Book ^3 7 
 
 CopigM? 
 
 COPYRIGHT i>EPOSE£ 
 
Nervous Exhaustion. 
 
 HORSFORD'S ACID PHOSPHATE. 
 
 Recommended as a restorative in all cases where the 
 nervous system has been reduced below the normal standard, 
 by overwork, as found in brain-workers, professional men, 
 teachers, students, etc., in debility from seminal losses, dys- 
 pepsia of nervous origin, insomnia where the nervous system 
 suffers. 
 
 It is readily assimilated and promotes digestion. 
 
 Dr. Edwin F. Vose, Portland, Me., says: "I have pre- 
 scribed it for many of the various forms of nervous debility, 
 and it has never failed to do good." 
 
 Send for descriptive circular. Physicians who wish to test it will be 
 furnished, upon application, with a sample by mail, or a full-size bottle 
 without expense except express charges. 
 
 Prepared under the direction of Prof. E. N. Horsford, by the 
 
 RUMFORD CHEMICAL WORKS, Providence, R. I. 
 
 Beware of Substitutes and Imitations. 
 

 MPOTENGE 
 
 SEXUAL WEAKNESS 
 
 MALE AND FEMALE. 
 
 y^ 
 
 / 
 
 EDWARD MARTIN, A.M., M. D„ 
 
 Surgeon to the Howard Hospital: Clinical Professor of Qenito-Urinary 
 Surgery, University of Pennsylvania. 
 
 1893. 
 GEORGE S. DAVIS. 
 
 DKTROIT, MICH. 
 
 
 

 Copyrighted by 
 
 (iKORGE S. DAVIS. 
 
 1893. 
 
THIS WORK IS DEDICATED, 
 AS A MARK OF FRIENDSHIP AND RESPECT, TO 
 
 J. WILLIAM WHITE, M. D., 
 
 CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY 
 OF PENNSYLVANIA. 
 
TABLE OF CONTENTS. 
 
 IMPOTENCE AND SEXUAL WEAKNESS. 
 
 Tage 
 Anatomy and Physiology of the Sexual Organs — 
 
 Organic Impotence — Psychical Impotence— Atonic 
 
 Impotence : Irritative and Paralytic — Etiology, 
 
 Diagnosis, Prognosis, and Treatment 1-74 
 
 PROSTATORRHCEA. 
 
 Origin, Symptoms, Prognosis, and Treatment 75-84 
 
 INVOLUNTARY SEMINAL EMISSIONS. 
 
 Nocturnal Pollution — Diurnal Pollution — Spermator- 
 rhoea — Causes, Diagnosis, Prognosis, and Treat- 
 ment 85-96 
 
 IMPOTENCE OF THE FEMALE. 
 
 Varieties — Congenital Anomalies — Local Inflammation 
 
 — Displacements— Neuroses— Treatment 97-102 
 
IMPOTENCE AND SEXUAL WEAKNESS IN THE MALE 
 AND FEMALE. 
 
 Sexual weakness is an expression which conveys 
 no clearly defined meaning; it implies that the 
 sexual act is performed in an imperfect manner, the 
 departure from normal being in the direction of defi- 
 ciency. Under this general heading impotence 
 would necessarily fall. 
 
 The term impotence implies a lack of ability to 
 perform the sexual act. It may be partial or com- 
 plete. Impotence is not necessarily associated with 
 sterility, nor on the contrary does sterility always 
 imply even a moderate degree of impotence. Thus, 
 many patients who have suffered from a double 
 obliterating epididymitis and in whose seminal dis- 
 charge no spermatozoa are found, are potent to a high 
 degree; while some patients in whom the power of 
 erection is totally lost may be able to discharge 
 semen swarming with apparently healthy sperma- 
 tozoa. 
 
 Impotence in the male may be due to congenital 
 or acquired deformity, or to absent or deficient 
 erection. By far the large majority of impotent 
 patients suffer from imperfect erection. 
 
 In so far as the purposes of the present work are 
 
concerned, a brief consideration of the anatomy and 
 physiology of the sexual organs is sufficient. 
 
 The spermatozoa, or life-giving elements of the 
 semen, are secreted in the testicles, pass into the epi- 
 didymis, a minute canal twenty feet in length pro- 
 vided with ciliated epithelium, and are carried from 
 this tube by means of the vasa deferentia to the 
 seminal vesicles and prostatic urethra. The vasa 
 deferentia are about 24 inches in length, and are pro- 
 vided with strong muscular walls for the purpose of 
 propelling the semen towards the urethra. External 
 to the vas of each side, and situated between the wall 
 of the bladder and the recto-vesical fascia, lie the sem- 
 inal vesicles. These form two bulbous masses of 
 convoluted tubes, which may be considered as diver- 
 ticula from the vasa deferentia, into the lumen of 
 which they open at the back of the prostate. By 
 the junction of the vasa deferentia and seminal vesicles 
 are formed the common ejaculatory ducts, each about 
 ^ inch in length, much narrower than either of 
 the channels which form it, and provided with ex- 
 tremely thin walls. The common ducts traverse the 
 prostate and open by slit-like orifices near the en- 
 trance of the sinus pocularis or uterus masculinus. 
 
 The urethra is a mucous canal about eight inches 
 in length, surrounded throughout its entire length 
 by muscular fibres and erectile tissue. 
 
 The prostatic portion of the urethra is that part of 
 the canal which lies in or upon the prostate gland. 
 
— 3 — 
 
 It is about an inch and a quarter long, excepting the 
 bulb, and is the widest and most dilatable part of the 
 entire urethra. Upon its floor there is an elevated 
 ridge, the veru montanum, projecting somewhat as a 
 cock's comb and hence called the caput gallinaginis; 
 this ridge is made up of muscular and erectile tissue, 
 and during ejaculation prevents the backward flow of 
 the semen into the bladder. The summit of this ridge 
 is excavated in the middle line by a pouch about 
 two-fifths of an inch deep and extending backward 
 through the greater thickness of the prostate gland. 
 This pouch is called the sinus pocularis. The slit-like 
 openings of the common seminal ducts are found 
 on the veru montanum to the right and left of the 
 prostatic sinus. In the furrows on either side of the 
 veru montanum are found the orifices of the prostatic 
 ducts. The prostatic urethra is surrounded by an 
 unstriped muscular layer, further reinforced by the 
 muscular fibres which make up the greater part of 
 the prostate gland. The nerve supply to this portion 
 of the urethra is peculiarly rich. The superior rectal 
 and vesical arteries send comparatively insignificant 
 branches to the prostate; the veins are, however, 
 generally large and anastomose freely. 
 
 The prostatic urethra runs almost directly down- 
 ward to the membranous urethra which passes down- 
 ward and forward. This portion of the canal is about 
 \ inch long, and is included between the anterior and 
 posterior layers of the triangular ligament. It is 
 
surrounded by a thin layer of erectile tissue and by 
 both involuntary and voluntary muscular fibres, the 
 latter forming the compressor urethra? muscle. The 
 membranous urethra is, with the exception of the 
 meatus, the narrowest and least dilatable part of the 
 canal. 
 
 The penile or spongy urethra is six inches long 
 and is surrounded by the erectile tissue of the spongy 
 body. It exhibits two regions of physiological dila- 
 tation, namely, at its posterior or bulbous part, just 
 anterior to the termination of the membranous ure- 
 thra, and at its anterior part just behind the meatus, 
 the fossa navicularis. Into the lumen of the ure- 
 thra open mucous crypts, the glands of Littre, es- 
 pecially numerous in the pars bulbosa, and certain 
 lacume, the largest one of which, termed the lacuna 
 magna, is found in the roof of the fossa navicularis. 
 The ducts of Cowper's glands open into the bulbous 
 part of the urethra. These glands are each about 
 the size of a pea and are placed beneath the mem- 
 branous urethra, their ducts passing forward. 
 
 The penis is mainly made up of erectile tissue, 
 which is separated by means of fibrous investments 
 into three irregular columns: the corpus spongiosum, 
 containing the urethra and expanding to form the 
 glans penis, and the two corpora cavernosa, forming 
 the body of the organ and ending at about the position 
 of the coronary sulcus, where they are capped by the 
 glans. 
 
The corpora cavernosa arise from the pubic rami 
 by strong fibrous processes called the crura, and are 
 anchored to the pubic symphysis by a fibrous expan- 
 sion termed the suspensory ligament. The crura are 
 continued forward as two irregularly cylindrical 
 bodies placed side by side. The walls of these bodies 
 are made up of dense fibrous and elastic tissue. 
 From these walls are given off many trabecule con- 
 taining fibrous tissue and smooth muscular fibres. 
 This gives the interior of the cavernous bodies the 
 appearance of a sponge. Along the trabecule pass 
 the arteries, which, either directly or by means of 
 capillaries, pour their contents into the large spaces 
 resulting from the formation of the parts. The 
 spaces of each corpus freely communicate with the 
 other, and in the anterior part of the penis there is 
 only a very imperfect septum between the two cav- 
 ernous bodies. 
 
 The arterial supply to this series of venous sinuses 
 is derived from the arteries of the corpora cavernosa 
 and from the dorsal artery of the penis. Branches 
 from these vessels penetrate through the outer fib- 
 rous investment, pass along the trabecule, and 
 either terminate as a capillary network, the branches 
 of which open into the sinuses, or become greatly con- 
 voluted forming the helicine arteries, and supply 
 by their capillaries the trabecular structure. The 
 blood from the cavernous spaces is returned by veins, 
 the greater number of which pass directly back- 
 
— 6 — 
 
 wards to join the prostatic plexus, while some pass 
 into the dorsal vein of the penis. 
 
 The corpus spongiosum occupies the same relation 
 to the corpora cavernosa, as does the ram-rod to a 
 double-barreled gun. It begins posteriorly in the 
 bulb, a tuberous enlargement situated between the 
 diverging crura and the corpora cavernosa, and ter- 
 minates anteriorly at the glans penis. Its blood 
 supply is derived from the arteries of the bulb. 
 
 The muscles of the penis are the erector penis, the 
 accelerator u rinse, and the unstriped muscular tissue 
 surrounding the urethra and found in the trabecule 
 of the erectile tissue. The erector penis passes for- 
 ward from the inner surface of the tuberosity of 
 the ischium, to be inserted into the sides and under 
 surface of the unattached part of the crus. The 
 accelerator urinse or bulbo-cavernous muscle arises 
 from the central perineal tendon. Its two halves 
 are united in a central raphe from which the fibres 
 spread laterally, enveloping the bulb and spreading 
 upward as a fibrous expansion over the dorsum of 
 the penis. 
 
 The mechanism of erection. When the arteries sup- 
 plying the erectile tissue of the penis are in their ordi- 
 nary condition, and when the unstriped muscular fibres 
 of the trabecule are in a state of tonic contraction, 
 thus to a great extent obliterating the venous spaces, 
 the blood in its course has no tendency to overfill these 
 spaces, but rather passes by the ordinary system of 
 
capillaries into the veins. Certain nerve fibres called 
 nervi erigentes or erector nerves pass from the lower 
 lumbar or upper sacral nerves to the vessels and 
 muscular structure of the erectile tissue; these when 
 stimulated cause dilatation of the arteries, hence an 
 increased influx of blood, and relaxation of the 
 trabecular muscles, hence lessened resistance in the 
 venous spaces. As a result the spongy and cavern- 
 ous bodies become turgid, enlarging in all direc- 
 tions. In consequence of the swelling, the efferent 
 veins passing along the trabecule and the fibrous 
 investment of the spongy and cavernous bodies 
 are pressed upon, and the congestion and blood 
 pressure in the penis is increased. The return of the 
 blood from the penis is still further prevented by 
 contraction of the erector penis, compressor urethrse 
 and accelerator urinse muscles. The penis is me- 
 chanically carried up to an elevation beyond 45° by 
 the action of the suspensory ligament, the erector 
 penis or ischio-cavernosi muscles being particularly 
 concerned in maintaining venous congestion, though 
 by drawing downward and backward at the root of 
 the penis they undoubtedly exert a distinct effect 
 in carrying the point of the organ upward. 
 
 The center for erection is placed in the lumbar 
 region. Though stimulation of the erector nerves will 
 produce a turgid condition of the penis, it will not 
 occasion full erection, since, for the completion of 
 the act, participation of the voluntary muscular fibres, 
 
— 8 — 
 
 the ischio-cavernosi, the bulbo-cavernosi and the trans- 
 versa perinei, is necessary. With all these factors 
 working harmoniously the corpora cavernosa become 
 of almost cartilaginous hardness. The corpus spong- 
 iosum and its expansion, the glans, remain somewhat 
 softer, because the investing fibrous capsule is less 
 dense. When erection is completed, the blood re- 
 turn from the penis may be still further obstructed 
 by a voluntary muscular effort of the muscles of 
 the penis and perineum, and the comparatively soft 
 glans may be made to materially increase in size 
 and become harder. The whole organ participates 
 in this increase, but not to the same extent as the 
 glans. An atonic condition of the perineal muscles 
 prevents complete vigorous erections. 
 
 Emission. The epididymis with its coni vasculosi 
 acts as a reservoir for the spermatozoa, which, when 
 they fill this space, pass into the vas and are 
 carried by the peristaltic action of the muscular coat 
 of this tube to the vesiculae seminales. Incident with 
 erection the testicles are drawn close to the external 
 rings. It is probable that the muscular coats of the 
 vas act with more than usual vigor. As a result of the 
 afferent impulse carried from the nerves of the glans 
 the common ejaculatory ducts become patulous and 
 the contents of the seminal vesicles is passed into 
 the prostatic urethra. The muscular substance of 
 the prostate contracts, squeezing out the secretion 
 from its own follicles to be mixed with the sperma- 
 
tozoa and secretion of the seminal vesicles. As a 
 result of this contraction, and the simultaneous relax- 
 ation of the compressor urethrse, the combined 
 secretions is forced into the bulbous urethra, since 
 the turgid veru montanum prevents it from being 
 forced backward into the bladder. From here it 
 is driven forward by clonic contractions of the 
 accelerator urinas, aided by the entire perineal 
 group and by the unstriped muscular fibres of the 
 urethra. The muscular contractions pass forward 
 as a wave and are repeated till all the semen 
 is ejaculated. It is probable that the first volup- 
 tuous sensations are associated with the ejaculation 
 of the semen into the prostatic urethra and the con- 
 traction of the muscular substance of this gland for 
 the purpose of driving the semen and its secretion 
 forward, since ejaculation does not immediately 
 follow the first contractions. 
 
 Slightly before the orgasm Cowper's glands dis- 
 charge their contents into the bulbous urethra; this 
 act is accompanied by sensations which are usually 
 unnoticed, since they precede the orgasm by such a 
 slight interval that they are unnoticed or forgotten 
 in the greater nerve impression. I have seen patients 
 who could produce this discharge from Cowper's 
 glands without the emission of either the prostatic 
 or testicular secretion. 
 
 The semen is made up of the secretion of the tes- 
 ticles, the seminal vesicles, the prostate, Cowper's 
 
— 10 — 
 
 glands and the urethral crypts and follicles. When 
 first ejaculated it is a thick gray fluid with an odor 
 somewhat like a raw potato. It shortly becomes 
 gelatinous, but after further exposure to the air for 
 ten to twenty minutes becomes liquid. If allowed to 
 stand, there settles from it a white layer of sperma- 
 tozoa, above which lies a gray, translucent liquid. 
 These two layers should, according to Ultzmann, be 
 of equal bulk in normal semen. The spermatozoa 
 should live from twelve to twenty-four hours after 
 the semen has been ejaculated, provided it is kept 
 warm and has not been allowed to evaporate. In 
 the latter case the addition of a mildly alkaline sol- 
 ution will often restore motion to spermatozoa which 
 are apparently dead. When the semen is deposited 
 in the female genitalia, spermatozoa are found living 
 for upwards of a week. After standing for two or 
 three days, spermatic crystals are deposited. 
 
 The amount of semen discharged as a result of one 
 orgasm is about two drachms, though after long con- 
 tinence double this quantity may be ejaculated, or 
 when repeated drains are made on the strength only 
 a few drops may appear. 
 
 The erectile centre may be stimulated to transmit 
 an impulse through the nervi erigentes, either from 
 the brain; from direct irritation; from the spinal 
 cord; from the prostatic urethra, or other parts 
 of the sexual apparatus; or from the anus or other 
 regions under the domination of an associated nerve 
 plexus. 
 
— 11 — 
 
 The centre for erection in the cord is undoubtedly 
 under the domination of the vaso-dilator centre in 
 the medulla oblongata, fibres within the cord making 
 the communication. Psychical impressions have a 
 marked influence upon the vaso-dilator nerves, a com- 
 mon example of this influence being offered in the flush 
 caused by anger or shame, the dilatation of the blood- 
 vessels of the head being due to stimulation of the 
 vaso-dilator fibres; by a similar mechanism, when the 
 thoughts are strongly directed towards sexual sub- 
 jects, there results a powerful action upon the nervi 
 erigentes. Thus sights, sounds, odors, memories, in 
 fact all mental impressions which suggest sexual 
 desire, may produce powerful erections. 
 
 As examples of erections due to direct spinal irrita- 
 tion, may be mentioned those which sometimes occur 
 in the early stages of disease of the cord or those which 
 are noted after injury. When this injury is inflicted 
 high up, the priapism which occurs is due to a cutting 
 off of the inhibitory fibres rather than to direct irri- 
 tation of the centre. 1 
 
 1 I have recently had under my care a young man with 
 fracture of the spine in the dorso-lumbar region with com- 
 plete paraplegia ; there was partial control over the bladder and 
 rectum. For three weeks after the injury his penis was con- 
 stantly in a condition of priapism. This gradually subsided 
 and was followed by a rather rapid atrophy of the testicles, 
 which at the present time are no larger than those of a child 
 of ten or twelve years, although the penis is of normal size. 
 
— 12 — 
 
 Erection is excited by peripheral stimuli. Thus the 
 priapism which sometimes occurs as the result of 
 mechanical friction while riding horseback; the con- 
 tinued erections often associated with prostatic cal- 
 culus or inflammation of this part of the urethra; the 
 erections associated with full bladder, are examples 
 of reflexes arising from the sexual organs. 
 
 Erections excited by stimulation of associated 
 fibres are instanced by the priapism which occurs in 
 children on examination of the hip, or the erections 
 due to flagellation of the buttocks, or those asso- 
 ciated with inflammatory or irritative conditions of 
 the anus and rectum. 
 
 Before considering the question of impotence, it is 
 well to determine what may be considered a normal 
 amount of sexual strength. Individuals vary so in this 
 respect that it is impossible to set a standard. Per- 
 haps it is fair, however, to state, that a man, between 
 his twentieth and fiftieth year, who is not over- 
 worked or unduly harassed, who is in good physical 
 condition, and who has the proper and legitimate 
 degree of sexual excitement, should be able to have 
 intercourse on an average of twice a week (the act 
 lasting from three to five minutes before ejaculation), 
 and should not experience as an after-result a sense 
 of fatigue or exhaustion. 
 
