i.<<$Ai*M •,%*?..'-.« ^f|% IVNOIIVN 3NOIQ3W dO AoVaaM IVNOIIVN 3NI3IQ3W dO NLfl 0S10T5S1 7 •JAL LIBRARY OF MEDICINE 4: \ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR ]3w do Aavaan ivnoiivn snidiosw do Aavaan tvnoiivn gNmaaw do Aavaan ivnoiivn snidiqsw do •JAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE Q_ 33w do Aavaan tvnoiivn 3Ni3ia3w do Aavaan tvnoiivn 3NiDia3w do Aavaan tvnoiivn snidiosw do =7 vlAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR/ ]3w do Aavaan tvnoiivn snidiosw do Aavaan ivnoiivn 3nioio3w do Aavaan tvnoiivn snidiqsw do ; 0 n' ^^ ^ D >JAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR/ :3w do Aavaan tvnoiivn 3Nioia3w do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn snisiosw do MAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR> ]3w do Aavaan tvnoiivn snio.qsw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn SNOiaaw do NLM051095517 national library of medicine national library of medicine national library of medicine 3nidio3w do Aavaan tvnoiivn 3NOia3w do Aavaan ivnoiivn snidicisw do Aavaan tvnoiivn ilfx ! national library of medicine national library of medicine national library of medicine SNioiaaw do Aavaan tvnoiivn 3ni3iq3w do Aavaan tvnoiivn snidiqsw do Aavaan ivnoiivn national library of medicine national library of medicine national library of medicine 3noio3w do Aavaan tvnoiivn snoiqsw do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn □ Q- "O national library of medicine national library of medicine national library of medicine 3NiDiQ3w do Aavaan ivnoiivn snidiqsw do Aavaan tvnoiivn 3nidiq3w do Aavaan tvnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE SNiDiasw do Aavaan ivnoiivn snidiqsw do Aavaan tvnoiivn 3Ni3ici3w do Aavaan tvnoiivn s 'Or A PRACTICAL TREATISE IMPOTENCE, STERILITY ALLIED DISORDERS MALE SEXUAL ORGANS BY SAMUEL W. GROSS, A.M., M.D. PROFESSOR OP THE PRINCIPLES OF SURGERY AND CLINICAL SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; FORMERLY PRESIDENT OF THE PATHOLOGICAL SOCIETY OF PHILADELPHIA; AUTHOR OF A PRACTICAL TREATISE ON TUMORS OF THE MAMMARY GLAND; FELLOW OF AND FORMERLY MUTTER LECTURER ON SURGICAL PATHOLOGY IN THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; FELLOW OF THE ACADEMY OF SURGERY OF PHILADELPHIA, ETC. ETC. '*. a;a. SECOND EDITION, THOROUGHLY REVISED. WITH SIXTEEN ILLUSTRATIONS. -'MXB^ PHILADELPHIA: HENRY C. LEA'S SON & CO., 1883. \a/JA G?7?p Entered according to Act of Congress, in the year 1883, by HENRY C. LEA'S SON & CO., in the Office of the Librarian of Congress, at Washington. DORNAN, PRINTER. P R E F A C E. The rapid exhaustion of a large edition of this work, the favorable comments which it has received from the periodical press, its translation into the Russian language, and the fact that it has been out of print for several months, constitute valid evidence that it has filled the void for which it was originally designed. As was stated in the first edition, of the affections discussed in this brochure at least two—Impotence and Spermatorrhoea—are commonly described as functional diseases of the testicles; while, according to my observations, they usually depend upon reflex disturbances of the genito- spinal centre, and are almost invariably induced or maintained by appre- ciable lesions of the prostatic portion of the urethra, which, as they may not be perceived by the patient, are frequently overlooked by the physician. A more extended knowledge of these pathological facts, it is hoped, will afford a more rational and simple basis for treatment. My aim has been to supply in a compact form practical and strictly scientific information, especially adapted to the wants of the general practitioner, in regard to a class of common and grave disorders, upon the correction of which so much of human happiness depends. In the chapter on Sterility, the abnormal conditions of the semen and the causes which deprive it of its fecundating properties are fully considered—a portion of the work intended to supplement the subject of sterility in the female. From answers to letters addressed to many of the most prominent writers in this country on gynecology, I find that, with few exceptions, the woman alone commands attention in unfruitful marriages. The importance of examining the husband before subjecting the wife to operation will be best appreciated when I state that he is, as a rule, at fault in at least one instance in every six. S. W. GROSS. Philadelphia, i i 12 Walnut Street, June, 1883. CONTENTS. CHAPTER I. IMPOTENCE. PAGE Sect. I.—General observations—Mechanism of erection, . 17-20 Sect. II.—Atonic impotence. A. Atonic impotence from hyperaesthesia and inflam- mation of the prostatic urethra — Etiology — Local effects of masturbation — Masturbation a cause of stricture of the urethra—General effects of masturba- tion—Classification—Clinical history — Neurasthenia —Diagnosis—Prognosis—Local treatment—General treatment, ........ 20-57 B. Atonic impotence without hyperaesthesia of the pros- tatic urethra—Etiology—Treatment, . . 5 7—58 Sect. IIT.—Psychical impotence. Etiology—Prognosis—Treatment, .... 58_6S Sect. IV.—Symptomatic impotence. From the prolonged use of cerebral sedatives and cere- bral excitants—From injuries of the brain and spinal cord—Prognosis—Treatment,.....65-67 Sect. V.—Organic impotence. A. Impotence from abnormal conditions of the penis —From malformations of the penis—From variations in the size of the penis—From adhesion of the penis VI CONTENTS. to the scrotum—From distortion of the penis—From induration of the corpora cavernosa—From gummata of the corpora cavernosa—From calcification of the septum pectiniforme, or corpora cavernosa—From retention of a ball in the corpus cavernosum—From shortness of the frenum — From varix of the dorsal vein of the penis, ....... 67-76 B. Impotence from defects and disease of the testes— From cryptorchidism—From loss of the testes—From progressive atrophy of the testes — From syphilitic orchitis—From tumors and tubercle, 7 7—79 CHAPTER II. STERILITY. Skct. I.—General observations. Composition of the semen—Functions of the prostatic fluid—Spermatozoa — Spermatic crystals — Classifica- tion—Relative frequency in the two sexes, . . 80-87 Sect. II.—Azoospermism. From bilateral anorchidism—From congenital bilateral deficiency of the epididymis and vas deferens—From affections of the testes—From bilateral atrophy of the testes—From parenchymatous orchitis and total disorganization of the substance of the testes—From syphilitic orchitis—From bilateral obliteration of the epididymis and vas deferens—From abnormal con- ditions of the semen —Sexual excesses a cause of infertile semen — Neurasthenia a cause of infertile semen—General diseases a cause of infertile semen- Abnormal density of the semen a cause of sterility —Purulent semen a cause of sterility—Diagnosis- Watery semen—Colloid semen—Catarrhal semen- Prognosis—Treatment, . 8-7-tt? CONTENTS. Vll Sect. III.—Aspermatism. A. Organic aspermatism—From congenital occlusion, and deviation of the ejaculatory ducts—From strict- ure of the ejaculatory ducts, and deviation of their orifices—From obstruction of the ejaculatory canals by sympexions—From stricture of the urethra—From phimosis, . . . . . .113-122 B. Atonic aspermatism—Etiology, 122 C. xVnassthetic aspermatism—Etiology, . . 124 D. Psychical aspermatism — Etiology — Diagnosis of aspermatism—Prognosis—Treatment, . . . 126 Sect. IV.—Misemission. From vices of conformation of the urethra—From mal- position of the meatus—Treatment, . . . . 132 CHAPTER III. SPERMATORRHEA. Classification — Nocturnal pollutions — Diurnal pollu- tions— Spermorrhagia—Clinical history — Etiology — Anatomical characters — Diagnosis — Prognosis— Treatment, ........ 134 CHAPTER IV. PROSTATORRHOZA. Etiology—Clinical history—Prostatic crystals—Patho- logical characters — Diagnosis — Prognosis — Treat- ment, ......... 162 EIST OF lEEUSTRATIONS. i. Exploratory bulbous bougie, 2. Conical steel bougie, 3. Urethral dilator, .... 4. Urethrotome, ..... 5. Syringe and perforated bulbous explorer, 6. Bulbous nozzle, 7. Catheter-syringe, 8. Porte-caustique, 9. Cupped conical steel bougie, 10. Porte-remede, . 11. Psychrophor, 12. Spermatozoa, . 13. Spermatic crystals, 14. Watery semen, 15. Colloid semen, 16. Prostatic crystals, From Ultzmann . Ibid. . Ibid. IMPOTENCE, STERILITY, AND ALLIED DISORDERS OF THE MALE SEXUAL ORGANS. CHAPTER I. IMPOTENCE. Sect. I. General Observations. Impotence, or inability to copulate or perform the sexual act, is one of the most common of the derange- ments of the generative functions, and is due either to deficiency or absence of erection, or to congenital or acquired abnormal conditions of the genital organs, which render intromission of the penis impracticable. Hence, men who are impotent are usually sterile, the power of procreating children being dependent upon that of having connection; but as sterility, in the strict acceptation of the term, implies non-ejaculation, or emission of infertile semen, it will be discussed in a separate chapter. For a clear comprehension of the pathology of the most frequent forms of impotence, a knowledge of the mechanism of normal erection and of the nervous centres which preside over it is essential. Erection consists in augmentation of the volume, in 2 18 IMPOTENCE. stiffness, and in rigidity of the penis, and is due to an increased flow of blood into that organ, as has been experimentally demonstrated by Eckhard.1 Loven,2 who extended the investigations of Eckhard, was, however, the first to show, in opposition to former theories, that the essential factor in the phenomenon is active dilatation of the arterioles of the cavernous and spongy bodies, and not merely a stasis of blood produced by constriction of the veins, although it is certain that erection is strength- ened by obstruction to the outflow of the blood through the dorsal vein by the contraction of the anterior fibres of the accelerator urinse muscle or the compressor venae dorsalis of Houston. The nerves concerned in the production of erection in the dog, and there is no reason to doubt their existence in man, arise, according to Eckhard, by two roots at the sacral plexus from the first to the third sacral nerves. Electrical stimulation of these, the erigent nerves, is fol- lowed by erection and ejaculation, while their division renders erection and emission impossible. Eckhard, moreover, produced erection by excitation of the lumbar, and lower and upper segments of the cervical spinal cord, the pons, and the crura cerebri, from which he inferred that the fibres of the erigent nerves which con- vey the impressions for erection arose in the cerebrum, and passed down through the crura and the pons to the cord. Goltz,3 however, discovered that, after the separa- tion of the lumbar segment of the cord from its upper portion, irritation of the glans penis provoked a full 1 Beitrage zur Anat. und Phys., Bd. iii. p. 125, and Bd. vii. p. 67. 2 Arbeiten aus der Phys. Anstatt zu Leipzig, 1866, p. i. 8 Pfluger's Archiv, Bd. viii. p. 460. MECHANISM OF ERECTION. 19 erection, from which he concluded that the lumbar cord constituted an independent reflex centre for the genital functions; and, what is important in the study of psy- chical impotence, he demonstrated that this centre could be acted upon inhibitorily from the brain. From the preceding considerations it is obvious that erections in the lower animals can be produced by stim- ulation of the brain, the spinal cord, and the peripheral nerves; and ample observations, both in health and disease, demonstrate that they originate in the same localities in man. The influence of certain emotional conditions of the mind over erection is illustrated by its being induced by sexual desires, or even by the sight or thought of certain women; while it may be arrested or prevented by mental preoccupation, or by depressing emotions, as fear of inability to consummate the vene- real act, the loss of the object of one's affections, modesty, disgust, or frigidity. Irritation of the cord, and particularly of its cervical portion,1 from disease, concus- sion, effusion of blood, or fracture or dislocation of the vertebrae, frequently occasions erections; and these may constitute the first sign of incipient ataxia,2 or general paralysis of the insane, and other spinal affections. As illustrations of erections from peripheral irritation, those arising from the morning fulness of the bladder, from affections of the rectum, and from inflammation of the prostatic urethra and of the seminal vesicles may be mentioned. The capacity for coition is most marked between the 1 Ollivier, Traite des Maladies de la Moelle Epiniere, 3d ed., t. iii. p. 316. 2 Trousseau, Clin. Med. de l'Hotel-Dieu de Paris, t. ii. p. 511; and Erb, Ziemssen's Cyclopaedia, Amer. ed., vol. xiii. p. 545. 20 ATONIC IMPOTENCE. ages of twenty and forty-five years; after which it gradually declines, and usually ceases after the sixty- fifth year. Sexual vigor is, moreover, greatly diminished by bodily exertion, such as gymnastic exercises, and by close mental occupation. Desire is also obtunded by the same causes. Impotence may arise from diminished or abolished reflex excitability of the genito-spinal centre, or from dis- turbances of the brain which restrain the action of that centre; or it may be symptomatic of the prolonged use of certain remedies and beverages, or of various acute and chronic diseases; or it may depend upon congenital or acquired defects of the genital organs. In accordance with its etiology it may, therefore, be described as Atonic, Psychical, Symptomatic, and Organic. Of one hundred and seventy-five cases of which I have notes, one hundred and seventy-one were atonic, one was psy- chical, one was symptomatic, and two were organic. Sect. II. Atonic Impotence. When the lumbar reflex centre for erection fails wholly or partially to respond to the ordinary stimuli the resulting impotence may be termed atonic, in the sense that the centre is deficient in activity, mobility, excit- ability, or tonicity, through which the muscular walls of the arterioles and the muscular fibres of the trabeculse of the erectile tissues are prevented from relaxing and ETIOLOGY. 21 admitting the requisite flow of blood into the penis, and through which the contractility of the ischio-cavernous and bulbo-cavernous muscles is impaired. Atonic impotence depends either upon, or is main- tained by, inflammation and hyperesthesia of the pros- tatic portion of the urethra, or upon diminished or abolished reflex excitability of the genito-spinal centre without the intervention of those lesions. Of the one hundred and seventy-one cases that have come under my observation, one hundred and fifty-nine were of the former variety, and only twelve of the latter variety. A.--ATONIC IMPOTENCE FROM HYPERESTHESIA AND INFLAM- MATION OF THE PROSTATIC URETHRA. Etiology.—From independent researches, which were first published in 1877,1 I long ago reached the conclu- sion that impotence was generally induced by subacute #. or chronic inflammation and morbid sensibility of the prostatic urethra, which were frequently associated with stricture, and which were usually due to masturbation, gonorrhoea, sexual excesses, and constant excitement of the genital organs without gratification of the passions. In subsequent papers2 I called attention to the fact, pre- viously noticed by other writers, that inflammation of the prostatic urethra bears the same relation to the spinal reflexes of the male that inflammation of the uterus bears to allied disorders in the female, and that it is a 1 Medical and Surgical Reporter, May 5, 1877, p. 391. 2 Trans. Amer. Med. Assoc, vol. 28, p. 523; and Med. News and Library, Sept. 1880, p. 513. 22 ATONIC IMPOTENCE. constant source of irritation of the genital nerves which terminate in that locality. An enfeebled state of the lumbar division of the cord and exhaustion of the cells that minister to its reflex functions are thus finally brought about. In thirty-eight of the cases the subjects had been con- firmed masturbators, and had also suffered from gonor- rhoea, so that it is impossible to say upon which of these factors the trouble depended. Of one hundred and twenty-one patients, however, in whom the history was clear, eighty-two were masturbators, thirty-seven had had gonorrhoea, and two had indulged in excessive coition. Just how often prolonged and repeatedly ungratified sexual excitement produced by toying with females, as in Case XX., is to be considered a cause of the morbid changes which induce or maintain the affec- tion I am unable to say, since young men addicted to this habit indulge their propensities in various ways. With regard to masturbators who either never had sexual intercourse, or had never contracted gonorrhoea, I have made some notes that are interesting and practi- cally important. Thus, I find that one in every three has an elongated prepuce; one in every five has an inflamed meatus; one in every two and a half has an exquisitely sensitive urethra; that the same proportion suffers from prostatic or abnormal seminal discharges; and that one in every ten has a small, and usually a pointed and rigid, penis. In the papers already referred to I endeavored to show that confirmed masturbation is just as sure to result in urethritis and the formation of a stricture as is gleet; and that the failure to discover this lesion would not have occurred to the majority of ETIOLOGY. 23 writers on the subject if they had resorted to the bul- bous bougie for exploring the urethra. Of the eighty- two masturbators who suffered from atonic impotence, and of the ninety-one who had seminal incontinence, as will be seen in the chapter oh spermatorrhoea, or of one hundred and seventy-three in all, only twenty-two were free from stricture, so that a coarctation should always be looked for in this class of subjects. In about three- fourths of the cases there is only one stricture, while in the remainder two or more are present. In about one- half of the entire number the contraction is situated near the meatus. As the knowledge of the connection between stricture of the urethra from masturbation and impotence, prosta- torrhoea, pollutions, and spermatorrhoea is of the utmost importance in regard to the treatment of these affections, I still further extended my investigations in this direction by an examination of fifty-six onanists in the Insane Department of the Philadelphia Hospital and the Penn- sylvania Hospital for the Insane. Of twenty-seven inmates whose histories could be traced back, eighteen declared that they never had gonorrhoea. These were either epileptics, who, when their mental faculties are not enfeebled, are as capable of giving sensible accounts of themselves as others not so affected, or the subjects of chronic insanity or dementia, of whom it is characteristic that, if they remember anything at all, they can recall even the most trifling incidents that may have happened prior to the attack of insanity. In four other instances it was improbable that the patients ever had gonorrhoea, since they had been imbecile from childhood. In the remaining five cases, the question of gonorrhoea could 24 ATONIC IMPOTENCE. not be entertained, because the subjects were admitted at too early an age, and had afterwards never left the hospital. Their histories are briefly as follows: Case I. An epileptic, aged twenty, admitted at the age of ten, had a stricture at six inches, which was defined by a No. 181 bulbous explorer. Case II. An epileptic, aged twenty-three, had been in the house twelve years, having been transferred from the Children's Asylum at the age of eleven. A stricture, calibre 19, was detected at six inches and a half from the meatus, which was contracted; there was a gleety discharge; and the penis was large. Case III. An epileptic, aged thirteen, an inmate for three months, suffered from phimosis, with a stricture, calibre 17, at six inches and a half, and very marked prostatic hyperesthesia. Case IV. An epileptic, aged nineteen, admitted at the age of eleven, had a stricture, calibre 19, at six inches, with a very sensitive urethra, and a gleety discharge. Case V. An idiot, aged fifteen, an inmate for three years, had a gleety discharge, and a stricture, calibre 18, at five inches and three- quarters. These five cases, occurring, as they did, in young sub- jects, in whom the idea of gonorrhoea must be discarded, sustain the view heretofore expressed that organic strict- ure is a common lesion of masturbation. The coarcta- tions imparted the sensation of a firm, resisting obstacle 1 This and the succeeding measurements are in accordance with the French catheter scale. The calibre, therefore, represents the corre- sponding number of millimetres in circumference, a millimetre being equal to about the one-twenty-fifth of an inch. ETIOLOGY. 25 upon the withdrawal of the bulbous explorer, and were distinctly recognized by my residents, Dr. Murray and Dr. Van Valzah, by Dr. Dease, Dr. Heath, and Dr. Musser. Exclusive of these cases, my notes show that thirteen out of every one hundred cases of stricture are due to onanism; and Otis1 states that nine per cent, of all cases are traceable to that practice. Ricord, Phillips, Leroy, Henry Smith, Gouley, and Gross also mention mastur- bation as a cause of stricture ; and my views are, more- over, supported by the evidence of other authors, who are more explicit in their statements than those just referred to. Thus, Black2 reports a typical case, asso- ciated with hyperaesthesia of the prostatic urethra, for which he was consulted on account of fear of sexual incapacity. In speaking of the etiology of stricture, Wade says: "I have good reason to believe that the pernicious habit of self-abuse is a much more frequent cause of stricture than is generally supposed. In sev- eral instances of the kind, in which there has been no sexual intercourse, the strictures, which were at the bulb, proved more than usually refractory, from the extreme morbid sensitiveness of the entire urethral canal." . . . "The complication of spermatorrhoea with stricture and a highly irritable state of the urethra often proves very troublesome, and requires great care and gentleness in its treatment. Such strictures are, in fact, not infrequently caused by masturbation."3 Lizars 1 On Stricture of the Male Urethra. Pamphlet, New York, 1875. 2 On the Functional Diseases of the Renal, Urinary, and Reproductive Organs, Phila., 1872, p. 196. 3 Stricture of the Urethra: Its Complications and Effects. 4th ed., pp. 21 and 318. 26 ATONIC IMPOTENCE. asserts that stricture "is also often produced by self- abuse, since we find, in those affected with spermator- rhoea, that there exists more or less stricture of the urethra, for which it is necessary to dilate the canal before having recourse to the porte-caustique."1 Lalle- mand2 refers to two cases in masturbators who had never had sexual intercourse, in one of which the strict- ure was very tight and rebellious to treatment. Three- quarters of a century ago, Sir Everard Home, in his work on the subject,3 devoted a chapter to " Strictures brought on by Onanism," but he classified them as spasmodic. In thus recognizing spasm of the urethra as an effect of masturbation, he described the condition which is the forerunner of permanent stricture, since, as is well known, spasmodic contraction is a very com- mon cause of organic coarctation, and is, indeed, not infrequently found in connection with it. In addition to the foregoing lesions, masturbation may be followed by other local affections, which are due mainly to the extension of the morbid action from the inflamed prostatic urethra. Among the more common of these are irritability of the neck of the bladder, prostatorrhcea, nocturnal seminal discharges, and sper- matorrhoea. It may also occasion spermatocystitis, funic- ulitis, epididymitis,4 aspermatism,5 through obstruction of the epididymes or vasa deferentia, wasting of the 1 Practical Observations on the Treatment of Stricture of the Urethra. 2d ed., p. i. 2 Des Pertes Seminales Involontaires, t. i. p. 479. 3 Practical Observations on the Treatment, etc., vol. ii. p. 243. 4 See Case XV. p. 36. 5 Liegeois, Medical Times and Gazette, vol. ii. 1869, p. 381; and Ter- rillon, Annates de Dermatologie et de Syphiligraphie, ser. 2, t. i. p. 439. ETIOLOGY. 27 testes,1 and, as will be pointed out in the next chapter, it is a fruitful source of azoospermism. While in persons with an inherited predisposition to nervous diseases, as insanity and epilepsy, there is no reason to doubt that onanism may hasten their appear- ance, I believe that in the majority of cases it should be regarded rather as the effect than as the cause of these affections. From the constant occupation of the mind with the local troubles which it induces, it certainly does, however, give rise to a bad form of hypochondrism, which is akin to insanity. Masturbation and sexual ex- cesses are among the most common of the causes of general paralysis of the insane, and the disorder is supposed to extend upwards from the cord to the brain. An examination of four cases of this affection has con- vinced me that there is a source of reflex irritability of the cord in the urethra. In one, in the second stage, there was a stricture, calibre twenty-one, at seven inches from the meatus. In another instance, in the first stage, there was a large granular patch at six inches and a half, and a gleety discharge. A similar condition was detected at six inches and a quarter, in a man in the second stage; while, in the fourth case, which was far advanced in the third stage, there was also a granular patch at six inches and a half, and the bougie brought away an abundant brownish fluid from the prostatic urethra. Whether these morbid states served as fac- tors in the production of the disease, or simply main- tained the nervous disturbance, I am unable to decide; but, if the former view be the correct one, functional 1 Curling, Diseases of the Testes, 4th ed., p. 78; and Brodie, Lond. Med. and Phys. Journ., vol. lvi. p. 297. 28 ATONIC IMPOTENCE. conditions of the cord should be prevented from passing into organic changes by curing the peripheral sources of irritation in the first stage of the affection, or when the peculiar gait and slight trouble in speech are asso- ciated with extravagant ideas. I have never known insanity, dementia, or phthisis to follow onanism, as they are said to do by Ritchie, Esquirol, Pinel, Des- ksides, Maudsley, Smith, Acton, and other writers, nor have I ever met with the distressing cases described by Lallemand; and I fully agree with Sir James Paget1 in the statements that "masturbation does neither more nor less harm than sexual intercourse practised with the same frequency in the same conditions of general health, and age, and circumstances," and that the ills which result from it when indulged in by young persons are due more to the "quantity, not the method." Unfortu- nately, however, it is begun earlier in life2 than coition ; and, as it does not require the cooperation of the oppo- site sex, it can be practised to a greater extent, and at all times, and even when erection is incomplete. Of the remaining remote causes of atonic impotence, namely, gonorrhoea and sexual excesses, which induce and keep up hyperaesthesia and inflammation of the prostatic urethra, it need only be said that they are followed by precisely the same lesions as are met with in masturbation. In his classical writings on Diseases of 1 Clinical Lectures and Essays, p. 284. 2 Fleischmann, in the Wiener Med. Presse, 1878, p. 9, narrates a case in which an infant began to masturbate at nine months of age, by cross- ing the legs and setting up rocking motions of the pelvis and body; and Barthez-Rilliet, Marjolin, Von Bambecke, Jacobi, and Morton have re- corded examples in young children who were not sucklings. CLASSIFICATION. 29 the Spinal Cord, Erb1 declares that sexual excesses and irregularities occupy a prominent position in the predis- position to, and production of, many spinal affections, among which may be mentioned spinal irritation, neur- asthenia, chronic meningitis and myelitis, softening, and inflammation of the anterior horns, or poliomyelitis; and this view is held by many other distinguished authors, as Rosenthal, Hammond, and Romberg. Classification.—Atonic impotence varies in degree, and may be divided into the following classes: First. The erection is imperfect and of short dura- tion, and ejaculation is frequently too precipitate, but sexual desire remains, and intercourse is possible, al- though incomplete. Second. The erection is either so feeble that intro- mission is impossible, or it is entirely absent. As in the preceding form, desire is present. Third. In the last phase of the affection, not only is there loss of power of erection, but desire is com- pletely abolished. Of the relative frequency of these three varieties of impotence, an examination of the one hundred and fifty- nine cases previously alluded to shows that one hundred and forty were examples of feeble erection and pre- mature ejaculation; fourteen were instances of loss of power of erection, with retention of desire; and five were examples of failure of both erection and desire; and I have no hesitation in declaring that the first form is more common than impotence from all other causes combined. 1 Loc. cit., p. 147. 30 atonic impotence. Clinical History.—As my readers will gain a better insight into the peculiarities of the three varieties by a narration of cases than by a general and abstract de- scription, I append some typical examples. Case VI. A grocer, twenty-two years of age, consulted me on the 12th of October, 1876, on account of impaired erections and premature ejaculation. He began to masturbate at the age of four- teen, and continued the practice for three years. Its abandonment was followed by nocturnal seminal emissions of an intermittent character, that is to say, they recurred almost every night for a fortnight, when there was an intermission of a week's duration. He had been under treatment for two years before coming to me, the effect of which was to improve his general health and materially lessen the frequency of the nocturnal discharges. Up to one year ago he had never had sexual intercourse. At that time he found that erection was incomplete, the gland of the penis, in particular, being soft and inelastic, and that ejaculation took place in a few seconds. The same troubles had existed ever since. During the past two months, nocturnal emissions had occurred from one to five times a week, and he noticed that flakes of mucus, which he sup- posed to be semen, were discharged in advance of the stream of urine. He was easily fatigued, his hand was unsteady in writing, he was habitually constipated, and he suffered from dull, heavy pains in the groins and back. Examination with the bulbous explorer disclosed slight tenderness of the urethra half an inch from the meatus, and decided tenderness at four inches and a half, which increased as the prostatic urethra was reached. On withdrawing the instrument, a stricture, calibre 10, was detected at five inches and a quarter from the meatus. The bulb brought out a whitish fluid, which showed, under the micro- scope, a large amount of pus and epithelium. The urine was acid, and loaded with lithates, but the genital organs were normal. I prescribed a laxative pill, to be taken as often as it might be required, warm hip-baths, and warm enemata night and morning, and thirty grains of bromide of potassium every eight hours. The diet was restricted to perfectly bland and digestible articles; sexual intercourse and stimulating drinks were interdicted; and an injec- CLINICAL HISTORY. 31 tion of one drachm of Goulard's extract to ten ounces of water was directed to be thrown into the urethra three times a day. On the 14th I passed a No. 10 steel bougie, and continued its introduction every second day until the 26th, when it was employed once every twenty-four hours by the patient himself. At first it was immediately withdrawn, but as the sensibility of the urethra became obtunded, it was permitted to remain longer, but at no time more than five minutes. The size was gradually increased, until toward the close of the treatment it reached No. 27. During the first week there were three nocturnal emissions; but from that time until I dis- charged the patient, on the 3d of December, when his sexual powers were entirely regained, there was only one. I saw this man again early in January, 1877, on account of a chancre, when he informed me that he had experienced no trouble whatever in sexual congress. Case VII. A mechanic, twenty-six years of age, states that he has had intercourse with one woman three or four times every night for the past eighteen months, and that he occasionally fulfilled engage- ments of a similar nature with other females. He had never mastur- bated much, nor had he ever contracted gonorrhoea. Lately he has observed that his powers were growing feeble; and at present the erections are flabby, and the ejaculations, when penetration is possible, are precipitate. He looks pale, is easily fatigued, and suffers from pain in the back, and from frequent and painful micturition. A No. 25 explorer detects a very sensitive urethra, and a stricture seated at six inches from the meatus. The neck of the bladder is so sensitive that it contracts when the instrument comes in contact with it, so that its onward progress is momentarily arrested. Case VIII. A weaver, thirty-seven years of age, has had gonor- rhoea three times, the last attack having occurred fourteen years ago. For the past three years he has noticed that the erections were be- coming more and more feeble, until they frequently passed off before intromission, and coition was always attended with hasty emission. In addition to his sexual troubles, he complains of numbness along the outer side of the left thigh, almost constant dorsal pain, and a dull, heavy pain in the back of the head, the left side of the neck, and the left shoulder, all of which localities now and then suddenly 32 ATONIC IMPOTENCE. become red and hot. The suffering is aggravated by exercise and continuous work; his sleep is unrefreshing, and he has dyspeptic symptoms. He has two strictures, the first of which, calibre 17, is located at three inches and a half, and the second, calibre 15, is six inches from the meatus; and the prostatic urethra is morbidly sensitive. In the preceding illustrations of the first variety of atonic impotence, the exciting causes were chronic hyperaesthesia and inflammation of the prostatic urethra, which were produced, respectively, by masturbation, by sexual excesses, and by gonorrhoea, and were maintained by one or more strictures. One case was complicated by nocturnal emissions, and another by inflammation of the neck of the bladder; and in all there were symptoms of neurasthenia. In this form of the affection may be included the con- dition known as irritable weakness, or spasmodic sperma- torrhoea, or spermaspasmos, in which, the erection being more or less complete, ejaculation occurs before penetra- tion, simultaneously with erection, or even before erec- tion. These points are illustrated by the following cases: Case IX. A merchant, thirty-seven years of age, had masturbated up to his eighteenth year, and has been in the habit of toying with women ever since. At his first attempt at connection, which took place when he was twenty-nine years old, he found that the erection was imperfect, and that ejaculation occurred before intromission; and he stated that these troubles still continued. There was a stricture, calibre 18, at six inches from the meatus, and the prostatic urethra was exquisitely sensitive. Case X. A clerk, thirty years of age, brought me a specimen of urine for examination, which I found to contain an abundance of motionless spermatozoa, oxalate of lime, and a few pus corpuscles and epithelial cells. He never had gonorrhoea, but he had masturbated CLINICAL HISTORY. 