svime curious vital clian^'e takes plaee 
in the tissues. The meal-worm, for instance, will^ af*er a certain 
'Dumber of days under ordinary circumstances, become a beetle. 
After exposure to the ar-rays, however, this normal metamor- 
phosis does not take place, but the meal-worm continues to live 
and eat and thrive without any tendency to go through the rest 
of its cycle of existence until death finally overtakes it." 

He further calls attention to the following facta: "Allxrs- 
Schonlx^rg, alxiut a year ag*>, first dnnv atti^ntinn to live fact that 
in male rabbits and guinea-pigs in which the abdomen was ex- 
posed to the action of the j-rays, an azonspemiia was gTadually 
developed. Tlien Frieben found that this was due to the dis- 
appearance of the epithelium in the seminal tubules, which re- 
sulted in an atrophy of the testes." 

Halljerstaedter' studied the effects of the Roentgen rays on the 
ovaries of rabbits and found that by exposing one side of the 
abiloraen while the other was suitably protected, markefl macro- 
scopic and microscopic alterations took place as determined by 
subsequent autopsies. In order to avoid any possibility of error, 
the ovaries in another series of animals were first inspected by 
performing an exploratory laparotomy and then exposing them 
to the rays after the abdominal wound had healed. Any inherent 
difference between the two organs could thus l)e noted. It was 
provc<l that the marked differences between the two sides c<>uld be 
ascril>ed to nothing else than the rays. The histological change 
most in evidence was the complete disappearance of the Graafian 
follicles in about fifteen days. Whether this loss is permanent, 
and whether or not regeneration can take place, has not yet been 
detennined. It was also fomid that the ovaries seemed niore 
sensitive to the effects of the rays than the outer skin of the alxlo- 
men, and when compared with control experiments in male rabbits 
,develoi>ed degenerative changes in shorter time and with fewer 

Berlin, klin. WochenBchrifl, January 16, 1905. 


His comments on the whole subject are as follows: "How far 
these observations in animals apply to human beings cannot as 
yet be definitely stated, nor is it known how permanent the effects 
may be. Whether individual susceptibility has any influence is 
also unknown. Dr. Brown's observations, which are appar- 
ently the first made on the human subject, seem to be confirmed 
by the animal experiments of our German confreres. While 
further proof is still desirable, it may be just as well to take the 
bull by the horns and institute measures for securing efficient 
means of protection for both patient and physician. Well-tested 
methods of shutting out the rays from localities where their effect 
is not desired are definitely known. It would seem a simple mat- 
ter by the exercise of a little ingenuity to produce a suitable pro- 
tectant with materials impervious to the x-rays, which we have at 
hand. If our fears are proved to be groundless, which now seems 
hardly likely, the trouble taken will not be very costly, and no 
restrictions will be placed on the use of what is one of the greatest 
of modem therapeutic and diagnostic measures." 



As has already been shown in a previous chapter, in healthy 
men each ejaculation of semen, after some days of continence, 
contains nmny millions of spermatozoa. There is, a,s has already 
been stated, much variation in the strueture and vital ac'ti\ity of 
these bodies in different men. In the strong ami vigorous they 
are large and long and very lively, and from this standard (see 
Fig. 43) they decrease Ixith in size and in vital energy. In all 
prx)l>ability there are in man, as in animals, periods in which the 
process of spennatogenesis is less active tiian at other times, and 
that intervals of rest may actually occur. In some men this func- 
tion is most active and continuous^ and as a result the sexual desire 
fis verj' keen. In others it is more sluggish, and has intervals of 
reposcj and the sexual activity of the man is less pronounced; 
while in still others the production of spermatozoa is very slow, 
halting, and feeble, and these vitaliiied bodies are much less de- 
veloped and active than they are in very vigorous men. We thus 
find that the development of spermatowm reprt^scnts a sliding scale 
from full, vigorous structures down to puny and almost inanimate 


'ITie observation of Li^gois, already quoted (see p. 81), which 
has the support of many other investigators, goes to show that 
after excesses in coitus there is for a time absence of s|)erniatozoa 
from the .seminal fluid. Recovery from this ciuidilion is speedy 
in some men and more or less delayed in others. la Li^gois' 


case it was found by the microscope that after abstinence from 
coitus for three weeks large numbers of these bodies were found. 
Tlic tnost extended series of observations as to the effect of coitus 
ii|Nin (he size and number of spermatozoa is that contained lo 
the cas4* reported by Casper/ which is very instructive. Ca^r 
says: "A vigorous naturalist, sixty years of age, a married mao, 
nnti father of a large family, and accustomed to the use of ibe 
nui-nKHfoj^e. whom I had interested in this question, examinwl 
witli me fnr some time continuously his own semen after coitus. 
Ilrrt* we found the greatest variations, which were accurately 
noted by l>oth of us together. After coitus on the tliird day, 
ivi'koniiig fnini the \i\si pLTfornmnee of the act, there was a lar||f 
nuiulK*r of very small spermatozoa; after renewed coitus on ih^ 
fuuilii day, few and small; after a pause of only two days, none; 
nfler a (»inse of only one day there was only a watery sperm. 
In whit'h no zo<>s|)enns were found. At another time, on thf 
\\t\\\ day after the last coitus, the zf>osperms were very numcTDus; 
ntuttl^^'^ tiiiii', after a pause of six days, they were few, but larpp 
\\\ «Ue; ftiur months after the last examination, and sevemy-lwit 
\\\\\\X% after the last act, the zoosperms were comparatively vert 
mimll. **i»d at another time, on the thin! day after the last art. 
\\\s^\ were innuniorable. Immediately after coitus, and befoi 
vm|»ivl»»U ^''*' bi»iddt'r, the urctlini was twice examined. Twi 
|<kUV h««»l'« H^ter the last act a drop passed out of the ui 
^sKll^tUHl numerous small zoosperms; at another time, after 
VU^^V diw«* inlervnl, there was not a single zoosperm." 

\\S \W event of re|>eated coitus it is probable that the su] 

ul w^'H«*to*\itt ic exliausted after the first few acts, and that 

;t \ in iHJtes of excess the secretion comes from the seminal 

aHi'liupN a lit^h* frtmi the prostate) and from Cowprr's 

f^^i^UHhutH glands of the urethra. In the observation 

WiHifUni Kv Uu«»Hi*'t.' in which a man had coitus eleven times in 

-fi uUM»n. it \n noted that after the eighth encounter the 
v.,,. , u<*^W\l i»*dy of turbid serosity {sirosiU louche), 

\ IVvvaakk Mwliplnr Sydenham Society's edition, 18M, p. Sft2. 
is \ r«ivut«« Wwinile-, etc., p. 2U et Mq. 


These careful observations have been fully confirmed by experi- 
ments upon animals by means of electric stimulation of the spinal 
centre. It is reasonable to suppose from what has tlni.s far Ix^en 
presented that the semen of men who are addicted to loiigH?on- 
tinucd 3e?aial excesses is, as a nih\ tinfertile, and that the power 
of fecundation (pntentia geiicrandi) can only hv. repaired by con- 
tinence and as the result of the re^storation of Nigorous health. 


Any morbid condition which interferes with the integrity of 
the pn>static ,S4'cretion is liable to so aher the ctmilition of the 
semen that its fnn-tifnng elements may Ix'come unfertile. These 
morbid eomlitions are mainly chronic posterior urethritis and 
chronic inflammation of the prostatic tubules, and in the same 
category may be inchuled the plngj^ing of the prostatic ducts 
with concretions, destruction, more or less great, of the gland fol- 
lowing gonorriueal abscesses, and the late developing small cell, 
submucous infiltration resulting from chronic posterior urethritis, 
which so scleroses the tissues that the ducts cannot perform dieir 
function. As causes of these morbid conditions, besides gonor- 
rhoea, may be mentionetl masturbation, excesses, anrl unsatisfied 
sexual desire, which cause congestion of the prostatic tubules, 
with the consequent loss of impairment of their secretory func- 
tion. Since all of these morbifl conditions may Iea<l to .sexual 
neurasthenia ami impotence, a further impainnent of the integrity 
of the semen may arise in the exliausted condition of t!ie system, 
which for a time may hold in abeyance the process of si>ermato- 
genesis. I have myself made many observations upon this class 
of cases, and have found that the spermatoiwa are very small and 
dwarfed in size, scanty in numbers, and very feeble and languid 
in their movements. When, however, the integrity of the function 
of the prostate is restored, and with it the establishment of a 
renewal of health, the eondirions of the zoosperms gradually 
change until they assume normal proportions and l>ecome vigor- 
ously active. 


My obs<Tvations and studies h&vc convinced me that to the nor- 
uittl <-!i<'ini<*fll compositifiii of the pnistatie Huid, consisting lar^r 
of phospliutt's of lime and soda, the healthy condition of the svmea 
is lar^'ly due. (See page 87 «/ seq.) 

In the chronic subacute prostatitis which follows excessive 
nmsturhution and sexual excesses it is not uncommon to find the 
irntttular jihospliutes in sufierubundant quantity suspended in i 
rtither thick, ^lalinuus mucus. Now, in the semen of many of 
thcw* cases I have observed that the zoosperms were Httle, frul 
IxMlics, having scarcely a»»y activity. The pertinent question, 
thnvfore, suggests itself whether this great excess of alkftfioe 
ndunxturt* has a devitalizing effect on the spermatozoa? Several 
huHltand.^ whom I have known to Ik* thus atfected were childksi, 
nhhoni<li they had vigorous and tiarid wives. 

Ali«en<^' or scantiness of the prostatic secretion in the ejacuUti- 
\\M\\ U'ttii to Sterility (imiMjiefttia generandi) by reason of the 
mmMMMMirrence of the normal fluidity of the secretion. We hai<' 
altvadv Hfcn tliat the dense, Ininpy, viscid secretions of the am- 
u^dlldioM^ (»r the vasa deferentia and of the seminal vesicles aiv 
iiMllliillv li*HH'(ied hy the admixture of the alkaline prostatic secir- 
\\\\\\s and that (hen the spennutiiiyia having nothing to impede their 
vIIhI H^llvltV «>r ^'^ prevent their invasion of the genital canals of 
\\\V* h^Hiahv When tlii.s partial liquefaction does not occur the 
lkl<lilM*HU« at«\ HO to speak, held prisoners, and they cannot go uzi 
^\s V^MV hi die fertilization of the female ovule. I have seen 
iVWIhI S^^""^ i'* wbich men's ejaculate has been a little grayis^i. 
iUWKV UIH*". <»' cnnsiilerable consistence, about the size of two 
m'H*. i»» W'Ki*'l*» *'^''" ^l**^"'^ ^■**''y recently voided, the spermatozoa 
WV^V OUUi JMtiiy, and nUnosl lifeless. In these cases some of the 
\m\K V^VW' tu bad lirwlth, and in others there was chronic pro»Utic 

i, , lAiiHiitiMl a c»ise in which this variety of semen was 

1 K\\ yt\\{A\ ftH'undation occurred as a result of throwing 

A m^^\ nHV^U*Wi \y\ Wnnn water into the vagina after coitus. II 

^ ^Uii^hfit«a^ NV«tUtu)t»tiliMchlechU,«tc. Erlangen. 1874, Bv il. pw 791. 


lis measure is to be of benefit in the melting-down of the seni- 

lal mass, it seems to mc that the most rutioiml solvent would 

a very dilute, w^atery solution of phosphate of lime and soda 

►r chlorid? of sodium (1 : 100 or 1 : 200) slightly warmed. In my 

?s benefit followed topical treatment of the genital tract. 



In acute gonorrhoea of the urethra the seminal fluid is more or 
ess contaminated by pus-admixture, and the spermatozoa are 
■found to be lifeless or capable of very little motion, as I have 
Seen in numert)us microscopic examinations. It is very probable 
hat gonorrhcca or its toxins exert a deleterious or even deadly 
inHiience on these frail bodien. Terrillon* has clearly shown that 
in bilateral gojiorrho^al epididymitis the semen is mixed with pus 
and that spermatoi&oa are absent. His observations go to show 
that as long as pus is produced in the epidiilymis, even in small 
quantity, its elTect is so lethal to spermatozoa that the semen 
remaiiiii unfertile. In all probability healthy spennatow>a are 
killed in the female genitals by pus or its poisons. In some cases 
failure of impregnation undoubtedly is due to the presence of 
the thick, viscid plug of mucus or mucopus in the uterine neck, 
which, by its density, offers a burner to the spermatic invasion. 

The extent of the influence of acute or chronic gonorrhceal 
seminal vesiculitis and gonorrlmcal inflammation of the defer- 
ential ampullations is really not well known, and most of the 
reported cases of this morbid condition are fragmentary and unsat- 
isfactory. Just after recovery from acute gonorrhu-al seminal 
vesi<'ulitis it is {Mtsitively known, oh I can attirni from uhservation, 
that the senu*n is a thin, turbid, yellowish secretion » more copiou.s 
than in heiilth, containing few, if any, spermatoicoa aud more or 
less pus. Ntnv, in these caries it is probable that tlie s]K*rn]atozoa 
have been killed by gonococci or toxins. IIow long this condition 
lasts we are unable to say, but it is fair to assume that healthy 
spermatozoa can only live in these secretions when they are nor- 

■ Op. ciL, p. 439. 


s mil- 

mal and free from toxic admixture. In chronic seminal vesiculitis, 
though the pus may be less in quantity and the toxiiis less riiu- 
lent, such is the effect of their presence that the nutritive 
of the spermatozoa (the secretions of the ampullations and 
seminal vesicles) are so altered that these organisms are 
dwarfed or killed outright. 

Wliether a purulent inflammation of the ejaculatoiy ducts cao 
so alter the composition of the semen as to render it unfertile we 
are not able to say, hut it is ob\ious that gr)nr>rrhcpal pus-a<Imiv 
ture is a dangerous factor^ even when present in small quantiiv. 

^Vhen we reflert upon the foregoing considerations the convic- 
tion forces its<*lf on our minds that pus in the deep sexual jwirt.^ 
may have much to do in causing temporary or permanent azo6spe^ 

Blood-admixture. Bloody Ejaculations. 

The semen may become mixed or streaked with blood, 
to a morbid comlition of some part of the sexual tract. 
difficult to determine how far blood-admixture tends to inducr of 
produce azoospermatism. To settle the question it is necessarj- to 
understand the nature of the processes which lead to or cause the 
escape of the blood, and to ascertain whether this fluid can e3 
a morbid cfYect on the zotispcrms. Experience and study scero 
show quite clearly that a small amount of blood mixed with 
semen dot\s not destroy its fecundnting |>rf)|M'rty. T^rge amoun( 
however, may so dihite this fluid that its genuinative faculty 
lost, probably thn)ugh dilution. In tul)erculosis of the testis 
semen may become thoroughly mixed with bliMKl, and may then 
resemble red currant jelly (rose semen). Such semen is, as a rule, 
unfertile, as a result of toxin action, and the blood-atlmixture h«»_ 
probably little effect on its Integrity. 

In acute and chronic gonorrho'al inflammation of the semii 
vesicles and deferential ampullations the escape of blood is 
unc*ommon. But in these cases there is an underlying vii 
process, which may by its poisons kill the spennatozoa, 
semen in these conditions may have a fresh re<l color or ii 
have a decided rusty tint. The intennixture of blood and sei 



is in these cases usually intimate and well blended. It is very 
probable, as claimed by Jamin/ that a passive congestion of the 
seminal vesicles (and, 1 would add, the ampullations) may result, 
without gonorrhccal infection, from excessive coitus, masturbation, 
and perhaps even from prolonged continence, and that this con- 
gestion may give rise to little hemorrhages and blood-admixture. 
Wliei] tins occurs the semen has the nj.sty color alivaijy mentioned. 
We have no knowledge as to whetlier such semen is fertile. 

lu cases of gonorrhtea involving the ejaculatory ducts small 
hemorrhages in and aroun*! these tubes have been found, on post- 
mortem examination^ to have occurred. It is fair, therefore, to 
assume that in some cases the semen may become strt^aked with 
blood in its passage througli these canals. In its acute declining 
stage and in chronic gone>rrlKeal posterior urethritis more or less 
copious hemorrhages may occur in coitus or in pollutions, and as 
a result the semen is sti*cakcd with bright-red blood. In like 
manner in acute or chronic gonorrhoea of the bulb of the urethra 
hemorrhages sometimes occur in coitus or pollutions, and in some 
instances they are very copious. I have seen several men in 
whom the flow of blood was quite severe, and who when in coitus 
thought it was due to incipient menstruation in the female. 

In all probability blood itself is not noxious to the vitality of 
the sjiermatozoa, Imt the gonorrlnea! process is distinctly so. In 
large (|uantity, however, the blocjd ujay so dihite the seminal fluid 
that the fecundating j)ower of the ^oosperms is lost. 

It is very rare that lesions seated in the course of the pendu- 
lous urethra cause enough bleeding to tinge the semen in transUu^ 


In sexual neurasthenia it is n4»t unoomniua to fiml axoiispemia- 
tism, which may be due to the general malnutrition of the patient 
or to the local lesion which is the main cause of the nervous state. 

* Considerations Patbogeniques snr ril^tDOBpermie d'Origine noii-iiiHamma' 
toire. Annalea dm Mai. des Org. Gt^n.-urin., 1891, p. 765 et f)ei|. 


In general, in this class of cases there is some form of chronic 
prostatic affection or disease of the arnpullatioii>i and of the sesoh 
inal vesicles which leads to an unfertile condition of the semen. 

It is no longer contended that all persons suffering from tuber- 
culosis are azoospermatous, since spermatozoa have been found in 
the deep sewial parts of many men who died of phthisis. Wben 
the testes or epididymes are invaded by tuberculous inffanunatkm 
the spermatozoa are probably killed by the toxins developed. Ift 
several instances 1 have seen such viscidity and lumpiness of ibe 
semen of consumptive men that I have been certain that the punT 
and sometimes fatty degenerated spermatozoa were incapable of 
impregnation. 1 have seen several instances in which such mett 
have {'oba!>itod for long periods with perfectly healthy women who 
did iiiit U'come pregnant, although they had taken absolutely no 
measures to avoid that condition. 

In all probability when phthisis causes azoospermatism it is 
by its local lesions in the testes and epididymes, in the ampullo- 
tions) and seminal vesicles, and in the prostate or by* lis genenJ 
atlynamic effect, which dwarfs the production of healthy zoosperms 
and prevents the fommtion of a mucus of proper nutritive qualitj 
and of normal specific gravity. The influence of syphilis oo 
spermatogenesis has already been considered. (See page 201 H 
seq.) It may be added, however, that perhaps in the early stagr, 
when the poison is very active and abundant, it may interfeTf 
with the delicate process of zoosperra development. It is not 
uncommon, however, to see men in whom sypliilis is yet active 
impregnate healthy women, nor is it rare to see recently syphilitic 
women Ix^come pregnant by healthy or syphiliti*' men. 

We have no scientific evidence as to the influence of general 
infective processes upon the formation of the semen. It is prob- 
able that during the activity of the disease, and jx^rhaps for some 
time afterward, spermatogenesis ceases or is impaired. 

No general statement can be made as to the effect of old age 
upon the productioti of semen, since there is so much variatioaj 
in the sexual actixnty and capacity of different men. In some 
instances fertile semeu is present in men of sixty-five, seventy- 





•• •• 

Sr.niiial O lis nnd Grnnulai Phospliates fror 



.five, and even beyond ninety years. In general, however, a 
'gradual or rapid dpcline in the proHiirtivity of the testes begins 
at or before the sixtieth year. In snme men, however, the sper- 
matogenic function is lost much earlier in life. 

Any cause, therefore, which deranges the structure of the testis 
^impairs its function, and as a result spermatfizoa may not he pro- 
duced, and the seminal cells may be pre.sent iuj or they may l)e 
absent from, the semen. 

Tu Plate TX. azoosjxrmatous semen from a patient who .suf- 
fered from chronic gonorrhceal epididynio-r»rchitis is depicted in 
which seminal ceils and granular phosphates are present. 


Watery Semen and OoUoid Semen. 

Though special mention is made of these forms of semen, they 
are in reality only .sj'mptoraatic of some chronic affection of the 
ampuUations of the seminal vesicles, of the prostate, or of the 

Watery semen is usually of a slightly yellowish, turbid color, 
and consists of a thin mucus in which arc suspended living or 
dead spermatozoa in small quantity, with perhaps some pus cells 
and granular phosphates. In some cases it has lieen obser^'ed 
that watery semen is very copious, since as much as one or two 
tablespoonfuls, or even two ounces, have tM*en discharged at one 
ejaculation — a condition which is called polyspermia. In such 
cases impregnation can scarcely occur, since the spermatozoa 
cannot obtain a hold on the vaginal mucous membrane, but are 
carried awav in the flood. 

Watery semen is the direct result of morbid changes in the 
aropullations and in the seminal vesicles, which so impair the 
functions of the muciparous glands that a very diluted secretion 
is produced instead of the normal viscid and heavy mucus. Fol- 
lowing double gonorrhceal epididymitis, watery semen may be 
ejaculated for varying periods of time. 

A colloid condition of the semen is, as a nde, observed in ca,ses 
in which the prostatic secretion is not thrown into the urethra at 


dbr timr of eniUsion. It is, therefore, the direct outcome of chronic 
HHOtb^l processes in the prostate gland. NonnaUy, as we hart 
9(*n (pttf^ ^)f ^he secretion of the ampullations and the semioAl 
Y^iicipji is nscid and lunipy, as shown in Fig. 45, in which the 
itMind. oval, and irregular, small, large, and ven-' large masses of 
AiAvy and glassy mucus are shown. This lumpy condition b 
mmdly li<iuctietl and broken up when the prostatic fluid is mixrd 
in the prostatic urethra with the secretions from behind — r. ^^ 
fn>m the ampullations and the seminal vesicles. 

Tn this colloid condition of the semen the movements of Uir 
siM'muilozoa, even if healthy, are so hindered that they cannot 
bring about their irruption into the uterine cavity, hence the semm 
is bv reason of a mcclinnicnl caus<\ unfertile. With the cure of 
the prostatic iutinnitv antl the re-estabHshment of tlie sc<'reU>r)* 
function of that gland the colloid condition of the semen eeAses, 
and it again bet^omes a fertile fluid. In the semen of persons 
addicted *o the opiimi habit or other drug addiction sperraatoro* 
urt^ cither abs<-nt or ixiorly developed. 

DiminiBfaed Quantity of Semen. 
When the six^rmutic rjaciiliitc of a man is very small he is said 
In be suffering fnim th*^ condition imeuphonously ca!le<i oii^ 
' This condition is found in feeble and old men, in con- 
^Indves or persons who have committed sexual excesses, and. 
^\\^' 11,, jn chronic, seminal vesicular, and deferential div 
\^ In some men. even in those seemingly very healthy, the 

^^y. of semen is normally very small, even to the amount of 

. j„ others the rpiantity is larger, an<l so on the scale 

* «Rn1 the uonual free ejaculation is present. 

1 order to give » patient an intelligent and honeft 

his sexual futun' in cases of disease or imj>erfe<1 

bs<»hitely necessary to get a full and accurate hLstorj 

1 ti bits uimI to ch-arly usivrtain the morbid conditioo 

ntinnity. lo cases of sexual excess of any kiad' 

i.i^^iids entin^lv upon the docility and future 

■| ij^ patient. When urethral, prostatic, seminal-, 




vesicular, and ampullation morbid conditions are the direct causes, 
the future of the case intimately depends' upon the accuracy of 
the diagnosis and the efficiency of the treatment. 

In tuberculosis we cannot hold out bright hopes of sexual resto- 
ration; but in neurasthenia, in general debility, and in syphilis it 
is fair to assume that appropriate treatment, together with good 
hygiene in its broadest sense, will bring about improvement and 
even cure. In all cases in which gonorrhoea is an active factor 
the outcome depends on the ability of the surgeon to remove the 
morbid process. 

Treatment. — It is unnecessary here to do other than refer to 
the therapeutic sections of the chapters on diseases of the testes, 
on chronic posterior urethritis, prostatitis, and seminal vesiculitis. 



The term iispermatisni is applied to that corulhion in whidi 
the power of normal coitus exists, hut in which the ejaculation 
semen does not occur either in that act or during sexual exci 
ment. In such cases the final perinri of the sexual act U aJtfei 
Patients thus aftlirted say that tlie contrartions of the pel 
muscles which complete ejaculation are absent, 'ilje term is 
ther used to omhrace oases in which there is a defiriencv id 
quutitity of seiiUMi ejaeutated. and also those in which ther 
is irnpefled, defeftive, or iTJi|jerfeft ejaculation. 

This condition is much rarer than azoospemiBtism, Bnd & 
depends on lesions seated between the deferential anipullntions and 
the seminal vesicles and the meatus urinarius or the piepiiliai 

The essential cause of aspermatism is the stenosis, or hlorkin^J 
up, or destruction of some part of the sexual tract to such M 
extent that in the rhythrnical movements of ejaculation the .semi 
fluid is either directed from or dammed hack in the course of 
urethm. The impediment may occur in the seminal vesicles^ tl 
deferential ampullations, the ejacuhUory duets, the prostrate giaixl/ 
the urethral ennal, at the lueatus urinarius, or the preputial orificf. 

Aspermatism may be either permanent and alxsolute or tem| 
rary am! relative. 


Aspermatism due to fistulous tracts passing from the 
vesicles to the rectum or hhidder Is so rai'e that such a woul 
be looked upon as a curiasity. Several such cases are on rccoi 



the fistulffi resulted from bladder or Uthotoniy opera- 
ions. In tFiese cases the semen was ejacuhited into the reetmn. 
It is possible that sympexia may become lodged in the orifice of 
the seminal vesicle or in tliat of the deferential ampuUations; in 
^general, however, the plugging up occurs in the ejaculatory ducts. 



A variety of morbid conditions may occur in and around the 
ejacnlator}^ ducts which may rt*snlt In aspermatism. Tlie pUig- 
gtng up of these minute canals by sympexia is of rather rare 
o<'cnrn^iKv. A most striking instance of this accident is presented 
y Reli(|uet's' case. It was that of a man, aged thirty-five, who 
in coitus was seized with a severe pain in the deep urethra which 
radiated to the anus and perineum. Afterward defecation and 
urination became painful, and coitus was so agonizing that is was 
not indulged in. By rectal examination the left seminal vesicle 
was found swollen, llie man was examined by means of a litho- 
trite, and after withdrawal tlie patient experienced severe pain in 
the penis, wliich was followed by the discharge from the urethra 
of a large quantity of sympexia. After this relief the perform- 
ance of the sexual function was perfect. 

It Ls very probable that in thus and in similar ciLses the great 
distention of one ejaculatory duct blocks the other one up very 
cfTertuHlIy, as these caiials lie so close together in the prostate. 

Cases have Iml^cu reported in wliich, on post-mortem examination, 
the ejaculatory ducts have been found to be plugged by concretions 
as large as a pea or a cherry, which were composed of carbonate 
and phosphate of lime, and mucus and spermatozoa. Chronic 
gonorrhfpa has l)een found to produce a stenosing condition of the 
ejaculatory (hicts, cliiefly by its round-cell infiltration of the sub- 
Diucous connective tissue of the verumontanum, which it attacks 
more severely than other portions of the posterior urethra. Round- 
cell infiltration around the ducts pnxlucing stenosis has been 
found in the dead subject. 

1 Picard. Tmild des Maladies de la Proaute. Piru, 1B77, p- 129. 



Dense fibrous bands upon and behind the veruiuontauum h»we 
been seen to so compress or distort the ejaculatory ducts that eidier 
stenosis has been produced, or a deviation in the course of tbf 
ducts or of their orifices has resulted. In tlie former event the 
semen was dammed backward; in the latter it was in coitus thrown 
backward into the bladder. 

Arch-like bands of fibrous tissue have been found seated s&didk- 
like across the summit of the verumontanum, and as a coDsequtnce 
one or both ducts were obliterated. Gonorrhoea may cause absos 
formation in some or any of the prostatic tuliules, which vni\ 
result in such scar-tissue development that the ejaculuiorj' liucts 
arc destroyed. 

In some cases of chronic gonorrhoea the involwinent of 
tubules has ended in cystic degeueralioii, whicli was produced 
sclerosis of the tissues and obliteration of the ducts. 

Cases are on record in which traumatism of the prostate ai 
verumoiitanum, resulting from the passage of, or retention at 
sounds and catheters, has l:)een so severe that the ejaculatoij 
ducts have either been compressed or the direction of their oi 
has l)een thrown so much out of place that they have looked back- 
ward to the bladder. This retroversion of the orifices may \k 
partial und only cause them to look upward, or it may bt 
complete, in which event the discharge of semen occurs dirvcd; 

Dispiaceinont of the ducts and of the prostate has been koovo 
to follow abscesses of and injury of the [M'rineuni (from ftIK 
blows, and infectious processes), which caused a dense fibrou* 
cicatricial muss to draw tliat gland downward and to much distort 
the anojH^rineal and rectal regions. 

In tuberculous iaflannnation of the prostate the ejaculatorr 
ducts nuiy be compressed or destroyed. 

In old men these canals may, when the prostate becomes h; 
trophied, either Ije narrowed or entirely stenosed. 

Calculi and concretions in the prostate may cause compi 
or stenosis of the ejuculator)' (hicts, and aspermatisiu may- 
It is probable that when many prostatic tubules and their di 




re plugged up by lime, salts, mucas, and amyloid bodies inju- 
ious compression may be exerted upon the ducts. 

Abscess of the prostate with its (in favorable cases) subsequent 
cicatricial development and resulting contniction may utterly oblit- 
erate these little canals. A very interesting case was reported 
many years ago by Dongas/ which is worthy of a brief summary. 
A man, aged twenty-six years, was attankrd after a long horse- 
Lack ride with pain and tenesmus in urination and shooting 
winges in the rectum. He had fever and was delirious. The 
prostjite was found, upon rectal examiimtitni, to Ije very lar^e and 
painful, and an abscess was suspected. The operator, with his 
left index finger in the rectum, firmly supported the prostsile, 
"while with the other hand he introduced a sound into the urethra, 
the tip of wiiich, on abutting against the abscess, ruptured it and 
a quantity of pus soon escaped. Two months after this the man 
complained of an acute pain during ejaculation, and stated that 
his emission was only half as copious as it was before his sick- 

In all probability one of the ejaculatory ducts of this patient 
was obliterated, for it was noted after healing had taken place 
that the prostate had lost one-third of its vohime. 

Diminution in size and distortion of the shape of the organ are 
generally found after abscess of the prastate. 

It is not uncommon for abscess of the prostate to open into the 
rccttirn, into which the urine and semen arc for King or short 
periods tliseharged. In tins event temporary or permanent 
aspermatism may result. This may occur also wl»en the abscess 
opens into the bladder, the inguinal region, an<! the sciatic notch. 

Perineal fistula* may result from abscess of t!ie prostate, and in 
this event if the ejaculatory ducts be not obliterated the emission 
will probably pass through the false passages and ooste out at the 

Permanent aspermatbm may result from injury of the ejacula- 
;ory ducts in the operations of latend or bilateral lithotomy. 

> Th^ de MontpelUer, 1832. 


There are a nuniljer of well-reported cases on reconl» i\w\ ti 
have l>een added by Horwitz,* 

A brief synopsis of Horwitz's cases develops the followi 
interesting facts: Tlie patient, a married man, aged 20, si 
that he was in perfect health, as far as his sexual functions 
concerned, up to the spring of 1890, when, suffering from sXi 
in the bladder, he was openited upon by a prominent surgeon, 
who performed the lateral openition for Uthotoiny. 

The stone was very large and it retiuired a good deal of four 
and trouble to remove it. After the oj>erdtion be remained an 
invalid for the space of six weeks, a fistulous opening remaiiiiiif 
which continued for tiiree months, discharging a few drops i*^ 
urine whenever he was called upon to micturate. The oprninf 
finally closed without sui^ical aid. 

After he had become convalescent he found that Ijis 
powers were much impaired. His erections were weak and flabbr; 
frequently subsiding before intromission, and when he succee«W 
in having an erection sufficiently vigorous to j>ermit the sexittl 
act, no emission followed. His desire for sexual intercourse vii 
unimpaired. As time went on his erections became more aoJ 
more feeble, until he altogether lost sexual power, altliough dcsiff 
was still strong, 

Tlie penis and testicles were normal. On examining the un 
hy means of an endoscope, the cicatrical tissue resulting 
the operation was found to extend front the membniuous toai 
half the length of the prostatic portion of (he canal; then* wjtf 
great deal of congestion, as well as marked hypenesthesia. 
nonnal calibre of the urethra was 33 T.; the meatus, 26 F. 

The treatment consisted in enlarging the meatus up to tlie 
calibre of the canal. At the end of four uKuitlis the con| 
and hypenesthesia had tlisappeared, and the patient began to 
healthy, vigorous erections in t!ie morning* Cold local baths 
now used, and the constant current passed for twenty rainutrt* 
daily, extending from the lumbar portions of the spine throu^ilW 
peniS| testicles, and perineum. 

* Journal of th« American Medical Aattociatlon, April 8, 1893^ 






TTnilcr this treatment, continued for six months, an entire cure 
of the iinpntencc wns effected^ hut the conilition of HspennHtisin 

nuiined. Wlien the orgasm takes place there is a slight <]is- 
harge from the urethra of mucus with prostatic secretion, which 

ntains no semen. 

He was informed that he would alwa^'s remain sterile. 

Tlie second case was that of a young man twenty-eight years 
Id, immarried, who had enjoyed perfect health up to three years 
previous to his first visit. 

He iia<l l>een treated for the space of two years for wliat his 
hysician called cystitis, when he was examined by a physician 

ho detected a stone in the bladder, T^his was removed by the 
left lateral operation. When he regained his health some four 
^'wks after tlie ofH-ration he discovered timt his sexual power, 
which was normal Wore the operation, had become very feeble; 
the erections were infrequent, flabby and transitory'. He luid had 
o emission since the operation. The erections t)ecame more 
nd more feeble, and farther and further apart as time progressed. 

A year after the operation he was first seen by Horwitz, at whicit 
time he had not only lost all power of erectioji. but his sexual 
desiiv had entirely ceased. His condition so aflecterl his mind 
that he was in a most distressing hypochondriacal condition, 
together with marked neurasthenia. He was ])ale, thin, with a 
coatetJ tongue, constipated Ivowels, cold, clammy skin, especlHlly 
affecting the hands and the feet. His expression was careworn, 
anxious, and gloomy. He was unable to apply his minci to any- 
thing requiring serious thought, and did not for a moment forget 
his trouble. Ix>cid examination showed najch the same con- 
dition described in the first case. 

The treatment was the same as that observed in the first case, 
and every effort was nuide to arouse and interest the pntient, 
without avail. 

He l)ecame the prey of rmmerous quacks, and when last heard 
from was m seclusion in a private asylum. 

An this was a form of impotence in which both power and 
desire are lost, and which is frequently associated witli hypo- 


cliondriusLs, an iinfuvoral)le prognosis was given for the reason 
that tl»e iLspernmtisiu wns due to structunil injury, a conditko 
beyond surgical relief. 

In both these cases the indivifluals were sexually strong and 
vigorous prior to the performance of tlie lateral operations. 
became sterile and impotent only after they had suhinitted to- 
surgeon's knife. Ilorwitz asks tlie fiuestion, '*Is this not a 
reason for advocating the high operation whenever practicable' 

In the rare event of congenibil ahsetioe or atrophy of the pros- 
tate semen cnnnot reaeli the urethra, for the reason tliat there 
no ejaculatory ducts to transmit it. 


Stricture of the un^thni is not nucoinnionly the cause of asper^ 
matistn, and also of impeded or imperfect ejaculation. It b to 
be remendw^red that in normal coitus the semen having been 
thrown into the bulbous urethra, the intrinsic and extrinsic musdr* 
of this segment of the nmal then foreilily contract and throw the 
ejaculate towanl the meatus. (See |iage 60.) For the propcf 
perfonuance of this part of ejaculation it is necessary that the 
integrity of the uretlira outside of the triangular ligament shoukl 
be retained. Whenever, therefore, any considerable contmction 
of the bulbous urcthra is produced (and it is genenilly caused 
gonorrh(ea) the ejaculatory act will be lanie and halting at 
part. Thus it is not unconunon for men having soft strietui 
down to 15 or 20 of the Frencli scale, to complain of disal 
and a sense of some impediment Ijeing present at the end of 
in the bull>ar region. In some of tFiese cases the ejaculatii 
weak an<] prolonge<I; in others it is more or less incomplete, 
as the penis becomes flaccid the emission slowly dribbles from 

In the case of a tight stricture at the hull) there niay be 
emission at all in coitus, but a dribbling discharge may occur 
time after the completion of tlie act. In tliis event the sci 





dammed backwanl in the membranous urethra and in the ante- 
rior portions of the prostatic urethra, and it slowly flows forwanl 
after a short or quite long interval. Men thus afflicted sometimes 
complain of pain, due to slight spasm of the compressor urethras 
muscle and to the abnormal distention of the canal. In other 
cases a sense of fulness is experienced, and such a check is pro- 
Liced in the rhythmical contractions of the sexual tract that the 
;jpical sensation is obtunded or is aljsent. 

Tn very old and extensive inodular strictures of the biilbo-mem- 
ranous junction tliere is no post-<'oitionul flow of semen, and this 
Secretion tiien passes backward into the bladder and is nnxed and 
expelled with the urine, which then lias u very milky appearance. 
MHien these cases an* cfiinplicated with one or more perineal fistnlffi 
the semen passes into tlie tracts and oozes over the anojjerineal 
Tegion. (See Fig. 4S.) 

Strictures at the penoscrotal angle in the anterior urethra cause 
impediment to tlie escape of semen in proportion to tlie smallness 
of their calibre. Wlien the contraction is very slight little hin- 
drance to ejaculation is offered, but when it reaches the degree of 
reduction in calibre of 10 or 15 French then imperfect and defec- 
tive expulsion may be produced and post-coitional dribbling may 
occur. In these cases, even when the stenosis of t!ic urethra is 
quite complete, there Is no reflux of semen into the bladder, and 
it, when the parts become relaxed^ slowly dribbles from the meatus. 
In sevend of these cases the paiients have tuld me that after coitus 
they experienced a sensation of fulness in the perineum, which was 
only relieved by compressive manipulation, which caused the se' en 
to gradually escape forward. 

In those somewhat rare cases in which the whole anterior ure- 

ra is the seat of tight stricture ejaculation is very iinj>erfect and 
halting, and such subjects are practically aspermatous. (See 
Fig. 49.) 

Stricture at the meatus, which b the result usually of chan- 
croids, chancres, gangrene, warts, chemical and instrumental tmu- 
matism, and perhaps of gonorrhcra, may lead to the various grades 
of aspennatisni, from slight and feeble discharge to post-coitional 


dribbling, or even to the damming back of the ejaculate. In these 
cases t!ie urine usually escapes in a fine stream, hut in coitus, with 
its turgescence of the mucous membrane and a secretion of much 
greater density passing through the stricture, the conditions are so 
altered that more or less perfect aspennatism resultii. 

Stenixsis, or smallness of the preputial orifice, whether congen- 
ital or acfjiiired, is not infrequently the cause of vaning degrees 
of aspermatlsni. Patients having tliis form of phimosis usually 
state tliat in their earlier sexual years ejaculations were satisfac- 
tory, and, to their mind, uninii>eded. ;Vs they grow old the stenosed 
condition usually Ijecomes more pronounced, and with the dimixi* 
ishing calibre of tlie preputial orifice the various grades of morbid 
emission, from defective and impeded ejaculation up to complete 
aspemiatism^ are produced. 

Fio. 90 

Uretbr&) c&lculus eorapoAed of phosphate of lime. Natural eiee. CalcaliB 
ooDdisted of four articulated segments. ( After Dolbcau. ) 

The pn)lmble explanation of these cases of stenosis of the meatus 
urinarins himI of the prepuce, which are quite jvenneable to the 
escape of urine, and which iitfer an inipeeliuient to spermatic emis- 
sion, is that the urine is a mucli thinner fluiil than the semen, and 
that in urniation the vis a tergo is greater than in coitus. 

It is well to remeniljer that after coitus, in almost alt cases of 
aspennatism, there is the escape of a few drops of clear mucus 
from the meatus, which is secreted by the urethral muciparous 
follicles and crypts and by Co\^'per*s glands. 
Preputial calculi may be (he cause of organic Impotence or of 
temporary uspennatisni. 

Calculi are sometimes foun<l in the urethra, where they may 
increase to such a size that blocking up of the canal is produced. 
(See Fig. 90.) In such cases the ini|>etliment to urination nmy be 
tolerably well marked, but the escape of semen is so much retarded 



that incomplete or tJilficuU ejaculations, or actual ai^penuatism, 
'mav result. Tliese calculi may be seated in the bulbous urethra 
Bt the penoscrotiil angle or in the course of the anterior ui'ethra. 

Many men suffering from priapism, while capable of intromis- 
sion, fail in the act of ejaculation, lliey are, therefore, tempor- 
arily at least, aspermatous. 



Two anomalous cases of asperniatism have !)een reported by 
Ultzmaun/ The first was that of a man, forty years of age, who, 
though married, had never been able to produce semen. During 
coitus he experienced tlie sensation of ejacuh'ition and felt a kind 
of satisfaction. His testicles were small, i>ut his genital organs 
were pronounced by ITltzmann to Ije perfect. It was proved by 
examination of the urine that the semen in coitus di<l not regur- 
gitate into the bladder. 

The second case was that of a robust man, aged twenty-four 
years, who was potent as to coitus, but had never had an ejacula- 
tion or a pollution. He had never liad any sexual desire, and his 
genital organs were j»roni>unced to be iioniial. He remained per- 
manently aspennatous. 

Belkowsy descrilies the case of a man who, although murried 
for four years, had never been able to jH'rfonn the M'xual act. In 
spite of the fact tliat his genitals were normal in development and 
his general bodily condition was excellent, he was totally devoid 
of sexual sensations, had never in his life had erections, and only 
(|uite lately had he had some nocturnal emissions (consisting in 
att probability of the secretion of Cow[)er*s glands), accompanied, 
however, by only imperfect erections. He was totally indifferent 
to the female sex, but no trace of sexual perversion could be 

Such cases as the foregoing are paradoxes, and the attempt to 
explain them on the ground of non-excitability of tlve reflex centre 

^ Op. dL, p. 116etaeq. 


of ejaculation (the existence of which has not been proved) b 
very UTKsatisfactory. Cases liave l>een reported, however, in wliich 
it is probahic that disease or traumatism of the nervous system 
resulted in asj)emiatism. Thus the old-time case of tbe soldier, 
who, as a result of concussion of the spine, wius afFected vrilb 
complete anivsttiesia of the external genitals, an<l aspermutism in 
coitus, althou/^h lie had noctiinial jK>lhitious, present-s a clear and 
intelligible clinical picture. Other cases are on record in whidi 
anaesthesia of the glans penis was the cause of teuiporarv aspcr- 
matisni^ but tliey are so lackijig in essential detiiils as to possess 
but little value. 

In fibroid sclerosis of the corpora cavernosa anseathesla of the 
glaus sometimes occurs toother with non-turgescence of the pMts 
in sexual excitement and coitus. In such cases ejaculation maj 
be difficult, incomplete, or entirely al>sent. 

In cases of destruction of the distal portion of the penis from 
chancroids, chancres, gangrene, and phagedena, such has l^een the 
anaesthesia or the insensitiveness of tlie parts produced tliat more 
or less complete aspennatism has followed, although the calibrr 
of the urethra was not injuriously stenosed. 

Mutilating Meatotomy and Damage to the Urethra. 

I have seen two cases in which, after extensive and grcatlv 
deforming meatotomy, an aspemiatoiis condition was produce*! 
which the patients uccouiitcd for on the gi'ouikl of unnatural insen- 
sitiveness of the glans y>enis. In several cases of so-called strictures 
of large calibre, which were very much overdilated and deeply cut 
by zealous surgeons^ these patients, besides suffering from decided 
curvature of the penis, experienced such queer and ainioying 
sensations (tingling feelings and darting pains) in the urethra in 
coitus that partial ejaculation only occurred after very prolonged 
and tiresome efforts. 

Partial Asperinati^m. 

Some men are tenipon»rily asjvennalous in consequence of the 
inhibitory action of the bntin. In these cases men nniy have 



itbfactory coitus with some women and cannot complete the act 
ith others. In other instances apathy, loss of affection, fear, 
isgust, peculiar environments and situations, unattntctiveness of 

vr some objectionable condition or habit in the female so alfect a 
.n's raind that, although erection occurs, ejaculation is inipos- 

lible. These cases resemble in some particulars psychical impo- 
fnce. (See p. 97 et seq,) In many of them the semen dribbles 

iway after sexual excitement has subsided. 

Debility and Lack of Nerve-force. 

Then, again, some men are so weak and so much debilitated or 

lentuUy worried, that although erection, partial or complete, 

;ciirs, there is not sufficient nerve-force in tliem to call hito 

[vigorous action the intrinsic and extrinsic muscles of the sexual 

tpparatus. Tins condition has been designated atonic asperma- 

tism, and it is not of necessity of permanent duration. In most 

cases it has been preceded by a period of full sexual activity, 

Di&gnosis.^In every case of aspermatism it is absolutely neces- 
sary to get a full history of the symptoms and antecedents of the 
case, and then to make a discriminating examination of all the 
segments of the sexual tract. In all cases a thorough examination 
of the urine should be made. When the symptoms point to lesions 
of the ampullar and seminal vesicles, exploration of these parts 
and examination of the urine are necessary. If the troul>le is 
seated in the ejaculatory ducts, the <juestion arises, Has the patient 
had gonorrhrra, or abscess of the prostate, or is the disability due 
to plugging up by concretions or calculi? An intelligent iind 
searching inquiry on these subjects will usually elicit importaiit 
information. Ijcsions of the prostate being so often the cause of 
aspennatism, inquiry into the antecedent'^ of the case and rectal 
examination of that gland are to be made. 

In most cases of stricture of the uretlira symptoms referable 
to t!mt condition will coexist with the aspennatism, and then a 
careful exploration of the urethral canal should be tiuide. 'Diesc 
same remarks apply to instances of urethral calculi. 

In the cases which in this chapter have been denominated 


anomalous the inost searching inquiry into and exploration oft) 
sexual sphere should be made, in order to find out wht-ther tl»e 
are any malformations or obscure conditions produced hj diseac«J 
It is usually very easy to learn concerning nerve traumatismT and 
when mutilation or destruction of the penis exists careful e 
ination will re\*eal its nature and extent. 

Fro^noais. — In genemi, the prognosis of aspermatism is n 
encouraging, particularly if due to malformations. \Mien 
stnictunil damage ha.s F>een done {.seminal vesicles, ampullir, eja 
latory ducts, mid prostate gland) little hope can be offered lot 
patient of his reacquiring good sexual ability. 

Calculi in the proatatt^ or ejaculatory ducts can be removed 
oi)enifion. In tlie milder forms of sfriciure i»f the urethra, and 
even in severe forms, cure of aspermatism can be brought a 
by the re-establishment of the calibre of the urethra. In the vei 
old cases of nodular stricture at tjie bulho-membraiious junction^ 
particularly when complicated by perineal fistulse, it is ha/jinloitf 
to give a favorable prognosis. 

When the meatus or the urethra has Wen pennanently damapJi 
by ill-advise<I .surgical procedim^s surgery offers very little in tht 
way of relief. In some cases of very extensive meatotomy thtr 
parts may lje restored by proper surgical technique. 

Treatment.— In all the foregoing cases in which serious stnic- 
tunil changes are present in the deep sexual tract little of rral 
U'riefit can lie done by surgical means. 

Calculi may be removed from the deep urethra, tlie prostate, 
and ejaculatory ilucts either by the urethnd forceps, the lithotrilr, 
or by external urcthrotomy. 

vStricture of tlie urethra, if of the soft variety, rany be cured hy 
instillations of nitrate of silver and by careful gradual dilatation. 
Inndular strictures and ijuite dense annular strictures call for cither 
internal or external uretlirotomy. 

Cases of aspennatisni due to the inhibitory influence of the brain 
shouhi Ih' carefully iiiquiivd into, and when the exciting cause 
as(rrtaiued« its avoidance or removal will, in all pro1>abiHty, 
promjitly followed by normal ejaculation. 



AVhen severe stenosis of the meatus unnarius is present the 
resulting asperniatism may be promptly relieved by a properly 
performed meatotomy. In like manner, in cases of pinhole-sized 
preputial orifice, circumcision is followed by very gratifying 




So many cases of sexual weakness and impotence are daHl 
structural changes in tlie deep portions of the urethra that i 
knowledge of these morbid conditions and of the methods of tbei 
scientific treatment is absolutely neccssaiy. 





In the bnlhous urethra the gonorrhoea! process shows a 
tendency to become chronic, and its pen>istency causes it to be verj 
rebellious to treatment. In this part of the urethra tlie vascuUl 
supply is so great, the tissues are so succulent, and, we may say, 
relaxed, that every condition favorable to chronic inflammal 
there present. 

Chronic urethritis of the bulbous urethra may give rise 
secretion %'isihle at the meatus, llien, again, the pus may beT3 
copious and Hnid in consistence that it may glue up the meatus 
in the morning and [K-rhaps during the day, or may escape onc^ 
a day or oftener as a decided drop. Owing to the fact that the 
bulbous portion is in direct continuity with the membninous utr* 
thm tiiis portion may be the seat of hypersemia or inflaniuuUug 
in Inilbous uretliritis. ^| 

Chrouic urethritis of the bulb runs a markedly protracted course; 
For a time there may be no impediment to urination, and the ool] 
symptoms may be the slight discharge, or even gonorrhoea! tlireadf 
in the morning urine, and perhaps uneasy, even burning, sensatiot 
in the perineum. In many cases early in the chronic stage theij 
may be no disturbance in the sexual function; but as time 




n, and the calibre of the bulbous urethra becomes lessened, more 
r less sexual debility may occur. It is well, however, to enipha- 
ize the fact tliat in many cases in which the bulb is much involved 
o sexual weakness is noted. 
At the bulbous portion of the uretha, i^ith the expanded and 
ueh thicker spongy body cncircHng it, the round-cell infiltration 
to the submucous connective-tissue layer, caused by gODorrha?a, 
comes more exuberant than elsewhere. The tissues are here 
'soft and succulent, and the blond supply is copious. Moreover, 
here is no firm, fibrous capsule around the bulb; therefore, there 
not that hindrance to profuse hypera^mia and inflammation that 
there wouUl be if the parts were quite firmly invested in a capsule 
of dense tissue. For these reasons the post-gouorrhoeal inflam- 
matory process is severe and long-lasting, and its resulting cell- 
infiltration exuberant and extensive. In the bulbj therefore, the 
infiltration is at first in the submucous connective tissue, and later 
on it becomes inextricably mixed with muscular and elastic fibres 
and vessels, and the condition called soft stricture then results. 
The morbid condition then consists of round-cell infiltration with 
a tendency to the development of fibrous tissue. \Mjen this fibrous 
tissue is de\'eloped, and when tolerably copious and intermixed 
with the round-cell infiltration, the resulting contraction is of 
semifibrous structure. Then, as time goes on and the morbid 
process increases very dcciilcdly in extent and depth, the newly- 
formed fibrous tissue takes the place of the erectile and vascular 
tissues, the areolae are obliterated, and the normal structure of the 
parts iMTomes wholly and Replaced by a uniform sclerotic and 
atrophic fibnius tissue, white, firm, and homogeneous in structure, 
w^hich constitutes what is called inodular stricture. 

It will be thus seen that in the bullK)Us portion of the urethra 
we find varying grades in the extent and the intensity of the same 
morbid prt>cess. The determination of the existence of these mor- 
bid stages is to l>e arrived at by means of urethral examinations 
•with the bougie h boidc or the olivary bougie. 

No precise statements can be made as to the rapidity of growth 
of the gonorrhoeal infiltration into the bulbous urethra. 


In some quite exceptional cases the cell-proliferation is quite 
active, and in about six months the calibre of the canal at this 
point may be reduced to 15 of the French scale, or even to smaller 
size. In cases of loss of calibre there may be experienced some 
inability to normally expel the urine. As a rule, the process grows 
quite slowly, and months, and even years, may elapse before very 
marked contraction occurs. In many such cases there may be 
some loss of sexual desire. In general, however, when these 
patients complain of an impediment in the sexual function, they 
say that toward the end of ejaculation something seems wrong, 
and that the act is not performed so promptly and satisfactonlj 
as in earlier days. The reason for this functional impairment is 
largely a mechanical one. As we have already seen (see page 71 d 
acq.) in ejaculation the secretion is thrown from the prostate into 
the capacious bulb of the urethra, and that then the intrinsic and 
extrinsic muscles contract powerfully and send the ejaculate out 
of the meatus. Now, in chronic urethritis of the bulbous portion 
the walls of the canal at this part become more and more rigid, 
and consequently less expansible, and the involuntary muscular 
fibres, which usually exert a powerful action, lose more or less of 
their contractile force. Therefore, when the copious ejaculate 
reaches this segment of the canal the latter can only be moderately, 
if at all, expanded by the volume of the secretion, and, thus crip- 
pled, can only exert a moderate, if indeed any, expulsive force 
upon it. Thus, ejaculation becomes lame and halting just before 
its <'ompletion, and this impc<liniont may cause much disturbance 
in the mind of the patient. 

With the increasin*^ diminution in the calibre of the urethra at 
this point the difiiculty in urination increases, and there is a total 
loss of extensibility and of contraction of the canal during coitus. 

As the soft stricture tissue increases in quantity and density the 
rigidity and inextensibility of the canal become more marked in 
the semifibrous and fibrous stages. Then, as the stenosis of the 
canal increases until an inodular stricture is produced, its calibre 
becomes so small tliat urine may escape with difficulty in a small 
stream or in drops, and the seminal ejaculate in coitus may be so 


^barred that it cannot go forward, and flows back into the bladder. 
In this event the patient is aspennatous. 

In many cases of tliis chronic^ graduaUy stenosing iTiflamuiatiun 
of the biilhfms urethra, besides the Inca-asing impediuieut to the 
sexual act, there seems to be developed some peculiar reflex con- 
dition, perhaps in the sexual centre, which results in a greater or 
less condition of impotence. This form of impotence usually 
develops slowly, and in very many cases it disappears more or 
less promptly when proper treatment is instituted and faithfully 
folio we<l up. 


Chronic posterior urethritis follows in many cases the subsidence 
of the acute procos.s. Owing to the complexity of structure of the 
posterior urethra the symptomatology of this affection is often well 
marked. Wlien there is simply uncomplicated chronic inflamma- 
tion of the umcuus iiiciiibratie the symptoms may be negative or 
very slight in character. But when the prostatic sinuses, the 
orifices of the ejaculatory ducts, the iitriculus masculinus, and the 
caput gallinaginis are, together or in part, the seat of trouble, we 
find a varied group of symptoms referable to the sexual apparatus 
and its function. 

In chronic urethritis distinctly Hmited to the posterior urethra 
there is usually no escape of pus into the anterior portion, for the 
reason that it is small in quantity and viscid in consistency. There 
arc, however, t)ordcr-Iiue casey in the extreme terminal stage of 
the acute afl'ection in which the pus is still rather copious, and it 
escapes through the membraTious urethra and passes toward the 
glans. The compressor urethne muscle cloes not, as claimed by 
some authors, usually contract the lumen of the urethra to a hiur- 
sixed calibn*, an<l in general it is a moderately patulous canal at 
this point. There certainly is not, in the majority of cases, such 
a tonicity of the compressor urethne muclc as will keep back a 
quite copious discharge. While in many cases, owing to its small 
quantity, the pus may l)e retained in the posterior urethra by the 
cut-off muscle, in some cases it certainly is not thus dammed back- 



ward. The cases of chronic posterior urethritis in which a dis- 
charge reaches the meatus are very rare, but they occur. 

In very many cases of posterior urethritis, there being no visible 
discharge and the patient complaining of no symptoms referable 
to the deep urethra, the affection remfuns dormant, latent, and 
unrecognize<l. llius the cases may drag on for one or more, and 
even five, ten, and fifteen years, without giving any indication of 
lurking trouble. In some of these cases an exacerbation may 
occur, and then the patient realizes that he has had an uncured 
gonorrhopa. In many cases the first disturbing sjinptom is a 
greater or less loss of or defect in the sexual function, and exam- 
ination shows that chronic posterior urethritis has existed perhaps 
for a long time. 

In some instances the exacerbation of the posterior urethritis 
is subacute in character, attended only with mild or insignificant 
symptoms, and its presence would not be suspected or sought for 
had not an attack of epididymitis or epididymo-orchitis developed 
as a complication. In many cases of this deep-seated urethritis, 
in which epitlidymitis or epidi<lymo-orchitis is developed in the 
initial attack, recrudescences in the testicular trouble are frequently 
observed at late and rtmiote periods as a result of an exacerba- 
tion in tlu* |K)sterior urethra. In these cases sexual debility may 
Tvsuh hon\ the uretliral trouble, while the recurring infiammation 
of the tests and epididymis may cause azoospermatism. 

In somewhat rare instances chronic [)osterior urethritis, usually 
as a rt\sult of excesses, l>ec()mo dovelojKHi into a true acute attack 
with all its symptoms and its discomforts. It may then run its 
course, but in some cases the inflammatory process extends forward 
into tlie anterior urt^thra, which also lx*comes the seat of an acute 
phlegmasia. In these cases, when the discharge is well estab- 
lished in the anterior urethra, the sufTcrings of the patient, expe- 
rienced wluni the [K)stcrior segment alone was afTected, cease, and 
the case then takes on the featuiws of gonorrluea of the totality 
of the urethra in its declining stage. 

Symptoms. — The symptoms of chronic |)osterior urethritis are 
manv and varied, mild and severe. 



Tliis affection was formerly rather vaguely understood, and to it 
le names of neuralgia of the bladder, neuralgia of the neck of 
the bladder, and irritability of the bladder have l>oen given. In 
the light of modern study all these names may be dispensed with 
tnd the term ''chronic posterior urethritis" may be retained. 
Cases of this affection may be, for purposes of study, separated 
ito groups according to the nature and severity of their symptoms. 
There arc found in practice a goodly number of cases in which 
^a frequent desire to urinate and some uneasiness at the end of the 
•t, and sometimes at its beginning, are the only sjTnptoms com- 
ilained of. In .some of these cas<\s the increased fn^qnency in 
^urination is not much above normal; in others it is well marked. 
some eases the paiu is slight ami dull, or of a quick, stabbing, 
mt very ephemeral character. In others it is dull, heavy, per- 
laps spasmodic, and radiates into the rectum, pelvis, testes, and 
(ins. In these cases the act of urination may go on smoothly, 
►r it may be interrupted by slight or severe spa,sm of the com- 
»re.ssor urethrse muscle or of the detrusor vesica muscles. This 
mdition has been called "cystospasmus." It is liable to occur 
ier coitus or difficult defecation. In other cases there is no dis- 
irbance of urination at all, hut patients complain of dull or aching 
(ain in the perineum, deep in the pelvis and prt)state, and in the 
jctum. Sometimes tliese patients coniplmn of pmn over the 
mbcs, and of uneasy, vague pains in the cord and testes. In 
"some cases mild and even severe neuralgic pains are complained 
of in the loins, groias, and thighs. These painful symptoms, par- 
icularly when severe, arc, fortunately, not always present. They 
rar}' frnin day to day, .so that the patient has intervals of com- 
larative comfort. 

Chronic posterior urethritis may exist for many years (five to 
twenty), and yet the patient may regard himself as free fnmi nil 
tnorrhceal sequelae. In some of these cases sexual and alcoholic 
accesses excite exacerbations of the urethritis, which usually yield 
quite readily to treatment. In other and exceptional cases the 
first sj^Tnptom of the existence of the chnintc trouble is more or 
less profuse hcemaluria, which, as a rule, occurs after or toward 


the end of urination. In some cases the onset of sexual weakness 
is the first sign of disease in the posterior urethra. 

Diagnosis. — ^The diagnosis of chronic posterior urethritis can 
usually be clearly established by eliciting the history of an earlier 
acute affection. 

In chronic posterior urethritis the amount of morbid secretion 
is usually very small, hence the two-glass test of the urine, yi\M\ 
gives such clear indications in acute posterior urethritis, cannot 
be relied upon as an infallible guide. If this test is used in the 
chronic affection, the first part of the morning urine will contain 
threads, while the second will be clear; but in such an examina- 
tion it may occur that tissue-elements from the anterior urethra 
will also be present in the urine. The best plan is to carefulW 
wash out the anterior urethra as far as the triangular ligament with 
warm water; then, when the urine is passed, if it contains threads, 
it is quite certain that they come from the posterior urethra. 

In this connection it is well to remember that small, comma-like, 
fleecy plugs or threads, which are thought to be formed in the ex- 
cretory ducts of the prostatic glands and voided with the last drops 
of urine, being pressed out by muscular and prostatic contraction, 
arc quite diagnostic of chronic posterior urethritis. (See Fig. 91.) 

Perhaps the most serious and, for the physician, trying cases of 
posterior urethritis, even in those in which no trouble of the pros- 
tate can Ix* found on careful examination, are those in which there 
is some distiirlmnee of the sexual fimction. Some patients com- 
plain of a severe stabbing ])ain at the moment of or after ejiU'U- 
lation of the semen. Others state that all pleasurable sensations 
are either absent or lessen(»<i in degree in sexual intercourse, ami 
they are thereby nuieh worried. In still other cases the ejacula- 
tions oeeur U'forc^ intromission or shortly afterward. 

Tn some cases pollutions are frequ<Mit, and with their occurrence 
diminution in tlie sexiuil ap])etite may l>e felt. Many of these 
patients iK'eome weak, nervous, and apprehensive. Their diges- 
tion iH'eonies poor, and they suH'er from constipation. Then the 
passage of u hanl fecal plug presses the prostate and ex|)els the 
accunnilateil mucoj)us, which appears at the meatus, causing the 



patient to think he is losing semen. In some of these cases some 
of the secretion of the seminal vesicles is at the same time ex]»elled, 
an<l this also to many is convlneing proof that they are suffering 
from spermatorrhoea. Occasionally these patients are much 
alarmed at the occurrence of bloody pollutions, which are due to 
great hj'pertfmia of the ejaculatory ducts and tlie pn:>static and 

Fig. 91 

Showing the niicroBcopic appeiirRnce of the secretion of posterior arethritis. 

bulbous urethra, and sometimes the seminal vesicles. In any of 
these cases of disturbance of the sexual function wc are liable to 
find more or less deterioration of the health. Tliis may consist 
simply of weakness and lassitude^ and it may be a condition of 
great nervousness, of melancholia, or even of true neurasthenia. 
Between these two extR'mcs there are many degrees of bodily and 
mental debility. 


The foregoing symptom-complex may be found in cases in 
which, as has been stated before, careful examination will show 
that the prostate is not synchronously the seat of chronic inflam- 
mation. But in other cases true posterior urethritis with chronic 
prostatitis may exist, and the patient may complain of the symp- 
toms as just now detailed. 

Pathological Appearances. — ^The most constant morbid con- 
dition seen in chronic bulbous urethritis is a rather deep-red, even 
purplish, color of the mucous membrane, which is more or less 
thickened. This redness may involve a segment of the canal or 
a limited portion on one or two sides. In these cases more or less 
pus, thin or inspissated, may be seen in the examination. TTiick- 
ened, red, circumscribed spots or plaques of chronic inflammation 
are very common. Another appearance quite conmxonly seen is 
called by some granular urethritis. The membrane b thickened, 
red, even purplish in streaks, and rough and studded with small 
projections, which consist either of epithelial hyperplasia or of 
little eminences caused by the growth of new capillary vessels. 
This condition is frequently found in the bulbous urethra and also 
in the pendulous portion. 

The morbid appearances of the mucous membrane of the poste- 
rior urethra are conspicuously striking. They consist of thicken- 
ing, more or less papulation, together with increased redness. 
Frequently the caput gallinaglnis and the orifices of the prostatic 
ducts are seen to be swollen. The underlying pathological process 
is precisely similar to that of the anterior urethra. 

Treatment. — It is IxHter to give here the treatment of chronic 
posterior urethritis from the period of decline of the gonorrhoea! 
process than to begin with the very late stages of posterior urethritis. 

Tiie duration of the urethritis has an important bearing upon 
its treatment. Ix;t us first consider the cases in which the disease 
lias lasted only a few mouths. Such patients may compltdn only 
of the morning drop, or they may state that they seem well so 
long as they use an injection, abstain from coitus, and do not drink 
beer and alcoliolics or oat highly seasoned food. When they cease 
injecting and indulge in creature comforts and excesses the mom- 


ing drop reappears, with perbap a more or less profuse discharge 
during the whole day. Examination of the urethra in these cases 
shows a catarrhal and exudative oomlition from the Inilb forward, 
perhaps nearly to the meatus. In many of these cases the poste- 
rior urethra is also involved. The morning urine is rather cloudy, 
like turbid cider, contains much mucus and some long, thin or thick 
threads (sometimes three or four inches long). There may or may 
not be a few gonococci present. In these cases the best treatment 
is irrigation of the posterior and anterior urethra, using at first 

Irrigating syringe and stopcock (all metal ; 4 ounoee). (Hayden. ) 

warm solutions of alnm and sulphate of zinc or permanganate of 
potassium, beginning with a strength of 1: 5000, and increasing 
according to the result obtained. 

'^llie instruments necessary for these instillations of the bulbous 
urethra are a soft-rubber reflux catheter of a cnlibre of al>out 
14 to 16 French scale (see Fig. 92) and an irrigating syringe (see 
Pig. 03). The end of the catheter should he passed down to the 
bulb, and then the nozzle of the syringe is inserted and the injec- 
tion is given. For injecting the prostatic urethra the ordinary 
soft catheter should be cut off so that it measures eight and a half 


inches. (See Fig. 94.) This rubber catheter (10 to 12 French J 
lubrifated with glycerin or lubrichoiidriii, is pusscni down tfari 
urethra until its eye enters the prostatic urethra, which is usuaDj 
seven or seven and a half inches down. Tlie bladder being eniptj: 
pressure on the piston then throws the injection into the prostatic 
urethra. It is well now to withdraw the catheter a little until ill 
end is in the membranous urethra; then on pressing the pistol 
gently resistance will be felt and no fluid will flow. ITiis telk 
the surgeon that he is in the membranous urethra, and thai thi 
irritation of his procedure has caused the contraction of the ooni! 
pressor urethne muscle. Tlicn push the catheter inward aboul 
half an inch and inject again, when the fluid will readily pftsa^ 
By this manoeuvre the eye of the catheter is placed just atjk 

»Sort-riibber catheter. ^^^^^| 

apex of the prostate and at the very beginning of the prosta^ 
urethra. The injection is then slowly thrown in, and it passe] 
tlirough tlie whole of the prostatic urethra into the bladder. II 
only a rather small injection is to be given, alxjut one-half of the 
contents of the s^Tinge may be used posteriorly. Then, 
still pressing the piston, the surgeon gently draws out the 
cter, and finds that as its eye passes through the membratw 
urethra the flow stops again, but is at once resumed wh< 
eye reaches the bullious urethra, which is then irrigated wit 
remainder of the fluid. 

Usually one irrigation several times a week is suf!icit*nt,^ 
[HTliiips one each day may be well lionie. The sensations oj 
patient and the condition of the urine are infallible guides 
the required frequency of treatment. As a general rule, afl 

01 iDe 




■ trc 




or two weeks* treatment these irrigations seem to Insc llieir efficacy, 
having done some good, but not having produced a cure. Perhaps 

these conditions permanganate of potiissiiim irrigations (always 

ot), 1 : 1000 or 1 : 2000, may bring about a cure. If this remedy 

fails we resort to nitrate of silver, beginning with solutions of the 

strength of 1 : lf),UOO or 1 : 8(K)0, and sometimes even weaker; 

ml this usually results in a cure if the treatment is carefully 

a<i ministered. If the morbid process is more severe in the anterior 

uretlira the bulbous reflux catlietersliould be introduced n.s far as 

tlie bulb, ami one ut two syringefuls of the irrigatiug Ihiid sliunhl 

injected. The posterior urethra should then be similarly 

trcatetl. Sometimes it is necessary to finish with quite strong, 

deep injections. In these cases much pain is frequently produced 

by the passing of sounds, particularly of large ones. This fact 

should be borne in mind, since many patients thus treated suffer 

verely, while in others the disease is so aggravated that it l>ecomes 

jst difficult to cure. Some of these cases are thus rendered 
practically incurable even when the most judicious and prolonged 
treatment is followed. Too much attention cannot be paid to the 
fact that in some cases of chronic gonorrha?a sounds, particularly 
large ones, may be productive of incalculable harm when used 
too early. 