 It must be clearly recognized that everything which 
 tends to lower vitality, such as anxiety, excessive 
 work, bodily or mental, insufficient food, impaired 
 
— 13 — 
 
 health, the alcoholic and tobacco habits, may render 
 an indulgence to the extent above mentioned dis- 
 tinctly injurious, or even quite impossible. 
 
 Per contra, those of exceptionally vigorous consti- 
 tution and particularly those who live much in the 
 open air may quite safely far exceed the limit given. 
 It must also be recognized, that power and desire are 
 not always commensurate, and that, particularly in 
 the case of brain workers, the latter is liable to be 
 greatly in excess of the former. 
 
 The power of erection begins at birth and departs 
 usually from the sixty-fifth to the seventieth year, 
 though sometimes it continues much longer, there 
 being many recorded cases of men who up to their 
 eightieth or even ninetieth year have full powers of 
 intercourse, and are apparently able to beget. I have 
 seen one man, aged seventy-eight, an observer of 
 the laws, and apparently a lover of truth, who, 
 marrying a young woman, became in due time the 
 father of a child. In his eightieth year he stated, 
 that since his marriage he had performed the sexual 
 act every night, excepting at such times as the con- 
 dition of his partner made it impossible. He noticed 
 no change in his power except for the fact that 
 emission was delayed. I have also seen a child less 
 than one year of age who masturbated and appar- 
 ently experienced an orgasm, or at least some form 
 of nervous crisis. 
 
 A consideration of the physiology of erection and 
 
— 14 — 
 
 ejaculation suggests, as a reasonable clinical classi- 
 fication of the forms of impotence, the following: 
 
 1. Organic Impotence. 
 
 2. Psychical Impotence. 
 
 3. Atonic Impotence. 
 
 Organic Impotence. — This form of impotence 
 may be due to either congenital or acquired central 
 changes affecting the cord and lumbar centres, or the 
 afferent or efferent nerve fibres communicating with 
 the erector centre. 
 
 In the vast majority of the cases falling under 
 this head, impotence is due to malformation of the 
 external genitalia. This malformation may affect 
 the penis or the testicles, or both these organs, as 
 in cases of hypospadia; or with perfectly healthy 
 genital organs, malformation may affect the sur- 
 rounding parts in such a way that sexual congress 
 is impossible. 
 
 The pei as may be completely absent, may exist only 
 as a rudiment, or may be deformed. 
 
 If the penis is absent or exists only as a rudiment, 
 the impotence is absolute and incurable. 
 
 If the organ is present and normal, excepting in 
 regard to size, even though it is exceedingly small, 
 the patient is not necessarily impotent. Indeed, 
 one case is quoted by Roubaud in which an organ 
 but two inches long and of the circumference of a 
 quill was by a mechanical device rendered service- 
 
— 15 — 
 
 able. In the case of this young man sexual con- 
 gress was not followed by ejaculation, and although 
 both desire and erection were well developed, he was 
 able to experience emissions with their coincident 
 sensations only by means of masturbation. 
 
 Roubaud fitted this stunted organ with a rubber 
 cylinder the size of an ordinary penis. Into the in- 
 terior of this the erect penis was introduced. The 
 apparatus was held in place by an elastic band 
 passing around the back. The movements of copu- 
 lation, when this apparatus was in place, were sufficient 
 to excite ejaculation. As a result of this treatment 
 the organ increased considerably. 
 
 In Wilson's case, a man of twenty-six, whose gen- 
 ital organs were not more developed than those of a 
 child of eight years, after two years of married 
 life and physiological activity there was complete 
 restoration to the normal size. 
 
 The practical point to be remembered in the con- 
 sideration of these cases of arrested development 
 is, that treatment may be followed by satisfactory 
 results. The application of an apparatus which 
 tends to produce venous congestion has in some 
 cases, it is alleged, been followed by satisfactory 
 results in so far as growth is concerned. Such an 
 apparatus consists of a chamber into which the penis 
 can be introduced, and from which the air can be 
 partially exhausted. As a result it is daimed that an 
 augmentation in volume takes place, which, on con- 
 
— 16 — 
 
 tinuing the treatment for weeks or months, is 
 permanent. In many cases considerable increase in 
 the size of the organ has been noted in the first years 
 of married life. 
 
 Enormous size of the organ sometimes renders 
 intercourse impossible, excepting under especially 
 favoring circumstances. For such a condition sur- 
 gical treatment would scarcely be required. 
 
 Adhesions of the penis and the scrotum may 
 occasion impotence; this is relieved only by plastic 
 operation. 
 
 The distortion of the penis, such as is constantly 
 found in hypospadias, that is, a downward curve, 
 may prevent intercourse. Such distortion may also 
 result from wounds or from the contraction of 
 cicatrices. It may be remedied by cutting a wedge- 
 shaped piece from the convexity of the deformed 
 organ and apposing the raw transverse sections of 
 the corpora cavernosa by deep sutures. Though this 
 will straighten the organ it is very liable to inter- 
 fere with perfect erection, the cavernous bodies 
 anterior to the point of section remaining more or 
 less flaccid while the rest of the organ is rigid. 
 
 Fibrous, cartilaginous, or gummatous indurations 
 of the erectile tissue or the fibrous sheath of the 
 penis may cause great distortion of the organ, and 
 may render coitus difficult or impossible, since erec- 
 tion to the distal side of such indurations is exceed- 
 ingly feeble. Fibrous induration is commonly found 
 
— 17 — 
 
 associated with rheumatism and gout. It is not in- 
 frequent after gonorrhoea, and is by some authors 
 ascribed to syphilis, though, excepting in the case of 
 unmistakable gummata, this relation has been vigor- 
 ously contested by Mauriac. 
 
 The treatment required is constitutional, depending 
 upon the diathesis with which the lesion is associated. 
 Gummatous deposits often yield to specific treatment, 
 but the indurations associated with gonorrhoea or 
 gout, or ascribable to no local or general cause, are ex- 
 ceedingly obstinate. Local treatment is of little ser- 
 vice. Inunctions of mercury ointment should be 
 used, however, and the beneficial resolvent effects 
 of heat, moisture and pressure should be secured by 
 the application of a thin rubber bandage to the 
 penis. 
 
 Aneurismal dilatation of the corpora cavernosa, 
 sometimes congenital, sometimes due to violence, 
 may form a tumor which may offer mechanical ob- 
 struction to the sexual act so great as to entirely in- 
 hibit its performance. 
 
 In such cases the application of rubber supports or 
 bandages will usually give temporary relief. 
 
 Congenitally acquired shortness of the frenum or 
 varix of the dorsal vein of the penis may also cause 
 impotence. Section of the one and excision or liga- 
 tion of the other will relieve the disability. 
 
 Swellings of the external genitalia, such as is 
 observed in elephantiasis and oedema, or enlargements 
 
— 18 — 
 
 and projection of neighboring parts, as in large 
 herniae, scrotal tumors and overhanging belly, all 
 may occasion impotence by rendering impossible 
 intromission of the penis, even though this organ be 
 of good size and capable of healthy erection. 
 
 Certain malformations and diseases of the testicle 
 also occasion impotence; in this case from lack 
 of power to obtain erections, for the penis is at times 
 of full size. Thus absence of the testicles, or anor- 
 chidism, is always associated with impotence. Crypt- 
 orchids, or those in whom the testicles are retained 
 in the abdomen or groin, are usually potent, although 
 they often are sterile. The removal of both testicles 
 is always followed by impotence. This may not result 
 for a number of years, Cooper quoting a case in 
 which intercourse was practised nine years after such 
 an operation, though there was progressive loss of 
 sexual strength. 
 
 Destruction of the testicles as the result of inflam- 
 matory processes, is destructive of virility. Orchitis 
 secondary to mumps very commonly goes on to the 
 stage of atrophy. If both testicles have been involved 
 in the process, impotence will result. The epididy- 
 mitis secondary to gonorrhoeal urethritis is not an 
 inflammation of the testicle, the secreting structure 
 of this gland being spared; hence, even though both 
 sides be affected by this form of inflammation, im- 
 potence will not result, though the patient may remain 
 absolutely sterile. 
 
— 19 — 
 
 Tumors, and tubercular and syphilitic infiltration 
 of the testicle, passiye congestion dependent on 
 varicocele, when involving both testicles, are often 
 associated with absolute impotence. Even though 
 one testicle is involved, the other remaining healthy, 
 the patient is frequently impotent. This is especially 
 true of the tubercular lesions, possibly because when 
 they appear in the testicle, they have already as a 
 rule invaded the prostatic urethra. I have recently 
 seen a powerful man, who, following a tubercular 
 involvement of his right epididymis, has been impo- 
 tent for 12 years. The tubercular process has become 
 encysted; the man seems to be perfectly healthy, but 
 he never has normal erections. 
 
 Psychical Impotence. — This form of impotence 
 implies well formed sexual organs with full power of 
 erection, but with this power not under the control of 
 the will. Patients suffering from psychical impo- 
 tence usually have exceedingly vigorous erections 
 occasioned by lascivious thoughts, by a full bladder, 
 or by any of the causes which are sufficient to 
 excite the centre for erection. When, however, 
 opportunity for sexual intercourse is given, there is 
 either an imperfect erection or, in place of enlarg- 
 ing, the penis may actually become smaller than in 
 its ordinary flaccid condition. 
 
 The usual cause for this is timidity, and the condi- 
 tion is observed in its simplest form in those whose 
 
— 20 — 
 
 lives have been most chaste. The nervous, highly- 
 strung man, innocent of sexual matters, who recol- 
 lects with shame and horror the period when he in- 
 dulged to a greater or less extent in masturbation 
 — shame indissolubly connected with the act; horror 
 from the fancied consequences, which the lurid com- 
 mercial literature on tbis subject assures him will 
 surely follow — will experience, in addition to the per- 
 turbation incident to his new experience, the power- 
 ful anaphrodisiac of fear lest his first attempts posi- 
 tively demonstrate the sexual weakness begotten by 
 his early habits. 
 
 Even without this element of fear, in those of 
 sensitive organism, the conditions of early married 
 life are not adapted to the fullest stimulation of the 
 sexual instinct. Under such circumstances erections 
 may be conspicuous by their absence. If the ele- 
 ment of distrust and fear were absent before, after 
 one failure it is present in full force, and is often 
 sufficiently strong to render subsequent approach 
 equally unsatisfactory. 
 
 Although psychical impotence is most often ob- 
 served in the aesthetic recluse or the chaste farmer, 
 those of looser morals do not always escape. The 
 mental effect is produced somewhat as follows: 
 After some months, or possibly years, of life about 
 town, the youth who has heretofore stopped short of 
 sexual congress, finally, when well under the in- 
 fluence of liquor, yields to temptation, but finds him- 
 
— 21 — 
 
 self unable to complete the act. In this case the 
 inhibitory influence of rum has produced a tempor- 
 ary condition which the patient is prone to regard as 
 permanent, and, even should he make his next at- 
 tempt under more favoring circumstances, he is liable 
 to meet with disappointment from distrust in his 
 powers. 
 
 Many men of lively temperament are chaste from 
 the fear of disease, unfortunately the most potent 
 factor in maintaining virtue. This finally gives way 
 to a more than usual] } r severe temptation. At the 
 very time when such thoughts should be banished 
 from the mind, the old fear returns with redoubled 
 vigor, producing its characteristic physical effect, and 
 subsequently begetting in the patient a condition of 
 distrust as to his sexual powers, highly desirable so 
 long as he remains single, but often so deeply rooted 
 as to be productive of much distress should he decide 
 to marry. 
 
 Sometimes the circumstances under which fornica- 
 tion is undertaken are such as to render the perform- 
 ance of the act difficult. Necessity for haste; fear of 
 discovery; a dozen different causes may render the 
 man quite unable to perform his part. One failure in 
 men of neurotic temperament strongly predisposes to 
 another. 
 
 In some cases remorse is sufficient to prevent erec- 
 tion, and to produce a profound mental impression 
 from which the patient with difficulty rids himself; 
 
— 22 — 
 
 usually, however, this emotion i6 not experienced 
 till its workings are of little immediate practical 
 value. Disgusting sights or odors have begotten a 
 psychical impotence which has proved difficult to 
 overcome. 
 
 I have seen patients who were so shocked by the 
 appearance of vermin or of filth on or about the 
 woman toward whom they made their first approaches, 
 that passion was at once subdued, and though subse- 
 quently excited by other and more attractive objects, 
 and under more favorable circumstances, was no 
 longer accompanied by a satisfactory amount of 
 power. 
 
 As an instance of some of the forms of psychical 
 impotence the following case may be cited. A. B., 
 an exceptionally healthy and vigorous man, aged 23, 
 consulted me for impotence. His sexual organs 
 were well formed; he suffered from nocturnal emis- 
 sions about once in six weeks. Examination of his 
 emission on one occasion proved it to be swarming 
 with seemingly healthy spermatozoa. In the morn- 
 ing he woke with vigorous erections, and strong 
 erections were excited by sights or stories calculated 
 to produce this effect. On four different occasions 
 he attempted intercourse, in each case with women 
 of the town, and on all four occasions was entirely 
 unable to have an erection. 
 
 This patient was advised to make no further trial 
 until after his marraige, which was then impending, 
 and to make no trial at intercourse for two weeks 
 
— 23 — 
 
 after that date. He subsequently regained complete 
 control of his sexual powers, although the directions 
 in regard to his post-marital conduct were not strict- 
 ly observed. 
 
 II. A. B., an unusually powerful man, much given 
 to promiscuous fornication, was suddenly surprised 
 when about to have sexual relations with a young 
 woman of supposed respectability. His erection im- 
 mediately subsided, and did not recur for many 
 months. One year after, he had morning erections 
 and occasionally those excited by mental impressions 
 calculated to produce this effect. He has not yet, 
 however, recovered his full sexual power, every at- 
 tempt at intercourse proving abortive. The penis, in 
 place of becoming erect, seems to shrivel to about 
 half its normal size. 
 
 III. A. B., a strong man of 25, indulged for some 
 years in every form of dissipation, excepting forni- 
 cation. After a heavy drinking bout, he passed the 
 night with a woman of the town. In the morning 
 she told him that he had unsuccessfully attempted 
 fornication. He recollected nothing of the night, 
 but was then absolutely without erection or desire, 
 and only anxious to escape from the house. 
 
 In thinking of the matter afterward, the statement 
 of the woman produced a powerful impression upon 
 his mind. He fancied that he was suffering from 
 impotence, and to determine this question he made 
 several trials, in each case unsuccessfully. His morn- 
 
— 24 — 
 
 ing erections were powerful, his sexual apparatus 
 perfectly healthy; and as soon as the true nature of 
 his case was explained to him, his convalescence was 
 rapid and complete. 
 
 There is also a form of psychical impotence, rare 
 certainly, but none the lef-s existing, dependent upon 
 almost total want of desire. 
 
 For such persons women offer very slight attraction. 
 Their erections may be normal, but the pleasure in- 
 cident to sexual relation is so slight that it offers no 
 adequate compensation for the trouble necessary to 
 obtain it. 
 
 There are certain patients in whom the psychical 
 impotence is relative. That is, with some women 
 they may be exceptionally vigorous, with others 
 their powers may be slight or altogether wanting. 
 
 It is undoubtedly true that, as a rule, educated and 
 refined women are less passionate than men; indeed, 
 I think this may be said of women of every degree. 
 Their desire for sexual congress is less; and many 
 wives, laudable in all respects, are not the sexual 
 equals of their husbands. To such women sexual 
 approach is sometimes a matter of total indifference; 
 sometimes disagreeable; occasionally painful or re- 
 volting. To some men this mental attitude is suf- 
 ficient to render the sexual act impossible. In ad- 
 dition the flabby vulva, the relaxed vagina, the 
 passive reception of the approach, does away with 
 the local stimulus which is such a powerful aid 
 
— 25 — 
 
 to the proper completion of the sexual act. It is, 
 unfortunately, with their legitimate partners that 
 men are most frequently not in sexual accord. 
 
 Even though women may be well fitted to play 
 their part in the sexual act, men will be encountered 
 to whom intercourse is impossible save with certain 
 individuals. Thus, I saw one patient who was never 
 able to secure an erection except when in the company 
 of a woman of a certain complexion and stature. He 
 asserted that in early life he loved and intended to 
 marry a woman of this type; none other had ever 
 caused in him sexual excitement. 
 
 Those sexual perverts may also be considered 
 impotent, who have no desire for the possession of 
 women in the carnal sense, but who find their pleas- 
 ure by caressing objects of women's apparel or locks 
 of their hair; in simply looking at them and imagin- 
 ing the circumstances of a sexual relation. To this 
 class would also belong men who desire their own sex, 
 or whose desires lead them to unnatural practices 
 with beasts. 
 
 The treatment of psychical impotence will be suc- 
 cessful in its issue in accordance with the power of 
 the physician to make upon the mind of the patient 
 a strong impression. It is perfectly futile to dismiss 
 such patients with a few words of good advice. 
 They have suffered for months or even years from a 
 condition which has preyed upon their minds and 
 often has altered their entire characters. They come 
 
— 26 — 
 
 with fixed beliefs; with a conviction as to the organic 
 nature of their weakness so profound, that no argu- 
 ment is sufficient to shake them out of it. They 
 are usually well assured that they are impotent 
 on account of distinct lesion or because of the wear- 
 ing out of that portion of the nervous system which 
 presides over the function of erection and ejacula- 
 tion. In the great majority of cases they attribute 
 this to masturbation, since this is practised to a 
 greater or less extent by nearly every boy at one time 
 in his life. These patients usually postpone seeking 
 advice till driven to desperation by the mental suf- 
 fering which their condition entails. They consent to 
 make what they consider their shame known on the 
 chance that medical help may serve them. An over- 
 wrought, hysterical, hypochrondrical patient is not 
 to have his habits of thought, his profoundest con- 
 victions, brushed aside with a few words. If he is 
 sensible he will not be content with one or two 
 dogmatic assertions; if he is foolish he will neither 
 understand nor remember them. He must be con- 
 vinced that his case has been carefully studied, and 
 must be made to believe that a rational and probably 
 successful treatment has been instituted. 
 
 Before making a diagnosis as to the nature of 
 psychical impotence, an accurate and careful history 
 of the entire case should first be taken. This will 
 throw much light, not only on the cause and the true 
 nature or extent of the weakness, but will also give 
 
— 27 
 
 the surgeon an insight into the mental processes of 
 the patient. This history should include the patient's 
 routine of living; the amount of exercise he takes; 
 the regularity with which he takes his meals; the 
 condition of his stomach and bowels; his hours of 
 sleeping and of waking; and the presence or absence 
 of rheumatic, gouty or scrofulous tendencies. More- 
 over from the history may be learned whether the 
 patient is hereditarily neurotic; whether his sexual 
 weakness depends upon abuse of tobacco, alcohol, 
 or other drugs; whether it is due to general debility 
 consequent to exposure; or to acute diseases such as 
 diphtheria. 
 