33 from his sixteenth to his twenty-first year, on an average, twice a day. There was a constant sticky feeling at the meatus, and he informed me that for the past three years, whenever he passed an evening with the lady upon whom he had fixed his affections, he had an erection, with a simultaneous emission. The hands and feet were habitually cold, and he had no knowledge of nocturnal emissions for five years. The explorer detected a stricture, calibre 17, at six inches and a half from the meatus, and there was marked hyperaesthesia of the prostatic urethra. Case XL A physician, thirty-four years of age, had masturbated from his fifteenth to his seventeenth year, and had contracted gonor- rhoea eleven years ago. For ten years he was unable to have connec- tion, in consequence of ejaculations at the moment of penetration ; and for the past three years emission occurred before erection, and he had nocturnal pollutions from two to three times a week. The meatus would admit only a No. 17 explorer; but after its enlargement, a stricture, calibre 25, was discovered at six inches and one-eighth, and the prostatic urethra was very sensitive. The subjoined illustrations are good examples of the second variety of impotence, or of that in which desire is retained, but in which the power of erection is lost, and coition is impossible. Case XII. A tavern-keeper, thirty-two years of age, of robust frame, stated that he was engaged to be married in six weeks; that he could not command an erection, although he had sexual desires; that the presence of the object of his affections, and the most lascivious books and pictures, which formerly brought on an erection, had lost that effect; and that the thought of his disability on his wedding-night was constantly preying upon his mind. This condition of affairs had existed for five months, during which time he had nocturnal seminal emissions about twice a week. He was, moreover, much alarmed at the presence of some shreds of purulent mucus in his urine, which he thought was seminal fluid. He had three attacks of gonorrhoea, the 3 34 ATONIC IMPOTENCE. last of which occurred seven years ago, since which period he has always had a slight gleety discharge, and for the past few months a dribbling of a few drops of urine in his clothes after the act of mic- turition was apparently completed. He suffered from habitual con- stipation, but in other respects he was the picture of health. The bulbous explorer defined two strictures, calibre 23, located, respectively, at six inches, and at six inches and a half, from the external meatus, as well as marked hyperaesthesia of the prostatic urethra. Case XIII. A mechanic, twenty-three years of age, at about his sixteenth year, after having been in the habit of masturbating freely for six or seven years, observed a urethral discharge. He had never had sexual intercourse until he was twenty-one; and, after a few months of moderate indulgence, the discharge had increased, and the erections had become more and more weak, until he was finally unable to consummate the act, although the desire remained. He is pale; suffers much from pain in the back, the shoulders, the anus, and the left temporo-maxillary articulation ; and is easily fatigued. Examination with a No. 25 explorer disclosed intense hyperaesthesia of the entire urethra, and particularly of its prostatic portion, but there was no indication of a stricture. As soon as the instrument entered the passage it occasioned tremor and retraction of the testes, and when it reached the prostatic portion he shrank from the excessive suffering which it awakened, and the muscles of the lids, nose, and mouth twitched convulsively. On its withdrawal, the bulb brought away a considerable prostatic discharge. He afterwards rode to his house in the street cars, and about two hours later, after urinating, he was seized with a curious crawling sensation in his arms and legs, lost consciousness, and, when found by his friends, was lying on the floor, and his face was livid. Three days subsequently, he was placed upon thirty grains of bromide of potassium, with five drops each of juice of belladonna and tincture of gelsemium, every eight hours, and directed to take ten grains of quinia one hour before his next visit, which occurred one week ago. At that time a conical steel bougie was passed, and one-third of a grain of morphia thrown under his skin. A slight epileptoid paroxysm, as indicated by clonic spasms of the muscles of the arms and eyelids, and a feeling as if he would become CLINICAL HISTORY. 35 unconscious, ensued; and these symptoms were followed by prostra- tion and numbness of both hands. In the third phase, or as it is sometimes called the paralytic form, of the affection, erection and desire are completely abolished, as is illustrated by the following instances: Case XIV. A medical student, twenty-four years of age, had mas- turbated excessively for six years, and for the past two years, during which period he had discontinued the practice, had nocturnal seminal emissions, on an average, twice a week. When I saw him he stated that he had lost all desire, and had been unable to command an erec- tion for three months. He was very watchful of a gleety discharge, and brought with him, for my inspection, a specimen of urine which contained little threads of mucus, which he imagined to be semen. His general health was broken; his expression was woe-begone; he was gloomy, shy, and reserved, and unable to fix his attention upon his studies, and easily fatigued. He was constantly thinking of his previous bad habit and the nocturnal emissions, and was con- vinced that his condition was beyond relief. In a word, he was a victim of sexual hypochondrism. The external genital organs, and the prostate and seminal vesicles, as far as rectal touch enabled me to form an opinion, were perfectly normal; but the urinary meatus was constantly moist, and its lips were red and pouting. At five inches and three-quarters from the meatus I detected a stricture, calibre 17, and also found that the urethra behind it was extremely sensitive. Placing a little of the fluid, which was withdrawn by the explorer, under the microscope, I demonstrated to my patient that it was free from spermatozoa, and I still further endeavored to gain his confidence by assuring him that his disability was temporary, since, from its dependence upon appreciable lesions, it could be cured. Under appropriate treatment, in three weeks, the pollutions had decreased in frequency, the pros- tatic discharge had lessened in quantity, the hyperaesthesia had notably diminished, and he had begun to have feeble erections. At the ex- piration of a month I divided the stricture, and he went with me to 36 ATONIC IMPOTENCE. the seashore. In three weeks, or eleven weeks from the commence- ment of the treatment, he had good erections, and his mental anxiety was calmed; but, unfortunately, he desired to test his powers, and had an almost instantaneous ejaculation with cessation of erection. This act, which he undertook entirely on his own responsibility, undid all the good I had effected; and it was only after the expiration of eight months that he finally recovered under the employment of galvanism. Case XV. A druggist, twenty-four years of age, came to me on account of vesical irritability, under which he had labored for six years. He has never had sexual intercourse, but had masturbated from boyhood until his twentieth year, and desire and power of erec- tion had been abolished for nearly four years. The entire urethra and neck of the bladder were excessively sensitive, and a stricture, calibre 17, was detected at six inches and one-fifth from the meatus, which measured thirty-three millimetres in circumference. The epi- didymes, but especially the right, were enlarged and indurated. In the majority of cases of atonic impotence which I have inserted for the purpose of illustrating the various phases of the affection, in addition to the lesions of the urethra, it will have been perceived that certain subjec- tive symptoms were present, which were indicative of spinal exhaustion, the depressed form of spinal irrita- tion, or neurasthenia. Prominent among these signs are pain in the back, which is increased by exercise, exposure to atmospheric vicissitudes, and attempts at coition, and muscular weakness of the limbs, so that the subjects are tired out by comparatively slight exertions and walking. These symptoms point, to use the term introduced by Beard,1 to myelasthenia of the lumbar division of the cord. In a certain number of examples, as in Case VIII., there is dull, heavy pain in the back of 1 A Practical Treatise on Nervous Exhaustion, 2d ed., p. 106; and Medical Record, vol. i., 1879, P- *84. DIAGNOSIS. 37 Fig. i. the head, the neck, and shoulders, which now and then become flushed, signs which are indicative of exhaustion of the upper portion of the cord. In other instances, the symptoms are those of cerebras- thenia, such as impairment of memory, mental debility, depression, anxiety, or irritability, a feeling of fulness in the head, asthenopia, and other disorders of the special senses; all of which are signs of enfeeblement of the functional power of the brain, and which may be readily explained by the commissural connections between the lumbar division of the cord and the higher centres. In other cases, again, the symptoms are variously interwoven; and in all troubled and unrefreshing sleep, a feeling of heaviness on rising, coldness of the hands and feet, poor appetite, coated tongue, flatulence, a sense of weight in the epigastrium after eating, palpitation of the heart, sick headache, vertigo, and constipation, are very common. The various phenomena of neurasthenia, which are so frequently met with in the affections of the male reproductive or- gans, have been exhaustively investigated in this country by Beard, and his writings on that subject are well worthy of careful study. Exploratory bulbous bougie. Diagnosis. — The diagnosis of atonic impotence is readily made from a consideration of the preceding ob- 38 ATONIC IMPOTENCE. servations. In all cases the urethra should be examined with the view of determining the presence or absence of lesions which induce or maintain the disorder. For this purpose, the exploratory, or acorn-headed, soft bougie, represented in Fig. i, should be resorted to, as it is the only instrument with which granular patches and strictures of large calibre can be accurately defined, and with which morbid discharges can be withdrawn for minute examination. One being selected which fills, without unpleasantly stretching, the meatus, it is well oiled and inserted as far as the bladder. If there be a coarctation, its introduction will be arrested, when smaller sizes are successively employed, until one will pass without difficulty. On its withdrawal, the abrupt shoulder of the bulb coming in contact with the poste- rior face of the obstruction imparts to the touch a sensation as if it had jumped over a narrow band, which is as perceptible to the patient as it is to the surgeon, and is very different from the sensation con- veyed by spasm. In the latter, the instrument may be grasped for a time, but the muscular contractions soon cease, or may be made to cease by carrying the bulb several times through the obstruction; while a granular patch gives the impression of a limited roughness of the canal. Hyperaesthesia of the urethra is readily detected by the ordinary metallic bougie, catheter, or sound; and its existence should never be based upon the passage of the soft explorer alone, as the insertion of that instru- ment is productive of far more pain than the ordinary nickel-plated bougie. If the surgeon should deem it desirable, he may confirm his diagnosis by a resort to PROGNOSIS. 39 the endoscope, with which Grunfeld1 has discovered hyperaemia and catarrhal swelling of the verumontanum in cases of impotence, prostatorrhcea, and spermator- rhoea. I myself never employ it, nor do I think that any additional information is to be gained from its use. In the absence of proper instruments for exploring the urethra, the general practitioner may suspect inflam- mation and morbid sensibility if there be painful and frequent micturition, painful ejaculation, a feeling of weight in the ano-rectal region, a gleety discharge, prostatorrhcea, abnormal nocturnal emissions, and sen- sibility of the prostate on pressure with the finger in the rectum. Prognosis.—The milder forms of impotence are very amenable to treatment, as is illustrated by the following example: Case XVI. A carriage-builder, twenty-three years of age, came to me on the 8th of April, 1880, on account of a gleety discharge, which kept the lips of the meatus glued together, and had existed for two years and a half; of a discharge of prostatic fluid at stool; and of nocturnal seminal emissions, which were often as frequent as every night during a single week, now and then occurring to the number of three in a night, and averaging three a week. The erections were feeble, and ejaculation was premature. The bowels were costive, but he had no signs of spinal exhaustion. Examination with a No. 17 explorer disclosed a stricture one-eighth of an inch behind a con- tracted meatus, and a highly sensitive urethra, especially in its mem- branous and prostatic divisions. On withdrawing the instrument, a few drops of prostatic fluid came away. I laid open the meatus along with the stricture, and directed a pill composed of two grains of 1 Endoskopische Befunde bei Erkrankungen des Samenhugels. Wien, 1880. 40 ATONIC IMPOTENCE. compound extract of colocynth and half a grain of extract of nux vomica at bedtime, along with the one-sixtieth of a grain of atropia in solution, and thirty grains of bromide of potassium every eight hours. The incision was prevented from closing by the passage of a No. 30 conical steel bougie, which was carried through the entire urethra every other day. On the 6th of May, the hyperaesthesia had almost entirely disappeared; the gleet had ceased ; there was merely a slight prostatic discharge, if the bowels were allowed to become constipated, but he had not noticed it for several days; there were nocturnal emissions on the nights of April 17 and 18, and the erec- tions were improving in vigor. The treatment was continued, and a cure was effected in another month. This case is not a selected one; and whenever a pa- tient presents himself who has erections and desire, even if he has a prostatic discharge, or too frequent nocturnal pollutions, or is suffering with both of these complications, the surgeon will be perfectly justifiable in promising relief. In the second variety of the affec- ^ tion, in which desire remains, but in which the erections are so feeble that penetration is impossible, or are en- tirely absent, it is not uncommon for the man to have an erection and emission under the influence of a volupt- uous dream, thereby showing that the sexual instinct is not entirely lost. In such a case as this the prognosis is also favorable, although the patient will have to re- main longer under treatment. When both desire and erection are abolished, and the man is suffering from hypochondrism, the outlook is bad, particularly if we cannot gain his confidence, and he is not open to moral treatment. In this class of cases, if there is neither hypochondrism nor neurasthenia, the prognosis is good. In Case XII., which was an example of the latter con- dition, I divided the strictures on the nth of September, TREATMENT. 41 and placed the man upon bromide of potassium and tincture of veratrum viride, a laxative pill, as it might be required, warm sitz-baths, and a restricted diet, and enjoined abstinence from everything which was calcu- lated to excite the genital organs. He married on the 6th of November, having in the mean while passed a No. 32 conical steel bougie every twenty-four hours until the tenderness of the prostatic urethra had dis- appeared, and he wrote me five days subsequently that he had had connection every night. I cautioned him against committing such marital excess, lest sexual abuse might cause a relapse. The prognosis is not so good when the disorder arises from excessive onanism commenced early in life by ner- vous, impressible boys. When impotence is developed after the age of forty, the patient should be made to understand that his pristine vigor can scarcely be ex- pected to be restored, since the power to copulate naturally diminishes at that age. Treatment.—In the management of atonic impotence, r a thorough examination of the genital and associated organs should be made, with a view of getting rid of the causes which produce and maintain it. If the patient has a redundant prepuce, it should be removed; if the meatus be contracted, it should be enlarged; while herpes of the prepuce and glans, or balanitis, should be treated in the usual way. All of these lesions are capable of setting up hyperaesthesia of the prostatic portion of the urethra, or even of exciting reflex im- potence without the intervention of prostatic trouble, and their relief is quite sufficient in mild cases to bring 42 ATONIC IMPOTENCE. about a cure. The same statement is true of certain diseases of the bladder and rectum, so that these viscera should not be overlooked. Atonic impotence usually occurs in robust subjects, in whom inflammation and morbid sensibility of the prostatic portion of the urethra have set in before the signs of myelasthenia are pronounced, the usual symp- tom, according to my experience, being pain in the back. Hence the treatment, whether this be local or general, must be of a sedative nature; and the patient, at the outset, should be impressed with the importance of avoiding all sources of sexual excitement, such as mas- turbation, attempts at intercourse, dalliance with women, and lascivious thoughts and literature; and if his sexual propensities are marked, they should be kept under con- trol by mental application and gymnastic exercises. Of the local measures to overcome hyperaemia, inflam- mation, and hyperaesthesia of the prostatic urethra, not one is so universally applicable as the passage of the nickel-plated conical steel bougie represented in Fig. 2. The size of the instrument is to be gauged by that of the meatus, if it be normal, or by that of the stricture, if one be present, and its circumference should be grad- ually increased up to that of the full capacity of the urethra, as indicated by the urethrameter. To effect this, however, the meatus will have to be enlarged as a preliminary measure; or, instead of this, my urethral dilator, represented in Fig. 3, which dispenses with the operation, may be employed. At first the bougie should be at once withdrawn, and the intervals between the insertions should be seventy-two hours. With the de- crease of the sensibility it should be retained longer, TREATMENT. 43 and the intervals of introduction be shortened until it is passed daily. If the case is complicated by an irritable or resilient stricture, it should be subjected to internal division from behind forwards, as no progress can be made unless the contraction is a simple one. For this purpose, I prefer the instrument devised by myself several years ago, as I have found from ample experience that its simplicity of construction and perfection of action leave nothing to be desired. The essential part of the contrivance is its acorn-headed distal extremity, through which the situation of the coarctation is accurately determined. To use the exploratory urethrotome, the stricture having been passed, and its posterior face having been defined by the projecting shoulder of the bulb, the bulb is carried at least half an inch towards the bladder, as the object is to divide, along with the contraction, the sound tissues to that extent behind and in front of it; then the blade is protruded, as in Fig. 4, and the parts cut as the instrument is withdrawn, the penis being put upon the stretch to render the urethra tense. In the event of the tissues being thick or resistant, the section may be materially aided by counterpressure with the fingers of the left hand along the median line. The bulb is then used as an explorer to detect any undivided bands, which, if discovered, should be severed, since thorough section of all narrowed points is essential to success. In regard to the subsequent treatment, I need only refer to my views published elsewhere,1 as its consideration would be out of place here. 1 Gross on the Urinary Organs, 3d ed., p. 480; Med. Record, June 15, 1878, p. 461; and Trans. Med. Soc. State of Penna., vol. xii. part i. p. 67. 44 ATONIC IMPOTENCE. It now and then happens, as in Case XIII., that the entire urethra is so excessively sensitive that the in- Fig. 2. Fig. 3. Fig. 4. Conical steel bougie. Author's urethral dilator. Author's urethrotome. troduction of the bougie is followed by an epileptoid paroxysm, or that the patient faints. Under these cir- TREATMENT. 45 cumstances, it is wiser to desist from its use until the sensibility of the passage has been obtunded by the injection, every eight hours, of three grains of chloral, and ten grains of bromide of potassium to the ounce of water, and by the internal exhibition, at the same intervals, of thirty grains of the bromide, ten drops of tincture of cannabis indica, and five drops of tincture of gelsemium, and by sitz-baths of water as warm as it can be borne. In many instances it will be found that the inflamma- mation and hyperaesthesia are finally reduced to a small, and probably granular, patch, which proves rebellious to the bougie, but which usually disappears under the application of astringent remedies. Of these, I prefer a solution of nitrate of silver, carried to the tender spot by a contrivance which is essentially that of Felix Guyon,1 and which, as is shown in Fig. 5, consists of a syringe of the capacity of rather less than a drachm, and of an ordinary bulbous explorer perforated at the apex of the bulb. The syringe having been charged with the solution, arid its nozzle attached to the ex- plorer, pressure is made upon the piston, until a drop of the fluid appears at the small opening. Wiping this off, the oiled instrument is then carried down until the bulb defines the inflamed patch—and it does this with the greatest accuracy—when it is slightly withdrawn, and a few drops are deposited in the urethra. The bladder should be evacuated before the application of the instrument, and the patient should be kept in bed and use demulcent drinks for a few hours subsequently. 1 Bull. Gen. de Ther., 1867, p. 501. 46 ATONIC IMPOTENCE. With these precautions, the pain and desire to urinate will usually not last more than thirty minutes, but there will be some scalding during the next act of micturition. When I first adopted this practice, about twelve years Fig- 5- Syringe and perforated bulbous explorer. ago, I employed ten grains of the salt to the ounce of distilled water, at intervals of one week; but from an ex- tended experience, I now commonly use thirty grains, and repeat the injection every four days. TREATMENT. 47 As the soft, perforated, bulbous explorers are not easily procured in this country, and as they are liable to wear out, I have had constructed a curved hard-rubber Fig. 7- Fig. 6. Bulbous nozzle. Dick's catheter-syringe. attachment for the syringe, which is eight inches long, and which is provided, as is shown in Fig. 6, with an acorn-shaped head or bulb. This instrument is not 48 ATONIC IMPOTENCE. quite so good in regard to accuracy of definition of the inflamed patch as the preceding one, but, with that Fig. 8. Fig. 9. Fig. IO. S. D. Gross' porte- caustique. Cupped conical steel bougie. Harrison's porte- remede. exception, it constitutes the best of the contrivances for the purposes to which it is adapted. In the absence of the foregoing instruments, Dick's TREATMENT. 49 catheter-syringe, Fig. 7, may be employed; or the cup attached to the stylet of Gross's porte-caustique, Fig. 8, may be charged with five grains of nitrate of silver to the drachm of ointment of stramonium, which I regard as far preferable to the fused salt, as the latter exerts a destructive action on the mucous membrane unless the cauterization is lightly performed. The glycerole of tannin, applied by means of a sound, Fig. 9, having a cup at the convexity of the curve, just anterior to the shaft, frequently answers a good purpose. The de- pression filled with the solid mass is kept in contact with the inflamed patch for a few minutes, or until it is melted by the heat of the parts; but this mode of medication is open to the objection that some of the liquefied paste is deposited along the whole length of the urethra during the withdrawal of the instrument. Another excellent mode of applying astringents is by the deposition of small soluble suppositories of cocoa butter in the affected portion of the urethra by means of the modified porte-remede of Harrison, of Liverpool, shown in Fig, 10. The instrument consists of a metallic catheter, open at the end for the reception of the sup- pository, which is so shaped as to form a bulbous ex- tremity for the instrument. The exposed surface is hardened by a layer of spermaceti, so as to prevent its becoming dissolved in passing down the urethra. For ordinary use the suppository may contain a quarter of a grain of nitrate of silver, or two grains of tannin, or half a grain of acetate of lead. When the affection proves to be more obstinate, I have found that flying blisters, made by pencilling can- tharidal collodion first on the one side of the perineal 4 50 ATONIC IMPOTENCE. raphe, and, after the surface has healed, on the opposite side, are of the utmost value. The agent should be applied in the morning, as it is liable to prevent sleep, and great care should be taken to avoid vesication of the scrotum and anus. Of general remedies, the aphrodisiacs, as cantharides, phosphorus, phosphide of zinc, strychnia, and damiana, are to be studiously avoided, since the parts are to be kept still further at rest by the administration of agents which diminish the reflex excitability of the cord and suspend sexual desires and the power of erection. Of the remedies of this class, bromide of potassium is by far the best, as it not only blunts the venereal appetite, but corrects the acidity of the urine, and exerts an an- aesthetic influence upon the mucous membrane of the urethra. I am in the habit of administering thirty grains of the salt every eight hours, unless I find that it makes the patient drowsy during the day, when I order a drachm to be taken at bedtime. If it is not well borne, as is indicated by physical and mental languor, weak- ness of the heart, pallor, uncertain gait, acne, and other signs of bromism, its use must be discontinued for a time; or its cumulative action must be prevented by promoting its excretion by the urine by combining with it a diurectic, as ten grains of nitrate or bitartrate of potassium, as recommended by Rosenthal;1 this com- bination is far better than that with Fowler's solution, which is advised by Gowers and Bartholow.2 When the patient is anaemic, I prefer to administer a drachm at night, and give him three grains of quinine along 1 Wiener Klinik, May, 1880, p. 159. 2 Materia Medica and Therapeutics, 3d ed., p. 406. TREATMENT. 51 with twenty-five drops of the tincture of the chloride of iron three times during the day. My own empirical observations in regard to the value of quinine in de- creasing the depression produced by the bromides in asthenic subjects have recently been confirmed by Dr. Landon Carter Gray,1 who has shown that it not only increases the sedative effects of the latter, but that it diminishes or dispels bromism. When the patient is robust and plethoric, I frequently add to each dose of the bromide ten drops of the tincture of veratrum viride or tincture of gelsemium; or the bromide may be given in half an ounce of the infusion of digitalis; arid I have every reason to be pleased with the action of the combinations. Instead of the bromide of potassium, the monobromide of camphor may be employed to the extent of about twelve grains in the twenty-four hours, but its effects are not so striking as those of the former remedy. When the penis is cold and rigid, atropia is indicated to overcome the contraction of the muscular fibres of the trabeculae of the erectile bodies, and to induce dila- tation of the arterioles and an increased flow of blood through the organ; and its good effects are also evinced by the diminution of the number or the entire cessation of the nocturnal emissions and prostatic discharges which frequently complicate the affection. One-sixtieth of a grain in solution should be administered on rising; and when its peculiar action is denoted by dryness of * the mouth, thirst, dilatation of the pupils, and slight confusion of vision, that quantity should be taken on 1 Archives of Medicine, October, 1880, p. 191. 52 ATONIC IMPOTENCE. retiring, so that the patient may sleep through its dis- agreeable effects. Of the remaining anaphrodisiacs, which have been *' recommended in the management of impotence, cam- phor and lupuline cannot be relied upon; while arsenic evinces its depressing action on the sexual functions only when administered in such large doses as to occa- sion objectionable disorders of the circulatory, digestive, and nervous systems. Among the accessory measures I know of none that is more grateful to the patient, and more relaxing and soothing to the irritable organs, than a sitz-bath at a temperature of about 950 F., taken for fifteen minutes every morning and evening. In the absence of facilities for bathing, a sponge dipped in water at a temperature of about ioo° F. may be applied to the perineum and the back. Cold baths, which are recommended by many authors, are to be studiously avoided, as they aggravate the local troubles. ^ In a large proportion of cases the bowels are habitu- ally constipated. They should be kept in a soluble con- dition, particular attention being paid to the rectum. For this purpose, tepid water may be injected every morning, as it has the additional advantage of soothing the hyper- aesthetic prostatic urethra. If enemata do not answer the purpose, and if there is atony of the muscular coat of the intestines, a pill composed of two grains of compound ex- tract of colocynth, half a grain of extract of nux vomica, and the tenth of a grain of extract of belladonna may be administered on going to bed; or a wineglass of Hun- yadi water, or two drachms of equal parts of Epsom and Rochelle salt, may be ordered every morning. TREATMENT. 53 Any special dyspeptic symptoms are to be met by appropriate remedies. The diet should be nutritious and digestible, but unstimulating; and coffee, malt, and alcoholic liquors must be eschewed, and the last daily meal should be light. The patient should sleep on a hard mattress, use only the lightest coverings, and empty his bladder thoroughly on retiring, and early in the morning if a more or less complete erection indi- cates fulness of that viscus. He is, moreover, to be warned against horseback exercise and driving over rough streets, and all other forms of amusement which tend to produce hyperaemia of the genitalia, as well as against bodily and mental fatigue if the signs of spinal and cerebral neurasthenia be marked. Up to this point, the treatment, both local and gen- eral, has been addressed to relieving the inflammation and hyperaesthesia of the prostatic portion of the urethra. When this has been accomplished, abundant observation has convinced me that nothing more, as a rule, is required. Cases, however, do occur in which, after the local lesions have been cured, the irritability of the genital centre is still so exhausted that the erections are not sufficiently vigorous, and the ejaculations are premature. Under these circumstances, as well as in the rarer form of atonic impotence, in which the pros- tatic urethra is devoid of lesions, but in which a stricture, if one be present, will require preliminary treatment, the object is to restore the sexual powers to their nor- mal condition by remedies which tone up the system at large and excite the reflex activity of the genito-spinal centre. An excellent combination is twenty-five drops of the tincture of the chloride of iron, ten drops of 54 ATONIC IMPOTENCE. tincture of nux vomica, and two grains of quinia, to be taken before meals in a wineglassful of sweetened water, which may be replaced by the syrup of the phosphate of iron, quinia, and strychnia, in teaspoonful doses, or by the following combination, which is probably more efficacious than either of the preceding ones: R.—Quiniae sulph., Ferri sulph., aa ^ij; Zinci phosphidi, gr. ij; Acidi arseniosi, gr. jss ; Strychniae sulph., gr. %. M.—Ft. pil. no. xl. S.—Two pills every eight hours. The fluid extract of damiana, in doses of from two to four drachms every eight hours, is said by Caldwell,1 of Baltimore, to be a capital tonic to the nervous centres which preside over erection, and his observations are confirmed by Edwards,2 of Richmond. Among the tonic agents cold sitz-baths and cold ap- plications to the lumbar region for about ten minutes hold a high position. At the commencement it will be wise to employ water at a temperature of 6o° F., and to gradually lower the temperature until it is finally reduced to 460 F. The efficiency of the remedy will be heightened by gently projecting a stream of cold water against the perineum and back; and one of my patients informs me that he has derived the best results from douches of moderate volume after emerging from a Turkish bath. To promote reaction and increase the flow of blood to the lower divisions of the spinal cord and the genitalia, the parts should be briskly rubbed 1 Virginia Med. Monthly, 1879, p. 444. 2 Ibid., p. 716. TREATMENT. 