When the disease is limited to the bulbous portion, where it 
shows a great tendency to remain indefinitely, the retrojections of 
alum, sulphate of zinc, and nitrate of silver may be used. These 
injections will materially modify the morbid process, and some- 
times cure it, but they often fail to bring about a thorough cure. 
In that event it is well to make direct local applications of solu- 
tions of nitrate of silver, beginning with a solution of 1 : 2000, 
and perhaps going as high as 1 : 250 and 1 : 125. 

A very useful and perfectly effective syringe is the one generally 
used by me. {See Fig 95.) There is nothing whatever original 
about this syringe. It is simply a well-made instrument, very 
easily worked, having a ring and shoulders for the thumb and 
fingers, and a very conical nozzle, which will fit into a small, soft 
catheter. Tlie piston is marked with numbers to regulate the 


drops. The injecting medium is any well-made soft-ruhljercalheUr, 
10 to 12 or 14 French, cut off to measure eight and a half inches 
in length. When the catheter is introduced six or six and a half 
inches its end is in the sinus of the bulb, and the very sliglit impedi- 
ment it encounters there shows the operator that he is just at tli^ 
opening In the triangular ligament. 

This little catheter, when slowly passed, causes no pain or ini- 
tation. Then ten or fifteen drops of the silver nitrate solution 
may be throwTi into the urethra. This treatment may sometimes 
be varied by using 1, 2, or 3 per cent, sulphate of copper soluticn, 

Fu». 96 

Endusoopic tube. 

or a 1 : 1000 permanganate solution. Tliis treatment may be 
atlministered by the surgeon every five days or twice a week, and 
perhaps oftener if the indications of the case point to the neceasity 
of increased frequency. In the intervals the patient may use mild 
stimulant and astringent injections by means of a penis syriogf. 
This form of chronic urethritis being very rel>eUious, it is some- 
times necessary to pass an endoscopic tube do>*'n to the bulb 
/ Fie. ^)> *"*' having ascertained the morbid appearances, to 
sparingly apply «" «>"*>" ^* ^^^ ^"^ ^^ ^" applicator a strong 
solution of silver nitrate (thirty to sixty grains to one ounce o( 




In the more chrouic cases of anterior urethritis we find spots, 
patches^ and areas of inflammation at the penoscrotal angle (some- 
times seemingly caused by the pressure of the suspensory worn 
during the declining stage) and in the pendulous urethra as far as 
its beginning. 

The first essential in the treatment of these cases is to locate the 
trouble and to determine its nature. Now, in this part we find 
subepithelial infiltration, with or without a greater or less epithe- 
lial hyperplasia, erosions, and superficial ulcerations, always acconi- 
panied with submucous thickenings and follicular inflammation. 
The thickened mucosa may be granular, ^illousj or papillomatous. 
The urine can do little in enlightening us as to the exact nature of 

Fig. 97 

Boiigli; t\ t>oiile 

the morbid process unless it contains old fiabby and fatty epithe- 
lial cells, which point to an old ulcer which is in too atonic a con- 
dition to heal of itself. In these cases much aid can be obtained 
as to location by the bougie h boule. This instrument consists of 
a conical or acom-shaped head with a well-marked sharp but 
gently rounded shoulder, which is attached to a flexible gum- 
elastic staff. (See Fig. 97.) For the cases under consideration 
we may need these bougies h bottle in size ranging from 18 to 30 
French. For strictures we may use the smaller siises, which begin 
as small as 8 or 10 French. 

In the treatment of posterior urethritis, with or without anterior 
urethritis, great care is required to determine as nearly as possible 


the exact cf)nflition of aiTairs. In the more recent cases we some* 
times 6nd some evidence of bladder iacoiupctence (the urine show- 
iuR no involvement of that viscus), which shows itself by the 
escape of a little (two drachms to one-half ounce or more) residual 
urine when the eye of the catheter reaches the neck of the bladder. 
In these rather early cases mild irrigations of the astringents and 
of permanganate of potassium may be used, and perhaps with 
benefit. The most uniformly effective agent here also is the 
nitrate of silver, which may at first be used well diluted, 1 ; 16,000 
or 1 : SCXK), in the form of hot irrigations. 

• For older and very chronic cases of posterior urethritis the 
stronger silver nitrate injections, 1:5(X), 1:250, 1:125 and even 
stronger may be used. In my experience, fifteen drops or more 
of these solutions produce better effects than a more sparing 
injection of stronger solutions. These injections should be given 
every third or fourth day. They may, however, produce benefit 
in some cases if made more frequently. Daily injections are liaUe 
to cause acute suppuration, which means irritation, and 
must be avoided. 

Posterior urethritis, accompanied by sexual disability, p 
ture ejaculations, pnllutians, and absence of erections and I 
sexual desire, usually require the injection of a few drops of the 
stronger solutions just mentioned. 

Treatment of Stenosis and Strictures of tlie Bulbous Urethra. 


Stenosis and stricture of the bulbous portion of the urethra may 
be soft, semifibrous, fibrous, and inodular, all of which require 
appropriate treatment. 

Soft and semifibrous strictures should, as a rule, never be in< 
until milder means have been tried and have failed. 

The diagnosis having been carefully made, the calibre of 
stricture is to be determined. Now, on this point no rule can be 
laid down, since cases differ so strikingly. Thus in some patients 
the canal may be reduced to 20 or 15 F., and yet these strictiuMJ 
are of the soft variety. In others, with similar calibres, they idm 
be semifibrous or fibrous. Then, again, it is not very uncommon 





tn find a urethra reduced to even 6 or 8 F. by an exudative hyper- 
plasia, which we call soft stricture. These various and varying 
conditions have to be ascertauied, and as the surgeon grows in 
experience he will become more and more expert in recognizing 

Gradual Dilatation,— When the stricture in the bulbous urethra 
is yet in the soft, or even in the semifibrous, stage, the aim should 
be to remove as far as possible the cell-infiltration, and thus, in a 
manner, to restore the mucous membrane to its natural condition. 
This can be done in many cases by careful and gradual dilatation. 

Seeing that a soft stricture may contract the urethral lumen 
even as low as 7 to 8 F., and that in many cases where the calibre 
is 15 or 20 F.. the infiltration is yet soft and succulent, it is always 
well to make the attempt to cure by the introduction of the bougie 
or sound before the knife is resorted to. When, however, a fibrous 
or inodular stricture of small calibre is discovered our chief thought 
is not toward gradual dilatation. 

I liave in so many instances been able to restore the urethra 
even when contracted to 7 or 8 to 30 F., that T am always loath 
to operate more ra<lically. 

In the process of gradual dilatation much care, patience, and 
good ju<lgment are necessary. The operation should always be 
carefully and slowly performed in a manner to cause no pain or 
uneasiness and no dan^age to the tissues. By the pressure and 
stimulation of tlie distending instrument we hope to cause the 
absorption of the exudation and to give tone and resiliency to the 
dilated vessels. It will thus be seen that we are always liable to 
cause inflammation, and this condition will either delay the cure 
or pi-rhaps thwart our efforts. In cases when; the contraction is 
as grt»at as 7 or 8 F., and also where the calibre of the stricture 
is much larger, there may be posterior urethritis or even urethro- 
cystitis, and these conditions should then receive proper treatment. 

Beginning with a small olivary bougie (see Fig. 98), the sur- 
geon should gradually and slowly increase the size of the instru- 
ment as the progress of the case will indicate to him. In the early 
part of the treatment the bougie maybe introduced once a week, 



and then in favorable conditions the interval may be fijced at abont 
five days. It is almost always well to allow this interval of time 
to elapse between the stances of treatment. Many men have failed 
in this method of treating stricture by the too frequent introduc- 
tion of the instrument^ and many patients have not received the 
benefit they wouI<l have had if there had been less baste. In 
gradual dilatation, particularly in the early stages, the sensations 
of the patient sl^ould be carefully considered and the urine regu- 
larly and methodically examined. If the operation causes uneasi- 
ness and pain in the perineum and over the pubes, and continued 
frequency in urination, and if the parts resist the gradual increase 
in the size of the instrument, it will be necessary to suspend the 
treatment temporarily, and jx'rhai»s pcnnanently. In many of 
these cases local medication to the anterior and posterior urethra 

Flexible olivarr bougie. 

will put the parts in such a condition that gradually dilatation 
may again be resumed. 

It will be generally found, when dilatation is commenced, in 
the form of stricture under consideration, with very small olivarr 
bougies, that at first the sizes may be increased quite regularly, 
and no trouble, or perhaps very little, is experienced by the sur- 
geon until he gets up as high as 20 or 22 F. Then he will gt^n- 
erally find that the dilating process goes on much more slowly, 
and that it may be necessary to introduce sounds of one size several 
times before larger ones can be used. 

The prompt and usually p<*rceptible effect produced by the early 
systematic production of small bougies has much bearing on the 
future of the case. Patients watch the progress made step by step, 
and as they sec that they are gaining in urethral calibre, and tliat 
they have lost their unpleasant sMnptoms (urethra! or vesical), 
they become sanguine of an eventful cure, and present themselves 




»gijlarly for treatment. It is most essential in the cases that the 
tatient should have implicit confidence in the surgeon, and that he 
ihould keep his moral courage up in the ordeal through which he 
passing. Though these patients are neither hurt nor inconve- 
lienced, the irksomeness of having at stated intervals to go to the 
lurgeon is very trying to some. Others, and indeed the majority, 
tppreciating the infirmities and sufferings which strictures almost 
inevitably lead to, resolve to keep on till they are cured. The main, 
ind indeed the only, valid ohjrrtions to gradual dilatation are that 
it is a slow process and occupies a tjuite long stretch of time. But 
it must always be remcml)ercd that if it is followed up until the 
[nrethra is restore*! to a calibrt* of 30 F., in the majority of cases 
will only be necessary to have soun^ls introduced once or twice 

Fio. 99 

•ii.'.'-Vi^i^i t-i- 

Conical ftteel i»»uiid. 

year thereafter; whereas it can l>c said, without fear of contra- 
diction, that when a man's urethra has once been cut he has fif he 
would keep the cliannel open) to puss irislrumeats at short inter- 
vals all his life. All these considerations should be presented by 
tlie surgeon to liis patient as the treatment goes on. Men often 
get careless and even indifferent at the time when they may be 
said to be about half-cured. In these circumstances the sur- 
geon should use alt his inHuence against faltering and back- 

When in the course of this treatment tlie urethra will admit an 
olivary bougie No. 20 F., it is well to resort to the cur\*ed steel 
(unds (see Fig. 99), and with them finish the cure. In many 
rs when the coarctation is extensive and involves the whole 
snCUl of the bulbous urethra, the Benequ6 sound will produce 


particularly good results. (See Fig. 100.) Its double curve seems 
to exert a beneficial pressure not obtainable by the use of the 
ordinary curved sound. 

The trend of thought as regards the treatment of urethral 
stricture of late years has been so unswervingly toward cuttiDg 
operations that many surgeons are wholly unaware of the benefi- 
cent and lasting effects of gradual dilatation. I am to-day more 
than ever convinced that cutting operations should be a last resort, 
and that intemperate incisions and over-stretching are very fre- 
quently the cause of never-ending suffering and inconveniences. 

It is impossible to state exactly the period of time necessary for 
cure by gradual dilatation, since it varies in each case, and so 
much depends on the regularity and sedulousness of the patient. 

Fig. 100 

Benequ('''9 sound. 

In .some cases tlie normal uretliral lumen may be restored in three 
months, and in others in six, nine, and twelve months. A.s a 
general rule, a six months' treatment will be followed by better 
results than a shorter course. 

There is one point which deserves especial emphasis, and it is 
this: To produce satisfactory permanent results by gradual dila- 
tation the urethral canal must be brought up to the calibre of 30 
or perhaps 32 F., and when this is attained the dilating process 
must be continued for some time, until these large sounds pass 
easily and witlunit any grasping. 

Continuous dilatation is very rarely resorted to at the present 
time. In some ciLses wliere a filiform has after a long struggle 
been pas.sed through the stricture, it may be retained there for 



ime hours, or perhaps for a day, in order to render certain the 

of a larger instrument. 

lii the majority of cases the process of cure by gradual dila- 

ition is uneventful, but in a small minority certain complications 

may arise and give more or less trouble. These complications 

tre: 1, fever and chills; 2, urethritis and urethrocystitis; 3, a 

jndency to hemorrhage; 4, temporary retention; 5, rheumatism; 

»d 6, pysemic abscesses. It is well to state in advance that since 

the beginning of the era of asepsis and antisepsis in surgery these 

[complications occur much less frequently than formerly, and they 

ire much less severe. 

The occurrence of chills and fever shows that there is a low 

grade of suppuration in the deep urethra, but it need not cause 

the permanent discontinuance of dilatation. Such cases should be 

treated on the lines laid down for chronic anterior and posterior 

^urethritis and urethrocystitis. 

^m When the sound causes inflammatory reaction its use should 
I be discontinued until appropriate treatment removes the tendency 
Hfchereto, as it will do in most cases. Exceptionally, however, it 
^^appens that the resulting inflammation is so great and so con- 
stant that it is necessary to wholly abamlon this form of treat- 
^unent. In many such cases judicious topical urethral medication 
after a time brings about such a change that the sound may be 
used again. In some .severe and exceptional ca-ses the expediency 
of external urethrotomy will suggest itself to the mind of the sur- 

In like manner, the teiulency to slight oozing of blood after 
dilatation run gi^nerally be checked by the instillation of a few 
drops of a solution of nitrate of silver. 1:250 to 1:125, and 
perhaps stronger. 

kWien in the course of gradual dilatation retention of urine 
ccurs once or at intervals it is [)erfectly certain that one or two 
auses are at work; these are swellmg of the mucous membrane 
in and near the stricture and temporary spasm of the compressor 
urt*thne muscle. In such cases there is need of topical urethral 
ledication, and the intervals between the passage of the bougies 



or sounds should be materially lengthened. When carefully man- 
aged this complication may be overcome. 

The occurrence of rheumatism and of pysemic abscesses indi- 
cates very clearly that, besides the stricture process, a decided 
suppuration of the urethra also exists, which can be cured by the 
means described in the section on the treatment of chronic ante- 
rior and posterior urethritis. 

It will l)c seen, therefore, that in the successful employment ol 
gra<Iual dilatation the surgeon must be thoroughly conversant 
with all forms of urethral inflammation. 

The scope of this volume will not admit of the consideration oj 
the treatinrnt of strictures by internal and external urethrotomy, 
but, in a ^riieral way, it may be stated that undilatable stricture in 
the jHMidulous urethra requires internal urethrotomy, while those 
of the buUx>us and membranous urethra require external urethrot- 
omy; for full information concerning which the reader may con- 
sult my work entitled A Practical Treatise on Genitourinary and 
Venereal Diseases and Sijphilis, Philadelphia, 1904. 



By far the most frequent cause of sexunl weakness and impo- 
tence is chronic inflaniniation of the prostate gland, lliis morbid 
^ptondition is produced by various causes, the most frequent prob- 
ably being acute and chronic gouorrhcea, the next in order being 
P masturbation and sexual excesses, while in a less number of cases 
traumatisms, such a^ damage to the posterior urethra by sourjds, 
lithotnte.Sj dilators, endoscopes, and very caustic deep injections 
are the starting points of the trouble. 

It is necessary to clearly understand the far-reiiching effects 
which acute and chrome gonorrhcea often exert upon the prostate, 
since such knowledge renders clear the etiology of many cases 
which might otherwise seem very obscure. 


The most common fona of iufiamuiation of the prostate in the 
lurse of gonorrhoea is congestion of more or less severity. This 
•edition occurs with, and Is dependent upon, acute posterior 
urethritis. In the latter condition the submucous connective 
tissue is the seat of au acute phlegmasia, and as a result the sub- 
stance of the prostate becomes hypereemic. With thb farther 
extension of the gonorrhoeal process the patient has still other 
'symptoms besides those of the posterior urctliritis. He complaius 
of a sensation of dull weiglit and pressure in the perineum deep in 
the pelvis, and an uneasy sense of fulness in the rectimi or anus. 
In severe cases rectal tenesmus may add to the patient's discomfort. 
The vesical tenesmus may be increased, and often in defecation 
the patient experiences severe pain in the prostate when the fecal 


mass passes under it. Wien there is much swelling the stool 
smnll ami nlihon-slmpcrL Rectal examination reveals a sw< 
orj^aii, broader than noniial from side tosiile, and bulging 
erably into the rectum. The fingor-tip reveals the fact thi 
part is hot and decidetUy painful, and on its withdrawal vesic 
uiid rectal tenesmus frtnjneiitly ensues. In many ceases polhitions 
are a distressing symptom. The swollen state of the prostate 
generully causes dysuria, or even such a contjitioii of reteution 
that it is necessary to remove the urine with a catheter. 

In the great majority of cases this congestion is temporary. It 
may last a few days or two or three weeks; usually, howei 
resolution takes place in about ten days. With the decline 
posterior'urethritis the swelling and tenderness usually sul 

Fici. 101 


Kemp's double current hard-rubber rerUiI irrigator. 

In some cases the involution of this congested condition of ftp' 
prostate occurs suddenly and nnexpectedly a few days aft< 

Congestion of the prastate may be due to violence from 
catheters, Hthotrity instruments, to the irritation of a stone 
bladder or of a fragment of stone, or of small stones unpad 
its mucous niemhrune, and to stricture. It is not very pi 
as claimed by some, that injections used by patients in 
rior urethra cause congestion of the prostate. 

Ix)ng-coutinued masturbation is also a frequent cause of cl 
congestion of the prostate. 

Treatment. — In the acute stage of congestion of the pi 
rest ill bed and antiphlogistic treatment are required. 
1 When the congestion liecomes chronic the condition 




discovered by the finger-tip in the rectum, which finds the organ 
soft and hogg^' or swollen and tense. At this time gentle massage 
may do much good, but it may cause distress, and then it should 
be stopped. Warm, hot, or cold saline solution irrigations of the 
rectum may be given once or twice a day by means of Kemp's 
prostatic cooler (Fig- 101), and are often of much benefit. Tliis 
useful instrument is made of both hard and soft rubJjer, so .the 
surgeon may have his choice, 

A recta! cooling apparatus called the zerodone (Fig. 102) lias been 
invented by Dr. A. Rose/ and it may prove of l>enefit in cases of 
prostatic congestion. 

Pio. 102 

^V Rose says: Tlie peculiar feature of this contrivance is a water 
^^ chamber from which, by means of the working of a rubl:)er bulb, 

a double current passes through a cylinder inserted into the rectum* 

There b no connection with a fountain syringe. 

Tlie chamber — in case of cold application being desired — is 

filled with as much ice as it will hoU! and cold water up to the 
_ screw. 

^B llie bulb is then to be gently squeezed imtil conipletely col- 
^^lapsed, then allowed to resume its natural shape, and this may 
be repeated to make .sure thai the air in the dianne] through which 

The f-erodone. 

New York Medical Jonraol, December 10, 1904. 


the current is to pass is exhausted. If necessary, add now enough 
water to fill two-thirds of the cliniiiljer, then screw the cap on tight. 

By pressing the bulb the water returns from the cylinder into the 
cliamber; by releasing the bulb the water is forced hack again into 
the cylinder. 

The zerodone, like the other contrivances called coolers, can 
be made to have currents of hot water wherever these are indi- 

They all may serve, proper attaclunents Ijeing provided, to apply 
dry heat or dry cold in the vagina. 

In chronic congestion of the prostate, mercurial, ichtliyol. or 
iodide of potassium suppositories may be used {vide infra). lu 
all cases the condition of the urethra should be ascertained, and if 
diseased it should be treated. 


Tills form of chronic prostatitis is not veiy uncommon, and is 
found, as a rule, in young men from about eighteen to tw^enty-fiw 
years of age. The underlpng causes are either prolonged rafts- 
turbation, or, rather less frequently, chronic posterior urethritis, or 
both may be factors. Patients thus afflicted may enjoy toleratJj 
good health or they may be ana?mic or even neurasthenic. (See 
section on Chronic Posterior Urethritb, with which this condition 
b sometimes combined.) 
-» The first s^Tnptoms pointing to this prostatic disorder are refer- 
able to the sexual system. In those patients who indulge in coitus 
it is first noticed that they suffer from premature ejaculations. 
Erections may be firm and desire may be great, but the sexual 
act is aborted, 'llien, as time goes on, the erections become less 
vigorous and the ejaculations are weak and dribbling. Unless 
relieved such patients Vjecome impotent. Beside these symptoms 
nocturnal pollutions may trouble the patient* who may also obsenr 
the escape of mucus from the urethra after urination or defecation. 
In some cases a sense of weakness and depression follows the sup- 




posed loss of semen. All these symptoms may be obsen^ed in 
those whose trouble originated in masturbation. 

When the emission or ejaculate is examined under the micro- 
scope it is found to consist of mucin and granular phosphates, as 
a nile (see Fig. 103), but in some quite chronic cases puny and 
dead spermatozoa may be seen in the fluid, together with cuboidal 
cells, pus, and perhaps oxalate of lime. 

Wlieu the urine is examined, if pasterior urethritis exists, the 
first few ounces will cnntaln gonorrhoea! threads, the second 

Fig. 103 

Grtnnlar phosphftles. 

Specimen will be clear, and in somfe instances the third speci- 
men will have a decidedly milky appearance, due to the mucus 
and (^nular phosphates which have been expressed by the con- 
traction of the prostate. If, however, after the second cylinder 
has been filled with clear urine and some of the residuum 
is still left in the bladder, massage of the prostate will cause a 
more or less copious flow (one-hulf to two or three drachms) of 
a mucus which may be tliin and milky or as thick as condensed 


milk. This secretion may escape from the meatus or it may bt^ 
voided with the urine. In any event, in tliis form of prostatil 
(and the same Is seen in other forms) the dominatinjy^ coinpoi 
parts will be found to be mucus and granular phosphates. (1 
Fig. 103.) And it may be here stated that this combination is the 
one which, with more or less admixture of other crystals and of 
tissue-elements, will be found througliout the course of the variotri 
form.s of prostatitis yet to he considered. Sometimes mucus 
escapes which is not mixed witli phosphates, but this is not of fre- 
quent occurrence. It is most important, therefore, that the sur- 
geon sliould l>ecome thoroughly familiar witli this mucophosphalM^ 
secretion and with the urine which is so commonly voided by the^^ 
patients. The urine is usually of low specific gravity (1004 to 
1010), of modpratcly neutnd, alkaline, or not very acid reaetii 
Its color is of a pide-straw tint, and it is usually voided in 
sidemble f|nnntities. Much familiarity with these cases will enal 
the surgeon (if he were so disposed) to make a diagnasis simply 
from inspection and mIcn>sropic examiiintion of the urine. 
has already been said» the domiuating featuiv of the abnoi 
discharge is the combination of mucus and granular phosphates. 

These patients sooner or later complain of frequent urination: 
in some it occurs at night, in others in the daytime, and in st 
others botli by day and by niglit. Some patients complain 
pain in the passage of the urine as if it scalded, or as if a hot ii 
were in the canal, »"<! it is not uncommon for these patients to' 
experience a dull pain in the glans penis at the end of urinatioi 
Some patients have a sensation as if their urine escaped, bi 
examination of the penis shows that it is dry. 

Endoscopic examinations of these cases should not, as a nil< 
l)e made, since they are usually very painful, and the conditiou^ 
which they reveal can be determined by other and less sei 
meatis. The facts already in our possession, derived from 
endosciipic study of the prostatic urethra in these cases, show vi 
(rleurly tfiat the whole canal is very red and swollen, and this 
olwuTVed ptiHiculnrly in the verumontanum and the adjacent si 


*ion; " 







Examination of these cases with the bougie h hotde shows the 
same state of affairs. As the bulb enters the prostatic urethra the 
already apprehensive patient may experience a severe and even 
stabbing pain^ which causes him to cry out, particularly as it 
glides over the veniraonianum. In many instances on the with- 
drawal of tl»c iustrunient h little blood will Ix* seen on the bulb or 
at the meatus. 

In some cases when the steel sound is introduced there may be 
sorae inipedinieiit at the bulb, due to spasm of the compressor 
urethra* muscle- This, however, is soon and painlessly overcome^ 
and then the tip of the instrument passes into the prostatic ure- 
thra, where it may cause at first as much pain as the bulb does. 
In some cases a powerful spasn» of the prostate may lie induced, 
by which the sound is thrown out of tlie urethra, or an orgasm 
may occur, and the same result may be produced. As a rule, the 
great sensitiveness of the deep urethra disappears under careful 
treatment, and the introduction of the sound then comes to be a 
source of comfort. 

Now, when these cases are further examined by means of the 
finger in the rectum much important information may be obtained. 
On careful palpation of the prostate with the finger-tip the sur- 
geon may find no enlargement or perceptible change; indeed, no 
pain may be produced unless deep pressure be made. If, how- 
ever, the sound is left in the urethra, and then pressure by the 
finger-tip in the rectum is made, the j>atient may experience pain, 
and even cry out in agony. 

Now, by this study of the S}Tnptomatology, by the considera- 
tion of the antecedents and age of the patient, and by the results of 
instrumental and urinary examination, we are warranted in draw- 
ing the conclusion which has been largely fortified by post-mortem 
examinations, that such patients are suffering from exudative 
catarrhal iriflanunation of the mucous membrane of the prostatic 
urethra, and that the verumontanum, with its numerous contained 
mucous tubules and copious nen'e- and blood-supply, h the focus 
of that process. This condition, which is now generally vaguely 
alluded to as spermatorrhoea, to my mind is a distinct morbid 


entity^ nnd it may exist, T am positive, wthout any extension or 
involvement of the environing prostatic substance or of the sexual 
parts l)eyond. Careful studies of post-mortem subjects have 
clearly proved this condition, which can rea<lily be demonstrated 
in life if the surgeon has suflficient experience and skill. 

Tliia affection, a.s it becomes verj* chronic, may lead to catar- 
rhal inflammation of all the gland-tubules, and then distinct 
enlargement of the organ can be readily made out. 

Prognosis. — As a rule, these patients are quite promptly benefitwl 
by treatment, provided they will conform to the requirements of 
sexual hygiene. Sexual and akoholic excesses prove great draw- 
backs to a cure and materially interfere with the treatment. 

In aniemic and neurasthenic subjects this form of prostatitis is 
sometimes very chronic, and the continuance of local inflammi- 
tion leads to the intensification of the general low condition. In 
many cases, however, brilliant results follow a carefully adapted 
method of treatment. 

Treatment. — Tlie treatment in the main is that advised for 
posterior urethritis. The healtli and morale of the patient should 
lie improved as much as possible by all hygienic influences. In 
anaemic and neurasthenic cases iron, quinine, and strychnine are 
very beneficial, and they may be combined with coca extract 
(See p. 124.) 

This combination will he found useful in most cases of sexual 
disorder in which amemia or neurasthenia coexists. 

But in all these cases the existence of the local inflammation 
deleterioualy reacts on the sexual centre and the general nervous 
system, and it is of prime importance to cure that. To tliis eod 
tlie careful introduction of a goodly sized (20 to 30 French scale) 
steel sound (chilled in ice-water), two or three times a week, and 
its retention in the urethra for three or four minutes, may be very 
beneBcial; or, should the surgeon prefer, he may use the now- 
nearly-out-of-dute psychrophor.^ (See Fig. 104.) 

' "A double-current catheter without eyen, the two canals comrannicating near 
the point of the iafitruaient. It ie introduced into the urethra until ils ()oint 
has passed the para proslutica, and it ia then uttached b^ rubber tubing Xo a 




Tnstilliitions and irrigations of nitrate of silver, permanganate 
of potiissiinn, or of tiluni and sulphate of zinc, may be used in 
most cases with iniicli iH^iH^fit. 

Good results often follow the use of the cupped sound of a 
calibre of 24 to 30 French scale, which may be introduced once or 
twice a week. (See Fig. 105.) Into the little depressions on tlie 
curved part of the sound small portions of an ointment composed 
of nitrate of silver and vaselin or simple cerate (*'>ss-oj to 5j) 

Fuj. 1D4 



Kiii. 105 


Capped sound. 

may be placed, wfiich, when the instrument is in the urethra, will 
ladt and soak into the morbid tissues. 

Constipation should be avoided, and coffee, liquors, asparagus, 
and spiced dishes should not be indulged in. 

Bromide of potassium, belladonna, and byoscyamus may be 

reMerToir containinfi^ wat«r of the desired lemperaliire. On turning the Biopcock, 
the water flowB into one canal aud out thnmgh tlie other. In this way the caput 
gHltitiaginis and the entire mucous membrane nre eximsed to the mechanical 
action of pr^wure and the Dedalivc* action of cold." 


tatd with CAiition to meet the condition of erethism when it 
PlusUtic massage is not, as a rule, indicated in tliese cases. 


Hiis condition is not very uncommon, and in order to 
understand it it is necessary to be familiar with the genenil ftod 


mintite anatomy of the prostate. (See page 44.) 

In s«>me cases gonorrhcea and in others masturbation is 
i>rimar\' cause, 'llie essential lesions are, first, a round-cdl 
iiitiltmtion and hypenemia in tlie connective tissue around the ^ 
glftmi-t"'>ulcs; and, second, simple catarrh of the lining ni(^| 
hnine of the ^lan«l-tnl>ules. Tliis periglandular inflammatioo^n 
hsimIIv ciMitinuous willi that of the mucous membrane of 
■JWiWir xtrrthra; but in some cases this latter condition 
wfM wvrtjst, or it may \ye only an insignificant feature, 

neHokv*^'*! invcstigiitLoiis have sliowu that in souie ci 
^JkJMWMtiiH^ of tlie prastatic urethra only the ducts of the 
W^ heem \xiw^\y^'^* consecjuently the parench}Tna of the profttaie 
tt i\t^ tt^so been shown tliat one or more grou| 
mav l>e attacked in an irregularly scattered mai 
TlhflfciJMi WWK^ ««^c ^'^ both, and that symmetrical involveniejit 

«^^ or in both halves of the prostate, llie bfiam- 
^< «vav invade in an irregular manner several groups 
.^K <»(* ****^^ sides of tlie organ, and there may b^ 
■ mm! ihoTB groups which remain unatl*ecte<l. '^^I 
^W Hnv*t»»^ic inflammation is due to the anatomiSP 
wi |h^ tubules, wliich, in passing into the dept 
te|MMkiyM srlBttmfe from one another. Tlius it ha 
. i^AMiMi^W pr^vYSS* when attacking a tubule or a 
",\n« them to their blind ends, and tlms 
. ifsittWncy to invade the peripheral parts 
,.\ miww of gland-tubules may be a 
• ^n ni h-V" ** r\^J«"> *^ "^"^ ^'^O' in some cases the 
*ll^ ill itibrrs its surface feels nodulated 



m Li 



mpy, aud in still others presents the sensation as if many good- 
sized shot were deeply enilx»dded in the capsule of (he prostate. J 
In the first case the glands of the whole organ are quite unifonnly I 
attaeked; in the secomi case groups of glancJs are swollen and cause I 
^ nodulations and lumps on its external surface; and in the third I 
^ case individual glands scattered irregularly over the organ are the I 

I seat of the iriHaiunmtion which by its limited swelling gives the | 
finger the sensation as if shot were seated in the tissues. 
Such are the anatomico-pathological facts aud the resulting 

conditions which are revealed to the surgeon in examining cases - 

of chronic catarrh of the prostate. I 

Tlie pathological conditions here mentioned may lead to various I 

secondary morbid states, which will l>e brought out later on. I 

Chronic prostatitis \s obser^'ed in the period l>etween puberty " 
and middle age, but mostly between twenty and forty-five years. 

It occurs in all classes, in the poor and in the rich. Though the J 

I morbid conditions in the prostide are nearly the same in all cases, I 

the symptoms presented vary considerably in different cases. ^ 
H Tills marked variation in the symptoms allows tlie classification 

into certain forms of the disease, the description of which will J 

(lead to recognition. I 

Tempemment, habits, and age have much to do with the diver- I 
sity of the symptoms; but in the clironic course of the disease 

certain secondary conditions are developed and certain complica- ■ 

tions may be induced which also give rise to marked symptoms. I 

HThus in many cases the symptom-complex is veiy striking. I 

Some patients suffering from chronic prostatitis experience little ■ 

^ trouble, and they give themselves scarcely any concern about the " 
f matter. Other patients may l)e troubled more or less in mind, 
but their health is not seriously affected^ while still others become 

weak and nervous, and even truly neurasthenic. In some cases j 

prostatitis causes no symptoms, or if present they are unrecog- I 

nized until some failure of the health occurs from dyspepsia, ■ 

mental worry, grip, or acute adynamic diseases. After catching 1 

cold, standing for a long time in the cold, or sitting on cohi stones, I 

^the symptoms of chronic prostatitb have first shown themselves. I 





15 lasted 
lich IB 

There is clear evidence at Land that chronic prostatitis has lasted 
many years (five to fifteen) witliout having caused appi 
symptoms, and its existence was unsuspected by tlie patient. 

Chronic prostatitis runs a long and irregular course, with 
or h>ng periods of exacerbation and of remission, in which 
symptoms are insignificant, mild, and hcnrable. ^J 

My experience and study have convinced me that the inost^H 
rect and satisfactory division of chronic prostatitis is, first, that 
fortn which is ohsencd in patients between the twentieth and 
thirtieth years, or thereabouts, uiid, second, a more advanced fonu, 
whicli is seen mostly in patients beyond the thirtieth year. This 
division is not at all arbitrary, but is based upon certain qiiitc 
uniform type-forms. 


Catarrhal Prostatitis in Youngs Snbjects. 

Tlie symptoms which cause patients of this class io seel 
at the hands of the surgeon may be arranged, for clearness of 
description, into three categories : First, those of patients who com- 
plain of uneasiness in the prostate and [K*rineum and rectum; 
second, those of patients who after defection, urination, and 
severe muscular exertion notice a mucous discharge from the 
penis; and, third, those of patients who complain of some form 
of sexual weakness. 

In some of these cases there is coexistent inflammation 
verumontanum. (See previous section.) 

Patients who complain of uneasiness and pain in the pj 
are mostly those who have nmsturbated immoderately, or 
trouble l)egan in specific posterior uretliritls. Verj' often tlic 
symptom is so slight that it causes no annoyance or impairmcjit 
of health. Li some cases the worry and fret lead to amemia. and 
in severe cases neurasthenia may be induced. Hie pain or un< 
ness may be continuous or spiismodic, or it may only be felt 
defecation, urination, and severe bodily exertion. 

Examination of the prostate by means of the finger-tip inl 
rectum simws various con<litions, as follows: the whole ol 
may be a tittle or umch swollen in all directions, or but oi 




of it (and usually it is the left one) may be the seat of tlie con- 
gestive infiltration. Moderate or severe pain may be produced 
by pressure, or sneh may l»e the extreme seiisitiveuess of the gland 
that the patient will not allow it to be touched. Tlien, again, 
one lump or many of them may be felt — in most cases, I tJdnk, 
limited to one lobe, and in a smaller number found irregularly 
scattered in both lobes. These lumps are more or less painful. 
And, lastly, there may l>e found scattered over tne whole prostate 

Fi«. 106 

Granular phosphates, oxalate of lime, spermatozoa, and pus-oellB. 


half pea-sized or large shot-sized prominences, of which there may 
be two or three or even a goodly number seated on one or both 
lobes. The discovery of these morbiti foci clearly warrants the 
diagnosis of chronic prostatitis, (In some caries the existence of 
tuberculosis may be suspected.) In any of the foregoing condi- 
tions massage of the prostate will cause certain abnormal mucoid 
secretions to escape from the meatus or to appear in the urine. 
These secretions are as follows: 1, that of chronic posterior ure- 
thritis (see Fig, 91); 2, a clear, viscid mucus; 3, mucus and cyUn- 


drical prostatic epithelium (see Fig. 46); 4, mucus (thin or thick 
and viscid) and graDular phos{dia(es (this is the secretion most 
commonly found); 5, mucus, granular |Aios[duite8, and cfia- 
diical epithelium (these are usuaUy found in veiy xeoent cases); 
6, mucus, granular phosphates, dead and puny iqpeimatosoa, and 
oxalate of lime (see Fig. 106); 7, mucus, granular [diosfduUes 
with either triple phosphates (see Fig. 107) or crystalline phosphate 
of lime (see Fig. 108). In any of these secretions there may be 
at some time spermatozoa and pus present. 

The essential secretion of all chronic catarrhal prostatic inflam- 
mation is mucus in which there is a greater or less admixture of 
granular phosphates.^ (See Fig. 103.) lliis secretion in excess 
attests the activity of the cylindrical epthelial cells lining the 
tubules, whose function in health is to secrete a thin miU^ flmd, 
together with the granular phosphates, wfaidi constitute the true 
phosphatic fluid which plays such an important rob in the produc- 
tion of pure, fertile semen. (See p. 46.) In disease this normal 
process becomes exaggerated, and as a result we see when examin- 

' In many cases the quantity of these salts in the orine^ the ^aoolate, or in the 
expressed secretion is not very large ; bat in some it is Barprisingf to see the Tcry 
large amount of these granular salts which have been voided in the third speci- 
men of urine, or have been pressed out by prostatic massege. In one instance, 
after urination into two cylinders, in neither of which any granular -phoaph^st 
were present, the balance of clear urine was drawn off by means of a small soft, 
mbber catheter, and four ounces of sterile water were thrown into the bladder. 
Then, the prostate having been well massaged, the patient expelled the injected 
water, together with the expressed mucus. After settling, this liquid ihoweda 
thick layer of granular phoflphates, and when the whole were thrown nptm t 
filter, and the salts were dried and collected, it was found that they wdghed one 
hundred and fifteen grains. These facts, which can be verified by anyoDe who 
will carefully examine his cases, very clearly show that very many cum vbid 
are now classed under the title phosphatarla, and in which It b wntyo eed that 
some disturbances of the nervous system causes the exoev of phospbates, aie 
really instances of chronic catarrhal prostatitis. These observatioos ^ao ynj 
clearly show that those authors who consider many sexual disorderato beaeneory 
and motor neuroses, due to some undefined nervous condition in whidk fiboe* 
phates are found in excess in the urine, have confounded caose wiUi eflaeL Thi 
truth in, the diseased prostate produces the phosphatic excess, and, actns M a 
central focus of irritation, it, in all probability, reacts locally on the ooid, and 
through it upon the whole nervous system. 



of catarrhal prostatitis the clear viscid mucus, the milky 
^Secretion, and that whicli looks as it escapes from the meatus like 
B wormy mass of coiuJeiised milk. When the prostatic inflamma- 
Ition becomes still more chronic we find the other admixtures 
which have just been enumerated. It may here be mentioned 
and emphasized that in most cases of chronic catarrhal prostatitis 
in young subjects the ejaculation in masturbation is composed 
mostly of the above-mentioned abnormal prostatic secretion, with 
iOX without the other salts or spermatozoa. Further, it is well to 

Fio, 107 

Triple phoHphatts, granular phoephatea, and tfperiuatoxoa. 

•ar in mind that the so-called nocturnal pnlhitions in these causes, 
the defecation and urination ejaculate, and the secretion which 
escapes from the urethra after hard work, are all wholly or nearly 
composed of mucus and granular phosphate. In some cases, 
owing to causes to Ix: mentioned a little later, some spermatozoa 
may be found in the ejaculate. With this statement of facts held 
well in mind (which I have verified in clinical obsen'ations and by 
microscopic studies scores of times), the vague conception of that 
old-time bugl>ear of medicine — namely, spermatorrhoea — really 
becomes an enlightened subject. 



In some of these cases theze is increased frequenqr of urinalioa 
during the day, and peihi^ during the ni^^, and there may be 
more or less uneasiness or pain at the end of the act In some 
cases at the end of urination there is maribed tenesmus, which 
may radiate to the pelvis, rectum, and anus, and cause much dis- 
tress of mind and suffering. Tliese patients, besides uttering their 

Fig. 106 

Crystals of phosphate of lime and granular phosphates. 

complaints as to prostatic pain and soreness, often become much 
worried and nervous about their pollutions, which they think will 
render them permanently weak. Many of them sooner or later 
present evidences of declining sexual power. 

Unless cured by proper treatment these patients continue in an 
unsatisfactory state for months and years. Some may appear 
ruddy and healthy, even though they suffer somewhat, and 



worry; others become decidedly nervous and ansenuc, while not 

I a few really become neurasthenic. 
In proportion as the mental and physical reaction is severe, so is 
the case unpromising as to ultimate relief. In general, with the 
improvement in the urethral and prostatic trouble which proper 
treatment brings about, the mental and physical condition improves. 
Many young men suffering from chronic catarrhal prostatitis 
make no complaint of symptoms which point to the prostate as 
the source of their trouble, but lay much stress upon their so-called 
loss of semen after defecation and urination and bodily exercise, 
and by nocturnal polhitions. In these patients, as a rule, we find 
by rectal examination all the tangible conditions of the prostate 
ilrcady mentioned, and microscopic examination of their tirine, 
[of their ejaculates, (vr of the exj^ressed secretion of the prostate 
will reveal the appearances detailed in the preceding pages. 

This class of patients usually become very nervous and excited, 
[and fnjm aniemia rapidly pass into a neurasthenic condition^ and 
■complain of an infinitude of morbi*! symptoms. They l»ecome 
[sexually weak, while at the same time they are abnormally sex- 
ually excited, and tlie result is sometimes vcrj' depressing and 
discouraging. In many instances great harm results to these 
patients by their persistence in masturbation, futile attempts at 
coitus, and dalliance with women. The result in many cases is 
physical and mental exhaustion. 
A certain number of patients suffering from this form of pros- 
ttic disorder seek relief for tlieir sexual weakness, which is the 
lomtnating symptom in their minds. In some cases erections are 
[normal, but coitus after prolonged effort does not result in ejacu- 
lation. In other cases the art is pei-formrd in a weakly and unsatis- 
iTj manner, and ejaculation is not attended with much, if 
any, sensation, and it collapses in feeble dribbling. Then, agnin, 
some patients complain of moderate erections and premature 
ejaculations, while in some erections no longer occur. In many 
of the cases thus summarized there is escape of morbid mucus 
either in nightly pollutions or after urination or defecation. Many 
of these patients arc weak or anaemic, the majority of them are 


^ntally mudb worried, and aonoe of tliem are deddedlj nmua^ 
thenic. Unless relieved by proper treatment, these patients go 
from bad to worse, llie essential pcnnt to be lemembeied b aO 
of them is the necesfflty of the cure of the focus of the tnraUe in 
the prostate. 

As catarrhal prostatitis becomes chronic in some eases tte 
morUd process creeps up the ejaculatoiy ducts and involves the 
mucous membrane and that of the ampullae and of the aemiBsl 
veades. The direct result of this extension is a more or les 
severe catarrhal condition of these parts. But the most strildsg 
effect produced is a condition of flablnness of the outlet ducts d 
the ampullse and of the seminal vesdes and the development d 
more or less patulousness in the not very strong muscular fibres 
of the ejaculatory ducts. The process whidi really takes jJaoe in 
all these parts which normally saf^uard the retention of the semen 
and prevent its escape is one of weakness and of inconq^etenoe, 
which allows the secretion to escape under various mechanical con- 
ditions (abdominal pressure, defecation, particulariy with fiim 
fecal bolus, and urination). When, therefore, chronic prostatitis 
is present with this, as we may term it, seminal incontinence, tbe 
abnormal ejaculate is composed of prostatic mucus and some of 
the secretion of the ampullae and seminal vesicles. As a rule, the 
amount of this fluid lost at any time by these patients is very small. 
The loss of this secretion fcr se is not the cause of the deterioration 
of the health of the patient, as is so generaly believed. The real 
morbid factors are the local lesions and the resulting mental 
unbalance and general depression of the economy, 

Oatairhal Prostatitis in Older Subjects. 

There is no uniformity in the clinical history of the cases of 
chronic prostatitis in patients beyond the thirtieth year. In some 
cases the symptoms are few and not well marked; in others thej 
are more pronounced, while in a few so striking is the symptom- 
complex that prostatic inflammation at once suggests itself to tbe 
mind of the surgeon. In these older patients we do not have to 
listen to so much persistence in the recital of their troubles cod- 



leming sexual discharges and tlie multifarious syiuptoms of sexual 
icurasthenia as we do in younger subjects. Older patients may 
jconie ana?mic, and even more or less neurasthenic, but they 
irely reach the deplorable condition so often seen in young sub- 
jects. The older patients, as a rule, have started in sexual life 
with their organs in a healthy condition, and disease has set in 
later. In the younger subjects the integrity of their sexual organs 
jwas much impaired and damaged before and at puberty. 

Examination of the prostate by means of the finger in the 
Irectum of these older patients gives somewhat different results from 
[those found in young subjects. The whole prostate may be sym- 
I metrically enlarged to as much as double its normal size; only 
■one-half of it may be more or less enlarged, or we may only fin<l 
one or more well-defined large or small lumps, whieh, in exceji- 
ftional cases^ may have a soft structure. But in these cases, as a 
rule, there is evidence of finu .structure, 4'ven approaeliing true 
hardness, and the finger-tip gives the aurgeon the impretssion tliat 
marked cell-proliferation must have occurred in the organ. This 
clinical fact is clearly explained by the results of histological 
studies, which have shown that with the chronicity of the inflam- 
matory process new connective tissue has been developed around 
|the tubules to such an extent as to produce a semisclerotic condi- 
'tion of the gland. For a long time this new cell-growth causes 
the decided increase in the size of the gland which has been men- 
tioned, but later on a cirrhotic condition sets in, by which the size 
of the gland is materially decreased, even to the point of atrophy. 
(Sec Fig. lOOO 

It is sometimes observed that when one lobe of the prostate is 
attacked there is pain in the corresponding side of the rectum. 
This condition is also found in some cases of unilateral seminal 
vesiculitis. In still other coses we find an enlarged, somewhat 
ebumated organ, which is the seat of firm, half pea-sized nudula- 

With the continuance of the chronic catarrhal process the lumen 
of the tubes in many cases becomes more or less plugged up by 
iphosphatic concretions, by desiccated masses of old, cast-off 


epithelial cells, and by amyloid lx>dies. Some of these abnc 
products may be sometimes observed iu younger patients. 

Catarrhal prostatitis in older subjects not infrequently give 
to very poorly marked symptoms. Some patients complain 
uneasiness, as they term it, at the neck of the bladder, and otbei% 

FiG. 109 

Rliowing pro9lat6 of a man in wlilrh fiwiile changes are heg-inning' to derelopii 
Tlii)t section wax mnde thmngh ihe posterior portion of the prostate. Here Um 
duclA run frtrwani, ami ihpy rhcri'fore api>ear in cross-section in ibe dmviofi 
The iobiilAtion apparent in the j^roHtute of the yoang subject (nee Fig. 28) U (M 
longer distinct, owing to the derelnpment oT fibrous and muscular tissae, Vsl" 
antarjr musclc-fibrt.'s are prorutnenily developed on the superior surface of tfcl 
oi^an. In tiie vernmouLantiru the lefl ejaculatory duct iti wen opening omtzallf 
into the prostatir idnns. The right ejsrtilatnrr duct nhowfi sa yet no commanica- 
tion with the prostatic siniiH, but openit at a point further forward. (Drawn from 
the Fidinger projection apparatus ; much magniBed. ) 

speak of more or less deep pelvic pain, which they think is in 
some manner connected with the rectum. In some cases the paio 
is felt on standing up, in others after muscular exertion, bicydc 
exercise, and horseback-riding, while in still others it is felt whca 
in certain positions on sitting down, particularly on the edge of 




chair. In some cases the uneasiness is also felt in the perineum 
and anus, and in other cases on one side of the body corresponding 
to the siile of the prostate involved. In some coses pain in one 
Iiip-joiut is complained of. In many of these cases there is fre- 
quency of urination, and in some there is pain in the glans penis 
at the end of the act. Most patients thus affected have some form 
of sexual weakness, which is either mild or pronounced, and some 
have abnormal mucoid discharges. 

The uneasiness and pain in the prostate may be more or less 
continuous, or mildly paroxysmal, or it may be rendered worse 
when the bladder i.s much distended and when constipation or 
diarrhoea is present, in which instances there may be decided 

Some of these patients speak of a vague feeling of numbness 
deep in the pelvis and in the prostate, and this feeling may also 
exist in the i>eriiieum. In these cases there may not be much dis- 
turi>ance of the health, though some patients become anaemic and 

In marked contrast with the foregoing mild order of cases are 
those in which the symptoms are numerous, severe, and complex. 
In these cases there is more or less ill-health, and in some neuras- 
thenia. Such patients first complain of vague and sometimes fugi- 
tive pains in the back, loins, and pelvis. Inquiry then will usually 
bring out the statement that there is increased frequency of urina- 
tion, and perhaps pain in the prostate and the glans at the end of the 
act, and that their sexual capacity is rather weak. Sometimes 
it will be found that one lobe of the prostate has been involved, 
and that the pain in the glans penis is referred by the patient to 
the ccrresponiiing side of the prostate gland. There may be 
present either sexual apathy or erethism. These patients some- 
times notice the escape of morbid mucus, which may he thin and 
milky, or clear and very viscid (like hquid glue), or it may look 
Uke condensed milk or very thick glue. (See Fig. 110.) When 
in these conditions the ampullations and the seminal vesicles are 
also involved, some of their secretion may escape and become 
mixed with the prostatic mucus, in which event the secretion is 


usually of a yellowish-brown color. It will generally be found/ 
ia these okler patients, that when the set'retion romes from the 
prostate it is white or slightly turbid, like liqui<] glue, or grumou**; 
but that when it comes from the seminal vesicles or ampullatiom 
it is of a yellowish-browTi, or, exceptionally, of a dark-brown tint 
The diagnostic indications which are observed by inspection of 
the color of the morbid mucus from the deep seminal parts can 
readily be verified by microscopic examination. 

Fia. 110 

8ecrelion of chronic proetatiits, showing granular phosphates, degenented 
cylindrical epithelial colle, and pas. 


The urine of these patients is usually of rather low 
gravity (1008 to 1013), of pale color, of feeble acidity, or perhaps 
it may be quite constantly alkaline. It is, as a rule, rather opaque 
and sometimes of decidedly milky hue, and upon its surface w 
frequently an iridescent pellicle forms. The phosphatic 
being in great excess, sometimes appear like a sheen of 
whitish glistening particles. On standing in the cylinder or ui 
glass the sediment first collects throughout the specimen in 

! vg 



cloudy tufts, somewhat resembling water which is slowly freezing, 
'llien, in a short time, the sediment sinks to the bottom of the 
glass and forms a tolerably thick mass, which has a Hocculent, 
grajish-white appearance, very different from that presented by 

In some of these cases of chronic prostatitis in older subjects 
(and it is sometimes seen in younger patients) a peculiar form of 
emission or ejaculate is observed which needs description. Such 
patients more or less frequently see, after urination or defecation 
or liard work, a thick ropy, whitish mass escape from the urethra 
fevrhich looks like plaster-of-Paris mixed with water. In some 
cases the escape of this stuff is unattended with any unpleasant 
symptom, but in others there is a sensation of sickness at the stomach 
and great weakness during and for a time after its passage. In 
some cases there is a scalding sensation in the whole course of the 
urethra, beginning at the prostate, and such may be the patient's 
suffering that he becomes pallid, is thrown into a cold sw^eat, and he 
may be on the point of fainting. This discharge may occur at 
short or quite long intervals, and the fear of its occurrence creates 
in the minds of some patients great apprehension and fear. 

Microscopic examination of these abnormal discharges shows 
that they are composed of mucus and granular phosphates, 
together with (in some instances) triple phosphates and crystalline 
phosphate of lime. (See Figs. 10(1, 107, and lOS.) There may also 
be other components, such as pus-cells, prostatic epithelium (see 
Fig. 73), and some spermatozoa. Many of these patients think 
that they are suffering from a particularly severe form of sperma- 
torrhoea, and they may become much depressed in mind and even 
mildly neurasthenic. 

In some cases of chronic prostatitis in older subjects there is at 
one time hypenesthesia of the prostatic urethra, in which event 
there may be much sexual eretliism, some frequency of urination, 
and more or less pain in the whole act. Ejaculation may be some- 
what premature, but it is usually attended with unpleasant, even 
painful, sensations, which may soon cease or which may last for 

lurs or for a day or two. In some of these cases of erethism 


>isonDEns OF the mali 

the penis is often in a semicrect condition, and prostatic 
flows from the urethra at times. 

The course of this hypersensitiveness of the prostate and pn»- 
tatic urethra, when uninfluenced by treatment, is much prolonged, 
and it may be uneventful or be attended by marked exacerbations. 
As time elapses the erethism gradually ceases, and in some casrj 
it is followed by very decided aneesthesia in the parts, which may 
extend throughout the course of the urethra, and in a mild form 
involve the bladder. There may also be partial insensitiveness 
of the testes, scrntinn, j>orineum, and upper portions of the thighs, 
In some rather rare cases of prostatitis with involvement of the 
ampullie and of the seminal vesicles T have seen this queer asso* 
ciation of these numb sensations. In this condition there maybe 
interfL'renee with the function of urination and with coitus. Such 
patients state that sometimes they are not aware of the fact tbftt 
the bladder is full, and when they attempt its evacuation, thougb 
the stream may be full in size, it is feeble and more or less halt- 
ing. Then, again, erections may be normal, but ejaculatioa h 
feeble, and the sexual act may suddenly collapse. 

By massage of the prostate thus affected we cause the esca] 
several forms of mucus w^iich present somewhat different features 
from one another. This expressed secretion may consist of mucus 
or mucus and glandular phosphates, perhaps combined with triple 
phosphates and phosphate of time, or it may contain degenerated 
prostatic epithelium, pus, spermatozoa, phosphatic concretions, 
amyloid lx>dies, and cylindrical casts of the prostatic tube-glands. 

In tliese older eases it is very common to see (as we sometlmr^ 
do in the secretion of younger subjects) tiie granular phosphate^ 
arranged in the sliape of regular cylinders, which are straight ol 
more or less curved. (See Figs. 103 and 111.) These cjtinded 
are formed in the tubules by the functional overactivity of thfl 
prostatic epithelial cells. Phosphate of lime is formed in excesi 
at the same time that a thick, gluey rnucus is proliferated. These 
two component parts, remaining for a time in the tubules, become 
amalgamateil, and the mucophosphatic cylin4lers arc the result 
These granular phosphates also give rise in the prostate to 






little oval or round boclios^ to whit'li the term prostatic concretions 
should, I think, be applied. They are small masses, fain[>osed 
of the same structures as tlie cyhnders — namely, mucus and gran- 
ular phosphates. They are variously colored; some are yellow 
(and may be mistaken for urates, but cheui][*al analysts will prove 
their true nature), or they may be moderately red or of a deep 
purple tint. (See Plate X,) These little bodies remain in an 
indolent manner in the tubules (and undoubtedly cause pain and 
uneasiness), and they may excite m.ore or less hemorrhage, in 
which event they become colored to a greater or less extent 
These phosphatic concretions may become the nuclei of calculi. 
In some specimens of urine and of expressed prostatic secretion 
we find very firm threads, which are of a yellowish, a brown, or 
a purple color, and on examination an? found to consist of gran- 
ular phosphates, mucus, and altered blood cells. Tlicse threads 
are undoubtedly the initial forms of the V\U\v colored phosphatic 

In some exceptional cases, particularly of old men, we find well- 
marked hyaline cylinders. 

Tliese hyaline cylinders, which look like large hyaline renal 
casts, are undoubtedly due to the inflammatory exudation which 
takes place in the depth of the gland-tubules. They are some- 
times quite long, wavy, of irregular contour, and "in some cases 
somewhat bulbous on one end. They are not of constant occur- 
rence, and are usually found in cases in which the painful symp- 
toms are well marked. 

Corpora amylacea or amyloid bodies are not, as stated in the 
books, of frequent occurrence. They are seldom seen in the 
prostatic secretion of younger subjects, and are rather exception- 
ally found in that of older patients.^ We cannot to-day state 

* According to Friedreich and Kekiile the percentage composition of the amy- 
loid Bubatance is .Vi.6 ; U 7.0; N 15.0; Hand O 24.4. Addition of iodine 
caufleH liic amyloid subsiance Ui turn rcddi-ih ; sulphuric acid and iodine change 
its color to violet or blue. It in disiiolvcd by concentrated hydrochloric acid. A 
precipitate from this noliilinn oblainnl by dihiling the latter with water, reacts 
like acid albumin ( hydrocblorate). Dissolved in a concentrated solution of 


d^nitely what are thdr component puts, but lli^ are in all prob- 
ability composed of mucus, denccaled albuminous matter, inter- 
mingled with phosphatic salts. Tbese bodies present distinct 
and symmetrical striations, which are yerj deaily shown in Hale 
XI., which also shows the structure and anangement of the tubular 
prostatic g^ds. 

Small prostatic concretions resembling mustard seeds may be 
found in the ducts of many tube^^ands and thej may cause any 
of the foregoing painful symptoms. T^tait little round, brownish, 
shot-like masses are largely composed of mucus and lime salts. 

Phosphatic calculi may exist in the ducts or in the tube-glands 
themselves, and produce painful symptoms. These calculi are 
composed of lime salts, sometimes in combination with oxalate of 
lime. They are oat-shaped or bean-shaped, though sometimes 

potMriam or aodiam hydnto tha unjloid ■ntwNnwt U ooiiTartvd into u 


The oorpon uaylacM ^muI from tlie iodine nacUoa lutTe noCUna in oommoa 
with genuine amjloid subeUmces, nor ate thej identieal with vcgetabla rtardi. 
Poeoer thinks that their formation is partlj doe to ooagnlation of albuninoai 
glandalar coDtents, P^rtlj to cellular disintegration, and that ledthin in Tarjing 
amoants frequently enters into their composition. 

The smaller round and ovoid amyloid bodies, unmingled as they are with em- 
talline elements, are the most simple concretions occurring in the body. AU 
other animal concretions contain besides their organic base at least one minenl 
or crystailiDe substance. 

In the larger corpora amylacea (which mostly occur in elderly individuals is 
the composition of whose prostates mineral matters are the greatly preponderating 
solids) more or less inorganic material is found to be deposited aa a role. Ctki- 
fication, however, will not ensue when lecithin had already been depoaited into 
the framework of the amyloid body. These concretions, as previously stated, sre 
of quite normal occurrence, particularly during advanced life, and are not infre- 
quently discharged with the urinary flow. The larger irregular variety of prostsSic 
calculi have been found to be composed of: 

Water 8.0 percent 

Organic substances (N 2 per vent. J . . . 16.8 " 

Lime 87.64 " 

Magnesia 2.88 " 

Soda 1.76 " 

Potash as " 

Phosphoric acid 38.77 " 

Iron trace. 



y ••JL , 



J • 

■ • • 




•V 'I •% 

/ I > * •• 



Amyloid Bodies in the Prostatic Tubules 
Shown on Transverse Section. 






they are round. There may be one calculus, or there may be as 
many as a dozen, or several dozens, in one prostate, 

There can be no doubt that these various concretions just 
rribetl act as foreign bodies, which, by plugging up, destroy 
the function of the tubules, and by their presence give rise to the 
uneasy sensations and pains complained of by these patients under 
varying conditions (sitting down» horseback and bicycle exercise, 
golf, urination, defecation^ and copulation). 

Chronic prostatitis in older subjects, as in younger ones, may 
be complicated with chronic bulbous or posterior urethritis, and it 
is not infrequently coexistent with chronic inflammation of tlie 
ampulltc and of the seminal vesicles. When these sacs at the base 
of tlie bladder are involved there may be the same seminal incon- 
tinence which is observed in voune men. 

f In some rare cases of chronic prostatitis the dischai^ is so copi- 
ous that the term prostatorrhoea has been applied to them. In 
these cases, when they are well marked, there seems to be a con- 
tinual production of mucus by the prostatic tubular glands ; there- 
fore, the most constant symptom is the escape from the meatus of 
a clear mucous fluid or of a mucus mixed with pus and perhaps a 
little blood. This mucous fluid may be scant in quantity, only 
a few drops appearing at the meatus in a day. It may also be 
more copious, and keep the end of the penis in a moist condition 
continuously, and in very pnjnounced cases the escape is so exces- 
sive that patients complain of a constant and amioying "drip- 
ping," which may wet and stain a large part of their shirt-flap or 
of the liandkerchief, which they instinctively make use of under 
these cirtni instances. The escape of this discharge in large quan- 
tities occurs frequently during the act of defecation^ particularly 
when the fecal bolus is hard and firm. In some ca^es the escape 
of the nmcus causes a peculiar tickling feeling in the pnxstate and 
urethra, while in others it pnjduces pleasurable voliijituous and 
lascivious sensations. Some patients claim that they can feel^the 


escape of the fluid from the prostate into the urethra. In r&tfaei 
rare cases the esca[)e of mucus, particularly after defecation, it 
attended with a sickening sensation of great faintness, which maj 
last for seveml iiituutes. Many of these cases have been treated 
for speniiatorrhtea. 

Although we have no pathological knowledge on the subject, 9 
seems fair to assume that in prostatorrhoea there is such an atonic 
condition of the compressor urethne muscle that it cannot prevenl 
the escape of the fluid into tlie anterior urethra. The next mod 
constant symptom is increased frequency in urination, which niA] 
be very excessive or only about twice as often as the nonDal 
desire. There may be decided uneasiness at tlie end of the act, 
and there may be a slight pain or decided scalding sensatioDi 
which passes from the prostate to the end of the penis. In many 
ca-ses the stream is small and weak — a condition which seems to 
point to an atonic state of the detrusors. A sense of duhiess and 
weight is often felt in the prostate and in the rectum, and paiq 
and uneasy sensations are experienced in the perineum, thi|^ 
and lumbosacral regions. 

Some patients suffer from chronic prostatorrhoea withoui 
becoming much <]isturbed in mind by it. But there are others U 
whom this afl'ection is little less than a calamity. Tlicy liecoDM 
exceedingly nervous about their trouble, even to the extent ol 
being melancholy. Tliey lose flesh, strength, and appetite; 
become irritable and incapable of mental and physical e: 
In fact, in some cases the whole morale of the man seems lost. 

In many cases of prostatorrhoea there is more or less disturb- 
ance in the sexual function. In some subjects it is morbidlj 
exaggerated; in others there is much desire, much erethism, man^ 
erections, but verj' little is accomplLshed, owing to tlie precipitat4 
ejaculations. In still other subjects there is little if any desire, 
even as a result of mucli excitement, and the penis and scrotuid 
seem shnmken, cold, and letliargic. 

Rectal examination of cases of prostatorrhoea reveab an enlarged 
organ, usually jutting more or less backward on the gut, and bci 
decidedly broader than normal. Ver}\ often only one lobe 

ite; tbq 




portion of one may be involved. Sometimes it feels soft, and 
again it may seem decidedly indurate<l. There is eommonly more 
[or less tenderness, even severe pain, on pressure by tbe fiu^r-tip. 
Uretbral examination, even witb a sii^all and not stiH instrument 
often causes a great outcry from pain wben the tip passes through 

^^the prostatic urethra. 

^P Diagnosis. — When the foregoing descriptions of clinical cases 
are bonie in mind the suspicion of chronic prostatitis will force 
itself upon the surgeon's mind. Then rectal palpation will reveal 

II the extent and severity of the local condition. At the same time 

^kihe condition of the urine must be examined, and it, with any 
expressed mucus, must be carefully studied by means of the micro- 

I scope. If these requirements are fulfilled, a very satisfactory 
estimate of the case can always be made. 
It may be well here to inform the beginner in the study of 
chronic prostatic diseaise that all the pictures of microscopic appear- 
ances already enumerated will not be found, as a rule, in one 
microscopic field. In the preparation of the specimens for these 
drawings I have carefully selected t^^pical appearances offered by 
many microscopic fields, and have grouped them into one figure, 
which contains all the t^'pe-forms and some rather unusual ones. 
In every instance the endeavor has been made to delineate nature 
truthfully and exacdy. 

Chronic prostatitis may be caused by tuberculosis, and by the 
exercise of care and skill a correct diagnosis can soon be positively 
made. The examination of the urine in these cases for the bacillus 
tuberculosis will in many true cases be unattended with the detec- 
tion of the micro-organism. It is absolutely necessary in these 
cases to examine preferably the expressed or the escaped prostatic 
secretion after proper staining. Great care should be taken that 
the penis, and particularly the glans, be rendered absolutely sterile, 
since upon these pavtA the smegma bacillus lives and hibernates, and 
^kthe detection of this inert microbe might lead the unw^ary examiner 
to mistake it for that deadly bacillus which causes tuberculosis. 

But, in addition to tin- e-ondttion «f the prostate, the surgeon 
must make himself familiar with that of the urethra, chiefly its 


bulbous and prostatic portions, and also of the state of the sem! 
vesicles and of the ampiiUations. In forming an estimate of a case 
it is well to bear in mind that in young individuals a more ol 
less recent gonorrhoea may have existed, and that it is verycom^ 
mon to find the damage quite sharply limited to the deep urethn 
and prostate, and perhaps largely to the gland. It is exceptional 
to find seminal vesicular involvement in young subjects. In oldd 
individuals the prostate and the seminal vesicles and ampullatiofri 
may be the seat of clironic inflammation, and this complicated coo? 
dition can be clearly made out by rectal exploration and by micK> 
scopic study of the expressed secretions or of the urinary sediment 

Pro^osis. — In very many uncomplicated cases of catarrhal 
prostatitis most satisfactory results follow the adoption of propfi 
treatment. In every case, if the patient persists in sexual or alco- 
holic excesses or in any way transgresses against the rules d 
sexual hygiene, Lis ultimate cure will be greatly retarded. 

In young men suffering from the effects of masturbation and 
chronic posterior urethritis the prognosis is, as a rule, good, pro- 
vided the patient is not very anipmic: or neurasthenic. In thos< 
cases in which the vtorale of the patient is much below par thi 
progress toward cure is slow and often unsatisfactory and halting 
The occurrence of cystitis by extension, particularly in chnmk 
masturbators, is of serious import, for such cases are very 
tory to the most careful forms of treatment, 

In very many older men an excellent prognosis may be givco 
they can control their sexual tendencies by moderation and wO 
not overindulge in alcohol. The coexistence of chronic posterioi 
urethritis, of seminal vesiculitis, or of chronic inflammation of th< 
ampulire b a rather serious drawback which may tax the akj 
and patience of the surgeon. Very many of these cases, hoi 
are nuich benefited, and even unpromising ones can be cm 

Treatment.^The first essentials in the treatment of 
prostatitis are a regular, quite life, al>stinence from alcoholics, 
the avoidance of all kinds of sexual excess or excitement 
bland, nutritious diet should l>e taken, and spices, eoffee» 
highly seasoned dislies, and asparagus should be avoided. 

pvco t 

rad wO 


of thi 

the akd 





rpctnm .slnHikl W thoroughly eniptleil every day at least onee, an(1 
if the tiatural evaeuatioii <lt>es not occur a mild aperient must Ijc 
taken. These patents mast avoid taking eoUl, and they shouKI 
not take part in violent sports, nor should they indulge in bicycle 
or horsehack exercise. 

Moderate and rather infrequent sexual intercourse may be 
practised, provided no ill effects are found to follow it. 