 This should be followed by a thorough examina- 
 tion — not only a local examination as to the sexual 
 weakness, but a general examination of the condition 
 and functional activity of all the important organs 
 of the body. The condition of the heart and lungs 
 must be determined; functional or organic alterations 
 of the central nervous system must be excluded; the 
 quantity and quality of the urine must be determined; 
 the anus should also be examined to determine the 
 presence or absence of a cause for reflex irritation. 
 
 The penis and testicles must be examined care- 
 fully. The condition of the entire urethra is deter- 
 mined by means of sounds and bulbous bougies. A 
 finger passed into the rectum can readily palpate the 
 prostate gland, and determine the presence or ab- 
 sence of gross lesions. 
 
— 28 — 
 
 If the case be one of entirely psychical impotence, 
 such an inspection will show the absence of local 
 lesions. 
 
 The examination having been completed, it is well 
 to inform the patient that there is nothing organ- 
 ically wrong, that the disease is entirely curable, 
 that he can confidently hope for restoration of his 
 powers. It may be taken for granted that he has 
 read to a greater or less degree the errors-of -youth 
 and manhood-restored literature, so widely circulated 
 by charlatans for the purpose of extorting money 
 from this very class of patients. It is, therefore, advis- 
 able to explain the misleading nature of these writ- 
 ings. 
 
 These patients should always be given medicine; 
 sometimes this medicine is of great value. Thus, 
 examination of the urine may show the oxalic dia- 
 thesis, which will be corrected by diet and by nitro- 
 muriatic acid or other appropriate remedies; or there 
 may be great excess of uric acid, to be remedied by 
 appropriate diet; or the bowels may be torpid, and may 
 be stimulated to activity by the exhibition of strych- 
 nia and belladonna or other drugs; or digestion may 
 be feeble and will be helped by pepsin and hydro- 
 chloric acid and by tonics. If there is no distinct 
 indication for medication, a general tonic may be 
 ordered; such as compound syrup of the hypophos- 
 phites, or compound tincture of cinchona, or wine 
 of coca and celery. 
 
— 29 — 
 
 If the patient has been recently married, it is well 
 to tell him that a medicine will be given which will 
 act as a powerful sexual excitant; at the same time 
 some words of advice are offered as to the time and 
 method of approach. Perhaps the best stimulating 
 medication in these cases, is a pifi made up of ex- 
 tract of damiana 2 grains, phosphorus y^ of a grain, 
 strychnia -^V of a grain. This is to be admin- 
 istered three times a day, and an added dose may 
 be taken at night. The patient is advised against 
 attempting intercourse for six nights after he begins 
 taking the medicine, and is told that when he does 
 attempt congress, advantage should be taken of the 
 morning erection, and the act should be instituted as 
 promptly as possible, without preliminaries or delay 
 of any kind. 
 
 The treatment of those who are unmarried should 
 be conducted on somewhat different lines. Although 
 it is true that the great majority of single men past 
 eighteen seek and find sexual gratification, it is not a 
 part of the physician's duty to order this as a treatment, 
 nor do I think it is ever necessary. In such cases a 
 general treatment, including rigorous exercise and 
 cold bathing, should be supplemented by the pa'ssage 
 of instruments. The introduction of the cold sound 
 or the urethral electrode into the prostatic urethra 
 will often be followed by immediate and vigorous 
 erections, in themelves a source of infinite comfort 
 to the patient, since he fancies that a response on the 
 
— 30 — 
 
 part of the penis to a mechanical insult of this kind 
 is a certain sign of pristine vigor. 
 
 These patients must be especially cautioned against 
 trials to discover whether or not their power is re- 
 stored. The women they usually seek, animated only 
 by mercenary motives, often poorly feigning pas- 
 sion they never feel, are neither physically nor men- 
 tally attractive, and are ill calculated to develop 
 power which the patient fancies he has lost. Under 
 favorable circumstances such patients can confidently 
 expect to find themselves completely potent; and 
 with this assurance and with careful treatment 
 designed to improve the general health and to create 
 a feeling of confidence as to sexual power, the physi- 
 cian must rest content. 
 
 For cases of relative impotence, that is, inability to 
 perform the sexual act with certain females, little can 
 be done. Each individual case must be managed on 
 its merits; in each case the physician must act wisely 
 and for the best interests of morality; then, if his 
 counsel and treatment accomplish no good, he is 
 at least spared the regret of having left affairs in a 
 worse condition than he found them. In these cases 
 a word to the woman sometimes may be productive 
 of good. 
 
 Stimulation of the sexual centres, either directly 
 or by alcohol, strychnia, phosphorus, and damiana, 
 or reflexly by cantharides, may, at times, be of 
 temporary benefit. Rich food, pure air, and shun- 
 
— 31 — 
 
 ning the society of other women for a long period, 
 will accomplish more than any other method of treat- 
 ment. 
 
 Atonic Impotence. — This term implies such a 
 weakening of the lumbar centres for erection and 
 ejaculation that these functions are no longer per- 
 formed in the normal manner. 
 
 This condition of the reflex centres is usually de- 
 pendent upon a hypertonic or inflammatory condition 
 of the prostatic urethra. In consequence of hyperee- 
 mia and inflammation, the efferent nerves which are 
 so richly distributed through this portion of the ure- 
 thra, and particularly to the veru montanum, are 
 hypersensitive. As a result the lumbar centres are 
 kept in a condition of constant irritation, inevitably 
 resulting in exhaustion, as shown by the imperfect 
 functional performance of the parts presided over by 
 these centres. 
 
 At times the excitability of the genito-spinal cen- 
 tre is abolished quite independently of any abnormal 
 condition of the posterior urethra. 
 
 Certain general conditions, such as anaemia, either 
 idiopathic or due to any of the various cachexias, 
 diabetes, acute rheumatism, uraemia, cola?mia, are 
 often accompanied by loss of sexual power. Fortun- 
 ately in these cases the desire fails with power. 
 
 Not infrequently after diphtheria temporary impo- 
 tence may be the first sign of subsequent paralysis; 
 sometimes it may be the only manifestation. 
 
— ;?2 — 
 
 Many drugs, if taken until toxic effects are pro- 
 duced, cause complete impotence. Saturnine intoxica- 
 cation is frequently accompanied by anaphrodisia and 
 impotence. Carbonic acid gas, after the immediate 
 poisonous effects have passed off, sometimes leaves 
 the patient in a condition of complete impotence. 
 Fodere cites the case of a man who was unable to 
 have connection for six months after recovery from 
 an attack of poisoning of this kind. Bisulphide of 
 carbon and antimony are also said to have produced 
 anaphrodisia and loss of power in those whose work 
 required them to breathe an atmosphere containing 
 traces of these drugs. 
 
 Alcohol and tobacco claim the most victims. ^The 
 former drug, stimulating in small doses, when long 
 continued, destroys power and usually desire. In the 
 case of both these drugs, the effect often long out- 
 lives the continuance of the bad habit. Months or 
 even years may be required before power is regained. 
 
 Certain individuals exhibit an idiosyncrasy toward 
 tobacco so that a comparatively small dose is suffi- 
 cient to destroy their sexual powers, even though it 
 produces no other appreciable injurious effect. Cig- 
 arettes, particularly when their fumes are inhaled, 
 are credited with exercising a more sinister effect 
 than tobacco used in other forms. 
 
 It cannot be stated as a rule that among those 
 working in tobacco factories there is any loss of sex- 
 ual power. It is believed that this is because their 
 
— 33 — 
 
 life is so arranged, that more than usually favor- 
 able opportunities are offered and possibly an artifi- 
 cial stimulus provided. This very fact would, how- 
 ever, make more apparent failing sexual power. Cer- 
 tain individuals in such factories will, however, seek 
 advice on account of impotence, and in them it is 
 always possible that their malady may be due to 
 idiosyncrasy toward this powerful drug. 
 
 Trousseau says that coffee is a powerful anaphro- 
 disiac, and of itself is able to produce complete 
 impotence. It is quite certain that this drug taken 
 in enormous doses may produce such an effect, but 
 rather because of the general nervous break-down it 
 produces than from any direct effect upon the 
 sexual organs. In ordinary doses, that is, one or two 
 cups a day, and to those who exhibit no idiosyn- 
 crasy, the effect of this drug is rather stimulating. 
 
 Many drugs when given in physiological doses will 
 temporarily lessen sexual power. Among these the 
 bromides are particularly potent, and cocaine is also 
 stated to possess this power. Morphia in full doses 
 is operative only in certain individuals. Like tobacco, 
 when used habitually and to excess it abolishes both 
 desire and power. 
 
 The treatment of impotence dependent upon gen- 
 eral conditions, such as post-pyrexial adynamia, anae- 
 mia or toxa?mia, must be conducted on general prin- 
 ciples. When the general health is restored the sex- 
 ual impotence will disappear. Drug impotence will 
 
 8 
 
— 34 — 
 
 be cured when the cause producing it is removed; 
 but the restoration in these cases may be very slow. 
 Atonic impotence may be classified in accordance 
 with its clinical symptoms as follows : 
 
 1. Irritative form. Erections may be complete ; 
 they are often imperfect. Emissions are always pre- 
 mature, often occurring immediately on contact. The 
 sexual desire is usually strong. 
 
 2. The paralytic form. Erections are absent, or 
 at the most are extremely feeble; desire is wanting; 
 ejaculation occurs with little or no pleasure, semen 
 dropping from the flaccid penis. 
 
 The irritative form of impotence, i. e., that char- 
 acterized by premature ejaculation, with or without 
 feeble erection, is by far the most frequent. The 
 cause of this form of impotence is nearly always a 
 diseased condition of the prostatic urethra, the mu- 
 cous membrane being either hyperaemic or actually 
 inflamed. This condition of the prostatic urethra 
 may depend upon a number of causes. Among these 
 may be mentioned the following: (1) Gonorrhceal 
 inflammation and its sequel, stricture; (2) Prolonged 
 and ungratified sexual excitement; (3) Excessive 
 venery; (4) Strongly acid or irritating conditions of 
 the urine. 
 
 Of these causes gonorrhozal inflammation with its 
 commonest sequel, stricture, is by far the most fre- 
 quent. After this would be placed in order of impor- 
 
— 35 — 
 
 tance, excessive venery, including under this heading 
 onanism; prolonged and ungratified sexual excite- 
 ment, the victims from this coming mostly from 
 country regions; and, finally, irritation from the 
 urine. 
 
 Atonic impotence from gonorrhceal inflamma- 
 tion. — Acute gonorrhoea commonly involves the 
 prostatic urethra, but subsides promptly and com- 
 pletely. In a certain percentage of cases the pros- 
 tatic urethra becomes acutely inflamed, producing 
 symptoms quite as distressing as those which accom- 
 pany inflammation of the anterior portion of this 
 tube. In addition to urgency and frequency of 
 urination, there is often distressing tenesmus, and a 
 few drops of blood will be discharged at the end of 
 each act of micturition. These symptoms subside 
 in a few days, but continue with more or less severity 
 for some months, being awakened to new activity 
 from time to time by exposure to cold, indulgence 
 in alcohol, sexual excesses, or other imprudence. 
 The discharge from the penis ceases entirely between 
 apparent relapses; the patient regards himself as 
 cured, and suffers only from increased frequency of 
 urination and an occasional subacute attack of 
 what he is usually told is cystitis. Examination of 
 the urine will show, however, that pus is always 
 present. 
 
 As a consequence of this long-continued irritation, 
 the mucous membrane of the prostate undergoes the 
 
— 36 — 
 
 changes characteristic of chronic catarrh. The ter- 
 minal sensory nerve filaments are involved, and re- 
 flexly keep the centres for erection and ejaculation 
 in a condition of hyperesthesia. Frequently this 
 chronic catarrh runs on to a condition called prosta- 
 torrhoea. In this case the patient complains of dis- 
 charge of prostatic fluid during defecation, after urina- 
 tion, and during erection, when sufficient stimulus for 
 ejaculation is not applied. 
 
 Chronic inflammation of the prostatic urethra may 
 be kept alive by simple persistence of gonorrhoeal 
 inflammation, or perhaps more frequently by the 
 formation of a stricture in the membranous or pos- 
 terior portion of the penile urethra. The relation of 
 stricture to impotence has been well shown by many 
 reported cases. The mechanical obstruction offered by 
 stricture even of large calibre, is sufficient to indefin- 
 itely prolong an inflammation behind the point of 
 narrowing, when this has once started. 
 
 Atonic impotence from sexual excess is probably 
 more frequent than the histories of cases would lead 
 the surgeon to infer. This is because men and boys 
 are notoriously untruthful in regard to the amount of 
 their sexual indulgence. Some, and usually those with 
 the smallest powers, and who exhibit these powers 
 most moderately, narrate experiences before which 
 the records of the wildest satyriasis pale. Others 
 cursed with violent and unchecked passions, are, ac- 
 cording to their accounts, moderate to an extreme. 
 
— 37 — 
 
 It is particularly in those who practise self-abuse that 
 the form of impotence due to sexual excess is found. 
 With these unfortunate patients, an admission as to 
 the extent to which they yield to temptation is al- 
 most never obtainable. In a fairly extended experi- 
 ence I have known of but one instance where the 
 patient frankly acknowledged that he still continued 
 the habit and was unable to conquer it. 
 
 The question has often been raised as to whether 
 masturbation affects the general system more injuri- 
 ously than sexual intercourse, if both be practised to 
 the same extent. This is a difficult question to 
 answer, since the conditions of comparison are 
 practically impossible of fulfilment. There is a wide- 
 spread belief not only in the community, but among 
 the doctors, as to the disastrous effects produced by 
 masturbation per se. There is a constant tendency 
 to refer back to this practice many or all of the ills 
 which arise during the course of a lifetime. Dis- 
 eases of the genito-urinary organs are peculiarly 
 liable to be considered as dependent upon onan- 
 ism — justly in some cases, no doubt. Hence, while 
 the number of people who attribute their ills to 
 masturbation is legion, those who complain of the 
 results of excessive sexual gratification are com- 
 paratively few. Immoderate indulgence in sexual 
 intercourse requires the consent of another person, 
 and, as a matter of fact, marks for its victims, at 
 least in so far as immediate consequences are con- 
 cerned, a comparatively small number of patients. 
 
— 38 — 
 
 The excesses of the libertine are usually paroxys- 
 mal, and are associated with inordinate use of stimu- 
 lants, the general effect of which quite overshadows 
 the results from undue sexual activity. Among the 
 men-about-town impotence is rare, except that form 
 resulting from gonorrheal inflammation and its results. 
 Occasionally, however, after an unusually prolonged 
 debauch, patients will appear complaining of feeble or 
 absent erections. It is always a question in these cases 
 as to whether this is the result of tobacco and rum, 
 or is due to sexual excess. 
 
 The ultimate effect of sexual excess seems to be 
 the institution of certain sclerotic changes in the 
 cord, resulting in locomotor ataxia and kindred dis- 
 orders. When these changes occur, impotence 
 shortly becomes complete. 
 
 The following is a typical case of temporary im- 
 potence from over-activity. 
 
 A. B., aged 30; married ten months; had syphilis; 
 never suffered from gonorrhoea; masturbated moder- 
 ately when a boy; was never excessive in venery 
 afterward; sexual functions performed normally; did 
 not suffer from any signs of vesical irritability. The 
 patient's wife was of an exceedingly passionate disposi- 
 tion. During the ten months of his married life, with 
 the exception of intervals of two or three days, twice a 
 month, when he was called out of town, he was re- 
 quired to perform the sexual act two or three times 
 every night. In the last month he was troubled with 
 
— 39 — 
 
 frequent urination and some urgency ; with imperfect 
 erections; with premature ejaculations; and imme- 
 diate subsidence of erection after this. At the same 
 time he lost twenty pounds in weight; suffered 
 from headache; vertigo; palpitation; some dyspeptic 
 symptoms; constipation and a feeling of lassitude. 
 He was excessively nervous, so that the slightest 
 sound would make him start violently; he had be- 
 come petulant, morose, and had his mind almost 
 constantly turned on sexual subjects. He was not 
 able to concentrate his attention on business matters; 
 was restless and exceedingly disturbed over his loss 
 of power. After two months of moderation his 
 health was completely restored. 
 
 Masturbation may be learned at a very early age. 
 I have seen one child, nine months old, who to all 
 appearances practised onanism. Children of two or 
 three years either learn it themselves or are taught 
 the practice by their elders ; sometimes by nurses 
 who find that fingering the genitals is an efficient 
 method of keeping a baby quiet. It is generally be- 
 lieved that masturbation is one of the evils incident to 
 school life. Many of the young men whom I have 
 questioned on this subject state that they discovered 
 themselves the pleasurable sensations which could 
 be obtained by friction; sometimes the first stimulus 
 was provided by horseback riding, or sliding down 
 banisters, or often from handling of the penis in- 
 duced by the itching occasioned by a mild balano- 
 
— 40 — 
 
 posthitis. Once learned, the habit is liable to be con- 
 tinued with an instinctive knowledge that conceal- 
 ment is necessary, until the boy is clearly made to 
 understand that he is doing himself a permanent in- 
 jury. Many medical students have stated that not 
 until they began their professional reading did they 
 learn that the practice in which they indulged was 
 injurious. The effect produced varies greatly in in- 
 dividual cases. I have seen men who stated that 
 from their fifth to the eighteenth year they mastur- 
 bated almost constantly — that is, several times a 
 week — and yet who experienced no ill effects from it. 
 Ordinarily where indulgence is excessive, the general 
 symptoms are sufficiently well marked. 
 
 The local symptoms, in the period of boyhood at 
 least, excite neither attention nor anxiety. It is com- 
 monly taught that the masturbator may be known by 
 certain peculiarities. Thus he is given a low, mean 
 look, a hang-dog expression; a pallid face; hollow, 
 watery eyes; cold, moist hands; lustreless hair; con- 
 strained, embarrassed manner; drooping shoulders; 
 a tendency toward twitching the muscles; frequent 
 repetition of swallowing motions on being addressed; 
 weak knees; shrunken sexual organs; a timid, soli, 
 tary, irritable disposition ; is supposed to be uncleanly 
 in his habits; averse to all society, particularly to 
 that of girls; and incapable of intellectual effort. 
 This description is no doubt true in certain extreme 
 cases, but the absence of any or all of these features 
 
— 41 — 
 
 will not exclude the fact of this habit being practised, 
 and to considerable excess. Some of the frankest, 
 manliest and apparently healthiest boys I have seen, 
 indulged without stint in this practice, taught their 
 comrades with open-hearted generosity, delighted 
 in the presence of the opposite sex, and showed in 
 their expression and bearing self-respect and inno- 
 cent joy in life. 
 
 As a typical instance of aggravated impotence 
 directly traceable to masturbation, the following may 
 be narrated. 
 