55 Fig. ii. after they are dry with a moderately coarse towel or with a flesh-brush. Cold may be applied directly to the prostatic portion of the urethra by means of the cooling sound or psy- chrophor of Winternitz,1 represented in Fig. n, which is nothing more than a double cur- rent eyeless catheter closed at its beak. To the proximal extremities of this rubber tubes are attached, through one of which the fluid flows into, and through the other out of, the instrument. The former, pro- vided with a stopcock, is connected with a rubber bag suspended a few feet above the patient, while the latter is received in an empty vessel placed at the patient's feet. At the outset, the temperature should be about 570 F., and be gradually re- duced to 52° F., and the sittings be lengthened from five to ten min- utes. The device has been found to be the most beneficial when the ejaculations are too precipitate. Galvanism very deservedly en- joys a high reputation in the treat- ment of impotence. Not only are the electrotonic effects of the con- stant current valuable in increasing the excitability of the genito-spinal centre, but galvani- zation is far more serviceable in restoring the tonicity * Winternitz's psychrophor. 1 Ziemssen's Hdbch. der Allg. Ther., Bd. n, Theil 3, 1881, p. 238. 56 ATONIC IMPOTENCE. of the arterioles of the erectile tissues of the penis, and in increasing the amount of blood flowing in them, than are the measures to which I have just alluded. Although the dose of the current cannot be accurately prescribed by the number of elements of the / battery, the quantity generated by from fifteen to twenty cells will, as a rule, be found to answer the purpose. The anode, or positive electrode, which should be of large size, is placed over the lumbar spine, and the cathode carried over the gland and back of the penis, the cords, testes, and perineum. The sittings at first should be limited to two or three minutes every forty- eight hours; but they may soon be lengthened to five minutes daily. In obstinate cases, particularly if they are complicated by prostatic or seminal discharges, an insulated catheter negative electrode may be passed down to the prostatic urethra, while the anode is applied to the back, groin, or perineum, or it may be replaced by the rectal reophore. Great caution must, however, be observed in the employment of the urethral elec- trode, lest it awaken inflammation of the urethra, or neuralgia of the testis or cord, or even induce suppura- tion of the testis, as I have known to happen in one case from the use of too strong a current. In all cases it will be wise for the operator to begin with from three to five cells, and to test the current by passing it through his own temples, and cautiously to increase the number of elements to fifteen,1 if pain is not excited. In the third or paralytic variety of the affection, or in the other varieties, if galvanism does not bring about the desired result, faradization of the erector muscles of the penis 1 Althaus, Medical Electricity, 3d ed., p. 671. TREATMENT. 57 and the accelerator muscle of the urine is frequently highly serviceable. If this method fails, the interrupted current may be passed through one reophore in the urethra to the other, placed on the perineum and the genitalia, or inserted in the rectum ; while some cases will improve more rapidly, if local faradization and gal- vanization of the cord are employed on alternate days. When the skin of the penis is deficient in sensibility, the electrical brush is indicated. Central galvanization1 and general faradization are beneficial when the symptoms are those of cerebral and spinal exhaustion. In addition to the foregoing measures, a change of air, travel, exercise, amusement, sea-bathing, good food, and a glass of generous wine will do much to give tone to the parts, and the system at large. The end having been accomplished, it remains to put the patient on his guard against marital excess, for unless he practises moderation he is liable to a relapse. In a large proportion of cases the trouble is met with in young men who are engaged to be married. Under these circumstances matrimony should not be delayed, as regular and temperate intercourse tends to promote sexual quietude. When marriage is not contemplated, the patient should lead a continent life, and avoid all sources of sexual excitability. B.--ATONIC IMPOTENCE WITHOUT HYPERESTHESIA OF THE PROSTATIC URETHRA. Imperfect or deficient erection may arise indepen- dently of any lesion of the prostatic portion of the urethra 1 Beard and Rockwell, Med. and Surg. Uses of Electricity, 3d ed., p. 376. 58 PSYCHICAL IMPOTENCE. in persons of nervous or sensitive temperaments, a class of subjects in whom diminished reflex excitability of the lumbar genital centre appears to be induced before pros- tatic inflammation has had time to declare itself. In the preceding form of impotence the patients are, as a rule, robust and strong, and inflammation and hyperaesthesia of the deep urethra are set up before the functions of the genital centre have been much impaired. Of the twelve cases that have come under my notice, eight were due to excessive masturbation, two to gonor- rhoea and masturbation, and two to gonorrhoea alone. In nine a stricture was detected, while three were free from that complication, and the prostatic portion of the urethra was not morbidly sensitive in a single one. In eight of the cases the erections were feeble, and the ejaculations were precipitate; and in four intercourse was impossible, although desire was retained. The treatment of this variety of atonic impotence is the same as that directed for the preceding form after the hyperaesthesia has been remedied. Sect. III. Psychical Impotence. Impotence from the restraining or inhibitory control of the brain over the genito-spinal centre is infinitely less common than the preceding variety; but that erec- tion may fail or cease under the influence of excitement, depressing or other emotions, or mental preoccupation, ETIOLOGY. 59 is a fact with which every one is familiar. Thus newly married men, who were previously potent, and had never indulged in sexual or unnatural excesses, are liable to be troubled in this way, the undue stimulation of the passions at their first efforts at coition having the effect of causing the erection to cease before the act is completed, or of rendering it so feeble that penetration is impossible, or of precipitating emission, or of prevent- ing erection altogether. Grimaud de Caux1 relates the case of a mathematician in whom erection failed before emission, because his thoughts wandered towards the solution of an abstruse problem. Onimus and Legros2 refer to a young man who remained impotent for years after having been surprised at the moment of connec- tion by the husband; and Robaud3 met with a man who had been unable to command an erection during the six months following a railway accident in which he was terribly frightened. The death of a beloved child or wife, as in the cases of Robaud4 and Ultzmann,5 may occasion temporary impotence ; and the loss of a large sum of money6 or the drawing of a prize in a lottery7 may bring about the same result. In other cases, the impotence is, in regard to certain women, due to indiffer- ence, repugnance, or a suspicion of infidelity. Impotence is very frequently entirely imaginary or mental, although it is based upon existing legions. Thus too small a penis, occasional nocturnal seminal losses, 1 Physiologie de l'Espece, p. 341. 2 Traite d'Electricite Medicale, p. 215. 3 Traite de lTmpuissance et de la Sterilite, t. i. p. 186. 4 Op. cit., p. 433. 5 Wiener Klinik, May and June, 1879, P- I3I- 6 Ibid. 7 Robaud, op. cit., p. 186. 60 PSYCHICAL IMPOTENCE. stricture of the urethra, a tight prepuce, varicocele, a gleety discharge, or irritability or neuralgia of the testis, not infrequently restrain erection through fear of ina- bility to penetrate, or of increasing the pollutions, or of impossibility of ejaculating, or of aggravating the local troubles. The same statement is true of moderate masturbators, who probably have normal nocturnal emissions which they assume to be or have been in- formed are indicative of a diseased condition, and who seem to regard impotence as a heritage of their vice. In not one of these conditions is there any valid reason for the trouble, but it has been ignorantly brought on by the constant thought that impotence was the natural result of the supposed infirmities. I have already alluded to the fact that young husbands, in their eagerness to consummate the rite, not infre- quently fail; and I fancy that there are few men who did not ejaculate prematurely when they had connection for the first time. In such cases, the repetition of the act soon corrects the trouble. Most writers on impo- tence, however, teach that it is not uncommon for newly married men to be baffled, simply because they are afraid that they cannot accomplish the act properly, or because the mortification which results from the unfor- tunate attempt gives rise to so much distress and anxiety in regard to its recurrence that the otherwise healthy subjects are really rendered impotent. I am no believer in this doctrine, which is as false in fact as it is perni- cious in regard to the treatment which such cases demand; but I do believe that this condition arises from overlooked lesions of the prostatic urethra which were induced, as a rule, by masturbation. An examination of ETIOLOGY. 61 the views of writers on this subject, as, for example, Van Buren and Keyes,1 Curschmann,2 Rosenthal,3 and Ultzmann,4 will show that nervous or psychical impotence is usually met with in masturbators, subjects who are always more or less timid as to their virile powers, and many of whom are incapable of normal sexual excite- ment. Instead of accepting the statements of these patients, that their failure was due to normal impetuosity, timidity, or want of self-confidence, it will be wise for the surgeon to explore the urethra, since, as I have * already indicated, onanism is the most fruitful source of inflammation and hyperaesthesia of the prostatic portion of the urethra, a view in which I am sustained by Rosenthal, Ultzmann, Black,5 Acton,6 and nearly all sur- gical authors. Hence, the failure to copulate in this class of patients is due to diminished reflex irritability of the centre for erection, although it is possible that undue excitement or timidity may aggravate that condition by exerting an inhibitory influence over the centre. Such cases should, therefore, be relegated to the preceding or atonic variety of impotence. The only case of psychical impotence that I have ever met with is the following : Case XVII. A widower, fifty-two years of age, was engaged to be married, and, despite the fact that he had erections in the presence of 1 Genito-Urinary Diseases, with Syphilis, p. 453. 2 Ziemssen's Cyclopaedia, vol. viii. p. 892. 3 Wiener Klinik, May, 1880, p. 137. 4 Ibid., May and June, 1879, P- I3°- 5 On the Functional Diseases of the Renal, Urinary, and Reproductive Organs. Philada., 1872, pp. 229 and 269. 6 The Functions and Disorders of the Reproductive Organs. 2d Amer. ed., pp. 91 and 240. 62 PSYCHICAL IMPOTENCE. the object of his affection, he was so fearful that he would disgrace himself on the night of his wedding, that he made the experiment with another woman, and utterly failed. As a consequence of this unfortunate test, he constantly brooded over his imaginary trouble, for which he sought my opinion. I found that his genital organs and prostatic urethra were perfectly normal, and succeeded in obtaining his confidence by assuring him that I had met with many cases of a similar nature, and that they had always yielded readily to teaspoonful doses of fluid extract of damiana taken every eight hours for three days before marriage. As a result of this ruse, he subsequently wrote me that the remedy had acted like a charm. The following would have been classified as cases of psychical impotence by physicians who are not in the habit of exploring the urethra in this and allied affections: Case XVIII. A merchant, twenty-eight years of age, stated that he was suffering from spermatorrhoea, which had so weakened his powers that, on attempting intercourse four years previously, the erec- tion was so feeble that it passed off before the completion of the act. He had not renewed the effort, as he was convinced that he was per- manently impotent. I found that the so-called spermatorrhoea con- sisted in an intermittent discharge of prostatic fluid at stool, and in an occasional nocturnal emission. A stricture, calibre 25, was detected at six inches from the meatus, the prostatic urethra was excessively sensitive, and the man had almost constant pain in the back. Case XIX. A lumberman, thirty years of age, consulted me on account of impotence, which he ascribed to undue size of his penis, as he found that on his first connection intromission was difficult, and ejaculation was precipitate and painful; and that on several subsequent efforts the erections did not come up to the proper standard. He had abstained from intercourse for about thirty months, as he was con- vinced that the trouble arose from the size of the organ. He suffered from pain in the back, and weakness of vision, and informed me that he had masturbated from his fifteenth to his twenty-seventh year. There was a stricture, calibre 18, at six inches and a quarter from the meatus, and the prostatic urethra was morbidly sensitive. ETIOLOGY. 63 Case XX. A commercial traveller, thirty-six years of age, com- plains that he has been married for four days, but that he has been unable to consummate the rite, in consequence of the impossibility of intromission from insufficient erections. He has never had gonor- rhoea, nor did he masturbate much in his youth; but during his engagement, which preceded his marriage by seven months, his geni- talia were kept in a constant state of excitement by fondling the object of his affection, and he did not have illicit intercourse to re- lieve his passions. The entire urethra was exquisitely sensitive; but there was no evidence of a coarctation. In the first two of the foregoing cases an inexperi- enced observer might readily have assumed that the trouble depended upon brooding over conditions which the patients thought had prevented natural copulation; and he might have ascribed the failure of erections in the third case to congenital deficiency, a variety of im- potence which is described by certain authors, when the causes are inexplicable. In all of these examples, how- ever, the failure of the first attempts was due to debility of the genital centre, a lesion of which the men were naturally entirely ignorant. I have dwelt somewhat at length upon the erroneous diagnosis which is usually made in cases of so-called psychical or nervous impotence, in order that I might call attention prominently to the importance of examin- ing the urethra in all examples of impotence, since the prognosis is far more favorable when the trouble de- pends upon hyperaesthesia of its prostatic portion than when that condition is absent. Had this precaution been observed by many writers on the subject, they would have been able to give a less gloomy account of psychical impotence, and have said less of the impor- 64 PSYCHICAL IMPOTENCE. tance of gaining the patient's confidence, and of the moral treatment adapted to each case. Treatment.—In the management of psychical impo- tence from undue sexual excitement or emotional causes, little need be done, except to administer a placebo, with the assurance that it will afford relief, since such cases usually remedy themselves. In the case of Grimaud de Caux, the wife resorted to the stratagem of slightly intoxicating the husband before connection, through which he was rendered capable of procreating. In the variety of mental impotence in which an exist- ing lesion has thoroughly impressed the patient with the belief that it is the source of his trouble, the treat- ment usually advised, namely, to gain the man's con- fidence, is not easily carried out. Such patients are very watchful of themselves and of their physicians, and it is useless to try to convince them that a varicocele, for example, is productive of no harm, as far as the sexual functions are concerned, or that the involuntary emissions are strictly within the limits of health. Hence, it is far better to agree with them that their imaginary infirmities demand treatment, to assure them that they are capable of relief, and above all to institute the treatment laid down in surgical works, as it will be found that they are more or less familiar with the various maladies of which they complain. A tight or redundant prepuce should, therefore, be removed, and the introduction of bougies, or local galvanization or faradization, or other measures be resorted to, along with a bitter tonic, and a systematic regulation of the diet, bathing, and exercise. The mind is open to per- SYMPTOMATIC IMPOTENCE. Q5 suasion in this way, but not by mere assurances, or by making light of the fancied disorder. If the subject is contemplating matrimony, he should be advised to fulfil his engagement; and a placebo, such as a minute quantity of phosphorus, or a drachm of the tincture of damiana, of the presumed virtues of which he will have some knowledge, should be administered at stated intervals for a few days previously. ' Sect. IV. Symptomatic Impotence. Sexual power is now and then greatly impaired, if not absolutely destroyed, by the prolonged use of certain cerebral sedatives, as opium, morphia, chloral, bromide of potassium, and alcohol, as well as of cerebral ex- citants, as cannabis indica, and by the administration of or exposure to arsenic, antimony, lead, sulphide of carbon, and iodine. All of these agents are capable of exerting a harmful influence upon the entire organism,, but particularly upon the nervous system and the gen- ital organs, when pushed to an undue extent. The anaphrodisiac action of chloral, of bromide of potassium, and of spirituous and malt liquors is too well known to require illustration. Rosenthal1 has recorded two cases of impotence and azoospermism from the hypodermic injection of several grains of morphia daily; 1 Wiener Klinik, May, 1880, p. 149. 5 66 symptomatic impotence. and Siredey1 states that the habitual use of hashish by the Orientals induces absolute impotence early in life. Biett,2 Charcot,3 Rosenthal,4 and Rayer5 have observed that sexual vigor diminishes and finally ceases with the increase of the dose of arsenic in the treatment of dis- eases of the skin; and Rosenthal6 observed the same effect in a merchant who resided in a room covered with arsenical paper. Lohmerer7 witnessed impotence in four men who were exposed to the fumes of anti- mony; and the absorption of the vapor of sulphide of carbon by workmen engaged in the manufacture of vulcanized caoutchouc is said by Delpech8 to be fol- lowed by loss of virility. Lead poisoning may cause temporary impotence, as in the cases recorded by Sire- dey,9 Portal,10 Roubaud,11 and Rosenthal;12 and Bar- tholow13 thinks that the prolonged use of the iodides has resulted in permanent loss of the sexual power. Impotence is not an uncommon secondary effect of injuries of the brain and spinal cord ; and it may also be symptomatic of various functional disorders and of acute and chronic affections, but particularly of the nervous, digestive, and urinary systems, as brain worry, spinal irritation and weakness, spinal meningitis and myelitis, locomotor ataxia, progressive muscular atrophy, dyspepsia, saccharine diabetes, and albuminuria. I have 1 Diet, de Med. et de Chir. Prat., t. xviii. p. 456. 2 Ibid. 8 Bull, de Ther., Jan. 1864, p. 529. * Loc. cit., p. 151. 5 Ibid. 6 Ibid., p. 152. 7 Orfila, Trait6 de Toxicologie, t. i. p. 650. 8 Diet, de Med. et de Chir. Prat., t. xviii. p. 456. 9 Ibid., p. 455. 10 Cours d'Anat. M6d., t. v. p. 434. 11 Op. cit., p. 303. 12 Loc. cit., p. 153. 1S Materia Medica and Therapeutics, 3d ed., p. 189. PROGNOSIS AND TREATMENT. 67 myself met with a case in a young man in which failure of erections was one of the earliest signs of diabetes, although the quantity of sugar in the urine was small, and the general powers of the system were not reduced. The grade of impotence in that affection, as Seegen1 has demonstrated, is not dependent upon the amount of sugar excreted, as virility may not be impaired when the quantity is large. In the preceding affections, the form of impotence generally met with is the so-called irritable weakness, or the condition characterized by feeble erections and hasty ejaculations, which is soon followed by complete loss of erections with abolition of the sexual appetite. Prognosis and Treatment.—When impotence arises from the excessive use of remedial agents, from satura- tion of the system with arsenic, lead, or other toxic sub- stances, and from certain chronic disorders, the power of erection usually returns with the improvement in the symptoms ; but when it depends upon injuries of the cerebro-spinal axis the outlook is unfavorable. When all signs of inflammation have subsided after disease or injury of the cord, and, in other cases, if the erections are insufficient after the cure of the original trouble, tonics, with a few drops of tincture of cantharides, or minute doses of phosphide of zinc, along with cold douches and galvanization of the spinal cord and testes, are indicated. 1 Der Diabetes Mellitus, p. 112. 68 ORGANIC IMPOTENCE. Sect. V. Organic Impotence. The power of sexual intercourse may be temporarily or permanently abolished in consequence of certain con- genital or acquired malformations, injuries, or diseases of the external genital organs, through which penetra- tion is rendered impossible, or in which the loss of erection depends upon arrested secretory activity of the testes. A.--IMPOTENCE FROM ABNORMAL CONDITIONS OF THE PENIS. a. The malformations of the penis, which prevent coition, are complete absence, a rudimentary condition, or division of the organ, of which vices of conformation, examples have been recorded, respectively, by Goschler,1 Fodere,2 and Forster.3 A double penis, as in the case observed by Van Buren and Keyes,4 may prevent intro- mission ; but in the Portuguese, nineteen years of age, of whom Hart5 gives a full account, there was consider- able virile power left, and the left organ was used in coition. /?. Variations in the size of the penis are causes of rel- ative impotence. In the case of Roubaud,6 in which the organ was only two inches long and of the circumfer- ence of the quill of the porcupine, its volume was increased and intercourse rendered practicable by a mechanical contrivance; while in the case of Wilson,7 in 1 Prajer Vierteljahrschrift, Bd. iii., 1859, P- 89. 2 Medecine Legale, t. i. p. 360. 3 Klebs, Hdbch. der Path. Anat., p. 1132. * Op. cit., p. 5. 5 Lancet, vol. ii., 1865, p. 124. 6 Op. cit., t. i. p. 160. 7 Lectures on the Urinary and Genital Organs, p. 424. ETIOLOGY. 69 which, at the age of twenty-six, the penis and testes were scarcely larger than those of a boy of eight years, the organs acquired the usual size in twenty-four months after marriage. Nothing can be done for the stunted penis which is associated with exstrophy of the bladder. The organ may also be unfitted for use by being par- tially or completely buried or concealed in a large scrotal hernia, hydrocele, or elephantiasis of the scrotum, from which it may be freed by appropriate operations, or by the application of a truss if the hernia be reducible. Extreme size of the penis may also involve relative incapacity for intercourse; and inordinate bulk from elephantiasis or morbid growths of the prepuce, gland, or body of the organ, or from urethral or preputial calculi, may prevent penetration. In these lesions the prognosis is usually favorable, even if the operations for their relief necessitate the removal of the entire gland. Loss of the penis through disease or through design is irremediable. y. Adhesion of the penis to the scrotum, the penis palme of the French writers, in which the former is tied down by its under surface to the latter, and is frequently incurvated, is a rare cause of impotence, but is remedi- able. In the more simple form of the affection liberation of the organ may be effected by division of the web of skin. When, on the other hand, the union is more considerable, and the penis is curved downwards, the combined operation of Weir1 and Bouisson2 holds forth 1 New York Med. Journ., vol, xix. p. 281. 2 De 1'Hypospadias et de son Trait. Chir., t. ii. p. 536. 70 ORGANIC IMPOTENCE. excellent prospects for a good result, and is described by the former surgeon in the following terms: 'An incision was made on each side of the scrotum sufficiently free from the body of the penis to afford skin enough to cover the under surface when released, and the flaps were dissected up to the penis. This constituted the first step of the operation. The second consisted in sepa- rating the urethra, with the corpus spongiosum, from the corpora cavernosa as far back as the posterior margin of the scrotum. This required but a few cuts of the scissors, as the band was only about one inch and a half long, and produced no effect upon the curvature of the penis. On stretching out the curved organ, the septum between the corpora cavernosa could be easily felt as a tense, thickened band, and its division constituted the third step in the operation. It was accomplished by a tenotomy knife, introduced, however, not so far as described by Bouisson, and cutting freely the septum in its lower part and half way between the glans and the scrotum. Immediately after this section was made, the curve was readily abolished, and the deformity thoroughly overcome. The transverse incision made involved, however, the tissues of both corpora cavernosa, and gave rise to persistent and troublesome oozing of blood, only arrested by a ligature placed around an acupressure needle. The skin flaps were then united by a suture on the under surface of the penis, and the gaping edges of the scrotal wound brought together without tension; having, however, first secured the mucous membrane of the urethra by fine sutures to the integument at the pos- terior angle of the wound, that is to say, at the junction of the scrotum with the perineum. The penis was laid ETIOLOGY. 71 against the abdomen, without need of a retaining band- age, and cold-water dressings were applied to the parts." s. Distortion of the penis may prevent copulation, and may be due to congenital or acquired affections of the corpus spongiosum or the corpora cavernosa. i. The most common cause of unusual shape of the male organ, according to my observation, is congenital shortness of the corpus spongiosum, which acts like the string of a bow, and keeps the penis bent downwards towards the perineum. In a few examples this is the only deformity; but in the majority there is a slight degree of hypospadias, and the gland is somewhat flattened. I have myself met with impotence from this cause in two instances, and have seen at least a dozen additional cases in the practice of Professor Gross and Professor Pancoast. For the relief of this condition, the operation of cutting a wedge out of the corpora cavernosa, which was devised by Physick1 and which has been successfully practised by Gross, Pancoast, Furneaux Jordan,2 of Birmingham, and myself, is attended with the most grat- ifying results. The skin of the dorsum of the penis, behind the gland, having been pinched up and divided transversely by transfixing its base, a V-shaped portion, embracing about two-thirds of the thickness of the corpora cavernosa, and of sufficient length to remedy the deformity, is excised by carrying the bistoury first from behind forwards, and then from before backwards, the second incision being made about a quarter of an 1 Gross's Surgery, 6th ed., vol. ii. p. 834. 2 Lancet, vol. i., 1876, p. 169. 72 ORGANIC IMPOTENCE. inch behind the head of the penis. The arteries, two or three in number, having been secured by fine ligatures, the edges of the wound are approximated by three sil- ver sutures, one of which is carried through the cut sur- faces of the septum, and the other through the sides of the tunica albuginea, the edges of the wound of the skin being brought together separately. The penis is then supported upon a splint and kept covered with cold water, and the stitches are removed in eight or ten days. For some days previous to the operation, full doses of bromide of potassium should be administered, with the view to prevent erections. 2. Vicious direction of the penis is generally due to the formation of circumscribed plates or lumps of indura- tion in the erectile tissue and fibrous sheath of the corpora cavernosa, an affection which was first described by La Peyronie,1 and subsequently by Boyer,2 Kirby,3 Johnson,4 Galligo,5 Cruveilhier,6 Gross,7 Hewett,8 Van Buren and Keyes,9 Curling,10 Scholz,11 and other observers. The areas of induration are usually single, and confined to one of the cylinders, although, as in several examples recorded by Kirby and Galligo, they may be multiple, and be scattered throughout the organ ; and, as in a case observed by Curling, they may be associated with a 1 Mem. de l'Acad. Roy. de Chir., t. i., 1819, p. 316. 2 Traite des Mai. Chir., t. vi. p. 802. 3 Dublin Med. Press, Oct. 3, 1849, P- 2°9- 4 London Lancet, vol. ii., 1851, p. 481. 5 Gaz. Med. de Paris, 1852, p. 440. 6 Anat. Path. t. iii. p. 593. 7 Op. cit., vol. ii. pp. 833 and 858. 8 British Med. Journ., Feb. 1872. 9 New York Med. Journ., vol. xix. p. 390, and op. cit., p. 24. 10 Op. cit., p. 462. u Schmidt's Jahrb., Bd. cii. p. 33. ETIOLOGY. 73 similar lesion of the corpus spongiosum. Their con- sistence varies, but it is usually hard and cartilaginous. As the natural result of the obliteration of the meshes of the erectile tissue, the organ, during erection, deviates towards the lesion, so that it may be drawn upwards, downwards, or to either side, thereby materially inter- fering with coition, if not rendering that act impracti- cable. In one case reported by Van Buren and Keyes, the penis curved almost to a right angle, and in others it assumed a spiral form. The affection is almost always met with after middle life, but its etiology is obscure. Of twenty-five examples which I have collated, in ten the cause could not be determined ; in seven it was connected with the gouty diathesis; in four it resulted from injury during coition; in three it was ascribed to gonorrhoea; and in one it arose from a violent erection. Kirby, Curling, and Hewett believe that it is connected with gout; Gross has met with it most frequently in men who have committed venereal excesses; while others think that it usually arises from extension of gonorrhceal inflammation. Of the intimate nature of the lesion, nothing is accu- rately known, as the condition has not been verified by post-mortem inspection. Hewett supposes that the nodules arise from clots of blood in the meshes of the corpora cavernosa; Van Buren and Keyes think that they depend essentially upon chronic inflammatory plastic obliteration of the meshes ; and Klebs1 teaches that they are the result of a combination of inflamma- tion and thrombosis. 1 Hdbch. der Path. Anat., p. 1152. 74 ORGANIC IMPOTENCE. e. Closely allied to the preceding affection is cicatricial induration of the corpora cavernosa, the effect of injury, abscess, or destructive inflammation. Thus, Cursch- mann1 relates a case of upward and lateral deviation of the penis from an induration resulting from forcing the erect penis downwards. Baudens2 records an example of gunshot wound of one corpus cavernosum, with lateral curvature. Johnson3 met with an instance of distortion from abscess of the right corpus cavernosum; and he also describes a case in which the glans penis came in contact with the left side of the pubes from burrowing phagedaena. f. Gummata of the corpora cavernosa, of which con- dition Ricord4 has given a good description, are not in- frequently attended with faulty curvature of the penis; but, as they do not evince any tendency to break down, they are indistinguishable from the patches of induration resulting from other causes. v- Calcification of the septum pectiniforme, or the cor- pora cavernosa, may give rise to impotence from upward or downward curvature of the penis. In the case of a man, fifty-two years of age, McClellan5 relieved the deformity by removing a so-called ossified septum by an incision which extended throughout the entire length of the organ ; and Regnoli6 also restored the power of 1 Loc. cit., p. 886. 2 Clinique des Plaies d'Armes a. Feu, p. 408. 3 Loc. cit., p. 574. 4 Bumstead and Taylor, Venereal Diseases, 4th ed., p. 639. 5 Lancet, vol. i., 1828, p. 714. 6 Petrequin, Brit, and For. Med. Rev., vol. xx. p. 136. ETIOLOGY. 75 normal erection by excising the ossified portion, which did not include the entire thickness of the cylinders. When distortion of the penis arises from gummata, the prospect of relief from the administration of iodide of potassium and bichloride of mercury, and from fric- tion with mercurial ointment, is favorable. The indura- « tion resulting from laceration, or so-called fracture, of the corpora cavernosa is irremediable. The prognosis in circumscribed patches of these bodies is notoriously unfavorable, as the only cure from general measures, of which I have any knowledge, is that obtained by Scholz by the application of tincture of iodine, plaster of Vigo, and warm douches; although Curling1 records a case in which the hardness nearly disappeared, and in which the erections were almost normal, by the internal administration of biniodide of mercury and by the local use of tincture of iodine. In a case narrated by Fried- berg,2 an induration of the corpus cavernosum as large as a hazel-nut was made to disappear by inserting a seton under the skin, and permitting it to remain in contact with the tunica albuginea for one month. Boyer and Gross recommend excision of the patches, a prac- tice which I myself would follow if they were single, and of moderate volume. When the curvature depends upon calcification of the corpora cavernosa or its sep- tum, the outlook is far better, since the removal of the offending substance, as in cases of McClellan and Reg- noli, is followed by the most gratifying results. After a shot wound of the right corpus cavernosum, which 1 Op. cit., p. 464. 2 Prajer Vierteljahrschrift, Bd. i. 1862, p. 20. 76 ORGANIC IMPOTENCE. terminated in a hard, depressed, and adherent cicatrix, Baudens succeeded in effecting a cure by making two incisions in the opposite cylinder, on a level with the upper and lower extremities of the scar, and exciting suppuration by the insertion of tents, through which manoeuvre a compensating induration was obtained, and the curvature was remedied. e. The power of erection may be lost in consequence of the permanent retention of a ball in the corpus caver- nosum, of which curious condition I have recorded an example.1 The missile was encysted in the right cyl- inder, and its point presented towards the pubes, from which it was separated about one inch; but the man refused to have it removed. i. Impotence may depend upon congenital or acquired shortness of the frenum, through which the head of the penis is distorted; and coition is abstained from on account of the suffering with which the act is attended. The proper remedy is division. x- Finally, insufficient erections are occasioned by varix of the dorsal vein of the penis. In a case of this description, Parona2 effected- a rapid cure by the intra- venous injection of equal parts of chloral and water; and Bartholow3 states that he has obtained excellent results from the hypodermic injection of ergotine in the immediate vicinity of the enlarged and tortuous vein. 1 Med. and Surg. History of the War of the Rebellion, Part II., vol. ii. P- 345- 2 Annales de Derm, et de la Syph., t. v. p. 453. 