When chronic hnlhous or posterior urethritis is present active 
treatment must be inslitutcMl for the relief of these conditions, 
wliic'fi niatcrifilly aggravate the ca»se and reniler it more n*l»ellii>ns. 
In like manner strictures of the urethra should receive pro|jer 
attention and treatment. luNttllatlons of nitrate of silver, irri- 
gations with watery solutions of the same salt (1:.500, 1: 1000, 
to 1 : 2000), of permanganate of potassium (1 : MM) to 1 : 10.000), 
or of sulphate of zinc and alum (each 1:500 to I; 1000), may be 
^ven ever)' few days. 

In many cases the careful introduction of a steel sound cooled 
in ice-water, ever}' four to seven days, is most grateful and bene- 
ficial. The psychrophor may be used instead of the sound if the 
surgeon so desires. 

Direct treatment to the prostate by the surgeon may l>e made 
by means of the finger-tip in the patient's rectum. Preparatory 
to be^inninjL? the treatment of massa^ of the ]>rostate the surgeon 
should acquaint himself with the size *)f the organ and ascertain 
what part is affected, or whether the totality of the gland is in- 
volved. Then (lie relative softness, bogginess, and Imnlness 
should lie learncil. When (he conditions of the organ are luscer- 
tained full <lctails thereof should Ix* noted down for future refer- 
ence and comparison. The main object is to reduce the sisse of 
the swollen oi^^n. and by massage we press out pathological 
products [vide aupra), stiunilate the tissues, and cause the absorp- 
tion of more or less of the inflammatory exudation, by means, 
probai>ly, of the increased rircidation in the vessels and lym- 
phatics. In addition to these changes, we undoubtedly give tone 
and resiliency to the llabby bloodvessels and also stimulation to 
the relaxed muscular fibres. A certain healthy stimulus seems to 



be communicated to the nerves of the prostate by judiciously 
administered massafje. The technique of the operation i.s very 
sii»iple. Tiie patient stands with his feet slightly separated aad 
l>cnds the body forwanl at a right angle. Then the surgeon, 
having li!>erally greased liis forefinger with vaselin, gently inserts 
it until he reaches the prostate. Then, by means of extended 
lateral and up-and-down gentle but firm presstiiv, he thoroughly 
kneafis the organ. Patients act and feel every dilTerently while 
thi.s ()peni(i(ni is tuking place. Some cry out with pain, particu- 
larly at the first .samcc: others sulFer a little and make no com- 
plaint, while others are entirely passive and perhaps say that the 
sensation is a little unpleasant. In some patients partial or full 
erections are produced, and in altnast all of them there is inability 
to urinate for several iriinutes after the operation. The secretions 
which are expressed have already been descril^ed. 

In most cases prastatic massage proiluces nuicli Ijenefit and 
comfort, but in some it is necessary to proceed verj' guardedly. 
lest irritation be set up. No absolute rule can be laid down as to 
the frequency of repetition of this treatment. In general, one mas- 
sage in five or seven days, or even ten, will be found sufficient to 
produce good results. \\'hen there is concomitant chronic ure- 
thritis of the btdb, posterior urethritis, or involvement of the 
venmionlanum, the patient may l»e more or less sensitive to thi-i 
pnvcciiur(\ and it behooves the surgeon to proceed slowly ami 
carefully, 'llie indications for the continuance and the fnequenr}* 
of the massage are the comfort and lienefit the patient says he 
cNiM'rienccs, and also the moral effect, whit^h in many cases trans- 
forms a gloomy and wtn-rying palicnt irili* ii cheerful and hopefnl 
(Hic. As a rule, when no ill effects are ]>rmhiced, as attested hy 
the feeling of general and local ccnnfort experienced l)y the patient, 
when there Is no abnormal desire to urinate, and when pus in 
uiuisuid (piantity does not appear in the urine, the surgeon mav he 
certain that he is on the right track, and can continue. He can 
also gain much information by ascertaining from his records how 
n»uch involution in the prostate he has produced, and by repeated 
microscopic examinations in auspicious cases he can convince 




himself that the pus, effete epithelial cells, j^runiilar phaiphates, 
perhaps tiil)e-ciLsl.s, proshitic roneretions, anil ainyloi^l ltr»lies 

I are growing less luirnertnis i\s the patient improves in every 

^m particular. 

During the massage treatment rectal irrigations w-ith very 
wann water, administered by means of Kemp's instnnnent (see 
Fig. 101), are often of signal U'uefit in causing the involution of 
the swollen organ and the absorption of diseased products. In 
some cases, also, cold water thus administere<l seems to \ye very 
beneficial. Tlie zerodone may be useful in thc^e cases. 

In order to obtain the beneficial effects of heat in the rectum 
it may be necessarj' to use water of the temperature of 100** 
to 120°. The increase in heat can be accomplished gradually 
until the higher temperature of 130° is reached. When hot 
water is thus used, many patients from the very first experience 
grt^at relief and gladly consent to the elevation of the temperature 
of the irrigations. It is probable that these hot rectal applications 
pnjve Ijeneficial by their stinuiiant action upon the nen'es, the 
blocHJvessels, and lymphatics. 

'Die U8e of cold water by rectal irrigations should l>e carefully 
watched, atiil it shouhl be tliscoutitiued at once if discomfort to 
the patient is produced, llie temperatun- of cold irrigations 
shoulil rangt* from .50° to that of ice-water. 

Many patients state that their sexual function is much improved 
by the use of the vey hut rectal irrigations. 

I know of no morbid condition in which such relialilc data can 
Ix' obtained by physical and microsc4>pic cxanu'nations nf (he 
patient and of his urine as are presented by cases of chronic pros- 

H Many cases of chronic prostatitis are much l>enefited by tonic 

^■^ mixtures which contain goo4lly doses of nitronniriatic acid com- 
bined with strychiiiue an<l fpiinine. 'Ilie neurnsthenia and weak- 
ness which very often occur in the course of chronic prostatitis 
should l>e can^fully treated. Such patients should receive kintlly 
eiK'ourageuienl, and their general well-being should be sedulously 
cared for. 


In addition to systematic local treatment, much benefit nuy 
fdlow the internal administration of full doses of fluid extract of 
ergot and stiychnine. llie muriate tincture of iron combined with 
strychnine is sometimes veij eJBBcient, particulaily in debilitated 

It is also well to mention mercurial, ichthyid, and iodide of 
potassium suppositories, ^diich should be introduced into the 
rectum every night. The inert bans of these suppc^tories is a 
mixture of cocoa-butter and white wax. In each suppository may 
be incorporated twenty grains of strong mercurial ointment, fifteen 
to twenty drops of ichthyd, and thirty grains of the iodide of 

In all cases the surgeon should be on the watch for urethral, 
vesical, and seminal vesicle complications. 


Hie scope of this treatise precludes the full consideration of the 
subject of hypertrophy of the prostate, therefore, the genital and 
sexual symptoms induced by this morbid condition will receive 

most attention. 

In all probability many cases of hypertrophy of the prostate 
take theirorigin in the chronic catarrhal processes already described. 
In general, it may be said that this morbid state begins to develop 
or to reveal itself by symptoms after the fiftieth year, though it 
may begin at an earlier date. 

Succinctly stated, bypertroj)hy of the prastate consists largely 
in enormous overgrowths of the gland-tissue of the organ, together 
with increase in the nniscular fibres and connective tissue of the 
stroma. This overgrowth in most cases occurs in the path of 
least resistance, which is toward the bladder, but it also takes 
place laterally and backward, when it bulges more or less into the 
rectum. With the lengthening of the lobes the urethra becomes 
elongated, and with the growth of these parts the lumen of the 
canal is impinged upon, and it is rendered smaller, inextensile, 
and very frequently tortuous. In some cases the so-called third 



lobe becomes enlarged into a round or pear-shaped body, which 
acts as a ball-valve at the vesical orifice. In some instances » 
true bar across tlie lower part of the vesical neck is fomied. With 
the increase of this overgrowth at the neck of the bladder, which 
then is no longer dilatable, more or less diflioulty in exj)elling 
the urine is experiencet!, until in tlie en<l in many causes expulsitm 
l»ecoines impossible. Some patientj> state that their iirst knowl- 
edge of the trouble was revealed to them by their want of power 
I to start the urinary stream. 
In many cases the development of enlarged prostate Is very 
slow and insidious and unattended with marked symptoms, while 
in others its onset is quite rapid. Tlie mast constant symptom is 
fretjnency of urination, particularly at niglit. In stricture of the 
urethra this syuiptoui is mostly observeil during tlie ilay, while 
in old prostatic cases it is complained of at night. After a time 
the j>atient l>ecomes conscious that the outlet or the neck of the 
bladder is contracteil, aii<l that expulsion of the urine liini 
much greater effort than it did formerly. Ilie stream of urine 
is then small, feeble, often falls perpendicularly on hia shoes, is 
sometimes su(hleiily arrested, and ends in unsatisfa<'tory dribbling. 
With the ]>rfjgressive development of this <)vergnivvth the impedi- 
ment to urination Increases and the bladder may l>ecome over- 
distended, and then chronic incontinence witli all its painful symp- 
toms and unpleasant features is observed. Synchronously with 
the overgrowth of the prostate certain hypertrophic changes take 
H place in the bladder by which its walls are much thickened and 
its inner surface Is rendered rugose and much trabeculated. Rarly 
or late a pouchy condition of the bladder liehind the trigonum 
forms, and a receptacle is thus made in which an increasing quan- 
tity of urine accumulates which is termed residual urine. As 
I the case grows worse the irritation of the neck of the bla<lder 
becomes more and more painful, and a burning, scalding sensation 
Is felt in the whole urethra togt^ther with, in many cases, severe 
pain in the glans penis. After urination some prostatic mucus 
may drip from the meatus. Many patients suffering from hy]>er- 
Irophy of the prostate give evidence of sexual erethism. Erec- 


tions more or less perfect quite constantly occur, and nocturnal 
emissions are not infrequent. In some rare cases these men 
become in a measure sexually perverted, and not being satisfied 
by coitus, they indulge actively or passively in many unnatural 
practices. As a rule, however, this period of eroticism sooner or 
later passes away and the man lapses into a condition of sexual 
apathy and permanent impotence. In other cases, happily the 
more numerous, as the hypertrophy of the prostate develops and 
its incident sufferings increase, sexual desire slowly or quickly 
dies out. 

Desides the sexual symptoms some patients complain of pain in 
the penis, particularly in the glans, in the testes and scrotum, and 
in the perineum. Many patients complain of uneasy sensations 
and dull pains in the sacral, hypogastric, and lumbar regions, 
which they wrongly attribute to rheumatism and lumbago. Pain 
near the rectum or anus or in the perineum, when in certain posi- 
tions, or when the body is roughly jolted, or on sitting down, is 
not at all infrequent. 

With the progress of the case, when unrelieved, the health 
sooner or later fails. In many cases cystitis becomes a most dls- 
tn\ssing symptom, and this bladder infection creeps up the ureters 
and involves the kidneys. The cystitis causes uriimr}- poisoning, 
and tlio damage to the kidney prevents the elimination of the 
effete product.s of metabolism, so tijat the patient is really doubly 

As liis diseased conditions f^row worse he loses his ap|>etitc and 
he l>econies thin and sallow. He suffers from a peculiarly dry 
tongue, and liis breath has a urinous odor. Then chills and fever 
and niarasnms set in, and deatli ensues. 

Treatment. — Care shouhi l)e taken as to the mode of life of the 
patient. He should eat easily <ligested food in sparing quantities, 
should not overexercise, and shouhi avoid taking cold. It is im- 
portant that his bowels should move freely every day. Spirituous 
liijuors should Ix' taken in great modenition. 

In tlie first stages of hypertrophied prostate in some cases much 
l>enefit results from the very careful and paiidess passage of sound 



and bougies, which seem for a time at least to keep the lumen of 
the urethra patulous. Rectal injecticMis of hot or cohl water may 
lie beneficial. Iti many cases warm irrigations of tlie bhulder 
and urethra with boric acid and hot water (two drachms to sixteen 
ounces) are very jjratefnl and soothing, ami the same may be sjiid 
of very mild warm solutions of nitrate of silver (1 :500Qto 1 :2(»,0(H)J, 
or of pennan^atiatc of potassium (1:K0(X) to l:10,0tK3). Alkalies 
or acids, as the case demantls, may be given internally to render 
the urine bland. Urotrt)pin should lie ^iven in tlecided ca^es of 
alkalinity of the urine- 'iliese patients shinild be told not to trj' 
to hohl their urine when the desire for expulsion comes on. Mas- 
sage of the prostate may sometimes he very lieneficial. As n rule, 
these patients have to ivsort tpiite early to the catheter, the use cif 
which may make them comfortable for many veans. 

In certain .selecteil cases pro.statotomy and prostatectomy, ure- 
thnd or perineal, may lie performed. Castration and vasectomy 
liave nut prove d to l>e t he brwins which they were ex|X'cled to l>e. 
In many cases permanent perineal or suprapubic drainings may of 
necessity l>e resorted to. In appropriate cases Uottini*s o])eration 
may l>e re.sorted to. (For a full consi^Ieratron of this subject, 
see my work -I Prartifal I'rcafm' nrt CeniUtunnunj and I'tumal 
Diseases and Syphilh. Fhihulelpliia, 1904.) 



Ik some cases seminal vesiculitis is the cause of sexual weak- 
ness, iiupotence, and of neurasthenia. This affection is reallj nut 
so frequent as it has heen claimed to be, yet it is found in a goodly 
number of cases. It is due to chronic gonorrhoea^ masturbation, 
an<l sexual excesses. 

Seminal vesiculitis may be acute or chronic. The acute form 
has many points of anal(^ with epididymitis. Both affections 
are almost always secondary to gonorrhoea, occurring in the third 
or fourth week, or to hypercemia of the posterior urethra, due to 
masturbation and venereal excesses or to inflamnmtion of this 
region, resulting from traumatism, catheterization, endoscopy, and 
strong injections. In both there are inflammation of the mucous 
membrane and hyperplasia of the connective tissue. In epididy- 
mitis the testicle does not swell, and in seminal vesiculitis the 
prostate is not usually affected. In both cases suppuration in 
the sense of abscess-formation is the exception and resolution the 

Symptoms. — ^llie symptoms of the acute form of seminal vesic- 
ulitis are quite similar to tliose of posterior urethritis and to those 
given as diagnostic of tlie severe varieties of prostatitis. The 
patient first experienced pain, either of a dull or throbbing char- 
acter, or a sensation of weight, which he refers to the deep portion 
of the pelvis just within the anus or at the neck of the blarlder or 
in the perineum. There is markedly increased frequency of urina- 
tion with tenesmus, sometimes mild, again quite decided, and in 
some cases very severe. As the bladder fills the painful symp- 
toms increase in severity, and there may be pain at the end and 
sometimes at the root of the penis. There may be fever, chills, 



and malaise. All these symptoms may be present in posterior 
urethritis, so that thp crucial test iti iHagiiosis is palpatio?! of tlie 
prostate and seriniial vesicles by means of the Hiiger in the reelinn. 
If the case is one of acute posterior urethritis the prostate may be 
tender, even painful^ on pre.ssure, aiul perhaps swollen. If semi- 

Inal vesiriiJitis is pn\sent and exploited for early, one or both vesi- 
cles will be found to be much eidarge d in all directions in the sliape 
of a distended leech, hot, brawny, and exquisitely tender. In 
a few days the swe]]in>( may still further increase, and tlieii ino<l- 
erate fluct^iation may t>e felt. In some of these cases the patient 
presents a pitiable spectacle. lie suffers from pain in the perineum, 
rectum, bladder, and at the top of the sacrum. He has frequent 
desire to urinate, and the act is attended with much pain, or again, 
in some eases, there is very distressing dysuria. Defecation is very 
^■painful, and perhaps complicated with rectal tenesmus, and may 
■ he attended with vesical spasms; sleep is heavy and unrefrcsh- 
ing, and often during the ni^ht painful erections ami pollutions, 
. perhaps bloody, may add to the patient's sufferings. The urine 
^■may contain pus and epithelial cells, hut these tissue elements may 
" be absent for Iioni-s or for days, during which the urine is clear; 
and in this feature acute seminal vesiculitis differs from acute 
posterior urethritis, in which the dischar/^ of pus or blood is con- 
stantly seen. At the onset, and early in the course, of seminal 
vesiculitis the gonorrhwal discharge may disappear entirely, and 
in this it resembles epididymitis. But in a short tirne the discharge 
reappears, and it may l>e more or less bloody. In seminal vesic- 
ulitis the blood is mixed with the pus or the latter is streaked with 
I it, wheieas in posterior urethritis the blood follows the act of urina- 
tion, or there may be a worm-like thread of coagulated bloo<] with 
the first jet of the urine. 
The iuHanimntory stage of seminal vesiculitis usually pursn*'s 
a course similar to that of epididj^nltis, and at the em! of a wtn^k 
or ten days the syniptcmis become ameliorated, and resolution 
gmihudly sets in. In all pn)I>ability, in many ciuses the parts 
siMuier or later liecome tiornuil agjdn. In some eases after resolu- 
'iou of tlie vesicular inflamination the uiethral discharge reappears, 


while in others the urethra is left in u henlthy contlition. In this 
acute stage of inflammation the morhi(l process resembles that of 
gonorrha'a in tlie redness antl swelling of the mucous memhrune 
and in t!ie submucous cell-increase. When, however, the phleg- 
niH.sia l>ee()nies intense a true suppurative process or aheteest 
forms, in which event the local and general symptoms aw more 
pronounced and the suffering of the patient greater. Rectal 
exploration then reveals a large boggy, painful swelling at (he 
liiise of the bladder, l^yond and to the outer edge of ihr 
prtxstate. This swelling is very large when both vesicles are 

While the ejaculatory duct of the seminal vesicle remains patu- 
lous the contained pus may escape, or perhaps may Ije niilkeil. bv 
means of the finger-tip, into the urethra, in which event full ivsi>- 
lution without ulterior bad results may occur. If, however, the 
duct L>ecoTnes occluded by the swelling of its mucous meinbranr 
or by l>eing plugged up by sympexia or masses of mucus dislodged 
from the diverticula of the vesicle, the abscess may attain a verr 
large size, and, if not promptly incisetl and its contents evacuated 
the pus may |>erfomte its walls and i)urst into the ischioirctal 
fassa or arr)und the rectum into the l)ladder. the rectum, and tlic 
[X'ritoneum, sometimes causing fleath and generally leading to tlw 
fonutition of Mstulous tracts which are very ilifhcult to cure. 

It is stateil that the abscess never ruptures into both bladder 
and rectum. In any of these very painful events examination of 
the parts is necessary, anil from it the line of operative proee«lure 
will l)e arrived at. The intimate relations of the vas deferens, 
the ejaculatory <luct, and the senuiial vesicle are such that the last 
structures and the testicles may lie involved at the same time, it 
is j)robal)le thnt in some cases seminal vesiculitis and epididjt'mitis 
ct>exist, but that the violence of the symptoms of the testicular 
tmuble masks those of the vesicular atfection. It is also very 
probable thai the ititrapelvic pain which so frequently accom- 
panies acute epididymitis, and which we have been taught is due to 
w complicating pbleginusia of the j>elvic part of the xfis deferens 
b sometimes realty symptomatic of involvement of the seminHl 






vesicle. I'he statement that ibis afTectinn is a common accoin- 

niment of goimrrlKjeal ppitliilyiiiitis needs eoiifirination. 

It can be remlily uiKlerstooiij after a eonsiileraliciii of tiie fon»- 
going facts, why acute seminal vesiculitis has often been wrongly 
diagnosticated a.s posterior urethritis and acute pn>.statitis, and by 
many, under the influence of old iilea.s, rus infiauniiHliun itf the 
vcsiciil neck and floor of the lilailder. 

■ This form of seminal vesiculitis may result from the non-occur- 
rence of resolution in the acute affection, and in this event the 
clinical history is tolerably dear and striking. But in the majority 
of cases of chronic seminal vesiculitis it begins a.s a low-gratJe 
inHammatory process in persons, particularly of neurotic or neur- 
asthenic types, who may suffer from chronic subacute posterior 
urethritis or chronic pmstatitis, and in conHnned mtustu rim tors 
anil in those given to excessive vener^' and alcoholics. The diffi- 
culty in the study of the chronic form of seminal vesiculitis is 
that in many cases the syni()toins are so few and so vague, and 
jMjint so indelinitely, if at all, to tronl>le in the vesicles, that tjflen- 
times their origin is not suspected by the surgeon. Then, again, 
cases are seen in which the s^inptoms are very clearly and stn^ngly 
marked, yet they may Ih* with seemingly good reason attributeti 
to trouble in the posterior urethra and in the prostate. 

^h Cases of seminal vesiculitis which follow quite directly a recent 
or more or less remote attack of gonorrhtea very often present such 
a group of symptoms that the surgeon is led to suspect their origin 
in inttanimation of the seminal vesicles, particularly if no trouble 
is found in the posterior urethra. Such patients, who are usually 
young men and not over thirty years of age, state that since an 
attaick of gonorrlia'a or a relapse they have not felt well as regards 
their sexual organs. Some ctjmplain that they are sexually weak, 
that they have little flesire, or that they have prematun^ and ^>er- 
haps painful ejaculations, which in some eases are mixed with 
blood. Others, again, arc subject to a constant slight or profuse 

;.:'.v' >:. !'iS":inf:Rs of the male a\'d female 

;i."V. li'.ioh is of a mucous or mucopurulent cbarafter. 

■::.> f. r.ii of ilir^-harge may l)e iiitermittcut. There may 

y-. *r. a lUviilotl chronic seminal vesiculitis without any 

j..-y^ A-i. h is {X'nrptible. Not infrequently patients ba\ing 

: .-■ :' ■ •:•.*' or inorv attacks of gonorrlia^a state that they 

■ \*- • .1 :::il«l or nuxlerately severe, even buniing, pain nr 

^ - ji ^'ii-it' of weight in the course of the urethra, in i\v 

l.nitU'r. anus, ami rectum. In addition to this, thev 


ift'on of chronic suminal vesiculitis. 

,■ *■. of sexual <'n'tliisi!i with or without irratiticii- 

.- M^'TUOtinics of iiuTcas4*<i dcsiri*, wliiU' little relief 

. .'". of the syni])toins, may follow the sexual a<*t. 

A "'.s may Ik* ])n'M'iit in cases of chnniii- pM^- 

.^. \vsicnlitis in yonnt^cr men consists in a suli- 

.^>.. ■ v.hratioii hrnrath the mucous inemhraiif, 

^ v-.H^nemia and purulent eatarrli. If ean* U' 

^.^ 'x. .;T\nhra of the disehargi* from ]>ostcrior nre- 



tlirilis and from any form of prostatitis (if these morbid conditions 
coexist), a grayish or brownish mucus cun l>e cxpronsctl in some 
cases from the vesicles by the hnger-tip in the i-ectiim. This sivrc- 
^Rion may be very copious or decidedly moderate iti rjnantity. It 
is very viscous, and in the earlier days of the inflanmiation it may 
be tingecl with blood or pus more or less abundantly. Wien this 
secretion is examined by means of the microscope it will Ik* found 
to contain vesicular mucus in large and small globules, granular 
and perhaj>s crystalline phosphates, pus-cells (perhaps red cor- 
puscles), and spermatoz4>a, which in most cases are lifeless. Tliese 
features are well shown in Fig. Ill, the secretion having been 
gcjlten by massage from a patient and examined by myself. These 
appearances are quite constantly found in the secretion of cases of 
young men in whom, though the affection is chronic, it has not 
yet reached its full development. In these cases, which, by their 
clinical history and their secretion, seem to constitute a distinct 
class, the cell-intiltration and consequent thickening of the walls 
and structural damage of the vesicles are not yet very great, ami 
the prognosis generally is better than in more advanced cases. 


More Advanced Form of Seminal Vesiculitis. 

In the cases of pronounced masturhators, In old gonorrhti?ics, 
those given to excessive indulgi-ncCf particularly with the aiidition 
of alcoholic excesses, chronic seminal vesiculitis may sometimes be 
found in a mon' S4:^'vere form. These cases arc often those of 
anicinic, neurotic, and ncurastlieiiic subjects who rt^spond very 
indilFert*iitly to tn-alineiit. Su<'h patients, who arc usually l>eyonil 
thirty years of age, in whom the affection is very chronic, may 
complain of some pain or disturbance in the un^thra, bladder, 
anus, or rectum, and they may pnvsent a discharge; then, again, 
all these symptoms may he wanting. Most of them, however, 
give a history of disturbutu'c in the sexual function similar to 
those just detailed. These disturbances are mainly in two forms: 
first, those of lowered power, and, si-cond, those of erethism nf tlie 
al organs. In the first order cyf cases we find abseni^v or 


incornplr(t'iU'.s.s (»f erections, emissions from slight catises, withont 
eularpMiient of the penis. In these eases there is often n haunt- 
ing tlesire for tTcction, wUh no response. Very often these patients 
suffer from a eoustant <lribbling of a dirty^ray or hmwnl*ih 
inuens, which may during the (hiy V>e so copious as to saturate 
one or two pocket-handkerchiefs. Then, again, some of tht-^e 
patients have no such discharge, but an emission of a thin, gray, 
watery, and sometimes brownish and even curdy fluid occurs 
<laily, or more frerjuently. 

In these advanecfl cases, particularly in subjects who are a^ 
preaching middle life, the stnictural changes in the vesicle^^l 
mucli more pronovmced than they are in the youn^r class of cases. 
The .suliunirous infiltratiiKi will then l>e found to have thickei»e<l 
the walls of these sacs very much, and in some cases there will 
he fonnd a ver\' decided increase in the density and quantity of 
the p(Tivesicnlar conm^ctive tissue; whereas in the earlier class of 
rases the vesicle\s to \hv touch feel like a distendetl leech, and 
yet compressible. In the most advanced cases these 
are firm, perhaps very resistantj and they convey to the min< 
means of the fin^'r-tip, the impression that a well-<lefine<l, 
pact, perhaps indurated, mass has taken the place of a tole 
soft sac. The conghjmerate morbid process then consists 
thelial hypertn>phy, submucous n>un4l-eell infilt ration, gen< 
increase in the connective-tissue stroma, and much hyjK'rtn>ph] 
the })erivesicu!ar fibrous tissues. In these cases, as time g?) 
contraction takes place in the newly formed morbid tissues, 
the calibre of the chambtTs of the vesicles Ix^come.s much 
tracted. In this event the muscular contrwtile function of tl ieaeii 
sacs is more or less impaired or is wholly lost. 

Wien a post-mortem specimen of the seminal vesicles in 
less advance^l form of the morbid process is examined, it is 
found that the calibre of the vesicles and of their chambei 
not been materially decreased, and that, although the wall 
thicker than normal, they are yet compressible and tolcl 
extensible. In thi* older cases alxive mentioned the rigidil 
the parts contrasts strongly with the condition just now desci 


r^ / / boo »^ . Yr^,, ©- 

0^ . , ,.- 


Secretion ol Very Clironio Sonunal Vesiculitis, Conta 
Phosphatic Concretions, Granular Phosphates, 
Sympexia, Pus Cells, Mucoid 
Globules and Spermatozoa. 



The normal secretion of tlie seminal vesieles is of a duU-^ay 
fjlor, jH-rhaps slightly tin^'fl with light brown. In disease this 
»cretion l^ctjmes more and mon* bn>wn. In the less advanced 
class of cases it is of a yellowish-brown color, and in the advanced 
cases it is of a very pronounced dirty, sometimes rusty, bmwii 
color. In the diseased condition, as age advances, the secretion 
becomes much more \'iscid than it is normal! v. 

The dark color of the secretion in very chronic seminal vesicu- 
litis is due mainly to phosphatic concretions hekl together by 
mucus and more or less stained with blood-pipnent. Then we 
also find lai^ round or oval tissues of the dried mucus peculiar 
to the vesicles, which seem to have l)ecome stained by blood and 
to have become condensed into spheres. Further than this will he 
found large, flat, irregular plates of epithelial <*ells grouped together 
in a chaotic mass and deeply tinged with yellow pigment derived 
from the blood. These are the main (Minstitiients of the seereti**!! 
of v*'ry fhmnic seminal vesienlitis, and their presence is very con- 
stant, as I have often observed. In addition, we find more or less 
granular phosphates, yery often of a yellowish color, red blood 
cells, pus cells in varying (juantity, anil s[M»rmatoz(>a, which are, 
as a rule, dea<L 

In Plate XII. the secretion of very chronic seminal vesiculitis is 
well shown. The secretion used in the preparation of the plate 
was drawn by me from the seminal vesicles of a man, aged forty- 
two, who died of alcoholism, and who in life suffered from chronic 
seminal vesiculitis. 

I have foim<I in ]K)st-mortem sj>eciniens that the secr<»tion of 
the stMninal vesicles in health an<l in disease is exactly like that of 
the deferential anipullations, except that perhaps 8f>ermatozoa may 
\yc rather more numerous in the latter secretion. Now, as these 
parts are so closely coapted, anil iu> their function and structure 
are precisely similar, it is very probable that the ampullations are 
also involved in sfime cases of .seminal vesiculitis, an<t it may 
happen that the disease may be limited to the ampullations. In 
the living subjeei 1 can well conceive that it vvoulil l>e s^^metimes 
very difficult to <liagno8ticate, by means of the finger-tip in the 


rcctiiin, l>otwt^n chronic seminal vesiculitis and chronic inflamma- 
tion of the ampiillations. I have before mc, as I write, the semiiuJ 
vesicles of a nmn which are the scat of advancetl chronic inflam* 
ination, and their stnictural condition and their secretion i« 
|)refis('ly similar to those of the ampullations which lie in dose 
4'cnitat't at the inner side of the vesicles. If such a case wert 
examined in life, in the light of our present ideas, the diagnoAS 
of *-hronic sorninal vesiculitis woiil*! be unhesitatingly made. It 
is probable, therefore, that in cases of chronic, and perhaps acut«^ 
seminal vesiculitis the ampulljc may also be involvetl by the saiM 
morbid change. 

Such is the erotic condition of some patients suffering from 
chronic seminal vesiculitis, that the sight of a pretty woman, of 
her breast or her ankle, throws them into a high state of nenou3- 
ncss and sexual erethism. I have known several instances in 
wliich one woman only exerted this morbid influence upon the 
man. Accidental slight contact, the glance of the eye, the snund 
of the voice, and the grasp of the han<l served to so excite and 
exalt them sexually that an orgasm, with or without partial erec- 
tion, wt)uld result, Tliis erotic condition is also not infrequenth 
observed in men suffering from chronic catarrhal prostatitis. 

These cases, as we may tenn them ver}* chronic, run a somr- 
what peculiar course. In some the symptoms and conditions cod- 
tinuc in a more or less subflue<l manner, and though thev disturb 
the patients considerably, the latter arrive at a state of mind by 
which they liear their troubles m«>rc or less philosophically. In 
tliis class of cases tlie aflcction nms on from year to vear in a 
monotonous way. Such patients are neither healthy jior very sick. 
Hut cases are sometimes seen in which the chronic, uncvcotfol 
cours4^ of the affection is varied by the development of more or 
less severe exacerbations. In this event the health Ix'c^onies dete- 
riorated, the patients lose their app'tite and weight, and pttrsrol 
the appearance of very weak anrl sick men. C4)neurrentlv with 
lliis condition the nervous system becomes much disturlied »i>4 
the patients present the symptoms of neurasthenia. A nentw* 
up])rehension and anxiety arc very fa^jucnt concomitants. Suci 




an e.xarerhation mny last months or years, and may Icatl to per- 
manent invulitlisin. 

In olil MH'n snfTering from hypertrophy of the prostate a low 
grade of s*minal vesiculitis is a not uncommon Bccompuniment. 
In many of these cases the vesicular complication passes unnotice<l, 
for tlie reason that it may give rise to no symptoms at all, or, if 
present, they are not pronounced in character. Then, again, they 
may be masked by the disturbances produced by the prostatic 

Diagnoflifl. — The diagnosis of seminal vesiculitis, in whate\'er 
form it may exist, is to be arrived at mainly through palpation 
of the parts by the finger inserted into the rectum. It has already 
Ix'cn shown how little light the subjective symptoms thmw u]>on 
the nature uf the trouble. It is not, as a rule, as easy as it is 
claimed to be by some to make out clearly the outlines and dimen- 
sions of the seminal vesicles. In the examination sttme authors 
state that the patient should stand and Ix^id the lH>dy forward 
a^ far as he can, his feet being about a foot apart. It is always 
well that the bladder should Ix* full, for in that condition the vesicles 
are more readily detected. Then tlie finger is introduced to the 
pmstate, and, having defined its outline, the vesicles are sought 
for above and to the outside of this body. 

This examination can also Ik* made with the patient on his 
back, in which event the bladder, being full, tends to sag down 
in the pclns. It is easy to conceive that in some patients in the 
hending-forward-and-standing |x)sition the bladder may tilt for- 
ward toward the abdominal wall, and (hen the vesicles will l>e 
more innc<'es.sible. 

At the prostate the two vesicles approach to within a finger's 
breailth of one another, and on the inner side of each one is the 
vas deferens, which at this part Ijecomes much cnlarge^l and 
ampuUated. I myself think that very often the anvpullatieui of 
the vas deferens, which may be increased in siise by the gonor- 
rhtral or chronic hypercemic process, is mistaken f<ir enlargement 
of the seminal vesicles. It certainly is next to impossible to say 
from rectal exaniination in life that the vas deferens is not swollen 


and the voside is. Tliese part.s arc in such intimate juxtaprKsition 
that it is nearly ini|x>]ilc to distinguish In'tween the two. It i* 
iniiK>rtant. a!.si>, to liave a g»Kxl knowledge of the .stnieture ami 
physical cliaraetersof the vesicles in their nonnal state. To this 
end study on healthy men is necessary. The seminal vesicles ia 
health have a firm, somewlmt resistant structure, which, while not 
prt\scnting a hrawny fee! to the touch, give the sensation of haung 
tolerably thick walls. Therefore, the surgeon must not enter upon 
the examination with the idea that he is to always feel two oblong, 
rather soft, and readily compressible little bladders. 

If diseaseii, the seminal vesicles will, in the acute stage, feci 
much swollen in all directions, tender, jx-rhaps hot, and may 
present a doughy sensation, like that of the overfilled leech. In 
the stage of abscess the swelling will Ix' great, the pain intense, 
and the symptoms severe and pointing to intrapelvic trouUe. 

In the <'hronic forms a qnite firm tnmor may Ix? felt. If Ixjth 
vesicles are involved, the bane of the bladder lx»yond the prostate 
is the seat of the tumor, which is usually of goodly size, often very 
large. AlMlomimd pressure, exerteil deep down and toward the 
pelvis, ] I my often afford much aiil in these examinations. Some 
autlieirs lay stress ujiou the presi^nceof asound in the bladder, push- 
ing its base downwan) toward the rectum, as being of great help 
to (he (inger in therectun». Perhaps in some cases this proeeilure 
may l>e admissible or practicable, but it should never be n*sortefl 
to without due thought coiieenung the nature of the case and the 
state of the deep urethra and prostate. In all acute cases the 
introduction of the sound as an accessory aid to diagnosis » 
strictly interdicted. In chronic cases the surgeon must always 
rememlx^r that the posterior urethra may be the seat of a low 
grade of inflammation, and that the prostate may also l)e at least 
h\7)erjemic. This same caution applies very strongly to the cases 
of old men who are suffering fr(»m enlargement of the prostate and 
also from a chronic inflanmiatory condition of the seminal vesicles 
— a complication, as we have seen, which is sometimes met with. 

Examination anil manipulation of the seminal vesicles by means 
of the finger-tip cause a How of pus, with perhaps blood, into tht 




urethra when the inflammation is recent ami active. In the sub- 
acute oases the tlischarge is mueopurulent and mucoid. 

Pathology. — In the acute ^norrha-a! stage it is probable that 
the lesion of the mueous membrane \s similar to that of gonor- 
rhoea of the urethra. This is a field worthy of careful study. 
As yet the observations have been macnweopie rather than 
microscopic. In the main, the morbid process consists of swell- 
ing of the mucous membrane and small-cell thickening in the sub- 
mucous connective tissue. The vesicles then may be much dilated, 
or, again, they may, by contraction of the newly formed tissue, 
become much shrivelled. Within the vesicles a brownish mucus, 
mucopus, spermatozoa (alive or deatl), sympcxia, and calcareous 
ccincretions may he found. 

PrognosiB. — In the acute form of this trouble resolution usually 
takes place- In the chronic forms amelioration und cure may \ye 
ubtaine<L In some cases, however, the morbid prf)cess goes on to 
the formation of large tumors which retpure operative measures, 
TulxTculous infiltration of the seminal vesicles may perhaps un- 
dergo resolution or lead to eicatri^^tion or caseation, but in most 
cases it is continuous with or concomitanl to a similar affection of 
other organs, and in the end death results. In malignant new- 
growths a lethal outcome is inevitable. 

Treatment. — When recognized in the acute stage seminal vesic- 
ulitis is to Ix* treated on the general principles which govern the 
management of all acute phlegmasia; of the genital and urinary 
organs. In some eases it is well to apply a large numl>er of 
leeches upon the perineum and the margin of the anus. Injec- 
tions of cold water may l>e used, and the rect\im may Ix- packed 
with ice if the procc{lure is pleasant to the patient, or hot irriga- 
tions may be a*iministered by means of Kemp\s rectal cooler or 
the zerodone. (See Figs. 101 and 102.) These ap])lieati(ms may 
be used once or twice a day, or even more frequently. ()|)ium in 
suppositories, tliluents, and saline cathartics may Ix^ admiiii.sten'd 
as necessity ret^uires. 

Should an altscessform it nuiy lie reachwl by means of a curved 
incision in the perineum just anterior (alxjut tlireeHjuarters of an 



inch) to tlie anus, great care being taken that the raenibi 
urethra, tlie prostate, and the rectum are not cut. In this opera- 
ticin mueh aid will 1x? given by means of the finger in the rectum 
arul a sound in the urethra. The incision may be ma^le in th< 
mcilian line laterally, or, if both vesicles are the seat of acuti 
su|ij)uratioii, it may l>e crescentic. Then the dissection lietwrcfl 

the base of the bladder and the rectum must be caiitioiislv made, 


The n'sulting ca\ity should be treated on general surgical 

In the treatment of chrfjnie seminal vesiculitis, in which Vtv 
find distended, pouchy, <>r brawny vesicles, it is well to carvfullj 
massage the parts. This procedure is accomplished by the fingrr- 
tip (gently but Hrmly pressing or kneading as much of the orp^n 
OS is within reach from nlx)ve downward, so as to express the con* 
tents through the cjaeulatory duet into the prostatic urethra. The 
patient should lie on his back, or if in the erect posation he should 
lH'!id his liody at a right angle to his lower extremities, and io 
this position the surgeou introduces the finger, all the while 
making counteq>ressure on the abdomen, the bladder l^eing, il 
possible, well filled. As has already been said, it is no easy mattd 
in many cases to reach the vesicles ami clearly define their sill 
and shape, even when every favoring condition is present. Then 
again, at the best, only the lower half of the vesicle is really «* 
cessible to the massaging process. Further than this, it must h 
clearly remeTnl>ered, as has already l>oen pointer! out, that th 
stnninal vesicles are made up of blind-cmled tul>es or iliverticuttti 
and that they have not the structure and arrangement of raeeinasi 
glands, firm pressure on which will cattse the contents (o cxwh 
into the excretory duct. An inspection of Fig. 33 will clcftrijl 
show that it is a physical impossibility to cause the contents ol 
the thiril ttd>e — or, as we call it, the handle of the jack-kniff — M 
exuile into the urethra, for the reason that it is a blind sac nt 
[N>uch, its non-patulou3 part ending downwanl near the pitxttaif^ 
This portion of the \'esicle is fidly a,s large a.s the other tw 
thirds, and the contents of this large part cannot in any 
cxtrudiHl into the ua'thra. For anatomical reasons it 




clearly seen that the utmost tliat can be accomplished in mas- 
saging a vesicle is to act upon alx>ut one-(|uarter of its whole struc- 
ture. In theory, massaging the vesicles seems to be a rational 
treatment, in that it seeks to rid these organs of retained chronic 
inflammatory matter and to restore the tone in muscular and 
mucous tissues which have become relaxed and flabby. Un- 
doubtedly, in many cases benefit does result from the procedure. 
The treatment of the cases of chronic seminal vesiculitis in 
which there are neurasthenia, debility, and often great mental 
depression, belongs largely to the domain of general medicine. 
Such cases require good hygiene, and, if possible, an entire change 
of scene, rest, and pleasant surroundings. Tonics, combineil with 
nux vomica and ergot, produce much benefit. Iron, quinine, and 
cocoa are also indispensable in some causes. The urethra, biaddrr, 
prostate, and seminal vesicles should Ik* very carefully examincti 
by instruments ancl by inspection of the urine and expressed 
secretions. If there is, us so fret]uently happens, a coexistent 
posterior urethritis or prostatitis, these morbid conditiuiis should 
be properly treated. 



ARicncEi.E is that varicose fon<lition of the spermatic veins 
by which a locali/ved or generalizt'd swelling of the scrotum is 

As a rule, when the tumor is small it is a simple, painless affrc- 
tion; hut when the swelling is largo it may cause sensations of 
dragging weiglil which extend to the parts beyond, and are morr 
severe in hot weather and after bodily exertion. In some cases 
there is a dull, aching, intermittent pain; in otheTS the paiu is 
sharp and crampy. 

To the eye and to digital examination varicocele reveals itself 
(1) as an elongated, diffuse swelling, which extends from the 
external aMominal ring down to the testicle, and is usually larger 
higher up than lower down; (2) as a dilTuse tumor surmundiu); 
the testicle, particularly its npjxT part, and extending half-way up 
to the external alxlominal ring, and (3) as a gocxlly sizeil tumor lielow the ring and extending half-way down to the testis. 
(S(H» Fig. !12.) 

Wlien a varicocele is palpated a sensation is conveyed to the 
fingers like that of a mass of earth-worms, and this simile is some- 
times rendered all the more striking by the contraction of the crr- 
master muscle. Very often the scrotum is lax antl dependent, 
and in its walls tortuous, flaccid veins can be distinctly seen. 
(See Fig. 113.) Under the influence of coUl the s<Totum and itJ 
varicocele contract materially, while heat and excitation tend In 
pnxluce laxity and elongation of the parts. 

Varicocele is mostly ol)iierved on the left side of the scrotum; 
exceptionally it is found on both sides. 

'I'he causes of varicocele arc: the entrance of the left Hpemutic 
at right angles into the corresponding renal vein, pressure on the 



spermatic vein hy rectal and intestinal distention, ami by tumors 
in tlie gn)in iiiul within the alwlonietu Tncoinpetence of the cre- 
uiHster nmst'lt- may act as a ctnitributciry cuusie. 

Fio. 112 


Varicocele. (Afler Osliorii. ) 


Although in former years it was claiine<l that varicoeele was the 
direct cause of ath>pliy of the testis, this \new tu-tlay has few suf>- 
porters. Tlie truth of the matter is that, as a result of varicocele. 
there is usually at the time of testicular increase in the years 
preceding puberty an arrest of development. As a result, we find 

Fia. 113 

Vftricocele and var-icose enlargement of the veins of acroud walU. 

small, soft, and sometimes quite insensitive testes, which are ill 
fitte(] to pn>ducv spermatozoa. It is very prt*bal)le that, owing to 
the disturbance in the circulation of the organ by the backward 
pressure of the blood, its spermatogenic function is interfered 
with ami perhtips held in al>eyance. The organ is not necessarily 
sterile; with the removal of the varicocele by operation the nutri- 


.tion of the testis will become re-establisbed, the organ will grow 
in size and fimiuess, ami its function will soon Ix^ restored. I 
have seen this result so often, and there are so many well-attested 
Teported cases in proof of the statement here ventured, that I 
make it without hesitation or reserve. In all pi-obability in those 
cases in which atrophy of the testis has been found associated with 
varicocele of the same side, the mischief has been produced by 
Ksome antecedent cause, such as heretlitary syphilis, gonorrhoea 
(which is found even in infants and young children), tuberculosis, 

• or traumatisms. In many reported cases of airopliy of the testis 
there is evidence of want of thorough clinical investigation, and 
the impression left on one's mind is that the surgeon jumped to 

I the conclusion that the varicocele was the morbid factor. Some 
autliorities, however, are willing to admit tliat vcjy exceptionally 
atrophy of the testis may result from uncomplicated varicocele. 
In most cases varicocele causes its bearer very little, if any, 
mental disturbance. This is the case usually in subjects who are 
mentally and physically in good condition, and who are not 
H addictefl to masturbation. In weakly, lascivious, and neurotic sub- 
jects this condition of the spermatic veins causes a state of mind 
which is to ho descril)ed presently. I have several times observed 
B that when in excellent health subjects having varicocele gave 
themselves no concern regarding the affection, and that in a state 
of debility and worry from business or other troubles their minds 
became fixed on the scrotal tumor, and they gave way to appndien- 
Hsion and anxiety. 

There is no evidence at hand to prove the contention that vari- 
cocele is a result of masturbation. The occurrence of the venous 
anomaly in the persons of confirmed masturbators is no proof that 
the deformity was pn)duced by this bad habit. When Inns or 

I men have been adilicted to masturbation the development and 
tletection of varicocele s*unetiixie,s cause in their nunds rnmfi dis- 
quietude, and even worry, and they often very wrongfully asso- 
ciate the two as effect and cause. Indeed, the reverse of what is 
generally lx.'lieved is true. The irritation of the varicocele and 
>tbe condition of disturbed nutrition in the testis lead to much 



esc tw 
1 <^ 



sexual irritation and increased desir(\ and as a result of these tlw* 
patient may fall into the liad hahits of masturbation ami 
depraved practices. This erethism of the sexual parts *Kt?U] 
very had time for the patient — namely, when he is in the pi 
of evohiiioii from the condition of the child to the maturil 
pul>erly, at which IJme his sexual apparatus is vigorouslv graw* 
ing and when his inclinations to coitus ate beginning to h^^| 
very keenlV' As the hahit of masturbation increases an irntS'' 
tive hyfKTiemia develops in tlie prostate, ejaculatory ducts, and 
perlmps lus far hack as the seminal vesicles and deferential ampuU 
lations. This syndrome of morbi<l conditions then further includo 
pollutions and abnormal senu'nal discharges. Thus, l)ejEnnning io 
UjcuI testicular irritation, the whole sexual apparatus may 
thrtjwn into a seriously morbid state by reason of the niasturl 
and the disturlx'd mental condition which ensues. Many of thesr 
patients Ix^come much worried and depressed, while others 
very melancholic, un<l some even show endencesof mild monoi 

In young men who are engaged to be married, and who pMf 
much time in ihc society of their fiancees, sexual erelbism and 
gratified c*ntus may be so seven* anil pn>tracted that the mi 
the health of the individual may be somewhat disturl»e<l. 
young men eome to the surgeon complaining of a sense of 
fulness, or even of pain in the spTmatic veins. If there 
mmlenite or piY»noimced varicocele pn\sent, the patient may 
himself up so much to worry and anxiety that his life heco 
burden, Tht*s4' patients are prone to think that imfH)tiMie«' is, 
pending, and tliat they will he unul>k' to i^jusuinmate matri 
If in tixis nnliappy state of mind nightly emissions nit:'ur, or it 
when in the presence of their fiancHeg, a glycerin-like mucus 
(nrfthrurrhra fx Hhidine) escapes from the meatus, their cup rf 
woe IxTomes tilled to the brim. Yet in these caae^ the u 
condition is really their only source of danger, since the ph 
condition can be relieved. Plain, sensible, kindly advice and t 
little treatment usually bring these patients (mt of their sonw 
position. In some instances the njoral effect of removal by 
tion of the varicocele is most gratifying. 

The simple existenee of a very small varicocele in some patients 
luses much depression and dejection, and in some well-marked 
tneurasthenia^ such as we see in suUjeots who imagine that they 
ive some deep-seated sexual disorder or some undefined or 
mdefinable rectal trouble. 

'llien, again, the presence of varicocele so operates on the minds 
►f some patients that they imagine they are impotent, and this 
:ate leads to no end of worry and dejection. In this frame of 
lind they may try to indulge in sexual intercourse, and they 
isually fail signally. As a result, such patients kx^come almost 
malterahiy convinced that they are impotent, and their distress of 
lind and general unhealthy, cachectic, and woe-begone appear- 
ance really make them pitiable objects. This state of mind is 
rery often further increased by tht* base misreprt'scntutions of 
luacks. Patients in this deplorable state require very careful 
lanagement. They should^ first of all, be assured that the impo- 
'uce is only temporary, and that it is largely due to their uubal- 
inced state of mind. Then proper attention should be given to 
[their general health, to their sexual hygiene, and also to their 
local disturbances. 

Treatment. — For the less developed class of cases, cold-water 
aiTusions, used night and morning, and a nicely fitting suspensory 
bandage worn during the day will give the patient comfort and 

When radical measures are necessary the open operation, with 
ligation and ablation of the venous mass, is by all means to Ih^ 
commended, since it always product^s beneficial ^*^sults. In all 
cases of varicocele the condition of the patient's mind must Ik* 
taken into consideration. In such cases gotxl, kindly, reassuring 
ailvice, with the regulation, as far as |H>HsibIe, of .s*'xua! hygiene 
and coitus, will bring back health and gla<lness to the sufferer. 

The radical cure of varicocele can Ik? cITected by a number of 
surgical procedures, many of which are complicated and attended 
with difficult after-treatment, and need not l>e mentioned. 

The two operations now mostly employed are Howse's opera- 
tion for excision, and its modification by Bennett. The results of 


the open operation are conspicuously and unifonnly goo<L T^e 
parts are so clearly exposed, the ligatures can be applied wth 
such precision, and there is so much simplicity about tlie opera- 
tion that it cannot be commended too highly. 

It is necessary to rcnieuil)er that the veins to be excised 
those of the painpinifurm plexus, which are surrounded by a 
defined connective-tissue sheath. These spermatic veins lie 
in front, while the vas deferens with its artery and veins are fu 
thtT backward and inward in the scrotum. If the testis is 
fully pulled downward, the vas is put on the stretch, and it can 
easily be felt, it being hard and firm like a whip-cord. The 
and the deferential artery and veins should l>e carefully avoid 
Only by gross carelessness will they be included in the ligation 
the veins. In that event there may be slouj^hing of the testidc 
frf>m want of bloo*! supply. 

ExciBioa of the Spermatic Veina. — The patient is properly 
pared for the opiM-atiou und phiced under the influence of ethrr. 
The hairs of the abdomen and genitals must l>e thoroughly slwvwl 
tLiid the parts — the scrotum especially — well washed witli soip 
and water, then with alcohol and ether, and then with bichlori«J« 
solution (1:2000). An assistant holds the testicle firmly and 
draws it horizontally downward l>etween the thighs. The partJ 
are then tense, the veins can be distinctly felt, and under them 
the vas is very perceptible. An incision is then made for an inch 
and a half in the longitudinal direction and over the prominence 
fif the veins. The edges of the wouih! are then separated by ir- 
tractors, and the coverings of the cord are carefully dissected until 
the sheath of the veins comes into view. It presents a shining 
whitish-gray color, through which the puqile veins am spta- 
This sheath of the pampiniform plexus, which must not be cut 
into, is tlien isolated with the knife, aitied by the fingers, ami 
then the ligatures, of gtiwi, strong catgut, are to be applied bf 
means of an eyed prol>e or aneurysm-needle about an inch and a 
half apart. The lower ligature is tied first, and then the upjicr 
one. The vessels are tlicii (rut with scissors al>out a quarter of a& 
inch from the ligatures. The wound cavity is then copiouslj 





irrigated, and put on the stretch, so as to bring the two edges of 
the scmtum in cx>aptatioii. This ran be done with the fingers nr 
hy means of two bhint hooks, one at each emi of the wound. 
Five or six, or perhaps more, eatgtit suturt*s are now apphcd, 
thus firmly fixing the parts. A small opening in the dependent 
part of tlie wound is left for drainage. Usually no drainage-tul>e 
is necessary. The continuous or interrupted suture may also 
be used. 

Bennett's modification of the foregoing operation is the one I 
now most commonly employ, since its results are so uniformly 
satisfactory. I can do no better than to tjuote Mr. Bennett's 
words. lie says: "The precise extent of the varicocele which 
it is desirable to resect in any given case is l)est determined by 
placing the patient in the standing position and roughly estimut- 
ing with the eye — or, better, by measuring with a tape — the 
degree of elongation of the coni; for instance, should the testis be 
three inches lower than normal, then certainly not less than three 
inches of vein should l>e included l>ctwccn the two ligatures, as 
it will be desirable to excise at least two inches and a half." Ben- 
nett dissects down to the sheath of the fascia, which he also says 
Khould not 1h^ opened; then he passes his two ligatures, ties, and 
leaves them tjiiite long. Then he cuts out the segment of the veins 
included lx?tweeu the ligatures. "The cut-ends of the stumps 
left by the tjivisioji of the varicocele are then brought together 
and r<'tained in permanent apposition by knotting the ends of the 
upper ligature to those of the lower, thus at once raising the testis 
to alx>ut its natural level. The ligature<l ends are cut off quite 

Then, after the operation, the wound may be dusted with iodo- 
form and a sterile gausse dressing, and a spica bandage may be 
applied. The first dressing may remain on for several days. 
Perfect healing usually occurs as early as seven and as late as ten 
or twelve tlays; very rarely is it delayed longer. VVlien healing 
has occurred a callon.s mass will b<' felt at the jKjint of jimcture 
of the ends of the veins. This will gruflually Ix* ahsorlx-d, and 
in the end a little firm nodule will lie felt. It is well to cause the 


patient to wear a suspenaory bandage 6vr a ahort time after i 
of the radical operatioiu for varicocele. 

The patient is tuuaUj confined to his bed for a week or peilH 

Subcutaneous ligation for variooode is an inexact and dm 
gical operation, and is to-day practically obsolete. 



Certain inorbul njiiditions of the genital tract ami «listurl>- 
jances of the sexual function, with more or less lowering of the 
•fiioralc of the patient, have their ori^^n in excessive and Uinjj-eou- 
tinueil mastiirhatioii aiui .sexual excpsi>es. Miu-h (^^af;f^'ration 
hius l>een itululgeil in, ami an unnecessary amount of sentiment 
has been bestowed by lay and medical writers, and notably by 
quacks^ on the habit of self-abuse; therefore, it will only be tn-ated 

I of here in a purely scientifie manner. 
It is a great mistake to claim that among the majority oF Ijoys 
excessive indulgence in masturbation is very common, sinee the 
truth is that such is the exception nvllier than the rule. There are 
boys whose nervous system is not stable, and those who an^ pre- 
cocious in their mental processes, who like to st^ekule themselves 
very much fmni the games and sports of their eomra(h\s, tind who, 
having imlulged in self-abuse, keep up the bad habjt until it pro- 
duces harmful results. But» as a rule, Ijoys like tf) Ix' up and 
doing, and eaeh feels that he likes to stand a.s high in all pursuits 

• of early life us his fellows, lliis generous rivalry tends to elevate 
the moral nature of tlie lx>y. Thus it is that a healthy moral 
.status exists which tends to keep Iwys in the right path. If, 
perchance, a lx>y has indulgt^d unnaturally, he» ivs a rule, i-i,i*vs the 
error of his ways, and he leaves otf his ba<i habit» or indulgt's in 
it quite infre*|uendy. Undoubtedly, in many cases the exag- 
gerated accounts of the ills which follow masturbation have a 
<lecidedly deterrent etfect. While in the main the foregoing sur- 
vey of this subject holds good for the l»etter classes of our com- 
munity, it must be confessed that among the poor and squalid, 

33G SKXVAL of the MALK A\0 ttMALE 

who art' closely hertled together, the moral tone is low and the 
habit is more widespread!. 

In boarding-schools and refonnatories it is saiil that masturba- 
tion is very common among the male subjects, but in the long run 
very few suffer fn>ni the habit. 

Masturbation has l)een obsen'cd in quite young children. In 
some cases there seems to be some nervous defect, of which sexiinl 
prec<K*ity is a prominent symptom. Then, again, phimosis, Imla- 
nitis, adherent prt^puee, congenital stricture, stf>nc in the bladder, 
retained smegma, uncleanliness, dcnnatitis of all forms about thr 
genitals, and thread-worms in the rectum cause erections, and thiis 
the child contracts the bad habit. Stone in the l>la<lder may aWi 
be the cause of sexual excitement in the infant. Then, again, it i.^ 
not imcommon for nurses and care-takers to fondle and titillate 
the penis of the child in order to keep it quiet, and thus the 
bad habit is engrafted upon him. 

Kpilepfics, liytlnxvphalic infants, and those suffering from 
many fonus of nervous disease are said to Ik? prone to eomniit 
mn,sturbatii)n. In older subjects, the victims of cerebral ainl 
spinal alYeclions, masturbation is fre(|uently a distressing symp- 

As a rule, these subjects are seen to constaotly handle tLfir 
genitals and to iinwluce erectioii.s, and tliey commit the self-ahaso 
by ix'culiar movements of the thighs, by rubbing up against fimi 
objects, or by rolling on their stomachs on the floor. 

It has been observed that flogging of young boys upon the baok 
and buttocks has in many instances caused erection of the p<*niA 
and ejaculation. This fact should act as a warning to botli teachers 
and fathers. Many boys have been known to wilfully misl)eh«w 
in order that they should Ijc flogged upon the buttocks by young 
anil pretty female school-teachers. 

Infantile onanists soon become sickly, flabby, peevish, and irri- 
table. Their gastrointestinal functions become much impaipnil. 
and as a result their nutrition is much lowered. 

Young l)oys are either taught this bail habit by older l)op or 
they acquire it by exploratory inquisitiveness. In many casw, 



articularly among boys approaching puberty, the morbid stimula- 
ioii of the imagination by reading lewd books or by the inspec- 
tion of lascivious pictures leads to more or leas confirmed mastur- 

Certahl facts regarding masturbation have been very forcibly 
brougiit out by the late Dr. J. W. Howe* in the remarks now 
quoted: "There are certain g}Tiinastic exercises provocative of 
masturbation. Tliese exercises are common in all gymnasiums 
and in many school-grounds. My attention was first called to 
this subject by the history which a confirmed masturbator gave 
me of his first experiences. He entered school at the age of seven 
years. The day after his admission he visited the school gymna- 
sium. His attention was attracted to the swinging pole around 
which a number of boys were enjoj-ing themselves. He took 
hold with the rest, sustaining the whole weight of the body by 
the hands, swinging himself around the circle for some time. In 
a few minutes he hmi such p-ciiliar sensations about the genitals 
that he was forced to discontinue the movement and rest. Again 
and again he swung himself around until he experienced the same 
effect, the sensations becoming more positive and intense. The 
next day, on trying the same experiment, the tingling sensations 
terminated in an orgasm. Tiiis led liim to a cloyer examina- 
tion of his organs, and also to new methods of increasing the 
same excitement, until finally he became a confirmed mastur- 

"Another, a patient now under treatment, said that the first 
time he ever felt pleasurable sensations in his genitals was while 
he was engaged in sliding down the mast of a whale-lK>at. The 
first repetition of the exercise produced an orgasm^ and from that 
grew the habit for which he was under treatment. A somewhat 
similar history has been given me by others, one a female, who 
learned the art by sliding down the stair-balusters. I^llemand 
relates the case of a boy who commenced masturbating by 
straddling down transverse bars, and another who excited himself 

Exoessire Venwy, etc New York, 1884, p. 66 et seq. 


while hanging by his arm, and thus sustaining the whole weight 
of the body." 

As a result of excessive unnatural indulgence these subjects 
lose their manliness, moral courage, and frankness of egression. 
They become secretive and seek seclusion rather than exercise and 
sports in the open air with their companions. La these cases the 
mind becomes centred on the genital organs, and the effect is to 
debase the moral standard. Some of these boys after a time be- 
come depressed in mind by the knowledge that they are victims 
of the indulgence in a secret habit. In perhaps the majority of 
instances, when the environments are favorable and the surround- 
ing influences are in the ri^t direction, the bad habit is discon- 
tinued, and the whole morale of the boy undergoes a total diangr. 

It is very probable that the emissions which occur from mastur^ 
bation have little, if any, lowering effect upon the general heahh 
of the subject. In very eaily years the ejaculate is simply pros- 
tatic and urethral follicular mucus, and its loss per se is not serious. 
Later on true semen may be emitted, but in most cases the amoaot 
lost at each indulgence is very small indeed, and most conunonly it 
is simply the secretion of the seminal vesicles and of the ampullr. 

In exceptional cases the bad habit is persisted in, and then more 
or less serious mischief is produced. Probably 2 per cent, of all 
cases seen at venerea! clinics are those of young men who suffer 
from the results of masturbation. The first, and most obvious, bad 
result of masturbation is lowering of the moral standard, as we 
have already seen. 

It is well to remember that in masturbators the normal sexual 
desire is absent, and the orgasm is produced by artificial friction 
and by brain-effort, which results from libidinous thoughts. ITie 
natural stimulants to sexual desire are also absent, and the act is, 
therefore, forced, unnatural, and abortive, and is very commonly 
followed by much temporary mental oppression and nervous agita- 

It must also be borne in mind that this act is committed bj 
boys when the sexual apparatus is in a state of growth and develop- 
ment and when the sexual centre has not yet been thorou^ly 




tievelopec! hy time and lu'althy processes. Tlie gnawing prostate 

and the (ievelopin^ st'iiiiniil v*'su'lf\s und ainpiillii" iirv thus acted 
upon by aUiuprinul stiruulutioti und by uctuul nervous shocks. 
This naturally explains why excessive and proloii^'d nuisliirhii- 
tion in the yonng is more disastrous in its effects than it is in 
oMer sul>jccts whose sexual organs have attained full develop- 
ment without damage during youth. 

The actual physical damage which results from masturbation 
occurs, therefore, in the sexual tract. The first morbid ettect is 
hyjK'ra*mia of tlie bulbous urt^tltra, wliieh is soon transfoniicd into 
true catarrhal iidlanimation. This morlml state creeps backward 
and involves first the raucous membrane of the prostatic urethra, 
the verumontaniim, and ihe sinus poculans, and may attack the 
prostatic tubules in part or in totality. Then, in bad cases, the 
morlmi pmccss extends through the ejaeiilatory ducts and attacks 
the ampullje and the seminal vesicles. Thus there is producetl a 
low grade of catarrhal inflammation which extends from the )>ulb 
backward to the seminal vesicles and tends to lower the tonus unil 
resiliency of these parts. 

The mucous membrane lM*eomes thickened and of a deep red 
am! even purplish coUir, and fnjm it a thick innei>ns sct'R'tion 
escH|M's. In soua* of these bh)od follows the onanistic act 
or is observed more or less constantly after urination. 

In somewhat exceptional cjises of con finned and Inveterate 
masturbation, particularly In boys approaching or during puU'rly, 
the orgasm is produced not by manipulation by the hand, hut by 
the intrtiduction into the urt^thra, as far down as the prostatic 
UH'thra, of some flexible instrument, which by titillatioii irritates 
the parts, particularly the vcrumuntanum. The instruments used 
are sounds and bougies, pieces of wire bent so that they can be 
introduet^l, or pit-ces of white wax moulded in the form uf bougies. 

In many cases there is more or less just complaint of relaxation 
and numbness or oversensitivencss of the scrotum and of a sense 
of softness of the testicles. Darkness of the skin of the penis, 
thickening f*f the mucous membrane of the prepuce, and density 
of the corpora cavernosa are found in many chrome masturbators. 



Then, again, llie unnatural orgasms act as darnaging shocks 
upon the nervous system, which then becomes deranged in its 
totality, and as a result the whole economy is more or less thrown 
into an ahnorntal state. With the development of the impaiivd 
nervous condition, and as a result of the irritation transmitted 
backward from the prostatic urethra, verumontanum, and pros- 
tate the integrity of the sexual centre is disturbed, and it is thrown 
into a cnndition of excitation and of decided irritability and incom- 
petence. All these sexual and mental disturbances result in a 
vast array of morbi<l symptoms^ physical and psychical, 
(~ Many cases are on record in whicfi the habit of masturbi 
is but one of the symptoms of men who are decidedly wer 
their mental and moral conditions. As an instance of depml 
due to central nervous disorder the following rase' is very striking: 
The patient was a gentleman, twenty-two years old, who was se^m 
ingly healthy, but disposed to be taciturn and retiring ui^H 
habits. He came of perfectly healthy stock. One evening after " 
a generous dinner he retirt^l to his room and locked the door. 
His m<itlier, anxious in c*<|ueiice of his behavior when at the 
table, followed, and through the keyhole saw him, erect and fully 
dressed, engaged in the act of violent masturbation. This eom- 
pU'te<l.he threw himself on his bed in his clothes and slept, 
mother informed the father of what she had seen, and there 
the young man was closely watched. 

Nine days afterward the i»atient left his friends at a picnic p 
in the woods, and tliis time the father followed him and witnessr-l 
the same scene as l)efore. After returning home in the evening 
the parent sternly reprimanded his son for his miscon<iuet, when tbf 
latter informed him that he was very miserable, that for more 
than a year he lia*i Inn-n subject to attacks of a furious sort id 
whi<h nuisturbation became an irresistible necessity- He beggnl 
his father's forgiveness and pnmiised that when he next lia*! pir- 
monitions of his trouble he would inform his friends, who ni 
then ^'cure his hands Ixrhind his back. 

• L'Ann^o M<yirJile Caen, No, 1, Tome ii. p. 7- December ISTrl 





After diuing a few days later he notified his father that he was 
about to be affected as before, and would soon be ahuost uncon- 
scious of what he was doiiifj. Hia hands werr itriniinliatt'ly l>onnd 
firmly Vx-hincl his back, when he wa.s at oiut seizpil with a convul- 
sion that lasted for ten minutes. He fell lo the ground, his respi- 
rations became accelerated, his face pallid and satyr-like. He 
also uttered hoarse cries in a strange voice. His father, thoroughly 
alarmed, hastened to liberate his son's hands, when the latter at 
once arose, and in the presence of both his parents proceedeil to 
perform the act of masturbation in the most furious manner, 
without pausing an instant. This over, he burst into tears, and 
concluded by falling asleep as usual. 

This man had no sexual desire. The first intimation he woultl 
have of the attack would be an insupportable pain in the back 
part of the head, occurring sometimes an hour or two before, 
sometimes immediately after meals; then there would be an erec- 
tion of the penis and unconsciousness of subse<)uent events, so 
that the presence of strangers presented no bar to the execution 
of the act. On one occasion of this sort, when observed by his 
physician, the latter describes his conthtion as wry disgusting; 
his face was pallid, his features distorted, and saliva cscaj)ed fn»m 
his mouth. Under careful hygiene and symptomatic medication 
this man recovered. Leeches were regularly applied to his 

A striking instance of periodical insanity with intense sexual 
impulse is worthy of brief mention. The father of the victim 
was a neuropathic, and addicted to sexual excesses, who died of 
cerebral disease. The patient up to his twenty-ninth year was 
sexually normal. At that time he suflVred from concussion of 
the brain tlue to a fall. x\fter this accident every thn^e or four 
months the man was seized vnih. such an intense desire to mastur- 
bate that wherever he happened to be, and no matter who wen* 
present, he at once exposed his organ and Frantically perfi>rnied 
the act. The sight of women seemed to cause the morbid seizure. 
When the frt^nzy passed away he would U^come calm, regain his 
self-control^ and sorrowfully regret the act. He was sent to an 


asylum for a time, but was later on discharged. This really was 
a case of exhibition insanity with intense sexual fervor.' 