 M. R., aged 26, a mechanic, was always healthy, 
 with the exception of convulsions, from which he was 
 said to suffer as a child; until his eighteenth year he 
 never practised masturbation. He then discovered 
 that pleasurable sensations could be produced by 
 local friction, and practised onanism several times a 
 day for one year. Learning that it was doing him 
 an injury, he stopped the practice as far as he was able, 
 but was not sufficiently resolved to give it up entire- 
 ly. Up to his eighteenth year he had been strong 
 and well, had morning erections, and on two occasions 
 had been able to perform the sexual act successfully. 
 He was small in size, with cold, clammy hands; 
 sunken, dark-ringed eyes avoiding the gaze of his 
 interlocutor and watering freely; muddy, pimply, 
 flabby face; dry, brittle, unkempt hair; scraggy neck, 
 with prominent Adam's-apple which rose and fell in 
 a distressing manner whenever he was addressed or 
 
— 42 — 
 
 attempted to speak. His gait was slouching; he was 
 uncertain, hesitating and timid in speech, with the 
 words imperfectly pronounced, and sentences half 
 spoken; and he twisted uneasily while sitting, or 
 supported himself while standing up, and nervously 
 shuffled his feet. From his incoherent speech I gath- 
 ered the history I have given and also the facts that his 
 memory was gone; that he was unable to concentrate 
 his attention upon any occupation; that he suffered 
 from pains in the back, running down along the anter- 
 ior and inner surfaces of the leg; that he passed water 
 frequently, and often had to hurry; that he had pol- 
 lutions once or twice a week. Within the last few 
 years he had occasionally feeble morning erections. 
 He was tortured with inordinate sexual desires, but on 
 the first sexual contact instantly ejaculated, often 
 without erection, or even without voluptuous sen- 
 sation, and was quite unable to complete the sexual 
 act. 
 
 Examination of his sexual organs showed that 
 they were not more developed than those of a boy of 
 twelve or fourteen years; the penis was two inches 
 in circumference, about two inches in length, and the 
 testicles were correspondingly small. Beyond this 
 there was no apparent abnormality. The meatus was 
 small, but on dividing it a 28 sound passed in 
 readily, occasioning great anguish when it reached 
 the prostatic urethra. The patient was in despair 
 over his condition, and was suffering from all the 
 
— 43 — 
 
 reflex urethral symptoms of which these cases com- 
 plain. 
 
 As a result of some weeks treatment, he returned 
 greatly improved in general health, and with partial 
 restoration of the power of erection. I have every 
 reason to believe that this patient during his treat- 
 ment steadily continued to masturbate and that his 
 ultimate cure was prevented (for I did not succeed 
 in curing him beyond the point mentioned) by the 
 continuance of this habit. 
 
 Atonic impotence from, prolonged and nngratified 
 sexual desire. Those who suffer from this form of 
 impotence are by no means the full-blooded pas- 
 sionate men, who either from necessity or from 
 strength of purpose, are debarred from sexual in- 
 dulgence. For instance, sailors who spend months or 
 even years in places where woman is unknown, are 
 not troubled with sexual weakness when opportunity 
 for indulgence is afforded. Nor are the robust men 
 of the cities whose minds and bodies are healthfully 
 occupied, frequently troubled with this form of im- 
 potence. The sufferers from prolonged excitement 
 are rather those of a neurotic tendency whose thoughts 
 habitually dwell on sexual pleasures, who are given 
 to fondling women without violating the written 
 law, or to onanism not carried to the point of ejacu- 
 lation, whose occupation is neither mentally en- 
 grossing nor physically fatiguing. Thus I have most 
 frequently seen young farmers troubled with impo- 
 
— 44 — 
 
 tence from this cause. Commonly it develops into a 
 condition of prostatorrhoea, which exceptionally runs 
 on to spermatorrhoea, and finally complete paralytic 
 impotence with profound deterioration of moral 
 fibre. Such a result is rarely produced by an excite- 
 ment prolonged through days, or even weeks and 
 months. It often takes years to produce appreciable 
 effects. The following case is fairly typical of its 
 class. 
 
 A. B., a healthy, ruddy, prosperous young farmer 
 of twenty-six, since his sixteenth year was much 
 given to fondling women. For several years, during 
 some part of every day he was subjected to pro- 
 nounced sexual excitement. In his twentieth year 
 his nocturnal emissions became more frequent than 
 before, averaging about once a week. Two years 
 later the patient found that the cerebral excitement 
 incident to ordinary endearments excited emission. 
 These emissions recurred with greater facility, but 
 gave him no concern till the time of his marriage, 
 when he attempted coitus for the first time in his life. 
 Emission took place before intromission, and this dis- 
 tressing hypersensitiveness continued in spite of the 
 strongest efforts of the will. General hygienic treat- 
 ment and a course of posterior instillations resulted 
 in complete cure. 
 
 A more serious case is the following : 
 A. B., a well-to-do farmer of twenty-two, has al- 
 ways been neurotic and somewhat solitary in his hab- 
 
— 45 — 
 
 its. In his fourteenth year, he masturbated once, 
 profiting by the verbal instructions of a friend. For- 
 tunately he was detected in the act, and was admon- 
 ished by rod and tongue to such purpose that he 
 never repeated it. During his childhood and youth 
 he brooded almost constantly on sexual subjects; 
 sights such as the mating of birds, or the congress of 
 animals, threw him into a condition of erotic excite- 
 ment which rendered him sleepless at night and unfit 
 for his work for days. At such times he would have 
 repeated and painful erections, would suffer from tes- 
 ticular pains, backache, and nocturnal emissions. 
 
 In his sixteenth year he was thrown much in the 
 company of a young woman, with whom the cir- 
 cumstances of country life left him alone, and 
 whom he caressed on every opportunity, confin- 
 ing himself within the limits of decency. As a result 
 his previous suffering became augmented, and his 
 nocturnal pollutions w r ere more frequent, averaging 
 two or three in the week. He finally suffered from 
 daily pollutions, at first after more than usually pro- 
 longed excitement and as the result of some slight 
 mechanical friction. These emissions were excited 
 more and more readily till finally they would take 
 place before the penis became fully erect and on the 
 slightest psychical or physical excitement. In his 
 twentieth year he eschewed the company of women, 
 but the sexual weakness steadily became more aggra- 
 vated. The jolting of a wagon or of a mowing 
 
— 46 — 
 
 machine would cause feeble erection and emission, 
 sometimes repeated two or three times a day. A well 
 marked condition of prostatorrhoea was developed, 
 and on approaching a female the semen flowed out 
 without the slightest sign of erection, and with only 
 very feeble pleasurable sensations.. The mental con- 
 dition of the patient was deplorable; he had lost 
 twenty pounds in weight, suffered from headache, 
 giddiness, from palpitation, heart-burn, weak back, 
 pains particularly severe in the hypogastric region 
 and the right hip, and had become so desperate and 
 despondent that he was prepared for any measure 
 which would give him relief. He begged to have 
 his testicles removed, and indeed was quite deter- 
 mined to perform this operation himself if the sur- 
 geon refused to perform it. 
 
 Treatment by dividing a narrow meatus, passing 
 full-sized sounds, dilating the prostatic urethra once 
 up to 40 F., and making instillations of copper sul- 
 phate 5 per cent, into the posterior urethra, produced 
 such a change in this man's condition that he became 
 active in all social affairs of the country side, ceased 
 to be troubled by diurnal pollutions, and had noctur- 
 nal emissions not more frequently than was normal. 
 He experienced vigorous morning erection?, absent 
 for more than two years, and regarded himself as 
 cured. 
 
 The treatment of impotence dependent upon pro- 
 longed and ungratified sexual excitement must be 
 
— 47 — 
 
 based on the avoidance of all that tends to pro- 
 duce such excitement. This end is not always 
 accomplished simply by forbidding association with 
 women. There is in the majority of these patients 
 a mental perversion, a persistent dwelling on sexual 
 subjects, which in itself is sufficient to produce local 
 congestions. In such cases the patient must be 
 urged to use all his strength of will to overcome this 
 tendency. He should be advised to seek an occupa- 
 tion which will keep him actively employed both 
 mentally and physically. If such occupation is 
 purely mental it must be supplemented by gymnastic 
 exercises. He should be encouraged to spend his 
 leisure time in certain lines of study, should be 
 directed to exercise vigorously for 15 minutes and 
 take a cool sponge bath before retiring, and should 
 begin the day with a ten-minute course of calis- 
 thenics, followed by a cold plunge bath or shower 
 bath. 
 
 This part of the treatment, by far the most impor- 
 tant, depends entirely upon the strength of purpose 
 exhibited by the patient. To advise such a patient 
 to give his passions full swing is, even from a thera- 
 peutic standpoint, distinctly objectionable, since he is 
 liable to exhibit some weakness in his first essays, 
 and, as a result of failure, will have added to his 
 original functional deficiency psychical impotence, 
 making his ultimate cure much more difficult. 
 
 While the patient is devoting his energies to avoid- 
 
— 48 — 
 
 ing causes of excitement and diverting his mind from 
 sexual subjects, the hypersensitive posterior urethra 
 should receive the treatment appropriate to these 
 cases; the cold sound, the psychrophor, the prostatic 
 dilator, or posterior instillation, being employed in 
 accordance with the severity of the local changes 
 which have resulted from frequently repeated, long- 
 continued congestions. 
 
 Impotence associated with abnormal conditions of 
 the urine. It seems reasonable to suppose that the 
 hypersesthetic condition of the posterior urethra, 
 which is the cause of nearly all cases of atonic impo 
 tence, may be occasioned by the irritation incident to 
 the passage of urine, which, from the fact that it is 
 strongly acid or otherwise abnormal, acts to a greater 
 or less extent as an irritant to the mucous membrane. 
 It is, however, impossible positively to decide wheth- 
 er or not the impotence may notjbe dependent on 
 the general causes which induce an abnormal condi- 
 tion of the urine, rather than on the direct irritating 
 effects of this fluid, since in diabetes, where impotence 
 is often absolute, and in Bright's disease, there is not 
 necessarily the slightest sign of local hyperemia, nor 
 does the introduction of an instrument occasion any 
 undue suffering. 
 
 I have, however, repeatedly seen men with oxaluria, 
 who suffered from all the local and reflex signs of 
 posterior urethritis associated with impotence, and 
 whose cure followed hard upon the disappearance of 
 
— 49 — 
 
 the oxaluria. Again, in the uric acid diathesis impo- 
 tence associated with signs of urethral irritation, is not 
 infrequently noted, and is usually cured by general 
 treatment. The strongly acid urine of acute ephem- 
 eral fevers occasionally produces distressing priapism 
 from its stimulating effect on the posterior urethra, 
 and it is reasonable to suppose that when such irrita- 
 tion is long continued atonic impotence will result. 
 
 Under the title Genito-urinary neuroses Ultzmann 
 has admirably described the reflex nervous symptoms 
 incident to hyperemia, or a chronically inflamed con- 
 dition of the prostatic urethra. 
 
 In men the bladder, seminal vesicles and prostate 
 are supplied from the vesical plexus, which in turn, is 
 made up of anastomosing branches from the hypogas- 
 tric plexus of the sympathetic together with filaments 
 from the sacral ganglia, and from the pudendal plexus 
 of the sacral nerves. This nerve suppl) T explains why 
 a constant irritation of the prostatic urethra should 
 excite such reflexes as pain passing down the inner 
 surfaces of the thighs, or referred to the hips, to the 
 anus, to the hypogastric region, or to the small of the 
 back. Indeed, all the general and local symptoms 
 observed in a hysterical woman, the subject of a 
 chronic inflammation of the uterus, are duplicated in 
 men, the subjects of chronic catarrh of the prostatic 
 urethra," since both the uterus and the prostate are 
 richly supplied from the same nerve plexus. 
 
— 50 — 
 
 The urine, in these cases, is often very abundant, 
 and of low specific gravity. Sometimes the polyuria 
 is associated with a transient glycosuria. At times 
 the urine when secreted is alkaline, dependent not 
 upon carbonate of ammonia, but usually upon the 
 presence of carbonate of soda. This urine on heat- 
 ing becomes turbid from precipitation of the earthy 
 phosphates. 
 
 Indican is occasionally observed in the urine of mas- 
 turbators, or of those who have indulged in excessive 
 venery. A transient albuminuria is also noted at 
 times. 
 
 Oxalate of lime frequently appears in great excess; 
 also the amorphous and crystalline salts of lime and 
 magnesia. Spermatozoa are also found singly in the 
 field of the microscope. 
 
 The sensory neuroses of the sexual system may be 
 confined to ] sensations like those produced by fluid 
 running through the urethra, though there is not the 
 slightest sign of discharge, or to neuralgic pains 
 referred to the testicles, anus, groins or any of the 
 regions innervated by branches communicating with 
 the hypogastric and sacral plexus. This hyperesthe- 
 sia is sometimes manifested by a sensation of severe 
 burning in the region of the meatus after ejaculation. 
 
 Rarely anaesthetic phenomena are observed; the 
 penis seems cold and shrivelled; it is sometimes non- 
 sensitive to such a degree that the mechanical stimulus 
 of coitus is scarcely sufficient to excite ejaculation; 
 
— 51 — 
 
 even application of the electric brush does not cause 
 pain. The urethra shares in this anaesthesia, so that a 
 sound may be passed into the bladder without excit- 
 ing discomfort. Usually the urethra is markedly 
 hyperaesthetic, the passage of an instrument causing 
 almost unbearable anguish. 
 
 The motor neuroses of the urinary and genital 
 system may appear in the form of over-action or 
 paralysis. Thus there is sometimes observed drib- 
 bling of urine after micturition from spasmodic con- 
 traction of the smooth circular muscles of the urethra. 
 Passage of bougies in such cases proves the absence 
 of strictures. 
 
 At times there is spasm of the external bladder 
 sphincter. In such cases, there is great difficulty in 
 starting the act of micturition; the first flow comes 
 in drops, or the stream is suddenly interrupted, and 
 at the end of the act there is dribbling. At times the 
 urine can not be passed, and retention must be re- 
 lieved by the administration of anodynes and anti- 
 spasmodics, or by the passage of a catheter. 
 
 True cystospasm, that is spasm of the detrusor 
 bladder muscles, is much more common than spasm 
 of the sphincters. When the detrusor muscles are 
 involved, the patient has difficulty in retaining the 
 water, is compelled to urinate frequently. Usually 
 there is no pain associated with this frequent urin- 
 ation. This motor neurosis is a very frequent accom- 
 paniment of catarrhal conditions of the prostatic 
 urethra. 
 
— 52 — 
 
 Paresis of the sphincters, or of the detrusor mus- 
 cles of the bladder, is exceedingly rare. When the 
 sphincters are involved, incontinence results; when the 
 detrusors are at fault, the patient suffers from reten- 
 tion. 
 
 The motor neuroses of the sexual system may be 
 manifested in the forms of priapism, or partial or 
 complete impotence, often associated with involun- 
 tary seminal emissions and spermatorrhoea. 
 
 Priapism is rarely observed except in the very 
 early stages of acute inflammatory involvement of 
 the prostatic urethra. Thus in acute posterior ure- 
 thritis, in certain cases of prostatic calculus, or 
 of growths in that region, there may be repeated 
 and prolonged erection, sometimes associated with 
 pollutions. 
 
 Impotence is commonly observed as a result of 
 chronic inflammation of the posterior urethra. The 
 pollutions with which it is associated are due to 
 spasm of the detrusors of the seminal vesicles, while 
 spermatorrhoea or dribbling of the semen without 
 erection or voluptuous sensation is due to paresis 
 of the muscular fibres of the ejaculatory ducts. 
 
 The secretory neuroses of the genital system are 
 manifested in the form of polyspermia, aspermia 
 and prostatorrhcea. 
 
 Polyspermia implies the ejaculation of an abnormal 
 quantity of semen; aspermia, the absence of semen; 
 prostatorrhcea, a hypersecretion from the prostatic. 
 
— 53 — 
 
 glands, the glands of Cowper, and the urethral crypts 
 and follicles. The great bulk of this hypersecretion 
 is contributed by the prostate. 
 
 In addition to these local neuroses, there is com- 
 monly in these cases of urethral irritation a pro- 
 found constitutional involvement; there is muscular 
 weakness, anaemia, dyspepsia, palpitation, asthma, con- 
 stipation. There are also psychical changes; the 
 patients become timid, morose, solitary, hypochon- 
 driacal. The slightest excitement throws them into 
 a state of profound agitation. No diversion is suf- 
 ficient to lift even for a moment the pall of despond- 
 ency which settles over them. I believe that the cause 
 of many an unexplained suicide could be found on 
 examination of the posterior urethra. 
 
 The diagnosis of atonic impotence. — To determine 
 whether or not a given case of impotence is due 
 to psychical influences, to organic changes in the 
 central nervous system, or to exhaustion of the erec- 
 tor and ejaculator centres, the main dependence 
 must be placed upon the history of the case. All 
 venereal troubles seem to exert more or less of an 
 inhibitory influence upon the truth centres, if such 
 exist. Hence in every history allowance must be 
 made. The physician should, however, be careful 
 not to be misled by a skepticism so absolute that the 
 improbable is not given close consideration. 
 
 After a careful review of the history, a thorough 
 
— 54 — 
 
 examination must be made. This will include the 
 condition of the circulatory, respiratory and central 
 nervous systems. The urine must be examined, and 
 in some cases the eye-ground carefully inspected. 
 In all cases of impotence a thorough examination of 
 the rectum must be made, since reflex impotence 
 from fissure, seat-worms or hemorrhoids is by no 
 means unknown. Examination of the urine is par- 
 ticularly important. Not only must the surgeon 
 know the total quantity passed during the day, but 
 its specific gravity; its acid, neutral or alkaline 
 reaction; the presence or absence of the earthy 
 phosphates; of oxalates; of uric acid or excess of 
 urates; of indican, sugar and albumen. He must 
 carefully search for traces of inflammation in the pros- 
 static urethra, and if he finds pus, probably from this 
 source, he must discover whether it is due simply to 
 the ordinary microbes of suppuration or is associated 
 with a still active gonorrhoea! inflammation. 
 
 To determine from which part of the urethra pus is 
 secreted, the surgeon should pass a small, soft rubber 
 catheter into the urethra as far as the compressor 
 urethras muscle, then by means of an irrigating bag 
 filled with a mild antiseptic solution, such as 4-per- 
 cent, boric acid, the whole anterior urethra should 
 be well flushed out. The patient is now directed to 
 pass his urine into three perfectly clean glasses. The 
 first glass receives the first ounce; the second glass 
 receives all but the last half -ounce; the last glass 
 
— 55 — 
 
 receives the water from the final straining efforts to 
 evacuate the bladder. If pus is contained in the first 
 glass and the contents of the others is clear, there is 
 probably present a moderate catarrhal condition of the 
 prostatic urethra, the secretion not being sufficient to 
 overfill this part of the tube and flow back into the 
 bladder. If all three portions contain pus, there 
 is a free discharge which fills the prostatic urethra 
 in the intervals of micturition and flows back into 
 the bladder. If the first and last alone contain pus, 
 there is marked involvement of the prostatic sinuses, 
 the contents of which are squeezed out by the last 
 act of micturition. Where there is a probability of 
 involvement of the bladder in inflammation, the pres- 
 ence of pus in the second and third glasses has not 
 exactly the same significance. 
 