3 Op. cit., p. 295. ETIOLOGY. 77 B.--IMPOTENCE FROM DEFECTS AND DISEASE OF THE TESTES. a. Congenital bilateral anorchidism, or absence of the testes, of which condition examples are quoted in the chapter on sterility, is necessarily attended with absolute impotence. Cryptorchids, or persons in whom the organs are retained in the abdomen or the groins, are on the other hand generally potent, although they are only ex- ceptionally fertile; and arrest of development, as a rule, diminishes virility. /3. Loss of the testes from disease, self-mutilation, or surgical interference is presumptive of inability to copu- late, although in exceptional cases the erections may continue for a considerable time, as is exemplified in the following instances. Sir Astley Cooper removed the testis of a man two years after the other had been excised. For the first twelve months he had connections. At the end of two years the erections were more rare and imperfect, and they usually ceased under attempts at congress. Ten years subsequently he stated that he had had intercourse only once during the previous year; and twenty-eight years after the operation the penis was shrivelled and wasted, and for many years coition had been impossible. Mr. Wilson1 removed both testes for malignant dis- ease, and the man survived the operation two years. He had occasional erections, and intercourse was at- tended with the usual feeling and with the ejaculation of some fluid. 1 Lectures on the Urinary and Genital Organs, p. 133. 78 ORGANIC IMPOTENCE. Professor Humphry1 met with a man who had sub- mitted to castration on account of nervous troubles, but who was able to have connections with an emission for more than a year, although less frequently than before the mutilation. Mr. Curling2 removed the right testis of an officer seven years after the excision of the left testis by an- other surgeon. At the expiration of four years and a half from the operation the officer informed Mr. Curling that he had intercourse with his wife about once a fort- night, but without an ejaculation. y. Progressive atrophy of the testes is very liable to be attended with impotence; and Liegeois3 found that the power of erection was diminished in four cases out of six of atrophy of one organ. £ Bilateral syphilitic orchitis generally involves impo- tence ;4 while of forty-one examples of double epididy- mitis analyzed by Liegeois5 and Gosselin6 virility was diminished in only eight. e. Tztmors, as carcinoma, and sarcoma, and tubercle, when they completely destroy or disorganize the paren- chyma of the testes, are also attended with impotence; but the statement does not hold good when one organ alone is affected. 1 Holmes' System of Surgery, 2d ed., vol. v. p. 160. 2 Op. cit., 4th ed., pp. 307 and 450. 3 Annales de Derm, et de la Syph., t. i. p. 437. 4 Liegeois, loc. cit., p. 431. 5 Ibid., p. 424. 6 Archives Generates, ser. 5, t. ii. p. 267. TREATMENT. 79 The power of erection after having been lost may usually be restored, when it depends upon syphilitic orchitis, by mercurial inunctions and the exhibition of iodide of potassium and bichloride of mercury. Arrest of development of the testes is sometimes overcome by the influence of sexual desires, as in the interesting example recorded by Wilson,1 in which, at the age of twenty-six, the glands were not larger than those of a child, but in which they increased almost to the volume of those of an adult man two years after marriage. In all the remaining causes of impotence from lesions of the testes the trouble is beyond relief. 1 Op. cit., p. 424. 80 STERILITY. CHAPTER II. STERILITY. Sect. I. General Observations. The generative act on the part of the male implies the completion of sexual congress with an ejaculation of fertile semen, and'its deposition in the upper part of the vagina. As we have already seen, the capacity for cop- ulation depends upon the perfect erection of the penis, the failure of which renders the man sterile from impo- tence. Sterility, on the other hand, not only does not include impotence, but is met with in subjects who are vigorous in intercourse, and who ejaculate a fluid which, in the absence of minute examination, presents all the properties of normal semen. Hence it is difficult for these subjects to realize that they are the cause of barren marriages. For the proper understanding of the alterations which the semen undergoes in disease, I consider it requisite to preface the consideration of sterility with a summary of the most important attributes of the normal fluid. Semen is the mixed product of the secretions of the testes, vasa deferentia, seminal vesicles, sinus pocularis, prostate, Cowper's glands, and the mucous follicles of the urethra. The thick, white, pasty secretion of the seminiferous tubes consists mainly of spermatoblasts, or seminal cells, out of which the spermatozoa, or fertilizing elements, are developed; but the spermatozoa first make their appearance in the rete testis, and constitute at composition of the semen. 81 least nine-tenths of the glutinous mass. In the epididy- mes and vasa deferentia the zoosperms are perfectly motionless from the density of the medium in which they are contained ; but when they have reached the seminal vesicles they are in active rhythmical undulating motion. These facts are noticed because some authors have erroneously based their conclusions in regard to the productiveness of the semen upon minute examination of the parenchyma of the testes and the epididymes, or situations in which spermatozoa are only forming, or in which they have as yet not acquired mobility. The fluid contained in the seminal vesicles is odorless, viscous, and colorless, resembling fresh honey, heavier than water, of neutral reaction, and does not coagulate. When, however, it is incorporated with the secretions of the prostatic and urethral glands, semen has an albu- minous consistence, a whitish or opalescent tint, and an alkaline reaction, and it emits a peculiar faint odor which is not unlike that of the raspings of fresh horn or bone. After ejaculation it is transformed into a gelatinous mass, but it becomes more fluid after exposure to the air for a few minutes. From the preceding considerations it is obvious that, while the testes furnish the fecundating elements of the semen, the secretions of the associated glands, and par- ticularly the secretion of the prostate, not only render it more thin and abundant, but also impart to it its color, odor, alkalinity, and coagulability. The prostatic fluid, moreover, has a more important function that that of serving as a vehicle for the transmission of the sperma- tozoa to the uterus, since Kraus1 has shown that, in its 1 Medical Times and Gazette,'vol. i., 1871, p. 170. 6 82 STERILITY. absence, these bodies cannot live in the uterine mucus, but that, with its aid, they often survive more than thirty- six hours, or even for eight days and a half, as has been demonstrated by Percy,1 of New York. As early as 1856 Dr. Marris Wilson2 assigned the same purpose to the secretion of the prostate, and regarded the neutral phosphate of lime contained in that fluid as the element upon which the vitality of the sper- matozoa depends, since it protects them against destruc- tion by the too acid or too alkaline conditions of the secretions of the passages through which they have to pass in their progress to the ovum. If the ejaculated semen be permitted to stand in a test tube for a few hours, it will separate into two layers, of which the upper one, or the liquor seminis, is thin, whey-like, and transparent, and contains a few epithelial cells derived from the seminal passages and detritus, while the lower one is thick, white, opaque, and consists of spermatozoa. From the thickness of the sediment, and the rapidity of its precipitation, Ultzmann3 states that a conclusion may be drawn in regard to the number of spermatozoa in any given specimen, as will be pointed out in the consideration of azoospermism from abnormal conditions of the semen. A drop of semen discloses under the microscope, as in Fig. 12, the male elements of generation, or sperma- tozoa, which are constituted by a pyriform, flattened head, an intermediate portion, or the beginning of the tail, and a long, tapering, filiform tail, which is in rapid undulating motion, and which propels the head directly 1 Sims, Uterine Surgery, p. 374. 2 Lancet, vol. ii., 1856, p. 483. 3 Wiener Klinik, May and June, 1879, P- I53« COMPOSITION of the SEMEN. 83 forwards. These movements should continue at least twelve hours after the fluid is ejaculated. If they are wanting, and the spermatozoa are alive, as may happen Fig. 12. Fig. 13. Spermatozoa. Spermatic crystals. when the semen is too thick, motion may be excited by the addition of weak alkaline solutions; but if they remain motionless under this treatment, they are inca- pable of impregnating the ovum. Minute examination of semen which has been allowed to dry on an object glass, or of the lower layer which forms after the secretion has stood for some time, shows, on the second or third day, at first a few and later a considerable number of transparent, variously modified rhombic prisms with their bases in apposition; the ends of these occasionally terminate in fine points, but usu- ally in rhombi, as in Fig. 13. They, were discovered by Van Deen1 and Boettcher,2 the latter of whom termed 1 Ctrbl. fiir die Med. Wiss., 1864, p. 355. 2 Virchow's Archiv, Bd. xxxii. p. 535. 84 STERILITY. them spermatic crystals, and regarded them as being composed of albumen. Ultzmann, however, says that they consist of phosphate of magnesium, while other ob- servers regard them as being composed of ammonio- magnesian phosphate, a view in which I coincide, and which is verified by Fig. 16. Ultzmann1 has directed attention to the fact, which has been confirmed by Rosenthal's2 and my own investigations, that the early and abundant formation of these crystals denotes a diminution of the number of the spermatozoa or their entire absence; and Fiibringer,3 from an examination of the contents of the seminal vesicles and the prostatic fluid of sixty-six bodies, and of the prostatic secretion derived from twenty-one healthy persons, has demon- strated that the crystals occur exclusively in the latter, and that they indicate functional activity of the glands of the prostate. Semen begins to be secreted at the epoch of puberty, and continues to be formed until an advanced age, although the sexual power is usually lost after the sixty- fifth year. Liegeois4 examined the ejaculated fluid of eight young persons, and found abundant spermatozoa in two at fourteen years, in four at sixteen years, and in two at eighteen years. Previous to the researches of Duplay5 in 1852, and of Dieu6 in 1867, the opinion was very general that the semen of old persons was as infertile as was that of impubic boys, although Wagner7 1 Loc. cit., p. 154. 2 Wiener Klinik, May, 1880, pp. 137, 139, and 149. 3 Volkmann's Vortrage, No. 207, pp. 1848-1851. * Medical Times and Gazette, vol. ii., 1869, p. 247. 5 Archives Gen6rales, ser. 4, t. xxx. p. 385. 6 Journ. de l'Anat. et de Phys., 1867, p. 449. T Histoire de la Generation, p. 31. CLASSIFICATION. 85 has noted the presence of spermatozoa in sexagenarians and septenarians, and Curling1 and Casper2 had met with them, respectively, at eighty-seven and ninety-six years. That old men in the enjoyment of good health are as able to produce zoosperms as younger men is shown by the investigations of Liegeois,3 who discovered them in every examination, thirteen in number, of the fluid emitted by that class of persons. When death, however, occurs from decrepitude, or without any organic lesions except those which are common to advanced age, Dieu found that the fluid of the seminal vesicles contained spermatozoa in only six, or twenty-three per cent., of twenty-three examinations. From these observations we may conclude that the secretion of semen continues to be formed in healthy old men, but that it is very liable to cease in decrepitude. These facts and the production of semen in disease will receive full attention in the succeeding section. Classification. — Sterility includes, first, azoosper- mism, or the condition in which either no semen whatso- ever, or unproductive semen, is secreted; secondly, aspermatism, in which spermatic fluid is not ejaculated; and, thirdly, misemission, or the failure to deposit fertile semen in the upper portion of the vagina. In the first variety intercourse and ejaculation are natural, but the essential anatomical elements are absent or dead, either because they are not formed or are imprisoned behind an obstacle seated in the epididymes or vasa deferentia, or because they are unable to live in the medium in 1 Op. cit., p. 432. 2 Forensic Medicine, Syd. ed., 1864, p. 292. 3 Loc. cit., p. 247. 86 STERILITY. which they are suspended. In the second variety the ability to copulate is unimpaired, but the power to ejacu- late is prevented by an impediment situated between the seminal vesicles and the urinary meatus. In the third variety coition and emission are perfect; but fruitful semen fails to reach its proper destination, in consequence of congenital deficiencies of the urethra, or of fistulous openings in that canal resulting from inflammation, or of abnormal positions of the meatus. Relative Frequency.—It is not at all uncommon for physicians to assume that a man who is potent, and who is able to ejaculate, is capable of procreating. As a result of the omission to examine the emitted fluid, and carefully to explore the male organs, little is known of the relative frequency of sterility in the two sexes; and gynecologists, with the exception of those men- tioned below, do not appear to have made any contribu- tions to the solution of this important subject. I have been able to collect one hundred and ninety-two cases in which examination of both the husband and wife demonstrates that the former was at fault in thirty- three, or in seventeen per cent. Of this number, Man- ningham1 records one in thirty; Pajot1 seven in eighty; Mondot one in ten ;x Kehrer2 fourteen in forty ; Courty3 one in ten; Noeggerath4 eight in fourteen; and I my- self have found that the male was deficient in one 1 Wiener Med. Blatter, 1879, PP- I223 and 1271. 2 Beitrage zur Klin, und Exper. Geburtskunde und Gynaekologie, Bd. ii. p. 76. 3 Wiener Med. Presse, 1880, p. 252. 4 Trans. Amer. Gynec. Soc, vol. i. p. 287. bilateral anorchids. 87 example in eight. The cause of the sterility was azoospermism is thirty-one, and aspermatism in two. These facts show that the husband is at fault in about one case out of every six; and they convey information which should be carefully weighed before the practi- tioner even resorts to inspection of the female organs of generation. Sect. II. Azoospermism. Azoospermism may be due, first, to congenital bi- lateral anorchidism; secondly, to congenital bilateral deficiencies of the epididymis or vas deferens; thirdly, to cryptorchidism ; fourthly, to affections of the testes; fifthly, to obliteration or obstruction of the epididymes or vasa deferentia; and sixthly, to abnormal conditions of the semen. Hence, the affection may be congenital or acquired, and absolute or relative. a.—bilateral anorchids. Men born without testes are not only azoospermous, but, from the fact that the accessory secreting organs are rudimentary, they are unable to ejaculate a drop of any kind of fluid. From a study of four cases, Godard1 found that persons in this condition resemble eunuchs mutilated early in life. They have no venereal desire, 1 Note sur l'Absence Congeniale du Testicule. Memoires de la Soc. de Biologie, 1859, p. 311. 88 AZOOSPKRMISM. and although they may have, as an exception, erections, they are absolutely impotent and sterile. It is important to bear in mind that a distinction may be made between anorchids and cryptorchids, when the testes are retained in the abdomen, as the latter are apt at coition, and emit a fluid which is, however, as a rule, devoid of spermatozoa. B.--CONGENITAL BILATERAL DEFICIENCY OF THE EPIDIDYMIS AND VAS DEFERENS. Double deficiencies of the excretory apparatus of the testes prevent the elimination of the secretion of the latter, and render them useless. Rhodius1 met with an instance of absence of the epididymes in an adult; and John Hunter2 dissected a body in which, while the testes were normal and were contained in the scrotum, the epididymes and vasa deferentia were deficient, and the seminal vesicles did not communicate with the urethra. Although the state of the genital functions in these cases must remain a matter of conjecture, there is no reason for believing that a mere deficiency of the excretory passages between the testes and seminal vesicles engenders impotence and incapability of ejacu- lation, provided the seminal vesicles, ejaculatory ducts, and the prostate are normal, as, under these circum- stances, the condition would not be worse than that of 1 Quoted by Godard in his Note sur l'Absence Congeniale du Canal Ex- creteur et du Reservoir de la Semence, le Testicule Existant. Ibid., p. 335. 2 Works by Palmer, vol. iv. p. 23. ABNORMAL POSITION OF TESTES. 89 imprisonment of the secretion of the testes by acquired obstruction of the vasa deferentia. C.--FAILURE OF THE TESTES TO DESCEND INTO THE SCROTUM. When the testes fail to descend into the scrotum, and are retained in the abdomen or the groins, they are generally small and undeveloped, and now and then atrophied through fibrous or fatty degeneration. As a result of these malpositions and morbid changes, cryp- torchids were, up to a comparatively recent date, declared to be absolutely sterile, although they were known to enjoy the capacity for copulation and ejaculation. Op- posed to this opinion, which was maintained by Follin,1 Gosselin,2 Godard,3 Liegeois,4 and formerly by Curling,5 are the instances recorded by Poland,6 Cock,7 Durham,8 and Debrou,9 of married cryptorchids who had procreated children. It is highly probable that fecundation in these cases was due to another source, a supposition which is strengthened by the fact that spermatozoa were not observed in the patient of Debrou after death from strangulated hernia, and that the ejaculated fluid does not appear to have been minutely examined in the others; and there is other evidence which proves that the retained testes may perform their functions. Thus, 1 Archives Generales, ser. 4, t. vi. p. 257. 2 Ibid., ser. 5, t. ii. p. 268. 3 Etudes sur la Monorchidie et la Cryptorchidie, p. 143. 4 Medical Times and Gazette, vol. ii., 1869, p. 248. 5 Brit, and For. Med.-Chir. Rev., April, 1864, p. 495 et seq. 6 Guy's Hospital Reports, ser. 2, vol. i. p. 162. 7 Curling, op. cit. 4th ed., pp. 470 and 471. s ibid. 9 Ibid. 90 AZOOSPERMISM. Beigel1 narrates the case of a man, two-and-twenty years of age, whose testes were situated in the groins, and whose emitted semen disclosed spermatozoa; and Val- lette2 found those bodies in the vas deferentia of an inguinal cryptorchid. On the whole, the evidence in regard to cryptorchids shows that while, as a rule, they are potent, and ejacu- late a fluid which is devoid of spermatozoa, exceptional instances indicate that they may be fertile. This opinion is held by Casper;3 but the question of fecundity should always be determined by microscopical examination of the ejaculated semen of such persons when they are contemplating matrimony. D.--AFFECTIONS OF THE TESTES. Disorders of the testes are liable to be accompanied with temporary or permanent absence of the sperma- tozoa. In six cases of bilateral atrophy, Liegeois4 found that these bodies were greatly diminished; and they are not formed when the wasting is excessive. The only instances in which the semen has been examined in the latter condition, of which I have any knowledge, are three recorded by Curling,5 and one by Laborde and Cousrem;6 and spermatozoa were absent in all. Simple parenchymatous orchitis, and total disorganization of the substance of the testes, from whatever cause they may 1 Virchow's Archiv, Bd. xxxviii. p. 144. 2 Pitha und Billroth's Handbuch, Bd. iii., Abth. ii., Lief. 7, p. 419, 3 Forensic Medicine, Syd. ed., 1864, p. 256. 4 Loc. cit., p. 541. 5 Op. cit., pp. 69 and 83. 6 Comptes Rendus de la Societe de Biologie, 1859, P- 24-8- OBLITERATION OF THE EXCRETORY PASSAGES. 91 arise, are followed by absolute azoospermism. Partial destruction by malignant, tubercular, cystic, and other new formations, on the other hand, does not necessarily occasion sterility. Syphilitic orchitis, when pronounced, generally abolishes the functions of the organs, but sper- matozoa may return under proper treatment. It need scarcely be added that loss of the testes, as from castra- tion, renders the subject permanently azoospermous, although he may for a certain time ejaculate the fluid of the accessory glands, a phenomenon which is referred to on page yy. Godard1 has called attention to the singular fact, which he confirmed by examination of the ejaculated semen and of the contents of the seminal vesicles, that one tubercular testis renders the subject absolutely sterile; and, what is more astonishing, he found that the azoospermism preceded the development of the tuber- cular affection from one to two years. Hence he utilizes this condition for the differential diagnosis between uni- lateral tubercular orchitis and ordinary orchitis, in the latter of which fertile semen is secreted. E.--BILATERAL OBLITERATION OF THE EPIDIDYMIS AND VAS DEFERENS. By far the most frequent and important of the causes of azoospermism is bilateral obliteration of the epididy- mis and vas deferens, through which the proper secretion of the testes is confined and is prevented from reaching the vesiculae seminales and the urethra, and the ejacu- lated fluid is of necessity deprived of spermatozoa. Ob- 1 Ante. 92 AZOOSPERMISM. literation of the seminal passages, as Gosselin1 first pointed out, is usually due to gonorrhoea, when it is, with few exceptions, confined to the epididymes, the vasa deferentia alone being rarely involved. I am not aware that it has ever been traced to traumatic inflam- mation, as wounds and contusions are generally limited to one side. Tubercular deposits in the epididymes not uncommonly occasion sterility; and a few examples are recorded of azoospermism from bilateral sarcomatous or carcinomatous degeneration of the epididymis. I have myself witnessed the same result in a case of double syphilitic epididymitis, the indurations having made their appearance on the seventy-second day after the first observation of the initial lesion. A most important inquiry in connection with oblitera- tions of the excretory apparatus of the testes is, whether the functional activity of the opposite gland is abrogated when the lesion is confined to one side. Liegeois2 found in thirteen examinations of the discharge of persons affected with unilateral epididymitis that the number of spermatozoa was greatly diminished; and he refers to three cases of Hirtz, Duplay, and Gosselin in which the spermatic fluid was entirely devoid of those bodies. As the same occurrence is witnessed in tubercular epididy- mitis of one side, Liegeois believes, and Ultzmann3 agrees with him, that the testes are so closely united by reflex ties that unilateral epididymitis may abolish the functions of the opposite gland and thereby produce sterility. This conclusion is supported by five cases of 1 Archives Generates, ser. 4, t. xiv. p. 406, and t. xv. p. 40, and ser. 5, t. ii. p. 257. 2 Loc. cit., p. 541. 3 Wiener Klinik, 1879, P- J56- OBLITERATION OF THE EXCRETORY PASSAGES. 93 unilateral epididymitis in which spermatozoa were en- tirely absent, recorded by Kehrer;1 but it is utterly at variance with observations based upon analogous con- ditions. Duplay, for example, has recorded six instances of obliteration of one vas deferens with spermatozoa in the epididymis of the opposite side; and Godard shows that congenital absence of one excretory duct, or even of one testis, exerts no effect upon the generative functions. In bilateral gonorrhceal epididymitis the inflammatory new material may be seated in the interior of the canals, in their walls, or in the interstitial connective tissue, and the resulting obstruction or induration is very liable to be permanent and incurable, since, of eighty-three cases recorded by Gosselin, Godard, and Liegeois,2 the sper- matozoa returned in only eight. The testes themselves continue to secrete and preserve their normal volume and appearances, and as the subjects ejaculate they are not aware that they are sterile. Liegeois found in twenty-one instances that impotence was present in eight; but of twenty cases observed by Gosselin all were thoroughly potent. The former3 states that the ejaculated fluid is rarely milky white, as in the normal condition, and that it possesses a yellowish tint when leucocytes are present in large numbers; while Gos- selin4 could not trace any variations from the natural color, quantity, odor, and consistence. In a case of azoospermism from double epididymitis, Nepveu5 found that the discharge contained hyaline cylinders which 1 Op. cit., pp. 79 and 82. 2 Loc. cit., p. 380. 3 Loc. cit., p. 511. * Archives Generates, ser. 5, t. ii. p. 267. 5 Gazette Medicate de Paris, 1874, p. 32. 94 AZOOSPERMISM. were casts of the vasa deferentia, and which frequently attained a length of from three to five centimetres. F.--ABNORMAL CONDITIONS OF THE SEMEN. The quality and composition of the ejaculated seminal fluid are liable to be materially altered by sexual ex- cesses, by various exhausting diseases, and by inflam- matory conditions of the epididymes, vasa deferentia, seminal vesicles, and prostate, which are entitled to a detailed examination. a. Temporary absence of the spermatozoa may be in- duced, in perfectly healthy men, by sexual excesses, and the frequent repetition of the act of coition renders the semen more and more watery and scanty, so that it consists merely of the secretions of the accessory glands. In the case of a medical student, recorded by Liegeois,1 who indulged in three or four connections daily for ten successive days, repeated examinations of the emissions demonstrated the complete absence of spermatozoa. Some months later, after an abstinence of three weeks, they were detected in large numbers. The case of Casper2 is so interesting in this respect that it is quoted entire: "A vigorous naturalist, sixty years of age, a married man, and father of a large family, and accus- tomed to the use of the microscope, whom I had in- terested in this question, examined with me for some time continuously his own semen after coitus. Here we found the greatest variations, which were accurately 1 Loc. cit., p. 247. 2 Op. cit., p. 292. ABNORMAL CONDITIONS OF THE SEMEN. 95 noted by both of us together. After coitus on the third day, reckoning from the last performance of the act, there was a large number of very small spermatozoa ; after renewed coitus on the fourth day, few and small; after a pause of only two days, none; after a pause of only one day there was only a watery sperma, in which no zoosperms were found. At another time, on the fifth day after the last coitus, the zoosperms were very numerous; another time, after a pause of six days, they were few, but large in size ; four months after the last examination, and seventy-two hours after the last act, the zoosperms were comparatively very small, and at another time, on the third day after the last act, they were innumerable. Immediately after coitus, and before emptying the bladder, the urethra was twice examined. Twenty-four hours after the last act, a drop passed out of the urethra exhibited numerous small zoosperms; at another time, after a three days' interval, there was not a single zoosperm." Permanent absence of the spermatozoa is said to occur now and then as an idiopathic affection. The only cases bearing upon this point, of which I have any knowledge, are those narrated by Hirtz.1 Two young, robust, married, but childless men, performed coition with unusual vigor. The ejaculations were never fol- lowed by the sense of fatigue so generally experienced after intercourse, and the fluid was void of spermatozoa. While it is impossible to explain these cases satisfac- torily, I am inclined to believe that the " unusual vigor " which they displayed points to their having indulged too often in proportion to their powers, and that they are 1 Gazette de Strasbourg, No. 5, 1861. 96 AZOOSPERMISM. to be classed among the cases of azoospermism from sexual excesses. /?. One of the most common causes of infertile semen is nervous exhaustion or neurasthenia, attended with abnormal seminal and prostatic discharges, and with various degrees of impotence. This condition is usu- ally brought about by onanism, venereal excesses, or ungratified desires, and may be regarded as an exag- gerated or advanced stage of the preceding variety of azoospermism. As a result of impaired nutrition, in- duced by perverted innervation, the secretory activity of the testes is interfered with, and either the evolution of the spermatozoa is arrested, or their number and their activity are diminished. In addition to this factor, it is highly probable that the zoosperms are unable to exist in the altered prostatic fluid, since the microscope shows that they are motionless, and thereby confirms the view of Kraus and Wilson, to which allusion has already been made in the study of normal semen, that the vitality of the spermatozoa is dependent upon the presence of the healthy secretion of the prostate. The investigations of Rosenthal,1 Ultzmann,2 and Curschmann3 demonstrate that, when potence is as yet little affected, and pollutions are merely beginning to overstep the natural limits, the ejaculated fluid is un- changed. When the pollutions are more frequent, and there are diurnal discharges, the spermatozoa are smaller and more scanty; their movements are less active than 1 Wiener Klinik, May, 1880, p. 137. 2 Wiener Med. Presse, 1876, p. 599. 3 Ziemssen's Cyclopaedia, Amer. ed., vol. viii. p. 852. ABNORMAL CONDITIONS OF THE SEMEN. 97 in the normal condition, are liable to be abolished in less than an hour, and are incapable of being reawakened by alkaline solutions. Spermatic crystals, moreover, form more rapidly, and in greater abundance than in health. In the worst cases, or in those characterized by diurnal and nocturnal pollutions, and by the presence of semen in the urine, the spermatozoa are either entirely absent, or, if they are present, they are motionless, stunted, or variously deformed. In these advanced in- stances the semen is frequently seen to have undergone fatty degeneration, as indicated by granular epithelium, by molecular detritus, and even by oil globules in the protoplasm of the altered spermatozoa. Spermatic crys- tals are also abundant, and appear quickly. These observations are in accord with those of Lalle- mand j1 and I have been able to confirm them by the few examinations that I have made, to which I allude in the succeeding chapter, and of which the following case is a good illustration: Case XXI. A commercial traveller, forty-five years of age, who had masturbated a great deal in his youth, and who had contracted gonorrhoea twenty years before I saw him, states that he has been constantly annoyed for the last two years by a discharge which is increased by straining at stool, and by toying with women without gratifying his passions, a practice in which he indulged, as he feared to have sexual congress on account of feeble erections. I detected a stricture, calibre 19, at five inches and a half from the meatus, along with a granular patch immediately behind the coarctation, and hyper- aesthesia of the prostatic urethra. On withdrawing the explorer, the bulb brought away a considerable gelatinous discharge, which, under the microscope, presented a few pus corpuscles, granular epithelium, 1 Op. cit., 3d Amer. ed., Phila., 1858, p. 265. 98 AZOOSPERMISM. and detritus, and a few motionless and deformed spermatozoa, several of which were occupied by fat globules. On examining the slide a few hours subsequently, I also discovered numerous spermatic crystals. Fatty degeneration of the spermatozoa has also been observed by Bianchi1 as rod-like bodies made up of shining points, which disappeared on the addition of ether. In a case of impotence from masturbation, compli- cated by spermatorrhoea, Heitzman2 found that the heads of the zoosperms were not much wider than the tails, and that their movements were very feeble. y. The relation of general diseases to anojnalies of the semen is a subject in regard to which widely different views are entertained. While there is no reason for believing that acute maladies impair the fertility of the semen of adults, it is quite certain that both acute and chronic affections of old age, and chronic diseases in the adult not infrequently lead to a suspension of the evolution of spermatozoa. The investigations in this direction have been con- fined almost exclusively to consumptives, in whom, as is well known, the parenchyma of the testes is usually very moist, pale, and anaemic, and in whom the epithe- lium of the tubules has not uncommonly undergone fatty degeneration. The frequency of azoospermism in phthisis, despite the changed condition of the testes, has, however, been greatly exaggerated. Lewin,3 Davy,4 1 Schmidt's Jahrbucher, Bd. clxxxi., 1879, P> 3%- 2 New York Med. Journal, August, 1879, P- I5%- 3 Deutsche Klinik, 1861, p. 319. 4 Edinb. Med. and Surg. Journ., July, 1839, P- *■ ABNORMAL CONDITIONS OF THE SEMEN. 99 Duplay,1 and Dieu2 examined the secretions of the epi- didymes, vasa deferentia, and vesiculae seminales of thirty-five persons dead of pulmonary tubercle, and found spermatozoa in twenty-three, or 65.7 per cent; and in thirteen inspections of the fluid at the orifice of the urethra, or pressed out of that passage, Lewin dis- covered zoosperms in eight. Hence, the semen con- tained fertile elements, and usually as numerous as in healthy persons, in thirty-one, or 64.5 per cent, of forty- eight subjects dead of phthisis; and what is remarkable is the fact that they were present in 62.5 per cent, of the semen of old persons, and in 65 per cent, of that of adults principally between thirty and forty years of age. The accuracy of these investigations has recently been confirmed by Busch,3 who detected spermatozoa in the fluids obtained from the testes, epididymes, and vasa deferentia of twenty-eight, or 66.6 per cent., of forty- two phthisical subjects; but it is to be noted that they were abundant in only eight. From these statements, it will be seen that the semen of consumptives contains zoosperms far more ■ frequently than certain writers would lead us to believe. Godard was of the opinion that spermatozoa were absent in persons who had be- come consumptive at the age corresponding to the establishment of the spermatic secretion; but that they persisted when tuberculosis began after that period. That acute and chronic diseases do impair the fer- tility of the semen of persons advanced in life is well shown by the investigations of Duplay and Dieu, since of 156 instances in which the fluid contained in the vasa 1 Ante. * Ante. 3 Ztschr. f. Biol., Bd. xviii. p. 496. 