Symptoms. — In the first place, the function of urination is more 
or less impaired. Frequent micturition is very commonly com- 
plained of, and in many patients there is more or less mild inoon- 
tinence or dribbling of urine after the act. In very bad cases 
such is the hypersemia of the mucous membrane of the bulbous 
and prostatic urethra that the passage of urine causes a severe 
scalding sensation (sometimes compared to the insertion of a hot 
iron in the canal), and toward the end of the act a more or less 
copious flow of blood. In some cases at the end of the act there 
is decided pain in the prostate, resulting from its physiological 
contraction. Examination of the affected portions of the urethra 
by means of the endoscope shows a thickened and inflamed 
condition of the mucous membrane, very often with marked 
swelling of the verumontanum and of the orifices of the sinus 
pocularis and of the ejaculatory ducts. In these cases the 
passage of goodly sized bougies h hovle (24 to 30 French) 
('aus<*s great pain in the deep urethra, and very often a flow of 

When the finger is intro<luce<l into the rectum and the pn)s- 
tate is carefully ox])U»nnI, it is usually found that this organ i--^ 
in part or in whole swollen and sensitive, and that pressure upon 
it causes tlu* escape of nnicus fn)m the urethra. If the exaniiiui- 
tion is pushed fartluT it may Ix* discovered that the ampulhv aiul 
seminal vesicles an' tender and distended. 

As a result of these lesions of the sexual organs and of the 
nervous disturbances there is usually more or less impairment of 
the s<'xual f\nK*tion. Such patients, when attempting coitus, find 
that they are sexually weak, although they may have normal 
desiiv. Their erections are either absent or incomplete, or, if 
normal, they last but a short time. As a r<*sult, the jH>wer of 
intromission is more or less lost, and, when present, the perform- 
ance of coitus enils in ]>rcinature ejaculation. In some of these 

' KrafU-Ebing: Psych opathi a Sexual is. Stutlgart, 1891, p. 298 et acq. 



cases vigorous erections occur at times when the pHtient is not 
near a woman, but they fail utterly when in close proximity. 

Such cases form a large contingent of the cla.s.s designated under 
the title symptomatic impotence. 

These patients are furtlier tormented with nocturnal emissions, 
with or without erotic dreams, also with da^*tinie pollutions, which 
may follow defecation or urination, or Ix* caused by miisi iilar 
efforts, or by the simple prcHcnce of a woman. 

The ill-health which is developed in consequence of excessive 
masturbation may iw exj)ressed by (he terms aniemia antl neuras- 
thenia. Neurasthenic niasturbators never cease complaining of 
all forms of morbid symptoms. The following list taken down 
verbiitim as it was rattled off by the patient may serve as a good 
specimen of these wailn. He said he suffered from insomnia. paJn 
in the heatl (occipital and frontal), in the eyes, back, down legs 
and feet, and in the body; felt nervous when he walked or worked; 
was more tired in the morning than at night, aiul felt mentally 
depressed; had friglitened tiream.s at night; his memory was 
failing; had ringing of Ix-jls in his ears and palpitation of the heart 
on the least exertion, and often sufferetl from shortness of breath; 
fever flashes at night, and then he feels hot and feverish; has 
cold, clammy hands and feet; gels very ilizzy jf anyone looks at 
hira in both eyes, and has no appetite and is troubled with consti- 
pation. He wound up by claiming that he had very sensitive and 
also numb .spots and l)!otche3 over the whole lx>dy. Many cases 
are much less severe and the patients only complain of a few 

In more severe (and we may say desperate) cases the symptoms 
are more accentuated, the p.sychical C4>ndition is much worse, and 
marked hypochondriasis may develop. In some of these cases 
the mental condition of the patient is rendennl infinitely worse 
by tlie p4'rsisteiiey of the [»c)lbttions nnd the une<*a.sing loss of 
erections and p*ivver of intromission. 

In .some ra.s+'s in which masturbation has been moderately in- 
didged in, and in wliieb no jMTnianent harm has lieen done to the 
patient, the recollection of the early transgivssiou may cause want 


of confidence and timidity in attempting coitus. In sucb a case, 
tlioii^rli there may Ix* one or two preliminary failures, tlie patient 
should not be discouraged, since success will come by repetition. 
especially if warm encouragement is given by the surgeon. 

In later Hfe the recollection of early indulgence in raasturbatioo 
very often comes to a man's mind, and is wTongly considered the 
cause of sexual weakness, which is usually due to conditioos 
which developed long aftcrwanl. 

Treatment. — Infants arldictcd to masturliation should be treated 
on a mechanical basis— that is, such measures and appliancfs 
should Ik^ adopted as will prevent the child from touching lus 

In young Iwiys the indications are to break up the haliit as 
soon a.s possible. To this end nuich careful watching i:* neces- 
sary, and reprimand and good counsel should be judiciously used. 
It is always well, when this habit is suspected, not to allow the 
patient to sleep with another boy. In such cases the boy should 
not lie kept closely to his studies, but .should be encouraged to in* 
terest himself in s}x>rts and games and out-door pastiintrs. Ii b 
not well to terrify these Imys, since good, wliolesome advicv and 
kiniity tpeulmcnt, persuasion, and sympathy will do more toward 
breaking up the bad habit than fear and punishment will. In some 
bad cases, however, it may be necessary to apply every night an 
adjusluble apparatus made out of tin or wire, like short drawers, 
which will cover over the genitals anrl buttocks and can be locked, 
so that the patient's hands cannot reach his penis. By this pro- 
cedure much lx*nefit may be produced. 

In the cases of masturbators suffering from nervous, cerebral, 
and spinal diseases the central condition should receive most atten- 
tion. Such cases, however, are very rarely benefited by any form 
of treatment, either moral, coercive, pharmaceutical or niechanical. 

In some incorrigible cases uf uld and insane masturbators ex- 
cision of a portion of the nerves of the penis near the root of thr 
organ may cause the cessation of the habit. Clark' reports the 

Lancet, H«pt«ml}«r 23, 1898. 




\case of a man thus operated upon who was thereby much bene- 

Boys at and Iwyon*! pulx?rty usually are afflicteiJ. as we have 
seen, with diseases of the sexual apparatus, and these should 
receive especial attention in the way of careful and continuous 
local treatment. 

Peripheral irritation very often leads, as we have already seen, 
to more or less confirmed masturbation. When the patient is 
[found to have phimosis he should l>e promptly circumtised. 
lesions of tlie prepuce and smegma retained in the preputial 
should receive proper surgical treatment in most cases, prefer- 
ence being given to circumcision. In the rather rare cases of 
congenital stricture of the urethra, internal urethrotomy should 
be performed. Erections caused by stone in the bladder call for 
proper surgical relief. 

[ By local treatment to the urethra and prostate much can Vh* 
done for the n-lirf of these patients. Wlirn tlie urethra is the 
seat of chronic congestion, irrigation with weak solutions of nitrate 
of silver, beginning with a strength of 1 : lO.tKM} and gradually 
increasing them to 1 : 5000 an4l 1 : 1000, will be very bene- 
ficial. Wlien the irritahilily of the urethra bus Ix^come less marked 
instillation of t!ie silver salt, 1 : 5iK) to 1:250, may often be 
resorted to with excellent results. When the prostate has been 
affected it will lie necessary to treat that condition acconling to 
the directions given on page 282. In many cases the occasional 
introduction of the cold steel sound will tend to allay urethral 

The indications for general methodical treatment in boys and 
men are, as far as possible, to restore the health and to improve 
the moral tone of the patient. Such dnigs as have a decided tonic 
action should be given, such as iron, quinine, strychnine, phos- 
phorus preparations, arsenic, ami jxThaps the animal extracts by 
injection. Tiromide of potassium is sometimes beneficial when 
there is great erethism and to prevent polhitions. Belladonna, 
coninm, gelsemium, cannabis indica^ pisciflia erj^hrina, antipyrin, 
and hyoscyarnus may also be used in these conditions. Sea and 


mountain air, cold baths, healthy out-door sports should be 
advised, together with faradization and massage. 

Such patients should eat good, wholesome food without much 
spicing; they should eat sparingly at night; should sleep on a 
hard mattress, with light covering, and in a cool, well-ventila<ed 
room. They should retire when they are tired and sleepy, and 
get up as soon as they awake in the morning. 



To sexual excesses much ujore barm to the economy is attributed 

itliaii the facts of the case really warrant. In many cases sexual 

^excesses are cominittcd by |>ersoiiH \vln> previously hail sutfeivd 

From tlie effects of masturbatioii^ and tlieu the consequences may 


Young men, particularly those newly married, are sometimes 

lilty of overindul^'iict' in coitus, and as a result they may 
►me debilitated or perhaps neurai;t!iei»ic. But in tliese cases 
le passion is spasmodic, and it generally ceases with the toss 
[of sti'cri^h. nien, as a rule, m(j<leration in sexual matters is ol>- 
i served, and the condition of the health Receives pn^vper attention, 
and in the end no permanent harm may be done to the system 
or the genital tract. The same remarks apply to overindulgence 
in youn^ unmarried men. 

It is well to rerneinljer that sexiial capacity varies greatly in 
dilferent individuals, and that what would I)e excess inoneinrson 
may 1m* eoiisideretl by anotlier to l)e about the average of normal 

As some men grow older they may indulge to excess sexually 
as well as with alcxiholics, and as a result ill-health is induced. 
In these <*ases a gi-ueral refonn is usually followed by the resto- 

» ration of health, if the patient is not also siitTcring from the physical 
effects of early masturbation. When, with the maturity of the 
man, the sexual apparatus and the nervous system arc perfectly 
healthy, he. as a nile, can undergo, without permanent ilaniage, 
severe an*! proloiige*l sexual ami alcoholic indulgence, ]>r(ivided 

Kese excesses do not extend over too long a iH*rio<l. In these 
Ma nature often shows remarkable powers of recuperation, 


and unless she is too severely overwrought, she can, in tin* nd 
by means of care on the part of the patient, efface the eStctf d 
overindulgence. The truth of this statement will be obvxws to 
those who have seen many such cases, in which it seems i>einffc- 
able that a man can retain his health and N-irility in sptteofpf^ 
longe<l and excessive sexual and aicoholic indulgences. 

Ill those cases in wliich men thus put a strain upon nature T«tf 
after year, as time goes on sexual weakness may develop, i 
beyond thr fortieth or fiftieth year they may become partiaBT or 
wholly impotent. Hut in these eases there are often otlier facloit 
in the decay besides those just mentioned. Such men may W 
irrejt^ilar lives, they may also tax their nervous system bj engiwfr 
ing projects and schemes which involve worry, doubt, aiw) f»r, s» 
tluit in also every particular their course of life is unhygiemc- 
is natural, therefore, that in the resulting physical and vaesid 
unsoundness the sexual function sliould be more or less impairaL 

Sexual excesses by means of bestial practic»es, esp>ociaIlT «ote 
ab ore, in many instances lea<l to ill-health, and in some cases Oi 
general paresis. But in these cases, as a rule, too much prooi- 
ncnce, I think, is attributed to the sexual errors, and other dazaa^ 
ing factors are not fully considered. As a rule, men wlio thusoifl*- 
indulge err in ahnost every direction of life. Iliey are irreguUr 
in eating, drinking, and in going to bed; sit up late in stuffy roomt, 
playing cards and drinking, an<I they do nothing whatever in tbf 
way of hygienic reparation. It can remiily be seen that under aicft 
conditions sexual excesses may ultimately lead to the man's do«iK 
fall. But there is still another powerful factor at work in manyof 
these cases — namely, chronic sypliilis (in many cases there in»J 
be antecedent arterial or connective-tissue degeneration in d* 
brain and cord) — the influence of which should be thorou^j 
Uirne in nnnd. According to my observation, the nervous and 
general break-flown of men which is commonly attributed to iiexiuil 
excesses, and particularly to immoderate coitus ab ore, has, u 
l»nwerful contributory factors, first a general, unliygienic vaodt 
of life; second, alcoholic and tobacco overindulgence; and, ihiid. 
clmHiic syphilis. It can readily be seen that excessive seaaial 


in in such individuals will inevitably lead to mental and per- 
laps physical decay. 

Treatment. — Tiie first indication is to bring about a cessation 
►f the excesses and then to estabUsh a oonditioii of normal .nexual 
lygiene. Tlie general health of the patient should be carefully 
►oked into, and any morbid condition should be promptly cured. 
'he surgeon should lay stress upon the avoidance of all sources 
if sexual excitement (lewd women and men, lascivious pictures, 
kbscene books, etc.), and should pay particular attention to 
[proving the vtorale of the patient, A careful and searching 
>hysical examination should be made, and if any part of the sexual 
tract is found to be damaged it should receive careful topical 
;reatnient. Little can be done to cure men suffering from nervous 
lecay from the causes just mentioned. 


The intensity of sexual desire and passion varies markedly in 

Liferent individuals. In some it is very moderate, in others it is 

lore [)rouf)uriced, while in a few it is very strong and enduring. 

[n cold and moderate climates, as a rule, the sexual appetite is 

lot excessively fervent, whereas in hot countries it is a constant 

tnd dominating force. As a rule, among Americans the sexual 

[appetite in fairly well developed, and in the majority of cases it 

as held well under control. In some exceptional instances we find 

roung men who are in a constant condition of sexual erethism, to 

mch an extent that it impairs their usefulness in life. Thus, we 

occasionally meet with cases of young men who, when they asso- 

iate with young women in business affairs and in social life, 

:ome so sexually excited that their condition is betrayed, or who 

[from fear retire from such association. Some young men employed 

shoe stores have been known to lose their heads when fitting 

ifaoes on lathes* feet; and in other pursuits and businesses the 

[association of the sexes is often interfered with by the abnormal 

[sexual erethism of the male. This rather abnormal state is not 

it all common in the female. 


GufUiot* reports a very interesting case of sexual erethism, ll 
was tliat of a liighly nervous man nf twenty-thri'e years of ngt*. 
Frciiu his fifteenth yi*ar such was tlie excitability of his genitit 
that the least touch on the glans penis produced ejiR^ulation. At 
the age of twenty-tli n-o this man ha<l coitus eleven tiuM's in one 
afternoon without fatigue with a woman sufTt'ring fn>in nvmpho- 
nuinia. It is state<l that from that time on this man could inxiiTpi 
seven ejaculations a day. 

In many of the rolore^l race such arc their brutal lieentiou:>nefi 
and the exaltation of their sexual apjX'tite that negroes an* (vn- 
stantly connivuig at the comraissiou of rape. 

1 once saw a gentleman who suffered from |x'rsistrnt srxuil 
erethism for years until he voided an oxalate of lime calculus fntni 
his prostatic urethra. 

We also see instances in which men l>eyond fifty or fiftv-fi*? 
years of age become the victims of an annoying sexual dcsin*, 
and, strange to say, many i»f them an* able to indulge in (vilas 
witli all the vigor and reserve force of a man of (hirtv. In mil 
probability tlie irritative structural and degenerative ohangn 
which are taldng y>lace in the prostate are at the root of this senile 
sexHul erethism. 

There is a class of cases of inordinate sexual ilesire in ibr 
male, to wliicii attention was first iUrectc<l by Beanl,' which tlo 
serves s{x*cial mention. In the nuijority of thest* cases tlic sul>* 
jects of this trouble are educated, intellectual, moral, and rpligiou* 
men, of exceeding sensitiveness of nature, most of whom shrink 
In horrrtr at the cont<'mplation of their conditiorr I have had a 
number of such cases under my care from time to time, but nottf 
of them gave such a graphic account of their condition aa ibiK 
pR'sented by one of Beard's patients, which I will trar. 
IVard .saN-s: '*A clergyman, aged forty years, came to m\ i- 1- 
anil, after long di'lay and marked hesitancy and confusion ci 
manner, relatwl substantially the foUowing history: '] aiu/ br 
said, *in a most lamentable, even desperate, condition. I ftar 

'Op. cir, p. 2U. 

' Sexual Neurasthenia, pp. 273 e( •!«). 



that my memory is cleserting me, and that I bill fair to become 
both a mental and physical \vreck.' He appeare<l healthy, anfl 
his iniiul, wht'ii din'ctod from his trouble, was as vi^>n»us as ever. 
He had b(HMi iimrritMl but live yt'ars, and by mntiiai agreement, 
based on their ideas of personal purity and reli^on, and perhaps 
also on an alniust complete lack of sexuality on the part of his 
wife, he had to a coixsidcrable degree suppressed sexual inclina- 
tions that were naturally very strong. lie did not, however, 
become unbearably annoyed througli tliese effects of repression 
until sonu* twt> years ago, wlien would occur and cotitinue 
for hours, <livertiiig his mind from study and irresistibly directing 
his thoughts in such licentious channels that he became at times 
overwhehned with nriguish iind despair. Intercourse bniught 
only partial and temporary relief, and sometimes he would lie 
awake for hours, after a Repetition of this natural effort for relief, 
with erections that would not subsitie. He was in constant fear 
that \\v would commit some act of folly wheiT alone with certain of 
his female parishioners, and fur this reason resorted to mctlK>ds 
and excuses to avoid meeting them alone that he thought might 
seem to them strange and inexplicable. This worried him greatly 
also." This patient had Ix^en operated upon, without result, for 
redundant prt*puce. He luid mild hemorrhoids Hn<l varicocele. 
He was treated by good hygiene with bromides and bitter tonics, 
and assurances of recovery were held out to him. 

Asaresultof treatment he says: " I have agood, healthy imagina- 
tion, almost free from voluptuous images. Again, instead of the 
unsatisfied burning tiesirc for sexual intercourse wliich came 
again ancl iigaiti during the day and night, the desire is now ver\' 
nu>d*'ralt' ancl at (imes not perrvptible. Instead of re|>eated enr- 
tions when alone, all s(^ms comfortable and quiet. Only one of 
the symptoms T sp(>kc of slill n'tuaiiis, and (hat is the insane 
desire to inkv hold of wona-n (who perhaps tempt me), to caress 
and fondle tliem, and play with tiiem. The pivsence of certain 
women excites my passions, but by no means in the same manner 
as Iw'fore. Please remendn'r that I never t*H»k lilwrtles with 
women in former years, and that 1 have not yielded to this desire, 


9 srl 


no matter how strongly tempted, yet I find it remains. My wile 
is a very chaste woman, and she regards my desire to foi 
look at, and admire her form as signs of manly weakness. 
thinks yielding to tliese things only hurts uie and excites 
passions. The desire to look at atu! fondle women is much strongrf 
than tlie longing to have intercourse with them. If this terriU^ 
longing is due to some disorder of my system, I want the phvji- 
cian's help; if it comes from a wicked heart, I'll fight it till tb«. 
<lay of my death. You perhaps can help me to decide." In 
case Beard says that good advice and the sedative efTe<*Ls ot\ 
bromides produced a cure. My own experience in these 
has taught me that in general there is some deep-seated ti 
in the sexual tract, which has been caused by early and chi 
masturbation (perhaps by clininic gonorrhcea) and hy the cwi 
tion of the .sexual parts which results from prolonged indulgi 
in libidinous thoughts antl from dalliance with women without 

Treatment. — In aJ! eases a thorough examination of the patM 
should he marie as to his general condition — mental and pliysM 
C'are should be taken that tlie general nervous system is imp] 
hy fres!» air, healthy out-door exercise, cool bathing, change of; 
and scene if possible, and by the use of good, simple, nutril 
food. A thorough examination of the genitourinary tract should 
be made, ami if any structural damage is discovered it should be 
treated on the general lines laid down for the management 
chronic urethritis, prostatitis, and seminal vesiculitis. {Vi 
9upra.) Bnimides and sedatives may produce temporary rel 
but they can hardly be expected to cause a cure. 



In" the light of our present knowleilge of the morbid c-omlitions 
of the prostate, rlcferential ampnllatioris, and seiniim! vesicles, and 
chronic urethral inflammation, the subject termed sperraatorrhcea 
can be lucidly elaborated in a few pages, whereas in the past, when 
the scope and exact nature of this symptom were not clearly 
known, many pages and even volumes were required to tell what 
we really did not know*. In the past spermatorrhoea has been 
the bugl>ear alike to the layman and the surgeon, while to-day the 
term itself is a misnomer as applied to most eases, and when used 
in any connection it is imprecise and unscicntihe. 

As has alrcatly been shown in the chapters on Chronic Prosta- 
titis and on Masttirbationj the abnormal discharges observed in 
cases l>elonging to these categories arc, as a rule, not of seminal 
fluid, but of a morbid prostatic mucus with perliaps a few zoo- 
sperms. Patients who have mastiirl>ated excessively in youth, 
and wlio liave damugtMl their pn>atates, ejaculatory ducts, aitd 
tlie seminal vesicles, fall into a condition of ill-health in which 
hyptK'hondriasis and neurasthenia are prominent symptoms. The 
physical and moral tone of these individuals is very much lowered; 
their thoughts are centre4l on the genital organs during the day 
an<l they dream of erotic sulijects at night. In this mild state 
of moral degradation the whole economy seems to go wrong, 
and such patients complain without ceasing of an infinitude of 
morbid symptoms. They talk and reason, as a rule, in a prolix 
and incoherent manner, and are, day by day, thrown into a con- 
dition of panic by the escape of a small amount of prostatic mucus, 
which they speak of as seminal fluid, the loss of winch they regard 
as so serious and so devitalizing to their health. Now, these cases 


, Imt ^^ 

m^y l>e smnnied up in the following way: First, young men 
as a result of masturhallon an«i perhaps gonorrhoea notice 
urination, defection, or hard labor, ami in their sleep, the 
of a fhiiil winch conies from the prostate. Second, cases ii 
same condition, plus a Httle discharge, due to relaxation ft 
chronic inflammation of the ejaculatorj* ducts, the ampnllatii 
and the seminal vesicles. 'Iln^L, older men, in whom gonorrl 
and sexual excesses have reacted on all the seminal parts, and 
spontaneously or in urination, or at stool, or in excesses, noli< 
quite copious secretion, which consists, in some cases, of pi 
mucus (see p. 28S), and also of the sccR'tions of tlie seminal \^\i 
and of the ampullations. In these three categories may be 
chidi'd all tlic <'ase.s (o which the term spcmiatorrhoea may in ant 
way l>c applied. As we shall sec a little farther on, more or lea 
perfected seminal flui^l miiy escape in some intlividuals, hut tbc_ 
underlying conditions an- not those of disease. The 
pollutions and emissiL>ns of chn>nic masturhators are, as a 
grossly exaggerated n.s to their c<tpiousness and fretpieney of 
rence. These patients come to the surgeon with a sorry 
the great extent of their seminal losses. The truth is 
most cases the morhid mucus which escapes during the da; 
night is very small in cpiantity. Sometimes it consists of 
a few drops, imd rarely, if ever, amounts to half a teaspooi 
The tendency to nu>rhidly exaggerate these soK'allcd seminal lo 
is so prevalent that the tnjth can hardly l)e ohtained by the 
geon. T have for several years investigated this subject ui 
varying conditions of difficulty, and I have reached the conciuj 
already siate<l. 

To my mind the terms defecation-spermatorrhoea and urinal 
spermatorrhoea arc unscientific and unnecessary, and they do \ 
hy reason of their ominous significance. 'I^he real facts are 
certain mechanical ennditions (the chief of which is alKlomii 
pressure) cause a little morhid mucus to cM^ajM* from a dami 
prostate or in consequence of a relaxed condition of tlie senoi 
parts alMive, In like numner I tliink that that ill-sounding U 
|)olluti4jns is a sort of a pathological scaarruw. These, for 



time, unbalanced boys and men have in their prostates and deep 
seminal parts a focus of irritation which may during sleep disturb 
the sexual centre, already in a condition of erethism, and this dis- 
turbance reacts in its turn badly on the unstable nervous system. 
The erotic dreams that are so much written and talked about are 
merely the result of a damaged sexual sphere and a general nervous 
depression. What is needed in the management of these cases is 
the recognition of the morbid condition of the sexual organs, and 
when a correct diagnosis of the case has. been made there is no 
necessity for refinement and elaboration in the details of unpleasant 
symptoms the importance of which is always unduly magnified. 
Most of these cases are much trouble<l about their loss of man- 
hood (and quacks foster this idea), and they are really made worse 
by the perusal of the ordinary treatises on si)ermatorrh(ra, with 
their unsavory symptom-complex. My experience has taught me 
that a great step is gained if by scientific methods we can demon- 
strate to these worried individuals that they are deceiving them- 
selves as to the quantity of morbid mucus lost, and that sperma- 
tozoa are not commonly found in it, an<l, if found, only in small 

With our more precise knowledge as to the nature of these 
cases, and our more practical methods of treating them, we shall, 
no doubt, as time goes on, see less chronicity of their course and 
very much less of the resulting mental depression and lowered 

Many continent men notice at times, owing to alxlominal press- 
ure or severe exercise or straining, the escape of a mucoid fluid 
from the meatus. In many instances this secretion is simply 
prostatic mucus, and in others it comes from the ampuUations and 
seminal vesicles. This condition is a very simple one, being only 
the partial removal of a plethora. When it <)c(;urs frequently 
it may, in nervous individuals, cause anxiety and drea<l, but it 
speedily ceases with the adoption of a rational sexual hygiene. 

A large amount of loose statement and exaggeration has been 
made regarding nocturnal pollutions and their supposedly disas- 
trous effects. The pollutions of young or older niasturbators are, 



as we have seen, the complex outcome of sexual damage, 

spinal ctird and general cerebral depression and weakness. 
it is ob\*ions that in healthy nien these conditions do not 
therefore the mviirrence of an occasional emission is not foil* 
by harmful results. According to my experience, most men who 
have tliese emissions seek and obtain the renie<ly in coitus, 
men, of a timid and nervous temperament, however, who 
moral scniples, will not Indulge in sexual intercourse, anc 
somewhat exceptional cases, their genital centre becomes irritated 
and the general health lowered. These cases, liowever, are 
very numerous, and by proper adnce can l>e l^enefitefl and 

It is impossible to say what number and what frequew 
emissions may occur without damage to the in<l]vidua], since 
men are sexually vigorous and others are the reverse. I 
known many men to have several emissions a week for a 
time, and jet their liealth was not at all affected; whePM 
others T have seen one such discharge in a week, or ten 6&v. 
less, followed by mental depression and physical debility. \\1 
a man is mentally and physically strong and vigorous, and tsi 
and abou^ in a lively way, a few and perfiaps many nightJy eji 
lations will do bim no harm. But a weakly, neunr>pathic 
with a worrying tendency, who shuns society and does not indi 
in healthy exercise, may Iwcomc much reduced. In these partis 
cases, however, the niltHl, by dwelling on the seminal loss and 
portent of possible impotence, is the chief factor of ilNiealtli. 
all cases it is important to establish a wholesome state of seJ 


Many young men who have indulged even moderately tii1 
turbation imagine in subsequent years that, as a result of 
former habit, they are then suffering from spermatorrha*a. 
idea is mendaciously set forth in tlie pamphlets of and in jiersot 
interviews with advertising quacks, and it causes in many pati< 
muclt worry and anxiety. Some of these patients ha\-e no si 
toms except those they conjure up in their minds, while in ot 





some slight deviation fR>iu a normal condition is magnified into a 
aerious evil. 

In most men in periods of sexual excitement a perfectly clear, 
viscid mucus escapes in small or large quantity from the meatus. 
It is the secretion of Cowper's glands and of the urethral follicles; 
therefore, it is perfectly normal in ever^' respect. After dalliance 
with women men notice this secretion, and some become much 
alarmed, as they think they are losing semen. In young and 
strong courting men (when the engagement is rather long and 
the mutual affection between lover and pancee is very intense) 
6exual excitement in the male is often so great, and this Cowper's 
gland secretion occurs sn constantly and so copiously, that much 
disquietude of mind is felt by them. Some uien even become 
hyp<K'hondriacal and neurasthenic. .Tlie trouble in these cases is 
that the excitement cannot be allayed by coitus. It cannot be too 
clearly understood that this condition is a perfectly hnmilcNS one, 
and tliat it will cease at once when marital relations are established. 
This condition is called ureihrorrkoea ex libidine. In some cases 
this secretion escapes during erections at night. 

Some patients, having recovered from gonorrhcea, may see for a 
time a little harmless, clear mucus within the meatus, and others 
who have not had gonorrhcea may see the same. Tliey run to the 
surgeon, milk out with more or less firm squeezing a little secre- 
tion, and then look the picture of wt>e, and claim tjiat they are 
losing their manhood. In other cases the declining and scanty 
gonorrhcea] secretion which escapes from the urethra, or the few 
threads which yet may lie seen in the urine, are looked upon by 
many as loss of semen, and they are more or less unhappy. Dur- 
ing the condition of involution wliich occurs after the subsidence 
of congestion of the prostate a little harmlesij prostatic mucus 
may escape from the urethra, particularly after defecation, and 
this may by some be looked upon as a sign of evil omen. 

Nervous and worried patients bring to tJie surgeon specimens 
of urine which they erroneously think contain sjM^rmatozoa, 

Some overworked and neurotic young men who may not have 
a full, liberal diet, and who eat a preponderance of vegetables, 


not infreq\iently bring to the surgeon specimens of sliglatlv luiil 
urine of low specilic gravity, whicli has a peculiar opu(.|ue cnkir 
Ixirderiug on a milky tint. '^Tlie constant passage of litis phts- 
phatic urine, and perhaps the tliought that in boyhood he bad 
nia.sturi>ated, results in convincing the ]>aticnt that he Ls losing 
seminal fluid. Others l>ecoi[U' likewise wiirrie<I about the pnesenre 
of urates in their urine. Quucks find these inilividuals pluuit aii&l 
oft-retuniing vi<*tiuis. In these case5 it is important for \}\c sur- 
geon to reiueuiber that a condition of lowered health may rxiai. 
and that in some instances these patients are somewhat neumv 
thenic. The most convincing evidence for such individuals is Ibf 
addition in their presence of a little acetic acid to the urine, whidi. 
if it contains much earthy phtjsphates, is rapidly rendered clear, 
and if it also contains carlx^nates there is an additional luarkf^ 
etfervescence. This little chemical test, together with wholesomr 
advice and tonic treatment, will soon put these patients in a Irtif-r 
state t)f mind, and then under favorable circumstances tlje laj AiUt 
may be restored. 

Horsehack-ritling. cycling, and severe jolting niay soni 
cause the escape of a little pn>static mucus or of the secret 
the seminal vesicles. In some cases the fluiil seem to oonie froa 
Cowper's glands. As a rule, these little discharges cause no wot 
to healthy and vigor^>us men; but nervous, worrj'ing, and neui 
thenic individuals may l)e very much troubled in mind. 





Many imlivitluals Iwcoiur worried al>out the coiidiLioii and 
the function of their gfnilal iipparatus, or of some pnrt of it, 
while others become possessed of a groundless, morbid fear uF 
some abnormal state or of tliest^ party which {lors not 
really exist. In t!ie majority of eases men or boys of avenige or 
marked intelligence, not knowing exactly what is normal, com- 
plain of sanple, harmless coiiditiona or of appearances which tliey 
think may lead to sometlung more or less dangerous to the func- 
tion of the parts. As a nile, cases of this category are simply 
instances of sexual worr}', which may be more or less acute and 
pn>longed, but rarely present a formidable condition. On the 
other hand, some indinduals become really sexually hyj>ochon- 
driacal and fall into a morbid state of mind. 

In the category of sexual worr}' there is an infinitude of com- 
plaints. A man consults the surgeon because one testis hangs 
lower than the otlicr, and he fears ill eonscfjuences may result. 
Another convinces himself that his penis is too small, or that his 
testes are ill developed, and that he iimy not be able to indulge in 
coitus. Such slight affections as simple red spots (perhaps microbic 
invasion) on the glans and scrotum sometimes send a man post- 
haste to the surgeon, thinking that something very bati has hap- 
pened. The normal redness of the meatus is not uncommonly 
the cause of much mental uneasiness. Then, again, the smegma, 
natural to the prepuce, may be regarded as an evidence of disease 
for which a man may anxiously seek treatment. One of the most 


persistent victims of sexual worry that I have ever seen was 
robust young man in whose coronal sulcus a few little cn'pts, notj 
as large as the head of a pin, caused by the invagination of tbej 
mucous membrane, were to be seen. Notwithstanding that tlie 
man was told impressively several times that his penis was io 
perfect condition, his worry caused him to come back a number 
of times a year for several years, in order to obtain fresh reassuf-| 
ance that he wa.s all right. 

It sometimes happens that the coronal collar or expansion of j 
the glans penis possesses a deeper hue than normal, eveu a deep 
red color, and that sometimes the p«rt appears minutely papillated. 
I have several times had tliis condition aln>wn to me by men in an 
anxious state of mind, and in some a deej>-r<x)ted fear of ulierinrj 
cancerous development was entertained. 

A phimotic condition of the pivpuce, moderate or well devel- 
oped, is a not unconmiun cause of worry, and mild or sevcnsj 
balanoposthitis has, in my c?q>erience, several times been the cai 
of much anguish of mind. 

Some men become worried l)ecause they find their scrotUQI^ 
studded with many little, harmless, unchangeable milia (thuje 
minute white papillations which are so common), and it was diffi- 
cult in some instances to comfort them. One man who bad 
several small wens seated in tlie scrotal tissues was firmly con- 
vinced that his spermatogenic function was entirely out of ord* 
and that these tumors were evidences of a vicarious activity whi< 
might lead to sterility. Notwithstanding the absurdity of tit 
assumption, it retjuired several inteniews t(» c<m\'ince the 
that he had nothing but little harmless tumors. 

Some men come to the surgeon complaining that their meJH 
is unnatural; in sorne^ from their standpoint, its lips are 
flaring and the orifice is too patulous; in others the lips are nal 
rally in close coaptation, and that must be wrong. I have 
many instances in which sensible men have worried over th 
abst^lutely normal conditions. 

Ec'/ema and psoriasis of the penis very often induce a woi 
condition of mind» and much apprehension has been entertaii 




\y many regarding signs of eczema marginatiun of the thighs, 
crural fold, and scrotum. Simple perspiration at the penoscrotal 
angle and in the crural fold has caused many men to think that 
their sexual apparatus was entirely out of gear. 

Minute spots or ])atchos of pigmentation about the genitals 
cause in the minds of some individuals much uneasiness, and tiie 
discovery of small superficial neevi of recent growth has sent the 
bearer to the surgeon in a condition of panic. 

Strange to say, the equanimity of patients sulfering from 
liydrocele, even when tlie tumor is large, is rarely even moder- 
ately disturbed; wliereas varicocele may cause such worry that a 
hypochondriacal or neurasthenic condition may result. (See 
Chapter XX.) 

Strange as it may seem, many men, particularly young and 
healthy ones, become thoroughly convinced that they are suffer- 
ing or have suffered from gonorrlia*a, although they have never 
presented any symptonos of that infection. Tliese men are usually 
old masturbators or sensitive men who are continent for long 
periods. They express by diligent efforts a little clear mucus 
ivam the meatus, and offer that as undoubted evidence of the 
correctness of their statements. Tliese patients very often assert 
that they experience vague, dull pains in the region of the pubis 
and in the course of the pendulous urethra. Fain at the end of 
the penis is also frequently complained of by tliem, and It causes 
them much worry. Such patients are prone to fall into the hands 
of quacks, who usually put them through a fearful ordeal in the 
way of cutting operations, sounds, and injections. I have seen 
several cases in which these patients had been under the care of 
regular but ignorant practitioners, who had proposed meatotomy 
and other wholly unnecessary and, to them, harmful procedures. 
If these patients are submitted to a careful urethral examination 
as well as a thorough examination of their urine, taken at different 
periods of the day, especially early in the morning, and they are 
found to be free from gonorrhua, it is usually easy in one or two 
inten'iews to convince them that they are only the victims of 
sexual worry. In such cases moderate coitus regularly indulged 


in is very l>eneficial, and, as a. result, these men soon ceaase 
complain i>f pains in (he genitals. 

Then, again, more or less pronounced worry raay occur in esses 
of obstinate chronic urethritis. Such patients continuallv sque«i^M 
the jjlanii penis from l)ehind forward, to see whether tliev can pn^™ 
dufe a drop of secretion. They are on the lookout, bright and 
early, for the uioniing drop, and they freely provide themjselv(|^| 
with glass vessels, into which they frequently urinate and then 
critically examine for urethral threads. In some cases thb wo 
is so prolonged that a mild neurasthenic condition is produced. 

Then, again, patients will come to the surgeon bringing s 
mens of urine laden with phosphates and carbonates or ura 
and claim that their sexual and urinary apparatuses are serious! 
out of order. If by a strange coincidence there is present aj»y 
of tlie foregijing harmless structural conditions, if there Is more 
or less imaginary pain felt in the testes, scrotum. ]>euis, or ingmual 
or hypogastric regions, the patient raay fully couvin<rc himself 
that his health is in a very critical condition. Many of tliese cfluses 
fall very readily into the hands of quacks, by whose ignorance and 
rapacity they are often greatly iujure<i and cruelly despoiled. 

In all the foregoing cases the worry of mind results from soiuc 
harmless condition or from some affection which is readily curable. 
The root of the trouble is that patients have gotten their minds 
fixed ujx>n their genital organs, and for a time more or less con- 
stantly this thought dominates their existence. In many iust^uces 
no effect on the health is produced; in others the menta' and 
physical vigor am somewhat impaired; while in still others dys- 
pepsia, iniUl sleeplessness, and moderate cachexia may supervene. 
As a rule, however, all these cases can be relieveil, amelioraied, 
or cun*d by sensible, kindly advice and encouragement or by well- 
directed treatment, k>cal or systemic. 



In my experience true li}pochondriasis, originating in sonw 
Imaginary sexual disorder, is very rare. Perhaps the specialist 



in nervous diseases may see more of these cases than the genito- 
urinary surgeon does. In the cases I liave seen the mental dis- 
turbance hinged on the early and vigorous practice of nia.sturl>a- 
tion, on the memory of sexual excesses, or on the fixed thought 
that an anteceden( gonorrha'u had never loeen cured. In some 
cases there was an abidingly haunting religious fear that in sexual 
induigent^e and excesses an unpardonable sin had been committed. 
In soruewliat rare cases in continent men nocturnal enu'ssions have 
led to a markedly hypochondnacal state of aiind. In these hypo- 
chondriacal cases morbid fears are not iincoainionly a marked 
symptom. patients are always in a state of excitement 
and worry about their digestive organs, in wliich diey claim vague 
radiating pain or u dull heaviness is present; about catclung cold, 
and the weak, distressed, and painful state of their lungs, and 
about the atony and cold sensations, or tingling and pricking 
feehngs, which are experienced in their g^^iital organs. They 
imagine they are going to suffer or are sufi'eriiig from softening 
of the brain, paresis, locomotor ataxia, or any disease which they 
hear of. In their rt^cital of their imaginary nilnients (hey are 
tediously prolix, and frequently enter into details which am really 
disgusting. They are most exacting, sometimes exasperating, in 
their requirements of the surgeon, and at each interview insist 
that a thorough physicid examination In? made of nearly every 
fjrgan <^f the body, as well ius of tlie .secretions, They are (»fteri 
hj'persensilive, and imagine that they are the objects of ridicule on 
the part t>f friends and otJiers. "^lliey can apply their minds to 
no useful purpj>se, and they are incapable of well-directed pliysical 


The term sexual neurasthenia or nervous prostration is to-day 
widely employed in an indiacriniiiiate manner as designating a 
large and hetemgeneous chiss of ciises in which there is more or 
less ill-health, together with some trouble, mild or severe, of the 
sexual apparatus. Too auich latitude has been given to the use 
of this term, and very frequently the inquiry into tlie etiology of 


the cases designated as neurasthenic has been too superficial ad 
of a routine character. There can be no doubt that certain 3c\u*l 
irregularities, excesses, and morbid states so weaken the nenrw 
system that a serious condition of ill-health is produced; but. «ti 
the other hand, this identical morbid state may be induwd h 
other causes, which in their turn more or less directiv lead U) 
sexual debility. 

Though the existence of neurasthenia as a definite morfiid entiti 
has been denied by some authorities, there can be no douhi tlui 
there exist many cases in which the symptoms of impainueot nf 
the nutrition of the nerve centres and of their lowered funclioB 
are sufficiently definite and common as to warrant the retentiouof 
this term iu our nosology, Wliile, therefore, neurasthenia cauDot 
be called an absolutely well-defined disease, like diphtheria of 
tuberculosis, it may be considered a well-marked morbid CDcnii* 
tion, having a wealth of symptoms which are tolerably coBStaot, 
and most of which are present in the majority of cases. TV 
fact of the matter is, that when one has become fully acquaintrd 
with this weakly and irritable condition of the whole nrr^ooj 
system, blended with anfcmia and chlorosis, its recognition is 
usually very easy. 

The main causes of neura.sthenia are severe mental and bodilj 
strain and overwork, anxiety, worry, excitement, uneertointy oi 
nund, and mental emotion of a depressing character. Certain mca* 
bid conditions, such as typhoid fever, malaria, sypliilis, and infln- 
eiiza, may leave m their wake a state of the nenous system w\M 
this name properly expresses. In this condition the drain on thr 
nervous system required by the vital processes is so great that ibefe 
is not at any time a reserve supply of nerve-force to call tipoo; 
hence it can readily be understood that sexual debility, iiiabQilVr 
or apathy may soon develop. In this event, however, it b Dot 
correct to class such a case as one of sexual ncunisthenia. TV 
sexual debility is the result of the ill-healtb, and not its cause. On 
the other hand, sexual excesses, unnatural prolongation of coitus, 
buccal coitus, conjugal onanism or withdrawal, mt&slurbatioD 
(particularly in men at or near middle life, also iu younger sub» 



jects), and long-continued sexiia! erethism with unsatisfied desire, 
not infrequently induce a condition of Ill-health in which the 
classical s}Tnptoms of neurasthenia are present. Such cases, there- 
fore, reasonably come under the category of sexual neunisthenia. 

An important question in the etiology of neurasthenia now pre- 
aents itself for consideration. We quite conunonly see young or 
middle-aged men who have chronic anterior and posterior gonor- 
rhGca, chronic prostatitis from masturbation or gonorrhoea, or 
chronic inflammation of the seminal vesicles and deferential 
ampullatioiis, and even from imaginary or real rectal disease, 
who fall into such a condition of ill-health with mental unrest 
and debility which no other term than neurasthenia will concisely 
express. In these cases the condition of the sexual ajjparatus 
seems to be the dominating inMueuce in the long morbid chain, 
and the condition is strikingly one of marked sexual disorder. 
"^llie question then presenfii itself: Are these cases prinuirily due 
to irritation which is reflected from the rnorbi<I area back to the 
genital centre, and from tliere to the spinal cord and brain, in 
which it sets up a condition of malnutrition? or are worry and 
m«)rbid fears induced by the genital trouble the cause of the 
mental and physical decay? These questions can only be par- 
tially answered by ingenious theories which may at will be elab- 
orated in support of either contention. Seeing that we have no 
lological facts and obsenations to guide us, the more rational 

rnise, to my mind, is to wait until, little by little, definite and 
scientific knowledge is acquired upon this very obscure subject.' 
One practical point, however, here suggests itself — namely, that 
in most of tliese cases relief of the local trouble is promptly 
followed by improvement of the mental and physical healtii 


' The reenlt or neMarchefl of Hodg« (Journal of Morphology, 18U2, vol. vi. p. 
95) are very iateresting as tending to throw socue light on the pnthntogy of neur- 
asthenia. This observer found that prolonged electric BtimulaCion and fatigue 
produced in the brain centreH of certain animnln tind bird.s mnrked degenerative 
changvH in the nuclei, cell-protuplBsiu, and cell- wall when prcHeiU. These 
changes dirtappeared nIowIv under rest and quiet, and afler n lapse of time the 
normal Htructure of the [wrt^ war rc-eHtahlif^hed. rerhafH in ncuranlhenia the 
molecular nerve changes are the underlying pathological causes. 


of the patient. Such cases are typical instances of sexual xxeca- 

Symptoms. — ^The onset of sexual neurasthenia is usually sV'« 
and insidious. The most common symptom is a dull, heavy f^ 
ing in the liead (fnnital or occipital), sometimes wiUi a sens* '4 
constriction, which is worse in the morning. Such a patient, ahrr 
a troul>U'd night, awakes, unrefreshed, in very much tlie state il 
a man who had indulged to excess in alcohol the night liefott. 
llien the appetite becomes capricious, and it may l>e nearly to$L 
The digestive functions become labored and slow, and coiistipatioa 
is apt to result. At this time a marked change in the monde ii 
the man can be noted. He is indisposed to perform his work, 
tmd has to force himself to keep up to his duties. His mind i? 
less acute, his uieniory less accurate and may become verv defec- 
tive, and his disposition becomes altered. He angeis easiW, and 
any slight cause irritates nnd worries him. Trembles of unv kind 
which in the normal state wtnjld be siK)n thrown off aiv bn>oded 
over, and severe mental depression may follow. Then sleep 
becomes much mure disturhed and unpleasant, and perhaivs ercide 
dreams keep the patient in a restless state during the niglit. In 
tlie clay the disroinfurt of the patient is very great by rmsot) *^ 
the weakness, the mental trnrest, and the torpidity of the gastio- 
intestinal processes. In a short time the facies of the suifeirr 
becomes much altered. A pallor with a dull, worrietl expitssioD 
is often ver}' noticeable, together with some or much eniaci«l»<^n 
of the face. In some cases these patients soon come to look like 
sickly or weakly old men. Genend loss of weight soon lie^iiiies 
noticeable and adds another source of worry to the patient's 

The foregoing description applies to very bad cases, and musl 
not be c<jnsitlcre*l as aixsc^htteiy typical. Thus we see crises in whkii 
men seem to he a little anji^niic or nni down; others as if tbry 
were somewhat overworked, or too much confined in-doors, or wIjo 
do not have sufficient sleep. In none of the cases can the pattent 
from his appearanc*e, l>e said to be n-ally .sick. Then, ogsun, we 
see men who appear well-nourished, and who have a fairly gond 

SEXUAL wonnv and HYPncnoNDmASJS 


)lor in their faces, who surprise us by their wealth of neuras- 
thenic symptoms. As a rule, however, the man carries in his 
Face the sti^nata of a nervous sj'stera the nutrition of which is 
fcvcry considerably impaired. 

The tale of woe which sexual neurasthenics pour into the aur- 
reon's ears or those nf anvone else who will listen t() them is 
.Imast endless and of infinite detail and variety. They complain 
[of vertigo, of dull pains in the head, spine, hack, and legs, and 
isist that they have painful areas all over the body, especially 
[over the tnink. lliey are graphic in tlu'ir descriptions as to how 
lot and cold flashes dash and ra^liate all over the bodv, and as to 
le acuteness of certain pricking or itching sensations or of a feel- 
ig as if water were tio%ving over their limbs. They also complain 
►f cold feet and hands, whicli, when felt, present a disagreeable, 
lammy sensation. They perspire on slight exertion, suffer from 
local liN^Jeridroses, and sometimes fnini a profuse general sweating 
hich exhausts them greatly. In the recital of their cardiac and 
lung troubles they are veiy diffuse and insistent. 'Jliey sometimes 
lave a dull, hea\'y pnecordial sensation, with a sense of suffoca- 
fon and sometimes of paifi, n'lnrnding one nf angina pectoris. 
'alpitatiiMis of the licarf, with a frequent, thin, wiry, and irregular 
adse, can very often be ft>nnd liy (he surgeon. '^J'hese patients 
imetirnes claim that they suffer severely in their lungs. They 
uneuhat unconiinouly are attacke<l Viy such a sense of suffocation 
that asthma is .simulated (asthma sexuale), I liave seen several 
cases in which there was much emaciation, and in which the 
patients so pertinaciously insisted that they had severe pains in the 
lungs and cougli, together with night-sweats, that a suspicion of 
tul>erculo.sis w;is for a time entertained. As Gray* pertinently 
says of these cases, the "prolonged nervous depression diminishes 
the good sense and increases the bad judgment and lack of self- 

In con.sidering the foregoing rich but sad symptomatology, in 
which the peace of mind and the health of the patient are so seri- 

Medic&l Xews, December 16, 1899, p. 788 ct eeq. 


ously (Iisturl>e(], it can l)e rea<lily seen that the \nctim is incjip«i 
of applying himself to any work, bodily or mental, and (hit 
the enjoyments of life are lost to hira. He becomes irritaVile kA 
excitable, and is anything but an agreeable companion. To 
surgeon he is often a sore trial, and in his importunities f*»r 
he taxes his patience and endurance to the utmost. In si^me 
cases I have observed an abiding spirit of marked ingrad 
notwithstanding the sufferers had received much kindlv and pa 
attention, together with proper advice and treatment. Tlieir 
merits and sufferings and demands for relief are always poi 
forth into the surgeon's ears, and no attention is paid to his 
offices previously extended. 

The attempt has been made in the foregoing descriptii 
depict the severer class of cases of sexual neurasthenia. It 
be remembered, however, that this disordered condition of 
nervous system varies in different individuals. In some it 
mild, and only a few of the clinical sjiuptoms are presrnt; 
others the condition is more severe and the syruptoui-<^nj 
greater, w^hile in the very severe cases the whole economy 
to be deranged. 

The local or sexual symptoms are numerous, and haw thcJi 
origin in some part of the sexual tract. In some case-s. when 
bealtli brings back memoncs of early masturbation and the 
begins to brood over the imaginary ill-consequences or the si 
ness of the act, sexual symptoms seem to spring up as if by mtgir. 
Neuralgia of the testis, or a lieavj', distended condition of 
glands, is complained of. Darting or dull, heavy pains in 
scrotum, gniins, and urethra are said to be frequent and sr 
The penis, testicles, and bladder seem to have lost their life, uwJ 
desire for coitus is more or less blunted. These patients complai 
that their genitals are cold or clammy or wet, and that ther 
certain that these organs are growing small or are withering 
Prostatic and bladder pains are also complained of. Coitus not 
being indulged in, emissions, mostly nocturnal, with or witboat 
erections, occur an<l l)ec(jme the source of great worry. Any 
escape of mucus from the urethra is looked upon as a dangrcoo* 



omen, iiiiil convinces the patient that he is l)ecoining devitah'zed. 
In the cases where there is tangible lesion of the sexua! tract there 
may be a chronic urethral discharge, especially in the intmiing. 
Tliere may be increased frequency in urination, and exceptionally 
post-niictional hfematuria, pain in tlie glans penis at the end of the 
act, pain or buniinp; sensation in tlie urethra and perineum, and 
deep in the pelvis from involvement of tJie ampuliations of the 
vasa dcferentia and seminal vesicles, or the pain may be referred 
to the rcrtnm itself. (For further inf4>nnat]on on these sut)jcct^ 
the reader is referred to the chapters on Masturbation, on ThTOnic 
Posterior Urethritis, Chronic Affections of the Prostate, and 
Inflammation of the Seminal Vesicles and of the Deferential 

Dia^^oais. — In sexual neurasthenia the disorder in the sexual 
apparatus so dominates the patient's mind that if the surgeon is 
sulficiently faniiUar with the trouble he can readily make a <hag- 
nosis. In all cases it is very important to make one's mind per- 
fectly clear as to whether the general morbid state had its origin 
in some imaginary or real sexual disorder, or whether in neuras- 
thenia the man's mind became disordered as to the condition of 
his sexual apparatus and its function. When the sexual tract is 
the seat of morbid change a thorough, painstaking investigation 
shouUI be instituted, in order to determine the location of the 
trouble as well as its nature, extent, and severity. Upon the 
accuracy and fulness of this investigation the intelligent treat- 
ment of the case and its outcome largely depend. 

I have seen several cjises of sexual neurasthenia in which the 
syntptotn-complex seerne4i to point to the existence of the ofjium- 
habit or cocaine-habit or to secret chronic alcoholism. 

Propioaia. — In sexual neurastlienia, as a rule, a good prognosis 
may ]ye given, since the disease, though chronic, does not lead to 
death. Such is the markedly beneficial effect produced on the 
mind by the relief of symptoms and the cure of morbid sexual 
conditions that the patient's health in genera! Iwcomes appreciably 
better at once. In some neuropathic and hypochondriacal cases, 
and in some patients with an inherited unstable nervous system, 



sexual neurasthenia may be very persistent, and a long period 
time — months or years — may elapse before a cure is b 
al)out. Such cases, however, are not very common, anil 
in most instances occurs in a few months or in less tban a rnt. 
The retuni to vigorous health may be slow. 

Treatment. — In sexual neurasthenia, as we have seen, 
morale of the patient is most improved when he e:q)eric 
amelioration of his local symptoms. With this fact in mind, tbr 
surgeon should enter upon a mihl and conservative t-ourse 
treatment directed to the part of the urethral canal which] 
affected. It is important that heroic measures or new faclssh 
hot be used in these cases, and that exacerbation of tlie u 
Iving chronic inflammation of the parts should not be indi 
The patient watches the progress of the with such tiMt^ 
scrutiny, and is so easily depressed if matters do not run smoothly 
that we cannot be too careful in the use of topical applica' 
or of instruments. Very often these patients are importiinatr, 
try to bully the surgeon into a change of treatment or to 
adoption of more stimulating applications. The course to pu 
in such an event is to placate as far as possible, but not to 
to measures of doubtful value or those which do even m 

The gtnieral management of a case requires much carr and 
iiiinsjK't'tion. The condition, disposition, and surroundings i>f 
]»atient must he fully studied; then a careful and grateful s 
of hygiene should he established. The patient should l>c 
quiet and at rest^ and all rnres and anxieties and obligations sboi 
as much as possible, l>e kept from him. The condition of 
stomach and bowels should receive much attention, and. if n 
snry, medication to aid digestion and pre\*ei»t constipation s 
be s])ariiigly administered. Pepsin, pepten^yme, bismuth. 
voniira, rhubarb and sotia, pancrobilin pills, and mild ii|>e 
shoidd l>e kept in mind and used as the occasion seems to dem 
The food should be simple, bland, and nutritious, and should ne 
be taken in too large quantities. Milk in abundance, if assinti 
lated, is excellent, as also are rare red meats b motleration, 



italc bread, rice, and hominy. Tea, coffee, and cocoa are, u % 
lie, harmful, and are liable to disagree with the patient or to 
Imake him inwre nervous. 

The condition of the lungs and of the heart should l>e farr*fullv 
[watched and treated symptomatically. In nil cases, liowcfvrr 
Irugs should be u^ed sparingly^ and tlieir action sliovild, us u nili*, 
regarded as secondary to the general system of njaiui^cmfnt of 
the It is well to bear in mind strychnine, arsenic, iron, 
[uinine, cocoa, preparations of phosphorus, the hypophoMphitrH 
[and phosphoalbumin ; but never to use them in a careless and 
[routine manner. Alcoholic liquors in general are not iM'ncliriul, 
put a mild claret or Burgiindy, or some pale ale or l>eer, niay, Ht 
imes, chiefly at meals, he of bencKt if taken in limited (|uari(ity, 
le use of tobacco should l>e reduced to a minimum, and cij^an**)**' 
tmnking should be firmly interdicted. 
In some cases the bromiiles, cautiously adniinistenMl, hrivc ii 
fvery sedative effect. Much care should he exercised if a jvrepiu 
'ration of opium is useil, lest a^Idictitm tu the dru^ sfiould Im' in- 
duced. Antipyrin, phenaoetin, trional, and all heart-depressaiib 
should t>nly be employed at certain urgent timers. 

It is well to keep these patients at rest and to aim at tranf^uillky 
\oi life. As pointe<l out by Gray/ it is seldom necessary to piii 
ipatients to bed for three to six weeks, as was at first propu«Mf|. 
As a rule, it will suffice to keep them there ten or twelv*' 
^out of the twenty-four, and to have them avoid fatigui* wi»*fj 
Sexual neurasthenics brood over their trouble so rriu« 
alone, that it is well that they should have mentnl diii-r 
that one or two compatible and companionable pcopU 
'ith them. Bathing is (»f ruuch benefit, particularij 
ishore, but care shouhl be exerrised that the temi 
water be not too low or the immersion too much proh 
[ligain, fresh*water baths should not, as a rule, bi* 
ig the body and mild rubbing down with a rouipb i 

■ hoc cit 


beneficial. The faradic current (the slowly intomipted fonn) 
may produce good effects if administered in short daily vi 
Massage carefully administered for short periods once or twice x 
day usually leads to sedation, and, later on, inngoration ; hut it must 
be rcnienibered that in some cases patients are really made wone;| 
hence it is neeessaiy to use caution in this procedure. Changrof 
scene and of air is of the highest importance in these cases. Sw 
voyages, short or protracted, restful qiuet in the mountains or 
in some pleasant country place, and camping out, offer soui 
of much relief, and often lead to marvellous improvement. 

Very pronounced anivniic patients need cai^ful feeding wil 
niti"ogcnized matter in the form of raw beef cut tip finely or of w< 
mafle iK^ef-tea, together with (Uher proteid material, such asrgfp^J 
milk, cream, and lamb. In this connection it is weM to n?ii>PtD»] 
ber the marked value and usefulness of liquid }>eptonoid5 atKJ' 
of pano[)epton. 

The latest therapeutic noielties in neurasthenic cases aie tbcj 
glycerophosphates of soda and lime, and phosphagon, both 
which are highly spoken of by specialists in nervous diseasr^ 

It is well also to mention the latest addition to the animill 
products which are said to b<; of benefit in impotence and 5«iuil| 
neurasthenia, which is called orcbipin. Sciallero (Bi forma Mfdif^ 
February 4, 1 905) describes it as an extract of the fresh testicki 
of the bull and the ram, made by dissolving the testicular $>iiK| 
stance properly pi^parcd in olive oil. The testes are tnken onlj 
from animals that have passed an examination by vx^lerinirfj 
surgeons stationed at the slaughter house. The prepai 
occurs as a clear, oily fluid which is neither alkaline nor arid 
reaction, and dues not c^)ntaiu any precipitable albumins. It 
very rich in phosphonis and in lecithin. It can be given in hrp 
doses without producing any toxic effects. 



A NOT infrequent cause of ill-health and of well-marked neu- 
rasthenia, particularly in the male in youth and in middle age, 
but also in the female, is that unnatural method of coitus which 
among us is called conjugal onanism, or withdrawal, and by Ger- 
mans, coittis reservattis vel interruptus. This harmful practice is 
mostly followed by well-to-do, refined, and educated people, and 
there is medical evidence at hand to prove that it is a rather 
widely spread custom, both in the married and the unmarried. 

The main object of this mode of coitus is to prevent concep- 
tion, and beyond that there are many underlying reasons and 
purposes. In some cases it is done without the woman's consent, 
and she, in her simplicity, thinks the method is proper. Between 
some men and women the arrangement for this procedure is 
deliberately made, while in some cases the man wishes it, and in 
others it is followed at the woman's instigation. The underlying 
motives are various; the wife or husband may not desire children; 
the wife may fear that pregnancy will spoil her beauty or ruin 
her good figure, or she may wish to avoid conception in order 
that she may not be removed from society's pleasures and obliga- 
tions or from the various functions into which many women enter 
with much zeal and* enthusiasm, such as church and parochial 
duties, charitable objects, literary and scientific clubs, bicycle 
practice, etc. Then, again, painful and dangerous parturition, 
puerperal fever, puerperal eclampsia, post-partum dementia, and 
the ill-health of the wife are the reasons why pregnancy is often 
feared and unnaturally avoided; and, further, in illegitimate 
coitus the fear of conception causes the adoption of this procedure. 


which also may be followed for economical reasons. In inanyc^aei 
the absence of the fear of conception leads to too frequertt ooitu*. 

Most persons have no knowledge whatever of the hannfulnrs^ 
of this procedure. 

It would l>e rash to say that this had habit is invariably detri- 
nientul to Llie himlth of the man or the wcmian, since ihrre U 
uhniidant evident'e to prove that many men and women pmctiof 
withdrawal for long periods witliout any perceptible (ii^comfort or 
ivsultiti^ deterioration of tlie health. Indeed, there is the wiilest 
vuriatioii in the etFect^i of tlie habit. In some men it induces ill- 
health very promptly in a few months, or a year or more, whQe 
in others the practice may extend over several or many years befoir 
its l)aneful effects begin to show themselves. 

The resulting harmful effects of withdrawal may be summed up 
under the head of neurasthenia, which varies very much in severity 
aiiri duration in different case.s. A perusal of three of my «wr? 
will give a good general idea of the harmful results of this prattiiT. 

Case I. — ^A man, aged twenty-nine, of excellent physical ami 
nervous condition, and with no previous damage to his .sexunJ 
system, hati practise*! coitus reservatus with his wife for three 
yeaw. He then Ix'gan to lose flesli, and l>ecame pallid, sufferrd 
from mild dys|)epsia and constipation, and was restless, irritable, 
and de.sp*»ndent for trifling reasons. In this way he remained for 
ruiirly a year, tlie various symptoms gradually becoming moiv 
pronounced. A sea voyage, a sojourn in Switzeriand, and generul 
tonic treatment, togetlier with batlis and electricity, prtNlmrd 
.scarcely any benefit. In my examination of this man I leaniet! 
his sexual history. Under a general invigorating regimen, with 
the use of tonics and with sexual rest, he became perfectly w«li 
in about two montfi.s. 

Several years after he again fell into his bad habit, and experi- 
enced a mild relape of his former symptoms. This time he wis 
cured Ijy sexual rest and out-door life in the mountains. After 
lw>t.i sicknesses there was decided sexual im^xitence, which in e«cb, 
iiistanct* gradually ceased and left tlie uian in a perfectly 




Case 11. — A man, aged forty-two years, had in general enjoyed 
rgood healtli and was not in the rieiirt>imtliif. He had suf- 
[fered at puberty from [)olluttuns induced by uiasturlmtionj and 
['When thirty-two years old had sufTered from chronic posterior 
irethritis. When thirty-six years old he married a strongly builtj 
passionate young woman, and had with her practised witiidrawal 
for six years. About five years after the conunencetnent of tliis 
unnatural coitus he began to obsen'e that his health was breaking 
down, lie had l>een under the care of a nunil>er of physicians 
for about a year when he came to me. He then was thin, pallid, 
'and sallow, and had an anxious facies. He complained of a 
nuiltitude of ailments with incessant volubility. He slept badly, 
ha<l bad dreams (.sometinie.s erotic), awoke in the morning with a 
i\\\\{y heavy head, pain over the eyes, and nuidi vertigo. /Vs the 
day wore on tlieae symptoms became less uiarkeil. He was gen- 
erally depres.sed in mind, and .sometimes (leeiileilly nieiancholic. 
lli.s memory was ver^* defective, and so great was the phyisical 
and mental Inertia that he could not attend to business or iix his 
tnind for any length of time on a subject. There were general well- 
marked toqx>r of the stomach and intestines; fre«|uent urination, 
with pain in the pn>ytate at the end of the act; dee|>'Seated jjelvic 
pain, tenderness in the perineum, and a burning sensation at the 
anus were t!ie .symptoms referable to his .sexual apparatus. His 
erections were weak, his ejaculations were feeble, and after difficult 
defecation a mass of mucus and pus escaped from the urethra. 
Examination showed that the posterior urethra was chronically 
inflamed and ex(juisitely tender, and that his pnistate wa.s much 
swollen in all tangible directions, and very sensitive to sligiit 
presstjre, after which manipulation a worm-like plug of glairyt 
gray mucus escaped from the meatn.s. 

As a n.\sult of well-regulated sexual hygiene and local treatment 
to the pro.state ami posterior urethra this man's liealth ini[jnjved 
surprisingly* and he became ia a few months perfectly well in all 
respects. In this case tonics and sea bathing acted as valuable 
adjuvants to the treatment of what at the start seemed a very 
unpromising case. 


Case HI. — A man, aged thirty-two, of fairly good physical 
structure, but whose nervous system was never wgorous, had 
suffered in early years from pollutions following long-continued 
masturbation, wliich he began when twelve years old. He recov- 
ered from the morbid condition and remained in good general and 
sexual health for several years. When thirty years old he iudtilgcd 
freely in coitus reservatus with an amorous mistress. In about] 
a year he noticed that his health was impaired, and he songlitl 
relief in taking all kinds of tonies, with no perceptible eflfcct 
When he came to me he presented a sorry appearance. He was] 
pale, emaciated, and haggard, and his symptoms were legiuni 
Utter weakness, loss of sleep, mental depression, lack of memonrj 
gastrointestinal inertia, palpitations, and profuse sweating 
slight cause were the principal s^TUptoms. He complained biiteHj 
of great and paroxysmal oppression to his breath, with a di 
cough and vague ])ains in his lungs. He was very nervous 
the subject of an abiding unrest, lie had pains in his heat]. 
down the spine from the occiput to the sacrum, had a sense of 
constriction around the abdomen, painful spots over the tjioi 
and there was decided para^sthesia of the legs and forearms, 
several occasions he had had attacks of severe cardialgia, whi< 
caused him much anjdety. He had imagined that he was suffc 
iiig fmni pulmonary tuberculosis, or from incipient locomoi 
ataxia or paresis, and had consulted men experienced Ln li 
trouble.s, who found those organs healthy, and neurologists, 
said that he wa.s neurasthenic. Carefully directed treatment hi 
failed to give liim any relief. Tfie recital of tliis exuberaii 
symptom-complex convinced me that the man was sufferii 
from the effects of coitus reservatus. This suspicion was o 
firmed by the patient, after nmch fencing and hesitation, on 

Discontinuance of the bad habit, and the establishnienC 
proper sexual relation.s, together with change of air and fonkiy 
did much to improve this man at once. His convalescence, how- 
ever, was slow and sometimes halting, but to-day he is free from 
his symptoms and may be caUe<! a well man. Further transgrr^ 



sions, even for a limited time, would probably throw him back into 
his former condition. 

These cases give a t[uite clear idea of the average run of mild 
and severe forms of this morbid state which are not of very fre- 
quent occurrence. 

At the risk of some slight repetition of what has already been 
said in the chapter on Sexual Neurasthenia, owing to tlie great 
importance of clearly understan^ltng the effects of this bad habit, 
the category of its resulting morbid symptoms will be further 
dilated upon. 

As a rule* the onset of this trouble is slow and insidious with- 
out any dominating symptom or symptoms pointing to the origin 
of the tniuble. In the main, the early symptoms most commonly 
observed are weakness, more or less loss of flesh, and palh>r, 
nervousness, irritability, unrest, dyspepsia, and constipation, 
together with a dull, heavy sensation in the head, likened by many 
patients to the feelings experienced after alcoholic indulgence. 
These bad symptoms are worse in the morning, and in a measure 
wear off as the day progresses. In general the nervous debility 
anfi ill-humor increase, in.somnia be<'oines persistent, and the 
patient becomes irritable at the slightest cause, despondent, 
morose, melancholy, and even monomaniacab There are often 
observed failure of memory and such an apathetic condition of 
mind that the slightest exertion is shrunk frtmi. In most cases 
there is lack of sexual vigor, and there may be even decided im- 
potence. The performance of the sexual act is followed by much 
weakness and ner\ousness, together with a sleepy tendency instead 
of the normal \Hgor and alertness of mind. 

In some cases nocturnal erections, erotic dreams, and pollutions 
are observed, particularly in those whose sexual apparatus has 
been damaged by excessive coitus, masturbation, or gonorrha'a. 

The wearing-out of the ncn'ous system which obtains in these 
shows itself in a large numljer of morbid phenomena. In 
addition to the many head-syniptorns already mentioned, in vari- 
ous cases we find evidence of faulty innen^ation in the cardialgia, 
palpitations, and rapid and small pulse, wliich are so fivijuent; 


iti the shortness of breath and sense of siiffocatiou (the so-ctflctl 
asthma sexuale), which are such prominent but not common 
features; in the spinal pain, general or local (spinal irritationl 
in the painful spots and joints; in the numbne&s and the various 
panesthcsific; in the sense of txmstriction, resembling prdle-pain;) 
in the excessive sweating, U>cal or general, on ver\' slight e\cJ 
tiun; in the nervous contraction of tlie larynx and CKsophi 
and ill the ^'iieral gastroiiitestiiial inertia. The syniptonis irfei 
able to the sexual splierc may be slightly marked or obtnisivel] 
prominent; in mild cases, in which there has been no ppc^iot 
sexual disorder, there may be simply an uneasy sensation in tl 
penis — a feeling of moisture — together, perhaps, with relaxati< 
of the scnjtauu Neuralgia of the testes is not uncommon, 
the pain may be dull, heavy, or aching, or lancinating, or \lwtt 
may only be present a sense of distress and fulness in these glands. 