 Finally comes the examination of the sexual or- 
 gans. The condition of the testicles must be noted, 
 their size, position, consistency, sensitivenes, and the 
 presence or absence of inflammatory swellings, or 
 new growths. The development of the penis is 
 next considered. It is palpated to discover whether 
 indurations are present along the course of the ure- 
 thra, or in the cavernous bodies. The prepuce is 
 examined as to whether it is redundant or too tight. 
 The condition of the lips of the meatus is noted and 
 the measurment of the circumference of the penis 
 just behind the corona is made. On an average this 
 will be from three to three and a half inches. This 
 
— 56 — 
 
 measurement gives us a*f airly good gauge as to what 
 should be the normal calibre of the urethra. The 
 urethra of a penis measuring three inches in circum- 
 ference should easily take a No. 30 sound. Each one- 
 quarter of an inch added to the circumference of the 
 penis should indicate a sound two numbers larger. 
 Thus a penis three and a quarter inches in circum- 
 ference should take a sound No. 32. In cases of impo- 
 tence will sometimes be found a penis not more than 
 two or two and a half inches in circumference. 
 The urethra in these small organs should, however, 
 take a No. 26 to 28 sound, since the shrinkage is 
 usually in the unstriped muscular fibres of the erectile 
 tissue. 
 
 Having determined the normal calibre of the 
 urethra, the glans penis is carefully cleansed with a 
 mild antiseptic (a pledget of cotton taken from a 
 solution of yoVo^ bichloride), and a sterile bulbous 
 bougie four sizes smaller than the normal calibre, 
 
 Fig. 9.— Bulbous Bougie. 
 
 should be lubricated with albolene or a mixture made 
 up of glycerine, 100 parts; boric acid, 4 parts; car- 
 bolic acid, 1 part, and gently introduced into the 
 bladder. About six inches from the meatus the in- 
 voluntary contraction of the compressor urethra? 
 muscle will stop its further passage for a moment. 
 
— 57 — 
 
 By continued gentle pressure, and particularly by 
 directing the patient to make efforts at micturition, 
 the spasm will yield and the instrument will pass into 
 the bladder, stopping for a moment, perhaps, at the 
 internal sphincter, that is, the layer of involuntary 
 muscular fibres surrounding the neck of the bladder 
 to the inner side of the prostate. The instrument 
 should then be slowly withdrawn. During the intro- 
 duction and withdrawal of the bougie, the physician 
 should note points of resistance to its progress, and 
 should look for areas of unusual tenderness. On with- 
 drawal, the shoulder of the bulb should be inspected 
 for pus, blood or mucus. 
 
 A stricture will be detected either by failure of the 
 large bulb to pass in, or by its being resisted for a 
 moment and then jumping past the obstacle. On 
 withdrawal, the square shoulder of the bulb catches 
 in a more pronounced way. Failure to pass the first 
 bulb should be followed by efforts to pass successively 
 smaller bulbs, unless the resistance be due to the 
 spasmodic contraction of the compressor urethrae 
 muscle. This is encountered about six inches from the 
 meatus; it yields to gentle continued pressure, aided 
 by efforts on the part of the patient to urinate, in 
 virtue of which the compressor urethrae is relaxed; 
 or, if it still resists the bulbous bougie, it can be 
 passed readily by means of a full sized steel sound. 
 J. William White has shown that on withdrawal of 
 the bulbous bougie, the resistance of the posterior 
 
— 58 — 
 
 layer of the triangular ligament will, in a perfectly 
 normal urethra, give the sensation of a slight stricture 
 This resistance will be encountered about 6f inches 
 from the meatus. Knowledge of this fact will pre- 
 vent the surgeon from diagnosing stricture in cases 
 where the urethra is normal. 
 
 Personally I have never seen a stricture due to 
 onanism, and have seen only one congenital narrow- 
 ing of the urethra un associated with other deform- 
 ities of the parts. This is, of course, setting aside 
 the narrowing which is frequently observed about 
 the meatus. 
 
 It may be found that the meatus or the urethra 
 just behind it is congenitally so narrow that it will 
 not admit a bougie sufficiently large to detect a large 
 calibre stricture (over 16 French), even if one is 
 present. In such cases there should be no hesitation 
 in performing a meatotomy. 
 
 By means of a 10 per cent, solution of cocaine the 
 area of operation, although it is exquisitely sensitive, 
 may be rendered absolutely anaesthetic. Cocaine is 
 applied by means of pledgets of cotton wrapped on 
 applicators (an ordinary match stick answers well). 
 This pledget is dipped into the cocaine solution, is 
 then introduced into the urethra to the depth of 1| 
 inches. The cocaine is allowed to remain for three 
 minutes, is withdrawn and another pledget inserted. 
 The surgeon then enlarges the opening by means of a 
 blunt pointed tenotome curved on its convex cutting 
 
— 59 — 
 
 edge. The incision should be downward and directly 
 in the middle line of the fraennm. Under exceptional 
 circumstances when the tissues in this direction are 
 unusually thin, part of the cutting may be done upon 
 the upper surface of the urethra. This cutting should 
 be so free that a bulbous bougie two sizes larger than 
 the normal calibre of the urethra can be entered and 
 withdrawn without meeting with abnormal resistance. 
 The patient is then griven a conical meatus bougie and 
 a 10 per cent, solution of cocaine. He is instructed to 
 cocainize the site of operation immediately before each 
 act of micturition: and to insert the meatus bougie 
 once a day for two weeks, employing cocaine before 
 its introduction, using albolene as a lubricant and 
 keeping his instrument as nearly sterile as possible. 
 
 I have seen this operation completely relieve ves- 
 ical irritability and partial impotence from which 
 the patient suffered for many months. It is pos- 
 sible, however, that it acted as much by the mental 
 impression it produced, as by any direct beneficial 
 effect upon the posterior urethra and indirectly 
 the lumbar centres. After division of the meatus, 
 either a bulbous bougie four sizes smaller than the 
 calibre of the urethra, or a full sized cylindrical 
 sound should be introduced into the bladder. A 
 cylindrical sound will determine the presence of a 
 stricture almost as well as a bulbous bougie; it causes 
 less pain than the latter, and allows the surgeon to 
 accurately determine the amount of hyperesthesia 
 present in the posterior urethra. 
 
— 60 — 
 
 Examination of the urethra with a urethroscope 
 should be employed when there are diseased areas in 
 the anterior urethra. The introduction of a straight 
 endoscopic tube into the bladder inevitably occasions 
 some contusion of the prostatic urethra. The infor- 
 mation gathered from inspection of this part is rarely 
 more valuable than that obtained by exploring instru- 
 ments, which occasion less local injury. The only 
 case of epididymitis I have ever had the misfortune 
 to occasion by the passage of instruments was due 
 to the introduction of a tube of the Leiter urethro- 
 scope. 
 
 An examination thus conducted, will show the 
 presence or absence of pathological conditions which 
 may reflexly produce a hypera?sthetic and finally 
 an adynamic condition of the lumbar centres. In 
 the vast majority of cases this reflex will start from 
 the vesico-prostatic plexus of nerves, a chronic pos- 
 terior urethritis being kept up by stricture or by the 
 persistence of a gonorrhceal inflammation. 
 
 Although examination of cases of atonic impotence 
 usually shows a hyperaesthetic condition of the ure- 
 thra, in certain cases, particularly in those associated 
 with prostatorrhoea and complete impotence, the whole 
 urethra becomes absolutely insensitive, so that the 
 passage of an instrument gives rise to no suffering. 
 This represents the most advanced and most hopeless 
 form of impotence. 
 
 The prognosis of atonic impotence is good, except- 
 
— 61 — 
 
 ing in the most advanced cases. Frequently, dilata- 
 tion of a stricture, and restoration of the urethra to 
 its normal calibre, will be found sufficient to produce 
 a cure. Generally the hyperemia or inflammation 
 of the prostatic urethra must be subdued by direct 
 local treatment. 
 
 In the cases suffering from premature ejaculation, 
 even though this be associated with imperfect erec- 
 tions, the outlook is generally favorable, especially, 
 when distinct lesions are found sufficient to cause 
 such functional disturbances. In more advanced 
 cases, where connection is impossible owing to defi- 
 cient or absent erections, if such patients have vo- 
 luptuous dreams with erections and emissions, and 
 have occasionally vigorous morning erections, the 
 outlook is fairly satisfactory, but sometimes a cure 
 is extremely difficult to accomplish, since here there 
 is a distinct psychical element added to the atonic 
 impotence. 
 
 In the paralytic form of the trouble when sexual 
 desire is absent, when emissions occur without pleas- 
 ure and without erections, the prognosis must be 
 extremely guarded, though even in some of these 
 cases persistence in rational treatment will bring 
 about a cure. 
 
 TREATMENT OF ATONIC IMPOTENCE. 
 
 The treatment of these cases must be both general 
 and local. The sleep, diet, exercise and general 
 
— 62 — 
 
 hygiene of the patient must be carefully regulated. 
 While under treatment, sexual relations must be 
 strictly interdicted with very few exceptions. The 
 patient should be particularly cautioned against 
 making an occasional secret trial to discover whether 
 or not he is gaining strength. 
 
 Fissure, hemorrhoids or other pathological condi- 
 tions about the rectum should receive prompt atten- 
 tion. If varicocele is present, it should be cured by 
 operation, or an appropriate suspensory bandage 
 should be ordered. A redundant prepuce would call 
 for circumcision; a narrow meatus for meatotomy. 
 
 All sexual excitement should be avoided with the 
 utmost care, and if the thoughts irresistibly run in 
 this direction, vigorous exercise and cold bathing 
 should be ordered. The urine should be rendered 
 bland and unirritating, and when it contains excess of 
 phosphates, oxalates, urates, uric acid, etc., appropriate 
 dietetic and medicinal treatment must be ordered. 
 
 The local treatment consists in the dilatation of 
 strictures; the healing of granular patches of the 
 anterior urethra by means of direct applications 
 through the endoscope; the curing of hyperaemic and 
 inflammatory conditions of the posterior urethra by 
 irrigations and instillations, and the passage of full 
 sized cold steel sounds, or by the use of the psychro- 
 phor. 
 
 The sound (Fig. 1) should be introduced every third 
 or fourth day, and should be allowed to remain in for 
 
— 63 — 
 
 fifteen minutes. In some cases the prostatic urethra 
 is so exquisitively sensitive that the introduction of 
 the sound occasions a distinct nervous shock. Very 
 exceptionally the whole urethra exhibits hyperesthe- 
 sia. This may be overcome by first injecting a one 
 per cent, solution of cocaine into the anterior urethra. 
 An instillator can then be carried down to the mem- 
 branous urethra, its tip inserted just within the grasp 
 of the compressor urethra? muscle, and ten drops of a 
 one per cent, solution of cocaine can be driven into 
 the membranous and prostatic urethra. The intro- 
 duction of the sound will then be almost painless. 
 
 %^ — * 
 
 Fig. 1.— Steel Sound. 
 
 When there are distinct evidences of a catarrhal con- 
 dition of the posterior urethra, irrigation and instil- 
 lation will usually be required before a cure is accom- 
 plished, though in many cases, particularly those 
 dependent on stricture, the use of the sound is suf- 
 ficient. 
 
 Irrigation is best practised by means of a small 
 (No. 10 F.) soft rubber catheter. This is attached 
 to a fountain syringe which contains the lotion to be 
 used, is lubricated with antisepticized glycerine, and 
 
— 64 — 
 
 is passed into the bladder. The stream is then 
 started, and the catheter is slowly withdrawn, thus 
 flushing out the entire urethra. The solutions which 
 give the best results are: nitrate of silver, 1: 6000 to 
 10,000; sulpho-carbolate of zinc, 1:1000 to 3000; 
 permanganate of potassium, 1:1000 to 3000; per- 
 manganate of zinc, 1:3000 to 6000; bichloride of 
 mercury, 1:10,000. The efficacy of these lotions is 
 increased by administering them as hot as can be 
 borne. Such an irrigation should precede the passage 
 of the sound, particularly in the cases where examina- 
 tion of the urine shows that pus is freely secreted 
 from the prostatic urethra. 
 
 After the passage of the sound, instillations should 
 be practised. These act directly upon the inflamed 
 area, promoting healing, and subduing the hyperes- 
 thesia of the terminal nerve filaments of the vesico- 
 prostatic plexus. 
 
 Instillations are made by means of a catheter, to 
 which is attached a small syringe (Fig. 2). The 
 catheter part of the instrument should be cylindrical, 
 not conical, it should not be longer than seven 
 inches, and its lumen should be very small. A hard 
 rubber tube thus constructed with a short terminal 
 curve and firmly attached by its shaft to an ordinary 
 hypodermic syringe will answer every purpose. 
 
 The medication which is to be employed, is sucked 
 up through the tube; the latter is lubricated with 
 antisepticized glycerine, and is introduced till its 
 
— 65 — 
 
 point has just been grasped by the compressor urethras 
 muscle. This can be known by the slight, often sud- 
 den, sense of yielding, which is felt after a moment's 
 steady pressure when the instrument stops at the 
 anterior layer of the triangular ligament. The piston 
 of the syringe is now driven down, and the instrument 
 is withdrawn. 
 
 If the application is made properly, not a single 
 drop should escape into the anterior urethra. It is 
 important that this should not take place, since solu- 
 tions are commonly used for instillation so strong 
 
 Fig. 2.— Instillator. 
 
 that undue inflammatory action would be excited by 
 their contact with the anterior urethra. 
 
 The quantity injected each time is ten to twenty 
 drops, and the instillations are best made when the 
 bladder is neither full nor entirely empty. Of the solu- 
 tions employed, nitrate of silver is by all odds the most 
 efficient, especially in cases dependent on gonorrhoeal 
 inflammation. Sulphate of copper, sulpho-carbolate 
 of zinc, iodine and carbolic acid may also be used. 
 If nitrate of silver is employed, ten drops of a one 
 per cent, solution are first thrown in; the strength of 
 the application is increased by one per cent, each 
 
 5 
 
— . 66 — 
 
 treatment, till it reaches the strength of ten per cent. 
 Copper sulphate and zinc sulpho-carbolate are used in 
 the same strength. In extremely obstinate cases five 
 drops of a mixture of equal parts of iodine and car- 
 bolic acid will be found serviceable. If these injec- 
 tions occasion local symptoms of excessive inflamma- 
 tory reaction, such as pain and continued vesical 
 tenesmus, the strength of the application must not 
 be increased too rapidly. In many cases it will be 
 well not to use solutions of a greater strength than 
 five per cent. When the immediate effect of the 
 injection is to occasion almost unbearable pain, an 
 instillation of cocaine should precede the application 
 of the more powerful drug. If a super-sensitive con- 
 dition of the anterior urethra is present, this may be 
 combatted by means of irrigations of silver nitrate, 
 beginning with a solution of the strength of 1 : 6000, 
 and running it up to 1 : 3000. 
 
 If in spite of the passage of sounds, tender spots, 
 the discharge of blood after instrumentation, and a 
 more or less chronic discharge, denote the presence of 
 ulcerating spots in the anterior urethra, these should 
 be treated by direct applications of a ten per cent, 
 solution of nitrate of silver. This can only be accom- 
 plished by means of the urethroscope. The Otis 
 pattern is the cheapest and the best. 
 
 Heat — Cold. — In some cases the hyperesthesia is 
 best combatted by the prolonged application of cold. 
 This is accomplished by the psychrophor (Fig. 3). 
 
— 67 — 
 
 This instrument may be kept at a low temperature 
 for as long a time as is desired by means of a stream 
 of water constantly flowing through it. The portion 
 of the tube passing through the anterior urethra is 
 not made cold by the liquid which is allowed to flow 
 through, since the latter comes in contact with the 
 external walls of the instrument only in its terminal 
 three inches. This instrument should be as large as 
 
 
 A 
 
 Fig. 3.— Psychrophor. 
 
 can be passed into the urethra without undue stretch- 
 ing. It is introduced until its curved extremity oc- 
 cupies the membranous and prostatic urethra. A cur- 
 rent of cold or hot water is then allowed to pass 
 slowly through the psychrophor, thus maintaining the 
 chamber at its curved end at about the temperature 
 of the water. This instrument is used once every 
 other day for fifteen to thirty minutes, unless it occa- 
 sions grjeat pain, in which case it may be removed 
 
— 68 — 
 
 sooner, and the intervals between each application 
 may be lengthened. 
 
 In cases of atonic impotence characterized by over- 
 sensitiveness to the introduction of the sound, and by 
 premature ejaculations, but without free pus secretion, 
 the passage of cold water through the psychrophor 
 is particularly serviceable. In the paralytic cases, 
 where the posterior urethra is less sensitive than nor- 
 mal, and where erections are feeble or altogether 
 lacking, prolonged hot applications will be found 
 more efficient. 
 
 The prostatic urethra can also be made to experi- 
 ence the beneficial influence of heat or cold, by apply- 
 ing these remedial agents through the rectum. Many 
 of these cases experience marked benefit from the 
 
 Fig. 4.— Rectal Irrigator. 
 
 use of a rectal douche (Fig. 4) ; cold in hypersesthetic 
 cases, or hot where the paralytic stage of the disease 
 is pronounced. The rectal douche is best applied by 
 means of a two-way injecting pipe, which allows the 
 water to flow out as fast as it enters. This douche 
 should be employed once a day, a forcible stream 
 being turned directly against the prostate. . 
 
— 69 — 
 
 Another excellent way of applying heat or cold 
 through the rectum is by the use of the rectal bag. 
 This is constructed very much on the principle of a 
 Barnes' bag, or rather the bag employed for elevation 
 of the bladder in the supra-pubic operation of cystot- 
 omy. It is introduced into the rectum and filled with 
 either cold or hot water in accordance with the 
 special indications of the case. This may be worn 
 for from thirty minutes to two hours at a time, and 
 may be daily employed during the early part of the 
 treatment. 
 
 When the impotence persists after urethral inflam- 
 mation or hyperesthesia has been completely subdued, 
 other methods of treatment must be employed to 
 restore power to the weakened centres and to the 
 muscles concerned in erection and ejaculation. The 
 alternate cold and hot needle spray applied to the 
 genitalia, the perineum, the hypogastric region, the 
 buttocks, the inner surfaces of the thighs, and the 
 lumbar spine, acts as a powerful stimulant to the 
 lumbar centres. It should be applied once daily, pre- 
 ferably in the morning, and should be continued for 
 from two to five minutes. 
 