100 AZOOSPERMISM. deferentia or vesiculae seminales of old men was ex- amined, spermatozoa were found only in one-half. Di- viding the cases in accordance with the periods of life— Of 25 sexagenarians spermatozoa were discovered in 17, or 68 per ct. " 76 septenarians " " 42, " 59.2 " " 51 octogenarians " " " 19, " 37.2 " " 4 nonagenarians " o. In none were they present after the age of eighty-six, and they decreased pari passu with advancing years. On analyzing the causes of death, I find that sperma- tozoa were entirely absent in affections of the urinary organs; that they were present in only 38 per cent, of diseases of the nervous system; and that they were discovered, respectively, in 68, yo, and 81 per cent of disorders of the lungs, the digestive organs, and the heart. Hence, we may assume that while diseases of the kidney and brain exert a most prejudicial influence upon the formation of zoosperms, affections of the other great systems interfere with their development only to a slight extent. Of the 78 cases in which spermatozoa were found, they were abundant in 50, and fewer than usual in 28. They were perfectly formed in 54; and in 24 their tails were absent or shortened, and they varied in size. From these facts we may infer that the inability of old men to procreate arises more from impotence than from the composition of their semen; and this view is sup- ported by the fact, based upon 51 examinations made by Duplay1 of the testes of men from sixty to eighty-six years, that the secreting organs are perfectly normal 1 Archives Generates, t. vi., ser. 5, pp. 136 and 439. ABNORMAL CONDITIONS OF THE SEMEN. 101 in structure, and only slightly diminished in size and weight. The gross appearances of the seminal fluid of old men are worthy of notice, since, in the absence of minute examination, they afford inferential aid in de- ciding the question of the absence or presence of sper- matozoa. When the secretion is of a more or less transparent grayish tint, thick, viscous, and abundant, it is almost always fertile; but when it is scanty, and either watery or gelatinous, spermatozoa are almost always absent; and a deep brown color, which is due to broken-down blood and pigment, favors the latter view. Constitutional syphilis does not appear to exert much influence upon the secretion of the testes, since Liegeois1 and Bryson2 detected spermatozoa in the fluid ejaculated by syphilitic subjects in sixteen cases out of twenty-one, and Lewin3 found them in three out of six examinations of the contents of the excretory seminal apparatus of men dead of that affection. Under this head may be mentioned the altered com- position of the semen produced by the excessive use of morphia, to which attention has been called by Rosen- thal.4 A man had injected under the skin, on account of cephalalgia and insomnia, from nine to twelve grains of morphia daily for three years. Paralysis of the bladder finally ensued; and examination of the whitish fluid, which was occasionally forcibly expelled with the last drops of urine, demonstrated spermatic crystals, but no 1 Loc. cit., p. 380. 2 New York Medical Abstract, July, 1882, p. 274. 3 Loc. cit., p. 319. 4 Wiener Klinik, May, 1880, p, 149. 102 AZOOSPERMISM. spermatozoa. Under proper treatment, at the expira- tion of a month, when the morphia had disappeared from the urine, a specimen of the semen ejaculated during coition was found to contain living zoosperms, but they were not so abundant or so lively in their movements as under normal circumstances. In a sec- ond case, in which nearly eight grains of morphia had been injected daily for one year, minute examination of a nocturnal pollution disclosed a few deformed and motionless spermatozoa, which did not react on the addition of a weak alkaline solution. 6. Abnormal density of the semen may render it unfit for fecundation. Beigel1 narrates a case in which the genital organs were normal, but in which repeated ex- aminations of the ejaculated fluid showed that it was thicker and more viscous than is usual, and that the spermatozoa were motionless and closely grouped side by side. The addition of a few drops of tepid water put them in lively motion; so that the injection of a small amount of lukewarm water into the vagina, after coition, was advised, and the woman subsequently bore several children. e. Purulent semen, which is met with principally in inflammation of the seminal vesicles, epididymes, vasa deferentia, and prostate, may occasion the death of its essential anatomical elements, as in the following case, which is at present under my care: Case XXII. A gentleman, thirty years of age, contracted gonor- rhoea in 1870, or rather more than ten years ago, and at the end of 1 Krank. des Weibl. Geschlechts, Bd. ii. p. 791. ABNORMAL CONDITIONS OF THE SEMEN. 103 six weeks was attacked by bilateral epididymitis, which confined him to his bed for a fortnight. Up to 1873 ne nac^ always had an ejacula- tion on coition, but during the succeeding two years he indulged so rarely that he does not remember whether he had a discharge or not. He married in 1875, and although he has always had good erections, intercourse was not completed with an emission; but by pressing along the course of the urethra, he could force a drop of sticky fluid out of the meatus. Exploration discovered a stricture, calibre 14, at five inches and three-quarters, and great hyperaesthesia of the prostatic urethra. The seminal vesicles and prostate were tender on pressure with the finger in the rectum. Having detected these morbid con- ditions, I learned, on further questioning, that intercourse was pain- ful, and that there was a constant feeling of dull, heavy pain in the rectum which was increased at stool. On the 12th of January, 1881, he brought me the entire quantity of urine passed less than an hour after intercourse. Examination of the sediment, as well as of the discharge which I removed from the urethra with the bulbous explorer, disclosed rather abundant pus corpuscles and epithelial cells, with some of the latter undergoing fatty degeneration, crystals of oxalate of lime, spermatic crystals, and a few stunted or tailless and dead spermatozoa. The case was therefore one of sterility from asper- matism dependent upon stricture of the urethra, and of azoospermism from inflammation of the seminal vesicles. Unilateral spermatocystitis may also prove destruc- tive of the spermatozoa, since in a case recorded by Heitzman1 they could be traced in all stages of trans- formation into pus corpuscles. In a recent paper,2 Terillon shows that the ejaculated fluid in acute bilateral gonorrhceal epididymitis is of a yellowish tint verging on green, and that while it con- tains abundant pus corpuscles and a few large granular 1 New York Med. Journ., August, 1879, P- J58- 2 Des Alterations du Sperme dans l'^pididymite Blennorrhagique. An- nates de Dermatologie et de Syphiligraphie, ser. 2, t. i. p. 439. 104 AZOOSPERMISM. corpuscles, spermatozoa are nearly always absent. Thus of twelve cases in which the semen was examined at from ten to ninety days after the implication of the second testis, or on the thirty-ninth day, on an average, there were no spermatozoa in eight, a few living ones in three, and an abundance in one. Even several years after the complete subsidence of the acute symptoms, when the epididymes and vasa deferentia are normal in volume and consistence, though tender on handling, the discharge may retain the same characters, but in a less pronounced degree ; and Terillon illustrates this im- portant statement by a case in which yellowish azoo- spermous semen, which contained relatively few pus corpuscles, continued to be emitted six years after the cessation of the inflammation. The man had been mar- ried four years, but had not procreated children. He also refers to a case of Marce,1 in which, after death, the seminal vesicle and vas deferens were filled with a purulent fluid, but in which there were no traces of spermatozoa; and he maintains, in a later publication,2 that the absence of spermatozoa in cases of bilateral epididymitis depends more upon the persistence of catarrhal inflammation than upon obliteration of these bodies. In the preceding examples it has been seen that the vitality and the changes in the form and dimensions of the essential anatomical elements of the semen were associated with purulent inflammation of the excretory passages of that fluid, so that the inference is justifiable that pus is destructive of their evolution and life. This 1 Gazette des Hopitaux, 1854, p. 59. 2 Bull, et Mem. de la Soc. de Chir., 1881, p. 159. ABNORMAL CONDITIONS OF THE SEMEN. 105 view is supported by the researches of Levy1 on the influence exerted upon the viability of the spermatozoa by the perverted secretion of the glands of the cervix in endometritis. Of fifty-seven cases in which the secretion after coition contained an abundance of pus corpuscles and epithelial cells, in not a single one were many spermatozoa detected, and in none did their movements, which were feeble from the first, continue for more than five hours ; whereas he frequently found that they were vigorous in the cervical mucus of healthy women for twenty-six hours after congress. In none of these cases were the phenomena to be ascribed to the reaction of the discharge. Sims2 states that when the cervical secretion is rich in epithelial cells it proves destructive of the spermatozoa; and he ascribes this action to its density and not to its chemical action. He3 moreover thinks that catarrh of the prostate is as del- eterious as is uterine catarrh; and there is, indeed, no reason why a muco-purulent discharge of the urethra should not kill the spermatozoa. Noeggerath4 believes that it acts as a poison; and in a letter which I recently received from him he says, "the poison in the secretion is certainly not the pus corpuscle, but the micrococci which infest, not only the leucocyte, but also the men- struum in which it is found;" and he refers me to a paper on the subject by Neisser, which, however, is not available. While these views are hypothetical, they are worthy of further investigation, as they would seem to 1 Aerztliches Intelligenzblatt, Bd. xxvi., 1879, pp. 3 and 12. 2 Uterine Surgery, p. 390. 3 New York Med. Journ., vol. viii. p. 407. 4 Trans. Amer. Gynec. Soc, vol. i. p. 287. 106 AZOOSPERMISM. be substantiated by a case of sterility from diabetes mellitus recorded by Beigel,1 in which examination of the semen contained in the urine disclosed, in addition to fragments of spermatozoa, abundant micrococci and a few cryptococci. Diagnosis. — The discrimination between anorchids and cryptorchids with the testes retained in the ab- domen is readily made, when it is remembered that the former are impotent, while the latter complete the sex- ual act in the usual manner. If spermatozoa have never appeared in the discharge, the question of congenital absence of the epididymes, or of want of union of the vasa deferentia with the seminal vesicles or the epi- didymes, may be entertained. In all other cases the diagnosis is to be established by repeated examinations of the semen, since, as we have already seen, that fluid is liable to undergo various changes in sterility from sexual excesses, masturbation, ungratified venereal desire, obstruction of the epidid- ymes, prostatitis, spermatocystitis, and epididymitis. Normal semen slowly throws down a white sediment, which constitutes from one-third to one-half of the dis- charge, while azoospermous semen rapidly precipitates a slight sediment. Under ordinary circumstances, the formation of spermatic crystals is delayed until the second or third day after ejaculation, and their number is small. In semen deprived of spermatozoa, on the other hand, the crystals appear in half an hour; or somewhat later, if there are few spermatozoa. The 1 Krank. des Weibl. Geschlechts, Bd. ii. p. 791. DIAGNOSIS. 107 earlier, therefore, a sediment is deposited, and the more rapidly and abundantly spermatic crystals form, the less fertile is the discharge. Ultzmann1 describes the following varieties of semen in which spermatozoa are not found, and his observa- tions are confirmed by others: First watery, transparent semen, which is normal in quantity, and becomes gelatinous immediately after Fig. 14. emission, as does the normal secretion. It, however, resumes its fluid state when it is thoroughly cooled, and presents a whey-like appearance. Its relatively slight sediment shows, under the microscope, as in Fig. 14, 1 Wiener Med. Presse, 1876, p. 599, and 1878, p. 78 ; and Wiener Klinik, 1879, P- J56. 108 AZOOSPERMISM. perfect spermatic crystals, a few lymph corpuscles, cyl- inder epithelium, and an abundance of fatty detritus. Secondly, colloid sperm, Fig. 15, which differs from the normal discharge only in the absence of spermatic crystals and spermatozoa, and in the presence of abun- dant epithelium which has undergone colloid degenera- tion, and of laminated spherical masses of various dimensions. Thirdly, catarrhal and purulent semen, which deposits a tolerably abundant whitish or yellowish sediment, is of normal consistence and quantity, and contains an Colloid semen. ■ abundance of epithelium, leucocytes, and a few blood corpuscles, and occasionally a few deformed and mo- tionless spermatozoa. When the semen is discharged with the urine, it is to PROGNOSIS. 109 be remembered that the movements of the spermatozoa are arrested if the latter fluid is acid or ammoniacal; whereas they are not materially interfered with if the urine is neutral or slightly alkaline. Prognosis.—Azoospermism offers, in the large majority of cases, little encouragement as regards the prospect of permanent relief; and the prognosis depends upon its exciting cause and the amenability of the cause to treatment. In congenital absence of the testes or deficiency of their excretory passages, cryptorchidism, progressive atrophy, parenchymatous inflammation, and total disor- ganization from tubercle and morbid growths, as well as in tubercle, sarcoma, and carcinoma of the epididymes, the absence of spermatozoa is, with few exceptions, permanent and absolute. In cases of arrest of develop- ment, the prognosis should be guarded, since the testes may resume their proper functions under amorous influences. Thus, in the remarkable example recorded by Wilson,1 the penis and testicles of a man, twenty-six years of age, were not larger than those of a boy of eight years of age. He had never had sexual desires until he had met his intended wife ; and in two years after marriage he had become a father, and the organs had increased nearly to the usual adult size. The chances in favor of a return of the fecundating elements are good when the affection arises from sexual excesses, mas- turbation, or ungratified passion, over-indulgence in morphia, and epididymitis from ordinary causes; while they are not promising in cases of syphilitic epididymitis 1 Lect. on the Urin. and Gen. Organs, p. 424. 110 AZOOSPERMISM. and orchitis, and in gonorrhceal epididymitis. Liegeois1 examined the semen of twenty-eight persons affected with bilateral epididymitis, and there were no spermatozoa in twenty-one. Of the seven in which spermatozoa had returned, only two were of gonorrhceal origin ; so that the prognosis is far more favorable when the induration depends upon common causes than when it follows blennorrhagia. In the gonorrhceal cases with a return of zoosperms, the induration lasted only ten days in one, and in the other only one side was seriously affected; while in those in which the azoospermism was permanent, the inflammation had lasted from fifteen to sixty days. Hence, the light cases are of far more favorable prog- nostic import than the intense ones. Liegeois, moreover, found that the induration persisted partially or completely in fifteen of the twenty-one cases of absolute azoosper- mism ; but that the epididymes seemed normal to the touch in six. Of the seven in which the functions of the testes were reestablished, five were free from indu- ration ; and in two, which were not of gonorrhceal origin, the induration persisted ; so that absence of swelling and hardness is not positively indicative of a return of fertility. In such cases the canal of the epididymes is strictured or obliterated. As a prognostic aid, the ejaculated fluid should be examined in all cases of bilateral epididymitis. If it presents the characters of watery or colloid sperm, the absence of spermatozoa will, in all probability, be per- manent. 1 Loc. cit. p, 380. TREATMENT. Ill Treatment.—The management of azoospermism is, as a rule, most unsatisfactory. When it depends upon chronic debilitating diseases and the excessive use of morphia, the remedies are to be addressed to the pri- mary affection and to the breaking up of the habit. Abstinence is enjoined when it is due to sexual excesses or masturbation; and moderation should be observed when the functions of the testes are restored. In advancing atrophy of the testes, provided it is not a symptom of lesions of the cerebro-spinal system, gal- vanism holds forth some prospect of success. The positive pole should be applied over the lumbar portion of the spinal column, and the negative pole should be passed over the affected organs, the precautions being taken to employ weak currents and to limit the daily sittings to two or three minutes. Azoospermism in cryptorchids may be prevented if the subjects are seen sufficiently early in life, and if the testes are retained in the groins, by carrying out the suggestion of Curling1 to promote their descent into the scrotum by gentle and repeated traction. In children the retained organs enjoy great mobility; and the manoeuvres might succeed in adolescents and young adults, in whom the testes are, however, usually fixed. Sir Astley Cooper witnessed in " many cases" their descent from the thir- teenth to the seventeenth year, and even as late as the twenty-first year; and I myself have known it to occur later, as in the following example: Case XXIII. In a widower, forty-six years of age, at present under my care for impotence, the right testis remained in the inguinal canal 1 Op. cit., p. 38. 112 AZOOSPERMISM. until six months after his marriage, at the age of twenty-four, when it passed into the scrotum, and is now soft, tender, and of about one- third of the volume of its fellow. In its descent it was accompanied by a portion of the intestine. The arrest of the evolution of spermatozoa in syphilitic orchitis may be anticipated, if the disease be recognized within a few weeks, by the internal administration of iodide of potassium and bichloride of mercury; or the latter agent may be replaced by mercurial inunctions, the testes in the meanwhile being properly supported. Syphilitic epididymitis, which I have occasionally met with as a secondary symptom, readily yields to a mer- curial course. In bilateral epididymitis early and vigorous antiphlo- gistic treatment will usually preserve the functions of the testes. The means upon which I place the most reliance are strict recumbency, light diet, a brisk purga- tive, the saline and antimonial mixture with a few drops of tincture of aconite pushed to the extent of provoking slight nausea, and keeping the parts well elevated and surrounded with absorbent cotton, wet with a strong solution of acetate of lead and laudanum. If, despite these measures, indurations remain after the active symptoms have subsided, they may frequently be made to disappear under the exhibition of iodide of potassium and bichloride of mercury, along with the local use of mercurial ointment, or oleate of mercury, or an ointment composed of one drachm of iodoform, two drachms of balsam of Peru, two drops of oil of gaultheria, and five drachms of cosmoline. This treatment should be steadily maintained, as the most chronic cases may terminate favorably. Thus, Gosselin, Godard, and Curling record ASPERMATISM. 113 a return of spermatozoa after eight, eighteen, and twenty- four months; and Godard even narrates an instance of cure in which the indurations had lasted for ten years. In all cases particular care should be observed to guard against recurrence of the inflammation. Finally, when the semen is too thick, as in the case of Beigel, narrated on page 102, although nothing can be done in the way of medication, as far as the man is con- cerned, impregnation may be insured by the injection of a small quantity of saccharine or alkaline tepid water into the vagina after sexual congress. Sect. III. Aspermatism. Aspermatism is the variety of sterility in which sexual intercourse is not finished with an ejaculation of semen, either because that fluid does not enter the urethra, or because its forcible expulsion is prevented by some obstacle in the urethra anterior to the prostate gland. The term is, therefore, restricted to those cases in which the lesions are seated between the seminal vesicles and the urinary meatus. Non-emission may be congenital or acquired, and per- manent or temporary; and it may depend, first, upon obstruction of the ejaculatory ducts or the urethra; secondly, upon deficient excitability of the spinal ejacu- latory centre; thirdly, upon abolished sensibility of the nerves of the penis; and, fourthly, upon the inhibitory action of the brain over the centre for ejaculation. 8 114 ASPERMATISM. Hence, in accordance with its etiology, it may be Organic, Atonic, Anaesthetic, and Psychical. A.--ORGANIC ASPERMATISM. The discharge of seminal fluid into the urethra may be prevented, a, by congenital vices; p, by inflammatory lesions of the ejaculatory ducts and the prostate; and, r, by sympexions; and the escape of semen from the urethra may be due, 6, to stricture of that passage, to a tight phimosis, or to induration of the corpora cavernosa. a. Congenital occlusion, absence, and deviation of the ejaculatory ducts have been rarely met with. Schmitt1 examined a man, thirty-five years of age, who had never had an emission either when awake or asleep, although his power to cohabit was unimpaired. He had not suf- fered from gonorrhoea, and his external organs were perfect; but the prostate could be felt through the rec- tum merely as a small, flat body, and the seminal vesicles appeared to be atrophied. Ultzmann2 records the case of a vigorous man, aged twenty-four, in whom, as in the preceding instance, there was no history of gonorrhoea, and who had never been able to ejaculate during coition or under the influence of a dream, although nothing abnormal could be discovered in regard to his reproduc- tive organs. Munroe3 describes a similar condition of affairs in a robust man, twenty-eight years of age. Under no circumstances had there ever been an emission; but 1 Wiirzburg Med. Zeitschrift, Bd. iii. 1862, p. 361. 2 Wiener Med. Presse, 1878, p. 6. 3 Boston Med. and Surg. Journ., Feb. 21, 1867, p. 62. LESIONS OF THE EJACULATORY DUCTS. 115 a drop or two of clear mucus could be pressed out of the urethra after intercourse, and examination of the urine passed soon disclosed abundant spermatozoa. While in the case of Schmitt it is highly probable that the atrophied prostate occluded the ejaculatory ducts, the cause of the trouble in that of Ultzmann must remain a matter of conjecture; but as the man never emitted seminal fluid, we may assume that the ducts were oblit- erated, or absent. That the latter inference is not unfair is attested by a preparation1 in the Hunterian Museum, in which the ducts are wanting, and in which the re- mainder of the sexual organs are completely developed. In the case of Munroe there was doubtless a congenital deviation of the orifices of the ducts, so that the semen regurgitated into the bladder during intercourse. p. Stricture of the ejaculatory ducts and deviation of their orifices, the results of inflammation or injury, are among the most common causes of organic aspermatism, although the evidence of their existence is based, for the most part, on the symptoms presented during life. In his researches on the condition of the genital organs of old men dead of acute and chronic diseases, Duplay2 made some interesting observations, which afford post- mortem proof that the ejaculatory ducts undergo certain alterations which are capable of preventing ejaculation. In one both ducts were entirely destroyed, and were sur- rounded by tubercular matter from the neck of the seminal vesicles to their entrance into the thickness of 1 Klebs, Path. Anat., p. 781. 2 Archives Generates, ser. 5, t. vi. pp. 437 and 438. 116 ASPERMATISM. the prostate; in one they were converted into small, im- permeable fibrous cords, and the man had had a catheter retained in his bladder for a long time for retention of urine; in one the prostate was hypertrophied, and the ducts were narrowed, but pervious to semen on pressing the seminal vesicles; in one both ducts were strictured, and the orifice of the right was completely obliterated, the prostate was enlarged and indurated, and the veru- montanum was hard and of the size of a big pea; and, in a fifth case, the orifices of the canals were strictured, but pressure on the seminal vesicles showed that they were open. Ample observation has moreover demon- strated not only that the extension of gonorrhceal in- flammation to the prostate obstructs its ducts through inspissation of the catarrhal secretion of its glands, and frequently brings about adhesion of the orifices of the ejaculatory ducts,1 but that the latter may be occluded by the secondary contraction or by the cicatrices which result from abscess. Cicatricial occlusion of the ducts from deeply seated abscess has been observed by Kocher.2 A man, forty- eight years of age, had received a blow on the perineum when twenty-eight years old, which was followed by suppuration and by induration of the tails of the epididy- mes. Previous to the injury his wife had borne him four children; but she afterwards failed to conceive in con- sequence of the inability of the husband to ejaculate. Injury of the canals in bilateral lithotomy, or even in the lateral operation during the extraction of the calculus, is liable to terminate in aspermatism. I have myself 1 Compare with Kraus, Med. Times and Gaz., vol. i., 1871, p. 272. 2 Pitha und Billroth's Hdbch., Bd. iii. Abth. 2, Lief. 7, p. 433. SYMPEXIONS. 117 witnessed sterility from this cause in two examples, and Teevan has recently recorded four cases.1 La Peyronie2 describes the case of a man, the father of three children, who, in consequence of a neglected gonorrhoea, lost the power to ejaculate, although semen oozed away shortly after coition. On post-mortem ex- amination a cicatrix was discovered on the summit of the verumontanum, which had so changed the direction of the orifices of the ejaculatory ducts that they looked backwards towards the bladder. Demeaux3 found in a man twenty-three years of age, after an abscess of the perineum from a fall, that the urine passed after an aspermous coition contained normal spermatozoa; and, as the urethra was not strictured, but the perineum was diminished in size, and the prostate was drawn down lower than usual, he properly inferred that the ejacula- tory ducts had been displaced. y. Aspermatism may arise, as Reliquet4 first pointed out, from obstruction of the ejaculatory canals by sympex- ions, or concretions composed of spermatozoa, concrete mucus, epithelial cells, and refracting granules, and formed in the seminal vesicles. In the three cases nar- rated by Reliquet, only one duct was involved, and he ascribes the loss of power to ejaculate to the compres- sion exerted upon the previous duct by the distended one, and to the arrest of the contraction of the former through the pain experienced at the commencement of 1 Trans. Clin. Soc. London, vol. vii. p. 179. 2 Mem. de l'Acad. Roy. de Chir., t. i. p. 316, 1819. 3 Gaz. des Hopitaux, No. 21, i860. 4 Ibid., 1879, PP- 891 and 915. 118 ASPERMATISM. the expulsive act. In one example the finger in the rectum detected a bosselation of the right lobe of the prostate, near its middle, and showed the boss to be continuous with the corresponding seminal vesicle; and in a second case, a small tumor, due to retention of the semen, was discovered at the site of the ducts. Bergh,1 of Copenhagen, met with a similar condition in a man twenty-nine years of age; but the case differed from the cases of Reliquet in that the non-ejaculation was of an intermittent character. The patient finished his first connection in the usual manner, but afterwards there was merely a sensation of distention; although, on two occasions during sleep, after dinner, there was an abun- dant discharge of semen. Bergh advised coition with a condom, with a view to examine the fluid, if any should be evacuated. During the act, the man felt as if some- thing had torn, and there was a seminal discharge, which was rich in spermatozoa and sympexions. Subsequently there was sometimes an emission, and at other times none. In an instance recorded by Dr. Blegny,2 the ducts were occluded with hard, spherical concretions as large as peas; and the verumontanum was indu- rated, and of the volume of a small nut. The patient, a widower, sixty years of age, and the father of several children, contracted a second marriage, but was unable to ejaculate. In this connection, it may be stated that Beckmann3 discovered a concretion as large as a cherry in the ejaculatory duct of an old man, the organic por- 1 Schmidt's Jahrbiicher, Bd. clxxxi., 1879, P- 3^- 2 Civiale, Traite Prat, sur les Maladies des Organes Genito-Urinaires, t. ii. p. 234. 3 Virchow's Archiv, Bd. xv. p. 540. STRICTURE OF THE URETHRA. 119 tion of which was composed of spermatozoa, and the inorganic portion principally of phosphate and carbonate of lime. The possibility of the formation of so large a concretion, and of its effecting closure of the opposite duct, should be remembered in framing a diagnosis. s. The fourth division of organic aspermatism includes those cases in which the semen is discharged into the urethra, but its escape is prevented by some obstacle anterior to the prostate gland. If the impediment to its evacuation is seated in the posterior portion of the urethra, the greater part will usually flow back into the bladder, and minute examination of the urine passed after coition will disclose spermatozoa. When the ob- stacle, on the other hand, is situated at the external orifice, the semen will dribble away with the subsidence of the erection. The most common cause of retention of the seminal fluid is stricture of the urethra, to which attention was first called by Petit;1 and it is not difficult to conceive how an opening, which, in the flaccid condition of the penis, admits of the passage of urine, may, during erection, when the normal calibre of the urethra is naturally diminished, become so narrowed through spasm that the semen is confined in the canal between the coarctation in front and the turgid caput gallinaginis behind, so that its escape, either forwards or backwards, is prevented until the penis becomes flaccid. At page 102, I have narrated the case of a man in whom the stricture admitted a No. 14 bulbous explorer, and in 1 Mem. de l'Acad. Roy. de Chir., t. i. 1819, p. 323. 120 ASPERMATISM. whom the parts behind the coarctation were very sensi- tive; and I have also met with the following cases in which the contractions were not so small: Case XXIV. A gentleman, twenty-eight years of age, had mas- turbated excessively from his fourteenth to his twenty-second year, and a few months subsequently, on his first sexual intercourse, dis- covered that, although the act was completed with the usual sensation and spasmodic ejaculatory movements, there was no escape of semen until the erection subsided, when a few drops could be pressed out of the urethra. Examination of the urine passed after copulation disclosed abundant spermatozoa; and a stricture, calibre 22, was discovered at one-third of an inch behind the meatus; and a second, calibre 18, was found at five inches and three-quarters from the external orifice. The prostatic urethra was extremely sensitive, and he suffered from prostatic discharges at stool. Case XXV. A laborer, twenty years of age, had masturbated, on an average, once every night for five years; and, on coition, six months before I saw him, he was unable to ejaculate. A stricture, calibre 19, was detected at five inches and a half from the meatus, and there was great tenderness throughout the entire curved portion of the urethra. In these cases, the fault is, in my opinion, to be ascribed less to the organic contraction than to the spasm of the muscular walls of the urethra beneath the sensitive mucous membrane, through which the opening is temporarily occluded. Hence, such cases are anal- ogous to those of stricture in which exposure to cold and wet, or acrid conditions of the urine react on the inflamed mucous membrane, and produce retention of urine from spasmodic contraction of the muscular fibres of the urethra; and it would probably be more correct to describe them as instances of retention of semen from STRICTURE OF THE URETHRA. 121 spasm. Since the stricture maintains the inflammation upon which the spasm depends, it is, however, needless to remove the cases from this category. Other examples of aspermatism from stricture are re- corded by Curschmann,1 Acton,2 and Blackwood.3 The case of Hirtz4 terminated by a spontaneous cure during coition, which was attended by violent pain, and followed by severe hemorrhage. The man had had repeated attacks of gonorrhoea, but never ejaculated, and sper- matozoa were detected in the urine. After the removal of the obstacle, the nature of which is not clear, his wife gave birth to a child. The second impediment to the spasmodic, forcible discharge of the semen is a tight phimosis, of which the following- is an illustration: Case XXVI. A farmer, thirty-six years of age, and married for fifteen years, consulted me in April, 1880, on account of inability to procreate children. The preputial orifice, which would only admit a small probe, was seated upon the back of the head of the penis, so that the meatus was completely hidden by the integuments. He informed me not only that the urine, but that the semen when the penis became flaccid, converted the prepuce into a sac, and that their egress had to be facilitated by manipulation. In a similar instance, Blackwood5 circumcised the pa- tient and relieved his trouble. In the case of Amussat,6 after a barren marriage of five years' duration, the re- moval of a very tight foreskin was crowned with success; 1 Loc. cit., p. 904. 