In one of Peyers^ cases the pain in the testis was so severe 
when it came on the man had to go to bed or lie down uo 
spot on which he stood when he was attacked. There is 
pain, deep and pircuniscriF>ed, in the pehns, in the groins, and 
the lumbar and sacral regions, which is more or less const 
In some cases aching and burning pains are experienced in 
perineum and anus. ITiere may also be increased frequencv 
urination, with pain in the act, especially at its end, and in 
glans penis. In some cases mild htematuria has been oliserved. 

In some cases there is a more or less constant state of erethism 
of tlie genitals, which has the effect of producing a desire for 
frequent coitus. 

In nearly all cases erections are less firm and enduring Uian in 
the normal state, ejaculations are less vigorous, the seminal fluid 
generally escaping in a feeble stream or by drops. 

The nuirbid effects of this unnatural moile of coitus pn>duce in i 
some women (but not in the majority) a condition of ill-health >&■ 
which general debility, ameinia, and neurasthenia are Uie cliirf 
features. As a nilc, women are not so profoundly affeeled as men 

■ Der Unvollstiindige Beischlaf, etc., 9(attgart, 1890. 

In young women of poor fibre and of neuropatliic tendency 
ithdravval in coitus and precipitate ejaculation on the part of 
leir male consorts sometimes give rise to distrcvssing heart-syinp- 
uns. The evil effect of the incompleted ^sexual act may show 
self simply in severe paIj>itation, which hcglns at once after the 
:t and ends in a few minutes or several hours afterward. As 
le case grows worse the irritaljility of the heart hecames more 
listressing and Is continually present. Then these women l>ecome 
lepressed and irritable and very emotional. They suIYer from 
leadaclie, indigestion, constipation, weakness, and vertrgtt, and 
rery frequently they have fainting spells. Though the pulse is 
reak, soft, and accelerated, and not infrequently intennittent and 
trhythniic, auscultation will reveal no structural lesion either in 
the heart or in the vessels. All these morbid phenomena quickly 
disappear when the bad habit is avoided and normal intercourse 
Is infhilged in. Tonics and good general hygiene are valuable 
adjuvants in the management of these cases. On this subject 
!isch/ of Prague, has recently published an interesting essay. 
A general consideration of what takes place in coitus rcservatus 
now necessarj' in order that we nuiy better understand the phys- 
ical and psychical damage wrought by this habit. The excitation 
>f both man and woman is in a great measure under restraint. 
riiat should be absolutely spontaneous and nnd'ananelled in llie 
'ay of desire and sensation becomes abnormal by reason of the 
lental process by which the act is interfered with at its most 
itical stage. On this point the words of EulenlKTg^ are really 
•aphic. He says: "The natural energetic sexual act experiences 
[>m the beginning an essentially artificial change. The attention 
lirected toward the postponement and prevention of the natural 
itra vaginal ejaculation infmducos an altogether hetenjgeneous 
irbitrar)' element in the process, which necessarily retards atul 



' Ilenbcfvhwerden der Fraiien verursacht (lurch den ('ohabitailoa-acL 

itnclien. med. WocheiiBchr., 1897, IJiind xtiv. p. 617. 

* Ueher CoiUw Refiervatus nls Ursac-he heximler NeiiraHthenia \)e\ Miinnern. 
Dteraat. Centrnlb). fur die PhvBiol. and Palh. der Hum und Sexusl-Orgaae, 
893, Hand iv. p. 3 et oerj. 




harms the proper working of the automatic reflex mechanism. 
The slower and less energetic friction, the weaker sexual feeUni;, 
and tjie less complete and sudden dissolution of the sexual ten- 
sion prevent the occurrence of such complete reaction as results 
from the natural ejaculation, by which, on account of the neces- 
sary energetic muscular action, a sudden emptying of the engorp^l 
bloodvessels of the genital apparatus results. 'The eentripctsl 
stimulus is set at naught, and through the disappearance of tiie 
central innervatiim the entire genital apparatus becomes suddenly^ 
and completely relaxed.'* In any case this act is most unsati*- ^ 
factory both to the man and the woman, neither of whom experi- 
ences the complacency of mind and the gratification which usuallv 
follow the proper perfonnance of the sexual function. 

It naturally follows from what has already been said that, in 
addition to the general condition of ill-health induced, ci«tu* 
iTservatus leads to more or less damage of the sexual apparatii5. 
Wlien a man has not previously suffered from chronic gonorrho** 
or from the effects of masturbation, this bad habit produces a low- 
grade of inflammation in the bulb of the urethra, in the posterior 
urethra, and in the prostatic follicles, and it may extend fartlicr 
and inv(tlve the ejaculatory ducts, the deferential ampullations 
and the seminal vesicles. In any case an irritable, flabby, and 
atonic condition is induced which is unfavorable to the proper 
l«'t'f(»rmance of coitu.s. When any of the above-mentioned parts 
lias previously been the seat of chronic gmiorrhceal iiiflamm»- 
tion, with its submucous infiltration and mucous membrua^ 
catarrhal condition^ an intensification of the process is naturaltv 

We have, theD, besides a damaged mind and body, a locnl and 
often deep-seated morbid state of the sexual apparatus. 

In funning an estimate of these cases it is necessarj* to tak< 
into consideration the general bodily and mental condition of lb* 
pmdent, the condition of the genital apparatus, and the halNt», 
obligations, and surroundings of tlie patient. Further, we must 
ascertain how long tlie habit has existed, and how frc<juently the 
sexual act has been performed. It is most important of all ti» 




determine the mental ralihre of the patient, whether he is of a 
neuropathic teiideticy, either aequired f>r hereditary. 

There eun be no doubt, as uiaintaiiied by Peyer, timt the results 
of coitus intemiptus are variable, and that very many practice it 
without experiencinfj bad re.sults. Some particularly stnm^ men 
(mentally and physically) can with impunity indulge in normal 
coitus once or more daily for many years; others reach their limit 
with one or two indulgences a week, and still others cannot attain 
that degree of frequency without suffering from bodily or menial 
fatigue. In some cases of coitus interruptus a strongs well- 
balanced nervous system is largely responsible for the immimity 
which so many men enjoy. In many cases worry, mental excite- 
nicnt, and various dyscrasia> arc factors in the general break-down 
of health. Ignorance of the baneful effects of this habit on the 
part of some patients, and feelings of modesty or shame in others, 
are the two principal causes of the difficulty of diagnosis of coitus 
reservatus. VMien, however, the attention of the pn^fession is 
prominently directed to llvis habit and its symptom-complex is 
generally understood, inquiries directed to its existence will be 
adopted, and ttie trutli will in all probability be revealed. Much 
difficulty is sometimes experienced in getting a true history fnun 
a patient, and the surgeon must exercise pnidence and tact, and 
he must call to his aid all his acumen. Parenthetically, I may 
remark that several patients have bitterly resented the mock, 
religious, and sentimental interrogatories and admonitions to 
which they had been subjected by some surgeons. Several patients 
have remarked to me that they have gone for medical and surgical 
aid, and not for platitudinous moralizing. 

There is one point which should always be borne in mind — 
ruunely, that most of these pntients suffer from some or many 
symptoms referable to the sexual apparatus, and that inquiry 
directed to these parts may reveal the existence of this bafl 
habit. Therefore, it is necessary to examine the morning urine for 
the presence of various tissue-elements, to carefully explore the 
urethra, especially it^ prostatic portion, and by digital examina- 
tion in the rectum to ascertain the condition of the prostate, and. 


if ponUey liiat of tbe deferential atnpullations and of the setmnal 

TytatiMlrt — In the mild form of ill-heajtb, simple discontinih 
ance of the habit may produce a prompt and encouraging effect, 
and general hygiene and tonics msj also be of veiy much benefit 

In ail cases, when necessary, proper and efficient treatment 
^KHild be directed to the undeiipng urethraJ or seminal lestoot 
wherever it may be. 

Rdaxation from business cares, rest^ and change of air an of 
much value. Tonics, nutiidous diet, carefully regulated, not 
ezcessivey muscular exercise (gymnastics, bicycle, golf, waUdqg^ 
etc.) should also be ordered &s the indications of the case msf 
prant Electricity in some cases produces good results. 

Whatever method of treatmeut is employed, it must be remem- 
bered that no benefit will result until the sexual life of the patient 
has been brought hack to its normal condition and un^l the mle^ 
rity of hb sexuaL apparatus has been restored. 



Whilk in the normal state erections last only a. short time, in 
certain morbid conditions they are, on the contrar}-, of pirjlonged 
duration, and constitute a condition to which the temi priapism is 

In cases of true priapism the erections are painful, persistent, 
and irreducible, and are unaccompanied by sexual desire. Much 
latitude has been ncrorded to the term priapism, since under it 
have been classed several orders of cases which really are only 

(instances of slightly prolonged and moderately painful erection, 
due to an obvious cause. 
Conforming lo usage, however, we may divide this affection 
into the following classes: 

K Priapism observed in infants and children, induced by reflex 
action In cases of long, tight, adherent prepuce, of stone in the 
bladder or prostatic urethra, and of worms in the rectum. 

2. Priapism in adult subjects, symptomatic of stone in the blad- 
der, stone in the prostatic urethra, stricture, cystitis, and obsen*ed 
during retentirin. In these cases the uneasy or painful sensation 
is felt in the glans penis, while the body of the organ usually is 
only moderately congested and sometimes curved downward or 
laterally. This conditiort disappears upon removal of the cause. 

3. Priapism symptomatic of gonorrhoea, with perhaps involve- 
ment of the corpus sfxmgiosum and downward curvature. Tliis 
condition is painful and transitorj', and may occur several times 

■during the night. In cases of doAvnward curvature of the penis, 
due to inflammatory engorgement of the corpus s|)ongiosura and 
Spasm of tlie musculature of the urethra, the term chordee is 


4. Priapism due to ingestion of cantharides, which is a fonn 
that is seldom or never seen now, since this drug is so ran-lv u^^A 
in medicine. 

5. Essential priapism. 

It is unnecessary here to consider tlie first four forras of so-ralletl 
priapism, as it is merely an intercurrent symptom, usually of .shurt 
duration, of well-known morbid or atmctural conditions, and, as a 
rule, is relieved hy operation or medical treatment. 

An attentive study of all rcptjrted cases, amplifiecl hy a coitsid- 
iTable personal experience, has conNinced me that we may diviik 
esaential pnapism into four varieties: 

1. Priapism caused hy iiijury to the spinal cord («*ither bi^^h 
nj> or low down), and hy blows or violence infllctetl upon tliei 

2. Priapism which is a symptom of cerebral or descendin 
spinal-cord disetise. 

3. Priapism which occurs after alcoholic and sexual ex< 

4. Priapism which attacks a person iu ill-health, in whom 
difficult to obtain data as to local injuiy and causation, and in whick' 
cases there is now a tendency to look upon leukaemia as the etio*j 
logical factor. 

Priapiflzn after Spinal Injury. 

in this form of priapism the traumatism has been found 
high up as the 'cervical and as low down as the lumbar and sacrti 
regions. When the injury is in the cenHcal region it u» probaKlei 
that irritation of the nerves which pass down the cord to the 
sexual centre is the cause of the trouble, and that the priapism 
is due to excitation communicated to the erigentes. \Mien the 
damage is inflicted low downi it is probable that the sexual petitrr 
is so irritated that it is thro\^^l into a state of chronic excitation, 
which shows itself in the engorgement of the penis. In these 
cases, as a rule, there is not great distention of the organ, nor are 
the attendant symptoms of a marked character. Such patients 
usually complain little of the condition of the penis^ and they 
have no sexual desire. 



Tlie course of these cases depends upon the extent and severity 
of the injury; in some the integrity of the parts is restored and 
the priapism ceases; in others death occurs sooner or later. 

Hunt* thinks that in the cases of traumatism of the spina] 
cohimn and cord in which priapism is a symptom there has been 
injnrj' to the sympathetic ganglia and nerves. He reports a case 
in which this lesion was found after death. 

Priapism in Cerebr&l and Descending Spinal Disease. 

The recordeil cases of this variety of priapism are very few, and 
in most neurological writings this symptom is not much dwelt 
upon. In a case reported by I^pros Clark' the patient, agetl thirty, 
had Jiuffered with heniicrauia, dnrinp^ the violence of which he had 
several attacks of He also liad pain in the lower part 
of the back, and in time became delirious, was attacked by epi- 
lepsy, became dull and stupid, and died in coma. After death 
the liver and spleen were found to Ijc cnlarjp^ed, and there was 
congestion of the base of the brain. It is unfortunate that a 
minute microscopic examination of the brain and cord was not 
nuwle in this case. 

In IlarwtKjdV case the man was twenty-eight years old, and 
was free from any disease. Following exjK)sure to cold lie had 
priapism and pains in his back, which gradually extended down 
his legs, lie then complained of pain in the perineum and of a 
sensation as if he had a belt around his body. He died of cere- 
bral symptoms, the priapism having lasted one hundred and six- 
teen days. 

In this class belongs a peculiarly interesting case reported by 
Dukeraan."* It was that of a man, aged thirty-five years, a fakir, 
who from early life had been a pronounced sexual per\'ert. He 
was ana-mic, seemed to be laboring under severe mental depres- 
sion, and practised hypnotism, in which art he was tolerably suc- 

* Medical Neim, Febniary aS, 1882, 

' St. Thomas' Hospiul Report^ 1887, N. S., vol. xri. p. 19 el seq. 
■ Interoftliooal Joarnal of Surgerjr, 1889, vol. ii. p. 7. 

* Pftcific Medical Journal, 1889, vol. xxxii. p. 480 et seq. 




cessful. No traces of spinal lesion could l)e found. For sevtinl 
years in Ihe attacks, varyinfr in fliiration lietween two and fite 
months, this man suffered from priapism. lie died of tutienni- 

J Iiave had two cases of spinal syphilis in which there w*rt^ 
inco-ordi nation of the movement of the legs, girdle pain, ar 
hyperesthesia of the integument of the abdomen and hack, il 
which mild priapism was a symptom, and which were cured bj 
antisypliilitic treatment. 

In the causes of locomotor ataxia and of sclerosis of the posti 
rior columns of the cord in which priapism is obser>-ed the snn| 
torn usually la-sts during the early or middle stages, and ceases 
the later jx^riods. 

Starr* reported the case nf an ill-<lcveloped male, aged tweiilj^J 
one years, who had lateral nirvatiire of the spine and meninRf>-j 
myelitis, who suffered from mild priapism for seven years. 


Priapism Due to Sexual and Alcoholic Excess. 

"^The greater number of cases of priapism may l>e denominai 
alcnliolic-erotic cases, since the trouble usually has its origin in « 
dniiiken sexual debauch. As a rule, the greater number of ihrpc 
who suffer from this form are yomig and vigorous men. althoujA 
medical annals show that men in middle and advancei] life fur- 
nish a moderate contingent. 

The mode «>f cmset of en)tic priapism diifers. In some e»sesj 
there is for a time increased fre<juency of erections, which mH 
premonitory and last a few or many minutes; in others, afier 
sexual ititereourse, the rigidity of the penis remains and becoro* 
|>ersistent; while in still others the patieivt, on awakening 
his debauch, finds that he is suffering from priapism. In 
cases, wlien the opportunity exists, these patients endoav 
relieve themselves by coitus, and they always fail. In excepdoi 
coses orgasm and emission, without pleasurable sensations, 
but, as a rule, there is no sexual desire, and ejaculation is not 

> New York Medical Journal, June 15, 1887, p. To 



duced. In fact, it is stated that in several cases the suffering of 
the patient was materially increased. 

During attacks of priapism the state of the penis has been 
found to present several variations in different In its most 
severe form the organ becomes much enlarged, tense, and com- 
parabie to cartilage in rigidity, and the seat of severe pain. The 
glans may be double in size^ much distended^ and glistening, as 
if it would burst. The corpora cavemasa are very dense and 
unyielding to pressure in their wliole length, including their 
crura. The corpus spongioisum is likewise hani and swolleuj 
and its btdbous expansion is in a similar condition. 

In some cases the perineal muscles can be felt as dense fibnnis 
bands, and the dorsal vein of the penis seems mucli distended anil 
feels like a whipcord. 

In many of these cases attentive examination reveals very pain- 
ful spots or perhaps nodules in the corpora cavernosa, parhVularly 
towani their root or in the crura. Then, again, digital pressure 
on the bulb and over the perineal muscles may cause an agony 
of pain. Spasm of the cremaster muscles may be present, and the 
testes then are drawn forcibly up to the internal ring. This 
symptom may be wanting. In some ca^ics there is pain in the 
lower part of the back and along the course of the sjwrmatic 
conls. Redness and swelling of the prepuce may be observed as 
complications. As a rule, the iixteguinent of the penis retains its 
normal color. In this pronounced condition the sulferings of the 
patient are very severe, and many authors apply the term atro- 
cious to the pain which is seated in the virile organ. The patients 
fear the least touch of their linen or of the bedclothes, and jarring 
of the bed or heavy steps in the room cause them agonizing suf- 
fering. They draw up their legs upon the abdomen, in order to 
protect the penis from the slightest touch. This organ may lie 
rigid against the abdomen, or it may he more or less erect and at a 
right angle with the body in the horizontal position. Very soon 
these patients become much worried and apprehensive, and their 
faces give evidence of anxiety and suffering. In these cases urina- 
tion may be accomplished either with little difficulty, or the act 


may be painful, slow, and halting, with a small, sputtering stream, 
or the patient may have to a^ssume the knee-elbow position in urdcr 
to expel the urine from the bladder. 

The atrociously painful symptoms are usually spasmodic in cliar- 
acter, hut the attacks may be very frequent and much prolong, 
in which event insomnia, ner\'ous exhaustion, and i^'nera] proslJ»*j 
tion supervene. In this way tlie man suffers from day to dar.i 
sometimes experiencing: very little amelioration of his condition 
for days or weeks. In many cfuses, however, there are intervals 
of coinpanilive frceelom from suffering, in which the hypenps- 
thesta and tui^dity of the oi^n are somewhat diminished and 
the pnlieiit may have some much-iieefled sleep. 

The duration of seven? priapism may be from two or three to 
six consecutive weeks, and even longer. In a liaspital case obsenTd 
by Birkett* it lasted five months. 

There is usually no fever, particularly in young, robust men, 
but in older subjectii ha\iiig leuka^nia or visceral leisions pyiexi* 
may he observed. 

In contrast to the foregoing veiy severe forms of priapism we 
observe cases in which tlie organ is less tense and disten^ied, and 
in which the mental and physical suffering is not very severf. 
In somewhat exceptional cases the patients suffer but litlJe pAiu, 
and t!ie discomfort experienced in the turgidity of the organ is 
tlie chief symptom. 

It is not the rule to find priapism Involving the corpora cavemnss 
and corpus sfHingioHum at the same time. Some cases ha\'e been 
<>l>served in wliicli the glans and the whole corpus Bpongiogum 
have been lax and extensile; others in which the turgescence of 
one cavernous body was very severe, while its mate was more 
supple, and otliers, again, in which tlie rigidity was unequally felt 
in the length of the corpora cavernosa. 

Wliile. as a rule, the invasion of this trouble is prompt, even 
sudden, and severe, its involution is always slow and often halt- 
ing, and attended with disheartening relapse. The first sign of 

L&Doet, 1867, voL i. p. 207. 



improvement is the diminished rigidity of the organ^ which soon 
becomes less painful, and thus the case progresses until the normal 
state is reached, hi that happy event the patient cannot be said 
to be entirely out of danger, for the reason that recurrences may 
foUow at short or long intervals, particularly if the patient is 
guilty of sexual or alcoholic indulgence or excess, is subjected to 
wet or cold, or is constrained to undergo severe bodily exertion. 

From the records of the various published cases, the inference 
seems to be warranted that in about one-half of the cases the 
patient is left impotent It would be unwise, however, to state 
this as a rule or law, since the publication of cases usually fol- 
lows quite promptly upon their occurrence. It may be that per- 
manent impotence is induced, or the condition may be of tempo- 
rary duration. In young and vigorous men it is to be presumed 
that their virility will later on be re-established. 

Xtioloffy. — While the etiology of this form of priapism cannot 
be clearly stated, certain suggestions may be made as to its causa- 
tion. In some cases there is strong evidence that damage has been 
done to the corpora cavernosa, particularly near their roots. Tliis 
is shown in the tender spots and the hard nodules left after invo- 
lution of the affection. Then, again, in some cases there is a 
probability of blood extravasation into the areola? of the cavernous 
tissue. Wliether or not in these alcoholic-erotic cases there has 
been irritation of the sexual centre and of the uervi erigentes, or 

I whether there has been injury to the sympathetic nerve, we cannot 
A numl>er of cases have been reported in which it was clear 
that priapism was caused by injury of tlie penis and [>erineum, 
notably that of Johnson Smith.* In all probability traumatism, 
though unrecogmzed, is the essential cause in all cases. 


Priapism of Leukseniic Origin (?) 

There is a class of cases of priapism in young men, but particu- 
larly in men of middle and ailvanced life, in which, during and 

Luoet, JuiM 7, 1873, p. 804. 


' New York Medical Journal, 1880, vol. xxxi. p. 463 H »*eq., And ibid., 
vol. xxxii. p. 272 H »«q. See also Klemme, Schmidt's Jahrbucher^ vol. ex 
p. ITS et«eq.; Edea, Boston Medical and Surgical Journal, Julj 27, It^Tl ; Loo 
guet, Progr^ Mt^dical, 1975, Tome ii. p. 447 ei seq. ; Maithiu, Atlg. med. CeSL- 
Ztg., 1876, Rand xW. p. 1185 et aeq.; Neidharl, ibid, 1876, Band xW. p. 681 
et acq.; Salzer, Berliner ktinischp Wochonachrirt, 1879, Hand xvi. p. 162 et teq.. 
and Wetherell, Medical Kecord, 1880, vol. xviii. p. 192. 


after a more or less prolonged period of ill-health, this symptom 

The clinical history of this form is similar to that already por- 
trayed, but in general there is an absenceof any data as to excesses 
of any kind. In this form we find cases with the pronounced 
agonizing group of symptoms and cases in which lesser degrees 
of priapism and suffering have been experienced. In these cases 
there is a hiRtr>ry either of neurasthenia, mental worry and depres- 
sion, or of ninlariul fever and leuk£eniia, sciatica, hemicrania, 
and numbness and cramps in the muscles. 

Owing ti> the fact that leuka^mic blood-changes and eular;gement 
of the liver and spleen have been obsen'ed in most of these cases, M 
some autliurs uiiliesilatingly accept leuksemia as the cause of th<? 
pna[Hsm, although Peabody,' who leans to this view, makes the 
guarded statement that "it may be regarded as an occasional 
symptom of leuoocythteraia" (leuknemia). While I am not pre- 
pared to deny that priapism may l>e etiologically related to leu- 
kaMnia, 1 am free to confess tlsat on the evidence thus far submitted 
this relation is in no manner made clear, and the suspicion foiws 
iLstdf upon one's mind that perhaps the occurrence was a coinci- 
dence. The trtjuble with the reported cases is that the antecedent 
history of the patient has not been thoroughly gone into. 

The facts have not been established that there has been no 
alcoholic or sexual indulgence, or in some cases that injury* Ur the 
penis has not occurred. Having the leukemic explanation in 
mind, this thought seems to have guided the various authors in 
their estimate and treatment of the case, and they have failed l<> 
pursue channels of investigation which might reveal some local 
injury to the sexual tract. Therefore, wliile I am not disposed 




deny that this morbid blood condition may partii-ipate in the 

development of this chronic turgescence of the penia, I liold to 

the opinion that this etiolog)' should not be fully awepteil, but 

lat injur}"^ in all casea should be pushed into the sexual ante- 

jdents of the patient, with a view of finding out whether there 

lad been sexual excess or wliether any part of the sexual sphere 

lad been damaged. lean hardly underst^ind why in some excep- 

[tional cases the genital centre and the nervi erigentes have been 

[thrown into a condition of severe and chronic excitation simply 

im general blood changes without there Ijeing some lesion of the 

parts under the control of or near to these nervous organs. 

K In general^ the facts concerning the troubles can he readily 

^'elicited from boys and young men, but middle-aged and old men 

are for various reasons less couiniunlcative as to their sexual habits 

and life. 

Prognoais. — Few definite statements can be made as to the 
prognosis of priapism of any form. In those cases in whicli injury 
to the corpora cavernosa or thnjmbosis can be made out, incisions 
may greatly expedite the cure. The existence of spinal disease 
necessitates a guarded prognosis. In very much nm-down neu- 
rasthenic subjects, in sexual perverts, and in those suffering frtnu 
leukaemia the chances are that the priapism will be very persistent, 
and when it disappears that it will be very liable to undergo 

Treatment.— In surveying the results of treatment of the^ cases 
of priapism already published one is forced to the opinion that 
notliing like a rtjutiiie int'thod can l>e laid down. Remedies 
which have produced more or less good in one man's hands have 
failed in those of another. This much, however, can be stated 
with emphasis: C^hlorofonn narcosis has failed in every case in 
which it has been used; ice usually does more harm than good; 
electricity has no value, am! may even be harmful; a)»d leeches, 

the number of sixteen and forty, have failed to produce any 
amelioration in the condition of the penis, and have been inju- 
rious in their depletory' effects. 

My own preference, after a review of this whole subject, is to 


392 se: 


resort early to moderate and tentative incisions into the most 
turgid part, or into parts the scat of continuous pain, or into 
nodular masses, in all probability the result of traumatism. Tlie 
parts should be carefully prepared for operation and thorough 
antisejvsis should he employed. With a clean, incised wound we 
need not have the scarring, nodulation, or loss of the tissues 
the cavernous bodies which almost always occurred in fo; 

Vorster^ reports a case in which, after priapism had 
various methods of treatment for thirty-two days, a cure followed 
four days after incision. 

In Booth's^ case, after six weeks of vain effort in relieving tb< 
patient, five-gram doses of the iodide of potassium four timrt 
a day gave inunediate relief and caused the disappearance of tbe 
priapism in two weeks. In Matthias* case a similar good result 
followed the use of this remedy, and in \V. H. TaylorV case cure 
was produced by the combination of a mercuric salt with iodide 
of potassium. My own opinion is that it is always good practice 
in priapism to use either the jwjtassium salt alone or in com- 
bination with menuiry when a history of antecedent or present 
syphilis ia elicited. 

Bromide of |>oULs.sium, chloral, belladonna, and morphine mar 
be of bejiefit» eHf)eL-ially during paroxysms; lupuline, camphor. 
and caiuiabis indica have been used with indilferent results, and 
the same may be said of ergot and strychnine. 

Of local applications, the fo]lo\\ing may be found to be lienefi- 
cial; hot baths, hot and cold spinal douches, sponging with very 
hot water, spinal cauterization, anodyne poultices (l>elladonna. 
stramonium, opium, hyoscyamus, and camphor), and perhaps, in 
some cases, ice-bags, btit the latter must be guardedly used. 

Any epliemeral or systemic disorder should receive appropriate 


1 DeuL Zlachr. fUr Chir., 1887-88, Band xxvii. p. ]7S et aeq. 

' Lanwl, 1887, vol. i. p. 978. 

* MaryUnd Medical Journal. 188^1884, vol. W. p. 854. 



In the wlioie field of medicine there is no more melancholy 
chapter to penise tlian that which treats of those degenerates who 
are victims of sexual perversion. This subject has of late been 
exploited ad nauseam^ and by reason of their pnirient details cer- 
tain psychological volumes on this morbid state iiave done much 
hann. I shall here only give a general outline of the various 
divisions of this subject. 


Sadism is the association of sexual lust with cnielty and vio- 
lence of varying degrees (biting, scratching, infliction of pain, 
inBiction of injury and wounds, and even death). The sadistic 
act is inflicted either during or after coitus, or with the \iew of 
stimulating the declining sexual power. Lust-murder, or anthro- 
pophagy, is the severest form of sadism, and its perpetrator may 
not only kill his victim, but also eat a part of her. In some indi- 
viduals the sadistic crime is the equivalent of coitus. In this 
revolting category are included the cases in which coitus is indulged 
in with corpses (which might also Ix^ more or lej>s mutilated), and 
those of men wlio can only have sexual intercourse when the live 
woman is laid out a.s a corpse with all funereal accessories. 

Tlie mildest form of sadism is that in which a man has an 
orgasm when he surreptitiously cuts the hair of young girls, which 
he keeps as a sexual fetish. Under this division may be included 
tlie cases of individuals who have orgasms when they whip boys 
on the naked nates or when tliey see cruelty Inflicted on animals. 

Sadism is very infrequently observed in women. 

In all probabihty vitriol-throwers are sadists. 



Masochism may be defined as tlie desire for abuse and humilia- 
tion as a means of sexual satisfaction. In cases of this form of 
perversion the individual seeks every opportunity to be beaten or 
injured by a woman. Such patients become sexually excited by 
any blow, or by direct injury, by flagellation, and by being trodden 
upon by women who have their shoes on. 

Fetich ism. 

Fetichism is the association of lust with the idea of certain 
portions of the female person, or with certain articles of femiaine 
attire, without which the performance of coitus is impossible. The 
inanimate sexual fetiches are handkerchiefs, shoes, stockings, 
gloves, l)eads, letters, locks of hair, articles of female underwear, 
and flowers belonging to some woman whom the pervert lows or 
has sexual passion for. 

The parts of the female bocly which have been selected as 
fetiches hy these perverts are tlie eyes, the hand, and the foot. 
In their tlioughts interest is concentrated on these parts, and not 
upon the geniiaiia. In some cases the fetich may be a cruss-c}vd 
woman or one with the amputated stump of one leg. Cases h*v« 
been reported in which meu were impotent unless the woman 
presented these abnormalities or defects. 

Mild cases of this form of trouble are really instances of psv- 
C'hical impotence. 

Hair-despoilers may be examples of the sadists and fetichisti 
combined, since in the act of cutting they have a sexual orgaira. 
and the stolen tresses afterward act as stimulants to sexual 

A mild form of fetichism is found in those individuals who are 
only sexually excited by a brunette and those to whom only « 
blonde is congenial. In this same category may be included di« 
cases of men whoj in order to become sexually excited, must sc< 



women dressed in a peculiar manner or have upon them some 
article which has taken their fancy (furs, velvet, silks, and 


Homosexuahty is that form of perversion in which t]ie sexual 
feehng for tlie opposite sex is diminished or absent, and in which 
sexual desire is centred on one of the same sex. Tlius men 
become enamored of certain men, and women of certain favored 
ones of their own sex. 


Urnings are certain homosexual individuals who have in their 
sexual life the same feelings as those experienced by normal sub- 
jects in heterosexual love. 

Krafft-Ebing says of these cases: "The uming loves and 
deifies the male object of his affection just as a man idealizes the 
woman he loves. He is capable of the greatest sacrifices for him, 
and experiences the pangs of tbe unfortunate, often unrequited 
love; suffers from the unfaithfulness of the In^loved object, and 
is subject to jealousy," etc. "Tlie attention of the male-loving 
man is given only to male dancers, actors, athletes, statues," etc. 

Effemination and Viraginity. 

Effemination and viraginity are forms of the perversiou known 
as urnings. In the male the subject likes to masquerade as a 
female. He seeks to make of himself by sweetness, sympathy, 
taste for cesthetics, etc., a fit mate for his homosexual lover. He 
endeavors to present a feminine appearance in gait, attitude, dress, 
and mode of speech. 

Tlie female uming in early life tries in every way to act as a 
boy, and avoiding girlish games and tastes, she adopts those of 
I boys. Later on she becomes mannish, and even amazonian in 
her manner. 

^The3e homasexual perverts practice all kinds of sexual de- 




Sodomy is a form of sexual perversion which is said to be mj 
frequent in most large cities. 

Many individuals who are persistenUy addicted to niastui 
are really mild sexual perverts, 


A mild form of sexual pen'ersiou is occasionally seen (mo3 
in neuropathies atid hysterical women) which is called exliibitio] 
ismus. Women addicted to this vice are prone to cause u] 
their breasts, abdomen (chiefly near the genitalia), buttocks, and^ 
tliighs, ulcers induced by severe caustic applications. They deny 
strenuously all self-niutilation, and for a time such cases may be j 
looked upon as feigned eruptions. A peculiarity of these patienl^l 
is tliat tliey like to submit to physical examination, particulaHy^ 
about the breasts and the genitals. Such patients ane, as a rule,j 
strongly given to erotic thoughts and very commonly are addici 
to systematic masturbation. A marked instance of this form 
sexual perversion has been reported by Engmann and Schwab.' 

Imporative Conceptions. 

This name is applied to a mental condition observed in per- 
verts and lunatics in which they entertain the most erratic and 
false ideas. ^_ 

Dr. H. T. Patrick* records nineteen cases of this obsession b^H 
a dominant morbid idea, and says that the treatment of iropen- 
tive conceptions, in the broadest sense, must embrace every means 
of breaking up a habit vicious and conHrmed. As in the case ol 
other bad habits, the same method is not applicable to every casr, 
and an intimate knowledge of malady and individual is an enoi 
mous advantage, indeed, generally a prerequisite of success. lol 
the great majority of cases a course of systematic education 

* A Studj of a L'W»e of Feigned Eruption. Medic&I Hcricw, St^L 2, 1899. 
' tlUnula .MediciJ Joutd&I, Norember, 1901. 




re-education based upon such knowledge constitutes the best 
treatnieiit. An imperative roneeption is neallv a mental tic — a 
mental halnt spa-sni — and as Brissand ha.s fniitu! that the t)est 
tlierapeusis of tic of muscles is careful, graduated, oft-repeated, 
and long-continued training of the indi\ndual in the suppression 
of ahnoniial movements, so the victim of an imperative concep- 
tion must l)e carefully taught to suppress his obtrusive idea and 
its results. The first step in this education should be an explana- 
tion to the patient of the nature and harmlessness of his affliction, 
for he is apt to be in dread of insanity, paralysis, death, or crime. 
NaturaPy, this explanation must be suited to the mental capacity, 
l>eliefs, and feelings of the person; but it must be plausible and 
encouniging, secure his confidence, and awaken his courage. 
ITie next step must be to teach him to be controlled by reason 
and judgment instead of by his feelings, emotions, and iniprps- 
sinns. These neurotics are much like chihlren and, like children, 
must be governed in different ways. Some can be reasoned with 
and by words made to see the folly of their ways: a positive state- 
ment is enough to arouse inhibition. Others can be led, yet others 
must l>e driven. Mere suggestion sometimes suffices, A process 
of pn)gressive demonstration is most frequently useful. Having 
to deal with an affection essentially mental, treatment must be 
aimed at mental processes. Bitter tonics, "reconstructives," and 
so-called nervines are ridiculous remedies except in a purely 
incidental way, and the same may be said of all assumed sources 
f "reflex irritation" unless it is considered wise to attack such 
eccant part for its purely suggestive effect. Treatment by sud- 
n compulsion is not successful and generally does harm. 



Much marital and domestic unh^>|Miie8S is often caused hj 
the non-occunenoe of impr^nation of the wife and the nssuHaat 
absence of children in the family. As a rule, in the eariy jeais of 
matrimony the want of chfldien on the part of the two conaoits ii 
not noticed, or, at least, is not keenly felt; but as years go by and no 
offspring appears, anxiety, discontent, unbappiness, and evm waaaj 
are experienced, and mutual recrimination may be indulged b. 

In former years sterility was incontinenfly laid to the put of 
the wife, but careful observations of late years have quite detiij 
proved that only in five cases out of sx is she the oonsort at fault 
lliis fact, that the husband may be the sterile partner in one-sixdi 
of all instances, therefore, puts him on trial as well as the wife. 
Therefore, before a married woman shall be suspected of being 
incapable of bearing children the husband and his semen must be 
carefully examined (vide swpra) and pronounced virile. 

Sterility is very common in the human race, and is the outcome 
or expression of many and varied morbid conditions. Tlie sexual 
apparatus of woman is very complicated, and anatomical study 
has shown that even in health its mechanism is not thorou^ly 
adequate for the harmonious functional activity between the Fal- 
lopian tubes and the ovaries. This point is often well iUustrated 
by cases in which the ovum does not fall into the tube, but bto 
the peritoneal cavity. 

It is stated on good authority that conception is most likely to 
occur a few days after the cessation of the menses, and tiiat it is 
not liable to occur just before their appearance; therefore, in seem- 
ingly healthy women who do not become impregnated it is wdl 
to ascertain the facts as to the time of coitus. 



It IS said in a general way that high conditions of civilization 
and hixiirioiis and indolent modes of life tend to cause sterility, 
hut l>efore we accept this unqualified and unsubstantiated state- 
ment it is well to ascertain whether, for obvious reasons, the^e 
married people do not shrink from the cares incident to parturi- 
tion and childhood, and whether they do not take measures to 
prevent pregnancy. 

The absence of sexual desire and feeling in some women has 
been urged by some authors as the cause of sterility; liut this 
contention is met with direct evidence wliich prf)ves that many 
women have borne children who never experienced sexual desire 
and to whom an orgasm was an unknown sensation. 

Though no direct pathological rca^son can Ik* as.signed for it. it 
seems to be established beyond doubt that prolongt^i intermarriage 
of blcx>d relatives tends in the end to produce at least a relative 
sterility, but it certainly does give rise to rather inferior grades 
of human offspring. 

Sufficient endence has been offered to prove that obesity, by 
reason of its accumulation of fat in and around the internal sexual 
apparatus of the woman, and its interference with its functional 
activity, is really an important factor in the establishment of ster- 
iKty in women. On this subject a very interesting paper has 
recently been published by Dr. J. V. Gaff.^ 

In anicmia, chlorosis, the adynamic conditions following grave 
diseases, and neurasthenia, temporar}' sterility may occur, which 
is due, in all probability, to the lowered functional activity of the 

Syphilis in women frequent abortions, and in some of 
these cases sterility occurs; but we are not yet in the necessary 
scientific position to account for these pathological results. 

The sterility so commonly observed in prostitutes is, as a rule, 
due to chnniic intlanunation of the uterus, of the tul»es, and of 
the ovaries. In this connection it is well to remember that gonor- 
rhoea is a potent and frequent factor in the production of uterine 

* Journal of the Americao Medical ANsoctation^ January 23, 1807. 



y«Ktc inflammation. Parturition is freqiicntlj the starting 
of these diseased conditions, which are not infrequentiv 
bv careless and meddlesome surgeons. 

b 4ie case of tlie absence of the oyanes, of t}ie Fallopian tubes, 
«r of the uterus, sterility is always found. 

Chrome oophoritis is a frequent cause of the suppression or 
llwilTiii tinii of the ovulci while in perior>phoritis tlie theca of the 
%yrTkr\ becomes so thickened that injurious pressure is exerted on the 
wcreting portion of the organ. In either event sterility is produced. 

TTie mechanical adjustment of the ovary to the fimbriatMi 
exttrniity of the Fallopian tulws may be impaiped or destroved by 
fibnnis bands left by peritonitis, an<i in this event the ovule can- 
iH>t escaj>e into the uterus, nor can spermatozoa find their way to 
the ovule, consequently fecundation is impossible. 

Ovarian cysts anrl various neoplasms may so destroy or distort 
the tissues of the ovary that it can no longer produce ovules. 

Salpingitis is a verj' frequent cause of sterility. In the catarrlisl 
%"ariety, with its hj'perajmic mucous membrane and tJie continual 
escujH* of mucopus into the uterus, the mechanical conditions air 
such (hat the irmption of spermatozoa into the uterus and lube» 
is itMidered impressible; therefore impregnation cannot occur. 

In hydrosalpingitis and pyosalpingitis an insurmountable b&r- 
riiT to tlie upward migration of spermatozoa is formed by tlie 
o»llrction of water and pus, and, as in these cases the ovaries anr 
usuallv diseased, it follows that a woman thus afflicted is irrenie- 
di«bly sterile. Chronic interstitial salpingitis results in atrophy 
Rnd stenosis of the tul)ei*, which are then no longer permeable. 

Atresia of the uterus, congenital or acquired, renders impir^ 
n«tion impossible. 

Atresia of the cervix uteri, caused by overcuretting, canstics, 
syphilitic and chancroidal ulcers, and syphilitic cell-infiltration 
olTerH a barrier which spermatozoa cannot overcome. In like 
manner, the plug of dense tenacious mucus which fonns in inflAm- 
nmtion of the uterine neck may act as a net which entangles the 
MX'nnatozoa. Ulceration of the cervix with inflammatorj' hypei 
plHJiia of the parts frequently renders a woman sterile. 




In catarrhal eiKlonietritis and endocervicitis the mucous nieni- 
brane is so altered that the necessar)' conditions for the fecunda- 
tion of the ovum are absent. In these conditions the profuse 
downward flow of pus both kills and washes away spennatozoa, 
and tiius prevent:? conception. 

Fissures of the uterine neck frequency react so seriously on 
the condition of the uterus that it is rendered unfit for the func- 
tion of conception. 

Hypertrnphy of the cer\'ix uteri, tojE^etlier with infiltrative 
h}'perpla.sia, simplex or specific, and elongation and coiiicity of 
the segment, in which stenosis of the cervical canal is a frt?(|uent 
concomitant, is a verj' common cause of sterility. Mali^iant and 
simple tumors of the uterus act as efficient barriers to conception. 

In superinvolutioa, inversion, and prolapse of the uterus such 
abnormal conditions of structure and position exist that impreg- 
nation is rendered impossibit 

In the rudimentary and undevelopeti uterus impregnation is 

In anteflexion and retroflexion of the utenis such distortioji of 
the lumen of the organ is produced that a barrier to the upward 
invasion of the spermatozoa is formed. 

Anteversion and retroversion of the uterus so throw the organ 
■out of position that a purely mechanical impediment is offered (o 
fhe ef[V)r1,s of sprnnatozoa to reach the interior of the organ. 

Ruptured perineum may cause so much disturbance in the sexual 
part8 of women that impregnation is prevented. 

Absence, atresia, }>rolapse, and cicatricial stenosis of the vagina 
prevent intromLssitm of the |>enis, and it follows that impregna- 
tion cannot l>e effected. In some cases in which the vagina is 
very short the semen is lost and fecundation does not occur. Tlie 
same accident is liable to happen to a woman with a very capacious 
vagina, in which all the parts are flabby an<l relaxed. 

In purulent vaginitis the zoosperms may be killed by the secre- 
tion or carrietl out of the paths of fecundation by it. 

In small and imperforate hymen such a barrier may exist that 
irapregnatioD is prevented. 


Uterine fibnnds may so distort the oigan or cause sadi dis- 
placement that spermatozoa cannot find a habitat in the cavitjr. 

It is onlj intended in this duqpter to pve a general outfine of 
the causes and conditions whidi produce sterility in women, wfaidi 
may form a basis for study and ofaserration. To give full tmt- 
ment of the various morbid OHiditions already mentioned would 
require a veiy large volume; therefore, for further details it is 
better for ihe reader to be referred to the various autikoritalive 
text-books on gynecology. 



AQINISMUS may he liefinecl iw an "ext'e.ssive liypenestliesiii of 
the liymeii and vulva, jitteniJed with such iiiVDhjntary spasmodic 
conlnit'tion of the ,s|>hiucter va^'inio as to preveiit otntuii." It is 
a somewhat rare affection, and is found in varying degrees of in- 
tensity in women from eighteen to forty years of age and beyond 
that period. 

The mildest cases of vaginismus are seen in young newly mar- 
ried women, particularly those of a nervous or hysterical nature, 
iij whom no vulvar or vaginal trouble can be found. In some of 
these cases on attempted intromission of the penis some pain is 
produced, which causes the woman to cry out in agony and the 
sexual purls to become the seat of uifirt* or ies.s spasm (sphincter 
vaginie, sphincter ani^ and levator ani). In some instances, owing 
to the self-abnegation and fortitude of the wife, the painful intro- 
mission of the penis is borne, and then after a few or many (rials 
the parts become so dilated that pain ceiuses and coitus can be 
normally indiilgeil in. Iti other cases only imperfect coitus is 
effected, on account of the bniising and perhaps laceration of the 
hymen which has taken place at the first attenij)!. In these cases 
the thought of sexual intercourse throws them into a condition of 
nervous dread and sometimes hysteria. 

It occasionally hap[)cns that in women who have had connec- 
tion for years, and even in those who have borne children ^ a fissure 
or fissures of the vaginal oriJice may give rise to well-marked 
vaginisums. In some of these cases the parts aw so sensitive 
that the least toncli by a finger-tip, a probe, or a feather causes 
involuntary contraction and of the vaginal outlet. 

Cases have been reported in wliich fissure of the anus has led 



to well-markpd vaginismus, in which coitus was rendered utierlj 
i nip rarti cable. 

Mikl and severe vaigjinisiuus is seen in young women in whom 
the free surface uf the liyinen is thickened in its whole extent, or^ 
in the form of small or large caruncles. Examination of the 
genital parts in these coses may reveal no abnorniality whatever 
in the tissue; but in some cases the little growtlis have a whitish- 
pink color, and in others they are decidedly red and inflamed, and] 
the contiguous parts of the hymen are in the same condition 
active hy]>erplasia. In some of these cases sexual intercourse! 
is patiently borne by (he woman, and the vaginismus gradually 
ceases; but in others the act causes agony and terror, and woi 
utterly refuse to thus submit themselves. 

There is a form of modified vaginismus somewhat early seen 
in young women who masturbate excessively and who use varioi 
rigid instruments to titillate the vagina and produce orgasm, 
a result of tliese practices the vaginal orifice or the hymeneal 
fringe becomes the seat of liyj>eq)hisia in a noiiulnr or annular fonii 
and great sensitiveness of the parts, with spasm and sometimes < 
pain, is producetl. In these cases very freciuently hysteria is * 
prominent symptom. 

Inveterate and exaggerated examples of vaginismus are» bap-* 
pily, rather rare. They are usually found in married women who 
ill the early months of marriage have suffered fn>m bruising or 
painful tears on attempted, but not successful, sexual iutercouj 
which has produced pain and spasm. 

Some of these women still retain their virginity; others 
more or less damaged and torn hymen or vulva*; but in none bff' 
true intercourse been practised and perfect intromission accom- 
plished. In some of these cases as many as twenty years eUp«d 
sinc^e the attempted coitus, and in others the period was shorter 

In these exaggerated ctises the whole morale of the patient miy 
be destroyed, and they become practically bed-ridden. Tlie late 
Dr. Marion Sims* has left a very graphic description of a typi- 

' Clinical NqIw on L*t«rine iiurger^r, ^ew York, 1873, p. 321 et wq. 





caily bad case of vaginismus. In a general way the facts are as 
follows: llie woman's nervous system was in a deplorable con- 
dition. She was exceedingly impressionable, the slightest noise 
being intensely disagreeable. She was able only to walk across 
her room, but did not often venture on this experinient, Ijeing 
confined most of the time to her cniich, where she ^avc herself 
up to uncejising intellectual effort. A vaginal examination was 
attempted, but failed completely. Tlie slightest touch of the 
mouth of the vagina produced intense suffering, throwing her 
nervous system into great commotion; there was general muscular 
agitation; her whole frame shivered as if with the rigors of chills 
and fever; she shrieked and sobbed aloud; her eyes glared wildly; 
tears rolle<l down her cheeks, and she presented altogether the 
most pitiable appearance of terror and agony. The woman had 
the moral fortitude to ask to have the examination of the parts 
made most thoroughly. Sims further says that after "pressing 
with all his strength for some moments he succeeded in intro- 
ducing tlie index finger into the vagina up to the second joint, but 
no farther. The resistance to its passage was so great and the 
vaginal contraction so firm as to deaden the sensation of the Hnger, 
and thu.s the examination revealed only an insuperable spasm of 
the sphincter vaginjv. The woman was etherised, and when nar- 
cosis was complete tlie mouth of the vagina became completely 
relaxed and the vagina itself seemed perfectly normal." 

In contradistinction to the foregoing form of vaginismus, sev- 
eral cases are on record in which spasm of the vagina occurred 
an inch or more within tliat canal. In these cases there may be 
such severe spasm that full insertion of the penis is impossible 
and the vagina l>ecomes a mere cul-de-sac. In some cases perfect 
intromission was at first possible, but during coitus such pro- 
nounced spasm of the levator ani occurred that the withdrawal 
of the penis was impossible until the spasm ceased — a condition 
called penis capthnis. Tliis condition has been described by 
several of the old authors — namely, Diemerbroc (1687), Riolan 
(16r)7), and by Schurigius (1729), who wrote upon it in his essay 

e CohcEsimie in Coitu. 


A nroiArkable case of this very rare form of vaginismus wtt 
■pOftsd by Dr. Egerton F, Davis,* who gave the following hcis: 
^MRktfB in practice at Peutonville, EiijE^and, I was sent for, about 
II rjl.. bv a gentleman whom, on my arriving at his house, I 
tmmA in a state of great perturbation, antl the stoiy he told nm 
»»$, biiefiy, as follows: 

"At bedtime, when g(»itig to the back kitchen to see if the house 
«:»s iihut up, a noise in the coachman's room attracted his atten- 
tMB. and, going in, he discovered to his horror that the man was 
in bed with one of the maids. She screamed, he struggled, and 
they rolled out of bed together and made frantic efforts ti> get 
apart, but without success. He was a big, burly man, over six 
fret, and she was a small woman, weighing not more than ninelv 
pounds. Siie was moaning and screaming and seemed in great 
agony, so that after several fruitless attempts to get them apart 
be ?eni for me. AMien I arrived I found the man standing up 
and supporting the woman in his arms, and it was (]uite e^-ident 
that his penis was tightly locked in her vagina, and any attempt 
to dislodge it was accompanied by much pain on the part of both. 
It was, indeed, a case ' J)e cohfcsione in coitu.' I applied water, 
antl then ice, but iuetiectiially, and at last sent for chloroform, » 
icvk whitfs of which sent the woman to sleep, relaxed the spasm, 
and lelieveil the captive penis, which was swollen, li\-id, and in a 
fttate of semierection, which ijid not go down for several hours, 
and for dax's the organ was extremely sore. The woman Pi*tw- 
numity and seemed none tlie worse. 
1 am 9orry that I did not examine if the sphincter ani wm 
but I did not think uf it. In this ease then? mast 
abo spasni of the muscle at the orifice as well as higiier 
iiff^ penis seemed nipped low down, and tliis contraction, 
l^t the blood retained ixnt] the organ erect. As an iii- 
^ Ji^ii's *\ienst with two hiuks' the picture was perfect. 
mndered how it was, considering with what agili^ 
»T certain circumstances, jump up. that Phineas. 



' Mcaicftl News, December 14, 1881 



the son of Eleazar. was able to tlinist his javelin t]irouo;h tlie man 
and the Midiaiiitish woman (rnde Exodus); but the occurrence of 
such cases as the above may offer a possible explanation." 
H A somewhat different case was reported by Hildebrandt' and 
entitled Spa^^m of Levator Ani dnrinff CoiUu^. The husband was 

PI a man of mature age but ver^- vigorous and passionate. His wife 
was young, excitable, and probably erotic. They had been mar- 
ried a year. The woman had suffered from uterine affectit>ns 
I since girlhood, but there wa.s no interference with coitus, which 
was nlway.s painlcHs. She appearecJ to l)e getting more nervous and 
hy.steriral as time went on, and was in the midst of treatment 
with sounds, tampons, etc., for her uterine tnHil>les. At this 
time, the patient l>eing highly nervous, (roitus, otherwise normal, 
ended witli inability of the husband to withdraw his penis. At- 
tempts at extraction were very painful to both parties, who were 
obliged to wait an iiHlefitnte j>enod after which tlie penis could 
he withdrawn. Examinatioji of tlie woman showed nothing 
B abnormal l>eyond moderate anteflexion of a hypertrophied uterus. 
The conditioti wa.s looked upon as vaginismus, affecting e.spe- 

Icially the levator ani muscle. 
In his treatise Scanzoni reports the case of a wtmian , married 
one and a half years. Her husband ha<l for a long time l>een 
compellerl to desist from coitus, l>ecause at each attempt his wife 
not only suffered greatly from vaginismus, but he liiniself was 
often held captive by the action of the cotisiruior cunni — for more 
than ten minutes on many occiLsinns. 

I Treatment, — It is gratifying to be able to slate that in most 
cases of vaginismus a prompt cure niay !«* proiluivd. In the 
milder class of cases, in which intnimission of the penis is im- 
possible by reason of the pain iluring the attempts at coitus and 
•the fear and nervous dread whicli results from these conditi(ms, 
it is best to follow the procedure employed by Sims — namely, to 
place the wonmn under an antesthetic an<l then allow the huslMind 
in have intercourse with her. Usuallv this is the end nf the 

> Aroh. r. Gyoaknl.. 1872, iii. 221. 


ti\>iiMe of tliese miicli worried consorts. Furtlier treatment, how- 
ever, may l>e uofessaryj owing to teiiJeniess of the parts and the 
uUiflin^^ fear of the woman. It is well, then, to use frequent ami 
copious vaginal irrigation of hot lead -water and to gradually and 
cautiously dilate the vagina, either with a hirge-size Ferguson's 
cylindrical speculum or by dilators of varying sizes, made for the 
purpovse, of glass. In these manipulations solutions of cocaine, 
cucaine, or adrenalin chloride may be used to produce moderate 
aiin^sthesia, or suppositories of orthoform may W employed (cocoa- 
hiilter and white wax with lU per cent, of orthoform). 

Should any painful spot or tab of hymen be felt which seems 
to cause the vaginismus^ it should he fully excised. 

{^Lses of painful vaginal canjncles should l»e promptly and ener- 
getically treated iiy a lil>eral excision of tlie parts under strict 
antisepsis. In all these cases it may be well to follow the opera- 
ti»)ii by carefully graduated tlilatation of the vaginal orifice and 
canal. In some cases the use of absorljent cotton tampons is 

The h\7>erirsthesia of the hymen or vaginal orifice caused by 
masturbation may be cured by exsection of the nodules and h>'peT- 
phustic fringes of the intniitus vagina*. 

Too much stress cannot be laid on the ini|)ortance and the 
ncifssity for energetic surgical treatment in the cases of invet- 
erate vaginismus. The topography of the vaginal outlet sliould 
be ottivfully studied, and then radical exsection should be per- 
formed. The patient being anaesthetized and the external genitals 
having been maile surgically clean, all the free parts of the ostium 
vtiginu', hynuMU'ii! orifice, fissure*! hymen, nodular canmcles, and 
niuoons membrane tabs should (>e cut away well down to the 
uuirgi»» of llic orifice. It may also be necessary to make deep 
lulerul inc sitms into the bulbocavernous muscles. The parts 
tUftV then Im? freijuently irrigated with plenty of hot bichloride 
solution (1 : 5(KX) or 1 : 2000), and, if necessary, for a time a cocainf 
MUpp<»Hitorv may l>e introduced. It is most important that sy»- 
tcnuUic gradual dilatation should Ite kept up until all soreness 
and trndemevss of the parts have passed away. For this puipodN* 



the trivalve, quadrivalve speculum or Ferguson's speculum, or 
glass dilators may be employed. 

In cases of what is known as superior vaginismus, in which 
there is spasm of the levator ani muscle and impediment to coitus, 
the woman should be thoroughly and antiseptically douched and 
then placed under ether. Then deep lateral incisions down into 
the muscle into the parts which were found to be the seat of stric- 
ture should be practised. After the operation dilatation by specula 
or antiseptic tampons should be systematically employed. 



TfiotTGH it is difficult to get at sc'entific testiinooT as to tbr 
prevalence of masturbation in female children azMi young women, 
the Ntatement seems to be warranted that this habit is not so frr- 
jjuent and widespread as in the male sex, and that in general do 
great harm is done to tlie system by the habit 

M&sturbation is sometimes seen in infants and youug cWIdren. 
both in those who come from healthy parents and in those who 
liave a greater or less neuropathic tendency. 

Masturliation in very young infants sometimes occurs, and 
unleM the physician is thoroughly skilled in pediatrics tlie pb*^ 
nomeiia prwluced by the bad habit may not be understood bv 
tlie attendant. For that reason I here transcril>e the catefullv 
prepared description of a case which is graphically describe*! hv 
iin accomplished ol>server: 

'"llie first indications of nervous trouble were noticed wiiiMi 
the child waM fourteen months old. 'lliey were veiy* slight and 
occurred when the child was lying in its mother's lap. J?3»c sud- 
denly Jiecamc pale, had a peculiar dazed expression, and her attpu- 
tion could not readily lx» attracted. On being raised up and moved 
.mIic iiriiucdiiitely l>ecame natural in looks and artion. This w*?* 
repeated a few times only, when the attacks clmnged in character. 
In u<ldition to tlie ai>|>eHniiu*e uf (lie countenance already de.M'riW 
there was much luuscidar rigidity; the amLS became ijuite stiff 
and strongly resisted Ijciiig flexed, and the hands were clenched 
and the little fist-s finnly pressed into the iliac region on either 
side. At the same time the legs were strongly extende<i at right 
angles to the bmly, an*I there was a strong contniction of the 
alKloininal muscles, and a straining as if at stool. If the child 




was held against one's breast she made strong pressure with the 
knees, and np-and-down movements of the l>o<Iy. After a short 
period — a moment or two— the respirations were quickened to a 
rapid panting, and |>erspiration started freely from the head and 
stoo*l in drops about the mouth. 11]e attacks often tenninated in 
sleep. There was at no time any spasmodic or convulsive move- 
ment, or unconsciousness, or mental distuilmiitv Ik^yoiid an upjmr- 
ent abstraction. 

"Tlie attacks came on irregularly; at times with intervals of 
some days, and, a^^aiii, they were repeatetl many times a day for 
several days in succession, and sometimes for two or tliree hours 
with but s 'ght interm'ssion. They never came on during sleep, 
but usually when the chih! was sitting on the lap, and occasion- 
ally wIkmi on the l>ed or floor. If she was placed on the floor 
early in the attack, and amused with her playthings, it would 
frequcndy l>e broken up; if, however, she was held until it was 
fully developed and then put down she would lie upon her side, 
and the attac*k would progress as described." 

It was further noted in these eases that the little girls were apt 
to kej'p their thighs closely joined, tn cn)ss their legs, and to ruli 
the limbs Aioleiitly, sometimes until they became pnq>le in the 



In some of these young subjects such nerx'ous phenomena as 
epilepsy, Saint Vitus' dance, idiocy, and stupidity have been 
observed . 

Several authors divide the subject of mastvirbatiori in women 
as follows; vaginal masturbation and clitoridean nuisturfiatton. 
In most cases the \ncious practice is performed by the girl or 
woman herself, but exceptionally a male or female confederate 
commits the act on the woman. 

Vaginal masturbation is mostly accomplished by manipulation 
by means of candles and in(»re or less rigi*! instruments nitide to 
resemble the penis. This form of vice is usually solitary. 

Clitoridean masturbation is said to l)e fretpiently performed by 
a second person, male or female, and consists in friction on the 
surface of tlie prepuce of the clitoris or upon the glans. 


In some rare cases masturbation is perfonucd by means of 
peculiar manipulations of the face. 

A is reported of a young woman of twenty-two, of bad 
family antecedents, who had been attacked with psychopatliic 
symptoms coincident witli menstrual derangement, and for some 
time had been in an asylum. The patient manifested choreic 
movements of the han<Ls, sometimes of one hand, at other times 
of both, terminating by curious manipulations of portions of Ibe 
face. Tlie doi*sum of tlie tliumb was placed in the centre of tlie 
clieekj tlien with tlie middle finger pressure was made alternately 
on the tip of the nose and the tragus of the ear. After manipu- 
lating a few times in this way the patient "would fold her hands 
in her lap with a far-away, pleased expression on her face, lasting 
some ^xe minutes." A thorough investigation elicited the fad 
thnt the patient could produce sexual excitement and satisfaction 
by the manipulations before referred to. She did not seem to 
have any idea of wrong-doing, but was ashamed and surprised 
when the nature of her act was explained to her. This case calls 
jitti*ntion to a possible explanation of many otherwise baffling 
practices on the part of young children, and should keep the 
practitioner ever on his guard in anomalous cases for possibly 
hitherto unsuspected methods of inducing sexual erethism. 

By consulting many atithorities we learn various facts as In Uie 
causes which lead to miisturbati<*t] in the female, a general summan* 
of which will now be given. In many cases the natural passion- 
ateness of the girl or woman leads to the performance of the act. 

In many cases the too rapid completion of the sexual act in 
the man leaves the woman unsatisfied, and .she as a result prtK 
duces the orgasm upon herself at the first opportunity. 

A veiy common cause of masturbation in girls and women L* 
due to lack of care and cleanliness of the genital origans, which 
as a result become irritated and are then scratched or rubbed. In 
this process pleasurable sensations are produced and the onanisdc 
habit is fonned. 

F^zema, psoriasis, dermatitis, and pruritus of the female grtii* 
tals are often the exciting cause of the vice. 




Many cases are on record in which coitus has been painful to 
women by reason of some structural peculiarity of the extenial 
genitals, such as small vaginal orifice, shortness of vagina, fissures 
or tabs of the orifice, or of ruptured hjmen, perineal fissure, and 
partial prolapse of the uterus, and as a result they have resorted 
to masturbation in place of sexual contact. 

Several authors, particularly Frenchmen, make the statement 
that various spices, cloves, cinnamon, pepper, mustard, etc., may 
lead to niB-sturbation in the female, ami that certain odors of prr- 
funie, such as musk anr! piitchouli, cause in them erotic dcsin*. 
Cantharides, phosphorus, and absinthe are generally regarded as 
BphnKlisiac stimulants. It is generally well known that high 
living and alcoholic leverages act as sexual stimulants to women, 
and may lead to masturbation. 

Constipation, by its mechanical congestion of the pelvic organs, 
is said to praduce sexual desire and lead to masturbation in 
children and young women, and pin-worms and round-worms 
in the rectum very often cause the same train of morbid condi- 

Vaginal discharges of all kinds cause genital irritation and are 
frequently the starting point of tbe onanistic habit. 

As a result of certain exercises in the gymnasium, horseback 
riding, long-continued use of the sewing-machine, and bicycling, 
pelvic congestion and genital irritations are produwd wliich lead 
to masturbation. A sedentary life and Ion g-c-on tinned sitting may 
produce the same result. 

The close herding of the sexes and the sleeping together of chil- 
dren and girls with older people are fi^fjuently the cause of sexual 
vice and masturbation. 

Many women, young and old, become the victims of onanism 
as a result of the insjjection of lewd pictures and nude statues, 
by reading obscene books, and by immoral conversation and 

The bad example set by one or more girls in a boarding-school, 

in a reformatory, or in an asylum very tjften leads to an epidemic 

f masturbation in which all the inmates become vitiated. Many 


cases are on record in which female servants and nurses have 
taught tna-sdirhation to the young girls under their t-are. 

Sexual coldness of the husband, personal indifference, imj^t- 
tence, and senility frequently lead to masturbation in young and 
passionat*' wouieii. Then^ a-K^ioj ^vidowhood^ the long al>sence or 
pt-rhaps illness of the husbami, may cause them to produce orgasms 
upon themselves. French authors have prominently mentioned 
obesity in the woman as being a sufficiently frequent cause of 
masturbation. In these cases, for physical reasons, coitus is ren- 
dered difficult or even impossible, and the woman resorts lo 
onanism or seeks others to perform the act for her. 

Und*uibtcdly tlie condition of the clitoris has much to do wilh 
the production of masturbation in women. It seems to be prett}- 
conclusively proved that shortness of the clitoris may lead to 
imperfect sexual connection by reason of the part not being 
tnuchod and titillated in the sexual act by the j)enis of the male 
consort, hence no gratification occurs in the woman, and she. 
being then excited and aggravated, has to resort to clitoridean 
manipulation to produce an orgasm. 

In stHne women the clitoris is highly placed well above the 
upper margin of the vaginal orifice, and in coitus it wholly escafifs 
friction from the penis, and as a result there b no orgasm. Such 
women are pnme to produce orgasms upon themselves. 

Adhesions of the glans of the clitoris to its prepuce, partial or 
conipk'te, are said to lie very common, and when i»resent tbcjr 
may cause much disturbance. In the Hrst place, it may be to 
bound down or lifted up that in sexual contact no titillation i** 
produced l>y the intronn'tting penis, and as a result the woman 
has no orgasm. In many cases a woman thus left unsatisfied 
resorts to niasturbatif>n. On the other hand, it has been obscrvwl 
that the full rievehipnieeit of the clitoris has been pre^Tnled bv 
adhesions, and a.s a result the function of this sexual appendii^ 
has been held in abeyance. 

In many cases in which there is no sfnictural defect in the 
clitoris it becomes irritated by the accumulation of smegma, p*^ 
ticularly in careless and uncleanly women. In such cases the 





all these instances it is ma^it important to look carefully ami fully 

inti) the ffmrlition of t!ie nervous system. 

la some of the milder cases of nymphomnnia women develop 
a remarkable tendency to undergo operatitms upon and exaniina- 
tion of the sexual organs. 

Several cases have l)een reported in which women suffering 
fn)ni marked sexual erethism have pretended to sulTer fitjui re- 
tention of urine^. and have been much comforted by the with- 
drawal of duit fluid by means of the catheter of the surgeon. 

As a result of extended recent studies in nervous an<l mental 
diseases the conviction seems to be fjrowiuf? tliat excessive mastur- 
bation is a symptom of nervous debility and disease rather than 
the exciting^ cause of these morbid phenomena. 

In the older books much stress was laid upon the faeies of the 
girl or woman atidicted to masturbation. As far as I can learn, 
in most cases masturbation Jn women (which it is probable Is n*>t 
very frtnpient) is indulged in in m(»deration, atui ww uiitowanl 
effects are prtiduced; certainly none which will appear at all 
pathognom(mic. Neither in their appearance nor in their actions 
do these women present auv unusual condition. 

In some cases in which females indulge excessively in mastur- 
bation, a deterioration in the health of tlie patient may be ol)served, 
but these women promptly get well under proper hygienic care 
and on ceasing to indulge in the bad habit. 

Excessive masturbation in women is said to shi>w itself in 
pale, sallow, and expressionless face, sunken eyes surrounded 
by l)lanched circles, and a secretive and hang-<iog Io4>king faeies. 
Such women have cold» clammy hands, a generally poor circula- 
tion, small, rapid pulse, and a tendency to shortness of breath. 
Indigestion, constipation, and insomnia are fref|uent and concom- 
itant symptoms. It will be seen that there is nothing absolutely 
chanieteristic in any of these sj'mptoms, all of whieh are fre- 
quently foun<l in neurasthenics and hysterical women. 

Tlie h^cal ctfects of inasturbatioTi in women ran Ih' seen in 
enlargement of the prepuce of the clitoris and of tins organ itself, 
a pigmented condition and excessive development of t]ie labia 



cases are on record in which female servants and nurses hav« 
taught masturbation to the young pris under their care. 

Sexual coldness of the husband, personal indilference, imptt- 
tence, and senility frequently lead to masturbation in young and 
passionate women. Then, again, widowhood, the long absence or 
perhaps illness of the husband, may cause them to produce orf^asms 
U[>(»n (hemselvrs. French authors have pmniinently mentioned 
obesity in (he wtinuin as being a sufficiently frequent cause of 
!iia.stiirbution. In these cases, for physical reasons, coitus is reri- 
(ietvtl diflieult (U* even im]X)Ssible, and the woman resorts to 
onanisui or seeks others to perform the act for her. 

Undoubtedly the condition of the clitoris has much to do with 
the produttion of masturbation in women. It seems to be pretty 
conclusively proved that shortness of the clitoris may lead to 
imperfect sexual connection by reason of the part not being 
touched and titillated in the sexual act by the penis of the miile 
consort, hence no gratification occurs in the woman, and she, 
l>eing then excited and aggravated, has to resort to cliloridcun 
manipulation to produce an orgasm. 

Ill some women the clitoris is highly placed w*ell above the 
upper margin of the vaginal orifice, and in niitus it wholly escaj*s 
friction from the penis, and as a result there is no orgasm. Such 
women an* pn>ne lo pru<Iuce orgasms upon themselves. 

Adhesions of the glans of the clitoris to its prepuce, partial or 
complete, are said to be very common, and when present they , 
may cause much disturbance. In the first place, it may be so ^| 
bound down or lifted up that in sexual contact no titillatioii w 
produced by the intromitting penis, and as a result the woman 
has no orgasm. In many cases a woman thus left unsausfkd 
resorts to masturbation. On the other hand, it has been obsen'ed 
that the full development of the clitoris has been prevented by 
adhesions, and as a result the function of this sexual appendi 
has been held in abeyance. 