 Wet packs, sitz baths, in fact a complete hydro- 
 pathic course will sometimes accomplish a cure, but 
 more from improvement in the general health than 
 from any special local action. 
 
 Electricity is one of the most powerful means of 
 stimulating the fagged lumbar centres. It may be 
 
— 70 — 
 
 applied in a variety of ways, and we have yet no 
 clear knowledge on the basis of which we can predict 
 what form of application will be followed by the best 
 results in a given case. Either the galvanic or far- 
 adic current may be employed. It should first be 
 passed the length of the spine, then should be used 
 locally. In its local use one pole, the positive, is 
 placed over the lumbar spine, the other to the peri- 
 neum, the hypogastric region, the anus, or the pros- 
 tatic urethra. The electric brush is exceedingly 
 valuable; it should be swept over the external genita- 
 lia, the hypogastric region, the perineum, buttocks and 
 inner surfaces of the thighs, in fact the regions inner- 
 vated by the nerves which communicate with the 
 hypogastric plexus, and thus with the erection and 
 ejaculation centres. 
 
 Fig. 5.— Rectal Electrode. 
 
 The rectal electrode (see Fig. 5) finds its applica- 
 tion in those cases of atonic impotence, in which the 
 erections are feeble or absent, and the semen dribbles 
 out in place of being ejaculated. The sponge of the 
 positive pole is in this case placed on the perineum, 
 and the entire perineal group of muscles is excited to 
 vigorous contraction by means of the electrode intro- 
 duced into the rectum. The part these muscles play 
 
— 71 — 
 
 in erection has been shown already. I prefer the 
 slowly interrupted faradic current for use in this 
 way. The application should last 15 minutes, and 
 should be repeated every other day. 
 
 By the urethral electrode (Fig. 6) the current is 
 applied directly to the prostatic urethra and its 
 associated muscular fibres. In this case both the far- 
 adic and galvanic current may be employed. The 
 latter should however never be of such strength as to 
 produce a destructive action. 
 
 Fig. 6.— Urethral Electrode. 
 
 Whether it be the psychical effect of electrical 
 apparatus and application, or the tonic influence of 
 the current, I cannot say; but it remains true, that, 
 excepting the results from the direct treatment of 
 demonstrable lesions, the percentage of cures of impo- 
 tence from the use of electricity is greater than that 
 from the use of any other single remedy. 
 
 As an instance of the etfect of electricity the fol- 
 lowing case is cited: 
 
 A. B., a man of leisure, aged 43, masturbated but 
 once in his life, and that at the age of fifteen. He was 
 never excessive in his sexual indulgence, and never 
 had venereal disease. He married at the age of 
 twenty-five, and begat healthy children. From the 
 twenty-fifth to the thirty-fifth year, he practised 
 intercourse on an average of once or twice a week. 
 
— 72 — 
 
 From the thirty-fifth to the fortieth year he was even 
 more abstemious, the intervals between intercourse 
 being considerably longer, this being necessitated by 
 his wife's failing health. In the last year of her life, 
 he abstained from intercourse entirely, though pre- 
 vious to this time he had experienced no diminu- 
 tion in either sexual appetite or power. For a year 
 after her death he continued faithful to her memory; 
 he was then exposed to temptation and yielded. He 
 had what seemed to be a vigorous erection, but ejac- 
 ulation occurred even before contact. The erection 
 at once subsided. Repeated efforts were followed by 
 a like result. The patient shortly drifted into a con- 
 dition of the most profound hypochondriasis, com- 
 plained of languor, feebleness, headache, vertigo, 
 lumbar and hypogastric pains radiating down the 
 thighs, constipation, and the general train of symp- 
 toms from which such patients suffer. He sank into 
 a condition of almost utter despair, meditated suicide, 
 and considered all treatment quite futile to help him. 
 Examination showed his organs to be healthy; his 
 urine normal and his sexual organs without disease. 
 His penis was somewhat undersized — 2f inches in 
 circumference — but admitted a 28 sound without the 
 slightest trouble. The prostatic urethra was unduly 
 sensitive. Examination through the rectum showed 
 a prostate normal in size. The urine contained no 
 pus, and the few shreds found in it were entirely 
 made up of mucus. 
 
— 73 — 
 
 For several weeks the cold sound was passed at 
 intervals of three days, and every six days ten drops 
 of a one per cent, solution of silver nitrate were 
 injected into the prostatic urethra. The diet, sleep, 
 exercise and all conditions of life were most carefully 
 regulated. In two months he had greatly improved 
 in general health, and the erection was entirely nor- 
 mal. Directly against the cautions given him, he 
 now tried his sexual powers and was shocked 
 to find that he was even more impotent than 
 before. Erection failed him entirely, though during 
 the last two weeks of his treatment he had the morn- 
 ing priapism. Strychnia, grain ^V, with phospho- 
 rus, grain ^, were administered three times a day; 
 hot rectal douches were ordered, two quarts of water 
 to be forcibly injected against the prostate once a 
 day. In addition he was told to use for three min- 
 utes every morning a cold and hot needle spray di- 
 rected particularly against the genitalia. Under this 
 treatment sexual power was markedly strengthened. 
 After six weeks another trial of strength was to him 
 at least encouraging, but not satisfactory. He then 
 went to a health resort in the mountains and placed 
 himself in the hands of a physician, who pursued a 
 vigorous tonic and hydropathic treatment, supple- 
 mented by injections of spermine. After several 
 months he returned to the city but little better than 
 when he left. Strychnia and arsenic were now 
 administered, 2V of the former and ^ of the latter 
 
_ 74 — 
 
 three times a day, and the patient was given the 
 electric current, galvanic and f aradic, the poles being 
 applied to the lumbar spine and to the rectum. Under 
 this, his improvement was rapid and marked. He 
 believed that the electricity helped him more than 
 other measures. After some weeks he was able to 
 have connection with almost his pristine vigor, re- 
 peating the act several times in a night. He cast off 
 all his morbid and melancholy forebodings; picked 
 up in weight, became again a cheerful, active mem- 
 ber of society, took to himself a wife, and showed, 
 by subsequent events, that he was both potent and 
 fertile. 
 
PROSTATORRHOEA. 
 
 The term prostatorrhoea is applied to the inter- 
 mittent oozing of the secretion of the prostate gland 
 from the urinary meatus. Although this is merely a 
 symptom of catarrh of the posterior urethra, it is so 
 characteristic of a large class of sexual neurasthenics, 
 that it merits detailed consideration. The running 
 is greater after micturition and during defecation. 
 Some drops of it can be made to flow by digital pres- 
 sure on the prostate through the rectum. It is like 
 white of egg in appearance, or may be somewhat 
 more milky. Microscopic examination shows that it 
 is made up of leucocytes, cylindrical epithelium, 
 concentric amyloid concretions, and Bottcher's sperm 
 crystals. These sperm crystals are quickly formed 
 by adding to the discharge a one per cent, solution 
 of ammonium phosphate and drying on an object- 
 glass. Occasionally blood is found, but this is nearly 
 always due to involvement of the seminal vesicles. 
 
 This discharge is nearly always associated with 
 marked sexual neurasthenia. It depends for its 
 existence upon a chronic catarrh of the prostatic ure- 
 thra, including the sinuses, ducts and follicles. The 
 examining finger in the rectum usually shows no en- 
 largement of the organ; not infrequently, however, 
 distinct nodular indurations can be felt in the inflamed 
 follicles. 
 
— 76 — 
 
 The hyper-secretion is constant, but does not flow 
 steadily from the meatus, because this is prevented by 
 the tonic contraction of the compressor urethrae mus- 
 cle. When this muscle is weakened, or when its 
 resistance is overcome, as by the passage of hardened 
 faeces through the rectum, the discharge will then 
 flow forward. 
 
 The patient always regards this discharge as semen, 
 and suffers from the psychical effects which reading 
 or hearsay has led him to believe are appropriate to 
 such a condition. 
 
 Since prostatorrhoea is dependent upon a chronic 
 catarrh of the prostatic urethra, its causes can be 
 traced to whatever brings about such catarrh. Of 
 these, gonorrhoea, masturbation and prolonged and 
 ungratified sexual desire undoubtedly are most com- 
 mon. Among others occasionally encountered may 
 be mentioned acute congestion dependent upon cold; 
 direct traumatism; infection as by the passage of a 
 dirty sound; the ingestion of certain irritating sub- 
 stances, such as turpentine or cantharides, or the 
 presence of a diathesis, such as rheumatism, which may 
 render the urine irritating. 
 
 In the gonorrhceal cases particularly, the pus cor- 
 puscles are fairly abundant. Very few spermatozoa 
 are found. If many are present constantly, the con- 
 dition is rather one of spermatorrhoea. 
 
 The clinical symptoms of prostatorrhoea are fairly 
 characteristic. There is a typical discharge — in sim- 
 
pie catarrhal cases unaccompanied by pain; in in- 
 flammatory cases, that is those approaching in type 
 follicular prostatitis, accompanied by pain in the deep 
 urethra, with tenderness in the perineum and some- 
 times the appearance of blood after urination. 
 
 The persistent discharge is usually associated with 
 marked change in temperament and bodily vigor. 
 
 Those unfortunates, the subjects of prostatorrhcea, 
 may suffer from any or all of the neuroses discussed 
 under the heading of atonic impotence. The local 
 symptoms beyond the discharge are commonly limited 
 to a sensation of liquid trickling along the canal; 
 tickling sensations far back; frequent urination and 
 some urgency in performing the act; reflex pains and 
 aches in the rectum, the hypogastrium, the small of 
 the back, and down the inner surface of both thighs. 
 All these pains are greatly aggravated by prolonged 
 standing, and are usually associated with a distinct 
 lessening of sexual power, so that emissions are pre- 
 mature, erections are feeble, or even may be quite 
 wanting at the critical time. In some cases, beyond 
 the prostatic discharge, there are no symptoms. 
 
 A fairly typical history of a case of prostatorrhcea 
 is as follows: 
 
 A. B., aged 18, student, was always healthy, and 
 had a good family history; never had venereal dis- 
 ease and was chaste in his conduct with the opposite 
 sex. From the thirteenth to the sixteenth year he 
 masturbated. He then stopped entirely. For one 
 
— 78 — 
 
 year he has been much worried about the condition 
 of his penis. He thinks it is too small; feels running 
 sensations through it at times; has not the power of 
 forcibly expressing the last few drops of urine, so 
 that there is some dribbling, and has nocturnal pollu- 
 tions about twice a month. He states that for some 
 months there has been, after the end of each urina- 
 tion a sticky, transparent drop, which hangs to the 
 meatus. This drop also appears after straining at 
 stools. He suffers from occasional pains in the back, 
 over the hypogastrium and down the inner surface of 
 the thighs. He passes water four times a day, and 
 rises once in the early morning to do this. Sometimes 
 he passes it more frequently, and suffers from 
 urgency. Before the beginning of his local troubles 
 he was exposed to prolonged, ungratified sexual 
 excitement. 
 
 The patient has not had normal erections lately, 
 but experienced normal desires for women, and on 
 appropriate stimulation had violen f [erection. He 
 complains of loss of memory, dull, heavy feelings 
 and a constant sense of fatigue. His mental suffer- 
 ing was accentuated by the fact, that he fancied the 
 flaccid penis should be about as movable in the nor- 
 mal person, as is the tail in the dog, and that he was 
 suffering from paralysis. 
 
 Examination of the urethra showed the absence of 
 stricture, but an excessively sensitive posterior ure- 
 thra. Rectal examination showed a prostate normal 
 
— 79 — 
 
 in size and slightly lobulated. Pressure upon the 
 gland caused several drops of prostatic fluid to flow 
 from the meatus. Microscopic examination of this 
 showed the typical discharge containing the concen- 
 tric amyloid bodies, without admixture either of pus 
 or spermatozoa. 
 
 After some weeks treatment by means of the cold 
 sound and instillations of weak solutions of nitrate 
 of silver, this patient entirely recovered. He no 
 longer had discharge of any fluid, was able to ride 
 horseback without experiencing any return of his 
 trouble, and appeared quite normal in every way, re- 
 suming his work with what was to him new vigor. 
 
 The prognosis of prostatorrhtea is as a rule very 
 good. The cases which present themselves are 
 usually derived from three classes: 
 
 1. Those suffering from the remains of an uncured 
 gonorrhoea. These represent mostly city men of 
 loose morals; 
 
 2. Men who have been the subjects of prolonged 
 ungratified sexual desire. These usually represent 
 countrymen, who, from reasons founded on morality 
 or from fear, resist, but do not flee temptation; 
 
 3. Half-grown or grown boys, who have been given 
 to inordinate masturbation, to lascivious reading and 
 to long brooding on sexual subjects. These are 
 drawn from either the city or country, are usually 
 of medium intelligence, often have in them germs of 
 disease such as tuberculosis, hereditary syphilis, etc. 
 
— 80 — 
 
 Patients belonging to the first two classes are cured 
 with but few exceptions, provided they can spare the 
 time necessary for treatment, and exert the self-con- 
 trol required by strict observance of the orders given 
 them. 
 
 Patients of the third class, though younger in 
 years, and hence a priori easier to cure, often do not 
 yield to treatment. This is probably because their 
 habit has such a hold upon them, that they cannot 
 overcome it, and because, being usually of weak con- 
 stitution, their recuperative power is slight. I am 
 certain that I have seen some of these cases distinctly 
 aggravated by vigorous treatment; each application 
 or mechanical interference acting as a shock to the 
 enfeebled constitution, from which reaction was slow 
 and imperfect. 
 
 Treatment. — Since the underlying lesion in these 
 cases is catarrh of the mucous membrane of the pros- 
 tatic urethra, this catarrh extending into the ducts 
 and glands, the treatment of prime importance is 
 that directed to the subduing of such catarrh. 
 
 Several times I have seen a prostatorrhcea of long 
 standing cured, by the observance of general hygie- 
 nic rules, and the ingestion of food and medicine cal- 
 culated to correct an abnormal condition of the urine. 
 
 The bowels must be opened regularly; fluid extract 
 of cascara, or better than this a teaspoonful of sul- 
 phate of magnesia in a quarter of a glass of water, or 
 a claret glass of hunyadi on rising in the morning, 
 will be found serviceable. 
 
— 81 — 
 
 The bathing must be regulated. Where the patients 
 are vigorous and cold water suits them, showers or a 
 plunge in the morning maybe recommended. If the 
 patients are feeble, a hot plunge bath is advisable. 
 
 Exercise must be prescribed. In some cases bi- 
 cycle riding or horseback exercise distinctly aggra- 
 vates the condition. This is particularly the case, 
 when there is a low grade of follicular prostatitis; that 
 is, when in addition to the catarrhal process the paren- 
 chyma of the gland is more or less involved. In other 
 cases such exercise is particularly serviceable, produc- 
 ing on the prostate the effect of massage, increasing 
 the tonicity of its blood vessels and materially les- 
 sening the quantity of discharge. 
 
 Stimulants must be tabooed except at meals, and 
 then they should be taken in moderation. 
 
 The clothing must be regulated in accordance with 
 the weather, and the feet must be protected from the 
 damp, since chilling of the surface exerts a particu- 
 larly bad effect upon inflammations about the neck of 
 the bladder. 
 
 Medical treatment, though of minor importance, 
 should not be neglected. Among the most useful 
 drugs are those which in their elimination stimulate 
 the prostatic mucous membrane. Oil of sandalwood 
 has seemed to me more valuable in its effects than 
 all the other remedies of this class. It may be given 
 encapsulated, in ten-minim doses three times a day, 
 one hour after each meal. Cubebs, copaiba, turpen- 
 
— 82 — 
 
 tine, cantharides in small doses, all have been highly- 
 recommended; belladonna is serviceable where there 
 is irritability of the bladder; indeed it and its alka- 
 loid atropia are held in high esteem by those most 
 experienced in this class of cases. Bromide of potas- 
 sium frequently is most useful, particularly where 
 there is intense hyperesthesia, and where general 
 neurasthenia is well marked. As general tonics the 
 compound syrup of the hypophosphites in teaspoon- 
 ful doses, cod-liver oil with iodide of iron, and 
 iron and nux vomica in combination are to be recom- 
 mended. 
 
 The local treatment is the one on which main 
 dependence must be placed. This is designed to 
 cure catarrh and to allay hyperesthesia. The various 
 methods of treatment have been already described 
 under Atonic Impotence. 
 
 The use of soluble prostatic bougies has not given 
 me as satisfactory results as have instillations. If 
 bougies are employed, the more strongly astringent 
 ones are to be preferred. Each bougie may con- 
 tain some such prescription as this: Zinc sulphate, 
 grains ii; carbolic acid, grains ii; fluid extract of hy- 
 drastis, m xv. These bougies are introduced by 
 means of a special carrier, and are perhaps most use- 
 ful, when the patient is himself compelled to continue 
 his treatment. 
 
 Occasionally the prostatic dilator (Fig. 7) will be of 
 service. It has seemed to me to accomplish its good 
 
83 
 
 effect by mechanically emptying the 
 diseased follicles of their contents, and 
 thus allowing the instillation, which 
 should always follow the dilatation, to 
 gain access to every part of the mucous 
 membrane. This is a means of treat- 
 ment which should not be repeated 
 more than once in ten days, and which 
 should be practised with caution. 
 Stretching should not be less than 36 
 of the French scale, nor more than 44. 
 Full dilatation of the prostatic urethra 
 by means of the steel sound is impossi- 
 ble, since an instrument sufficiently 
 large to overstretch the membranous 
 urethra, fits loosely in the physiologi- 
 cally wider prostatic portion of the tube. 
 Gross and others hold that flying blis- 
 ters to the perineum are extremely valu- 
 able. Personally I have never seen 
 marked beneficial effects follow their 
 use. They often occasion considerable 
 inconvenience or even actual suffering- 
 Electricity is often of service. The 
 proper current for any individual case 
 cannot be formulated. The galvanic 
 current, one pole applied to the lum- 
 bar spine, the other to the prostatic 
 urethra by means of a properly ar- 
 
— 84 — 
 
 ranged urethral electrode, is perhaps most popular. 
 I have, however, in some cases, particularly in those 
 where coincident with prostatorrhoea there was a very 
 marked failure of sexual power, seen much more rapid 
 effects from the farad ic current. 
 
 In nearly all cases sexual intercourse must be 
 interdicted. When the disease occurs as the result 
 of over-indulgence upon the part of married men, 
 after a brief period of abstinence moderate inter- 
 course may be allowed, since total prohibition may 
 keep the patient in a condition of prolonged and 
 ungratified sexual excitement. This, however, must 
 be determined by the effect produced by intercourse. 
 If this aggravates the discharge, and particularly if 
 it is followed by lassitude and lumbar pains, it must 
 be forbidden absolutely. 
 
 In the majority of cases recovery will follow in 
 from one to three months; sometimes a much longer 
 period is required. 
 