2 Op. cit., 4th Amer. ed., p. 224. 3 Proceedings of the Phila. Co. Med. Soc, vol. i. p. 4. 4 Gazette de Strasbourg, No. 5, 1861. 5 Loc. cit., p. 5. 6 Virchow's Hirsch's Jahresbericht, Bd. ii., 1866, p. 169. 122 ASPERMATISM. and Bergh,1 in the case of a man twenty-one years of age, effected a cure in three weeks by circumcision. The third obstacle to the proper ejaculation of the urine is induration of the corpora cavernosa, to which attention was first directed nearly a century and a quarter ago by La Peyronie.2 As this lesion is fully considered on page 72, it need not detain us in this connection. B.--ATONIC ASPERMATISM. In aspermatism from atony or loss of contractility of the muscles of the seminal vesicles, ejaculatory ducts, prostate, and urethra, although there is no obstacle to the ejaculation or escape of the seminal fluid, there is never an emission during intercourse or when the pa- tient is awake; but nocturnal pollutions under the in- fluence of lascivious dreams are not infrequent, and are accompanied with the usual pleasurable feelings. Hence the sexual act is never completed, and the subject has to abandon his efforts merely from a sense of exhaus- tion. In organic aspermatism, on the other hand, except when it depends upon congenital lesions, coition is fin- ished with a discharge which is prevented from escaping; or if the ejaculatory ducts are closed or obstructed, the convulsive movements are experienced with the ordinary sensations. Roubaud3 attributes this form of aspermatism, which is termed idiopathic by Bergh,4 and paradoxical by 1 Loc. cit., p. 37. 2 Mem. de l'Acad. Roy. de Chir., vol. i., 1761, p. 428. 8 Op. cit., t. i. p. 248. * Loc. cit., p. 37. ATONIC ASPERMATISM. 123 Rheinstaedter1 to spasmodic contraction of the ejacula- tory ducts. This opinion cannot be entertained, as the relaxation of the spasm should be followed by the escape of semen, which never happens. Schulz,2 Ultzmann, Rosenthal, Kocher, and other observers explain it by the absence of excitability in the lumbar reflex ejacula- tory centre, a view in which I entirely concur. In many examples, the general symptoms denote neurasthenia, or the depressed form of spinal irritation, which is pre- sumed to be due to exhaustion of the lumbar division of the spinal cord; and from the fact that the affection is most frequently met with in men who have been ad- dicted to masturbation or venereal excesses, or who have suffered from repeated attacks of gonorrhoea, a class of subjects in whom, as I have shown in the chapter on Impotence, there are, as a rule, inflamma- tion and hyperaesthesia of the prostatic portion of the urethra, I believe that, with few exceptions, exploration with a sound or bulbous bougie will disclose lesions which maintain, and are probably the cause of, the abolished excitability of the reflex ejaculatory centre. In the majority of the cases of aspermatism, other than of the organic variety, I find that the urethra was not examined, and that hyperaesthesia was discovered in seven out of nine cases in which an instrument was passed. Hence, exploration of the canal should never be omitted, since upon its condition will depend the employment of the proper measures for the relief of the trouble. 1 Deutsche Med. Wochenschrift, No. 26, 1879, P- 336- 2 Ibid., 1862, pp. 769 and 787. 124 ASPERMATISM. These statements are corroborated by the following cases from my private practice: Case XXVII. A merchant, twenty-six years of age, had mastur- bated from his thirteenth to his twentieth year, and erections were provoked by merely looking at a woman, and by other slight causes. At the age of twenty he had his first connection, but failed to ejacu- late ; and repeated subsequent efforts were attended with the same result. His erections were normal, and he had a nocturnal emission, with the usual sensations, about once every two weeks. The entire urethra was sensitive, and the prostatic portion excessively so; and there was a stricture, calibre 24, at six inches from the meatus. Case XXVIII. A clerk, thirty years of age, and married for two years, never had an ejaculation during coition, although he prolonged the act until fatigue required him to desist, and he states that ejacula- tion failed to occur during masturbation, which he practised up to the age of fifteen. He had, however, a nocturnal emission, which was attended with a pleasurable sensation, about once a week. He suffered from pain in the back, a feeling of soreness over the vertex, and palpitation of the heart; was easily fatigued, and his sleep was unrefreshing. The meatus was contracted, and the entire urethra was very sensitive upon exploration. The meatus was laid open on the 10th of June, steel bougies were passed at stated intervals, their size being gradually increased, and bromide of potassium was exhibited internally. On the 27th of August, sexual intercourse was completed with an emission; the symptoms of neurasthenia had disappeared in another month; and from this time he had no further difficulty in intercourse. C.--ANAESTHETIC ASPERMATISM. The first link in the chain of the phenomena con- cerned in the act of ejaculation is the conduction of the sensory impressions excited by the friction of the penis against the walls of the vagina to the lumbar division ANAESTHETIC ASPERMATISM. 125 of the spinal cord. If the sensory nerves fail to re- spond to the ordinary stimulus, reflex contraction of the ejaculatory muscles is prevented, and emission is ren- dered impossible. This variety of aspermatism, which may be termed anaesthetic, is not common, but the sub- joined illustrations demonstrate the possibility of its occurrence. As the result of concussion of the spine, a soldier was affected with insensibility of the prepuce, of the gland and skin of the penis, and of the scrotum to such a degree that pinching and pricking with pins were not perceived by him. Abundant nocturnal pollutions oc- curred at long intervals; but he was unable to ejaculate on coition or masturbation, the latter of which he re- sorted to with the vain hope of relieving priapism, from which he often suffered, and which constituted an ob- stacle to the discharge of the urine.1 A gentleman, aged twenty-eight years, with congenital absence of the prepuce, was unable to complete sexual congress with an emission, although he had an occasional nocturnal pollution. Concluding that the trouble arose from a want of excitability in the nerves of the gland of the penis, Curling2 applied the acetum cantharidis, which left the part in a very sensitive condition; and the man subsequently married, and seldom failed to finish inter- course in the normal manner. In the second case, under the charge of the same observer,3 a gentleman, forty-four years of age, was unable to ejaculate on account of insensibility of the gland and skin of the penis. Nearly the entire back of 1 Lallemand, op. cit., 3d Amer. ed., p. 211. 2 Op. cit., 4th ed., p. 483. 3 Ibid., p. 485. 126 ASPERMATISM. the organ was covered by a large, indurated scar, and the prepuce had disappeared, the lesions having been due to syphilis. In a third case, under the charge of Curling,1 the dis- tention of the glans and the irritability of its sensitive nerves were prevented by occlusion of the meshes of the corpus spongiosum by inflammatory deposits, through which the glans did not enter into perfect erection. Non-emission may also be due to obtunded sensibility of the prostatic portion of the urethra, which Van Buren and Keyes2 regard as being the seat of pleasure in the act of copulation. They record a case in which this condition was found in a man, thirty-six years of age, who had never experienced an ejaculation during his nine years of married life, although he had had noc- turnal emissions. D.--PSYCHICAL ASPERMATISM. That the reflex movements emanating from the lum- bar genital centre are amenable to the will is illustrated by the fact that many men, to avoid impregnation, are able to retard an emission until the penis is withdrawn from the vagina; and the restraining action of the cere- brum is also proved by two curious cases of atonic aspermatism, recorded by Roubaud3 and Hicquet,4 in which the ejaculation instantly ceased if the patient 1 Op. cit., 4th ed., p. 460. 2 Genito-Urinary Diseases with Syphilis, p. 466. 3 Op. cit., p. 244. * Bull de l'Acad. Roy. de Med. de Belgique, ser. 2, t. iv. p. 482. DIAGNOSIS. 127 awakened during a nocturnal pollution. Other men, through disgust, suspicion of infidelity, or loss of passion, are unable to complete sexual congress with their wives, although they succeed perfectly with other women. Hence, aspermatism from the inhibitory action of the brain over the centre for ejaculation is temporary or relative, emission being possible under some circum- stances and impossible under others; and it is alto- gether independent of organic lesions. Diagnosis.—The determination of the particular form of aspermatism is based upon the history of the case, upon the thorough exploration of the external and in- ternal organs of generation, upon the examination of the urine, and upon the conclusions drawn from the effects of the remedies employed for its relief. As these points have already been more or less fully con- sidered, little need be added in regard to them. The existence of congenital absence or obliteration of the ejaculatory ducts is rendered almost certain if there has never been an emission under any circum- stances whatsoever, if the urine is devoid of spermatozoa, and if there is no history of antecedent inflammation or injury. When, on the other hand, the urine passed after coition contains spermatozoa, and the other nega- tive signs are present, congenital deviation of the ducts with discharge of the semen into the bladder is a per- fectly fair inference. A history of deeply-seated abscess of the perineum or lithotomy points to cicatricial occlusion of the ducts; while the detection of spermatozoa in the urine after sexual congress in persons who have suffered from 128 ASPERMATISM. perineal abscess or from neglected gonorrhoea shows that there is acquired deviation of those canals. Ob- struction of the ejaculatory ducts by sympexions gives rise to the affection termed spermatic colic by Reliquet. There is always reflex contraction or loss of dilatability of the bladder. This makes itself known by difficult and very frequent urination, and by the expulsion of the last drops, which are liable to be bloody, being attended with lancinating pains which extend from the anus to the extremity of the penis. The subjects refrain from intercourse because excessive suffering is excited at the moment when ejaculation should occur; or is even in- duced by venereal desires or by commencing erection. Exploration through the rectum discloses a small, cir- cumscribed tumor in the region of the prostate; and if the latter be compressed between the finger and a sound in the urethra, either the swelling will at once disappear, and the instrument be covered with semisoft, grayish masses looking like bits of vermicelli or grains of boiled rice, or there will be an abundant discharge of semen, which contains sympexions, at the ejaculation during the first coition after the manipulations ; or sper- matozoa and seminal concretions will be passed at the succeeding act of micturition. In aspermatism from stricture of the urethra the patient has nocturnal emissions, the usual convulsive movements of ejaculation and pleasurable sensations are felt during coition, and the urine passed after sexual congress contains spermatozoa. The diagnosis is con- firmed by the use of the exploratory bougie, to which sufficient reference is made on page 37. When the trouble arises from a tight prepuce, its cause is obvious. PROGNOSIS AND TREATMENT. 129 Atonic aspermatism is always to be suspected in per- sons who have indulged excessively in venery or in masturbation, or who have had gonorrhoea; in those who suffer from the ordinary symptoms of neurasthenia; and in subjects who ejaculate under the influence of a lascivious dream. The diagnosis is confirmed by the existence of hyperaesthesia of the prostatic urethra. The anaesthetic form of the affection is denoted by the loss of sensibility of the gland and skin of the prepuce and penis; and non-ejaculation from emotional causes is readily determined by the history of the case. Prognosis.—Aspermatism from congenital or acquired absence, obliteration, or deviation of the ejaculatory ducts is permanent, and nothing is to be expected from treat- ment. When the ducts are obstructed by sympexions, or when the affection is referable to stricture of the urethra or phimosis, a cure may be looked for. The prognosis is good when the failure to ejaculate depends upon hyperaesthesia of the prostatic portion of the urethra; but atonic aspermatism without morbid sensi- bility of that division of the urethra calls for a certain amount of reserve in the expression of an opinion; and the same statement holds good for the anaesthetic variety. The psychical form is temporary or relative, and capable of correction. Treatment.—When the ejaculatory ducts are ob- structed, the plan proposed and successfully practised by Reliquet in two cases is to be recommended. A sound having been introduced into the bladder, the cir- cumscribed swelling is emptied by counterpressure with 9 130 ASPERMATISM. the finger in the rectum. When the trouble depends upon stricture of the urethra, dilatation or internal division should be resorted to; and if it arises from phimosis, circumcision will afford prompt relief. When the atonic variety of aspermatism is combined with inflammation and hyperaesthesia of the prostatic urethra, the measures should be directed to subduing the latter before attempts are made to restore the con- tractility of the muscles concerned in the act of ejacula- tion. Hence, the treatment is essentially the same as that described in pages 41-53, and its good effects are well illustrated by Case XXVIII. If, on the other hand, the prostatic portion of the urethra is insensitive, a tonic course should be at once instituted. The best prospects for relief are held out by quinine, iron, and strychnia, internally, cold sitz-baths,1 and galvanism,2 the negative catheter pole being in con- tact with the verumontanum, while the anode is placed over the lumbar portion of the spine or the perineum. Instead of continuous, induced currents3 may be em- ployed, as in the instance of Hicquet,4 in which a cure was effected in eight days after the failure of the reme- dies advised by Roubaud.5 In the case recorded by the latter author, under the idea that the affection was due to spasm of the ejaculatory ducts, normal coition was restored, after a preliminary venesection, by a pill com- posed of assafcetida, castoreum, extract of opium, and extract of hemlock, and by sprinkling the vesicated sur- face of the perineum with morphia. In another example 1 Consult page 54. 2 Consult page 55. 3 Consult page 56. 4 Loc. cit., p. 482. 5 Op. cit., p. 244. MISEMISSION. 131 of atonic aspermatism Hicquet1 succeeded in curing his patient in ten days by the internal exhibition of the alco- holic extract of nux vomica, gradually increased from two to six centigrammes a day. In anaesthetic aspermatism, the passage of the faradic brush over the penis, the anode being applied to the spine, is indicated, with the view to restore the obtunded or abolished sensibility of the nerves. In the event of the failure of this measure, the gland of the penis may be blistered with some prospect of success, as in an example from the practice of Curling.2 Aspermatism from disturbances of the brain, such as loss of affection for or repugnance to a certain woman, is hopeless, unless the subject undergoes a change of sentiment. Being entirely emotional, nothing can be done for him in the way of medication. Sect. IV. Misemission. In the preceding forms of sterility, no semen whatso- ever, or unproductive semen, is secreted; or there is failure to ejaculate. In the variety under consideration, fertile semen is emitted, but it is not deposited in the upper portion of the vagina; so that it differs from as- permatism from mechanical obstruction in that the secre- tion has an outlet, and does not regurgitate into the bladder, or slowly ooze from the urethra when the erec- tion has subsided. Hence, the term misemission is 1 Loc. cit., p. 492. Op. cit., p. 483. 132 MISEMISSION. employed in the sense that the ejaculation has a faulty direction. The most common causes of misemission are vices of conformation of the urethra. Thus, hypospadias may destroy the capacity for procreation, even when it is of light grade, as in two cases recorded by Kirsch ;x but the deformity does not usually involve sterility, unless the opening of the urethra is situated at the penoscrotal junction or in the perineum, and not even then, as, in exceptional instances,2 the posterior wall of the vagina may act by replacing the deficient inferior wall of the urethra, thereby permitting the ejaculated semen to reach its destination. The same statements are applicable to epispadias, and to fistulous openings in the urethra, the result of stricture or injury. In all of these conditions the prognosis is unfavorable, and the treatment is most unsatisfactory. If a plastic operation be practised, the precaution should be taken to make a perineal outlet for the urine. Malposition of the meatus, through which the semen is voided backwards and downwards, or to one side, is an occasional cause of misemission, and is usually due to congenital or acquired shortening of the frenum. Guerlain3 has reported the case of a man, thirty-five years of age, in which the penis was almost completely rotated from left to right, so that the dorsal surface reposed on the scrotum, and the meatus was situated on the side of, and about five-tenths of an inch behind, 1 Wiener Med. Presse, 1881, p. 214. 2 Morgagni, Anat. Path., 1838, t. iii. p. 73, and Casper, op. cit., p. 251. 3 Bull, de la Soc. Anat., ser. 2, t. iv. p. 87. ETIOLOGY. 133 the extremity of the gland; and Guillon1 met with a case in which the meatus opened on the side of the gland, and in which the stream of urine described almost a right angle with the penis. When the trouble arises from shortening of the frenum, the proper remedy is division of that structure. In the case of Guillon, ex- cision of the pouch-like walls of the meatus resulted in a cure. 1 Gaz. Med. de Paris, 1843, P- J6o. 134 SPERMATORRH.CE A. CHAPTER III. SPERMATORRHOEA. In its restricted sense spermatorrhoea means a con- stant escape of seminal fluid without erection or pleas- urable sensation; but the term, in a sense which has prolonged sanction, is employed in the following de- scription of the affection to designate all the. varieties of involuntary seminal losses which occur beyond the limits of health, and it is, therefore, synonymous with seminal incontinence. Under no circumstances should the affection be regarded as a "functional disorder of the testes," since, in the great majority of instances, it is primarily dependent upon and symptomatic of weak- ness or exhaustion along with increased impressibility, mobility, or excitability of the genito-spinal centre, phe- nomena usually induced by hyperaesthesia of the nerves which supply the prostatic portion of the urethra. Classification.—Seminal incontinence includes three conditions which may exist separately, or pass into one another, or be combined in the advanced stage of the disorder. These conditions constitute the following varieties of the disease: First. Nocturnal emissions or pollutions, which occur during sleep, and are generally attended with an erec- tion, pleasurable sensation, and an erotic dream. NOCTURNAL POLLUTIONS. 135 Second. Diurnal pollutions, which take place when the subject is awake, are excited by slight mechanical or psychical causes, and are usually accompanied with incomplete erection and diminished sensation. Third. Spermatorrhoea in the strict acceptation of the term, or a slight continual flow of semen from the urethra, without erection or specific sensation, without impure thoughts, or during urination or defecation. To avoid confusion I will employ the term spermorrhagia to indicate this phase of the affection. i. Nocturnal Pollutions. — Involuntary nocturnal seminal discharges constitute the variety of the affection in regard to which physicians are usually consulted, and about which not a little ignorance prevails, as they are natural to all men, and are most common after the epoch of puberty, when the mind is more or less taken up with sexual matters. Their frequency varies in accordance with a great many circumstances, such as age, climate, habits, constitution, temperament, diet, and predisposition, it having been observed that they are very liable to occur in young men who were affected in their childhood with nocturnal incontinence of urine. Their frequency also varies greatly in the same indi- vidual ; but it is impossible to determine the healthy standard merely by the intervals of their repetition, since what may be normal in one person may be mor-» bid in another. In a general way I should say that in single men who lead a continent life and possess a sound nervous system, emissions at intervals of two weeks are indicative of excellent health. In such per- sons they are merely reflex signs of fulness or distention 136 SPERMATORRHOEA. of the seminal passages, and constitute an inconvenience of ungratified sexual instinct. Even if they occur once or twice in a week, provided they are not followed by symptoms of nervous disorder, they are not at all in- consistent with temporary good health ; but, as I have just intimated, it is a question of individual tolerance and constitution, or vulnerability of the nervous system. Hence persons who consult the physician in regard to involuntary nocturnal losses should be informed that they are natural; and they should be impressed with the fact that the emissions need not awaken concern unless they are accompanied with unpleasant effects. Nocturnal pollutions are abnormal or pathological when they are followed by headache, backache, slight enfeeblement of the functional powers of the brain, mental depression, and bodily or mental languor or lassitude; when they occur in married or single men who indulge in regular intercourse; when they take place without erections or dreams, and the patient is only made aware of them by the stains on his linen; when they attend or follow acute or chronic diseases; and when they are complicated by diurnal pollutions or spermorrhagia. All of the preceding conditions are very liable to be attended with one of the varieties of impotence, which, indeed, may be the only indication that the emissions are pathological or one of the effects of impairment of the functions of the lumbar cord. In men of appar- ently the same amount of vigor and resistance, and in whom the pollutions occur with equal frequency, the associated symptoms of nervous exhaustion vary very much in degree, or they may be entirely absent. Thus, NOCTURNAL POLLUTIONS. 137 in Case VI., page 30, in which the emissions occurred from one to five times a week, the signs of neurasthenia were pronounced; while in Case XVI., page 39, which was characterized by an excessive number of pollutions, there was not the slightest evidence of spinal weakness. In Case XL, page t>3, there were no general symptoms whatsoever; while in Case XIV., page 35, the patient was a hypochondriac. In both, the emissions took place at the same intervals. In the first of the following ex- amples, which illustrate the same point, the man was in robust health; while in the second, although the patient evinced no outward evidence of impaired health, the signs of myelasthenia were marked. They are selected because they present many points in common. Case XXIX. A student of law, aged twenty-one, had masturbated from his eleventh to his eighteenth year, and has suffered from noc- turnal emissions for the past three years, on an average, three times a week. For the past five months he has had irritability of the bladder, and feeble erections with premature ejaculations, for which he sought my advice. The lips of the meatus were red and pouting, and I de- tected a stricture, calibre 13, at five inches and a half from the meatus, along with great sensitiveness from that point as far as the neck of the bladder. Case XXX. A bookkeeper, twenty-one years of age, has had noc- turnal pollutions, which were not always accompanied by voluptuous dreams, three times a week, on an average, for four years; and he had masturbated from his tenth to his seventeenth year. On the following morning he felt greatly prostrated; and he constantly suf- fered from pains in the back, ano-rectal region, and top of the head, vertigo, muscular weakness of the limbs, and mental lassitude and depression. The prostatic urethra was excessively sensitive, but there was no stricture, and he passed prostatic fluid when the bowels were constipated. 138 SPERMATORRHOEA. 2. Diurnal Pollutions.—Ejaculation of semen when the patient is awake is always morbid, and indicates a condition of irritable weakness of the genital organs and of the reflex centres which preside over them. In the lesser phase of this variety an emission is due to slight peripheral irritation, provoked by friction of the clothing, horseback exercise, driving over rough streets, or even shaving, or combing the hair,1 or shampooing the head ;2 while in the more aggravated form the ejac- ulation is induced by psychical irritation, as reading libidinous books, the sight of indecent pictures, lascivi- ous ideas, or simply looking at a female. In the former of these conditions there is a tolerable erection, but the sensation is diminished; in the latter the erection is flabby, or the penis is flaccid, and there is little or no pleasure. 3. Spermorrhagia.—When the trouble is more ad- vanced, semen is constantly discharged without the occurrence of the orgasm; and its passive loss, which appears to be associated with dilatation of the orifices of the ejaculatory ducts from paralysis of their mus- cular fibres, may be the only sign of seminal incon- tinence. The existence of this condition is denied by some writers, but its occurrence cannot be questioned; and Case XXL, page 97, in which the gelatinous fluid brought away by the bulbous explorer contained mo- tionless spermatozoa, and in which the discharge was increased by straining at stool, and by toying with 1 Townsend, Elements of the Therapeutics, vol. ii. p. 399. London, 1799. 2 Flint, Principles and Practice of Medicine, 5th ed., p. 938. SPERMORRHAGIA. 139 women without gratifying the passions, affords a capital illustration of it. Under this category should be included the condition in which the semen is unconsciously discharged in the acts of urination and defecation ; and it likewise de- pends upon irritable weakness of the seminal vesicles and ejaculatory ducts. While in the majority of in- stances the fluid pressed out of the urethra in these ways is derived from the prostate, the microscope dis- closes that it is spermatic in a certain proportion of cases. Some authors are sceptical in regard to the passage of semen with the urine; but its occurrence is attested, apart from older observations, by five cases recorded by Beard,1 by two under the care of Fiir- bringer,2 by two reported by Black,3 by Case X., at page 32, and by the following additional instance from my private notes: Case XXXI. A clerk, twenty-eight years of age, had masturbated freely for ten years, and for the past two years has had difficulty in acquiring an erection, although he still has sexual desire. He is greatly depressed, easily fatigued, incapable of prolonged mental ex- ertion, and has a woe-begone expression. There is a constant slight discharge of a clear, viscous fluid which causes the lips of the meatus to adhere during the night, and he is convinced that the urine con- tained semen. I found, on examination, that the urine was highly acid, and contained a few motionless spermatozoa, pus corpuscles, and crystals of oxalate of lime. Strictures, calibre 22, were detected at one-eighth of an inch and five inches from the meatus* and the prostatic urethra was highly sensitive. 1 Medical Record, 1879, PP- 73. 74. and 558; and 1880, pp. 507 and 508. 2 Volkmann's Vortrage, No. 207, 1881, pp. 1835 and 1856. 8 London Lancet, vol. ii., 1882, pp. 618 and 655. 140 SPERMATORRHEA. Clinical History.—Any one of the three forms of spermatorrhoea may exist separately, but they gradually pass into each other, and are variously intermixed in the advanced grade of the affection. When the case goes on from bad to worse, it usually pursues the following course, in consequence of the increase in the mobility of the ejaculatory centre, and of the advancing exhaustion of the entire nervous system. At first, ab- normal frequency of the nocturnal pollutions is asso- ciated with backache, headache, a sense of painful muscular fatigue, and slight paresis of the brain, as indicated by incapacity for any sustained mental effort. With the increase in the number of the emissions, the patient discovers that erections are becoming insuffi- cient, and that ejaculation on coition is precipitate; and the general symptoms are aggravated by the addition of dulness of perception, impairment of memory, ver- tigo, mental dejection, weakness of vision, trembling of the limbs, palpitation of the heart, shortness of breath, a sense of oppression in the chest, flatulence, constipa- tion, and other dyspeptic signs. Diurnal pollutions from slight mechanical or psychical causes are now superadded, and the emissions occur, with little or no erection or pleasurable sensation, or even when the penis is flaccid; and intercourse is impracticable, either from flabby erection or from anticipating ejaculation. The general symptoms also are more serious. The patient is liable to brood over his assumed lost virility, and the mental depression verges upon or passes into a condition of sexual hypochondrism. His gait is un- steady; he is subject to wandering neuralgic and rheu- matoid pains; the hands and feet are habitually cold; CLINICAL history. 141 he passes restless or sleepless nights; shuns society; fears to look one in the face; is utterly incapacitated for mental or physical exertion ; and thinks of nothing but his sexual organs. With the still further increase of the irritable weakness of the genitalia and nervous system, the semen constantly oozes out of the urethra, and its discharge is augmented during defecation and micturition. The man is converted into a confirmed hypochondriac, and if he comes from an insane family, he lapses into insanity, not, however, because of the seminal losses, but because of the disturbances of the nervous system which lead to the emissions. A person who has inherited a tendency to insanity, epilepsy, ataxia, or other nervous disorders, may, therefore, bring on those affections, the first link in the chain being functional troubles of the nervous centres, which gradu- ally pass into organic disease, and are caused, according to my observations, in rather more than nine-tenths of all cases, by masturbation. Of the general symptoms which are associated with abnormal seminal losses, and which indicate more or less complete exhaustion of the brain and spinal cord, an analysis of one hundred and one cases, of which I have notes, indicates the following interesting facts in regard to their importance and relative frequency. There was an anxious or depressed condition of the mind in thirty-four; constant dwelling upon sexual matters in thirty-five; hypochondrism in six; mental dejection after intercourse or emission in twenty-six; impairment of memory in twenty-six; incapacity for prolonged mental exertion in twenty-nine; headache in twenty-eight; vertigo in fourteen ; broken sleep in 142 spermatorrhoea. seven ; insomnia in two ; drowsiness in five ; irascibility in two; asthenopia, or muscae volitantes, in fifteen; noises in the ears in twelve; muscular weakness of the limbs and fatigue in fifty; trembling of the limbs in ten ; temporary reflex paraplegia in one; pain in the back in thirty-nine ; oppressed breathing in seven ; pain in the chest in three; constipation in twenty-six; dys- pepsia in eighteen; palpitation of the heart in twelve; subjective sensations of cold in nine, and of heat in four; loss of flesh in nine ; and pallor of the face in twelve. It will thus be perceived that constant occupation of the mind with the sexual functions, mental dejection, impairment of the memory, incapacity for mental work, headache, vertigo, muscular weakness of the limbs, pain in the back, noises in the ears, and irritability of the eyes constitute the most common of the disturbances of the cerebro-spinal axis and of the special senses; while, of the phenomena referable to the circulatory, respira- tory, digestive, vaso-motor, and nutritive systems, palpi- tation of the heart, oppression of breathing, constipation, indigestion, chilliness, a feeling of elevated temperature, pallor, and emaciation, are the most frequent. In six cases the presence of dark spaces under the eyes formed the subject of grave apprehension. A further analysis of the one hundred and one cases cases shows that certain local signs are connected with seminal incontinence. There was feebleness of erec- tion with premature ejaculation in twenty-two; irritable weakness in sixteen ; total failure of erection in five; elongation of the prepuce in twenty-four; relaxation of the scrotum in thirteen; irritable testis in four; varico- ETIOLOGY. 143 cele in two; coldness of the genitalia in six ; a feeling of heat in the genitalia in three; painful ejaculation on intercourse in three; bloody ejaculation in one; and irritability of the bladder in four. In thirteen examina- tions of the semen furnished by patients suffering from an aggravated form of the malady, I found that fluid to be watery, and that in three the spermatozoa were small, motionless, and variously deformed, and, there- fore, incapable of impregnating the ovum. As the changes which the semen undergoes in spinal exhaus- tion have been so fully considered in the section on azoospermism, they need only be referred to in this connection. Etiology.—Spermatorrhoea is not a distinct affection, but one of many symptoms of general and local lesions, or of both combined. In the vast majority of instances it must be regarded as a neurosis, or a functional de- rangement of the nervous system, which is indicated by increased susceptibility of the brain and cord, or feeble- ness of their powers of resistance to acts which in healthy persons would not be productive of evil conse- quences. Like other neuroses, it may be the result of congenital predisposition, when it is liable to be ob- served in several members of the same family through several generations. Under these circumstances, the subject is of a nervous, excitable, or irritable tempera- ment ; and he probably suffered during his infancy from nocturnal incontinence of urine, as was first pointed out by Trousseau,1 of which the following example is a marked illustration: 1 Op. cit., t. ii. p. 636. 