In many cases in which there is no structural defect in tftc* 
clitoris it becomes irritated by the accumulation of smegcna, par- 
ticularly in careless and uncleanly women. In such cases the 



all these instances it is most important to look carefully and fully 
into the ton^Htion of the nervous s}'Titein. 

In some of tlie tnilder cases of nyinphoraania women develop 
a remarkable tendency to undergo operations u}>on and examina- 
tion of the sexual organs. 

Several eases have t>epn rcpnrte*! in which women suffering 
fruiri marked sexual en'lhisni have [frt^ended to sulVer fiiJin w- 
tention cjf urine^ and have Ijeen nineh comforted tiy the with- 
drawal of that fluid by means of the catheter *»f the surgeon. 

As a result of extended I'ecent studies in nervous ajul mental 
diseases the conviction seems to be growing that excessive niastur- 
hation is a symptom of nervous debility and disease rather than 
the exciting cause of these morbi<l phenomena. 

In the okler botjks nuich stress was laid upon the facies of the 
girl or woman addicted to nuusturhatiou. As far as 1 can learn, 
in most cases masturbation in women (whicli it is probable is not 
very fre([uent) is indulged in in mfxleration, and no untoward 
effects are pruducetl; certainly none which Avili appear at all 
pathognomonic. Neither in their appearance nor in their actions 
do these women present any unusual condition. 

In some cases in which females indulge extt'ssively in mastur- 
bation, a lie terio ration in the health of the patient may be obser\'ed> 
but these women promptly get well under proper hygienic care 
and 0[i ceasing to indulge in the bad habit. 

Excessive nuisturbation in women is said to show itself in 
pale, sallow, and expressionless face, sunken eyes surn>unded 
by blanched circles, and a secretive aiul hang-<iog looking facies. 
Such women liave cold, clammy hands, a generally poor circula- 
tion, small, rapid pulse, and a tendency to shortness of breath. 
Indigestion, constipation, and insomnia are frerjuent and concom- 
itant symptoms. It will be seen that there is nothing absolutely 
characteristic in any of these symptoms, all of which arc fre- 
quently found in neurasthenics and hysterical women. 

The local effects of masturbation in women can Ix' seen in 
enlargement of the prepuce of the clitoris and of this organ itself, 
a pigmented cunditiou and excessive development of the labia 



minuni, and perhaps h}^erpliu>ia and hypenesthesia of the orifice 
of tlie vulva. 

I^r. K. II. Smith* has contributed an admirable article on the 
*'Sif»ns of Ma^sturbation in the Female.** He starts with the fol- 
lowing question: "VSTiat shall we look for?" In the unmarried 
winnun or in a married woman who has bonie children, who has 
at some lime practised niasturbation to any extent, the labia 
nmjora aiv prone to ^pe when the woman is sitting or Iving in 
nn unstrained and lazy position. In some there is a flatteniag 
of the upper portion of the labia majora, which gives the ditore 
an unusually prominent appearance. The labia majom are 
unusually soft and relaxed. The prepuce is abnormally long, and 
hun^ down like an eyelid affected with ptosis. The labia minnn 
are very much thickened, elongated, comigated, and usually 
one is larger than the (Uher. They are soft and dry an<i feel like 
scrotal tissue instead of the slightly moist, firm, normal labia. 
In soniv the labia arc so much enlarged in general area as to br 
thrown into scallops, ami look as though they had Ijeen crocheted 
in their place. The matter of one labium minor being larger thaD 
llie other is easy to explain. The woman nearly always uses the 
same hand for the manipulation, and thus one labium is subjecteil 
lo ga'Hter vinleace than the other. The degree of h}*pertP)pbv 
dtpends on how long the manipulation is practised, how often, and 
over how long a time the patient has been addicted to the vice. 
In some the labia present a distinctly elbowed appeaxajice, the 
elbow l>cing inverted, so that they hang down nearly to the f^m^ 
chf lt«. 'lliey present appearances of recent irritation and increas- 
injc hy]H»rtrophy in those who have not abandoned the habit, and 
«ln»phic changes superseding an old hj.'pertrophic condition in 
lhu-<r who have abandoned the habit. 

"A very serious mistake is genend as to the location of lb< 
jvnrU winch play tlie chief part in the orgasm. The clitoris iu 
ihr female is usually put down as the part chiefly invobtd. 
Wlu^th^r in tl\e male or the female, the urethra is tbe part in 

* IVufio MedicKl Jounul, Fvbrumry, 1901 





which the orgasm occurs. In the male it is caused by the pa^ssing 
of jets of semen over the nuirous membrane of the urethral ranal. 
In the female, hy jets of mucus from tlie neck of the bladiler 
through the urethra. After an orgasm in the female, however, 
produced, the labia and vestibule are flooded with mucus, which 
escapes not from the vagina altogether, but largely from the 
urethra. The reason why males who have suffered amputation 
of the glans, and women who have been deprived of tlie glans of 
the clitoris can still accomplish the sexual act with orgasm, is 
because the urethra is the seat of the peculiar nerve distribution 
necessary for its production. This explains the habit of some 
individuals of passing all manner of objects into the urethra, 
and even masturbating in that way." 

As to the class of patients, the author says that those "who 
present the most characteristic symptoms and who more often 
than otherwise full into the doctor's care in a mental and physical 
condition ripe for diagnosis, are, as a rule, from twenty-five to 
thirty-five years of age." As to symptoms, "first of importatice 
is ovarian pain, particularly at menstruation." It is a well- 
known fact tliat if a man suffers from prolonged se.xual excitement 
it frequently produces intense pain in the testicles. This gives a 
clue to one cause of ovarian pain. The congestion attending men- 
struation augments the pain. Overindulgence in any form of the 
sexnal act will cause more or less pain or tenderness in tire ovaries. 
Severe pain at menstruation, in an otherwise healthy girl with no 
developmental defect, is a strongly siLspicious sign of masturba- 

"Next in importance is the disturbance of the intestinal func- 
tions, intestinal indigestion, distention with gas, wakefulness, 
as a consequence, is common in these patients. A peculiarly 
obstinate f4>nstipji(i(>n is a most common accompaniment. Dur- 
ing tlie manipulation of the genitals the sphincter and levator 
ani muscles are contracted to the utmost. It is a part of the 
process whereby an orgasm is produced. Tlie result is a tonic 
contraction of the sphincter ani muscle. Constant taking of 
laxatives or cathartics adds to the trouble by destroying the mus- 


t'lilar tone of the rectum and colon. An examination of tJie rectum 
in case.s shows the mucous membrane relaxed and frequeutJy 
in deep and multitudinous lax folds, filled with ^lain* mucu.-t; 
the sphincter will scarcely admit the well-oiled finger. Lastly, 
the damage to the nervous system varies with the nervous type 
of the individual and the extent of the vicious practice." 

A further contrihution on this subject, which is worthy of 
repnxluction, is furnished by Dr. Dickinson,' who sajs: "TTic 
type, iir full <levelopment, of the deformity of the genitals consists 
in a liuely wrinkled and deeply pigmented enlargement of thr 
labia minora and hypertrophy of some adjacent structures. Thick- 
ened, elongated, curleil on themselves, thrown into tiny, dose-set, 
irregular folds that cn»ss at all angles, as in a coc'k's comb, tlie 
lesser labia pmtnide in all positions through the larger labia. 
The pigment deposit varies with the general type of coloring. 
One labium is sometimes gn»ater than its fellow. 'Ilir follidef* 
are often conspicuous as whitish spots, the prepuce commonly 
and the fourchette occasionally, participate in the corrugadon 
and duskiness or one of these may alone be affected. Al tiniwi 
wrinkled band runs olT to the labium majus. Certain veins near 
the clitoris stand t*ut. At the mouths of each urethral ^and a 
flap-like protrusion may be seen. Greater power and size of the 
pelvic floor accompany the other hypertrophies, Dbtioctivc 
increase in the size of the clitoris may lie present, hut contrary- tn 
the general l>elief it is infrequent. There may l»e enlargenieiit 
and changes in the areolae or in the breasts, resembling those of 
pregnancy. At a later stage flabhiness of the labia minora or 
pigment spots denotes atrophy of the structures once enlarge<i, 
but the hall-marks never disappear. Some part of the whole of 
the alterations occurs in about one-thir<l of those who suffer froin 
pelvic disonlers. One-fourth of the patients presenting hyper- 
trophies lx?long to the neurotic class. Tliese alterations are due 
to oft-repeated, prolonged sexual excitation, irrespective of coitus i 
or gestation. Pressure or friction causes them. Pregnancy prt>- 

* American Gjoecology, SeptomtMir, 1902. 



duces increase of size and some surface irre^ilarity, hut never the 
fully developed changes here specified." As to the causes of 
h}']>erlrophies alxjut tlie vulva the author says: *'A sufficient 
number of histories have been volunteered or frankly stated, in 
typical case3 of abiionnal enlar^ment, to warrant the Wief in 
the writer^smind tliat all much enlarged, deeply wrinkled uymphje 
are the result of nunjWrless congestions or tractions. In 127 
instances (30 per cent, of the cases here studied) full admission has 
been made. Therefore, it is fair to suppase that the same findings 
in the remainder are due to the .same causes, even though categor- 
ically denied, as with seven patients showing very marked en- 
largements. Denial with subsequent avowal is often encountered. 
Preasure, a.s witli crossed thighs, is as productive of the InijcHrophy 
as is friction. It is j>rol>ahle that, inasunich as the increase in 
size occurs chiefly in the labia minora, it is to them that the irrita- 
tion i.s applied.'" 

Treatment. — In tlie management of young girls who are addicted 
to masturbation the most careful surveillance and watchfulness 
on the part of the mother are necessary. \\'hen the sjTnptoras 
point to manipulation of the genitals the child .should 1^ stopped 
at once, an<l she should lie held in the lap with the (highs extende*!. 
Any condition of ill-health should l)e carefully treated, and if any 
irritation of the extenial genitals is observed it shonI<l Im? cure*!. 
When young girls are herded together at home or in boarding- 
schools, asylums, etc., it is important to watch them carefully and 
prevent, if possible, the indulgence in bad sexual habits. 

It is always well for mothers of young girls and boys to scni- 
tinisse carefully the habits and conduct of sen^unts and nurses, 
and to see that they do not teach the children ba<l liahtts and 
that they do not manipulate their genitals. 

In all cases irritation of any and all kinds of the sexual parts 
of children .should receive prt?inpt attentit>ii and Ijc thoruughly 
removed. When it comes within the provintre of the surgeon 
in the various cases he shouhl endeavor to prevent onanistic 
habits, which young women acquire in gymnastic exercises, horse- 
back riding, in the use of the sewing madiine and of the bicycle. 


In all cases the general hygiene and reginien of the patient 
must he looked into, and sound advice must be given. 

The condition of the clitoris must be carefully examined iu all 
cases of confinned masturbation. If there is smegma seated on 
the organ and under its prepuce the parts should be regularly 
and carefully cleansed, and for a time a little tuft of absorheut 
cotton soaked with lead-water should be kept over the parts. 

Irritation of the clitoris from any cause, such as uncleanliness. 
[K*diculosis, dcnnatitis, \nil\4tis, and vaginal discharges, should 
lie at once treated and the cause removed. 

In all cases where adhesions of the prepuce to the clitoris, 
whether partial or complete, are present it is imperative to cor- 
rect this defect at once. To thus end it is first necessary to thor- 
oughly irrigate the vagina and the vulva with hot bichloride solution 
(1:5000 or 1:2000), then to cocainize the parts, and then by 
gentle taxis or by manipulation with a probe or the handle of a 
small bistoury to slowly disengage the enveloping tissues froui 
the glans. 

This operation is very simple, and the subsequent treatment 
consists in the interposition of a little tuft of absorbent cotton 
covered with aristol or orthoform or soaked in lead-water. It 
is well to keep the interposed a)tton in the wound until full healing 
is produced. 

Cases of nymphomania are very distressing, and they tax th** 
surgeon severely in their treatment. Locally in some of the^e cases 
full exsection of the clitoris (clitoridectomy) may be perfonne<it 
hut in these casf\s the surgeon should seek consultation witli one 
or two expert colleagues. 'I'lie iu'r\'ous condition of these patienis 
should be fully and carefully considered and treated. 





Pruritus may affect a part or the whole of the integument of 
the body, anil in somewhat rare hi-stances it may occur upon and 
be limited to the region of female genitals. Though not essentially 
a disease, it is a -snl>jective symptom of the highest importanee, 
and although there may be liehind it many morbid conditions and 
diseases, this symptom itself dominates the pathological field and 
overshadows the underlying lesions and affections. 

Nosologically considered, pruritus of the vulva comes under 
the bead of sensor^' neuroses, and is essentially a hypera»sthesia 
of the mucous membranes and skin of the sexual parts. 

The itching varies in intensity in different cases. It can l^e 
variously described as a tickling, burning, creeping, tingling, 
twitching sensation, and sometimes as intense pain. It may be 
continuous or it may occur at inten^als. It may last half an hour 
or several hours, and may cease slowly or abruptly. l:suuny it 
comes on with attacks which are re[x'ated several times during 
the day, and it is always especially severe at night, when it may 
interfere wath sleep. The most constant sites of the itching are 
the internal surface of the labia majora, the vestibulci and the 
clitoris. In the more pronounced order of cases the whole vulva, 
the introitus vaginee, even to tlie os externus and the outer sur- 
faces of the labia majora and adjacent parts are attacked; in some 
cases the pruritus extemls to the anus. In many cases the condi- 
tion of the patient is so deplorable that it is beyond description. 
As a result violent scratching, harsh rubbing and hard pressure 
are resorted to, both by the finger-nails and various inanimate 
objects. The desire to scratch is often so imperative that the 
patient will yield to it, no matter where she may be nor in 




company she is present. In some particularly young and neumtic 
subjects the itching tends to masturbation, and even nympLo- 
inania. Some women desire coitus hoping thereby to be relieved; 
l)ut as a rule sexual contact exasperates the itching, thougli it 
sometimes ameliorates the condition. Itching has been known 
to attack the husband after coitus with a pruritic wife. 

At first no visible clvanges are observed in the pruritic areas 
l>eyorid mild hy[)crirmia, but, as a result of scratching and friction. 
thickening 4>f the labia, dryness and a lack of supplene&s, with 
more or less deep pigmentation and excoriation, are induced. 
Later on severe eczema may be developed, the vagina niav 
Ix^fonic hyp<Tplastic and excoriated, and a profuse mucopurulent 
discharge may o<*cur. 

Some cases of kraurosis vnlvffi have hml as their starting point 
pniritiis vulva*. 

Tbc general health of the patient is more or less impairetl by 
llie local malady and the worry. The sleeplessness and tlic con- 
stant intense nervous tension and suiTenng lead to loss of ap()etiie. 
debility, and melancholia. The sufferer shuns compjininn.ship 
and her family, and is so often despondent that life is a burden (n 
her. In many cases severe hysteria is produced. 

Etiologry. — Tlic most varied conditiims and affections are to 
ht' finind ius causes of pruritus uf the vulva. The more ephememi 
forms of tins aifection are met with in young and adolescent sub- 
jects as a result of local causes. In children and very young giri.s 
ascaritles or oxyurcs vcrmiciilares or pin-worms and ascarides 
lund>ricoides or romid womis may prove to be a distressing cause 
of vulvar |>ruritus. In subjects care ami rigid examination 
sh<»uld l»e exercised in the detection of these parasites. In younger 
subjects ;ils«» such vegetable parasites as the oidium albicans, the 
leptothrix vaginalis, penicilliiim glaucuni, and the aspergilliis 
glaucus and other mycoses maybe the morbific agents. In some 
cases of mngnet or sprue the genitals have become infected uii- 
(joubtcrlly by the <lirect transplantation of the microH3rganwm* 
from the moutli to tlic fenuile genitals. In this way the vulva ami 
vagina are invaded and as a result uterine pruritus may lie pn>- 






duced.' In these cases careful examination may -sliow hypeneraic 
Brcns covered with dirty brown friable membranes. Microscopic 
examinnlion will always render (he diagnosis easy and convincing. 

Various forms of vaginal and vidvar discharges may be the 
starting point of pruritus, and in these conditions their origin 
and nature should Ik* established by careful examination, and 
efficient treatment shouUl be institutetJ at once. During men- 
struation vulvar pruritus may be developed and it is probably 
due to the p}>ysioh>gical congestiori and j^erhaps to the decomfM> 
sitioii of the menstrual fluiii. Truuinatism is a not infrefjueMt 
cause of vulvar pniritus^ particularly in young and older women. 
In many cases in(em[[>erate and impetuous coitus, particulariy 
when the penis is of large size and the man is inconsiderate in the 
act, have caused severe and persistent pruritus vulvae. 

During pregnancy this symptom may occur and become very 
severe, and it hfX-? been known to cause such suffering iind mis- 
chief that abortion has ensued. As a rule, however, after delivery 
relief is obtained. 

In many cases pruritus is a symptom of diabetes; and par- 
ticularly in elderly women in whom no abnormality of the |>elvic 
organs an<! external sextial parts can be dctecte<l, exaininati4in of 
the urine should lie made. With the fiiscovery of sugar in the 
urine nnicli can be done by treatment to amehorate the general 
c<ni<Htion, anil cure the hical itching. Cystitis, uretiirul caruncles 
an<l [Mjlypi and hemorrhoids have been known to be the starting 
point in pruritus vuivjc. lu many cases of vulvar pruritus, how- 
ever, it may Ik* diflicult to find a cause for the symptom. Dys- 
menorrhu'a, ajneiiorrhfca, metritis antl endometritis, the meno- 
pause, ovarian, tubal, uterine, and vaginal affections and pelvic 

' Martin (Virchow'a Archiv^ 1A56, Hd. zi. p. 160) dencribes ■ cue of vulvar 
inf1»ninmtion due to the oidium albican!! occurring in a young pregnant woman 
after indulgence in finger-coiliin with her lover, a miller, ll was thought that 
the posnble pre»enct> of uii^h] on 0[ie of the 6og«n of the latter may have been 
the nidUB in which fungi were lodged. It seems powible that autoinfectiou waa, 
u «Q»I>ecte'l hy Ilauwinian (Centmlbl. fiirOynukol., Leipjcig, 1879. Bd. xi. p. 212), 
the cause of an nphthoun inflaninintion nf the labia niajora in twenty-four girls iu 

school, since iiphlltou.s stniuutiliM whm known to have exi8te4l among them. 


neoplasms have all been cited as the underljHng causes in these 
cases. It becomes tlie duty of tlie gynecologist, by reason of his 
breadth of knowledge and clinical acumen, to clear up that diag- 
nostic maze. 

Ilehra and Kaposi state that in a number of cases of pruritus 
vulvEC of several years' duration this symptom was the precursor 
of carcinoma of the uterus. 

In somewhat rare cases a varicose condition of the vagina and 
periva)2;inal connective tissue has been known to cause pruritus 
vulvir. It may be well to mention that demngement of the liver, 
notably jaundice, disordered digestion, rheumatic and gouty condi- 
tions and alcoholic excc.sses have been by many authors regarded 
as etiolf>gicu]iy n^lated t(j vulvar pruritus. Mild and ephemeral 
attacks of pruritus vulvte may be due to digestive €lisorders» pai^ 
ticiilarly from tlie ingestion of strawberries and shell fish and from 
articles of diet wliich by idiosyncrasy are hannful to the patient. 

Diagno&is. — This can rea<lily be made from tiie liistory of the 
case and its careful obsen'ation, particularly before local secondary 
changes have been induced. It is necessary to establish the fad 
that the itching existed l>efore the development of the dermatitis 
and eczema. As a rule eczema of the vulva is tolerably' amendable 
to treatment, whereas pruritus vulvie may persist after the inflam- 
matory symptoms have disappeared. 

PrognoBLB. — This depends largely upon the nature of the case. 
A consideration of the etiological factors already detailed will 
give a forecast of the probable outcome. 

In general it may be stated that the prognosis is good provided 
intelligent and energetic treatment is followed. T*he disease may 
last for some weeks or months, but ceases in most cases after a time. 
In the severe and rebellinus forms of vulvar pniritua the affectiou 
may be of long duration and the .sntfering may be intense. 

Pathology. — The pathology of pruritus vulvw has been carefully 
studied by J. C. Webster,* who has examined in detail the various 

* The Nerve Ending in the Libia Minora and Cliioria with Special Refcreno* 
to the Pathology of Priiritu» Vulv«, TrHDsactions of the Edinburgh OlMteriosI 
Society, 1891, vol. xvi. 



morbid changes. Tliese changes were of the nature of a slowly 
progressing fibrosis, affecting chiefly the nen'es and nen'e endings 
of the chtoris and labia minora. Many of the nerves, if traced 

I^m deeper parts toward their terminations, were seen to acquire 
B dense fibrous character, some appearing as well-marked fibrous 
cords, the nerve fibres being compressed or destroyed. In some 
cases they could be followed to their special end corpuscles, which 
also showed the same changes. The changes were most marked 
in the clitoris. 
^^ The Pacinian corpascles did not appear to bo affected, save in 
Hbne instance where there was an abnormal number of cells in 
the central core. Some globular end bulbs showed an increased 
number of cells; others appeart^d as liensc fibrous knobs. Some 
of the genital corpuscles showed the change in a marked degree, 
the windings of the terminal nerve fibres being often almost oblit- 
erated. The changes funnd in the connective-tissue framework 
of the clitoris and nympha^ were different, being of a subacute 
inflammatory nature, and evidently more recent in origin than 
Bibose found in the nervous structures. They were found most 
marked in the coriuui under the papilla\ and affected especially 
the prepuce aud nymphfe, being found in the clitoris oirly in the 
glans under the epithelium, and much less marked than in the 
labia minora. In the corium of the later were seen many minute 
vessels with abundant exudation of leukocytes into the perivas- 
cular IjTnphatics, while in many parts the subepithelial tissue was 
a mass of leukocytes and proliferating connective-tissue corpuscles. 
These changes were most marked in the hypertrophic njanphie. 
They were distinct from the chronic fibrosis affecting the ner\'ous 
structures, and were no doubt due to the long-continued irrita- 
tion of the scratching, lliey affected chiefly the superficial parts 
^ — viz., the prepuce and nymphie — the nerve fibrosis being most 
larked in the clitoris, in which there were only a very few acute 
>r subacute changes under the epithelium covering the surftice 
►f the glans. 
Treatment. — While in many cases of pruritus vnlvip our treat- 
kent is empirical by reason of our want of exact knowledge of the 


underlying niorbld condition, in many it is based on scientific 
lines. The first e^^sentiul in all cases is most scnipulous cleanli- 
ness and antisepsis. 

When infants and young children are affected, inquiry should 
be made on tlie lines of animal or vegetable parasites, trniimati'au, 
and vulvar and vaginal discharges of various kinds. When animal 
parasites are the cause, besides irrigation of the vagina and vulvi, 
appropriate treatment for the worms wliose habitat is in the rectum 
should l>e vigorously pu.shed. (The details t)f the management nf 
these cases belong to the domain of general medicine.) The irriga- 
tions should be copious, of vety warm water, alkalinizrd hr 
powdered borax nr supercarbonate of soda, to which carlK>lic arid 
has been added in 1, 2 or 3 per cent, solutions. Or these irri|ra- 
tions may be given without the carbolic, and they should lie fol- 
lowe<l by warm copious irrigations with bichloride of merniir, 
1 : 2000 or 1 : 4000 and in greater dilution. It is good pnu-tice in all 
cases nf vulvar pruritus to freely use these alkaline and antiseptic 
irrigations into the vagina, and to flush the vidva with them. In 
the intervals tampous of sterile absorbent cotton should be us^ 
in the introitus vaginne and in the vulvar sulcus. 

In all cases care must be taken that the bowels shall raovt 
freely once a day. The diet should be plain, simple, wholesomr, 
and naturally easily digestible. Coffee, asparagus, spices* and 
alcoholics arc to fx* absolutely interdicted. Rest and quiet aiv 
es.sential, since mental and physical repase go far toward ameli- 
oration. In all cases the history should be carefully gtine into and 
the physical exiuninaiion of the female genitalia should he tlioruugli 
but conchicted with rmich gentleness. 

In the general nin of cases in young women, and in fact in older 
ones, the condition of the urethra and bladder should Ik* in*:|>cctetl, 
;in4i if any discharge from these part:* is seen it should l»e property 
treated by l*»nd means. Thus, vegetations and caruncles of llie 
iiieatu.s and urethra should be removed, and local treatment, 
notaV)ly by weak and warm nitrate of .silver injections (1,2 or li ^■ 
to water .^xvi), .slioukl be thrown systematically into the bladder 
and the patient directed to expel them as in urination. For iIm^ 




tter viscus it inay l>e necessary to use umtropin, salol, or alkalies 
as (he ease may *leiiiaii*l. 

Wheti luealized (juU'lies cjf a dirty brownish or whitish mem- 
brane or a superficial sloughing area are found either on the vulva 
or in the vagina, it is neces-sarj' to make a microscopic exaiuina- 
tion of tl»e detritus and if any vegetable parasites are fouiul, the 
affection can be promptly cured by alkahiie irrigations, foUowed 
by bichloride of mercury solutions, which should l>e increased in 
strength until the membranes exfoliate and until the reparative 
process sets in. Experienc*e based on study and olHer\'ation will 
be the guides in adjusting the strength of the parasiticide injec- 
tions. In tlie intervals of treatment much comfort may follow the 
use of nioint absorbent cotton tampons. 

As local applications, always after irrigation, wann solutions 
of acetate of ahunina, boric acid, (roulard's water with or without 
the addition of laudaninn, and x^vy hot oatmeal-water are to be 
borne in mind. Black wash and yellow wash applied on lint are 
sometimes very soothing. Fluid extract of pinus canadensis was 
was much thought ()f by the late Prof. T. G. Tliomas in vulvar 
pnirltus. It may be sopped on the parts and applied on absorbent 

I cotton in full strengtli or in dilution. 

B Solutions of nitrate of silver in varying strengths are often very 
beneficial. Free hot irrigations of \ per cent, strength and even 
in weaker and stronger solutions frequently give mucli comfort. 

I Very stnnig solutions, even as high as 30 grains to the ounce of 

I water, applied locally and sparingly by means of a cotton holder, 
are sometimes of great benefit. A classical remedy, mu<-h thought 
of by tl»e older writers for this affection, is composed as follows: 
Bichloride of mercury grs. 1 to 4 dissolved in emulsion of bitter 
almonds 5iv. A solution of permanganate of potassium (1: 500 
and even stronger) will sonirtimes prr>ve to Im' a very efficient anti- 
pruritic remedy. The solution is to l>e carefully sopped on the 
morbid area by means of a camel's-hair pencil or cotton holder. 

Aqueous .solutions of ichthyol sometimes alleviate tlie itching for 
hort or long periods. 
Benefit may follow iu some cases ^IV^ilPfi^^ffW ^l^lJSPPdl^ 



Peru, tlie oil of cade or ichthyol usee! either in their full strength 
or mixed with vaselin, Ointments sometimes give much relief. 
The following may be resorted to: Atropin 4 grains to cold 
cream one ounce. 



Gaaiacol . 
Zinct oxid. 
Ung. aq. rowp 

-Menibol . 
Carbolic acid 
While vo«eUn 

gr. ij. 

gr. lij. 

ne ointment (official U. S. P.) nmy 

In okstinate cases veratri 
be cautiously tried. 

Various powders may be dusted ui>t>ii the pruritic surface.**. 
Robin recommends the following: 

R— Oflhoform, 


-(-'amphorse pulv. 
Zinri oxid., 
Pulv. amyli 


-Zinci oxid. 

Pulv. acid boric., 
Pulv. iiiuvlt 

AA equal qimntitfiai 
. gr. xxx-lx. 

. gr. T. 
. gr. X. 

It may be of interest to remember that in 1S61 Sir J. Y. Simpson 
recommended the rejection nf the pudic nerve in the tieatineot 
of vagiiiisniiis and pruritus vulva^, but that little attention wis 
paid to his views. Tavel* recently claimed that he has performed 
this oj>eratioh twice with highly satisfactory results. He employed 
and recommends a sagittal incision — from eight to ten centimetres 
in lengtli — which passes from before backward across the ischio- 
rectal fossa, midway between the anus and the ischial tul>erosity. 
The anus lies opposite the middle of the incision. After dividiog 

' Revue de Cbirurgie, Fobniarjr, XOOl. 



the integument the dissection is made toward the inner aspect 
of the ischium, care being taken not to damage the inferior 
hemorrhoitJal nen'e. On passing the finger over the fascia which 
covers the obturator intemus, the internal piidic artery can be 
felt pulsating as it passes throiigli Alcock's canal. The inner 
laver of the fuseJa forming the canal is divided, and the nerve 
isolate*! from tlie vessels. The inferior hemorrhoidal and the 
anal branch of the deep perineal are hooked back and the muscular 
branches isolated. They are recognized by the fact that wlien 
they are pinched the muscles contract. The branches which 
supply the muscles implicated are divided and avulsed after the 
method of Thiersch. The wound is closed witliout drainage. 

Barton Cooke Hirst* also thinks that surgical intervention 
promises better results than any other line of treatment so far 
suggested. He details a case and describes his method of opera- 
tion in which he resected the genitocniral, ilioinguinal, inferior 
pudendal, and superficial perineal nerves. 

It may be well to remember tbat J. C. Wel)ster^ has long been 
an advocate of thorough removal of the affected parts in pruritus 
vulvie. Webster removed more or less of the clitoris and parts fvf 
the nympiue with instant relief. Conaud' completely cured a 
ease in which the pruritus was limited to the clitoris by the extii^ 
pation of that body. Schmder and Lohlem* reported 5 cases suc- 
cessfully treated by tlie removal 4)f the aflieeteil area.s: in one the 
clitoris with it.s prepuce was remo%^ed; '\i\ another a small j>iece 
of the right labium majus; in another a large piece of the left 
labium majus, and in still another the clitoris and part of both 

In so distressing a disease as pruritus \nilv«e, all therapeutic 
suggestions which offer relief should be remembered; in this vein it 
may be well to renieml>er that Seeligman^ claims that he has been 
able to isolate and cultivate a diplococcus from all his cases within 

' American Medicine, May 10, 1903. 

* fenirulhlau fur Chirurgie, 1874, p. 431, 

* Ceil Irall.latt fur Uyniikol., 1884, p. 805. 

* iJeiit. raed. Woch., February 27, 1902, 

' Loc. cit. 


the last ten years. It resembles the gonoooccus in shape and ap- 
pearance, but di£Fers in the manner of growth; it takes readily the 
Gram and the aniline stains. It is quickly killed by a 10 per cent, 
guaiacol solution in vasogen, and this application has also given 
great success clinically. He has cured many primary and secondary 
cases by means of this remedy applied with a cotton swab on sevend 
successive evenings before retiring. If necessary a 15 or 20 percent. 
solution may be used, but is apt to prove irritating. 



PIekpes progenitalis is a mildly inflammatory aflFection, con- 
sisting of one or more vesicles or groups of vesicles. It occurs 
in both sexes, and is perhaps (|uite as freqiient in the female as it 
is in the male sex. 

In women her|H's progenitalis occurs on the inner a.spect of 
the labia majora, on all parts of the labia minora, on the vestibule 
and prepuce of the clitoris, at the orifice of the urethra, and occa- 
sionally on the outer surface of the labia majora and on the mens 
veneris. 1 have seen two ca-ses in which herpes of the whole 
labium majus wjis acconij)anicd with herpes zoster of the crural, 
external cutaneous, and small sciatic nerves of the same side. 

As mentioned by Hergh,' herj>es may develop on the cervix 
uteri, either alone or in association with similar lesions of the 

Fournier has observed the occurrence of vulvar and j>eri\'ulvar 
herpes with chancres of the os uteri. 

In women es}>ecially, and in men occasionally, herfK^s is found 
on the anogenital region an<l aroimd the margin of the anus, 
sometimes synchronously with involvement of the genital parts. 
In his statistical table I'nna^ records two cases of herpes vagina? 
which occurred in the Handnirg General Hospital. I have never 
recognized herpetic vesicles in this region. 

The evolution of the affection may occur without any prodn>mal 
symptoms whatever: sometimes it is antedated by various neuralgic 

' Ueber Ilerpetj MenstrualU, Monatehefte fur Prak. I)erin , 181*0, vol. x. 
|>. 1 et seq. 

' Herpes Progenitalis, eHpecially in Women, Journ. (.'ill. and Ven. Ditieases, 
vol. i. p. 322 et aeii. 



phenomena, but in most cases there are slight biirningi heAt, 
tickling, an<i itching just before the outbreak, In nervous and 
clilorotic women an intense pruritus often begins with, and lasts 
during, the attack. General morbid states seem to have Uttic 
influence on the evolution of this affection. 

The eruption may consist of a single vesicle or it may consist 
of a group closely packed, or, again, of a number of scattered 
vesicles, usually following the course of a nerve, llie first morbid 
change observed is a red spot, which is soon the seat of vesicles. 
Tliese lesions may he of the size of a pin's head or of the diameter 
of a line, and are roundeil translucent vesicles containing clear 
scrum. When seated on the mucous membranes they, owing to 
the succuk'nee of the parts and thinness of the epidermis, sixin 
rupture; indeed, it is verj- rare to see such lesions intact. XMien 
seated on the skin, however, they may remain intact for some daw, 
and unless scratched their contents become turbid and they dry 
into brownish scabs. Herpetic vesicles seated on the outer rim o( 
the labia minora, particularly when they are long, may be almost 
wholly obscured by the inflammatory cedema which the laxity of 
these tissues sometimes favors. Rupture of the vesicles leaves a 
shallow exidceration corresponding in size to that of the vesidc 
Its floor is at first of a deep rosy red, with a finely uneven surfacf, 
and its edges shaq)ly cut as if punched out, and sometimes under- 
mined, but not, as a nile, to the saint' extent as in chancroid. When 
there is a group of vesicles they fuse together and niplure, form- 
ing a fmtch which has been descrilied as having a polycyclic*! 
outline. Iliis is comparable to the outline presented by two pieer;* 
of thive-lraf clover place<i base to liase, which then has a festixine<! 
margin fonned by segments of circles. Eariy in their evolution 
the vesicles are surrounded by a well-marked redness, the tendency 
of which is to gradually decline instil a n»ere hypera^mic rim 

Usually the vesicles heal in a few days; in some cases tliry aw 
very persistent, and in others they become ulcerated and uudi?- 
tinguisbable from true chancroids. In this state tjieir secretion 
is sometimes nutoinoculable, and in some cases the ciiiise 




biihops. Herpes progenitalis sometimes assumes a more or less 

I destructive tendency. I have very frequently seen vesicles become 
covered with a thin, blackish, very a<lhereiit crust, and thus they 
may remain Indolent with no tendency to healing. 
\Mien fully develofjed there is usually an amelioration or sub- 
sidence of the itching, heat, or burning, but somewhat exceptionally 
the e.xcoriated surfaces are exquisitely sensitive, and the patient 
shrinks from the slightest touch of them. Uncomplicated cases 

I last from a few days to two weeks. Unlreated'cases, particularly 
in uncleanly subjects, are sometimes persistent and rebellious to 
Tliis affection is peculiarly prone to relapse, as shown hy Ooyon,* 
at longer or short inten'als, occasionally with distinct jieriodicity 
for nuiny years. 
In exceptional cases there arc swelling and pain in the inguinal 
ganglia of the ccjrrcsponding side. Soinetinies, when the vesicles 
hectnne inflamed and idcerated, suppurating btdiops oecur. 
H '^riiis affection is peculiar to adults as late as middle life, and is 
rarely, if ever, seen in old persons. 

Etiology. — V'arious coiistiiutional conditions — neurotic, gout}', 
rheumatic, and plethoric — were formerly regarded as the causes 
of herj>es progenitalis, but (heir inflvience. if such exists, is simply 
that of greater or less predisprisition. Extended clinical i>bservation 
ha.s shown that local detennining conditions are, as a nde, the exist- 
ing causes of the affection. 

In women, as in men, congestions and itiHannnations, e])hemeral 
or long continued, are always the underlying causes of herpes 
progenitalis. Prostitutes are those wht) suffer in greatest number 
from this affection, due, imdotditedly. to the very fretpient irrita- 
tion of their genital apparatus in coitus. The opinion has been 
expressed by several authors of autlK)rity that probably herpes 
progenitalis in puellm publictjB is due to the fact that in promiscuous 
interct)urse oft repeated the women play simply a passive part 
and seldom reacli orgasm. As a result such a strain occurs on 

' I)e I'Herpvs recidivKnt des Partett g^nilales, Paria, I8tf8. 


their nen^oiis system that herpetic explosions occur. Such is '\\^ 
frei|iieMcy anion^ these women that I'nna calls it the "vocation 
tlisease." ^'iolence to the female genitals in ru|>e and fmui exw-s- 
sive size of the penis, and in ma.sturbation, particularly wheu 
large and firm suKslitutes for tlie penis are employed, often pn>- 
duces lierpes of the parts. Wilvitis and vufjinitis, simple "or severe, 
are frecpiendy the forerunners of the affection. Congt^tion of 
the pelvic organs, dysmeiiorrhfca, jx-lxnc cellulitis, metritis, inflam- 
nifUion of the ovaries and tubes, pelvic neophisms and endoine- 
tritis an* likewise occasional excitants of the affection. It is aJs»», 
as pointed out Uy Hergli,' a frequent forerunner and concomitaot 
Htfe{"(ltjn of rnenstnnWion. so that in France tl»c term hautcm dr 
rhjlr hiLs been applied to it. l>uriag Uiis epoch it frerpiently attack;* 
young girls, young women, and even those of middle age. 'ITie 
attacks may come on everj' month or there may l»e intervals of 
free<lom of several months. It is perhaps rather more ffvquent 
in sexually inclined and neurasthenic women, as claimed hy 
Hergli. In women herpes progenitalis is seen in early an«i laie 
atliilt life, and found to relapse in an exasperating manner. 

It is probiibie that in all cases of herpes pmgenitalis disturbaiiu' 
occurs in the nen^ous arc which exists l>etween the genital appA- 
ratus and the spinal cord, and that irritation is transmitted from 
the external or deep portions of the genital apparatus hackwarrl 
to the spiniil nerve centres, atid from these conveyed (o some 
portion or portions 4>f the vnlva or mons veneris, (^linically, 
inanv cases of herpes progenitalis present features of similaritv (a 
herpes zoster, even to the point of being coexistent witli it. 

Altiiough it ha-s been suspecteil that berjies progenitalis may he 
of microbic origin, little is known in support of such an hypothesis. 

Diagnosis. —.\s a rule, the diagnosis of herpes of the femalr 
gcititalia is readily made. The sensation of heat, itching, ami 
burning, the superficial character of the legion, its less profuw 
secretion, and scarcely undermined edges will usually r^iuUuth 
the diagnosis, wliich may be strengtheneil l»y the history- of relapse*. 


' Op. cit. 



Further, the \ery frequeat unilateral |x>sition and peculiar group- 
ings of the herpes ve,sicles are iinpt^rtant diapiostic ai<ls, while 
in some ctisvs the arran^ment of these le^sions in the t-nurso cif a 
nerve jxjints niidoiilUedly to their nature. 

^fe It is a good ru!e to be always guarded an<l reserved in the diag- 
nosis of these minute lesions in women, partif-nlarly in cases in 
which there is absence of the prodronuil and acccmipanying 
symptoms of herpes, and especially when the lesion or lesions 
seem particularly insignificant. Tliis p4>int cannot be stated in a 
too impressive manner. It i.s these insignifieant lesions which 
usually ileveli>p into hard chancres in men and wt>nien. In h'ke 
manner a dear history of antecedent herpes should not embolden 
the surgeon to speak too confidently of the simple character of its 

■^m successor. 

B Treatment.— The most essentia! pfjint is the establishment of 
the most absolute cleanliness and antisepis of the parts. Any 
coexisting dyscrasia, gouty, rheumatic, nennitic, or pK'tlioric, 
should receive proper altenti^ui. Sexual, alcoholic, and dietary 
excesses should lie interdicted. 

In women, bs far as p4tssible, irritations, congestions, and 
inflammations should be avoided i>r remove<l by appropriate 
treatment. The fretpient and systematic use of hot alkalini'/ed 
irrigations with borax or supercurlwrnate of soda should In* insisted 
u[)oti,iind if there is uriy form of vulvar or vaginal (hscliarge hot 
bichloride imgiitimis { 1 : 20110. 1 : 4(KI0. ami 1 :(K1()(>) should l»e em- 
ployed. In addition the underlying morbid condition shouhl be 
recognized, and fi>r it efficient local treatment should l»c instituted. 
For irritaf>le herpes in either sex the Icad-and-opiurn wtish is 
often very soothing. Very often the persistent neuralgic an<l 
burning pains recjuire for their relief ven* carefid but thorough 
cauterization with carbolic acid, solutions of nitrate of silver 
(sixty grains to the ounce of waterj, or j>erhaps with fuming nitric 
acid, after which the lead-an<I-opium wash may l>e applied. As 
an adjuvant in these cases frequerU sitz baths of very hot water 
tre very soothing. Roracic acid and iodofonn. alone or in combi- 
ition, are frefjuently of benefit where a tendency to ulceration 


exists. Aristol and europhen of service. Iodoform 
and glycerin, or in ointment form mixed with vaselin (one drachm 
to the ounce), veiy frequently are beneficial in relieving the neu- 
ralgia and promoting healing. 

Various astringent lotions may be used by means of small 
tampons of lint or absorbent gauze. 

R — Pulv. alani, 

Zinci. sulph. 

Aquae . 
|£ — Zinci sulph. 

Spts. lavand. comp. 

U — Pnlv. alum 

Acid carbolic 

H — Argent! nitrat. . 

U — Resorcin 


q 8. ad 

Kr. xij. 
gr. xij. 

git. IX. 

gr. iv. 


are sometimes very soothing and 

Black and yellow wa.she> 

Various dusting powders are sometimes very beneficial, a.-* 

K — Calomel 

Pulv. amyli 
li — Zint'i oxid. 

li — Aristol or 

Kurophen . 

I*ulv. iimvli 

Wiicn tht'H' is trouhlesonie ulceration the following powder 
iMMV l)c used: 

K - lodnforni . 

Pulv. hornric; acid 


'Hm' odor of tilt' ictdofonn should he disguised by the addition 
of a few j^faiiis of ('((uniarin. 

Oiiitineiits are I'arety serviceable on the genitals of women with 
herpes progeiiitalis. 



rather rare affection, which is also called "serpiginous 
;ular (iefjeneration of the nyiiiphie" and "projjressive cutaneous 
ttrophy of the vulva," is observed chieily in women of advanced 
life, but cases have been reported in which the disease began about 
the thirtieth and fortieth years. It is a disease of chronic, persist- 
ently progressive development, and results in much destruction of 
the tissues of the external genitalia. During its course it renders 
coitus painful and often impossible, and when the destructive 
change-s have become fully developed intnimission nf the male 
orgau is wholly impracticable. 

This morbid condition begins with soreness, pain, and pruritus 
about the small and large labia, which are either continuous or are 
subject to more or less severe exacerbations. In all cases the 
parts are very sensitive to the touch. In some cases the pruritus 
is so severe that the patients vigorously scratch and tear the parts, 
and this leads to an intensity of their disonler. 

In most cases the disease begins about the region of the clitoris, 
and from there extends over the whole external genitalia; hut in 
some cases its development is unilateral. 

\Yhen first seen kraurosis of the vulva ap[>ears in the fonn of 
one or many rather small areas of thickened antl reddened mucous 
membrane, which is of a bright-re<l and even purple color. These 
chronically infhinied areas in the course of time U-come gradually 
more and more Ijlanched, until in the end they are shiny white 
and scar-like. As une group of these areas is becoming pale and 
atrophied, new red inflammatory ones form, until in the end the 
whole vulva is the seat of a firm fibrous membrane, which may 
be traversed by scar-like bands, which are particulariy well 
marked around the vaginal orifice. The original intensity of the 



morbid process is in the tissues of the clitoris, around the uretJirai 
orifice, auif the iiUroittis vaj^inie. From these centres tliey extend 
outward and forward toward the anus, which l>ecomes piicircleil 
by the atrophic process. When the inflainmatury iM)[iditiun 
attacks the small nymplite they are at first somewhat increased 

Fi«. Ilfi 

Showing tttrectefl iireii, wiili ooiitnicled va^nal orifice. 

(After BnlHynml Willtanu.) 

in size, Uuf mIh-m atntphv lie^ns to develop they >!jadually mell 
away aru! I>ecnn»e continuous with a similar condition of tlic 
internal surfaces of tlie labia niajora. 

A very j^raphic illustration of this destructive vulvar aJTectioti 
is sho\ni in Fig. 115. It will l)e seen that the urethral orificr i« 



S^yet patulous, but that it is surrounrled by the expanse of fibrous 
nicinbranc, which has so stenosed the vaginal orifice that (»nly the 
tip of the little finjjer etiiild Ih' intnHhiced a verv short distance. 
The anal oritice wius likewise contracted, but its function was not 

Etiology. — Xo scientific statement can be made a* to the cause 
of the aU'ection. It sectus cerliiin tliat sypliilis is not in any way 
an etiolojjical factor. Whether vapinal discharjres or irritative 
conditions of the external fennile genitaha, wliich may lead to 
pmritus and dennatitis and the conse(|uent s<Tatchin^ and bruis- 
ing of the parts, are the exciting causes, it is im[M>ssiblf to say. 
It has been suggested that (1) removal of the uterine appendages, 
(2) artificially induced mcnopans*-. luid ('!) diseaM* ttf the [wriph- 
cral trophic ricn'c filaments may be tlic i-titjloi^cal factors; but 
no precise statement cim be made. 

Pathology.— The disease is essentially a chrunic [iy|)erphusia 
of tlie sulMMitaneons tissmvs and coriurn, whicli later on undergo 
atrophy, with thi' formation of scar-ti.ssue and shrinking of the 

■ vulva. An exhaustive study of this subject, illustrated uith 

' photomicrographs, will l>e found in tlic essay of Baldy and 

^ Williams.* 

f In a more recent essay P. Jung' gives the results of his studies. 
According to him the morbid changes consist of inBltratiou of 
small cells, liy^H-nt^rnia and odema, Inssof elastic fibres, and partial 
sclerosis of the comiectivc tissue of the coriuin. According to 
Jung the histological <:lifTerence between a well-marked case of 
kraurosis and chronic vnh'iti.s is not cpud tativc and not ipinntita- 
tive; for (his reasmi the author hiLs convinced himself tlnit the dis- 
ease cannot be looked upon as an entity but must be cojisidered 

^■as the terminal stage of chronic vulvitis, 'llie causes which under- 
lie these conditions are pruritus, chronic vagina! discharge of u 
Specific or non-specific cliaracter, diabetes, sypliihs, ma.sturbation, 
|ancl ueopl&sms. 

' American Journal of the M«tlica] Seiencea, November, 1899, p. 528 et sec|. 
' ZeiU<ch. tiir (ieburuh. u. <iyniikn)ogie, 1903, vol. Hi., No. 1. 


Treatment. — In the early stages of kraurosis vulva? care should 
Im* taken that all irritating seeretions shall he systeniatirallv IreateH, 
and that frequent antiseptie vaginal doucbe.s shall be used. Loeall}' 
soothiug applications to pruritic and inHamed areas should be 
used in the shajM? of ointments or lotions of carbolic acid, cocainf, 
eucaine, aiitipyririj iocl<ifi»nii, iclithyol, according to indications. 
In some cases watery solutions of nitrate of silver, of the strength 
of 5 per cent, or of penuanganate of potassium, 2 per cent, may 
give ease and comfort when pruritus and dennatitis are trouble- 
some. When the disease is fully developed it may be necessary, 
after proper prejjarations of the patient under strict antisepsis, 
to dissect out the scar-tissue from around the vaginal orifice as 
far down as the margin of tlie anus, and then to apprtiximate the 
lu'uhhy skin and mucous membrane by means of continuous 
anil interrupted sutures of silk or silkwonn-gut. The vagina 
.should be packed wi'tli iodoform gauze and sterile gauze, held in 
place by means of a T-bandoge. The patient should be carheter- 
ized at each dressing. As a result of this operation the patidou^- 
ness of the vaginal orifice lias been restored and satisfactorv coitus 
has l>een rendered possible. 

Perri[i' lays stress on the necessity of early radical surgical 
inten'ention and claims that it ^ves the best results. It is (he 
only treatment which will exclude the always dreaded develop- 
ment of epithelioma. We tire to interfere before any vestige of 
epithelioma is present, just as soon as a diagnosis is made. T\ie 
radical operation removes all annoying symptoms of the <lisea9c. 


* Annalvtt de Dennatologie et de Sypliiligraphie, 1901. Tome ii., p. 21 f>t leq 



'l^us utfectioii, which as also called noma pudemli, is tonday 
very rare in consetjuence of the pn^^ress in asepsis and antisepsis. 

It was fonnerly not unconimon in public institutions, but it is 
heconiitig rarer every year. 

In past decades vulvar and buccal noma in children between 
two and three years old and as late as the tenth year were some- 
what frequently observed, and often in institutions in a quasi- 
epidemic fonn. It was seen as a secondary affection iti cases of 
and following measles, scarlet fever» ervsi|H'las, typlioid fever, 
diphtheria^ ami ej>idemics of aphtlious sore mouth or the same 
affections of the genitals. 

In children it was observed in weak, dirty, and uncared-for 
suhjects, and was usually the outcome of squalor, amemia, and 
adynamic conditions. In adult women tiie affection is very rare. 
and is usually the result of injury in childbirth, chiefly from long- 
continued pressure of the head in the third stage of labor. In 
some cases it has l»ecn a sequela of typhus, typhoid, and the 
exanthemata. It is also seen in cases in which women suffer 
from vulvar or vaginal discharges incident to some inflammation 
of the genital organs. 

In a period of twenty years in the City (Charity) Hospital 1 
saw two cases of gangrene of the vulva unconnected with chan- 
croids and syphilis in healthy young women in whom'ut* existing 
cause whatever could l)e ascertained. The ravages produced by 
this microbic affection are well shown in Plate XIII. In chil- 
dren the invasion of the affection is attended with a general 
febrile movement and the process is attended with a general ady- 
namic condition. In older subject:^ the systemic reaction at first 



may be slight, but during its course more or less severe fever ami 
pri>stratioii may In* present. 

Tlie onset of gangrene of tlie vulva is usually mild. Patients 
complain that they experience a buming pain in the vulva, usuiillr 
low down and seated in the larger or smaller labia. It is probahle 
that these parts soon become much swollen and very red. Tlifn 
the extension of the afTection begins in earnest ami we find over 
the labia major and on the parts l^eyond a grayish-brown hrawnv 
surface, which is at first tender to the touch. Usually the exten- 
sion of the affection, unless treatment .intervenes, is very rapi*l 
(the French use very appnipriately the wonis tapidUi: fffrayanU), 
ati<I the whole vulva and the adjacent parts, the perineum, anus. 
thighs, anteriorly ami posteriorly, and as far as the sacrum or the 
inons veneris, are invaded. The affection may travel up ibr 
vagina, and i( }ia.s l>een known to perforate the |)eritoneiim. In 
this condition t\\v suffering of the woman Is seven*, and mrireorless 
constitutiiKuil disfnrlwiiur may 1h' observed. With the ilrveloiv- 
ment of the tumefaction t»f lite \tnris gangrenous spots appear. 
\vl»ich are ut first deep red, then bluish-red, and then they ulcerate 
and become necn)tic. The (h.s<'harge of pus and sanies is very 
pn>fuse. The odor given off from these surfaces is very penr- 
trating, being even <lisgusting and sickening. With the deveJop- 
Tiicjit nf the ^jangrene the entire tissues of the muc<His menibrvne 
and adjoining skin art* destroyed, and the process may not stop 
imtil the muscles and fasciie are denuded. Sometimes sjkonta- 
neously, and again as the result of treatment, tlic morbid proceAS 
seems to have ex|)eiuled itself and a Hue of demarcation forms, 
(Jeneraliy the reparative pmccss sets in, the sloughy surface.s clear 
off, and healthy granulations spring up. 

In Plate XIII. is graphically shown one of my cases. 'Hie 
extent and'depth of the destruction of the tissues is very apparent. 
It is cleaHy evident that the gravamen of the microbio attack 
was in the deep and posterior parts of the extenial genitals. 

It has been observed that when the vagina and dee|MT part* 
have l>een attacked vesicovaginal and rectovjiginal fistulie and 
atresia of the vagina Iiave been produced. 



The fim-j^oin^' ilesoription will alsci apply to the gangrene due 
to parturition tniunia. 

In niy cases healing may be said to have rather promptly taken 
place. It was a matter of surprise to nic how nuich the repara- 
tive powers of nature do for these women. 'Hh' woman whose 
ease is jxirtrayeJ had lar^e cieatnceH of the anterior parts, luit 
B she was left in a condition favorahle to coitns with her hushand, 
and she retained the power of nearly f)t'rfei*l (lefet^alicjn. In 
some women such is the stenosis of the vagiiiu *hat coitus is 

DiagTiosis. — As a rule careful inspection of the genital parts 
will enable the surgeon to piromplly nnike a corre<'t diagnosis. 
He cerlainly will not be in donbt more than one or nu>re days. 

(_K<lema of the vnlva is not attended with such formidable symp- 
toms, and in dijvhtheritic and aj>hthous vnlvitls the presence of 
false membranes (and perhajjs the coexistence of diphtlicria and 
sprue in the same suliject or some other contiguous person nniy 
point to those forms of infection). 

Pathology.— Microscopic studies of the crusts and pus of my 
second case simply showed myriads of streptococci and staphy- 

Ilofman aru! Kiister' claim that they have succeeded in isolating 
a specific an^l hitherto undescribed bacterium from the tissues 
of a case of this affection. If the necrotic tissues be examined a 
great variety of germs, including staphylococci, streptococci, and 
diphtheria liacilli mny be detected, but in the cIccjmt strnctun's. 
wiicre iuthirnmHtion is just beginning, only a short, slightly c»irv*^J 
bacillus is found. This grows well on all culture media, but ii» ool 
identical with other microbes previously isolated in nomiu Tlir 
spirillum grows best in the j)rcsence of oxygen, is grani-nc|CBft^, 
and ftjrms long duiins. It may also l>e stained directly in d^ 
tissues, but here it appears more like a bacillus. 

Treatment. — (irmgrene of the vulva l>eiMg a l<Kal Hi.- <' 
process calls for thorough and energetic antisepsis. U i.*^-: -*- 

Munch, med. Wochrasch., Oct 25, IVOi 


the parts, superficial and deep, having first been thoroughly irri- 
|y;ated with wann sublimate solution, should be covered with asep- 
tic gauze continually moistened with the same solution, 1:2000 
or stronger. Hot sitz baths alkalinized with borax or hirar- 
btfnateof stnla should he empkiyed several times a day if possiliU'. 
When the gangrene has fully set in, it may be necessarj' to use 
hot charcoal pinjitices in alternation with the warm sublimate 
gauze. When the line of demarcation has fonne<I and the netnj- 
tic crusts have been cast off iodoform may be applied witii great 
care for fear of toxn?mia; or aristol, nosophen, or antinosin may 
be employed. Wien a granulation surface has formed the Ireiil- 
aient should be on regular surgical lines. In such cases balsam 
of Peru is very useful. Later on It may be necessary to apply 
solutions of nitrate of silver, 1 to 10 |>er cent., to check exuberant 
granulation and tr» produce complete healing. The generul 
health of the |)atient should be carefully looked after and con- 
served, and symptomatic ruedif-ation should l)e employed as 
may be necessary. 

It is interesting to note that phototherapy is reconled to have 
pri>duced a cure in this Molshan* reports a noteworthy 
case. The patient Avas a nine-year-old boy, who after having passed 
successfully through scarlatina, varicella, and measles devrlojied 
noma of one cheek, which went on to perforation. Imme<iiately 
upon the admission of the case to the hospital the local anc of 
rrd rav's l>y means of a 16-candle-power incandescent lamp with 
a red globe was resorted to. The wound alone was cjcposed U) 
the rays. I'he results of this treatment were s(x>n npparent. On 
the third (hiy pain disappeared. Seven days later the anterior 
ludf of tiie wound was filled with granulations. The nwriifir 
areas gradually diuiinLslicd. Two months later the patient wa^* 
presented before a medical society entirely cured. 

Arch, fiir Kinderheilk., 1905, vol 

No6. 4 to 6. 



The subject of traumatisms in the female due to coitus has 
received rather scant tieatment in Anglo-Saxon literature, and 
beyond the report of a few scattered cases no information is acces- 
sible in America or England. The subject, however, is of the 
highest importance both to the clinician and the expert medico- 
legal witness. 

In several text-books on legal medicine there appears a skeptic- 
ism in regard to the ability of the penis to cause serious injury 
to the female genitals, and the expert opinion appears to have 
been that such njuries were really due to other agencies, such 
as the introduction of the fingers, hand, foreign bodies, or various 
instruments. In some cases the etiology is more or less doubtful, 
but we positively know to-day tliat the penis alone is able to extensive lacerations of the female organs. Gynecologists 
know of such cases, and a study of the literature shows that such 
injuries are of more conmion occurrence than is commonly taught 
by authorities. 

The literature of this subject is found hir»:ely in Russian and 
Grerman journals, while some <ast's Iimvc been observed in France; 
a few reported occur in English and Anicrican medical 

It is to the credit of F. Xeugcbuuer' that he has made an ex- 
haustive study of the entire subject, that he has collected 150 
miscellaneous cases, has added several of his own, and has sub- 
mitted this mass of material to a comprehensive and scientific 
analysis. One wlio writes on this subject nuist of necessity follow 
the initiative of Neugebauer. 

^ Vemis Cruenta Viulan.s Interdiim < )cci(lenK, .Monanwchr. fiir OebiirtRhiilfe 
und Oyniikolo^ne, ISHD, ix, p. 221 et seq. 


[ shall encieavor by the citation of many cases an<l by a critiral 
Muinman' to give a clear idea of the whole subject. 

It \& generally known that a tear in the hymen i.s a simple matter^ 
that it occurs in most cases of first coitus and is attende<i witli 
slight hemorrhage. When, however, the tear extends beyond the 
Imse of attachment of the hymen into the vaginal walls severe 
licniorrha^' may occur. It is very rare, however, for a fatal 
result to follow this quasi-physiological process; but in a case 
rejK)r(ed by Zeiss' an unusuiilly deep tear of the h>7Hen of a virpin 
at the first night of marriage gave rise to such profuse hemorrhage 
that the girl died. 

Neugebaucr reports the following case: A woman had a severe 
hemorrhage from the genitals on her wedding night. She was an 
nndfvol(>pe<l prl i»f sixteen, aim*mic and rachitic. Iliert was 
a history of lwi> attempts at coitu.s, the sccoikI of which was 
attended by great pain and followed by bleeding, which would 
not yield to hieniostatic measures. The author found evidences 
of profuse heniorrhiige, with a hivmatonm of the right labia 
iiiiijiis. 'Hk* hyiiKM\ had not been nipture<l, and the left labium 
mujus wji.s inliicl. 'Hirrr was a laceration of the right lnl>iiim 
niajns I cm. Inn^, while (he corresponding labium minus was 
tr'demai<ju.s and l)hii>ih-red in color. There wius constant (H>7ing 
from tlie wouml. Inlruthiction of the finger showed a false ()assage 
filled with clots. The penis bad made an artificial route for itself 
ill the paravaginal ti.ssue. A tam|;^»nHtle failed to pro<luce ha*mo- 
stasis, and it became necessary to lay oj»en the bleeding area and 
ligate. The author explains the pe<-uliHr injury by the instinctive 
efforts of the bride to avoid the penetratiim of her umlevehnje*! 
organs by her husband. He <'alls attotition to the fact that the 
riglit side of the vulva is the one nH>rt» liable to suffer, aiding 
tliat the woman moves naturally to the left in avoiding the pain 
of coitus. 

(>. Frankel* a'ports a case in which he was consulte<l by a 

' (.'wuntlKUu nir <iyn.ik*ilogie, Kebrtiary 21, 188.*i. 

' MonaUwchr. f. iiebiirUh. unci Gyniikal, 1903, xvtii> 374. 


brltle of tliree days for liemorrha^ from the genitals incidental 
to first successful coitus. External genitals were intact, save for 
a tear in the hymen extending to the base. Vagina ample in size. 
Sagittal tear was found close to junction of uterus with vagina in 
lateral fornix. Husband's penis was normal in size. 

The early attempts at coitus had failed, the husband lacing 
unable to penetrate the vagina. During the third night the wife 
awoke with intense sexual desire, and sat astride of her husband^ 
he l)cing at the time in a high degree of excitement. The pt»nis 
fwnctrated at a single impulse, and great pain and hemorrhage 
followeflj although the coitus was completed. Within a quarter 
hour tlie gravity of the hemorrhage was realized and the* surgeon 
was consulted. Active hemorrhage had ceased, but the vagina 
was distended with clots. From the ragged and deep character 
of the wound in the fornix the writer assumed that coitus took 
place within it, including ejaculation. Both the wound and 
vagina were tamponed. Healing occurred without complications 
or secjuelfe. 

The writer regarded as causal factors the congestion induced 
by prolonged sexual excitement and a tonic contraction of the 
smooth muscle of the vagina due to same cause, together with 
the unnatura' attitude assumed in copulation, 

Chadwick' reports the case of a healthy woman, agcil forty-eight 
years, who hud lyeen six years married to a sailor, with whom she 
hail had repeated coitus. In December, 1884, he returned after 
four months' absence at sea and had coitus. The act was accom- 
pUsheil with difficulty, and as a result the woman suffered intense 
pain on the r'ght s de, internally, ami profuse hemorrhage. On 
examnation senile atrophy, the vagina being shorter and smaller 
than normal, wa.s found. On the right side was a fresh long tu<rmal 
rent ati inch long and half an inch deep in the upper thinl of the 
canal. It is difficult to explain why traumatism had not occurred 
before, since it seems incre<lible that atrophy so marked should 
occur in four months. The woman recovered. 

■ Boston Mett. and Surg. Journal, April 30, 188fi. 


MuikU'^ n^ports two cases. The first wn-s that uf a young woman 
nmriictl on the previous day, who the next morning was weak frum 
loss of blood. Inspection showed blood trickling from the vaginal 
orifice and a slight rent in the h^^Tnen at the left anterior lx)itler. 
'Die vagina was much distended from the escape of blood inward. 
On examination a deep fissure an inch long extending from the 
lesion in the hymen passed inward parallel with the urethra. 

The second case wa.s tlmt of a young woman aged twenty-two, 
who was married on the previous day. The next morning she was 
found nearly exsanguinated. She stated that coitus had been 
performed but once toward morning, was painful, but that she 
hafl fallen asleep. She awoke sonic hours later and found her- 
self ill a pL>ol of blood. By means of a Sims spTulum a deeii 
reiil was found in the left vaginal wall, extending from an inch 
alHfve the liymen nearly to the cii!Hle-.sac. 

In neither of these cases was there any tlLspnjporlion of liie 
relative sizes of the organs, nor was any unusual violence used. 

The vagina of both women was healthy. 

Price^ reports a case of vulvorectal fistula from coitus on (he 
wedding night in a woman aged twenty-two. Bleedijig persisted a 
month. Directly after first coitus feces and flatus escaped from 
vulva. Pain aiid hemorrhage followed each coitus, and eventually 
complete fecal incontinence resulted. Hymen found intact, and 
close beneath its base was found a transverse tear of fossa nari- 
cularis one and a half fingers' breadth in width, entering rectura. 

Revcrdin^ had under observation a woman age<J twenty-lwo, 
whose first coitus occurred four years before, when she bled pro- 
fusely. Four years later she had coitus with a new lover with thr 
same result. Hcverdin found that the first lowr had torn awav 
the hymcnial attachments without disturbing the integrity of mem- 
brane; while the second had entered by the right passage and 
ruptured the hymen. "^Plie first lover is said to have had a penis 
of unusual size. 

■ Boston Med. and Surg. Journal, Majr 10, 1885. 

* Obfitel. Qaxetle, Maj, 1886. * Arch, de Tocologte, IHgS, p. ItOt. 


Skrobanski* reports the case of a healtliy peasant woirian aged 
twenty-two years, who suffered a rupture of the perineum during 
the first attempt at coitus on her wedding night. The tear was 
about 2 cm. in depth and did not involve the anus. The wound 
was washed out and tamponed with iodoform gau7x^. Four days 
later the wound was healed and the patient was allowed to return 
home, but was cautioned not to permit coitus for some time. 
She did not return, and when hunted up a week later was found 
to have disreganled the injunction of abstinence, but with no 
evil results. 

In the Li/on M^dical^ July 8, 1900, is recorded the case of a 
woman in the ninth month of pregnancy who had intercourse 
twice in succession in a standing position. After the serond onset 
she cried for help, losing a large* quantity of lilood by the vagina. 
Twenty minutes later she died. At the autopsy a rent measuring 
2 cm. in length and A em. deep was found below and a little to 
the right of the clitorb. It had encroached upon the wall of the 
urethra an<l the right corpus cavemosum of the clitoris. The 
bottom of the rent was occupied by blood clots and small gaping 

A Parisian hainlrcsscr is sai<! to have caused the death of his 
three wives through [}erforation of the posterior fornix, 

Hermes' reports a case of vagina! injury in a young woman 
who pcrmitfed coitus in acarriage and during the act thn-w herself 
violently to one side. '^Fliere was a deep rupture of the right 
lateral wall of the vagina, with severe hemorrhage, which was 
controlled by tamponade, llie causes of tlie ruptun^ are ascribed 
by the reporter to excessive sexual excitement and to the abnormal 
position duritig coition. 

Ballin^ reports the case of a woman who suffered extensive 
lacerations of the vaginal walls during her first coitus. She 
was twenty-five years old, and the sexual act seemed to have 
been perfectly normal, according to her account, except that 

■ Vnttscb, December 4, 1899. 

' Centmlhlatt fiir Gymikologie, August 9, 1902. 

» Vralach, January 16, 1905. 



she had held her knees bent upon her abdomen, pressing 

them ilito this position with her hands. Very pnifnse henwr- 
rhage c»4M'urie<l after the aet. The external genitals were unin- 
jured, but two tears passed through the hymen down to the 
base of tliis membrane. The vagina was filled with blood clots, 
and the posterior vault showed a transverse laceration, which 
included a part of the left fornix. The small virgin cervix was 
completely torn away from the posterior wall, and was drawn 
forward. The author attriiMites the vaginal rupture in this case 
to a congenital rigidity of the vaginal walls, and not to an}'thing 
unusual in the sexual act. 

Ceal4c,^ of llucharest, reports the case of a woman, twenty- 
tw^o years old, who was described as of delicate build, while 
her hasband's penis was found to be abnonnully large. On the 
nuptial night he made three fruitless efforts at intercourse. 
In the fourth attempt he perforated the rectovaginal septum, 
making an opening an inch long, and lacerated the perineum. 
The wornLin stated that she had lost a good deal of blood at the 
time of receiving the injury. 

The following nine cases are worthy of reproduction. They 
an' here reported with much brevity. They first appeared in 
prominent medical jouniaLs: 

1. A girl indnlgcd in coitus three times in succession. After 
the thirtl time a profuse hemorrhage. Vagina duplex, the left 
side wider. Ixjss of blood due to rupture of the inter\*aginftl 
septum at its lower portion. I^aceration of posterior fornix, 
exposure of peritoneum, pr*ifuse hemorrhage. 