 In some cases local treatment appears to be dis- 
 tinctly aggravating. Here it is advisable, if the 
 patient's circumstances are such as to allow it, to 
 make a complete change in the mode of life. A pro- 
 longed vacation spent in travel or in camping out, or 
 on a shooting expedition will sometimes cure a case 
 which has obstinately resisted local and general treat- 
 ment. 
 
INVOLUNTARY SEMINAL EMISSIONS. 
 
 Involuntary seminal emissions, though properly 
 classed with the symptoms of atonic impotence, as- 
 sume such an importnce in the eyes of patients, and 
 appear in such varying clinical forms that they require 
 detailed consideration. 
 
 Cases suffering from seminal emissions will com- 
 plain of symptoms corresponding to the following 
 classification: 
 
 1. Nocturnal pollution, the result of lascivious 
 dreams, or a local hyperesthesia so marked, that 
 stimuli too feeble to produce any effect in health are 
 sufficient to excite ejaculation of semen. Usually at- 
 tended with vigorous erection and voluptuous sensa- 
 tion. 
 
 2. Diurnal pollution, the result of impure thoughts 
 or of a peripheral irritation too feeble to excite emis- 
 sion in a healthy man. Usually attended with feeble 
 erection or at least one which quickly subsides, and 
 with blunted voluptuous sensation. 
 
 3. Spermatorrhoea, a condition in which the semen 
 oozes from the meatus without erection, and without 
 pleasurable sensation. This loss may be due to im- 
 pure thoughts, or may occur quite independently of 
 appreciable psychical or physical stimulus. The dis- 
 charge flowing as in prostatorrhoea after micturition 
 and during defecation. 
 
 Nocturnal pollution. — An occasional emission dur- 
 ing sleep, once every two weeks for instance, is, in a 
 
— 86 — 
 
 continent men, no sign of undue irritability of the 
 sexual organs. Indeed it is rather to be desired, since 
 it disposes of an accumulated secretion the presence 
 of which is liable to excite disturbing reflexes. In 
 healthy young men who lead idle lives and who are 
 subjected to venereal excitement, these pollutions may 
 occur much more frequently, two or three times a 
 week, and yet indicate no abnormal local condition. 
 It is not uncommon to find healthy men who have no 
 pollution for many weeks; yet after prolonged physi- 
 cal exertion such as is required in an all-day hunt, or 
 a long walk, or without apparent cause, they may 
 have several emissions in a single night. Those who 
 work hard, who sleep and eat sparingly, and who are 
 not exposed to sexual excitement, may be continent 
 for months or years without a single emission. 
 
 Nocturnal pollutions can only be considered as in- 
 dications of seminal weakness when they are unduly 
 frequent, are followed by lassitude and mental de- 
 pression, and particularly when they are associated 
 with partial or complete impotence. 
 
 If such emissions persistently occur three or four 
 times a week, when the surroundings of the patient 
 are such that he is not exposed to prolonged sexual 
 excitement, and if there is a lessening of physical 
 strength, a sense of fatigue, a disinclination for mental 
 effort, it is quite certain that there is an asthenic con- 
 dition of the ejaculation centre brought about reflex- 
 ly or dependent upon systemic causes. 
 
— 87 — 
 
 These unduly frequent nocturnal pollutions are 
 often associated with full sexual vigor. If uncor- 
 rected, however, the erethism of the ejaculatory 
 centre becomes more marked, and there is developed 
 a more or less pronounced form of sexual weakness. 
 
 Diurnal pollutions, or ejaculations as a result of 
 slight psychical or local stimulation, may occur from 
 embracing a woman or even being in the same room 
 with her, from friction of the garments incident to 
 horse-back riding, from the titillation of a shower 
 bath. Indeed, any slight irritation applied to the 
 penis, maybe sufficient to excite immediate ejaculation. 
 I saw one man in whom the act of retracting the pre- 
 puce for the purpose of cleanliness invariably excited 
 ejaculation; the passage of a meatus bougie caused 
 the same result. In another case a digital examina- 
 tion of enlarged inguinal glands was sufficient to 
 excite an erection and ejaculation. The reading of 
 lascivious literature, the hearing of lewd stories, or 
 the simple imaginings of sexual relations are sufficient 
 to excite an orgasm. The erections when this con- 
 dition of erethism is developed, are usually feeble, 
 exceptionally they are vigorous, but subside promptly 
 when emission has taken place. 
 
 Spermatorrhoea. — The erection and emission cen- 
 tres, though distinct from each other, are so closely 
 related physiologically, that erethism and adynamia of 
 one imply a like condition of the other; hence in the 
 most aggravated form of sexual weakness, the semen 
 
— 88 — 
 
 is discharged without pleasurable sensation and with- 
 out erection, oozing from the urethra, instead of being 
 ejaculated by rhythmic muscular contraction. This 
 oozing may occur as a result of sexual excitement or 
 local irritation. The sight of a woman may cause it, 
 or it may be due to the jolting of a wagon or to in- 
 tentional friction. The following case sent me from 
 the country well illustrates this phase of seminal 
 weakness. 
 
 A. B., aet. 26, masturbated furiously when sixteen 
 years of age; this he continued for one year, then 
 stopped entirely. Following his excess in this direc- 
 tion, he was troubled with frequent nocturnal pollu- 
 tions, three or four a week. This continued for some 
 years, when he began to notice that attempts at in- 
 tercourse were not satisfactory, erection was imper- 
 fect and ejaculation premature. In the last year 
 seeing or touching a lewd woman at once excited an 
 emission, unattended with pleasurable sensations and 
 without erection. There was no discharge from the 
 penis after urination or defecation, no stricture, 
 nothing abnormal except a very small penis. He 
 stated that his morning erections were vigorous. 
 This last statement in regard to the morning erection, 
 if true, offers an exception to the general rule, for as 
 such cases belong to the paralytic type, the erection 
 centre and the muscles innervated by it, and the 
 plexuses anastomosing with it, are too much exhaust- 
 ed to react fully to the irritation of a full bladder. 
 
— 89 — 
 
 This patient under rectal douches, bougies, pos- 
 terior instillations and tonic treatment, recovered 
 sufficiently to break through the strict order in regard 
 to chastity and fornicate repeatedly. This act he 
 was able to accomplish, but from constant trials of his 
 strength did not regain full power, and finally dis- 
 appeared. 
 
 Spermatorrhoea, in the sense of a constant flow of 
 semen from the urethra after urination, during defe- 
 cation, and at odd times, spermatozoa also being found 
 in the urine, is very rare. Exceptionally a vigorous 
 man, who has been given to masturbation, or exces- 
 sive fornication, and who stops suddenly, will, in 
 place of frequent nocturnal pollutions, be troubled 
 with mucous discharge, which on examination will be 
 found to contain many spermatozoa; this represents 
 an overflow from the seminal vesicles due, no doubt, 
 to temporary paresis of the muscular fibres of their 
 ejaculatory ducts. It is, however, not associated with 
 loss of virile power, and though observed in those 
 who exhibit a mild degree of sexual hypochondriasis, 
 it is a condition which under appropriate treatment 
 promptly subsides. I have seen but one case of true 
 spermatorrhoea. This was as follows: 
 
 A. B., clerk, aged thirty -tw 7 o, addicted to mastur- 
 bation for twelve years; has never had connection 
 with a woman and feels for women no natural desires. 
 During the last two years he has had a constant 
 running from the penis, aggravated on urination and 
 
— 90 — 
 
 defecation. He has frequent nocturnal pollutions; 
 these do not wake him, and he is only aware of them 
 from finding the stains on his garments. During 
 defecation (especially if he is slightly constipated) the 
 discharge is pronounced, has a seminal odor, and 
 slightly pleasurable sensations are experienced during 
 its flow. This discharge runs from the penis in drops 
 without erection. Four years ago the patient noticed 
 that morning erections were absent and priapism did 
 not result from libidinous thoughts. Later, in the last 
 two years, libidinous thoughts caused running of 
 sperm-like fluid from the penis without marked pleas- 
 urable sensations. For the last year he has had no 
 erection. Friction of the glands produced discharge 
 of a whitish fluid. 
 
 The patient was in appearance a typical m.astur 
 bator. He was small, emaciated, hollow-chested 
 thin-necked, weak-kneed, shambling in his gait, 
 careless in his dress and person. In his deep-set 
 eyes rested the shadow of despair. His pale, hollow 
 cheeks, and general expression of moral abasement, 
 were sufficiently indicative of the practice which had 
 brought him to his condition. His penis and testi- 
 cles were unusually small. The penis was cold, 
 shriveled and almost cartilaginous in its density. 
 Examination of his urine showed large quantities of 
 spermatozoa and oxalates in abundance. The fluid 
 discharged during stool and after urination was 
 swarming with spermatozoa. He complained of all 
 
— 91 — 
 
 the various reflexes with which these patients are 
 afflicted, headache, loss of memory, tinnitus aurium, 
 bad taste in the mouth, wind on the stomach, obsti- 
 nate constipation, palpitation of the heart, shortness 
 of breath, colicky pains, backache, uncontrollable 
 restlessness, pains in the hypogastrium running down 
 the thighs, burning in the anus, etc. Application of 
 the porte caustique to his prostatic urethra stopped his 
 discharge. 
 
 He was lost sight of, however, before any return 
 of sexual power was noted. 
 
 The causes of involuntary seminal emissions are the 
 same as those which excite catarrh of the posterior 
 urethra and prostatorrhoea. The lesion produced is in 
 the first place hyperemia or inflammation of the 
 prostatic urethra. This leads to hypersensitiveness 
 of the erectile and ejaculatory centres, followed by 
 adynama, or exhaustion. Of the most frequent causes 
 may be mentioned prolonged and ungratified sexual 
 excitement, masturbation and sexual excess, gonor- 
 rhoea! inflammation, exhaustion from overwork, anx- 
 iety or grief; or from constitutional conditions, such 
 as acute fevers or consumption in its early stages; 
 organic lesions of the central nervous system, such as 
 are observed in bulbar paralysis; the abuse of drugs, 
 such as alcohol and opium; reflex irritation from the 
 penis, such as that due to phimosis or herpes of the 
 prepuce, or narrow meatus; reflexes from the anus and 
 rectum, such as are dependent on fissures, piles, 
 
— 92 — 
 
 polypi, or irritation incident to worms or to skin 
 eruptions or obstinate constipation. 
 
 The diagnosis of spermatorrhoea must be founded 
 on microscopic examination. If the sperm-like dis- 
 charge, which flows during defecation, after urination 
 and at other times, on repeated examination is found to 
 contain a few spermatozoa, never in great numbers, it 
 may be concluded that the case is one of prostatorrhcea. 
 If, however, spermatozoa are very numerous in this 
 discharge, and are nearly always found, the case is one 
 of spermatorrhoea. However, the differential diagnosis 
 is not very important, since the treatment of the 
 aggravated forms of both affections is much the 
 same. 
 
 The prognosis in these cases is fairly good, when 
 there is no organic lesion of the central nervous sys- 
 tem, and when the patient still possesses determina- 
 tion enough to help the physician. Some cases im- 
 prove rapidly under very simple treatment, particu- 
 larly that directed to subduing the hypersensitive- 
 ness of the prostatic urethra. Others, however, 
 yield not at all. In these cases it is possible that 
 the centres are permanently injured or that changes 
 have taken place in the secreting and excreting ap- 
 paratus too gross to be repaired. 
 
 The treatment of nocturnal pollutions must be 
 partly psychical. The great majority of patients 
 consulting physicians in regard to this condition, 
 have in reality emissions no oftener than are consis- 
 
tent with perfect health. From reading misleading 
 literature, however, the patient fancies that the loss 
 is producing a disastrous drain on his system, and is 
 apt-to suffer from symptoms which he judges would 
 be commensurate with this loss. The physiology of 
 such pollutions should be clearly explained; the life 
 should be regulated according to hygienic principles; 
 the patient should be cautioned against thoughts of a 
 libidinous nature, against everything which is liable 
 to cause sexual excitement. He should have his 
 bowels opened at night before retiring, either by cold 
 enema, or by means of salts taken during the day, until 
 the habit of evacuation at this time is acquired. He 
 should sleep on a rather hard bed, lightly covered. 
 He should avoid sleeping on his back, and this may be 
 managed by securing a band about the waist con- 
 taining a block so placed that it presses on the spine 
 when the patient assumes the dorsal decubitus; thus 
 sleep is disturbed. Furthermore the patient should 
 train himself to wake once during the night and 
 empty his bladder, and before retiring practise light 
 calisthenic exercises and take a cold or cool sponge 
 bath. 
 
 When, in spite of these precautions, erections and 
 emissions occur, the patient should adjust a ring to 
 the penis, so arranged, that when this organ becomes 
 congested, the sharp teeth with which the outer band 
 is set around press upon the skin and disturb sleep. 
 (See Fig. 8.) 
 
— 94 — 
 
 All sources of reflex irritation must be carefully 
 sought for and removed; thus the rectum should be 
 examined for fissure and hemorrhoids. The possi- 
 bility of ascarides must be considered. In cases of 
 phimosis, circumcision should be performed. Narrow- 
 ings of the meatus must be cut; strictures further 
 back must be divided or dilated; hyperesthesia or 
 hyperemia of the prostatic urethra must receive the 
 treatment described in discussing atonic impotence. 
 Varicocele or hydrocele, if present, should be cured. 
 
 Fig. 8.— Pollution Ring. 
 
 Though the local treatment is perhaps of prime 
 importance, general treatment must not be neglected. 
 When the nocturnal pollutions are very frequent, 
 bromide should be administered in full doses, 30 to 90 
 grains at bed-time. Bartholow particularly recom- 
 mends the mixture of this drug with the fluid extract 
 of gelsemium in 10-drop doses. Atropine, grain -g-i-g-, 
 three times daily with twice this quantity given at 
 bed-time; hyoscine, grain -g-^-g- to grain r | T at night; 
 lupulin, grains xx, three times a day; monobromate 
 of camphor, warmly commended by Hare, 5 grains 
 
— 95 — 
 
 in pill form three times a day; antipyrin, grains xv, 
 three times a day. Each of these drugs may, in in- 
 dividual cases, serve as a powerful auxiliary in accom- 
 plishing a cure. 
 
 In the cases which have progressed to the point of 
 diurnal pollutions, local treatment is of special im- 
 portance. In addition to the posterior instillations, 
 and the solid stick of silver nitrate applied by the 
 
 x . 'Jim an. '^zzzrrrrr-^zzzzi 
 
 JCJlBWT.V'=:s=._ 
 
 Fig. 10.— Porte Caustique. 
 
 porte caustique (Fig. 10), the patient should receive 
 hot rectal douche^, the hot and cold needle spray to 
 the external genitalia, perineum and lumbar region, 
 and the galvanic and f aradic current over the lumbar 
 spine, in the rectum, and in the prostatic urethra. 
 
 The first effect of electricity is to aggravate symp- 
 toms; shortly improvement sets in, and is generally 
 marked. 
 
 Of the drugs to be employed in the paralytic form 
 of seminal incontinence, those should be chosen, 
 which tend to restore tone to the weakened muscles, 
 and to revitalize the exhausted lumbar centres. 
 Among the drugs which have been found most effica- 
 cious are the following; the dose named is that 
 
— 96 — 
 
 appropriate to each administration, when the medi- 
 cine is ordered to be taken three times a day: Strych- 
 nia, grain 2V alone or in combination as found in 
 the compound syrup of the hypophosphites a tea- 
 spoonful; fluid extract of ergot a teaspoonful; arsen- 
 ious acid, grain ttj to grain *V; extract of damiana, 
 grains iii to grains v a day; phosphorus, grain jws. 
 
IMPOTENCE OF THE FEMALE. 
 
 If we adopt the same classification as was observed 
 in discussing impotence and sexual weakness in the 
 male, this affection, as observed in the female, 
 must be limited to cases of malformation either 
 hereditary or acquired, to obstruction from new 
 growths and to muscular spasm, since in the case of a 
 woman performance of the sexual act, at least in so- 
 far as her partner is concerned, requires only the 
 presence of a sufficiently long and patulous mucous 
 canal. 
 
 From the standpoint of the woman, however, fail- 
 ure to experience an orgasm, after what may be 
 regarded as sufficient mechanical stimulus, represents 
 a common form of impotence. 
 
 Impotence in the female may be classified under 
 the following heads: 
 
 1. Intromission of the male organ is impossible. 
 
 2. Intromission is possible, but causes extreme 
 pain. 
 
 3. Intromission is possible, and does not occasion 
 pain, but the mechanical and psychical stimulus is not 
 sufficient to excite orgasm. 
 
 1. Intromission of the male organ may be impos- 
 sible, because of obstructive pathological conditions 
 of the vulva and vagina; these may be congenital or 
 acquired. 
 
 The congenital anomalies may take the form of 
 
— 98 — 
 
 absence of the vagina; extreme narrowing of this 
 tube, or its division into two parts, each too small 
 to allow of intromission; or the vagina may have its 
 outlet in an abnormal position; thus it sometimes be- 
 comes continuous with the rectum. 
 
 On the part of the vulva there may be adhesions of 
 the greater or smaller lips; there may be hypertrophy 
 of the labia? or clitoris, or, what is perhaps the most 
 frequent congenital cause of obstruction to sexual 
 relations, there may be a rigid or imperforate hymen. 
 
 Barring the absence of the vulva and vagina and 
 the presence of an imperforate hymen, nearly all of 
 these conditions may be brought about by injury or 
 disease. Thus extreme atresia may result from acute 
 inflammation; elephantiasis may cause such swelling 
 of the labia? that sexual approach is impossible; gan- 
 grene, or extensive ulceration, may practically close 
 the vulva. Deformity, the result of disease, such as 
 coxalgia or spinal disease may render approach almost 
 impossible. 
 
 Treatment of impotence, when it depends upon 
 congenital absence of the vulva or vagina is, of course, 
 of little avail. In cases of narrowing, continued dila- 
 tation may bring about a cure. In at least one case 
 where the vagina opened into the rectum, the woman 
 became pregnant. 
 
 Rigid or imperforate hymen, adherence of the 
 labise, mechanical obstruction offered by tumors can 
 of course be relieved only by surgical operation. 
 
— 99 — 
 
 2. In women with whom intromission is possible but 
 who suffer such pain that all voluptuous sensations 
 are abolished, there may be some demonstrable path- 
 ological condition such as inflammation or malposi- 
 tion, or the most careful search may fail to find the 
 slightest sign of abnormality beyond intense hyper- 
 esthesia. 
 
 All acute inflammation about the vulva, vagina, 
 rectum, uterus or ovaries may render sexual approach 
 painful. Urethral caruncles and urethritis, fissures at 
 the neck of the bladder, hemorrhoids or rectal fissures, 
 ulcerations or displacement of the womb, inflamma- 
 tion of the fallopian tubes, disease or prolapse of the 
 ovaries, are frequently observed as causes of this con- 
 dition. At least, when such lesions are cured by ap- 
 propriate treatment, the pain attendant on sexual rela- 
 tion disappears and normal voluptuous sensations are 
 experienced. 
 