144 SPERMATORRHOEA. Case XXXII. A physician, fifty years of age, consulted me, March 14, 1881, on account of nervous exhaustion, seminal losses, and dread of impotence. Up to his tenth year he was troubled with nocturnal enuresis. He was a close student at college; and at the age of eighteen began to have nocturnal emissions, and his mind dwelt constantly on sexual ideas; but he never masturbated. Up to the time he saw me, or for thirty-two years, the emissions varied from one to three a week; but he did not evince any special signs of neurasthenia for several years after their commencement, when he observed that he was con- stantly drowsy, and that he was very restless, particularly in crowded assemblies and at social entertainments. He soon became easily fatigued, and was incapable of bodily exertion, and his brain was unequal to prolonged work. Three years ago he abandoned the practice of his profession, and during a visit to Europe, in the sum- mer of 1880, he had a mild attack of reflex paraplegia, which fol- lowed a sudden rush of blood to the head. He never had sexual intercourse. He has an erection nearly every morning, but the gland of the penis is rather flabby, and he notices that the lips of the meatus are glued together by a slight gleety discharge. The prepuce is somewhat long; there is a stricture, calibre 22, one-third of an inch behind the meatus; the prostatic urethra is highly sensitive; there is a large varicocele of the left side; and there is a tendency to irritability of the bladder. Among the predisposing causes may be mentioned erotic ideas. When constantly and involuntarily in- dulged in, even when the patient does not practise natural or unnatural acts, as in the preceding case, they constitute a powerful factor in the production of irritation of the genital organs and of reflex impressi- bility of the centres which preside over them. Seminal incontinence is usually acquired, and is due in the great majority of instances to masturbation. Thus of the one hundred and one cases of which I have a record, in only one was it the result of an in- herited predisposition. Of the remaining hundred, in ETIOLOGY. 145 nine-one it was traceable to onanism; in five it arose from gonorrhoea; and in four it was met with in men who had masturbated, suffered from gonorrhoea, and had indulged their propensities in various ways. Eighty- eight were single, ten were married, and two were widowers. Twenty cases occurred before the age of twenty; fifty-nine between twenty and thirty; sixteen between thirty and forty; and five between forty and fifty. All of the married men were given to sexual excesses ; and although three stated that they were not addicted to masturbation early in life, I believe that marital sexual excess is generally the natural result of a previously vicious habit. Of the ninety-one mastur- bators, all except nineteen had one or more strictures; and the remaining nine patients were affected in the same way. In only six cases was decided hyperaesthesia of the urethra absent; so that this condition is rather less frequent in cases of spermatorrhoea than in cases of impotence, in which, as has been pointed out on page 21, it was wanting in twelve cases out of one hundred and seventy-one. Under the influence of erotic ideas, masturbation, sexual 'excesses, or unsatisfied sexual excitement pro- duced by toying with females, exaggerated irritability of the genital organs is induced, and is soon followed by chronic or subacute inflammation and hyperaesthesia of the prostatic portion of the urethra, which culminate, in bad cases, or in those characterized by diurnal pollu- tions and spermorrhagia, in dilatation and relaxation of the orifices of the ejaculatory ducts. As the natural result of their constant excitability, the nerves distrib- uted to the prostatic urethra are alive to the slightest 10 146 SPERMATORRHOEA. impressions. This condition induces increased mobility or irritability of the reflex cerebral and spinal genital centres, through which the motor nerves which supply the ejaculatory apparatus are thrown into action, and an emission follows. This, it seems to me, is the rational explanation of seminal incontinence. Involuntary seminal losses are also met with during convalescence from or during the progress of certain acute and chronic diseases which are characterized by disturbances, or exhaustion, of the nervous system. Thus, it may be symptomatic of variola or phthisis,1 typhus,2 progressive muscular atrophy and commencing bulbar paralysis,3 of paraplegia,4 and of locomotor ataxia,5 in the last of which affections Hammond6 has recorded an example of eight nocturnal pollutions in a night Chronic alcoholism also predisposes to their occurrence; and Mitchell7 describes a case in which they seemed to be due to the habitual use of opium. Of the local causes of spermatorrhoea by far the most common are hyperaesthesia and chronic inflammation of the prostatic portion of the urethra, which are generally induced by masturbation; and these morbid conditions are just as important in its production as they are in the causation of impotence. In the vast majority of cases, they constitute the original source of the trouble, 1 Curschmann, loc. cit., p. 867. 5 Nowatschek, Wiener Med. Presse, 1879, P» 1067. 3 Stephanides, ibid., p. 913. * Roberts, Canada Med. Record, vol. vii. p. 253. 5 Erb, op. cit., pp. 543 and 585; Trousseau, op. cit., p. 510; and Topi- nard, De l'Ataxie Locomotrice, p. 171. 6 Treatise on the Diseases of the Nervous System, 6th ed., p. 593. 7 Amer. Med. Monthly, vol. xv. p. 285. ETIOLOGY. 147 and tend not only to excite reflex emissions, but also to maintain the disorder by keeping the mind occupied with sexual matters. Even in cases in which the affection would seem to depend upon other local lesions, they are almost invariably present, so that associated disorders of the penis, the urethra, or the rectum merely act by intensifying them. In a few cases it is true that the hyperaesthesia is not marked, and that other abnormal states, as a congenital contraction of the meatus, are sufficient to excite reflex contraction of the seminal vesi- cles ; but in these instances it is scarcely possible that local conditions would induce the trouble in persons who were not predisposed to it Hence, I think that no case should be treated without a preliminary examination of the urethra, which seems to be omitted by physicians in general, and by many surgeons. Of the local exciting causes phimosis, in the form of redundancy of the prepuce, is probably one of the most common, and it acts as a source of reflex irritation by keeping the gland moist, or by retaining the smegma. Not only is the prepuce elongated, but in many cases it will be found to constrict the gland when the penis is erect, a point which should always be looked into, as it has an important bearing upon the treatment. Herpes of the prepuce, which is far less frequently met with than the preceding condition, is another cause ; so also is congenital shortness of the frenum, as in a case recorded by Heulard Darcy.1 Of the conditions which relate to the urethra, the most important are congenital narrowing of the meatus,2 which 1 Virchow-Hirsch's Jahresbericht, Bd. ii., 1866, p. 169. 2 Hicguet, Canstatt's Jahresbericht, Bd. iii., i860, p. 225. 148 SPERMATORRHOEA. I have seen in four cases, and organic stricture, seated near the orifice, of which I have met with many ex- amples. Zeissl1 has quite recently declared that spas- modic stricture is a cause of very frequent pollutions. In a unique case recorded by Genaudet,2 the removal of a polyp from the prostatic portion of the urethra was followed by the cessation of the nocturnal emissions. Acute inflammation of the seminal vesicles is attended with frequent and painful, and it may be with bloody, pollutions. In an instance of chronic inflammation of these bodies under my care, the discharge was usually of a yellowish tint from the admixture of pus, and de- cidedly bloody when the pollutions followed each other in quick succession. In cases of this description the seminal losses are due to hyperaesthesia of the mucous membrane of the vesicles, so that the trouble is analo- gous to incontinence of urine from morbid sensibility of the lining membrane of the bladder. Liegeois3 states that epididymitis is a fruitful source of nocturnal emis- sions. Among other exciting causes of spermatorrhoea may be mentioned diseases of the rectum and anus, as piles, ascarides, fissures, pruritus, and painful eruptions; and Perrin4 has recorded a case in which nocturnal pollutions were induced by the cauterization of internal hemor- rhoids. As the rectum and anus are supplied by the same nerves as are distributed to the genitalia, it is not surprising that the reflex ejaculatory centre should 1 Med. News and Library, January, 1881, p. 41. 2 Virchow-Hirsch's Jahresbericht, ut supra, p. 163. 3 Loc. cit., p. 512. * Canstatt's Jahresbericht, 1857, p. 301. ANATOMICAL CHARACTERS. 149 respond to an impulse transmitted from them. The same statement is true of certain affections of the blad- der. Habitual constipation may also excite emissions through the pressure exerted upon the seminal vesicles during the evacuation of hardened feces; but this is ob- served only when the orifices of the ejaculatory ducts are dilated and paralyzed. The fluid which escapes from the urethra of healthy men, under these circumstances, is not seminal, but it is usually derived from the prostate. Anatomical Characters.—The morbid appearances which belong to spermatorrhoea in its early stage are utterly unknown as far as their verification by post- mortem inspection is concerned. That the exaltation of the sensibility of the urethra depends upon subacute or chronic inflammation of its mucous membrane, particu- larly in the region of the verumontanum, is rendered certain by the concomitant local symptoms, by explora- tion with the endoscope and the sound, aided by the finger in the rectum, and by the results of treatment. In seven aggravated cases, of which two are recorded by Lallemand,1 one is narrated by Curling,2 and four are collated by Kaula,3 there was a stricture in four, injection of the mucous membrane of the deep portion of the urethra in two, dilatation of the orifices of the ejacula- tory ducts in six, combined with excoriation in two, ulcer- ation in two, and enlargement of the canals themselves in one, suppuration of the prostate in four, suppuration 1 Op. cit., Phila., 1858, pp. 37 and 42. 2 Op. cit., 4th ed., p. 492. 3 De la Spermatorrhea, These de Paris, 1846, pp. 167-173. 150 SPERMATORRHOEA. of the seminal vesicles in three, and chronic inflammation of those bodies in two. As far as I am aware there have been no examinations of the nervous centres connected with the genital organs in spermatorrhoea, so that it is impossible to say whether they are the seat of structural lesions. In a case of paraplegia induced by sexual excesses, however, Sir William Gull1 was unable to detect the slightest change in the cord. The common view, that the cells which minister to the functions of the cord are completely exhausted, is, therefore, probably correct. Diagnosis.—The only mode of determining whether the fluid which constantly moistens the urethra, is dis- charged at stool or with the urine, or is brought away by the bulb of the explorer, is seminal in its character, is to examine it under the microscope with a power of about four hundred diameters, with the view of discover- ing spermatozoa. Should they be found, there need be no doubt as to its true nature; but it must be remem- bered that their absence is not an evidence that the case is not one of spermatorrhoea, since, as I showed at page 95, the exhausted sexual apparatus in aggravated ex- amples furnishes a watery fluid which may be devoid of fertilizing elements. Under these circumstances the history of the case, and the associated general symptoms are to be considered in framing the diagnosis ; and this is particularly true of the examples in which a discharge is expressed at stool, and which in the majority of in- stances is merely the secretion of the prostate gland. 1 Guy's Hosp. Reports, 1858, p. 175. PROGNOSIS. 151 Under the microscope the thin, more or less milky pros- tatic fluid will be found to contain cylinder epithelium, numberless colorless and refracting granules of lecithin, one-half the diameter of a red blood corpuscle, and minute concentric amyloid concretions; and spermatic crystals will soon make their appearance on the slide; while the thin, transparent, azoospermous semen contains cylinder epithelium, and probably epithelium which has undergone fatty or colloid degeneration, a few lymph corpuscles, an abundance of fatty detritus, and possibly a few small shining bodies which are the remains of badly evolved spermatozoa. In the absence of minute examination, the rule may be framed that the discharge which occurs during defe- cation in persons who are laboring merely under too frequent nocturnal pollutions is an evidence of coexist- ing prostatorrhcea; while the flocculent sediment con- tained in the urine, and the discharge at stool in persons who are suffering from nocturnal and diurnal pollutions, and a slight continued discharge from the urethra rep- resent semen. In the last case, the assumption that the orifices of the ejaculatory ducts are relaxed will generally be correct, and it will be strengthened if the patient is impotent. Prognosis.—According to my experience, the prog- nosis of seminal incontinence is far from being so unfavorable as many writers would lead one to believe. In regard to increased frequency of nocturnal emissions, the phase of the affection about which the physician is most frequently consulted, I have no hesitation in de- claring that it yields readily to treatment, particularly 152 SPERMATORRHOEA. when it is caused or kept up by appreciable local lesions, such as hyperaesthesia of the prostatic urethra, stricture, or hemorrhoids. The subject of Case XVI., page 39, is an excellent and not uncommon illustration of the truth of this statement. The pollutions had been excessive for two years, and were complicated by pros- tatorrhcea and a mild grade of impotence. On the 8th of April, I divided a stricture which was seated just behind the meatus, and ordered thirty grains of bromide of potassium to be taken at intervals of eight hours, along with one-sixtieth of a grain of atropia at bedtime, and a laxative pill as it might be required. On the 6th of May, a No. t,o conical steel bougie having been passed at stated intervals to overcome the morbid sen- sitiveness of the prostatic urethra, the patient reported that he had emissions on the nights of April 17 and 18; and four weeks later he informed me that he had a pollution on the 22d of May. Equally rapid and grati- fying results were obtained in the following example: Case XXXIII. A teacher, twenty-four years of age, had mastur- bated up to five years ago. He then began to be troubled with noc- turnal emissions, which frequently occurred for five consecutive nights, when there would be an interval of freedom for ten days. For the past two years the erections have been flabby, and ejaculation has been premature; but with the exception of pain in the back, there have been no signs of spinal exhaustion. The urethra has been very sensitive, but there has been no stricture. The measures employed were the same as those resorted to in the preceding case, with the addition of a hot sitz-bath at night. He was ordered to be awakened early in the morning, with the view to empty his bladder. The lum- bar pain ceased after the fourth insertion of the bougie; and when I saw him, three weeks subsequently, he told me that he had been entirely free from pollutions. PROGNOSIS. 153 Of the local lesions causative of nocturnal pollutions, by far the most rebellious to treatment which I have encountered is chronic inflammation of the seminal vesicles, of which the following is an instance: Case XXXIV. A man, twenty-two years of age, contracted gonor- rhoea, which extended to the vesicles, where it set up acute inflamma- tion. When he came to me, the acute signs had subsided, and for three months he had had painful pollutions, which frequently occurred two and three times during the night, when they left a yellowish-red stain upon his linen. There was a constant sense of fulness and bearing-down pain in the rectum. The pain was increased by urina- tion, defecation, and erections. The rectal touch disclosed two ovoidal, hot, and very tender bodies in the region of the vesicles; and there was a discharge of muco-purulent fluid from the urethra. Under sedative measures, and the local application of astringent solu- tions to the prostatic urethra, and of flying blisters to the perineum, I succeeded, after the expiration of seven months, in reducing the number of pollutions to one a week; and when I last saw him, three months afterwards, he had not had an emission for thirty days. With the above exception, when the pollutions are maintained by local lesions, and are associated with signs of myelasthenia, the prognosis is good, but the patient will have to remain longer under treatment than when signs of nervous exhaustion are absent. The outlook is still favorable when symptoms of cerebras- thenia are present; but it is decidedly bad if the subject is a sexual hypochondriac. Even when the emissions occur during the progress of acute or chronic general affections, the prognosis is not dismal, since I find that, in a case of progressive muscular atrophy and com- mencing bulbar paralysis, St^phanides succeeded in checking them by the internal exhibition of atropia, and 154 SPERMATORRHOEA. that Nowatschek was equally successful with the same remedy in an example of an aggravated form of sper- matorrhoea, the result of typhus. The prognosis is far better when the usual local lesion, namely, hyperaesthesia of the prostatic urethra, has been induced by gonorrhoea than when induced by masturbation; and it is also more favorable when the emissions occur in mature years from sexual excesses than when they are due early in life to onanism, espe- cially if the youthful subjects evince a tendency to inherited nervous disorders. The outlook is more unfavorable when the pollutions occur during the day, or when the patient is awake, and when they are excited by slight mechanical or psychical causes, since under these circumstances the assumption is fair that the inflammation of the deep portion of the urethra has resulted in atony and dilatation of the mus- cular fibres which surround the orifices of the ejacula- tory ducts. These cases are, however, quite amenable to properly directed measures, or even to the adminis- tration of atropia alone, as in the example of Nowatschek referred to above. Treatment.—In all cases of involuntary seminal emis- sions certain hygienic and moral rules must be observed. The diet should be nutritious and digestible, the evening meal in particular being light and dry, and all stimu- lating articles of food, as well as spirituous and malt liquors, should be avoided. Before retiring, the bladder is to be thoroughly emptied, and the habit of sleeping on the side upon a hair mattress without much covering should be cultivated. As the morning fulness of the treatment. 155 bladder has a very decided tendency to induce erec- tions, and as emissions usually occur in the morning, the patient should set an alarm clock one hour before the time at which he has usually observed that the pollutions take place, in order that he may be awakened to relieve that viscus of its contents. Horseback exer- cise and driving over rough roads should be interdicted. Masturbation, in which if the man be single he still in all probability indulges, and sexual intercourse must be abandoned, and the patient should be told that this enforced rest of the organs will possibly result in tem- porary increased frequency of the pollutions. Every- thing calculated to excite erotic thoughts and desire should be scrupulously avoided. With this end in view, he should keep the mind and body pleasantly occupied; and if he happens to belong to the class of society that has nothing to do, and if he is still robust and vigorous, he should have recourse to gymnastic exercises, or to the close study of any subject which he may most fancy. If, on the other hand, there are commencing or marked signs of spinal exhaustion, mental and physical modera- tion should be enjoined. An essential part of the treatment is the removal of any reflex or eccentric lesions or causes which predis- pose to the occurrence of seminal losses, or even excite them in impressible subjects. Hence, the external gen- italia and the anus and the rectum should be subjected to a careful examination. In many cases without the presence of a positive phimosis the redundant prepuce keeps the sensitive gland of the penis constantly moist, and favors the collection of sebaceous matter. The latter condition is very common among the lower classes, 156 SPERMATORRHOEA. and whether circumcision be resorted to or not, and I always advise it, the greatest cleanliness should be enjoined. Herpes of the prepuce and gland usually readily yields to attention to the bowels and diet, and to dusting the parts with subnitrate of bismuth and calomel, or to touching the excoriations, if they should exist, with a five-grain solution of nitrate of silver, and dressing them afterwards with scraped lint. If the meatus be contracted, or if a stricture be seated behind that orifice, it should be divided; and a short frenum should be clipped with the scissors. Internal piles should be. ligated; external piles be opened; rectal fissure be divided or lacerated by overstretching the sphincter; and pruritus be remedied by cleanliness and the application of four grains of the bichloride of mer- cury to the ounce of water. A varicocele, between which and spermatorrhoea, however, I see no causal relation, should be properly suspended, or be subjected to subcutaneous ligation if it be large and annoying. Habitual constipation, which is met with in one-third of the cases, demands particular attention. If there is atony of the intestines, a pill, composed of two grains of compound extract of colocynth, half a grain of ex- tract of nux vomica, and the tenth of a grain of extract of belladonna, may be administered at bedtime. In the majority of cases enemata of temperate water will fulfil the indication; or the patient may take two or three drachms of equal parts of Rochelle and Epsom salt in a tumbler of water before breakfast, or a wineglassful of Hunyadi water, or of an artificial mineral water composed of an ounce of sulphate of magnesium, a drachm of bitartrate of potassium, and ten grains of TREATMENT. 157 sulphate of iron to a quart of, water. This was a favorite remedy of the late Professor Dunglison, and I can bear testimony to its efficacy. Of the exciting causes of abnormal seminal losses by far the most constant and important are subacute or chronic inflammation and hyperaesthesia of the prostatic portion of the urethra and of the orifices of the ejacula- tory ducts, conditions which are frequently maintained and aggravated by stricture of the passage anterior to them. Of the treatment of stricture I can only refer to my views published elsewhere,1 as its consideration would be out of place here; but I may add that, although the stricture may be palliated by dilatation, and although the emissions may entirely cease under the employment of that measure, they will be sure to recur unless the bougie is methodically employed during the remainder of life. With regard to the inflammation and exaggerated sensibility and irritability of the prostatic urethra I need only say that the general and local measures for their relief do not differ in any respect from those indicated in the chapter on Impotence, pages 42-53. In all cases of seminal incontinence, with rare excep- tions, the remedies at the outset should be directed to overcoming the sensibility of the mucous membrane of the urethra, of the ejaculatory ducts, and of the seminal vesicles; to subduing the irritability of the muscles con- cerned in ejaculation; and to diminishing the reflex excitability of the genito-spinal centre. Hence, they should be of a calming and sedative nature. By the 1 Consult p. 43. 158 SPERMATORRHOEA. ignorant and indiscriminate employment of strychnia, cantharides, phosphorus, damiana, and cold sitz-baths or affusions during the stage of hyperaesthesia, much harm is done, and the therapeutics of spermatorrhoea are brought into disrepute. Premising the statement that the tonic should follow the sedative plan of treatment, I will now give an outline of my views as to the best management of the varieties of the affection. Under all circumstances, thirty grains of bromide of potassium, along with about ten drops of the fluid ex- tract of gelsemium,1 every eight hours, and one-sixtieth of a grain of sulphate of atropia2 on retiring, are worth all the other internal remedies combined. In anaemic subjects, the bromide may be administered at night, and quinine and iron be exhibited during the day; but if the bromide be badly borne, it should be guarded in the manner which is indicated on page 51, or it may be replaced by twenty grains of chloral. Not only does atropia diminish the reflex mobility of the genito-spinal centre, but the recent researches of Keuchel, Heiden- hain, and Strieker and Spina,3 show that it paralyzes the movements of the cells of the acinous glands and checks their secretion, so that it cannot be dispensed with. Of the local remedies, the conical steel bougie4 occu- pies the first rank; but when the inflammation and tenderness are reduced to a circumscribed area which includes the openings of the ejaculatory ducts, it should give way to the application of nitrate of silver,5 a remedy which is usually decried by physicians who 1 Bartholow, op. cit., p. 415. 2 Consult page 51. 3 Rosenthal, Wiener Klinik, May, 1880, p. 161. 4 Consult page 42. 5 Consult page 45. TREATMENT. 159 appear to have no practical experience with medication of the urethra, but which is highly recommended by such men as Trousseau,1 Niemeyer,2 C. Handheld Jones,3 and Rosenthal,4 and by the most eminent surgeons. In addition to these measures, the hot sitz-bath5 is invalu- able ; and Harrison6 advises douching the lower part of the spine with water at the temperature of 1200 F. Under this course of treatment, the majority of cases of nocturnal pollutions recover; but it may happen that the reflex genital centre is still too impressible, in which case galvanization,7 with the anode to the lumbar region and the cathode to the perineum,8 will prove highly serviceable. After the hyperaesthetic symptoms have subsided, if, from the occurrence of diurnal pollutions and of sperm- orrhagia, there is reason to suspect dilatation and atony of the mouths of the ejaculatory ducts, the continuous current, with the negative reophore in the rectum, and the positive on the perineum or the lumbar vertebrae, affords the most striking results. This plan is recom- mended by Mobius ;9 and in one case I succeeded in affording relief in twenty days by twelve sittings. Should galvanization prove inadequate, the induced current may be passed through a negative catheter electrode in the prostatic urethra to the anode placed on the peri- neum or spine; but this mode of application requires 1 Op. cit., t. ii. p. 643. 2 Text-Book of Practical Medicine, New York, 1870, vol. ii. p. 100. 3 Functional Nervous Disorders, p. 733. 4 Loc. cit., p. 162. 5 Consult page 52. 6 Op. cit., p. 62. 7 Consult page 55. 8 Benedikt, Elektrotherapie, p. 466. 9 Memorabilien, Heilbronn, 1879, 24. P- 545- 160 SPERMATORRHOEA. great caution,1 and care should be taken to employ a feeble power at the commencement. Hence I prefer, with Ultzmann,2 Rosenthal,3 and Mobius, to replace the urethral by the rectal reophore. In the absence of electrical apparatus, the tonicity of the muscles of the ejaculatory ducts may be greatly improved and even restored by the use of the psychrophor,4 by the applica- tion of nitrate of silver, and by cold sitz-baths,5 and the dashing of cold water against the perineum. In these cases of relaxation and atony of the ducts, ergot, which, if I do not mistake, was first employed by Mitchell,6 of New York, is also indicated, half a drachm of the fluid extract being administered in water after each meal; and strychnia should also be given in gradually increas- ing doses. Fifteen drops of a mixture composed of six drachms of tincture of chloride of iron and two drachms of tincture of cantharides will also prove serviceable. With the curious device of Trousseau,7 namely, an ivory or vulcanite plug inserted into the rectum, I have had no experience, nor does it appear to have met with favor. The same writer refers to Richard's good results from forcible dilatation of the anus; and I can readily imagine that it would be productive of benefit, if there was spasm of the sphincter. Of the operation of cas- tration, which some patients demand, and which some surgeons are weak enough to perform, I have only to say that I deem it unscientific and barbarous. When spermatorrhoea is incident to organic lesions 1 Consult page 56. 2 Wiener Med. Presse, 1876, p. 641. 3 Loc. cit., p. 162. 4 Consult page 55. 5 Consult page 54. 6 Amer. Med. Monthly, April, 1861, p. 282. 7 Op. cit., t. ii. p. 645. TREATMENT. 161 of the cerebro-spinal axis, or to convalescence from debilitating diseases, the treatment is that of the affec- tion itself, with the addition of atropia and of bromide of potassium, if the latter remedy is not contraindicated. To sum up the results of my experience in the man- agement of abnormal seminal losses, I may add that the steel bougie, bromide of potassium, and atropia are especially adapted to cases of nocturnal emissions, and that electricity, ergot, and strychnia are the most re- liable agents in diurnal pollutions and spermorrhagia. After recovery, moderation in sexual intercourse should be enjoined if the patient is married; matrimony should be advised if his circumstances and inclinations warrant it; and continence in thought and in action should be observed if he remains single. n 162 PROSTATORRHCEA. CHAPTER IV. PROSTATORRHCEA. Prostatorrhcea, an affection which was first described by Professor S. D. Gross,1 signifies a discharge from the urethra of the secretion of the prostate gland, espe- cially after defecation and micturition. It may -exist with or without inflammation of the prostate, represent- ing in the former event a catarrh, and in the latter merely a hypersecretion of the tubular glands of that organ. I believe that the malady is generally due to passive congestion; and I am certain that it does not follow an attack of acute inflammation of the prostate. In the majority of examples prostatorrhcea is a com- plication of other disorders of the generative organs. Thus, of fifty-six cases of which I have notes, in only sixteen did it exist alone; while it was associated with nocturnal pollutions in three, of which Case XXX., p. 137, is an illustration; with emissions and various grades of impotence in thirty-one, of which Case XVI., p. 39, is an instance; with impotence alone in five; and with aspermatism in one, as in Case XXVIII, p. 124. Hence my account is limited to the disease in its pure form. Etiology.—Of the sixteen cases, two began at the age of eighteen, eleven between twenty and thirty, and 1 North American Med.-Chir. Rev., July, i860, p. 693. ETIOLOGY. 163 three between thirty and forty years; while fifteen of the subjects were single, and one was married. In eleven it was due to masturbation, in four to the ex- tension of gonorrhceal inflammation, and in one to onanism practised early in life and to marital sexual excesses. In all there was exaggerated sensibility of the prostatic portion of the urethra, which was com- plicated by spasm of the compressor urethrae muscles in two, and by stricture in fourteen. In six there was one coarctation, which was seated within the first half an inch of the canal; in seven two strictures were de- tected, of which the first was near the meatus, and the second was in the bulbous urethra; and in one there were three strictures, which were seated, respectively, just behind the meatus, at two inches and a half from the meatus, and in the bulbous urethra. These observations correspond with those of Gross, who also states that the affection may be traced to dis- orders of the rectum, and that intemperance in eating and drinking, horseback exercise, drastic cathartics, can- tharides, and spirits of turpentine, or, in short, whatever is likely to produce a determination of blood to the pelvic organs, tend to excite it. Ledwich1 narrates a case in which it appears to have been occasioned by riding for several consecutive days in cold, damp weather; and both he and Lee2 believe that the stru- mous diathesis predisposes to its occurrence; and others trace it to sedentary habits. While I cannot deny the accuracy of these statements, I may be permitted to express my conviction that none of the above-men- 1 Dublin Quart. Journ. of Med. Sci., vol. xxiv., p. 35. 2 St. George's Hosp. Reps., vol. vi. p. 26. 164 PROSTATORRHCEA. tioned causes are capable of lighting up the affection independently of some preexisting lesion of the pros- tatic urethra. Clinical History.—The most prominent symptom of the disease is the discharge of a thin, and, as a rule, more or less milky, acid fluid from the meatus, which may be constant in its appearance, but which is always expressed from the urethra during straining at stool and during the forcible expulsion of the last drops of urine, or even during sneezing, coughing, or laughing. Prostatic crystals. The quantity secreted may be merely sufficient to in- duce an unpleasant sensation of wetness in the urethra and to agglutinate the lips of its orifice; or it may amount to a drachm or more during the twenty-four hours, and keep the linen stained. However this may be, it is increased by riding, by driving, by alcoholic and clinical history. 