2. An Arab aged sixteen niarried an tindeveloped girl of eleven. 
She dieil of hemorrhage on the wedding night. I^aecration of the 
labial commissure, destruction of navicular fossa, rent in posle* ^H 
rior fornix 49 mm. witle, whicli ojjcned into the peritoneal cavity. ^^ 

3. VVcunan, aged Iweuty-tbn'e years, married four months, com- 
plained of escape of feces and flatus fnmi vulva. Intad hymen 
biforis. Close beneath its insertion a rectovidvar fistida, readily 

KevisU de Chirurgia, iy04, No. 6; Centralb. f. Qyniikologte, March II, 190i 




admitting index finger. Beueatli fistula a cicatrix. On wedding 
night sjxiuse liad vainly sought to enter vagina. Finally the wife 
felt great pain and lost consciousness. Escape of flatus by vagina 
noticed three days later. Later attempts at coitus caused fresh 
pain and hemorrhage. 

4. Lacerated aiul contused wound at introitus vagiiue in eigh- 
teen-ycar-oid virgin with rudimentary vagina, and probable 
absence of uterus and ovaries. Penis tlid not penetrate, but tore 
left liil)inm rnajus from vagina and urethra. Wound renched 
from mons veneris to anus. Hynioti torn. Vagiiui a cu!-:k-sac 

h cm. deep. 

5. A woman, motherof several children, had intercourse with 
her husliand, both lieing drunk at the time. Profuse blefnling. 
Transverse tear of posterior fornix, iS or 4 cm. wide. Tam- 
ponade. Recovery. 

I C. The patient was aged seventeen years and had Wen <leflow- 
ered. Although the hymen had l>een ruptureil, the penis hai! made 
a false passage in the paravaginal tissue and the pusl<*rio[' vuginal 
wall. The passage made was 8 cm. deep. The patient recovered. 

7. Girl aged nineteen years. Severe pain on coitus duriug wed- 
ding night. Ble<J for a week. Urine came away fnjm vagiim. 
Hymen found torn in two places, with vesicovaginal fistula close 
Ijeneath cervix, due perhaps to pressure-necrosis following hemor- 
rhage into vesicovaginal .septum. Laceration of entire posterior 
vaginal fornix from coitus, extending to right and left. Perineum 
intact. Seven haemostatic sutures requiretl. During coitus woman 
seated, man stood. Penis of unusual size. Uterus retrofiexed. 

S. A Jewess, agird twenty-three years, since wedding night three 
days before had had pain in anus with difficult locomotion. First 
coitus painful, woman bled freely and fainted. Hymen intact. 
Fnemduni labiorum torn, laceration ex1en<ling thnjugh sphincter 
ani. Diagnosis: n*ctovaginovulval fistula plus laceration of the 
sphincter ani. 

9. A woman aged thirty-one years; the bridegoom unable for 
two nights to enter vagina by reason of pain. On third night in- 
tromission of penis followed by escape of blood and feces. Latter 


afterward came away fi"om vagina exclusively. A ileuse li>Tnen 
had caused penis to make a false passage. Initial wound in fossa- 
navicularLs. Canal in rectovaginal septum, ending in pet'tiini. 

Various explanations are given to the predisposing causes of 
trauma in coitus. Bohnstcdt* offers the following explanation: 
He assumes a cramp which takes place in tlie muscular tissue of 
the vagina and of that outside of the vagina, especially the pelvic 
floor, which results in a most vigorous and resistant tonic stale of 
the entire region and is probably referable to neuropathic condi- 
tions. The suggestion that this neuropathic state might after all 
be the cause of such accidents was presented to him by the result of 
an attempt to suture the part,s damaged in one of his cases. Dur- 
ing the operation precisely such a cramp or spasm took place* and 
hindered the placing of the sutures to a marked degree. While 
it is not necessary to assume a basis in neurological pathology, 
It is possible to grant that such a spasm, no matter what its source 
may be, would certainly \'ery largely account for this unfortunate 

On the other hand, Finkelkraut' formulates his views upon the 
etiological factors as follows: (Ij Abnormal erection of the jxrnis 
during coitus. Normally the penis passes along the posterior wall 
of the vay;ina. In retroversion, as well as during coitus, the uteru.s 
sinks downward and backward; thus the stretched posterior 
wall is easily ruptured by the abnormally erected penis. (2) In- 
sufficient development of the vagina or the weakness of its walls, 
as in cases of senile atrophy of the genital apparatus. (3) Too 
great a disproportion between the male and female genital organs. 
(4) Extremely impetuous coitus with unusually violent erection- 
In his cases two of the etiological factors were present — atrophy 
of the vaginal walls and nbnonnally violent coitus. 

An analytical study wa-i made by Neugebauer of his own rases 
and those he collected in literutiirc. The results of this analvsis 
are very interesting and important, and are worthy of careful 



* C«ulratbliitL fur OyDukoLogie, Noveiuber 17, 10OS. 
' GasvU Lekareka, No. 7, 1896. 



study. The combined material amounted to 157 cases, which 
represent injuries occurring in a quasi-pliysiologiral act. These 
injuries were due to various factors, such sis brutahty, drunken- 
ness of one or both participants, anatomical disproportion, unusual 
copulating |josition, ami pathological conditions of the female 

Of the 157 females, but 12 could be regarded as children. Only 
2 were prostitutes. In 28 cases the coitus represented a rape. In 
7 the man was drunk, and in 4 both participants were in this state. 
One of the women was menstruating at the time, and I was preg- 
nant. In 4 cases the woman had not long been delivered, and in 
6 cases they were of climacteric age (forty-five to fifty-eight). In 
53 cases tlie women were alreaily married, 39 cases being acci- 
dents of the wedding night. In 7(> cases the women injured were 

In 15 cases the women had cohabited for years, and in 12 they 
had borne children. Every degree of social status was repre- 
.sented, and 2 women were wives of physicians. 

The immediate consequences of injury were pain, hemorrhage, 
synco[)e, acute amrmia, fever, septiciemia, pyirmia. When death 
occurred the cause was hcmoirhage, peritonitis, septic para- 
metritis, etc. 

A considerable degree of hemorrhagic was noted in 72 cases 
and acute amentia in 40. 

In 2 cases the women were brought to the clinic with erroneous 
diagnoses (typhoid and cancer). 

In 2 cases the accident occurretl while in the bath-cabinet; and 
in 3 cases an abnormal position was assumed in coitus. 

There were 22 fatalities all told from hemorrhage, sepsis, peri- 
tonitis, etc. In a single instance death really occurred from 

In regard to predisjxising causes in apparently normal women 
there were 1 case of rudimentary development, 6 of climacteric 
changPH, several of j)uerperal uteri, and several of congenital or 
HC(pnre<l malformation. There were further 4 cases of recent 
operation for pt*rii»eorrhaphy and vesicovaginal Estula. 



Of other predisposing causes may bo mentioned retroflcxed 
uterus; romplete atn\sia of Innnen; rigidity of hymen (not un- 
(^oinnion in the elderly); al>senee of vagina; hymen hiforis (twice); 
vagina duplex (three times). 

In regard to localization of injury: in 22 cases there were simple 
tears of the hymen; in 17 the liymt^n was torn from its insertion 
without damagt* to the fonimen; in 13 the hymenial rents wen- 
prolonged into the vagina; in 22 there were longitudinal lears 
of <lie vagina, either poi^terior or lo tiie right; in 38 there wert* 
lacerations of the posterior fornix, 17 case-s of which extendeil 
into the parametrium, ami 4 into the peritoneal cavity. In bul 
1 case was there a laceration of the anterior fornix obsen-cd. 
There were 2 lacerations of the urethra and 1 of the clitoris. 

Five cases of artificial opening into the liymen IjcIow the natural 
foramen give the impression of a hymen biforis. 

Naturally the different injuries gave rise to various kinds of 
iistulii'. Of these there were 4 rectovaginal, 14 n^ctovulvar, I 
vidvovugintt), 3 rectoperineul, 3 vesicovaginal (reopening of okl 

Ill 4 cases the injury might he termed a peritoneovaginal 
fistula. The sphincter ani was torn through in cases and tlir 
rectovaginal septum in 3, 

'I'here were 12 cases of false passage into the paravaginal 

The hymen remained intact in 7 cases, although the women , 
had had coitus. ^H 

The right side of the vagina seems to be the one much more ^^ 
liable to injury from coitus. 

Vaginismus was not recorded in Neugebauer's statistical studv. 
It apparently plays little or no part in cases of injury in coitus. 

In tills c*mnection it is interesting to know that Tardieu, "Etude 
mr(iirtt-lf(/aie .tur Irs aiintfata mix nuyenrs* (Paris, 1S78), hii> 
descrilMMi 55 easels of rape, chiefly of childn?n. The injuries 
inflictcil on the genitals were not <lue necessarily to the ym^xxxs, 
l>nt to other violence as well (the hand, etc.). In a certain num- 
ber of cases the victims were afterward suffocated. 



Treatment. — In most cases of rupture of the hymen little need 
be done other than to employ antiseptic irrigation and to interpose 
a sterile tampon of gauze or absorbent cotton if the oozing per- 
sists. Such cases usually heal rapidly. \Mien the hemorrhage is 
more copious and when pain is experienced it is most important 
to make a thorough examination. The usual course in these 
cases is for the medical attendant to assume that the case is trivial 
and commonplace and that the lesion is limited to the hymen. 
A perusal of the foregoing cases will clearly show how severe and 
more or less deep seated these traumatisms may be, hence the 
necessity for a thorough examination and exploration of the deep 
genitalia. In all cases the most thorough antisepses must be 
adopted. All tears should be freely irrigated with hot antiseptic 
solutions, and when indicated tampons should be inserted. The 
severe order of laceration should be first carefully diagnosticated 
and then treated on the special surgical lines by suture and tampon- 
ade, and if necessary by plastic operation. 



Tt is noticeable that in the various text-books on diseases of 
women little if any iiiforniatioii on broad ground is given con- 
cerning hypertrophic lesions and simple new-growths of tiie vulva. 
In a number of scattered c^ssays these important subjects have 
l>een considered, but no definite and systematic description of 
theui ha.s been given. A fair presentment of the discordant views 
held t(nlay regarding .simple (and by that I mean all processes 
not included under the head of malignant degeneration) hyper- 
trophic and ulcerative vulvar lesions is as follows: 

L That they are identical with Iujmis or the estliioni^ne of 
Hugnier and French authors generally. 2. That they are the 
result of essential and specific syphilitic processes. 3. Tlmt they 
are the result of some indeterminate ulcerative process. 4. lliAl 
certain cases may be the result of tuberculous infection. 

It may be further added that certain of those who do not accept 
the lupus theory UmjIc upon these affections as being peculiar 
and even extraordinary, and while some even regard them as 
mysterious and specific, they only indulge in generalities in speak- 
ing of them. 

This being the condition of the uncertainty of opinion und of 
the inadequacy of systematic description, I availed myself, during 
a period of many years' service at the Charity Ilospitid, of Ihr 
opportunity to study these lesions on many thousand cases of 
women with sexual and genital disorders. As a result of these 
obsen'ations, supplemented by microscopic study, I have reached 
the following conclusions: 

1. That a large and perhaps the greater number of chnmic 
deforming vulvar affections are due to simple hyperplasia of the 


tissues, induced hy irritating causes, inflammation, atid traunia- 
tisms. 2. That chronic clmncroid is a cause in a certain propor- 
tion of cases. 3. That inany cases ai'e due to essential and spe- 
cific syphilitic uiBltrations. 4. Tl»at other cases are caused by 
the hard oedema which ()fU'n complicates and surrounds the initial 

• sclerosis and p€»rhaps gummatous infiltration. 5. That many cases 
are due to simple hyperplasia in old syphilitic subjects who suffer 
from chronic ulcerations of the vulva long after all specific lesions 

• have departed. 6. That some cases also in oUI syphilitics are due 
to simple hyperplasia without the existence of any concomitant 
ulcerative or infiltrative process, and seem to be caused by con- 
ditions which usually in healthy persons only result in %Tjlvar in- 

In the f()regoing categories the acting, contributory, and rt^mote 
causes are briefly outlined. 

Tlie systematic division of these new-growths and hy[M»rtro- 
phies i.s very essential in order that a clear and couiprt'hcnsive 
knowledge of them may be gained. My studies have convinceil 
me that this subject can most lucidly l>e treated by the recital 

• of the facts pi*esented by the smaller orders of lesions, which form 
an excellent grountlwork for a clear knowledge of the larger ones. 
Clinical observation shows that these lesions are divisible in the 
following categories: 

1. Small hyperplasia*, caruncles, and papillary gR)wths. 2. 
Large hyperplasire and hypertrophies. 3. Hyperplasia resulting 
from acute and chronic chancroids. 4. The various forms of 
hypertrophy induced by the indurating ccdema of syphilis. 5. 
Hyperplasia resulting fnim chronic ulcers, the so-called chan- 
croids, in intermediary and old syphilis. 0. Hyperplasia in old 
syphilitics^ presenting no s[>ecific character and occurring smjn 
or Ujng after the period of gunmiy infiltration, in some cases 
being coexistent witii si>ecific lesions elsewhere. 

The foregoing affections have neither in their clinical liistory 
nor their pathology any resemblances to lupus, nor do they par- 
take iu any manner of the natui*e of lesions produced by tuber- 
^kculous iufectiou. 


In the last periods of many cases in i^ch ulceration and 
destruction are very great, evidences of pulmonary phthisis may 
be seen, but my observation convinces me that the tuberculous 
infection does not occur throu|^ Ihe genitals, but in the lungs of 
women worn and spent with disease. Many authors, particulariy 
French, have lud stress on the point that these vulvar lemons are 
the outcome of scrofula. 

In the following chapters the vulvar affections will be suc- 
cinctly described. 

In many of these cases the walls of the vagina are also involved 
to a greater or less extent and depth. 



Tv general ve^yetations of the vulva may be rln-ssefl among the 
sMialltT growths, though they may iM^come very large. These 
smaller orders of tumors are, first, papillary growths or vegcta- 
tioDSj commonly called warts, anH» serond, hyperplasiie of the 
various prominences, folds, and anfractuosities found witfiiti the 
more or leas complete ellipse formed by the labia minora. 

Vegetations of the vulva may occur singly or in various num- 
liers, and are prone to develop in the vulvar sulcus, chiefly around 
the urethral and vaginal oritices, in children, and more frequently 
in adults, at or beyond puberty. They are commonly seen on all 
portions of the vulvoanal region, and show no tendency what- 
ever to localization to the vulvar ellipse. They are of a pinkish 
or deep-rt^d color, spear-shajxe, digitate, sessile, pedunculated, 
cauliflower-like, or they may resemble strawberries of various sizes. 
They are essentially papillary hy]>crtrophies, and show a tendency 
to exul)erant growth. The latter feature and their tendency to 
irregular and scattered tievelopment are points of diagnostic value 
in separating them from hyperplastic lesions considered further on. 

Thevse vegt'tations l>egin as very minute re<! spots of erosion, 
wlucli soon become elevated, and, if many arc present, tfie mucons 
memhrane at first presents a velvety appearan(*e. In a short time 
thes(* little masses l)ec<jme true warts with more or less papillated 
external structure. Their apj>eara!ice in early development is well 
shown in Fig. 116. They ra|iidly grow largi^r, and eoincidently 
very many new ones appear, until (if treatment or preventive 
means are not adopted) tfie whole vulva and the surrounding 
regions may lie literally covered. The appearance of exuberant 
vegetations on the female genitalia are portrayed in Fig. 117. 


Fig. 116 

Small vegela[iun^ in ti ^nung feniiile c)iil<J. 
Fig. 117 

Eiubertnt T^eUtionit of adult fetuftle geniUls. 



Vulvax Hypertrophy Consequent upon Vegetations. 

There is a form tif hypertropliy of tlie vulvoanal region of 
women which I believe has not heretofore l:>eeii mentioned by 

^r «.i*i 

Showing aimple vegetations in process n( chnnge into fleshy tabs snd 
hypertrophic muinies. 

autliors. The initial stage of this form consists in the develop- 
ment of simple vegetations on any part of the external genitals. 


Owing to neplect, want of care ami cleanliness, and of surgical 
intervention, these growihs become enlargf^, as they also usually 
increase in mimbers. As they grow in height and breadth, par- 
ticularly those on the outer fjortions of the labia majora fwhere 
they arc subject to amtinuous friction), tliey lose their warty 
appearance and come to look like nodules, processes, or tabs of 
skin. They are, as it were, polished off, losing entirely their 
granular^ strawherrj'-like look, and taking on the appearance of 
integument. In Fig. IIS this form of hypertrophy, in its initial 
and advanced stages, is well shown. TUv figure was taken from 
life, from a young pregnant woman who had .sufTered for a long 
time from leucorrhoea, the irritation of which led to the develop 
ment of the new-growths. In the depth of the vulva three rows 
of typical vegetations may be seen, and on the outer edge of each 
of the hibia majora a string of fleshy masses, which had l)eeii 
vegetations, but which had undergone the j>olishing-off process, 
may be seen. Over the perineum are a number of conical tumors 
of like origin, and hanging over the anus arc a large gourd-shaped 
mass and several smaller ones, which had resulted! from the trans- 
formation of several clusters of very exuberant warts. Unless 
ablated, these tumors inevitably lead to great hypertrophy and 
disHguirment of the parts. They, acting as low-grade inflamma- 
tory foci, induce hypcra*mia hihI hy[RTplasia in the vulva, and in 
the end lead to its great distortion. I have many tinu^ seen this 
general bypertrtijjhy of the external genitals by warts, and I 
iTcnll an instance in which these growths, being very large, were 
ablated, and in their stumps hyperplasia took place, which M 
to great deformity. The practical teaching of these cases Ls not 
only that these lunv-gn^wths should l>e thoroughly removed, but 
that great care should Ik' taken that their sites .shall not Imm'oiih- 
the foci of hyperplastic new-formations. 

Hyperplastic Orowths of the Volva. 

Simple new^-gromhs of the vulva have been variously cal 
p>!ypi of the iircthni and of the vagina, hj-pertrophicd carunclca 


-berry-like tumors— villous growths, warty excrescences, and 
papillary polypoid an^^ionia, Thouf;:h there is much uncertainty 
in the minds of medical men as to their real patholog}', and tJiough 
the most varied views are entertained as to their essentijil nature, 
the matter is a very simple one. In my studies of the larger 
orders of h>'pcrtrophies I included a consideration of the path- 
ology and clinical history of these smaller onejs. As a re.sult I 
found that, clinically, the larger growths were but exaggerations 
nf the smaller ones, ami I also learned, thrtjugh pathological and 
microscopic studieSj that the morbid pn>cess observed in small 
lesions can be traced in progressive and undeviating development 
through all sizes of these simple hj'pertrophies until the enor- 
mously large ones are reached. I thus strongly state these facts 
for the reason that I have seen the affection begin in an insignifi- 
cant manner on or within the labia minora, and in the course of 
years eventuate in the development of enormous vulvar h^-pcr- 
trophy. Further than this, I have been able to confirm the <*lin- 
ical facts which I have obsen-ed by what I deem satisfactory and 
convincing microscopic stiidies of the small, intermediate, and 
large lesions which I excised. 

' The small growths of the vulva, which may properly Ix^ called 
hyi)ertrophicd caruncles ami simple hy^ierplastic tumors, are found 
either singly or in n»[nl>ers (tf fnnn two to a dozen or more. 
They are sometimes very small, of the size of a large shot, or as 
large as a pea or a strawl^erry, or even larger. They may pre- 
sent a decided firmness of structure, or they may be soft and 
vascular, and between these two extremes there are many grada- 
tions. They may be of a pale-pink color, of a bright scarlet-red 
tint, of a deep-red, or of a purplish hue. When they are very firm 
the hj'perpla-sia is composed of all the cell elements of the mucous 
membrane and fibrous tissue, and the new-growth of vessels is 
not excessive; but in the softer variety there is a greater amount 
of new-vessel development, consequently they are more vascular, 
of deeper color, ami softer in structure. These facts will fully 
ex{>lain the varying clinical features of density and color. I may, 
in p&ssing, remark that these lesions may five rise to no uneasi- 




ness whatever, but may also be the cause of great suffering, par- 
oxysmal or continued. 

Ur«thral Canmcles. 

On the lips of the meatus urinarius and within tho uttMhra. 
more frequently on its jjosterior wall, one or more small or large 
warts are sometimes seen, and they are then called urethral 
caninoles. It is not uncommon for these lesions, even when 
vpry small, to become extremely sensitive, and even the scat of 
great pain, particularly in urination. This pain may radiate to 
the parts an)uiKlj and even down the legs. Not unconnnouly 
blei»(liij^r niay occur from a caruncle, and during micturition there 
may l)e severe spasm of the vesical sphincter. Cases have been 
observed in which one little urethral canmcle has produced such 
pain, distress, and anxiety thnt patients have fallen into severe ill- 
health and have suffered intolerable agony. Warts sealed near 
and around the introitus vaginre are also in some cases the seat of 
pain, and they may prevent coitus. 

When vegetations are few in number they may remain isolated, 
an<l as they grow they attain the size of strawberries, and they 
may resemble them in appearance or become of a dark-purp|p 
color. In these instances they are sometimes regarded as cantrr- 
otis, nml in times past they have been diagnosticated as lupus- 
growths. In young women these lesions are, as a rule, simple in 
nature. As age advances one must l)e more guard^ni in prognosis, 
since in old persons simple warts have a tendency to cancerous 
degenerati<Mi, and epithelioma of the vulva verj' often l>egias in 
a lesion which resembles a simple wart. As a broad, general ml*' 
warty lesion.n of the vulva before the fortieth or fiftieth year are 
of simple nature; after these ^nriods their structure is often doubt- 
ful, and the surgeon should strongly suspect epithelioma, and at 
once have a microscopic diagnosis established. 

It must not he assunicfl that all small growths increase in sizr 
and eventuate into larger ones. Many remain for wars without 
any increase in size, others become larger and troublesome, and 
are excised, and perhaps but few reach large propfirtions. Social 




position, personal cleanliness, and many other considerations tend 
to dctenuine the life-liistory of these growths. It should always 
be remembered that, as ag^ increases, these benign growths are 
wry liable to become malignant in character. This is particu- 
larly the case with the more vascular ones. Consequently, the 
surgeon should always recommend their ablation in women about 
and beyond forty years of age. 

Treatment. — The indications for the treatment of vegetations 
are their complete removal and the prevention of their return. In 
ever)* instance the immediate and surrounding parts should be 
thoroughly washed or irrigated with sohitions of car?x>lic acid 
(1: 100) or of the bichloride of mercury (1: 2000); then the sur- 
faces and interstices of the warts should be thoroughly painted 
•witii a!i S per cent, solution of muriate of cocaine. In very nervous 
iromen in whom the lesions cover a large or delicate surface, mild 
chloroform narcosis or ether narcosis may be required, lliis 
coiiditiou being induced, the necessary treatment can be more 
thorougldy and easily instituted. 
^h It may be stated as an axiom that surgical procedures for the 
removal of vegetations are much more rapid and effectual than 
caiistics are. The latter, however, are useful under certain cir- 
cumstances. \Vlien the vegetations are small they are readily 
removed by the dcnual curette or Volkmann's spoon, the scraping 
l>eing carried well to the level of the tissues, which, however, must 
not l>e wounded. A solution of persulphate or perchloride of 
iron should be carefully touched to the bleeding points, and the 
parts, when dry, quite firmly covered either with iodoform gaus^e 
or absorbent gauze — never with watery solutions. Such is the 
tendency to recurrence of these growths that the cure cannot be 
considered complete until the surfaces are smooth. In cases of 
recurrence, before the little growths have n^ached much salience. 
ch!ori>aeetic acid, lactic acid, acid nitrate of mercury, nitric acid, 
the various solutions of iron just spoken of, and strong tincture 
of iodine may be emplo}^d. Bichloride of mercury (thirty 
grains to the ounce of collodion) or salicylic acid (one drachm 
to the ounce of collodion) is sometimes a very effectual solu- 


tinn for small warts and those for which curetting is contraindi- 

Sessile or pedunculate^] warts of an area of an inch or more 
may be readily removed by strangulation with a silk ligature. 
In some cases this object may be accomplished by the elastic liga- 
ture, using tlie ordinary small ludia-rublxr t>ands, fixetl firmlv 
around the base of the warts; still, in all cases In which it is prac- 
ticable scraping is the best treatment. 

Warts of larger area than an inch are best treated by the gal- 
vanocautery loop, and these cases are the only ones in which tKl^ 
method of removal Ls really indicated. Their ablation must be 
slowly and carefully effected with the least loss of blood. Their 
further treatment is similar to that of the small growths. Rigid 
antisepsis is required in every case. ^M 

The utmost care must be oKserved in remoWng vegetations 
about the meatus, and when piissible scraping or tving should he 
employed. The part.s should be viewed in a clear light, and a 
urethral speculum should l>e used In order that no new-growth 
may escape. When curetting is impnieticable salicylic or bichlo- 
ride collodion or tincture of Iodine niay be used very carefully. 
The idea is simply to remove the new-growth and avoid damaging 
the parts and causing stricture of the urethra. As a rule, acids 
are contraindicated in this region. 

In cases where operati\'e procedures are not admissible, whether ^ 
owing to the size or situation of the warts, it is well to apply frrely ^M 
to them, after preliminary fomentations with very hot water, fol- ' 
lowed by washhig with bichloride or carWic solutions and by a 
powder of equal parts of calomel and salicylic acid. 

There is a poj>ular fallacy that warts in pregnant women shouM 
not he removed for fear of producing abortion. This view was 
the outcome of the ol<l and now, happily^ nearly obsolete treat- 
ment by vigorous and intemperate cauterization, which produced 
great vulvar and vaginal inflammation, and sometimes rigidilv, 
even stenosis, of the genital tract. No such n'sults are pnxluced 
when the growths are removed by curetting or other surgical, 
means supplemented by rigorous antisepsis. Since vegetatioi 






may act as impediments to parturition by reason of their own 
size and position and of the oedematous hyperplasia which they 
cause, they should always be promptly and thoroughly removed. 

After removal the surgeon should explain to the patient the 
conditions under which warts grow and luxuriate, with a view to 
prevent their recurrence. 

In persons beyond forty years of age persistent recurrence of 
an originally simple wart or papillomatous patch should always 
awaken suspicion of malignancy, and prompt and radical extir- 
pation should be practised. 

After any operative procedure careful local treatment should 
be instituted in the form of antiseptic lotions (mainly carbolic 
acid, lysol, and sublimate) and dry astringent powders followed 
by the interposition of pledgets of absorbent cotton or gauze. 
It is a good rule in all cases to make a microscopic examination 
of the tissue and detritus removed with the view of establishing 
their benignancy or malignancy. 



The larger orders of vulvar Iij^rtrophies, like the smaller 
ones, may be found in early puberty, up to middle life, and are 
less eommon iji persons beyond fifty years of age. 

These hyperplasia? an% a.s a rule, the dinTt result of some irri- 
tation or of traumatism. Vulvar iiiflararaation, whether simple 
or the outcome of antecedent chancroids, vaginitis, herbes pro- 
genitalisj leueorrhcea, ^oiiorrhcea, uiicleanliness, masturbation, 
tears in coitus and parturitioji, scratches, cuts, bruises, eczema, 
and all forms of traumatisms have been found to be excitinj^ 

It is impossible to give a systematic and comp^ehensi^'e descrip- 
tion of these hypertrophies, since they all differ from one another. 
This is due to the fact of the very great variation in the confor- 
mation of the YuWa in women. h\ some the labia majors arr 
large, in others very small and exceptionally absent. The labia 
minora ar(5 seen in an infinite number of sizes, shapes, and gen- 
eral configurations. Some are long and thin, some short and thick, 
some smooth on their free edge, others irregular an<l jx'rhajxs fes- 
tooned and frilleil. Then the structure of the vestibule, the con- 
dition of the introitus vaginte, and the shape of the fourehette are 
fount] to vary so greatly that nothing like uniformity occurs. It 
can be readily .seen, therefore, that a good-sized essay could he 
written on all the varying appearances offered by these vulvar 
gitiwths, and then the limit would not be reached. 

In some cases there is simple enlargement of the natural part-S 
but in the majority there is more or less deformity, and even Uis* 
tortion. \'ery little of diagnostic importance is offered by a study 
of the various shapes and sizes of these growths. A clear idea 


Hypertrophy of the Right Nympha and Perineum. 







of the appearance and history of iheiri can best be given by tlie 
pictures and details of tliree cases. The first case (see Plate XIV.) 
shows the localization of the afTectiou in one nympha, and its 
history is as follows: 

A woman, aged twenty-eight years, free from s^nphilis, had 
severe attacks of herpes progenitalis involving the right labium 
minus. About six months later slie had a profuse purulent vagi- 
nal discharge for a time, and then noticed that the right labium 
minus was sore and slightly inflamed. In a short time the in- 
flamed part became noticeably enlarged and of a deep piukish-red 
color, until it reached the proportions shown in Plate XIV. It is 
seen to be a flat tumor, semicircular iu shape, quite deeply in- 
dented on its free margin and limited sharply tn the right Jahiiim. 
Its color was of a whitish-pink when the patient was long in tlie 
recumbent position, and of a pronounced pinkish hue when she 
walked very much. She was very clear as to the fact that in its 
early days the tumor Avas of a itKsy-reil color, softer and thicker 
than now, and that as it had grown older it had become decidedly 
contracted and much firmer in consistence. At the base of the 
enlarged nympha corresponding to the introitus vaginre were two 
small superficial ulcers of simple character. The perineal raphe 
were somewhat thickened and ended in a thickened and flabby 
pouch-like mass of skin» which hung over the unaffected anus as 
she lay on her back. The inguinal ganglia were unaffected. 
Beyond a sensation of heat and pruritus, which occurred in short 
paroxysms, the patient experienced no tliscomfort. 

It will be noted that the labial hyperplasia l.w^gan in this woman 
at the age of twenty-eight, and reached the size depicted in Plate 
XrV. in al>out two years. 

It is important here to call attention to the flabby^ pouch-like 
tumor at the anal orifice, since growths like it an; aoconinmn in 
all cases of vulvar hyperti»phy, whatever may be their origin. 

These protrusions are not, strictly speaking, piles, for the reason 
that they are not of necessity connected with the anus, certainly 
in their early stages. They seem to begin as hyperf)lasia» of the 
skin of the perineum, and, as they grow, to settle themselves on 


the anterior margin of the anus. In the uncomplicated conditiou 
they do not impinge upon the anal orifice, but as they grow larger 
and broader they involve that outlet more or less, at fiR4 on its 
intcgumental part, and later, in very chronic cases, the rectal 
mucous membrane may become affected by the hyperplasia. 
The second case shows still further vulvar involvement: 
A woman, aged twenty-five years, American, single, had cohab- 
ited with men from her sixteenth year, but was free from syphilis. 
Slie had had numerous attacks of mild vulvar and vagina! iuflam- 
niution, due to sexual irritation, but gave no history of gunorrbcwu 
About a year before the date of operation she noticed that ihe 
curunculiP myrtiformes were rather red and tender, and that some 
of tliem MM)n increased to the size of small peas, being firm and 
somewhat shotty to the touch. Then she noticed that her exter- 
nal genitals were growing larger and protruded, whereas in former 
years the nymphre had habitually been closctl in by tlie labia 
majora. In the early period of development of these vulvar 
growths they were of a bright-red color, and from their inner 
surfaces bloody serum exuded at times. On one occasion a mild 
liemorrhage took place, which lasted several hours. At this time 
also the thickness of the labia was much greater than it i^'as 
when the swellings became as large as shown in the figure. Sbe 
experienced very little occasional heat and pruritus in the p&ru. 
and only applied for relief when they became rather obstructi*^ 
to copulation. When first seen the nymphte and clitoris werr 
much hypertrophied. The left tumor was fully five inches long, 
and by traumatism became gangrenous in its distal half, which 
soon fell off. The parts presented the appearance and color of 
integument, were firm, even leathery and resistant, not at all sen- 
sitive, perhaps rather callous, and they had an irregtdar lobulated 
and nodulated contour. They are well shown in Fig. 119. On 
several o<*casions mild and ephemeral ulcerations had existed in 
the deep vulva, but they caused no uneasiness. Two wetsks after 
removal of the hypertrophied parts the woman stated that she wa.** 
as well as ever, and left tlie hospital. In this case the irritation 
from the myrtiform caruncles extended to the leaser labia, and 




this led to their hypertrophy. In the early stage of the affection 
the parts were softer, more succulent, aad redder; as it grew older 
they become condensed and gradually lost their color, until they 

Fig. 139 

Shuwing hypertrophy of both ojrmphce and of thu ftbttth of the olllorU. 


came to closely resemble onlinary integument. The general 
health was wholly unaffected. There was no involvement of 
the inguinal ganglia. 

In thb case, as a result of simple local inSammations, the myr- 
tiforni caruncles became inflamed, and then hyperplastic, and from 
these fofi the new-growth extended and involved the labia minora, 
ineluding the prepuce of the clitoris, and that organ itself^ in hyper- 
trophy. Tlie low form of inflammatory, red, cederaatous infill ration 
of the vulva which was observed early in the woman's medical liis- 
tory will l>e fully discussed later on. In this and the preceding 
case the limitation of the morbid process to the vulva and nymph« 
is clearly marked. h\ them, also, the tendency of the affection 
to push outward and tiownward Ls well shown. I^ter on, how- 
ever, the deeper parts very often become invaded. This ease, 
therefor**, may Im^ accepted as a tyjural one, showing the in\iolve- 
uieiit {A each and all of the parts of the vulva. Though the 
introitus vagina^ was at the date of the operation thickened and 
less supple thait normal, this condition was undoubtedly due to 
symptomatic irritutioti^ since in a few weeks after the operation 
the natural condition of the parts was restored. 

In Plate XV. we observe the acme of the hj-ptTplastic process 
of vulvar distortion, which centred itself in the pr«eputium clitor- 
idis and a part of a nympha. 

A woman, aged twenty-six, Irish, married, had not suffered 
from any vulvar or vaginal affection. Six months before the 
operation she had fallen upon a fence and wounded the mons 
veneris and upper part of the vulva. These regions were the 
seat of ecchymosis and pain for about two weeks. Shortly after 
the patient noticed a protrusion from the upper part of the vulva, 
but, as it was unaccompanied by pain or inconvenience, she paid 
no attention to it. It, liowcver, grew quite rapidly, until in al>*>ul 
eighteen months the growth measured four inches, and, beside 
being very inconvenient from its bulk and situation, it causetl 
uneasiness by it^ weight. The patient noticed that when she 
was on her feet very much the tumor was larger and of a deeper 
color than it was if she remained recumbent. There was no 






affection of the inguinal ganglia. The mass is well shown in 
Plate XV. It was rather more than four inches long and about 
two inches at its widest part. It involved the prepuce of the 
clitoris and a portion of the upper part of the left nynipha. It 
was hard and firm in cnnsistence, of a pinkish-white color, and 
its surfiuT was studded with lolmlatlons and irxlcrseeted with large 
and amall furrows. It was ablated and the woman left tlie hos- 
pital cured. 

A special point of interest in this case is the rapidity of devel- 
opment of this enormous growth. Assuming that the patient's 
story was correct (and great care was taken to get at the truth) 
the large mass was developed in about eighteen months. This 
I may say is very exceptional, for in several other cases I have 
noted that the time occupied in the growth of hypertrophy of the 
clitoris has been two or more years. In the present instance the 
trouble began in trauma, but I have seen a number of cases in 
which hypertrophy of the prepuce of the clitoris was due to mas- 
turbation. I have now under observation a woman of twenty-two, 
who since her twelfth year has produced almost daily one or two 
orgasms by digital irritation of the clitoris, and yet the hypertro- 
phicd mass is iu»t larger than tlie first joint of tme's thumb. 

In this affeetiun it is very probable that the liyjK»q>lastie process 
begins in the prepuce, aud that later on the body of the clitoris 
is involved. 

These hjnpertrophic growths of the vulva have been wnmgly 
called elephantiasis, notably by Hildebrandt, and more recently 
(1S85) by Zweifel. Neither in their clinical history nor in their 
pathological anatomy do they in any way resemble true elephan- 
tiasic growths, which are due to lymphatic inflammatiun with 
connective tissue increase. They are elephantine only in size. 

There are a number of conditions relating to the early stages of 
these vulvar h>^erplasiae which demand consideration. In many 
subjects, particularly young, cleanly, and healthy ones, these 
hypertrophic growths nm their course to full development with- 
out any pcrcrptililc signs of inflammation. The growths in these 
subjects are, while increasing, of a pink or pinkish-red hue, and. 


as they grow larger and push from between the labia majora, they 
become blanched, and finally may look like integument 

In another class of cases, particularly in unhealthy, uncleanly 
women, in those subject to any vaginal discharge, end in women 
about and after the menopause, we see synchronously with their 
growth a decided increase in their inflammatory and oedematous 
features. In these cases there is always more or less concomitant 
vulvar hyperemia. The hyperplastic parts (when their mucous 
membrane is yet intact) are either of a deep-red or of a dull violet- 
red color. They have not the firmness of structure, perceptible 
to the touch, of the less hj-periemic growths, but are rather softer 
and, we may say, more succulent— a condition, in all probability 
due to a correlated oe^lematous exudation. 

In this soft and succulent stage of the hypertrophies tliere is, 
besides the lesser degree of shaq? limitation and of loculizution, a 
decided tendency to ulceration, particularly in the fissures, sinu- 
osities, and anfractuosities which are found in them. In all 
uncomplicated cases of these simple forms of hyperplasia tt will 
be evident to a careful examination that the ulcerative process is 
always secondary to the hypertrophy. It is usually plain to the 
observer that the power of resbtance of the morbid tissues to 
irritation is greatly impaired, and that when pressure exists, as 
from close coaptation of the parts, or when any irritation is ex- 
erted, there will be found ulceration. These ulcers, however, do 
not present any patliognomonic features, and it is amusing to 
peruse the descriptions of these lesions by those who lean to the 
view that they are due to lupus. The writers see distinctly that 
the ulcers have not a lupoid look, and they go over point after 
point trying to reconcile in their minds the evident discrep- 

We find as concomitant features of these vulvar hypertrophies 
simple excoriations, smooth ulcerations, with or without slight or 
pronounced granulating tendency, indolent conditions, and some- 
times sluggish ulcers covered with necrotic detritus. They arc 
almost always, however, in uncomplicated cases, what we may 
term simple ulcers, having the most varied shapes — linear, penni- 






form, irregiilar, and stellate — and differ very markedly from those 
we sfiall study in the two following chapters. 

But simple as they are, they exert a very bad effect upon the 
course of the new-growths. They tend to increase the morbid 
process itself, and they themselves very often grow and cansc 
incalculable mischief. Thus they may burrow and cause fistulous 
tracts into the labia and urethra, work their way forwanl and 
cause vesicovaginal fistula, pass backward into the ischiorectal 
space, and even into the rectum, forming a channel I^ctween it 
and the vulva or vagina. Then, again, they frequently lead to 
necrosis of small and even large hypertrophic growths by eating 
them away at their bases. 

These ulcerations often cause mild and even sex-ere hemorrhagic, 
which is usually readily controlled when they are superficial, but 
which may be very intractable when they are deeply seated. 

It not uncommonly happens, when both sides of the vulva, as 
is very common, are the seat of hypertrophy in the succulent 
stage, that excoriation of the coapted surfaces occurs, and from 
them there is an oozing of bloody serum or blood. It is this con- 
dition, undoubtedly, which the older writers observed in what 
they called oozing tumors, and which later on has been labelled 
hemorrhagic lupus. 

In favorable cases the succulent stage of these growths gradu- 
ally subsides and the parts slowly pass into the condition of con- 
densation, until in the end a dense, leathery state may be readied. 

In bad cases — and they are generally in old women — however, 
the trouble extends, and destruction of the \nilva and its canals is 
more or less complete. In this event the patient gradually wastes 
away from marasmus, dies of phthLsis, or of chronic diarrhcEa or 
dysentery. For many years, however, the general health may 
rt^main unclmnge<l, and only when the destruction is great, and 
the natural outlets of the l>ody more or less destroyed, do signs 
of breaking up begin to show themselves, 

Wlien ulceration attacks these hypertrophies there is very often 
more or less enlargement of the inguinal ganglia, 

I have been particularly struck with the fact that I haw never 


seen cancerous degeneration of any of these hypeqjlastic growths 
even when they have become very old and when very much irri- 
tated. The httle red vascular tumors of the caruncles and vulvar 
fringes may from irritation become epitheliomatous in women 
toward and lx*yond forty years of age, but when they have readied 
the stage of condensation they, like their larger congeners, may 
become much inflamed and ulcerated, may be the seat of abscesses, 
and may slough ofT, but they show no tendency to become epithe- 
liomatous. Tliis is probably due to the fact that, with the thick- 
ening of the skin, it becomes impervious to the invasion of exu- 
berant epithelial tissue from without. 

In some cases I have seen much ephemeral hyperemia and an 
erysipelatous condition of the growths and parts around theni, 
particularly in those who had become infected with gonorrhtjea, 
who had vaginal discharges and were uncleanly, and also in 
women who had returned to the hospital after a protracted de- 

In their succulent stage the^e hyperplasice might possibly be 
mistaken for ejiitliehtmia, but the mbtake should not last long. 
Epithelioma Ls iLsually more l(>catize<l, of a much greater density 
even to stoniness, Ls productive of a large warty or papillomatous 
and ulcerated surface, and is very soon accompanied by enlarge- 
ment of the inguinal lymphatic gangia. llie ulcerations of epi- 
thelioma are upon the surface of the neoplasm, while those of 
simple hyperplasia are mostly found in the interstices and fissures 
and at the bases of the simple hypertrophies. Epithelioma of the 
vulva gives rise to pain of a lancuiating character, while the sub- 
jective sjTiiptoms of the simple growths are not severe and consist 
mostly of heat and pruritus. In any case, the diagnosb can be 
nia4le at once by a microscopic examination of the morbid tissue. 

Pathology. — The morbid process producing these hypeq>lasia: 
is a form of inflammation with the production of new connective 
tissue, while congestion and exudative products are almost if 
not entirely absent, and is termed chronic productix^ or cJirattk 
ceilvlar inflamvialion. Productive inflammation in mucous mem- 
branes and transitional cutaneous mucous membranes produce a 



new-growth of connective tissue in the stroma, occurring diffusely 
or in tiie form of nodular polypoid outgrowths. A cliftmctcristic 
I feature of this form of inHammtition is Its slow deveh>])nn'nl und 
^kits tendeney to persist for a, long time. These general eharaeter- 
" istics of productive inflammation agree very well with the clinical 
^history and physical properties of the vulvar growths already 

H The foregoing description applies only to the anatomy of simple 
^ hyperplasiic, which have thus been traced through all periods of 
I their development and course. But it \h' remeniUTed dis- 
^ptinctly that hyperplasia in old s^^hilitic subjects presents precisely 
~ the same pathological appearances as in non-syphilitics. My aim 

I has been to clear away all the darkness that has obscured these 
vulvar lesions, by showing that the majority of them arc in no 
way specific or lupous in their nature, but that they are Aimplc 
hyperplasite which, owing to their situation, have uuilcrgone 
(various changes. I have not attempted to |M)rtrHy tlir patho- 
logical anatomy of any of the syphilitic new-growths, sinoe that 
has l>een done by many, an<l it is not essential here. 
(For further microscopic details as to this morbid pnK-irss, M-e 
my essay *'On Chronic Inflammation, Infiltration, an<l Ulceration 
of the External Genitals of Women/* New York Medical Juumal, 
January 4, 1890.) 

Treatment. — Thorough removal with the knife or with the 
galvanocautery of these growths is alway.s necessary, the incision 
being made with the view of pres4;rvirig the eonf<»rrnulion of the 
parts as much as possible. After operation, irrigation of the vagina 
and care as to the cleanliness of the vulva are very necefwary, 
■ Solutions of carbolic acid and lysol and sublimate are very 
efficacioiLS. Much care shouhl \it* paid to the tint' of tftrnjxtnt of 
absorbent cotton and gauze with the view of pmducing perfect 



IlYPERTRorHiEs of the labia majora and also of the !abia 
mijiora, and of the deeper tisanes, as the result of chronic chan- 
croids, are far from uncommon in hospitals for women suffering 
from venereal diseases. Anyone who has had large experience in 
treatment of these ulcers in women will at once call to muid 
cases where, after the healing of the ulcer or ulcers, a persistent 
and rebellious tliickening of tlic parts has remained. Time, care, 
and appropriate treatment will, in most cases, cause the disappear- 
ance of this residual thickening. But when patients are careless 
or refractory to treatment, uncleanly, and given to drink« the 
hypertrophy, if it has attained a moderate degree and extent, will 
almost inevitably increase. Then, again, we constantly find it per- 
petuated by gonorrhceal and leucorrhoeal discharges. The fore- 
going remarks apply to conditions secondary to what we may 
call acute chancroids — that is, lesions which have come and have 
disappeared within one, two, or four months, for this form of 
ulcer is very persistent in women. 

In like manner hypertrophy of the vaginal introitus, vulvar 
and juxta-anal region is far from infrequent as a dirrrt resuh of 
chronic chancroids. 

The history of a case will throw light on tlie course of tliia 
form of trouble: 

A domestic, aged forty-eight years, who never had sypliilis, liad 
a small chancroid just above the fourchette on the left labium 
minus, which liad lastwl nearly a year, when she entered the hos- 
pitaL It then was an elevated ulceration (ulcus elevatum) on the 
inner side of the left nympha, about the size of a silver quarter. 
It showed no tendency to extend, but remained in an indolent 


condition, became hyperplastic and elevated. The cniresponding 
nympha was very mneh thickened, hard, and elastic, and the 
hyperplasia coiit'mued from it into the vagiiiii for about an inch. 
The appearances are well shown in Fig. 120, which was made 

Fio. 120 

8howing chronic chancroid of the left ajrmpho, with bjperlrophy of 
the deeper parts. 

from a photograph taken fifteen months after the chancroidal 
infection. It will Im* .s^n-n that the hj-pcqjlasia i.s well limited to 
the affected nympha. Though this woman received the utmost 
care from my internes and nurses, the ulcer healed very slowly, 



and it required a full yearns treatment (for, contrary to the ciLstom 
of these patients, this woman remained continuously in the hos- 
pital) to produce perfect resolution In the nympha and to restore 
the elovSticity of the introitus vaginte. 

The foregoing case was an especially auspicious one, as die 
woman was kept under treatment uutil she was cured. These 
women are usually very bad patients, and will only submit to 
treatment for short periods of time. 

The painlessness of the genitals in this condition is very sur- 
prising, and, althougli the ostium vaginte is often hard and rather 
unyielding, these women may continue to have promiscuous coitus. 
After the acute stage the hyfXTiemia settles down into an indolent 
condition, which may thus remain indefinitely, or it may be suc- 
ceeded by an exacerbation of inflammation and ulceration due to 
drunkenness, ilebauchery, and general uncleanliness. Internal 
medication Ls (K)werless in these cases, and topical applicatioas 
which are slow to heal the parts in the early stage of the career 
of these women, in the latter periods have little and often do 
effect. As the trouble l>ecomes chronic the whole vulva, more 
or less of the vagina, the anus, the rectum, the vesicovaginnl , 
septum, and vaginorectal space become inflamed and hyper- ^| 
plastic, and, as a result, ulcerated. " 

In general, chronic chancroids on the clitoris and external jwr- 
tions of the genitals heal readily, while those of the ostium vagime. 
of the inner surfaces of the labia minora, and of the fourchette urn 
often vcr}' difficult to cure, and tliey show a tendency to become 
chronic and to induce h}^)eqthLsia and hv]>ertrophy of the parts. 
In the chronic stage, in proportion as the ulcers are deep and 
inaccessible, and a.s they involve tlie natural outlets, they are 
menaces to life by the disastrous conditions which tliey lead to. 

Lai^ or small fleshy masses, the result of an extension of the 
iidlammatory process, may occur on the perineum or at tbc 
margin of the anus. Fleshy tumors and excrescences may nUo 
result from chancroids hidden in the puckered folds of the anus. 

Chronic chancroids with great vulvar hypertrophy arc usually 
found in women beyond thirty and forty years of age. Such 


women, so long as they are in any way attractive to the male sex» 
remain in the hospital just long enough to become "patched up," 
as we may say. In the early years of their trouble their ^^nerul 
health does not suffer, ami it is to the uninitiated a matter of sur- 
prise to see women with distorted, disfigured, and ulceratetl vulvae 
complain so little, if at all, and seem so well. As time goes on, 
however, things change. Ulceration may |x?rforate the urethra, 
the bladih-r, the vagina, and the rectum, and may also burmw 
ami form large cavities which may open by fistulous tracts about 
the buttocks or thighs. Hemorrhages of greater or less severity 
may take platv, and erysipH?lalous inflammatiou, beginning alxjut 
the genital parts, may spreatl l>eyond and be accompanied by 
severe systemic reaction. Tlien, a^ years go by, signs of decay 
show thems(*lves. The patients begin to cough and emaciate, 
and a rapid phtliisLs may eml their misery. They may Ijecome 
attacked by affections of the kidneys and liver which prove fatal. 
Then, again, we constantly see these women fall into a con<litioji 
of marasmus, over which treatment has tio intiuence whatever. 
And, again, we see life gradually sapped by rebellious chronic 
rliarrhoeu or dj'sentery. I have seen several of these women 
carried off by well-marked pyiemic infection. 

In a gi'neral way, I should say that women suffering frt>m these 
severe forms of chronic chancroids and vulvar defr»rmity, with all 
their dangerous conconiitHtits, live from <Mglit t(i hftccn years; un 
averagi- of ten years, I think, is (piite constantly observed. 

Some patients are more prone to infhinnnation and irritation 
tlian otFiers, and they may In^come the subjects of vulvar hyper- 
plasia. I have not been led to look upon a dyscrasia its an under- 
lying cause of any monient in any tiou-syphihtic cases. In my 
experience the vulvar troubles begin when the women are well, 
and ill-health overtakes them when the hypertrophies have led to 
ulceration, fistula*, deep abscess, fissures, and to strictures of the 
urethra and rectum, and stenosis of the vagina. 

It is important to remember that, tlmugli we use the terra 
chronic chancroid, very many of the so-<ullcd ulcers do not pre- 
sent the typical and classical appearance of these lesions when of 


recent origin. Indeed, the term a^ applied to ulcers about the 
vulva Is one of great elasticity, since almost any good-sized in- 
tractable ulcer is thus denominated. These ulcers present wklo 
variations, since they may appear like ulcerated excoriations, they 
may present resemblance to (he classical chancroids, and they may 
Ix* rovcn»d with a greenish -brown or grayish-black film, or even 
with a layer of tenacious necrotic tissue. Their edges very fre- 
quently pn\seTit nothing pathognomonic, and their secretion nf 
pus an4l pus combined with molecular detritus, and even blood, 
will 1m' offensive to the nose in proportion as patients arc uncleanly 
and untreated. Some authors have laid much stress on the odor 
of the secretions in these cases of vulvar h^'pertrophy, but my 
experieiice teaches me that it conveys nothing of diagnostic ixu- 
portj but that all morbid secretions are exceedingly disgusting in 
unclean persons. 

In many instances the origin of these ulcers in a contaminating 
coitus is readily ascertained, while in others they seem to develop 
de novo. The truth of the matter is that in all cases of vulvar 
h\'pertrophy, pnrtictdarly in the aucoiilent stage, ulceration is liable 
to occur as a result of irritation or traumatisms of all kinds, and 
that they are undoubtedly caused by micro-organisms, which find 
a nutrient nidus in chronically inflamed tissues. 

Tn some cases we find hypertrophy precedes ulceration, and in 
others that chronic uUTratiou leads to hypertrophy. As a general 
rule, however, hyperplasia is by far the more active and the ulcer- 
ative the less prominent [}rocpss. It is remarkable to observe llic 
great chranicity and indolence of these vulvar ulcers. They, a* 
a rule, increase very slowly, and may remain many months^ and 
sometimes one or two years, without any perceptible change. In 
these cfises, however, the hyperplasia gm*s on more or less actively. 
'Ilie reascni for the shnv and indolent growth of these lesions lies 
in the fact that the condensation of the hyperplastic tissue ofTen, 
chiefly by its narrowing of the bloodvessels, a dense and unyield- 
ing soil for the destructive process. 

The inguinal ganglia in these cases are ti.sually somewhat en- 
lar^d and sometimes much swollen. In some case« no change 




is noted in them, consequently they are not of much aid in diag- 

Treatment. — When seen tolerably early chronic chancroids with 
vulvar hyperplasia should be treated systematically by means of 
frequent and copious injections of some antiseptic solution, notably 
sublimate 1 : 1000 to 1 : 4O0O, and preferably very hot. Watery 
solutions of powdered borax (5iij to 5xxxij) with one drachm of 
carbolic acid should be used three times a day. The next essential 
is to keep the morbid surfaces separated as much as possible and 
in a dry condition. To this end tampons of absorbent gauze dusted 
with iodoform, boric acid, or aristol should be carefully applied 
and frequently renewed. 

When the surfaces of the ulcers are sluggish, fluid carbolic 
acid may be carefully and sparingly applied, and then the tampon 
may be inserted. When the surface is very necrotic or fungoid 
it may be necessary to curette the parts or to apply pure nitric 
acid very carefully. 

Whenever fleshy masses protrude so much that they cause 
discomfort, they should be removed with the knife. Should 
infection of the cut surface occur, the continuance of the regular 
treatment will soon abort this threatened complication. 



The vulva and anal region are not infrequently the seat of 
syphilitic lesions in the secondary and tertiary periods of the 


In thi* sertmdnry period it is not unconimon to find, particu- 
larly in uncleanly women, pinkish or red, brtxul, flat, fleshy disks 

Fi(*. 121 

Showing condylomata of vulva and nnus. 

of tltickened tissue, which may l>eeonie remarkably salient, us 
shown in Fig. 121, and sometimes may present a warty surface. 
(\nuiyIonmta in the female may give rise to a viscid malo<lorous 
discharge, which, escaping down the thighs, causes much irrita- 


These lesions begin as one or two red eroded spots, in whioh 
'hyperplasia soon develops, and then tlie c<»ndylomftta increase in 
size and in height, until large fleshy masses may be produced. 
These run an indolent course and may cause much distortion of 
the vulva and perineum. Tliey usually yield quite promptly 
t4) treatment. In some neglected eases they lead to vulvar and 
vaginal deformity. 

Vulvar Deformities in the Early and Lat« Stages of Syphilis Due 
to Induiatiug (Edema. 

In some exceptional cases the initial sclerosis occupies a whole 
labium and much enlarges it. In a deeldeil numU'r uf instances 
ive find that accompanying the initial lesion, either artmnd it or 
in its vicinity, a hard oedema of one labium or both labia occurs. 
This oedema, which has been called sclerotic or indurating, is very 
peculiar, and is the sole appanage of syphilis. It usually begins 
in an indolent aphlegmasic manner, without pain, and perhaps 
with no heat and pruritus, and becomes fully formed in from one 
to three weeks. Then^ again, in some cases its onset is quite 
brusque and rapid, and in a few days a labium may l>e greatly 
enlarged. When such a labium is examined it may }ye found to 
Ix^ of double, even quadruple, its normal size. Its tegimientary 
covering may be normai in color or a little redder than u.sual, 
while its mucous membrane is of a dull red. In some eases the 
corresponding labium minus may be affected, and its pinkish-red 
color is then somewhat<i. There is no evidence of in- 
flammatory engorgement, nor of soft aMiematous swelling. The 
[jarts are not unusually hot, not tender on pressure or otherwise, 
as a rule, but they are of an extreme hardness, sometimes pre- 
senting a dense elasticity, like one's ear, and agairj a .sti»ny feel, 
like cartilage or sclerodermatous tissue, 'ilie impress of tlie finger 
always meets resistance. It may be that the whole labium or the 
labia (if l>oth are involveil) may be thus uniformly sclerotic, i>r, 
as often happens, there may seem to l>e a central kernel of great 
density surrounded by an atmospliere of elastic firmness. In 


. during pregnancy, and as a result of trauma- 

indurating cedema may extend lx*yond the labial limits. 

sccondar}' s\Tnptoms aw* iLsually constant concomi- 

Fi.;. 122 

sUiowiuK iadumtiiig a>(lema of both labU minora in Ute sypbUia. 

'11*0 npiwarnnces of indurating oedema of both labia minora iu 
IhIc *y|>liilis aw well portrayed in Fig. 122. 

TUiugb Muhiniting oedema is more commonly seen in the 
|«iumry and t^arly secondary stages of syphilis, it may occur 
Uirr in llie disease — namely, in the first, iiccond, and even third 
\T«rs. In these cases of late development, however, their U 


commonly a marked persistence and activity of the diathesis. 
While the indurating cedcma of the primary and secondary stages 
of the disease usuaUy aecoiiipaales or fallows the active lesions, 
that of the later periods may be unaccompanied by any previous 
or present syphiloma. Though late oedema may be thus coni- 

Fic). 123 

Showing indurating -i-detiia of both labiu majurii, with warty and 
pfipillonmtous growthit. 

plicated by various syphilitic processes, it very often is develope<l 
by vaginal or vulvar irritation, and also by Iraumalbm, 

In some cases very much enlargement and ilistorlion of the 
labia majora are produced by indurating <edcma, and rather 
Exceptionally the surface of the ncw-growtli becomes warty and 


papillomatous. When tliis warty condition is found on these 
densely hard and indolent tumors the diagnosis of epithelial 
cancer may be made. In Fig. 123 a typical mass of indurating 
nedema is showni on which many warty growths had <leveloj>cd. 
&»veral physicians who saw this case at first thouglit it was one 
of cancer. 

Indurating a?dema runs a long, sluggish course, and yields verj* 
slowly to treatment. whiHi should 1m» both loral and general. In 
soni«' cases ablation of the jiarts beeonies necessar}'. 

Ohroiiic Chancroids in Old Syphilitics. 

We fn'<|uently Hud in early syphilis and in later periods when 
the diathesis is active, and again when it is wanting, ukrers which 
up|H'ar de novo, and from tradition we call them "chancroids." 
It is to-tlay a generally accepted fact that chancroidal ulcere are 
caused by many forms of active pus, and that syphilis is a fie- 
(pient cause of the secretion which pve rise to these ulcers. Theiv 
undoubtedly exists in syphilitics a v\ilnerability of the tissues. 
sliowitig itself in their tendency to ulceration and h^'perplasia. 
Ahcut the female genitals this tendency is shown in the devclop- 
inrtit of cluincroids upon parts irritated by uterine, vaginal, and 
vulvar secretions, and especially upon any lesion of continuity, 
j*uch iw an excoriation, a tear, a fissure, or upon the seat of vesi- 
cles. In their early stages these ulcers may resemble the classical 
chancroid, but as they grow older they lose more or less of ihcir 
typical ap|H'arance. 

Tlicse ulcers usually have eloping edges and fairly smooth bases 
which are c*overed with a greenish-gray or brownish-red film of 
pus, luulcr which is a slightly papillated surface. Tliey look 
indnlriit, and their history proves that in general they are aphleg- 
um.Hu , p<'i-Ni.stent, and chronic. They occur on all parts of (he 
fcnndc gt'uitalia, and may remain without any perceptible exten- 
sion for a lung time, but yet they frequently cause great harm. 
As long as they remain they give rise to a wry low grade of sec- 
ondary inflammatory engorgement wliich leads to hyperplasia, 
which may extend up the vagina or into the vulva, thickeiting 



the vaginal ami often the rectal walls, attacking the labia minora 
by preference and causing their great hypertrophy, and also some- 
times inducing similar change in the labia majora. All of the 
clinical features of the vulvar hypertrophies which result from 
chronic chancroids may be produced by these chamToids of syph- 
ilitic orighi; tlierefore, having already described them, repetition 
is unnecessary. It, however, may be added with advantage that 
where the syphihtic diathesis is active, and often even when it is 
wanting, specific evidences of the disease ma}' \ie seen elsewhere 
upon the lx)dy. The hypertrophies produced by these syphilitic 
ulcers are similar to those of simple chancroids, except that we 
sometimes see a greater tendency to destructive ulceration, and 
in some cases to phagedenn. Though the clinical features of 
chancroidal and of this form of s>'phi]itic sequela; are hardly 
sharply enough drawn to warrant separate descriptions of their 
respective hyperplasia, the underlying facts must be stated, and 
this necessitates the division I have ma<lc. Hj'pertrophy of the 
vulva, therefore, ilepending on simple hy[>er]>lasia from ehiVHiic 
ulceration in syphilitic patients, b far from uncommon. 

Distortion of the Volva in Old Syphilitica. 

There is a condition of the tissues in older syphilitics, and 
usually in persons of the lower classes, which has not, according 
to my reading, been descrilx'd by any author, but which, I am 
convinced from years of study^ Is not extremely uneonunon about 
the genitals of women, particularly as seen in large venereal ser- 

This condition consists in a simple hyperplasia of the tissues 
of the genitalia, which results in more or less deformity. While 
early in the disease we so commonly see the tendency to ulcera- 
tion, later in the diathesis it seems to engraft on these tissues a 
tendency to a very low grade of intiaimnatory process by which 
organs and parts are much thickened and distorted, lliis hyper- 
plasia in s}ijhilitics is microscopically the same as that of non- 
syphilitics, and cannot in any sense be c^Al^e]ff^hu;4n ieaB|utial 
evidence of disease. STANFORD liNiyfRSITY 



-fie ias.jLi j£siaag3S ir rxr male axd female 

Sa ijMiriHM 'r ■'■-""if'"' -an dr ffv^ of these vulvar distor- 
acii&. SKF :w r«Bi •:■»? sir «tiur. ix al cases the natural shape 
azA* j e mJHu* }£ :^ M3& aoe laicp tfc less exila^ed and disfigured. 

«>t f^Bis XVL s^ nd sttivn tfe coaditkHi of the external 
ML a L ggut^i ■« ;&£ jeap -^4i ■iimiii who had had syphilis 
beixF^eiti^csr^aEinRMihaddrvek^ied. At this time 
t&e fcSov^ur •xm^ams veve siard bv me: The left labium 
mfr-3S V&5 T^^ rn»ac£y ^QirrvKvd e& kngth and thickness, the 
efiKtei* aai X5 pcwiKt; »«?• 3X3::^ hTpertiophied, and the right 
laLcnn. Tzzz.-::^ vz^b. -v^ms^ cc^malh' much shorter than its fellow) 
(orraed a i;-c^. 5f<cj pixwsi?^ witich hui^ down neariy two inches 
fcerwiwn iTje t- -r^s. TTw apcvaxaaces are wrfl shown in the Plate, 
lh*r hTpertrtj-c-cifo pwcr:? '»n^ hn>ught into prominence by 
meaa5 of iLrv^feis. T^ =i-jcvx£« membrane of these parts was 
somewhat uiickeoec azo 5£ZiOAr u> integument. The whole mass 
was of a deep vjoiet or ptirpie-wd color. At the base of these 
tumors w^re ihrve jcaliow uWr? which might be taken for chan- 
croids. Evtr^ion of the h7p?rpla5tic nym^^se showed a thickened 
violacieous condition of the whole rubra, with a decided narrowing 
of the t-aginal orilice by n^a^on of the thickening of the tissues, 
which extended into the va^a three inches. The orifice of the 
urethra was obscured by a cluster of hypertrophied caruncles. 
'r\u' labia niajora werv al^o enlai^eil and swollen, and the very 
nhort f^erineum endevl in a taWike mass of integument, seated 
just on the anterior borvler of tho anus, but not encroaching upon 
it. Fnjm the sienosed vaginal orifice a copious persistent db- 
ohargj; escaped. The hy|^*onn^phied nymphje presented a firm 
resistance to pressure, and the tissues of the vulva, though rather 
more dense than normal, were, as we may term it, in a succulent 
condition from the h}'penemia. The ulcerations were rather 
suiM-rficial, of brownish-red color, smeared with pus, smooth of 
Hurfufc, without well-defined outlines, and their margins devoid 
of any appearance of being undermined. There was little or no 
pain in the outer growths, though the vulva was rather tender, 
and sometimes, when irritated, the seat of stinging, smarting, 
and itching pain. The sufferings of tlie patient, however, did 


Hyperplasia of External Oenliala in an old SyphlllUc. 


not seem to be at all proportionate to the severity and extent of 
the morbid process. She liad at times been treated energetically 
with antis^'philitic remedies with no effect whatever. I ablated 
the external tumors, greatly to the relief of the patient. Later on, 
hot antiseptic injections and appropriate topical treatment rnrcd 
the ulcers and Ics.senod the vulvar hyperplasia. The woman left 
the hospital much improved. 

It Ls intertvsting to note that during tfie three or more years in 
which the vulvar hy]jerplasia was going on in this woman she 
suffered wry little from the local affection. The progress of ita 
development was slow, aphlegmasic, and unattended with any 
constitutional reaction. Microscopic examination of the re- 
moved masses showed that their strtict are was identical with that 
of hyperplasia occurring in non-sj^hilitic women. 

Distortion of the Vulva, with Destructive Ulceration. 

When the genitals are the seat of hN-perplasia in non-s>i»hilitic 
women ulceration may occur, but it is commonly limited in extent 
and not very destructive in tendency, though from the nature of 
the parts such damage may be done in tliese cases as will lead to 
invalidism and death. In chronic chancroid the ulcerative ten- 
dency is sometimes well-marked and even quite destructive. In 
s^'phiiitic subjects with these h^perplasiee the acme of disintegra- 
tion is often observed- In them, as a rule* the ulcerations arc 
more active and extensive than in non-s^-philitics. Not only do 
we find severe ulceration in syphilitic subjects, but also phagcilena, 
which may cause terrible destruction of the affected parts. 

In Fig. 124 are shown the external genitalia of a woman, thirty- 
two years ol<i, who became syphilitic when twenty-two. Seven 
years after infection, not having suffered from any manifestation, 
nor having presented any evidence of the disease for three years, 
she, after an attack of vaginitis, observed that her vulva became 
gradually swollen. This hypertrophy went on for three years, 
when it presented the appearances shown in Fig. 124. At this 
time she became much debilitated and took stimulants and opiates. 


While she was in this state ulceration began ui the vulvar ellipse 
aiitl destroyed coiisiderahie of the hj-perplastie tissue. Having 
built her up with tonics and generous diet, and nearly cured the 
ulcers, I removed the hypertrophied masses and obtained a very 

Fig. 124 

Sbuwjng hyperplasia of vulva and perineum and destructive nlcrration 
in nn old syphilitic. 

favorable result fmni cicatrizatioiu Microscopic examination 
the new-gro^vtlis showed simple h)-perplasia. 

In rare ca,ses phagedena may attack these vulvar tumors, par- 
ticularly when tlie patient is gettuig on in years, is unhealthy, am 



uncleanly. The course and results of phagedena in an old syph- 
ilitic in whom vulvar hyperplasia was present are well slmwn in 
Fig. 125 and by the following details of the case: A woman, aged 
forty-seven, had had for years great hyperplasia of the vulva fol- 
lowing sypliilis contracted ten years before. When she was in a 
dissipated and woe-begone condition^ ulceration began about the 
fourchette. This lasted several weeks, and then the parts began 
to melt away from phagedena^ with the result depicted in Fig. 125. 

Fig. 125 

Showing greftt destructioD of hrpertrophied vulva luid penDeum o( an 
old syphilitic. 

Under treatment, healing was induced, cicatrization took place, 
and a fairly good condition of the parts was left, incontinence of 
the feces being the most distressing symptom. 

The ultimate outcome of hyperplasiie of the vulva in old syph- 
ilitics Is about the same as that alrewly sketched of the declining 
days of patients suffering from chronic intractable chancroids of 
that region. 


Tlie chronicity and inveterate course of these \iiU-ar hyporpU&iv 
are undoubtedly due to the structural peculiarities of the %*ulv», 
to its excessive vascular and ner\*ous supply, to the conditions lo 

lich it is so constantly subjected, and to its dependent position 
tmpressed between tlic thighs. Except in the mouth (and that 
ver)' rarely), we do not see such persistent and deforming low- 
grade inflammation and hv-perplasia. 

In the past these chronic deforming lesions of the \-ulva, whether 
due to chancroids or in old syphilitics, were fancifully called by 
the following terms: lupus hyperirnphieus et tiJ}eros%ui^ lupug ter- 
piginosu^t and lupus prmninenSf esthiom^ne hyperttophiqiu- trde- 
mateux et vegHanif perforaiijig lupuSf and esthiairUne perfonmi dt 
I* amis et de la vulve. 