 As a consequence of the pain excited by efforts at 
 intromission, there sometimes occurs an involuntary 
 tetanic spasm of the perineal muscles, termed vagin- 
 ismus. This renders the sexual act extremely diffi- 
 cult, and sometimes makes it quite impossible, even 
 though the male possess a vigorous erection and bru- 
 tal insistence. It is observed particularly in hysterical 
 females. Not only the sphincter vagina? and transverse 
 perinei, but the sphincter and levator ani and also the 
 involuntary muscles of the vagina are involved. As a 
 result the orifice and vaginal canal tightly close, and 
 
— 100 — 
 
 any attempt to overcome the muscular resistance 
 occasions intolerable pain. 
 
 Occasionally this condition comes on after intro- 
 mission is effected. In such cases it is quite possible 
 for the male organ to be so tightly imprisoned that 
 release is not accomplished until ether is administered 
 to the female. Several such cases are reported in lit- 
 erature, and one recently occurred under the care of a 
 medical friend. 
 
 Though this condition is usually classed among the 
 pure neuroses, there is usually some source of irrita- 
 tion, which if treated relieves the condition. Rarely, 
 hyperesthesia of the vaginal mucous membrane seems 
 to be the sole cause of spasm. 
 
 The treatment of these cases depends for its suc- 
 cessful issue upon the cure of the abnormal conditions 
 which give rise to pain and excite reflexes. A most 
 careful examination of the entire genito-urinary tract 
 must be made. Lesions or displacements of appar- 
 ently slight moment must receive treatment. The 
 usual cause of this condition is inflammation, often 
 Assures at the neck of the bladder. The rectum must 
 be explored with the speculum, and ulceration, fissures, 
 or varicose veins must receive surgical attention. If 
 the vaginal introitus is unduly narrow it may be over- 
 stretched under ether. A partially ruptured hymen 
 must be divided. Finally if no lesions are discovered 
 and if the vaginal mucous membrane is hypersesthetic, 
 before sexual approach a ten per cent, solution of 
 
— 101 — 
 
 cocaine should be applied to this canal and its outlet 
 by means of cotten swabs, and the whole mucous 
 surface should be douched daily with hot boric acid 
 solution two quarts, and should be touched once a 
 week with a four per cent, solntion of silver nitrate. 
 
 3. Even though intromission is possible and painless, 
 it is often the case that no orgasm is experienced by the 
 woman. It is undoubtedly true that women, as a rule, 
 are less passionate than men, that many wives and 
 mothers have never experienced an orgasm, that the 
 sexual act is for them merely an expression of conjugal 
 obedience or a means of bearing children, that in 
 itself the whole process is unpleasant or even posi- 
 tively revolting. This depends, not so much upon 
 local conditions, as upon a frigidity mainly inborn, 
 but partly the result of education. 
 
 Many women occasionally experience an orgasm, 
 but usually stop short of this, since their husbands 
 are unable to continue the act for a sufficient length 
 of time. This is sometimes the fault of the man, but 
 more frequently is due to the slow response on the 
 part of the woman. 
 
 In cases such as these local treatment is of little 
 avail ; the impotence can be classed as psychical, and 
 as such must be treated by means of mental impres- 
 sions. Liquor in moderation, rich food, sea air, and 
 caresses may awaken some response, but at most a 
 feeble one. Since sexual desire is dead, pleasure in 
 the sexual act is not to be excited; nor is this to be 
 
— 102 — 
 
 regretted, since such women make good wives, loving 
 mothers, and are not tempted to stray in the paths 
 which the comparatively small number of their more 
 amorous sisters at times find too alluring. 
 
 When an orgasm is experienced only at rare inter- 
 vals, because of a too hasty partner, the remedy lies in 
 allowing longer intervals to elapse between each 
 approach, in making such approaches gradual, and 
 in an effort of the will on the part of the male, by 
 means of which ejaculation may be postponed. The 
 effect of continued efforts in this direction is truly 
 wonderful. I have seen men who stated that they 
 could postpone ejaculation for one or two hours, and 
 there is a religious sect in the state of New York 
 who train their youth so that the intercourse may be 
 continued for many hours without ejaculation. 
 
COCA CORDIAL. 
 
 THE IDEAL HEART STIMULANT AND TONIC! 
 
 This is a palatable preparation combining the medicinal 
 virtues of Coca Erythroxylon. 
 
 Its therapeutic application is manifold: As an Aphrodi- 
 siac, Emmenagogue, Anti-periodic; in Neurasthenia, Dys- 
 pepsia, Exhausting Mental Labor, Nausea and Vomiting, 
 Asthma, Nervous Exhaustion; in overcoming Drunkenness; 
 as a Restorative of the Circulation in Enfeebled Heart; and 
 in many other conditions of Malaise it is invaluable as a 
 Tonic and Stimulant. 
 
 Full information concerning our products afforded on 
 request, and samples to physicians who are willing to pay 
 express charges. 
 
 PARKE, DAVIS & CO., 
 
 Detroit, New York, Kansas City, and Walkerville, Ont. 
 
BUEEETIN "'PUBLICATION^ 
 
 OF 
 
 GEORGE S. DAYIS, Publisher. 
 
 THE THERAPEUTIC GAZETTE. 
 
 A. Monthly Journal of Physiological and Clinical Therapeutics 
 
 EDITED BY 
 
 H. A. HARE, M. D., G. E. DeSCHWEINITZ, M. D., EDWARD MARTIN, M. D. 
 SUBSCRIPTION PRICE, $2.00 PER YEAR. 
 
 THE INDEX MEDICUS. 
 
 A Monthly Classified Record of the Current Medical Literature of the World. 
 
 COMPILED UNDER THE DIRECTION OF 
 
 DR. JOHN S. BILLINGS, Surgeon U. S. A., 
 
 and DR. ROBERT FLETCHER, M. R. C. S., Eng. 
 
 SUBSCRIPTION PRICE, $ 1 O.OO PER YEAR. 
 THE AMERICAN LANCET. 
 
 EDITED BY 
 
 lej9le,tus oonsrnsroie,, im:. jd. 
 
 A MONTHLY JOURNAL DEVOTED TO REGULAR MEDICINE. 
 SUBSCRIPTION PRICE, $2.00 PER YEAR. 
 
 THE MEDICAL AGE. 
 
 EDITED BY 
 
 IB. SKT. ZF^UM^EIR, _A._ IM., IM. ID. 
 
 A Semi-Monthly Journal of Practical Medicine and Medical News 
 
 SUBSCRIPTION PRICE, $t.OO PER YEAR. 
 
 THE WESTERN MEDICAL REPORTER. 
 
 EDITED BY 
 
 J-. IE- HA.EPER, .A.. HUT.., HUE. JD. 
 
 A MONTHLY EPITOME OF MEDICAL PROGRESS. 
 
 SUBSCRIPTION PRICE, $I.OO PER YEAR. 
 
 THE BULLETIN OF PHARMACY. 
 
 EDITED BY 
 
 IB. -W- ZE^AJLZVTJEIR, A.. DVE., 3VE- 15. 
 
 A Monthly Exponent of Pharmaceutical Progress and. News. 
 
 SUBSCRIPTION PRICE, $ 1 .OO A YEAR. 
 
 New subscribers taking more than one journal, and accompanying subscription 
 by remittance, are entitled to the following special rates: 
 
 GAZETTE and AGE, $2.50 ; GAZETTE, AGE and LANCET. $4.00 ; LANCET 
 and AGE, $2.50 ; WESTERN MEDICAL REPORTER or BULLETIN with any of 
 the above at 20 per cent, less than regular rates. 
 
 Combined, these journals furnish a complete working library of current medi- 
 cal literature, all the medical news, and full reports of medical progress. 
 
 GEO. S. DAYIS, Publisher, Detroit, Mich. 
 
IN EXPLANATION OF 
 
 Tie Physicians' Leisure Iran. 
 
 This series has been universally commended by the medical press and profes- 
 sion; it represents a new era in the publication of medical books. 
 
 In the belief that these short practical treatises, prepared by well known 
 authors, containing the gist of what they had to say regarding the treatment of 
 diseases commonly met with and of which they had made a special study, sold at a 
 small price, would be welcomed by the majority of the profession, this form of pub- 
 lication was undertaken. 
 
 The books are amply illustrated, and issued in attractive form in durable paper 
 covers, and in cloth. 
 
 PHYSICIANS' LEISURE LIBRARY 
 
 PRICE: PAPER, 25 CT8. PER COPY, $2.50 PER SET; CLOTH, 50 CTS. PER COPY, 
 $5.00 PER SET. 
 
 SERIES I. 
 
 Inhalers, Inhalations and Inhalants. 
 
 By Beverley Robinson, M. D. 
 The Use of Electricity in the Removal of 
 Superfluous Hair and the Treatment of 
 Various Facial Blemishes. 
 
 By Geo. Henry Fox, M. D. 
 New Medications, Vol. I. 
 
 By Dujardin-Beaumetz, M. D. 
 New Medications, Vol. II. 
 
 By Dujardin-Beaumetz, M. D. 
 The Modern Treatment of Ear Diseases. 
 
 By Samuel Sexton, M. D. 
 The Modern Treatment of Eczema. 
 
 By Henry G. Piffard, M. D. 
 
 Antiseptic Midwifery. 
 
 By Henry J. Garrigues, M. D. 
 On the Determination of the Necessity for 
 Wearing Glasses. 
 
 By D. B. St. John Roosa, M. D. 
 The Physiological, Pathological and Ther- 
 apeutic Effects of Compressed Air. 
 
 By Andrew H. Smith, M. D. 
 GranularLidsandContagiousOphthalmia. 
 
 By W. F. Mittendorf, M.D. 
 Practical Bacteriology. 
 
 By Thomas E. Satterthwaite, M. D. 
 Pregnancy, Parturition, the Puerperal 
 State, and their Complications. 
 
 By Paul F. Munde, M. D. 
 
 SERIES II. 
 
 The Diagnosis and Treatment of Haem- 
 orrhoids. 
 
 By Chas. B. Kelsey, M. D. 
 Diseases of the Heart, Vol. I. 
 
 By Dujardin-Beaumetz, M. D. 
 Diseases of the Heart, Vol. II. 
 
 By Dujardin-Beaumetz, M. D. 
 The Modern Treatment of Diarrhoea and 
 Dysentery. 
 
 By A. B. Palmer, M. D. 
 Intestinal Diseases of Children, Vol. I. 
 
 By A. Jacobi, M. D. 
 Intestinal Diseases of Children, Vol. II. 
 
 By A. Jacobi, M. D. 
 
 The Modern Treatment of Headaches. 
 By Allan McLane Hamilton, M. D. 
 
 The Modern Treatment of Pleurisy and 
 Pneumonia. 
 
 By G. M. Garland, M. D. 
 
 Diseases of the Male Urethra. 
 
 By Fessenden N. Otis, M. D. 
 The Disorders of Menstruation. 
 
 By Edward W. Jenks, M. D. 
 
 The Infectious Diseases, Vol. I. 
 By Karl Liebermeister. 
 
 The Infectious Diseases, Vol. II- 
 By Karl Liebermeister. 
 
SERIES III. 
 
 Abdominal Surgery. 
 
 By Hal C. Wyman, M. D. 
 Diseases of the Liver. 
 
 By Dujardin-Beaumetz, M. D. 
 Hysteria and Epilepsy. 
 
 By J. Leonard Corning, M. D. 
 
 Diseases of the Kidney. 
 
 By Dujardin-Beaumetz, M. D. 
 
 The Theory and Practice of the Ophthal- 
 moscope. 
 
 By J. Herbert Claiborne, Jr., M. D. 
 
 Modern Treatment of Bright's Disease. 
 By Alfred L. Loomis, M. D. 
 
 Clinical Lectures on Certain Diseases of 
 the Nervous System! 
 
 By Prof. J. M. Charcot, M. D. 
 
 The Radical Cure of Hernia. 
 
 By Henry O. Marcy, A. M., M. D., 
 LL. D. 
 Spinal Irritation. 
 
 By William A. Hammond, M. D. 
 Dyspepsia. 
 
 By Frank Woodbury, M. D. 
 The Treatment of the Morphia Habit. 
 
 By Erlenmeyer. 
 The Etiology, Diagnosis and Therapy of 
 Tuberculosis. 
 
 By Prof. H. von Ziemssen. 
 
 SERIES IV. 
 
 Nervous Syphilis. 
 
 ByH. C. Wood, M. D. 
 Education and Culture as correlated to 
 the Health and Diseases of Women. 
 
 By A. J. C. Skene, M. D. 
 Diabetes. 
 
 By A. H. Smith, M. D. 
 A Treatise on Fractures. 
 
 By Armand Despres, M. D. 
 Some Major and Minor Fallacies concern- 
 ing Syphilis. 
 
 By E. L. Keyes, M. D. 
 Hypodermic Medication. 
 
 By Bournevifle and Bricon. 
 
 Practical Points in the Management of 
 Diseases of Children. 
 
 By I. N. Love, M. D. 
 Neuralgia. 
 
 By E. P. Hurd, M. D. 
 Rheumatism and Gout. 
 
 By F. Le Roy Satterlee, M. D. 
 Electricity, Its Application in Med'cine. 
 
 By Wellington Adams, M.D. [Vol.1.} 
 Electricity, Its Application in Medicine. 
 
 By Wellington Adams, M.D. [Vol.IL] 
 Auscultation and Percussion. 
 
 Ry Frederick C. Shattuck, M. D. 
 
 SERI 
 
 Taking Cold. 
 
 By F. H. Bosworth, M.D. 
 
 Practical Notes on Urinary Analysis. 
 By William B. Canfield, M. D. 
 
 Practical Intestinal Surgery. Vol. I. 
 
 By F. B. Robinson, M. D. 
 Practical Intestinal Surgery. Vol. II. 
 
 By F. B. Robinson, M. D. 
 
 Lectures on Tumors. 
 
 By John B. Hamilton, M. D., LL. D. 
 
 Pulmonary Consumption, a Nervous Dis- 
 ease. 
 
 By Thomas J. Mays, M.D 
 
 ES V. 
 
 Artificial Anaesthetics and Anaesthesia. 
 By DeForest Willard, M. D., and Dr. 
 Lewis H. Adler, Jr. 
 
 Lessons in the Diagnosis and Treatment 
 of Eye Diseases. 
 
 By Casey A. Wood, M. D. 
 The Modern Treatment of Hip Disease 
 
 By Charles F. Stillman, M. D. 
 Diseases of the Bladder and Prostate. 
 
 By Hal C. Wyman, M. D. 
 Cancer. 
 
 By Daniel Lewis, M. D. 
 Insomnia and Hypnotics. 
 
 By Germain See. 
 
 [Translated by E. P. Hurd, M. D. 
 
SERIES VI. 
 
 The Uses of Water in Modern Medicine. 
 By Simon Baruch, M. D. Vol. 1 . 
 
 The Uses of Water in Modern Medicine. 
 By Simon Baruch, M. D. Vol. II. 
 
 The Electro-Therapeutics of Gynaecol- 
 ogy. Vol. I. 
 By A. H. Goelet, M. D. 
 
 The Electro-Therapeutics of Gynaecol- 
 ogy. Vol. II. 
 By A. H. Goelet, M. D. 
 
 Cerebral Meningitis. 
 
 By Martin W. Barr, M. D. 
 
 Contributions of Physicians to English 
 and American Literature. 
 By Robert C. Kenner, M. D. 
 
 Gonorrhoea and Its Treatment. 
 By G. Frank Lydston, M. D. 
 
 Acne and Alopecia. 
 
 By L. Duncan Bulkley, M. D. 
 
 Fissure of the Anus and Fistula in Ano. 
 By Dr. Lewis H. Adler, Jr. 
 
 The Surgical Anatomy and Surgery of 
 the Ear. 
 By Albert H. Tuttle, M. D., S. B. 
 
 Recent Developments in Massage. 
 By Douglas Graham, M. D. 
 
 Sexual Weakness and Impotence. 
 , By Edward Martin, M. D. 
 
 SERIES VII, 
 
 Appendicitis and Perityphlitis. 
 
 By Charles Talamon, M. D. 
 Cholera. Vol. I. 
 Cholera. Vol.il. 
 
 ByG. Archie Stockwell, M.D.,F.Z.S. 
 Electro-Therapeutics of Neurasthenia. 
 
 By W. F. Robinson, M. D. 
 
 Diagnosis and Treatment of Surgical 
 Affections of the Peripheral Nerves. 
 
 By F. Jenner Hodges, M. D. 
 Deformities of the Foot. 
 
 By B. E. McKenzie, M. D. 
 
 Treatment of Steril ty in the Woman. 
 By Dr. De Sinety. 
 
 Bacterial Poisons. 
 
 By N. Gamaleia, M. D. 
 
 Treatise on Diphtheria. 
 
 By H. Bourges, M. D. * 
 Antiseptic Therapeutics. Vol. I. 
 Antiseptic Therapeutics. Vol. ir. 
 
 By E. Trouessart, M. D. 
 
 Treatment of Typhoid Fever. 
 By Juhet-Renoy, M. D. 
 
 GEORGE S. DAVIS, Publisher, 
 
 '- O- Box 470 
 
 IDetroit, ILv^icli. 
 
BOOKS BY LEADING AUTHORS. 
 
 THE PRINCIPLES AND PRACTICE OF BANDAGING. .. .$ 3.00 
 By Gwilym G. Davis, M. D., Universities of Pennsylvania 
 and Gottingen. 
 
 SEXUAL IMPOTENCE IN MALE AND FEMALE 3.00 
 
 By Wm. A. Hammond, M. D. 
 
 PHYSICIANS' PERFECT VISITING LIST 1.50 
 
 By G. Archie Stockwell, M. D. 
 
 PALATABLE PRESCRIBING 1 .00 
 
 By B. W. Palmer, A. M., M. D. 
 
 A NEW TREATMENT OF CHRONIC METRITIS 50 
 
 By Dr. Georges Apostoli. 
 
 CLINICAL THERAPEUTICS 4. 00 
 
 By Dujardin-Beaumetz, M. D. 
 
 SANITARY SUGGESTIONS (Paper) 25 
 
 By B. W. Palmer, M. D. 
 
 UNUSUAL BARGAIN. —The following three boohs will be sold, for a 
 limited time, at half their regular j)rice. J*rices quoted are strictly 
 net cash with order. 
 
 MICROSCOPICAL DIAGNOSIS $ 1.50 
 
 By Prof. Chas. H. Stowell, M. S. 
 
 UNTOWARD EFFECTS OF DRUGS 1 .00 
 
 By L. Lewin, M. D. 
 SELECT EXTRA-TROPICAL PLANTS 1.50 
 
 By Baron Ferd. von Miiller. 
 
 GEO. S. DA YIS, Publisher, 
 
 P. O. Box 470, 
 
 DETROIT, - - MICH. 
 

fc 
 
■