Treatment. — Condylomata lata of the vu!\*a and perineum 
should l)e treated Ixith locally and systemically. The first 
essentials of treatment are absolute cleanliness of the genital 
tract and a condition of drjTiess of the parts. Alkaline and anii- 
sieptic irrigations should be used freely and frequently. When 
the part5 are dried they should be well dusted over with a powder 
('(tm(H>sed of calomel and oxide of zinc, of equal parts. Then carp 
should Ijc exercised in keeping surfaces which tend to eoapt as 
niiirli Hpart as possililc by means of sterilizetl absorl>ent gauxe. 

When condylriitiata lata have Ix^^ome warty on their surface it 
may l)e necessary to apply very carefully and sparingly fluid car- 
bolic acid, or even nitric acid in rebellious eases. When in%*olu- 
tioii of the lesions Ls well under way a powder of oxide of rinc 
and liori<' a<;id (equal parts) may Ix* used. 

Systemic treatment may be a^lministered in the form of mer- 
cury by the mouth or by inunction or Injection, or by the use of 
the mixed treatment. 

Indurating oetlema of the vulva and the perineum is usually 
very persistent, even when active treatment is instituted. Clean- 
liness and dryness of the parts are aKsolutely necessary. ^lercu- 
rial ointment, strt^ng or mild, may be applied and kept on these 
grtiwths, and thus, with the internal use of mercurials, perhaps 
in combination with the iodide of potassium, we may cause rp«o- 


lution after a time. When indurating oedema attacks protruding 
parts or those which can be removed without destroying the con- 
formation of the vulva, therapeutics having failed, it is well to 
resort to the knife, treating the case with all antiseptic require- 

Chronic hyperplasise of the vulva, vagina, and perineum are 
always absolutely uninfluenced by local or general mercurial 
treatment. The best results follow the ablation of all prominent 
masses. Then healing may be induced, and though a more or 
less stenosed vaginal orifice and vulva may be left, the patient is 
at least more comfortable and not in so much danger of ulcera- 
tion, abscesses, fistulse, and septic complications. 




The fact is now so well established that tuberciilasis not infre- 
quently attacks the skin that the probability of tlie dex-elopmcnt 
nf the tuberculous ulcers upon the outer genitalia of the female 
can no longer be called in question. 

It may be stated as a broad fact that tuberculosis of Ihc femalp 
genitalia grows progressively more uncommon in occurrence as it 
descends from the ovaries, the tubes, and the uterus into the 
vagina and vulva. 

Tuberculosis of the vagina by extension of the process from 
above can hardly be called very rare. Involvement of the vagina 
alone Is far from common, and when it does occur in some c«.*r> 
the vulva may be more or less involved. 

I have seen three cases in which ulcers began jiLst beyond the 
external genital regions, and in their extension involved the vnl\*a, 
and of which the clinical diagnosis was tuberculosis of the skin 
and mucous membrane. These ulcers had finely and coarsely 
granular, papillomatous, and even fungating surfaces, and were 
cntirclcd by bard, somewhat everted, deep-red and even bluisb- 
rcd margins, with irregular ami somewhat festooned outlines, and 
they secreted an abun<lant'e of pus. They began as round or oval, 
deep, viola<'eous-r»'d lulwrcles, which so(jn broke down into ulecm- 
tion. In former years we classed these lesions under the head of 
scrojidide tuberculeuse tdcSren^it^ proposed by Hardy antl Bazin. 
Two of my cases occurred l^efore we knew of the existence of 
the baciJlus tuberculosis, while from tlie third and more recent 
case I was unable to excise a portion of the morbid tissue for 
examination. The patient, however, had pulmonary phthisis. 

Primary tuberculosis of the vulva, however, is rare, and thei 




most satisfactory case of it on record is that of Do.schanips.' 
ZweigbaumV case hiLs bt*en spoken of lus Ijcing rare and peculiar. 
It is rare in the sense that tuberculosis of the female genitalia is 
rare. The details of it show that the raorbid process began in 
the litems and extended downward to the vulva. Chiari's' case 
seems to have been one of tulHTeulous infection of the vulva, with 
involvement of the vagina. 

If it is wortli while to preser\^ the term lupus of the vulva, it 
may be applied to cases of ulcers caused by the lul)ereulous 

Treatment. — These tidiereulous ulcers should be thoroughly 
irrigated witli warm sublimate solution 1:1000 to 4:1000 and 
tlien should be eui-etted and dressed with liaLsam of Peru oint- 
ment. They heal very slowly and arc prone to relapse. 

The general tuberculous condition of the patient should be 
carefully treated, and if possible she should have an appropriate 
change of climate. 

The i-rays and radium may be tried in these cases. 

■ Ktude Rur quelquca ulo^rntiona rarefl et non-T^n^rienneA de la vulve et da 
vagin, Arcliivefi de Tocotogie, .liinuBry, Febnitiry, and March, lS8o. 

' Ein Fall vnn luberculoser Ulceration der Vulva, Vagina, tind der Porlio 
Vaginalis, Berlin, klin. WochcnHchrirt, May 28, 1888. 

* lleber den Befiind auugedehnter titberculimen Ulceratinn in der Vulva und 
Vagina, Vierte^jahr. fur Derm, und Syph., 1886, Band xriii. p. 341 etscq. 



There is a form of new-growth of the vulva, which was first 

desc'ril>cd bv 



years ago, which presents man; 
anil interesting features. I have had three cases of this trouble, 
but I shall in this chapter only describe two, since they contain 
all the essential facts. The first case was that of a woman who 
was perfectly healthy until her tliirty-fifth year. From the time 
of pulwrty she performed the duties of a domestic, and had inter* 
course, more or leJ^s frequently, \vith different men. In July, 1876, 
she was treated in the Charity Il4>sjHta] for a suppurating bul»t» of 
the left groin, which. Ijeing incised, li'ft a characteristic cicatrix. 
The patient had no knowledge of an ulcer upon the external 
genitals. Eurly in the year 1877 she again entered the hospital, 
suffering from a large chancroid in the sulcus between tlie left 
labia majora and minora. This ulcer was markedly persistent in 
its course, but was finally healed. At this time she remained in 
the hospital eight mouths. Neither at that time nor in later or 
recent years could 1 discover any history or evidence of s\*phili'*, 
nor did the patient present any sj'philitic lesions during a period 
of over twelve years. It may be stated, therefore, as beyond 
doubt that she was free from that disease. ^^ 

On her discharge from tlie hospital in, 1877, the patient ^H 
was in excellent health; she had no vaginal discharge, and a red- 
ness of the left side of the vulva wius the only sign of her previous 
trouble. At tliis date she was rather more than thirty-six years 
of age. 

Diuing the autumn of 1877 the patient suffered from excoria- 
tions of the vulva aljout the st*at of the already mentioned chan- 

^ Atnerican Journal oflKe Mediiiil 8ci«ucr«, February, 1890, and Jantui7, 19M. 


drunken debauches she was careless as to the condition of her 
genitals, and in consequence thereof slie had nuraerous attacks 
of varying Keverity of acute and subacute vulvitis. During all 
these years it seems clear from her story (which was elicited at 
various times with careful minuteness) that she suffen»d from an 
inflamed and excoriated condition of the left side of the vulva, 
which was subject to exacerbations an<! |>erio4ls of quiet»cence; as 
a result of this long-continued condition of irritation an anomalous 
form of new-growth develijped. 

llie appearances of this peculiar new-growth are well shown in 
Fig, 126, which was made about two and a half years after the 
date of its l)eginning. It will be seen that the normal appearances 
of the vulva are wholly lost. There ai'e no traces of the labia, 
large or small. The elitoris is represented by a central mass of 
cicatricial tissue, and the introitus vaginas looks like a raggtxl slit. 
The perineum is also invaded with processes of the new-growth 
jutting backward. Extending from the \'ulva the disease is s<*en 
to invade tlie pubes and the right groin, and lo extend downward 
over the skin of the fork of the thighs. lu no place is there e\*idence 
of tumor-like formation, as the new-growth is everywhere devel- 
oped eft surface; in other wonls, it Ls flat in structure. The surface 
of this neoplasm is of a maroon or chocolate color, with considerable 
glossiness. At times this morbid surface was perfectly dry, and 
at other times it gave issue to a thin, scanty, reddish senim. 

The parts present a firm but decidedly elastic feeling, as if the 
new-groA^ih |x>ssessed a fair amount of density. To the eye and 
to the finger-tip it is evident tliat the \nilvar and extragenital 
portion of the new-growth Ls uneven and thrown into slight, irreg- 
ular folds — a condition due undoubtedly to the natural eonforma* 
tion of tlie ]>arts. Iladiating from the clitoris region is a quite 
well-formed sheet of cicatricial tissue, and scattered on the outer 
and upper parts of the new-growth are irregular shaped islets of 
the same. Upon the lower part of the vu1\ti and towan.1 the 
perineum the mode of extension of the new-growth is well sbon'u. 
On the right side it juts outward by an abrupt semicircular ele- 
vated margin, while on the left side the morbid tissue ends in a 



similarly sharp festooned outline. In the upper and older parts 
of the morbid area the sharpness of the margiuation is lost in 
cicatricial tissue, and elsewhere as a result of tlie treatment adopted. 
At the time the drawing from which Fig. 126 was made the morbid 
process stopped at the orifice of the vagina, which, however, was 
somewhat contracted. Toward the end of life the new-growth 
became so copious and firm in this region that this orifice would 
only admit, and then with considerable pain, a soft bougie of about 
No. 26, French scale. There was never any evidence of stricture 
of the urethra. Besides the foregoing appearances there was evi- 
dence in life of a marked condensation and contraction in all of 
the affected parts, which increased very slowly and imperceptibly. 
The salience of the vulva was, in the end, wholly lost, and ex- 
amination of the new-growth en masse showed that it wa^ quite 
firmly adherent to the deeper parts. When the patient was on 
her back the genitalia had a peculiar^ flat appearance, and when 
she stood up it was evident that the labia majora no longer 
protruded between the thighs. 

This new-growth began as a thickened, slightly elevated patch, 
of deep-red color, upon the left small and large labium. Frt)m 
this region it extended by |)eripheral incR* toward the vaguial 
orifice, over the clitoris anil upward and downward on the right 
side, while on the left it jutted down to near the anal orifice. The 
increase in area took place slowly, and as the new morbid tissue 
was formed^ the older portions remained witliout any visible 
change, ulcerative or reparative, A slight amount of heat, pain, 
and pruritus were felt at irregular periods. The local symptoms, 
however, were for a long time so mild in character that the patient 
made little complaint. She could sit, walk, move, and lie down 
with little discomfort. Later on this was all changed. 

This form of new-growth, it seems, is not peculiar to mucous 
membranes alone. By its peripheral increase it involves the skin, 
and by it its progress on this tissue may be accurately studied. 
We find on the integument the same flat form of new-growth 
seen on the raucous membranes. The surface Ls smooth, even, 
and glossy, and the color a decided maroon. The elevation of 


the patches is from one to three lines, and they encl by a well- 
defined curved or festooned border, which, rounding off sharply, 
is lost in the sound skin. 

The elasticity of the infiltration remained for indefinite periods, 
and was slowly and gradually replaced by a marked condition of 
condensation, particularly in the central vulvar re^on. llie 
result was that the conformation of the genitals was more and 
more destroyed. 

As the new-growth infiltrates the tissues it is noticed that when 
con<lensation takes place the morbid areas become more or less 
iillacht'd ti) tlie bony or api)neurr)tic parts beneath until, in the 
end, ihey may feel as if soldere<l to them. Along the vulvar 
sulcus, where the disease orij^inally began, the tissues presented 
to the finger-tip an almost brawny sensation, whereas, at the 
periphery of the new-growth, well-marked but still decidedly 
firm elasticity was noted. 

On the mous veneris and the thighs evidences of healing were 
very often noted. This process usually began in spots of pearly 
cicatrization, which increased under favorable circumstances, until 
sometimes large healed areas were produced. But the cicatrici&l 
tissue always showed a great lack of vitality and endurance. So 
long as great care was observed, and the parts wert kept scrupu- 
lously clean and dry, the healed surfaces might remain intact. 
But any inattention (from indifferences of the nurse, during the 
menstrual epoch, or a drunken debauch) w^as inevitably followed 
by retrogression. It was surprising to see how rapidly the cica- 
tricial ti.ssue melted away. A part which was pretty well healed 
one day might a day or two later present a most t^-pical morbid 
iippciirance. It was always e^adent that ui healing, tliough the 
superfices of the morbid tissue became cicatrized, the deeper parts 
remained unaltered. Thus the disease oscillated between a cica- 
trized condition and the reverse month after month, in spite of 
the most careful treatment. 

The tendency to healing, however, was only observed in the 
ju.xtagenital parts just mentioned. At no time could we produce 
reparative changes on and within the vulva proper. There the 


secretions and the close coaptation of the parts wholly prevented 
cicatrization, even though the greatest care was paid to place inter- 
posing absorbent dressings. As time went on tkie condensation 
of the vulvar and vaginal tissues was so great that the vulva was 
converted into a raw slit of tough tissue, the lips of which were 
drawn more and mon^ tightly togtrther, and the vu^iiial orifice 
ahnost fornpletely stenosed. This state is well shown in Fig. 127, 
which was taken about three months before death. It is inter- 

Fio. 127 


Showing the condition of the genitalii three months before death. 

esting to study this picture in connection with Fig. 126. It will 
be seen tliat in rather more than two years the dlseast* lias ex- 
tended .somewhat in an outwanl and backwani dirpction. It is 
evident, however, that the hixurlance of the infiltration shows 
[ itself by involving the tissues in their whole thickiiesa and depth, 

f rather than by peripheral extension. The new-growth showed a 

I tendency to remain localized to the vulvar and juxtavulvar regions, 
^H During its whole course this new-growth showed no tendency 
^^^ to luxuriate upon the surface. There was never any evidence of 


tumor-like formation, since the infiltration never reached a greater 
height than three lines. There is never any endence whatever 
of ulceration, and though the morbid growth may, in more or 
less degree, become less salient, the decrease in its height was due 
to the slow and almost imperceptible melting away of its superiioes 
and to it-s inherent, slow, contractile tendency. Further than this, 
it was observed that in the recesses of the vulva where the lesiou 
was thrown intt) anfrai^'uositics tliere was not the slightest ulcera- 
tion l)etween its clefts and folds. It never presented any appear- 
ance resembling papillomatous outgrowtlis. 

Though this inflammatory and infiltrative process lasted many 
years, it did not seem to involve the contiguous lymphatic s^'stem. 
In both of my cases the ganglia were slightly larger tlian normal, 
but in none of them was there at any time any exndence of in- 
flammation. There was an entire absence of erythematous and 
erj'sipelatous complications. 

The disease shows no tendency whatever to malignant degen- 
eration, and of itself seems to have no direct influence upon the 
general economy. 

As 1 have already slated, the local symptoms were for a long 
time mild in character, and the patient made little complaint. 
Gradually, however, as the disease progressed without any abate- 
mcntj the soreness in the parts was replaced by pain, particularly 
on the slightest movement. Walking became almost Impossible, 
the erect position of the body could only be maintained witli the 
greatest difficulty and discomfort, and as sitting became painful 
and almost impossible, the patient was forced to take to her l>ed. 
Even in the recumbent position all movements caused uneasiness 
and pain. The swollen, contracted, and excoriated condition of 
the vulvar sulcus impeded urination; the stenosis of the vaginal 
orifice prevented the use of cleansing and soothing injections and 
impeded menstruation, while the rigidity and irritated condition 
of the parts prevented the application of absorbent tampons. In 
this hopeless, bedridden condition the patient was a pitiable object. 
Her sufferings, pain, and worrimcnt of mind led to utter demor^ 
alization, marasmus, and death. 




A second case observed by me was in appearance and histologi- 
cally the same as the one already detailed. It was that of a 
widow, aged twenty-five years, of remarkably healthy parentage, 
was well developed and tolerably strung, and meajiles in early in- 
fancy was the only sickness she could remember. When twenty- 
two years old she w^as married to a sailor, who seemed to her to 
be a perfectly healthy man. In the second year of her marriage 
(fully four months after the accidental death of her fnisband) she 
noticed a small pimple in the right inguinal fold at about the 
centre. This pimple gave her no pain and discharged no pus. 
In three months it had increased and formed a circular patch one 
and a half inches in diameter, with an exulcerated surface, and 
raised about an eighth of an inch above the normal plane of the 
skin. This new-growth steadily increased in size, running down 
on the outside of the right labium majus, and involving it and 
the corresponduig nympha, then gratlually it extended downwanl 
and backward, encircling and involving the anus well in toward 
the sphincter. From this region it ran up the outer side of the 
left labium majus, attacking and destroying, or causing to melt 
away, part of it and then the whole of the corresponding nympha 
and ending in iXw- left inguinal fold. The appearance of the parts 
is very clearly shown in Fig. 12S. The new-growth was sharply 
marginated by an elevated border nearly a quarter of an inch in 
height, beyond which the skin was somewhat pigmented, but 
seemingly healthy. The surface of the new-growth was puq>lish- 
red in its oldest parts and at the periphery, and of a dull pinkish- 
red in its centre. 'J'hc vulva was a raw, oozing slit, but it would 
admit with little uneasiness the first joint of the index finger. 
The anus was wholly involved, its tissues much condensed, and 
it w^as raw, sore, and painful on defecation. The surface of this 
new-growth was similar in its nature and character, but was 
rather more tmeven and more mummillated thati the prenous 
case. It gave issue to a scanty serous and serosanguinolent dis- 

In its early months this new-growth was the seat of ephem- 
eral, throbbing pain, but in general, though it caused some dis- 


comfort and mieasiness on urination and defecation, it could not 
be said to be painful. 

Early in her hospital days we gave this woman a thorough and 
vigorous antisyphilitic course of treatment as a tentative measure. 
She bore the medication very well, but her vulvar lesion remained 



Tn two nr three months the parts were fully cicatrize<I, hut the 
introitus vagina* was very much lessened In iliameter, ami the 
anus was nither rigkl and less distensible than normal. 

The most thorough examination and searching inquiries were 
made to ascertain whether the case was of sj-philitic nature, but 
in the end I became convinced that the woman never ha<l had 

Fig. 129 

Showing a lopagrapHical view of tbe lesion ; n, epidvrroiv irregularly thickened 
by ingrnwthR of tbe intcrpupilUrr portioni* of the rcte Malpighii ; A, layer of 
gmiuilaiion tissue; c, lymph apacea of the deeper bubcuianeous liwue tilled with 
granulation tiiwtie. 

Microscopic Examination and Pathology.— Portions of the new- 
prowth, in its full (hiVkncss, excise*! by nic from Ixilli cases, 
were i^xamincd by Dr. Ira Van Gieson, by whom the drawings 
(see Figs. 12^) and 130) were made. The tissue was composed of 
three layers: (1) a superficial layer corresponding to the cutis, 
which is irregularly thickened by a considerable ingrov\ih of the 
Maipighian layer; (2) beneath this» replacing the corium and a 


portion of the subcutaneous tissue, is a layer of tissue apparently 
identical with granulation tissue, except that in places it contains 
large numbers of free red blood cells; and (3) a third layer corrp- 
sponding to the deeper subcutaneous tissue, whose lymph spaces 
arc filled and distended with small round and small polyhedral 
cells (Fig. 130), 

Wliert* the m>dule beeamc continuous with the surroumlinj; 
skin the eutaneoiis lymph spaces were also filled with small 
round and polyhedral cells. 

Ftu. 130 

Showing the distention of the deeper subctitaneona lymph spaces with tb« 

granulation tiasae. 

There were no bacteria of any kind in any of the numerous 

The results of this examination^ therefore, seem to warrant tlie 
opinion that this chronic and incurable lesion consisted of simple 
local inflammatory tissue, which extended quite extensivel)' into 
the subcutaneous lymph spaces. 

Wien we consider the disastrous results produced by (hi» 
groulh it seems almost incredible that it should belong among 

the recognized simple and benign new-formations. Though pos- 
sessing no malignancy, it led in the region afFecterl in one case to 
as much suffering and to as deadly results as true malignant new- 
growths are known to produce. The conformation of and the 
conditions inherent to and acting upon the external female geni- 
tals are undoubtedly the underlying causes of the chronicity of 
the inflammation. 

Our knowledge of the behavior of inflammatory tissues in gen- 
eral may he used in the present instance in explaining the varied 
conditions which are observed in tlie new-growths. In its soft 
elastic stnge it consisted of the elements already mentioned. 
I^ater on, where the conditions would admit of it, healing occurred 
by the production of fibrous tissue out of the abundant infiltrating 
granulation cells. Upon the juxtapudendal regions — moiis ven- 
eris and thighs — this change resulted in true, but ephemeral cica- 
tricial tissue. In the \*ulvar circle fibrous tissue was formed out 
of this granulation tissue* and it produced in the new-growth the 
density and contractility which were observed to appear as the 
process grew old. But here surface healing did not occur. How 
far the color of the new-growth was due to the red blood cells 
which escaped from the new and thin capillaries we are unable 
to say. 

It scoms strange that such an active inflammatory process 
should incrt^ase so slowly and show such a slight tendency to grow 

Etiology.— The exclusion of syphilis as the cause of this new- 
growth is warranted not only by the absence of any history of 
that disease, but by the anatomical structure of its tissues. Tuber- 
culosis is also etiologically out of the question by reason of tlie 
clinical and microscopic facts induced. Though prolonged 
search was made for bacteria, none were found. For these reasons, 
therefore, we are warranted in concluding that the lesion was not 
a local expression of a general infective process, nor a result of 
a local infection. 

My studies convince me that the local inflammatory condition 
engrafted upon the vulva by the cliancroidal ulceration led to the 



occurrence of chronic vulvitis, and tliat this affection was the 
starting point of the ijiflammatory new-growth of the first case. 
Anyone who has seen a considerable number of casei? of chan- 
croids in women will recall instances in which the resulting in- 
flammatory thickening of the tissues was even more difficult to 
cure than the original ulcers. Though I look upon the ante- 
cedent chancroid in the first case as the pathological forenmncr 
of the new-growth, in the second I could not discover any sp«?ciai 
or specific cause whatever. The chancroidal ulceration induced 
a tendency to inflammation which remained long after it had lost 
its virulent nature and had healed. A virulent, ulcerative, and 
inflammatory process existed and was cured, but left in its wake 
a predisposition to simple local inflammation, which the nature 
of the parts and the uncleanly and disorderly habits of the patient 
tended to pfTpctuatc. The resulting inflammation was in no 
degree complicated with an ulcerative tendency. In the second 
case the new-growth lx?gan as a pimple in the gn^in, which was 
[)robahly subjected to irritation. 

Diagnosis. — Tlie clinical features of tliis new growih are pecu- 
liar and distinctive. I know of no affection which resembles it 
in course or appearances. At the first glance chronic serpiginous 
chancroid may suggest itself to the mind. It was different in all 
its features from syphilitic lesions of the skin and mucous mem- 
branes, and, though to superficial e^caraination the idea of lupus 
miglit suggest itself, a little reflection would convince the observer 
that neither in developmentj course, clinical features, nor micro- 
scopic anatomy was it like that disease. It has no appearancfj 
in common with epithelioma. So well marked and peculiar are 
the characteristics of this new-growth that anyone familiar with 
its description will readily recognize it. 

Prognosis. — The outlook in this disease b far from satisfactory. 
It is possible that if seen in the early stage of its course it might 
be arn\sted and cured, but when it has attacked the deeper por- 
tions of the vulva little hope can be entertained. 

Treatment. — In the first case the new-growtli had attained 
such pniportions when seen that palliative or destructive methods 



of treatment were out of the question. Various agents were used 
to induce healing, the most eflScient of which were iodoform and 
bismuth and iodoform combinations. When perfect cleanliness 
was obtainable these drugs, applied on absorbent gauze and 
supported by gentle but firm pressure of a bandage, usually did 
good. Unfortunately, this treatment could not be efficiently 
used in the vulvar sulcus, so that little progress was made there 
at any time. Though cicatrization was very often induced upon 
the juxtapudendal portion of the growth, it never lasted for a 
long period. In short, though of simple and benign nature, this 
new-growth is as rebellious to treatment as are the most malig- 
nant forms. It, however, may be said with some satisfaction 
that it does not give rise to the secondary metastatic growths 
which are such frequent complications of the latter. 

Systematic local and general antisyphilitic treatment was once 
carefully followed as a tentative measure, for some months, but 
no improvement whfitever was produced. In this first case the 
applications of mercurial ointment increased the irritability of 
the parts and the suffering of the patient. 

If I should ever encounter a similar case to the two just 
detailed, I shouM certainly thoroughly try the ar-rays or radium, j 


Abnormal sizes of penis, 137 
Abnormalities of clitoris from mas- 
turbation, 4H 
Absence of penis, from syphilitic 

phagedena, 130 
Alcoholic excessesj priapism and, 386 
Ampullations, differential, aspermat- 

ism and, 240 
Amyloid bodies in prostate, 299 
Anaimift and sterilitv in the female, 

Anastomosis, intertCRticiiIar, 196 
Anteflexion and sterility in the female. 

Anteversion and stcrilit}' in the female, 

Arteries of corpora cavernosa, 22 
Aspermatism, 240 

anomalous causes of, 249 

debility and, 251 

deferential ampullations and, 240 

diagnosis of, 251 

ejaculatory ducts and, 241 

lateral and bilateral lithotomy, a 

cause of, 244 
meatotoray and, 250 
nervous exhaustion and, 251 
partial, 250 
prognosis of, 251 
seminal vesicles and, 240 
sterility in male and, 188 
stricture of urethra and, 246 
treatment of, 251 
urethral calculi and, 246 

drainage and, 250 
Atonic impotence, 119 

treatment of, 123 
Atresia uteri and sterilitv in the 
female, 400 
of vagina and st erili ty in the 
female, 401 
Atrophy of testes, 224 
causes of, 224 
of vulva, progressive cutaneous, 

Azoospermatism, abnormal condition 
of semen and, 230 
blood in semen and, 234 
colloid semen and, 237 
excessive coitus and, 230 
general morbid conditions and,235 
gonorrhceal epididymitis and, 193 
prostatic secretion and, 231 
pus in semen and, 233 
scanty semen and, 237 
sterility in the male and, 187 
syphilis and, 205 
treatment of, 239 
tuberculosis of prostate and, 221 

of seminal vesicles and, 223 

of testes and, 217 
wuterj' semen and, 237 
x-rays and, 225 

Hexequk's sound, 272 

Bennett's operation for varicocele, ^66 

Bladder. 44 

neck of, 259 

neuralgia of, 259 

structure of, 50 . , 

Blood in semen, azoospermatism antt, 

Bloody ejaculations, 234 
Bdttcher's spenna-cr>'3tals, »o 
Bougie i houle, 267 

olivary, 270 „„, • 

Boutonder6glc. See Henx^s progeni- 

talis in women. , 

Brown on azoospc^rmatism and x-ra>s, 


Brj'son on syphilis and azoosperma- 
tism, 205 

Bulbous urethra. 36^ ^^^^„^,„, ,,^ 

urethritis, chronic, ^^ 

impotence and, •^^^„^. 
symptomatic impotence and 

109, 111 

^m ^K^r ^^^^^^^^^^H 

^H CALCirLi, phosptmti^ in prostate, 300 

Congestion, Konorrhceol. of profitAte, ^H 

^^B preputial, orKtinic impotence and, 

treatment of. 27G ^H 


ConjuRal onanism, 373 ^H 

^^m uretliral, aspermatisni and, 240 

and irritability of heart in ^H 

^^M CamiiA and GIpv on prostatic spcre- 

women, 379 ^H 

^B tion, 90 

local lesions of, 3S0 ^H 

^^L Cancer, abaeuce of penis and. 131 

mechanisni of. 379 ^H 

^^^^^ of penis, organic impob^nre and. 

motives of, 373 ^H 


and neuralgia of tostrs, 37S ^H 

^^^^™^ vopt«tions of vulva and. 469 

i^yniptoms of, in the mftlp,37>t ^H 

in women, 37S ^^M 

^^^^^ Catarrhal inflainmfttion of prostAtc 

irentniont of. 3-S2 ^H 

^^^^^K with comraenciDK son- 

Consitrirlor urethrw muscle. 34 ^K 

^^^^K^^ ill' change, 294 

Cnn\, torsion of, strangulation of cpi- ^B 

^^^^^^^L oldur subjects, 292 

didymis and. 211 ^H 

^^^^^^^H yo\]n^ subjects, 2SH 

of tcf^tes juul. 21 1 ^1 

^^^^^^^^ clinical bisiorv 

treatment of, 212 ^H 

^V of, 2S(i 

Curp<ira ainylacea in pmstatf. 21^1 ^H 

^H Catheter, reRux, '2i^ 

cavernosa, art^rie^ of. 22 ^| 

^H soft-rubl>cr, 2G4 

fibroid Rclerosifl of, 170 ^H 

^H Cavit.y of Kotziun. .5<) 

organic impoCMM*)' ^H 

^^H (Vrchml disea-ie. priapi-sm in, ^^5 

luid. 177 ■ 

^^^^ Cervix ntori, atresia of. and sterility 

structure of, 20 ^M 

^^^^^L in the female, 4(K) 

syphilitic nodes of, t7(i ^H 

^^^^H hypertrophy of. and :^U'rihl> 

organic inipot«iice ^H 

^^^^^ in th*' female, 401 

and. 170 ^M 

^^m i 'hnueroifi.s of peiiis, organic i mpot«*i i ce 
^H nrul, 142 

Corpus sp4jngiosum. 21 ^H 

Cowper's glands, secretion of. IKi ^H 

^^H of viiKa, cliruriir, 4S0 

Crypttf of Morgagtii. 43 ^H 

^^1 distortion in. INO 

secretion of, 93 ^^^^H 

^^M infiltration in, \H0 

Cupped sound, 283 ^^^H 

^H treatment of, 4H.'> 

Curvalur*' of penis, 178 ^^^^H 
Cylinders, hyaline, in prostAtc. 2d0^^^H 

^^H .ivphilift and. 490 

^^1 Chlorosis and sterility in tlic tVmale,301f 

CystoHpasmus, 250 ^H 

^^m Clitoridean masturbation, 411 

Cysts, ovarian, and sterilitv iu thf! ^H 

^H <.1itondi*ctomy. 422 

female. 4(N> ^M 

^^K Clitoris, nl^norinalitiea of, from mas- 


^^1 turbation, 414 


^^^^^^ critfiH nf. 41o 

Davis on vaginiamus, 406 ^H 

^^^^L hypertrophy of, 216 

Debility, afipermati^in and, 2o1 ^H 

^^^^^f siirp-ry 422 

Deferential anipullations, a^pennat- ^H 

^^^^^ Cohirsione in coitii. 405 

ism and, 240 ^H 

^H Coitus ab on* and sexual excess^?, 34S 

Defen'otitii). guucrrha'al, 200 ^^^ 

^^M excessive, .<iX(iospemial ifiii and, 

tn^atment of, 201 ^^^^H 


B>'philitic. 205 ^^^H 

^^H injuries of reniul)* KeiiilaU in. 44S 

treatment of. 206 ^^^^^| 

^H Xeufcebnuer on, 448 

Dingnoi^is of asprrmatiMm, 2.'jl ^H 

^B inl<*rnip1iiH, :f73 

of chronic po.^tcHor urothrittM, 2tiii ^H 

reservutus. 373 

}4iMniniil vesiculitis, .320 ^H 

treiitmenl of, 3S2 

nf eaiigrc'ne of vulva. 415 ^^| 
of herpes progenitalis in women, ^| 

HpHMii u\ levator ani diirin»t, 407 

* Colloid •jeiiirn. a-toosniTniMtism and. 


f 237 

(jf new-growthM nf \'idva. 512 ^H 

Coniprexsor urethre muHcIc, 33 

of prostatorrhcea, 303 ^H 

CVinceptiond, intpxTalivc. y9i> 

of pruritus of vulva, 42<i ^^M 

Concnaions, pntHiatic, 300 

of sexual neurasthenia. 369 ^U 

(>onw*stion, Konorrhneal, of prostate, 

Dickinson on masturbation in voixim, ^^| 



420 ^M 

^ . 



' Ditatation, gmdiiol, 209 | Feoinle i^enitnU, uijcirics of, in <'oi1u^, ^B 

i ftC'cidt'jits in, 273 

Neugebauer on, 448 ^^^M 

^^ Distortion in chn)mc dianrroiilft of 

sterihtv in, 399 ^^H 

■ vulva, 480 

Ketichism. 394 ^^^H 

^H of vulvu from syphilis, 491 

Fibroid sclerosis of eorpora eavemosji, ^^^^H 

^H Dorsal veins of i>eniM, enlargoment of, 


^ 140 

organic inipod-nrt- ^H 

Double penis, 139 

and, ^H 


Fibrosis of penis, organic impotence ^H 


and, 15<> ^H 

^f ErrEMiNA'noN. viragiaity and, 395 

Furbriiiger on prostatic secretion, ^H 

^ Ejaculation, bloody, 234 


' mechanism of, 71 

on speruia-ei^'8talfl. 87 ^^^H 
Fissure of os uteri and sterilitv in (lie ^^^H 

^m Ejnculutory ducU, 02 

^H ii;4|>f'nnatism and, 241 

female. 401 ^M 

^K c-ondilion of, m aspenna- 

Florence'p test for semen, 77 ^^^^H 

^B tism, 242 

FoIUcles of urethra. 41. 43 ^^^H 

^H Injurv to, a^pomiatii^ni and, 

Fossa navionlnris, 37 ^^^^H 


Fracture of penis, 181 ^^^^| 

^H injury to, lateral agd bilateral 

^m lithotomy and. 244 

8Ymptom» of, 182 ^^^^^ 

treatment 185 ^^^^^ 

^H KleuhautifLjUs, ubseniH; of iK'nia and, 

Frienum preputii, 25 ^^^^^ 

B 133 

Funiculitis, gonorrheal, 2(N> ^^^^H 

^B of penis, organic iinpotcace and, 

treatment of. 201 ^^^^H 

^ 152 

svphilitic, 205 ^^^M 

of vulva, 47.'i 

treatment of, 200 ^^^H 

[ Endoccrvicitis and sterility in the 


H tcniidir. 4U(> 


^H Knddnu'lril i.s and stcrilitv in the 

Ganouknr, absence of TMiti.s :tnd, ^H 

■ f'-niali^. 401 


■ Kndusiopir tubes, 200 

of p*'nis, organic impotence and, .^H 

^M Kpididyiiiis, obslruotion of, sterility 

144 _^^H 

^M due to. tivatrnfuit of, 196 


^L strangulation of, torttion of cord 
^ft and. 2U 

diagnosis of. 445 ^^^^| 

pathology of, 445 ^^^^^ 

^r 8vphiU8 of, 201 

trfatuicnl nf, 445 ^^^^^| 

* treatment of. 20t) 

Glan<l. Cowper's, secretion of, 93 ^^^^^ 

Epididymitis, chn>nir, 207 

prostate, ^^^^| 

j gonorrhceal, 193 

t^rreiion tif, H4 ^^^^H 

1 aJEOdspcnnalinni and, 193 


treatment of, 195 


Epispadias, absenee of pt'nis and, 135 

nUuidula' Tysunii, 20 ^^^^^| 

Epitneliuina. kranrosia vulva* and, 442 

GunorrlKvti of pn>state, 275 ^^^^^| 

Erection. uieehantHm of, 68 

tri'atnient of, 276 ^H 

Erethism, wNual, 34S 

GODorrbtenl congestion of pronrnic, ^H 

tri'atinent ol. 352 

Eulenberg on coituH n/rn'rvatuii, 379 

treatment of, 270 ^^^H 

Excision of spennatir veinn in vari- 

dcferentitis, 200 ^^^H 

eoeele, 332 

treatment of. 201 ^^^H 

1 Exhibitionii?m»«, 396 

cpididvnutis, 193 ^^^^| 

1 AxoOspenuatiHiit a,nd, 193 ^^^^H 

' treatment ^^^H 

TALiXipiAN tul>es, ab^nee of, and funietditi», 200 ^^^^| 

steriUty in the female. 400 

treatment of, 201 ^^^H 

j distortion of, ajid steriUtv in 

orchitis. 200 ^^^H 

the female, 400 

treatment of. 201 ^^^^| 

1 Feniale frcnitjUH, injuries of, in coitiu, 

Gray on sexual neurni^theuia, 3U9 ^^^^| 


Grip, iirchiliH fnim, ^^^^H 

^m 518 ri^DEX ■J^^^^^^^^^l 

^^M Hayden's irripiting s>Ting<e, 263 

Impotence, organic, elephantiwiie of^| 

^H Hirmatocelp, 213 

pcni.s and, 152 ^H 

^^M IreaUui'nl <»r, 214 

fibroid sclerosis of corpora ^H 

^H Henle's deep tninsverrte ligament of 

cavernosa and. 177 ^M 

^H pelvis. 32 

fibrosis of penis and, 156 ^H 
uangrene ut peni^ and. 144 ^B 

^^m lieredit.ur\' sn-pliilis of testes. 206 

^H 'treatment of, 206 

hard chancre and stricture of ^| 

^^M Herpes progeniialid in women, 433 

urethra and. Uto ^H 

^^^^^. eoucse of, 435 

horns of peni<^ and, 149 ^H 

^^^^fe^ of, 431) 

keloid of peni.s and, 156 ^H 

^^^^^^^^^ etiology of, 435 

a?dema, indurating, of iiexiis ^H 

^^^^^H seat o/, 433 

and, 162 ■ 

^^^^^^BP symptoms of, 

ossification of penis and, 169 ^H 
phagedena ana, 142 ^H 

^^^^^^ treatment of, 437 

^^B midebraridt on spo^m of levator unt 

prL-putial calculi and, 165 ^K 
sii-pliililic nodes of eorpom ^^ 

^H during cinivis, 407 

^H Hodge on ^M^Mial ueurastheDia^ 365 

cavenioria and. 176 

^H H(inio8exu.slity, 395 

Traumatism of penis and, Jt 

^H Homs nC punis, organic impotence 


^m and, 149 

tumor:^, sebaceous, of prnii ^| 

^H Horwitz on aApermatituii from injury' 

and, 15S H 

^H of ejaeulatory ductn from lateral 

varices of penis and, 157 ^H 

^H lithotomy, 244 

vegetations of penis and. ^H 

^H Howe on moi^turbation in males, 337 

146 ■ 

^H Hyaline evlinders in prostate, 299 

veins of penis and, 15S ^H 

^H Hydrocele' 212 

p.4ycliieal. 07 ^H 

^^^^ absence of penis and, 132 

treatment of. 105 ^M 

^^^^^k cbaiigcs in testis and, 213 

symptomatic, 107 ^H 

^^^V treatment of, 213 

bulbotis urethritis and, 109, ^H 

^ Hvdrosalpinpilis and sterility in the 

111 H 

^m 'female, 400 

jxTiplicral irritation nud, 108 ^| 

^H Hymen, [mperforate, and sterility in 

posterior urethritis and, til, ^H 

^H the female, 401 

114 ■ 

^H Hyperplastic growths of vulva, 4ft4 

prostatitis and. 113. 110 ^M 

^H^ Hypertrophy of cervix uteri ami Ht^r- 

seminal vcsinilitis and, 117 ^H 

^^^^_ ilitv in the female, -101 

stricture of urethra and, III ^B 

^^^M clitoris, 416 

urethritis imd, H 

^^^^^^^^ of prostate, 308 

bulbous, 253 ^M 

^^^^^^K course 

chronic posterior, 257 ^H 

^^^^^^^y sexual conditions in, 310 

Infants, masturbation in, 411 ^H 

^^^^^^^ treatment of, 310 

i^etjuela* of, 411 ^H 

^^^m nf viUva, 458. 477 

InfiltrationM in chronic chancroids of ^| 

^^^H 470 

vulva, 480 ^M 

^^^H syphilitic, 487 

Inflammation of prostate, cularrbal. ^| 

^^^^B from vegetations, 463 

with commencing sr- ^H 

^^f Hypochondriasis, sexual, 362 

nile change, 204 ^B 

^B Hypospadias, absen<'e of penis and, 134 

in older subieet&. 292 ^B 
in young subjects, 28Q ^H 

clinical bistort ^H 

Impehfoiiate hvraen and sterility in 

of, 286 ' ■ 

the female, 401 

chronic, 2S4 ^H 

Impotence, atonic, 119 

of Aominni vtssicles and .«<*xubI ^| 

treatment of, 123 

weakneHs, 312 ^B 

in male, 95 

of verunionlanum, 278 ^H 

forma of, 96 

prostatic urethra and, 278 ^M 

^^^^^ organic, 128 

prognosis of, 282 ^H 

^^^^^L cancer of {lenis and, 158 

treatment of, 282 ^M 

^^^^f chancroids of penis and, 142 

Integument of peais, 25 ^H 



Intertesticuiar anastomosis, 196 , 

Irritability of the heart and conjugal ! 

onanism, 379 ' 

Keloid of penis, organic impotence 
and, 156 ; 

Kemp's rectal irrigator, 276 ; 

Kisch on heart trouble in coitus reser- ■ 

vatus, 379 
Kraurosis vulvsc, 439 

Baldy and Williams on, 441 

description of, 439 

epithelioma and, 442 

etiology of, 441 

pathology of, 441 

Perrin on, 442 

treatment of, 442 

Laroyenne on syphilis and azoosper- , 

matism, 205 
Ijcukaemia, priapism and, 389 
Ijevator ani, spasm of, during coitus, 

Lidgois on spermatozoa, 81 
Ligament, triangular, 32 
Ligation, subcutaneous, in varicocple, 

Lithotomy, bilateral, aspermatism 
from, 244 
injury to ojaculotory ducts 
and, 244 \ 

lateral, aspermatism from, 244 
injury to cjaculator\' ducts ; 
and, 244 
Littre's follicles, 43 

secretion of, 93 
Lohenstein on prostatic secretion, 

Lubarsch on sperm a-crystals, 87 
Luxury of life and sterility in the 
female. 399 

Malarial orchitis, 210 
Male, impotence in, 95 
forms of, 96 

masturbation in, 336 

damage produced by, 339 
symptoms of, 342 
treatment of, 344 

sterility in, 188 

aspennatism and, 188 
azodspennatism and, 187 

urethra, 28 

course of, 31 
diyisions of, 30 

Male urethra, structure of, 29 
Malignant uterine growths and steril- 
ity in the female, 401 
Martin on intcrt«sticular anastomosis, 
operation for sterility in male, 

on treatment of sterility from 
gonorrhoeal epididymitis, 196 
Masochism, 394 

Massage, atonic impotence and. 126 
Masturbation, abnormalities of cli- 
toris from, 414 
clitoridean, 411 
in infants, 411 

sequelae of, 411 
in males, 336 

damage produced by, 339 
symptoms of, 342 
treatment of, 344 
yaginal, 411 
in women, 410 
causes of, 412 
treatment of, 421 
Meatotomy, asiK'muitism and, 250 
Meatus, 27 

structure of, 28 
Mechanism of ejaculation, 71 

of erection, 68 
Membranous urethra, 31 
structun; of, 31 
Morgagni's crypts, 43 
Mump orchitis, 209 
Muscles of sexual apparatus, (i4 
Muscular effort orchitis, 210 

treatment of, 211 

XtRyKs of penis, 23 

Neryoua exliauslion, a?<pcnnalism and, 

Xeugebauer on injuries of female geni- 
tals in coitus, 448 
Xeuralgia of blatlder, 258 

of neck of bladder, 259 
Xeurasthenia, sexual, 363 
diagnosis of. 369 
prognosis of, 309 
symptoms of, 3t>9 
treatment of, 370 
Xew-growth of yuha, 458, 500 
Xodes, syphilitic, of corpora caver- 
nosa, 176 
onEanic impotence 
and, 170 
Xympha', serpiginous yascular degen- 
eration of, 439 
Xymphomania, 415 

520 ^^^ ^^^^^^^^^1 

ijBKsn y ami slcriUtv in iUo fenjttle.3i*9 

Pejiile urethra. 36 ^^^^^H 

Obntnirtinii of fpUlidyniis, sttrility 

20 ^^^H 

<iut' to, treairiient oi, MMi 

abnormal sizes of, 137 ^^^^^B 

(Tdema, indunitinK, ol penis, orf^anio 

absence of, from *-anrcr, 131 ^^M 

inipott-nro am!, I(i2 

fmni elephantiaaii*. i:W ^^^^B 

m (»f vulva. 487 

from epi»pailiu5, 135 ^^^^H 

P trpatment of, 496 

from eungreno, 131 ^^^^^ 
frtim hydrocele. 132 ^^M 

Onunisin, ccmjugal. 373 

ill women, 412 

from hypoeipadiH!^, 134 ^^M 

OGphorilis in the female, 4tK) 

from ^vpliihtic pimeedeiin. ^H 

Orchitis, i'liniiiiiv 207 


—^ K^>"*-*rrhu'ii!, In^'atnieiit of, 207 

adhesion of, to scrotimi. 179 ^^ 

H fmni ^rip, 201 

cancer of, orgauic iiiipolenee and. 1 

H malarial. 210 

I5S J 

H from nniiiips, 209 

(*Hptiviis, 406 ^H 

H musnilar effort. 210 

ehimcroids of, organic impotence ^H 

■ treatment of, 211 

142 ^M 

H soarlatinous, 210 

curvature of, 17>t ^^M 

W svphililif, 202 

double, 130 ^H 

1 tonsillar. 2(ht 

elephant iH>:is of. orgauic imprr- ^H 

varioloiM, 20iJ 

tence and, 152 ^H 

Organic impotenro. 128 

erdurgejnent of dorsal veins of, ^H 

oanwr of penis and, 158 

140 ^M 

K ihaniToida of penis niiH. 142 

tibroai!) of. oi^nir impotrnce and, ^H 

^t^^ ('lcphanliai5ibofpeniHuml,l52 


^^^^^ fibroid sclerosis nf rorpora 

fracture of, 1S1 ^^M 

^^^^1 cavernosa and. 177 

syniptoinn of, 1H2 ^H 

^^^H HbroMs o( DC-uis and, 150 
^^^H gtm^rone of jhmu'h and, 144 

treatment of. 195 ^^M 

gangrene of, organir impotrncv ^H 

^^^H luifd chancre and stricture of 

and. 144 ^M 

^^^H urethra and, 1(V> 

horns of. organir impotence and. ^H 

^^^^B horns of penis and, 149 


^^^H keloid of penis and, 1.545 

integument of, 25 ^H 

^^^^H CGdeiua, inditraiiii^, (.>! jjeuis 

keloid of, organic inipotvnoe iind, ^H 


156 ^M 

^^^H oseification of neniN and, 1(39 
^^^H phuFEi-denn nni^, 142 

ne^^'etfof, 23 ^H 

(pdenm. indurating, of orguim ^H 

^^^^B pn^putiid raltuli an<l, 16.5 

impotence and. 162 ^^M 

^^^^H sypliilitic niKle,s ot' rorporu 

u^^»ilieation of, organic inifHiteiu-r ^^M 

^^^H caverno&H and, 176 

and. 109 H 

^^^H traumatifun of {H'uif and, 145 

palmatus. IHO ^H 

^^^H tvimors, wbaueous, of periis 

^trucliire of, 20 ^H 

^^H and, 158 

t nuunat i«<in of, organic inipuiencr ^H 

^^^^H varices of penis and, l<57 

and, 145 ^M 

^^^^H veicetut iooM of {)eiiis and, 1 46 
^^^^* veins of penis and, 158 

tumors of, sebaceous, organic ^^M 

impotence and, 15S ^H 

Osbom on varicocele, 32G 

twisted, 13t) ^H 

OHbiiieation of penis, organic impo- 

varices of. organic impotence and. ^H 

lentv and, 16» 


Os uteri, fissure of, and sti^rilitv in the 

vegetations of, organic itnpi>tcnre ^H 

female, 401 

and, 146 ^M 

(hariHij cvsls and stcrilitv in the 

webbed 180 ^M 
weuH of, organic imi)(>t4.<iice and ^H 

^ female. 40U 


158 H 


Pprionplioritis and sterility in the ^H 

pAKrimrriuN and sterilitv in the 

female. 400 ^H 

female, 400 

Peripheral irritation, symptciniatic ^^M 


IVafNol on MpennatogeneMS, 74 

impotence and, lOS ^^M 


^^M Peycr on <**>iius rvaervaius, 37S 

Prostate, inflanimalion of, caljtrrhal, ^H 

^H. PhuK'^tienu, organic impdteuce aiid, 

in voung aubjcctH, elinioMl ^^^^H 


of. 286 ^^^^1 

^^B syphtlitic, alisonre of penis and, 

284 ^^^^^H 


pfiosphatic calculi in. 3(Xt ^^^^H 

^H riiospliatii; calnuli in jmiistjilc, 300 

t al>crcuto.sis of, 221 ^^^^H 

^" I*(»siu'r aiul ('oheii on miplantation of 

az<^»tispennutism anil, 221 ^^^^^| 

va-s ftpferena into t'pididv- 

treatment 222 ^^^^H 

mis. 199 

Prostatic concretions, 300 ^^^^H 

intertpsticular anafitomosis, 

secretion, ^^^^H 


azo5spennatism and, 231 ^^^^H 

on proKlate secrptiou. 87 

tubules, 5:^ ^^^H 

Posteriur urctliriUs, chronic, 257 

urethra, 44 ^^^^H 

^^1 diaiJ:D06iu of, 200 

Prostatitis, svinpioniutic iinpotence ^^^^H 

^^1 iiiipott:'iu-e and, 2'j7 

and. U3. 1'16 ^M 

^^^^^^^^^m patholoprnl apix'nrunoc 

Prostatorrhcea, 301 ^^^^1 


diagnosis of, 303 ^^^^H 

^^^^^^^V syniptonis 

prognosis of, 304 ^^^^H 

^^^^^F irrntiru-nt o{, 202 

treatiiKuit of, 304 ^^M 

^^^^^ svinpUunatii- ini)>otcnce and, 

Prostitution and sterility in the ^^^^H 

' 111, lU 

female, 391> ^^^^H 

Poteutia ctcntuii. 120 

Pniritus of vulva, 424 ^^^^H 

gencrandi, i'29 

etiolog.v «>f, 424 ^^^^1 

Prepuce, 25 

frcpuum of, 25 

pathology of, 42ti ^^^H 

Klands of. 20 

progTin:jis of, 426 ^^^^^| 

Preputial ralf-nli, orRiinic impotence 

symptoms of, 424 ^^^^H 

and, 1(55 

treatment of. 427 ^^^^M 

Prtn'esiifal spat*. 'A^ 

operative, ^^^H 

Priapisn», 3H4 

Psyrhii'al irii|>oteturfr, ^^^^^| 

m alcoholic excesses, 386 

105 ^^^^1 

in cerebral disease, 385 

Psychrophor, 282 ^^^^B 

course of, 387 

Pvis in semen, a2o6^ x^nnatism ami. 233 ^^M 
Pvosalpingitis and sterililv in tliu ^^^^| 

etiology of, 389 

leukanuc ori>jiu, 389 

female, 400 ^^^H 

prognoftis of. 391 


in spinal disease, 3SS 


treatnipnl of, 391 

Rectal irrigator, 275 ^^^H 

Prostate, afle<-tionit of, 276 

Uetroflexion and sterilitv in Uie ^^^^B 

amyloid bodies in, 299 

female, 401 ^H 

corpora lunylacca in, 299 

Retroversion and sterility in the ^^M 

ghind. 4-1 

female, 401 ^H 

si'rri'tion of, S-l 

Uetzius, cavity of, 50 ^H 

structure of, 45 

Rose on Rernrfune, 277 ^H 

Ronorrlioea of, 275 

Ruptured perineuni and sterility in ^^^^H 
tl)e female, 401 ^^^H 

treatment of, 276 

gonorrhccal congeation of, 275 


treatment of, 276 


hyaline cylinders in, 290 


hypertrophy of, 308 

Salpingitis ami sterility in the female, ^^^^H 

eour*; of, :i09 

400 ^H 

sexual conditions in, 310 

8eantv semen, azoo^^tx-nnntitan and, ^^| 

tn*alHient of, 310 | 


inHaniuiation of, catarrhal, with ' 

Hcauzoni on spasm of levator ani dur- ^^^H 

commenciuK senile ' 

ine c<iitus, 407 ^^^^M 
Se^irlatiiia orcliitis, 210 ^^^^| 

cliange, 294 

in older subjects. 21)2 

Selen.isis, fibroid, of eorpfJOi caver- ^^^H 

in voung subjects, 286 

1 J 

uosa, 170 ^H 



Sderoms, fibroid, of corpora C4ivrr- 

nosH, organic iiiipolenw and, 177 
Scrotum. a<dhcHion» of pf-nis lo, 170 
Sebacecms tumors of penis, organii* 

impotenoe and, 15S 
Semen, 73 

abnonnal condition ot axoOsper- 

maiism and, 230 
blood ill, azo6spcrmatism and, 

colloid, azoospemiatism and, 237 
composition of, 73 
nature of, 73 

pus in, azo(>:j{>«miati8in and, 233 
scAiily, naoiiapemiatiHiu and, 237 
watery, azoiSspt-nniitiwn and, 237 
Seminal cdla, 7.S 
vesi(.'le8, 55 

ampuUations of, 62 
anatomy of, 5(i 
Aspenuatisin aud, 240 
iufi&mniation of, st'xual 

weokiirfss and, 312 
physiology of, 01 
secretion of 82 
structure of, 5(1 
tuberculosis of, 223 

a£oAspermatisra ami, 

treatment of, 224 
veaioulitis, 312 
chronic^ 315 

diagnosis of, 320 
prognosis of. 323 
symptoms of, 320 
treatment of, 323 
s\'mptomaiic impotence and, 
" 117 

symptoms of. 312 
Serpisinoiifl vascular degeneration of 

nymphtt, 439 
Scxiial apparatus, muacles of, 04 
eenln?, 23 
ervtKism, 348 

troaiment of, 352*>, 348 

treatment of, 340 
hypochondriasis. 362 
neurasthenia, 303 

diagnosis of, 369 
prognosis of. 309 
ayniptums of, 309 
t'n'at.ment of, 370 
perversion. 394 

weakness, inflammation of sem- 
inal vesicles and, 312 
worry, 359 
Sinus pocularis, 48 

Sims on vaginisnms, 404 

Smith on masturbation in women. 4lfi 

Sodomy, 3(»6 

Sound.* Bcnequtf*8, 272 

cupped, 283 
Spa«m of levator ani during roitna, 
of vagina, 405 
Spaismodic stricture of urethra. 34 
Spenna-(.r>'sLai«, HCttcber's, 8i5 
Spermatic veins, exciaon of, in vari- 

eoi-ele, 332 
Spermatogenesis, 74 
Spermatorrhopn, 354 
imaginary, 350 
Spermatoaoa, 70 

Spinal disease, priapism and, 386 
Stern on oomial prostatic serreiion 

Stenosis of vagina and sterility in the 

female, 401 
Sterility due lo obstruction of *indidv- 
mis, treatment of, l(m 
in the female, 398 

and ab^ncc of Fallopian 
tubes. 400 
of ovaries. MM) 
of uterus, 4(X) 
of vagina, 401 
and anirmia, 39t> 
and anteflexion. 401 
aiLd autoversiun, 4fll 
and atresia of cervix ut«n. 
of uterus, 400 
of vagina, 401 
and c)dun>sis, 390 
and distortion of Fallopian 

tubes. 400 
and endoeer^'icitis, 400 
and endometritis, 4tU 
and fissure of os uteri. Wl 
and h\dro}^ulpingiti^, 400 
and hyperln>phv of cervix 

uteri, 401 
and imperforate hymwi, 401 
and malignant growth* of 

uterus. 401 
aud modes of life, 399 
and ol»esity, 399 
and oophoritis, 400 
and ovaniiii cyst-?, 400 
and pnrturition, 100 
and p«ii'»ophc.»rilis. 400 
and prostitution, 399 
and pyosalpinfritis, 400 
n'lative freqtioncy of, 398 
and retroflexion, 401 

^^^^^ INDEX 523 ^^B 

^^1 Sterility in the female and retrover- 

Syphiliticdeferentiti3,treatmentof,206 ^H 

^^^ siun, iOl 

funiculitis, 205 ^^| 

^^H aud ruptured permeum^ 401 
^^^^^ and saJpingilis, 401 

trc^Ument of, 206 ^H 

nodes of corpora cavernosa, 176 ^H 

^^^^K and ^Kmo.sis of vugina, 4Ul 

organic impotence ^H 

^^^^H aiid sN-philis, 400 

and, 176 ^H 

^^^^ in the male. 188 

orchitis 202 ^H 

^H aspermatista and^ 188 

phagedena, absence of penis and, ^^| 

^^B azodsperroatism and, 187 


^^M Strangulation of enididymia and tor- 
^^^ sion af cord, 211 

Syringe, Haydon's irrigating, 263 ^^^^H 

Taylor's, 266 ^^^H 

^^H of testis and torsion of oord, 


■ 211 


^H treatment of, 212 

Taylor's svringe, 266 ^^^^| 

^^1 Stricture of urethra, aspcnnatisiii and, 


^B 246 

atruphy of, 224 ^^^H 

^^H of bulbous urethra, treatment 

causes of, 224 ^^^^H 

^^^_^ of, 268 

changes in, hydrocele and, 213 ^^^^H 

^^^^^B Bpasmodic, 34 

ectopia, 190 ^^| 

^^^^H symptomatic impotence and, 
^^^^P from svphilJR, orgaziic impo- 

strangulation of, torsion of cord ^^^H 

and, 211 ^^B 

treatment of. 212 ^^^H 

^^^^^ teuce and, 165 

structure of, 65 ^^^^H 

^H Symptomatic^ impotence, 107 

s>'philifi of, 201 ^^^^H 

^^H bulbous urethritis and, 109, 

hereditary, 206 ^^^H 


treatment of, 206 ^^^H 

^^1 peripheral irritation and, 108 

tuberculosis of, 214 ^^^^H 

^^B posterior urethritis and ,111, 

azoOspermatiam and, 317 ^^^^H 

^m 114 

forms of, ^^^^1 

^^1 pmtjtutius and, 113, 116 

treatment of, 220 ^^^^^| 

^^P seminal vesiculitis and, 117 

Tonsillar orchitis, 209 ^^^H 

^^ stricture of urethra and, 111 

Torsion of cord, strangulation of epi- ^^^^H 

Symptoms of chronic posterior ure- 

didyniis and. 211 ^^^^| 

thritis. 258 

te:«tis and, 211 ^^^^H 

seminal vefiicuUtis, 320 

treatment of, 202 ^^^^H 

of fracture of penis, 182 

XreaUnent of aspennaliam, 251 ^^^H 

of herpes progenitalia in women. 

of atonic impotence, 123 ^^^^H 


of a20(:isp(^rmatiam, 239 ^^^^H 

of mai^turbabion in males, 342 

of chrome chancroids of vulva, ^^^H 

of pniritus of vulva, 424 


^H of seminal vesiculitis, 312 

posterior urethritis, 262 ^^^^1 

^H of sexual neurasthenia, 369 

seminal vcsicuhtis, 323 ^^^^H 

^^ Syphilis, axoftsperraatism and, 205 

of coitus rciKr\'atus, 382 ^^^^H 

f chancroids of ^'ulva and, 491 

of fracture of penis, 1S5 ^^^^H 

^^ distortion of vulva from, 491 

of gangrene of vulva, 445 ^^^^H 

^^ of epididymis, 201 

of gonorrhoea of prostate, 276 ^H 

^H treatment of, 206 

of gonorrhoeaJ congestion of pros- ^^^M 

^H hereditary, of testes, 200 

tate, ^^^^1 

^H treatment of, 206 

dcfcrentitis. 201 ^^^^H 

^^1 hypertrophy of vulva from, 487 
^^P and sterility in the female, 400 

epididymitis, 195 ^^^^H 

funiculitis, 201 ^^^^H 

^^H stricture of urethra from, organic 

orchitis, 201 ^^^H 

^^B impotence and, 165 

of liiematooele, 214 ^^^^H 

^H of testes, 201 

of herpes progenitalis in women, ^^^H 

^H treatment of. 206 


^^H of vas deferens, 201 

of hydrocele, 213 ^^^H 

^^V of vulva, treatment of, 496 

of indurating csdenui of vulva, ^^^H 

^■^ Syphilitic defurentitis, 205 

1 ^ 

496 ^^^^^M 

^^^ ^^^^^^^^^^^1 

^^^^B Treatment nr iiiHanuualion of the 

I'LOEKATION uf VulVH. destfUCtive, ^M 

^^^^1 vrniinontHiium aiid pmstatic 

4U3 ■ 

^^^H urrthrn. 2S2 

ITi^ihra, bulbous, 3tl ■ 

^^^H of kraun>Bi8 yulvir, 442 

stricture of, treatment nf. ^1 

^^^^^1 of nta.sturbation in males, 344 

268 H 

^^^^H wom<>n, 421 

calibre of, 41 ^H 

^^^^H of muHCuIar t^^ort urcliitiij, 211 

ronfomiations of, 38 ^M 

^^^^^^^^ of nt'W-};ro>\'th of vulva, 513 

fuUidcs uf, 41, 43 ^^M 


28 ^^H 

^^^^^^V uf proutalnrrliaea, 304 

coun^ of. 31 ^^^1 

^^^^V of pmritufl of vulva. 427 

divisions of, 30 ^^^^H 

^^^^H operative, 430 

structure of, 29 ^^^H 

^^^^H of psychical impotence, 105 

membranous, 31 ^^^H 

^^^^H of eifxual erethism, 3A2 

structure of, 31 ^^^H 

^^^H excRsiiCia. 340 


^^^^^H Mf^unisiiheiiiH, 370 

44 ^^^H 

^^^^H nf sterility diif to obstruction of 

shape of, 38 ^^^H 

^^^^H epididymis, 196 

stricture of, aspermatism aud V 

^^^H nt ^tranf^laiion of testis from 

246 ■ 

^^^^H torsion of cord, 212 

spasmodic. 34 

^^^^B of stricture of biilfK)US urethra, 

Hvniptomatic impotence nml. 


Ill m 

^^^^^ of syphilis of cpididvmis, 206 

from syphilis, organic impo- ■ 

^^^^Hte tc-^tisi, 200 

tenee and, 105 ■ 


Itiberrulosis of, 222 ^M 


(Tn'thrul calculi, aspcrmatism and. H 

^^^^F of Hvphilitic defercntitis, 200 

246 ■ 

^^^^H 'funiculiti», 20t> 

caruncles, 406 H 

^^^^H of tuberculosis of prostatp. 222 

drainage, aspemiatism and. 250 H 

^^^^K^^ of seniiual vesicles, 223 

L'rethritis, bulbous, imixjtexife and, H 

^^^^^^^ of testes, 220 

253 ™ 

^^^^^H 4{^J 

svTnptomatic impotoncc and. 

^^^^^^^^ vagini»mii.s, 407 

109, 111 ^ 

^^^^^■^ vfiricocelo, '.iM 

chronic bulbous, 253 ^M 

^^^^^K uf vegetutions of vulva, 467 

posterior, 257 ^M 

^^^^H iu progtiant wonicn^ 

dia});Tiosii» of. 200 ^M 

impotence and^ 257 H 

^ Traimi:itism of penis, organic impo- 

pathological appear- ■ 

^H tence and, 145 

ances of, 2t)0 ^1 

^H TritiiiKiihir Hganicnt. 32 

svinptoms of, 258 ^M 

^H TubcrciUosis of prostate, 221 

treatment of, 262 ■ 

^B azoospcmial ism imd, 221 

impotencu and, 255 ^M 

^M trealmonl of. 222 

iwsterior, symptomatic impo- H 

^^^^_ of seminal vesicles, treatment of, 

tence and, HI, 114 ■ 

^^H 223 

Crethrorrhoea ex libidinc. OS H 

^^^^( juo68|>enaatiBm aud. 223 

Cterus, absence of. and hterilit v in lh*» ^M 

^^^^V testes, 214 

femaJe. 400 H 

^^^^V azu6t»pen)iati«m and, 217 

atresia of. and stcrilitv in thts^l 

^^^^ foiius of, 215 

femaJe. 400 ■ 

^V treatment of, 220 

malignant growths of, and sleril«^| 

^^^ of urethra, 222 

ity iu the feniule, 401 ^M 

(if vulva, AMU 

masruliima, 54 ^| 

ireaimnu of, 4*J9 


Tiibules, prostatic, 53 


i'umors, sieliawous. of penli*, orRiuiic 

VAGtNA. absence of, and stcriJitv ln^| 
the female, 401 ■ 

impotence ami. 15H 

TwisU'd (Jeiiis, 130 

atresia of, aud sierility iu tii«^| 

Tyson's glands, 20 

female. 401 ^B 



Vagina, spasm of, 405 

stenosis of, and sterility in the 
fem^e, 401 
Vaginal masturbation, 411 
Vaginismus, 403 
forms of, 404 
superior, 409 
treatment of, 407 
Varices of penis, organic impotence 

and, 157 
Varicocele, 326 
causes of, 327 
description of, 327 
treatment of, 331 

excision of spennatic veins 
in, 332 
ligation in, subcutaneous, 334 
Variola orchitis, 209 
Vas deferens, syphilis of, 201 
Vftsa deferentia, 62 
Vascular degeneration of nyinphip, 

serpiginous, 439 
Vegetations of penis, organic impo- 
tence and, 146 
of vulva, 461 

eancer and, 46!* 
hypertrophy from. Hi;i 
treatment of. 467 
Veins, spermatic, excision "l". in \nri- 

cocele, 332 
Verumontanum, 47 

inflammation of, 27S 
prostatic urethra and. 27S 

prognosis of, 2S2 
treatment of, 2S2 
Vocation disease. See Hori>es progeii- 

italis in women. 
Vulva, atrophy of, progressive cuta- 
neous, 430 
chancroids of, chronic, 4.S0 
distortion in. 4S0 
infiltration in, 480 
treatment of, 4S5 
syphilis and, 4!K) 
distortion of, from syphilis, 4!M 
elephantiasis of, 475 
gangrene of. 443 

diagnosis of, 44.5 
pathology of, 44n 
treatment of, 44."> 
iiyperpla.stic growths of, 464 
hvperlrophv of, 45S, 477 
largo. 470 
syphilitii', 487 

Vulva, hypertrophy of, treatment of, 
new-growths of, 458, 500 
diagnosis of, 512 
etiology of, 511 
pathology of, 509 
prognosis of. 512 
treatment of, 513 
cedema of, indurating, 4S7 
treatment of, 49(i 
pruritus of, 424 

diagnosis of, 426 
etidogy of, 424 
pathology of, 426 
prognosis of, 426 
symptoms of, 424 
treatment of, 427 
operative, 43*) 
syphilis of, treatment of, 406 
tuoerculosis of, 499 

treatment of, 499 
ulceration of, destnictive, 493 
vegetations of, 461 
eaiicer and, 469 

W \iKi(v s*-rnt'n. axoifspcnmitiHrn and, 


\V,-I.I,.-.| |K-tii-. 1H(» 

\\ i-uy of [»<TiiM. ori^Miiir itnpoh^nee and, 


Witluiraw.-il. ;i7;i 

Uonicn, Imtim's protrfiiilMli^ in, ^'.i'^ 
coiirs*' ot, i:',."» 
diaun<»^i-( o), M',*, 
etiolo^v of. 4:j.', of, 4:i:i 
symptoms of, V.H 
tn^atmont of, 437 
masturbation in. 410 
cause's of, 412 
tn-atmrnt of, 421 
onanism in, 412 

X-K.\vs, a/.0(is|>i'rmat ism and, 22.'i 
in treat men! of tuberculosis of 
testes, 221 on ma'^^ai;*' '" ;''"'"<■ 

imnotenee. 126 
Z*'rodone, 227 , 

Zohimbin, atonic inipolene»« and, Uft