165 malt liquors, and by the contraction of the perineal and other muscles during defecation and urination. Under the microscope it will be found to consist of cylindrical epithelial cells, countless refracting and colorless gran- ules of lecithin, and of minute, yellowish, concentric, amyloid concretions ; and after it has slowly dried upon the slide crystals of phosphate of magnesium, as in Fig. 13, page 83, or of ammonio-magnesian phosphate, as in Fig. 16 from one of my patients, will make their appear- ance. These characters, along with the absence of sper- matozoa, serve to distinguish it from semen and ordinary urethral discharges. When the secretion depends upon chronic catarrhal inflammation of the glands of the pros- tate, it is thicker, and contains, in addition to the fore- going morphological elements, pus and mucous corpus- cles, and filiform mucopurulent casts of the follicles and ducts. The escape of the fluid is occasionally attended with a pleasurable feeling of titillation; or there may be a dropping sensation in the urethra, which is due to reflex contraction of the muscular substance of the prostate induced by repletion of the glands with the secretion, and its consequent discharge into the prostatic sinus; or there may be a constant feeling of moisture in the canal. All of these abnormal sensations are increased by erec- tions. The only remaining local signs with which I have met were frequent and urgent desire to relieve the bladder in three; occasional scalding during urination in two; the loss of a few drops of blood at the end of the act in two; painful ejaculation in one; a sense of weight and fulness in the rectum after stool in two; and dull pains 166 prostatorrhcea. in the perineum, which were increased by exercise, especially in warm weather, in two. Hence, with the exception of pains radiating from the pelvis through the hips and thighs, and a constant sense of uneasiness about the loins, these symptoms agree with those portrayed by Adams,1 who described the affection as " Prostatitis from Onanism," and they are confirmatory of the observations of Gross. Prostatorrhcea differs widely from the affections which have already been considered in the absence of signs which point to nervous exhaustion, as I have met with them in only one example, of which the following is a brief account: Case XXXV. A banker, thirty-two years of age, had masturbated from his twelfth to his twenty-second year, when he married, and, to avoid having children, indulged in incomplete connection. At the expiration of six or eight months he began to be troubled with inter- mittent prostatic discharges at stool, and to experience fatigue on mental and physical exertion. When I saw him, ten years after the appearance of these symptoms, he was suffering from habitual consti- pation, indigestion, acid eructations, furred tongue, bad taste in the mouth, dizziness, muscae volitantes, troubled and unrefreshing sleep, impairment of memory, almost constant pain in the back of the head, neck, and left shoulder, incapacity for mental exertion, muscular weakness of the limbs, constant pain in the back, a sensation of numbness along the outer side of the left thigh, and occasional flushes of heat. The prostatic discharge had been habitual for many years at the water-closet and during erections, and there was a sense of ful- ness and weight in the rectum. The prostatic urethra was morbidly sensitive, and the bulbous explorer defined strictures at one-third of an inch from the meatus, calibre 22, and at five inches and three- quarters, calibre 18. 1 Anatomy and Diseases of the Prostate Gland, p. 48, 1851. pathological characters. 167 Cases of a somewhat similar nature are narrated by Ledwich; but in these as well as in my own it should be remarked that the signs of nervous exhaustion were de- pendent upon natural and unnatural excesses, and were in no wise connected with the diseased condition of the prostate. In only two of the patients under my care were the bowels habitually costive; and in only one was there backache. Twelve of the subjects consulted me under the fixed impression that they were suffering from spermatic in- continence, so that their minds dwelt constantly on the discharge, and two were verging upon hypochondrism. I was, however, fortunate enough to convince them that the fluid was free from spermatozoa, and in this way suc- ceeded in eliminating an element which would otherwise have perpetuated and aggravated the disease. Pathological Characters.—In two patients, dead of phthisis, Ledwich succeeded in obtaining post-mortem examinations, and describes the appearances in the fol- lowing terms : " The prostato-vesical plexus was full, and many of its branches varicose; the capsule of the pros- tate adhered intimately to its surface, and, on slicing the gland, it seemed soft, with large, open venous branches on the section, from which blood exuded, whilst the whole gland exhibited an augmented volume ; the mucous mem- brane of its urethral aspect was red, soft, thickened, and villous, whilst the ducts could be distinguished with the unassisted eye, the uvula and trigone vesicae were red and turgid, but the remainder of the bladder was healthy." These cases, and they are the only ones on record of which I have any knowledge, demonstrate that the affec- 168 prostatorrhcea. tion, in some instances, is essentially a chronic inflamma- tion of the glandular apparatus of the prostate, with relaxation, and consequent dilatation of, the muscular fibres which surround the orifices of the ducts. Hence the discharge may be readily accounted for by the con- traction of the muscular elements incited into action whenever the acini and ducts become distended by the abnormal secretion, or by the pressure exerted upon them during the first expulsive efforts of defecation and urination. This view is moreover confirmed by the sub- jective and objective symptoms, of which the most characteristic is the morbid sensibility evoked by the introduction of a sound. In a few cases the urgent and frequent calls to empty the bladder, the scalding during the act, and the passage of drops of blood at its comple- tion, point in the same direction, as does also the tumid and tender condition of the prostate, as elicited by rectal examination, with which I have met in two instances. Diagnosis.—In the inflammatory form of the affection, if the patient be requested to pass the first two or three ounces of urine in a glass, that fluid will be found to con- tain delicate filiform shreds, which are sometimes more than half an inch in length, and which are mucopurulent casts of the follicles and ducts of the prostate. This highly characteristic sign, when considered in connection with the local signs and the minute examination of the discharge, the composition of which has already been sufficiently considered, is quite sufficient to establish the true nature of the trouble. In the simple variety of the disorder, the thread-like casts are absent, so that the treatment. 169 diagnosis will have to be based on the microscopical appearances of the secretion. Prognosis.—Prostatorrhcea is a most obstinate affec- tion, unless it is subjected to early and persevering treatment. Ordinarily the outlook, especially when the discharge is comparatively recent, is most favorable, as the disease does not evince any tendency to suppuration or other lesions of the body of the organ. This state- ment is substantiated by Case XVL, page 39, in which a discharge of two years' duration entirely ceased under appropriate measures in eight weeks. When mental dis- quietude and gloom are so great that the patient cannot be convinced that his malady is harmless, the prognosis is grave, and the management is most unsatisfactory. Treatment.—When any lesion, as, for example, strict- ure, phimosis, or internal piles, which tends to maintain the disorder has been relieved, the therapeutics of pros- tatorrhcea are essentially those of impotence and sper- matorrhoea, the remedies being addressed to the relief of the morbid sensibility of the prostatic sinuses, the atony of the ducts, and the cessation of the discharge. To avoid needless repetition I will, therefore, merely indicate the measures which I have found to yield the best results. The bowels should be kept in a soluble condition, and straining at the closet should be avoided. Driving, riding, and much walking, if prolonged exercise excites pain in the perineum, or aggravates it if it be present, alcoholic and malt liquors, and sexual intercourse and unnatural practices must be interdicted. If, however, 170 prostatorrhcea. the subject be married, and if he finds that coition is not attended with painful ejaculations, or that it does not in- crease the sensation of soreness in the perineum, it may be moderately indulged in. In every instance, except two in which the affection was respectively of six and ten years' duration, the warm hip-bath,1 the introduction of the bougie,2 and the exhi- bition of bromide of potassium3 and atropia,4 combined with tincture of hyoscyamus and bicarbonate of potassium if there were vesical irritability and scalding on urination, fulfilled the indications. Rosenthal,5 indeed, speaks more favorably of atropia in prostatic than in seminal dis- charges, and my own experience confirms his views. In the two exceptional cases, after the exaggerated sensi- bility of the prostatic urethra had been allayed by the preceding treatment, and the discharge was apparently kept up by an atonic and dilated state of the orifices of the ducts, I stopped the above-mentioned measures, but continued the atropia, and finally succeeded in effecting a cure by the administration of the fluid extract of ergot,6 cold sitz-baths7 morning and evening, the injection of thirty grains of nitrate of silver to the ounce,8 and the application of flying blisters to the perineum,9 which I consider indispensable. Winternitz recommends the psychrophor10 for this condition, and Lederer11 also re- gards it with favor; while Lee12 relies upon the injection 1 Consult p. 52. 2 Consult p. 42. 3 Consult p. 50. « Consult p. 51. 5 Wiener Klinik, May, 1880, p. 160. 6 Consult p. 160. 7 Consult p. 54. 8 Consult p. 45. 9 Consult p. 49. 10 Consult p. 55. 11 Wiener Med. Presse, 1879, P- 3°6- 12 Loc. cit., p. 34. treatment. 171 of a solution composed of from two to four drachms of the liquor ferri persulphatis to eight ounces of water; and Ultzmann1 has obtained good results from the in- duced current with one reophore in the rectum. I have had no experience with these remedies, but think well of the last, and would employ it if the case resisted the measures which I have indicated. 1 Wiener Klinik, May and June, 1879, P- x^4' INDEX. ACETATE of lead in the treat- ment of azoospermism, 112 Anaesthetic aspermatism, 124 diagnosis of, 127 prognosis of, 129 treatment of, 131 Anorchidism, 87 Anus, affections of, as causes of im- potence, 42 of spermatorrhoea, 148 Aspermatism, 113 anaesthetic, 124 atonic, 122 organic, 114 psychical, 126 Atonic aspermatism, 122 diagnosis of, 129 prognosis of, 129 treatment of, 129 impotence, 20 classification of, 29 clinical history of, 30 diagnosis of, 37 etiology of, 21 prognosis of, 39 treatment of, 41 Atropia in treatment of impotence, 51 of prostatorrhcea, 170 of spermatorrhoea, 158 Azoospermism, 87 diagnosis of, 106 from abnormal states of semen, 94 from anorchidism, 87 from cryptorchidism, 89 from defects of epididymes, 88 from defects of vasa deferentia, Azoospermism— from affections of testes, 90 from obliteration of epididymes, r 9I from obliteration of vasa defer- entia, 91 prognosis of, 109 treatment of, 111 BICHLORIDEof mercury in treat- ment of azoospermism, 112 Bromide of potassium in treatment of impotence, 50 of prostatorrhcea, 170 of spermatorrhoea, 158 CANTHARIDES in the treatment of spermatorrhoea, 160 Catheter-syringe, 47 Cerebrasthenia, 37 Conical bougie in treatment of im- potence, 42 of prostatorrhcea, 170 of spermatorrhoea, 158 Constipation a cause of spermator- rhoea, 149 Cryptorchidism, 89 Crystals, prostatic, 164 spermatic, 83 Cupped bougie, 48 DAMIANA in treatment of impo- tence, 54 Diurnal pollutions, 138 174 INDEX. Ducts, ejaculatory, absence of, 114 deviation of, 115 occlusion of, 114 ELECTRICITY in treatment of impotence, 55 of prostatorrhcea, 171 of spermatorrhoea, 159 Epididymes, deficiency of, 88 obliteration of, 91 Epididymitis, gonorrhceal, 93, 103 Erection, mechanism of, 17 Ergot in treatment of prostatorrhoea, | 170 of spermatorrhoea, 160 Exhaustion, spinal, 36 a cause of azoospermism, J 96 Exploratory bougie, 37 FARADISM in treatment of im- potence, 56 of prostatorrhoea, 171 of spermatorrhoea, 159 GALVANISM in treatment of azoospermism, 111 of impotence, 55 of spermatorrhoea, 159 Gelsemium in treatment of impo- tence, 51 of spermatorrhoea, 158 Genito-spinal centre, 19 diminished excitability of, 20 increased excitability of, 134 Glycerole of tannin in treatment of impotence, 49 Gonorrhoea, a cause of impotence, 28 of prostatorrhoea, 163 of spermatorrhoea, 145 Gonorrhceal epididymitis, 93, 103 HERPES, a cause of spermator- rhoea, 147 Hyperaesthesia of the urethra, a cause of impotence, 21 of prostatorrhoea, 163 of spermatorrhoea, 145 IMPOTENCE, 17 atonic, 20 organic, 68 paralytic, 35 psychical, 58 symptomatic, 65 Iodide of potassium in treatment of azoospermism, 112 Iodoform in treatment of azoosperm- ism, 112 Iron in treatment of impotence, 51, 53 of prostatorrhoea, 171 of spermatorrhoea, 158, 160 Irritable weakness, 32 Irritation, spinal, 36 LAXATIVES in treatment of im- potence, 52 of prostatorrhoea, 169 of spermatorrhoea, 156 MASTURBATION, effects of, 22 hyperaesthesia of urethra from, 21 nervous disorders from, 27 prostatorrhcea from, 163 spermatorrhoea from, 144 stricture of urethra from, 23 Meatus, stricture of, a cause of sper- matorrhoea, 148 Misemission, 131 Monobromide of camphor in treat- ment of impotence, 51 Morphism, a cause of azoosperm- ism, 101 Myelasthenia, 36 NEURASTHENIA, a cause of azoospermism, 96 of impotence, 37 of prostatorrhcea, 166 of spermatorrhoea, 143 Nitrate of silver in treatment of im- potence, 45 of prostatorrhcea, 170 of spermatorrhoea, 158 Nocturnal pollutions, 135 INDEX. 175 ORGANIC aspermatism, 114 diagnosis of, 127 prognosis of, 129 treatment of, 129 Organic impotence, 68 PENIS, lesions of, causes of im- potence, 68 Phimosis, a cause of aspermatism, 121 of spermatorrhoea, 147 Phthisis, a cause of azoospermism, 98 Pollutions, diurnal, 138 nocturnal, 135 Porte-caustique, 48 Porte-remede, 48 Prostatic crystals, 164 fluid, uses of, 82 Prostatorrhcea, 162 clinical history of, 164 diagnosis of, 168 etiology of, 162 pathological characters of, 167 prognosis of, 169 treatment of, 169 Psychical aspermatism, 126 prognosis of, 129 treatment of, 131 impotence, 58 treatment of, 64 Psychrophor in treatment of impo tence, 55 of prostatorrhcea, 170 of spermatorrhoea, 160 Purulent semen, 102 QUININE in treatment of impo- tence, 50, 54 of spermatorrhoea, 158 RECTUM, affections of, causes of prostatorrhcea, 163 of spermatorrhoea, 148 SEMEN, abnormal conditions of, 94-106 colloid, 108 Semen— composition of, 80 purulent, 102,108 watery, 107 Sexual excesses, causes of azoo- spermism, 94 of impotence, 28 of prostatorrhoea, 163 of spermatorrhoea, 144 Sitz-bath, warm, in treatment of im- potence, 52 of prostatorrhoea, 170 of spermatorrhoea, 159 cold, in treatment of impotence, 54 of prostatorrhcea, 170 of spermatorrhoea, 160 Spinal exhaustion, 36 a cause of azoospermism, 96 of impotence, 36 of prostatorrhcea, 166 of spermatorrhoea, 143 Spermaspasmos, 32 Spermatic crystals, 83 colic, 128 Spermatocystitis, a cause of azoo- spermatism, 103 of spermatorrhoea, 148 Spermatozoa, 82 absence of, 95 infertile, 96-101 Spermatorrhoea, 134 anatomical characters of, 149 classification of, 134 clinical history of, 140 diagnosis of, 150 etiology of, 143 prognosis of, 151 treatment of, 154 Spermorrhagia, 138 Sterility, 80 classification of, 85 from aspermatism, 113 from azoospermism, 87 from misemission, 131 relative frequency of, 86 Stricture of ejaculatory ducts, 115 of urethra from masturbation, 23 a cause of aspermatism, 119 of prostatorrhcea, 163 of spermatorrhoea, 148 176 INDEX. Strychnia in treatment of impotence, 54 of spermatorrhoea, 160 Sympexions, 117 diagnosis of, 128 treatment of, 129 Symptomatic impotence, 65 prognosis of, 67 treatment of, 67 Syphilis, a cause of azoospermism, 101 rPESTES, absence of, 87 JL atrophy of, 90 lesions of, in azoospermism, 90 Testes, lesions of— in impotence, yj retained, 89 URETHRA, hyperaesthesia of, 21 stricture of, 23 Urethral dilator, 44 Urethrotome, 44 VASA DEFERENTIA, deficiency of, 88 obliteration of, 91 Veratrum viride in treatment of im- potence, 51 Vesication in impotence, 49 in prostatorrhcea, 170 THE END. IIEXRY C. LEA'S SOX A CO.'S (LATE HENRY C. LEA) CLASSIFIED CATALOGUE O P MEDICAL AND SUEGICAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the following pages, the publishers would state that no pains are spared to secure a continuance of the confi- dence earned for the publications of the house by their careful selection and accuracy and finish of execution. The large number of inquiries received from the profession for a finer class of bindings than is usually placed on medical books has induced us to put certain of our standard publications in half Russia; and, that the growing taste maybe encouraged, the prices have been fixed at so small an advance over the cost of sheep as to place it within the means of all to possess a library that shall have attractions as well for the eye as for the mind of the reading practitioner. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail postpaid on receipt of the price, and as the limit of mailable weight has been removed, no difficulty will be experienced in obtaining through the post-office any work in this cata- logue. No risks, however, are assumed either on the money or on the books, and no pub- lications but our own are supplied, so that gentlemen will in most cases find it more con- venient to deal with the nearest bookseller. A handsomely illustrated catalogue will be sent to any address on receipt of a three-cent stamp. HENRY C. LEA'S SON & CO. Xos. 706 and 708 Saxsom St., Philadelphia, June, 18S3. PROSPECTUS FOR 1833. A NEW WEEKLY MEDICAL JOURNAL. SUBSCRIPTION RATES. The Medical News.......Five Dollars. The American Journal of the Medical Sciences . Five Dollars. COMMUTATION RATES. The Medical News \ Nine Dollars per The American Journal of the Medical Sciences J annum, in advance. THE MEDICAL NEWS. A National Weekly Periodical, of from 28 to 32 Quarto Pages, containing- more Reading- Matter than any other Weekly Medical Journal in America. The unprecedented growth of the subscription list of The Medical News during 1882 is gratifying to all concerned in its publication, not only as assuring its continued success, but as proving that they were not mistaken in supposing that the profession felt the need of and would generously support a weekly journal, national in the fullest sense of the word, devoted to the best interests of medical science, and conducted with the forethought to devise and energy and ability necessary to execute every available plan for enhancing its usefulness. Encouraged by this approbation, those in charge of The News will make during 1883 renewed efforts to strengthen in every way its hold upon the respect and esteem of the 2 Henry C. Lk.a's .Son &. Co.'s Publications—The Medical News. profession. Advocating the highest standard of moral* and honor, The News will be an unsparing opponent of quackery in its countless forms. As the recognized national organ of the regular profession, it is the chosen vehicle for the conveyance of the most important intelligence from all parts of the country. The general plan of The News affords ample space for the presentation of articles upon all branches of medical science. The opening pages are devoted to Original Lectures by the ablest teachers of the day, which are invariably revised by their authors before publi- cation, thus insuring an authenticity and exactitude otherwise unattainable. In the de- partment of Original Articles, Tin: News will endeavor, as heretofore, to surpass its contemporaries in the intrinsic value of its contributions. Under the caption of Hos- pital Notes is laid open the vast and rich store of clinical information developed in the chief hospitals of the globe. The department of Medical Progress consists of con- densations of articles of importance appearing in the leading medical, pharmaceutical and scientific journals of the world. The Editorial Articles are from the pens of a large and able Editorial Board, and discuss living subjects in all departments of med- ical science in a thoughtful, independent and scholarly manner. Important subjects, re- quiring unusually elaborate consideration, sire treated in Special Articles. The Pro- ceedings of Societies in all parts of the country afford a means of imparting valuable informsition, for which due space is reserved. For the collection of News Items, and for Correspondence, The News enjoys sin orgsinization similar to that of a daily newspaper, and by mail sind telegraph receives notice of all professional events of interest through special correspondents, located in the following cities:—In the United States: Portland, Boston, New York, Baltimore, Pittsburgh, Washington, Charleston, New Or- leans, Cincinnati, Chicago, Detroit, Kansas City and San Francisco. In Canada : Mon- treal. In Great Britain : London and Edinburgh. In Continentsil Europe: Paris, Berlin, Vienna and Florence. In Asia: Yokohama, Canton, Hong Kong and Calcutta. In South America: Rio Janeiro and Valparaiso. In Cuba: Havansi. Due attention will be paid to New Publications, New Instruments and New Pharmaceutical Pre- parations, and a column will be devoted to Notes and Queries. Space is reserved each week for accurate reports of all changes in the Army and Navy Medical Service. The Medical News appears in a double-columned quarto form, printed by the latest improved Hoe speed presses, on handsome paper, from a clear, easily read type, specially cast for its use. It will thus be seen that The Medical News employs all the approved methods of modern journalism in its efforts to render itself indispensable to the profession; and, in the anticipation of an unprecedented circulation, its subscription has been placed at the ex- ceedingly low rate of s.3 per annum, in advance. At this price it ranks as the cheapest medical periodical in this country, and when taken in connection with The America x Jour- nal at NINE DOLLARS per annum, it is confidently asserted that a larger amount of material of the highest class is offered than can be obtained elsewhere, even at a much higher price. THE AMERICAN JOURNAL of the MEDICAL SCIENCES, Edited by I. MINIS HAYS, A. M., M. D., Is published Quarterly, on the first days of January, April, July and October, each Number containing over Three Hundred Octavo Pages, fully Illustrated. Founded in 1820, The American Journal entered with 1883 upon the sixty-fourth consecutive year of faithful and honorable service to the profession. Beine the only Henry C. Lea's Son & Co.'s Publications—Am. Journ. Med. Sci. 3 periodical in the English language capable of presenting elaborate articles—the form in which the most important discoveries have always been communicated to the profession— The American Journal cannot fail to be of the utmost value to physicians who would keep themselves au courant with the medical thought of the day. It may justly claim that it numbers among its contributors all the most distinguished members of the profession that its history is identified with the advances of medical knowledge, and that its circu- lation is co-extensive with the use of the English language. During 1883 The Journal will continue to present those features which have lcng proved so attractive to its readers. The Original Department will consist of elaborate and richly illustrated articles from the pens of the most eminent members of the profession in all parts of the country. The Review Department will maintain its well-earned reputation for discernment and impartiality, and will contain elaborate reviews of new works and topics of the day, and numerous analytical and bibliographical notices by competent writers. Following these comes the Quarterly Summary of Improvements and Dis- coveries in the Medical Sciences, which, being a classified and arranged condensation of important articles appearing in the chief medical journals of the world, furnishes a compact digest of medical progress abroad and at home. The subscription price of The American Journal of the Medical Sciences has never been raised during its long career. It is still sent free of postage for Five Dollars per annum in advance. Taken together, the Journal and News combine the advantages of the elaborate prep- aration that can be devoted to a quarterly with the prompt conveyance of intelligence by the weekly; while, by special management, duplication of matter is rendered im- possible. It will thus be seen that for the very moderate sum of NINE DOLLARS in advance the subscriber will receive free of postage a weekly and a quarterly journal, both reflecting the latest advances of the medical sciences, and containing an equivalent of more than 4000 octavo pages, stored with the choicest material, original and selected, that can be furnished by the best medical minds of both hemispheres. It would be impossible to find elsewhere so large an amount of matter of the same value offered at so low a price. Gentlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for 1883. 8®"" The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned; where these are not accessible, remittances for subscrip- tions may be made at the risk of the publishers by forwarding in registered letters. Address, Henry C. Lea's Son & Co., Xos. 706 and 708 Sansom St., Philadelphia, Pa. *#* Communications to both these periodicals are invited from gentlemen in sill parts of the country. Original articles contributed exclusively to either periodical are liberally paid for upon publication. When necessary to elucidate the text, illustrations will be fur- nished without cost to the author. All letters pertaining to the Editorial Department of The Medical News and The American Journal of the Medical Sciences should be addressed to the Editorial Offices 1004 Walnut Street, Philadelphia. All letters pertaining to the Business Department of these journals should be svddressed exclusively to Henry C. Lea's Son & Co., 706 and 708 Ssmsom Street, Philadelphia. 4 Henhv C. Lka'.s Son A: Co.'s Publications—Dictionaries. dvxglisox, roblfy, j/.z>., Late Professor of InsUtiita of Medicine in the Jrfferson Mb\-"iU; leatlier, raised bands, s7.50; very handsome half Russia, raised bands, s.s. The object of the author, from the outset, hsis not been to make the work si mere lexi- con or dictionary of terms, but to sitibrd under each word a condensed view of its various medicsd relsitions, and thus to render the work sm epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until sit length it hsis attained the position of si recognized and standard authority wherever the language is spoken. Special pains have been tsiken in the preparation of the present edition to maintain this enviable reputation. The additions to the vocabulary sire more numerous than in smy previous revision, and particular attention has been bestowed on the accent nation, which will be found marked on every word. The typographical arrangement has been greatly improved, rendering reference much more easy, smd every care has been taken with the mechanical execution. The volume now contains the matter of at least four ordinary octavos. A book of which every American ought to be work has been well known for about forty years, proud. When the learned author of the work and needs no words of praise on our part to recom- passed away, probably all of us feared lest the book mend it to the members of the medical, and like- should not maintain its place in the advancing wise of the pharmaceutical, profession. The latter science whose terms it defines. Fortunately, Dr. especially are in need of a work which gives ready Richard J. Dunglison, having assisted his father in and reliable information on thousands of subjects the revision of several editions of the work, and and terms which they are liable to encounter in having been, therefore, trained in the methods pursuing their daily vocations, but with which they and imbued with the spirit of the book, has been cannot be expected to be familiar. The work able to edit it as a work of the kind should be before us fully supplies this want.—American Jour- edited—to carry it on steadily, without jar or inter- nal, of Pharmacy, Feb. 1874. ruption, along the grooves of thought it has tray- Particular care has been devoted to derivation elled during its lifetime. To show the magnitude \ anti accentuation of terms. With regard to the of the task which Dr. Dunglison has assumed and ( latter, indeed, the present edition may be consid- carried through, it is only necessary to state that , ered a complete "Pronouncing Dictionary of more than six thousand new subjects have been | Medical Science." It is perhaps the most reliable added in the presentedition — Philadelphia Medical ! work published for the busy practitioner, as itcon- Times, Jan. 3,1874. < tains information upon every medical subject, in About the first book purchased by the medical a ?orl.n. for r?ady access and with a brevity as ad- student is the Medical Dictionary. The lexicon p1^'6-?s ll ls Poetical.—SowMer-n Medical Record, explanatory of technical terms is simply a sine qua tet)- 187'1- non. In a science so extensive and with such col- , A valuable dictionary of the terms employed in laterals as medicine, it is as much a necessity also : medicine and the allied sciences, and of the rela- to the practising physician. To meet the wants of ' tions of the subjects treated under each head. It students and most physicians the dictionary must ! well deserves the authority and popularity it has be condensed while comprehensive, and practical i obtained.—British Mid. Jour., Oct. :il, 1874. while perspicacious. It was because Dunglison's Few works of this class exhibit a grander monu- met these indications that it became at once the ; ment of patient research and of scientific lore.— dictionary of general use wherever medicine was Low/on Lancet, May 13, 1875. studied in the English language. In no former Dunglison's Dictionary is incalculably valuable, revision have the alterations and additions been I and indispensable to every practitioner of medi- so great. 1 he chiel terms have been set m black | oine, pharmacist and dentist.—Western Lancet, letter, while the derivatives follow in small caps; March 1874. an arrangement which greatly facilitates reference. i* L„'„ »u„ ™ •<. »i l-l .. • i u • i -ancintiati Clinic, Jan. 10, 1874. ,„'k/f hITf ment th.atltcert^»"y has no rival ' ' in the English language for accuracy and extent of As a standard work of reference Dunglison's references.—London Medical Gazette. HOBLYX, RICHARD D.,3I. 1). A Dictionary of the Terms Used in Medicine and the Collateral Sciences. Revised, with numerous additions, by Isaac Hays, M. I)., late editor of The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 double-columned pages. Cloth, Sl.oU ; leather, 82.00. It is the best book of definitions we have, and ought always to be upon the student's table.—Southern Medical and Surgical Journal. RODWELJL, G. F, F. R. A. 8., F. C. S., Lecturer ow Natural Science at CI if ton College, England. A Dictionary of Science: Comprising Astronomy, Chemistry, Dynamics, Elec- B.Sc. Preceded by an Esssiy on the History of the Physical Sciences. In one handsome octavo volume of 702 pages, with 143 illustrations. Cloth, $5.00. Henry C. Lea's Son & Co.'s Publications—Compends, Aiiat. 5 HARTSHORXE, HEXRY, M. D., Lately Professor of Hygiene in the University of Pennsylvania. A Conspectus of the Medical Sciences; Containing Handbooks on Anatomy, Physiology, Chemistry, Msiteria Medica, Practice of Medicine, Surgery and Obstetrics. Second edition, thoroughly revised and greatly improved. In one large roval 12mo. volume of 1028 pages, with 477 illustrations. Cloth, 84.25 ; leather, 85.00. The object of this manual is to afford a conven- j The work is intended as an aid to the medical ient work of reference to students during the brief ! student, and as such appears to fulfil admirably its moments at their command while in attendance object by its excellent arrangement, the full com- upon medical lectures. It is a favorable sign that j piiation of facts, the perspicuity and terseness of it has been found necessary, in a short space of ' language, and the clear and instructive illustra- time, to issue a new and carefully revised edition, j tions.—American Journal of Pharmacy July 1874 The illustrations are very numerous and unusu- j The volume will be found useful not only'to stu- ally clear, and each part seems to have received dents, but to many others who may desire to re- its due share of attention. We can conceive such i fresh their memories with the smallest possible a work to be useful not only to students, but to ; expenditure of time.—iV. Y. Med. Journ., Sept '74 practitioners as well. It reflects credit upon the rfK„ ..,„„,. u„,.__.„ ,______ _._ , ' "/^"■J* industry and energy of its able editor.—Boston Malicatand Surgical Journal, Sept. 3, 1874. We can say, with the strictest truth, that it is the best work of the kind with which we are acquaint The work before us has many redeeming fea- tures not possessed by others, and is the best we have seen. Dr. Hartshorne exhibits much skill in condensation. It is well adapted to the physician in active practice who can give but limited time to ed. It embodies in a condensed form all recent ; familiarizing himself with the important changes contributions to practical medicine, and is there- i that have been made since he attended lectures. fore useful to every busy practitioner throughout | The manual of physiology has also been improved our country, besides being admirably adapted to i and gives the most comprehensive view of the the use of students of medicine. The book is j latest advances in the science possible in the space faithfully and ably executed.—Charleston Medical devoted to the subject.—Penins. Jl. of Med. Sept. '74. Journal. April, 187,3. 1 XEILL, JOHX, M. D., and SMITH, F. G., M. D., Late Surgeon to the Penna. Hospital. Prof, of the Institutes of Med. in the Univ. of Penna. An Analytical Compendium of the Various Branches of Medical Science, for the use and examination of Students. A new edition, revised and improved. In one very large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, 84; strongly bound in leather, raised bands, 84.75. LUDLOW, J. L., 31. D., Consulting Physician to the Philadelphia Hospital, etc. A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised, and greatly extended and enlarged. In one handsome royal 12mo. volume of 816 large pages, with 370 illus- trations. Cloth, 83.25 ; leather, 83.75. The arrangement of this volume in the form of question and answer renders it espe- cially suitable for the office examination of students, and for those preparing for graduation. WILSOX, ERASMUS, F. R. S. A System of Human Anatomy, General and Special. Edited by \V. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, 84.00; leather, 85.00.________________________ SMITH, H. H, M. D., and HORXER, WM. E.,M.D., Emeritus Prof, of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna. An Anatomical Atlas, Illustrative of the Structure of the Human Body. In one large imperial octavo volume of 200 pages, with 634 beautiful figures. Cloth, 84.50. CLELAXD, JOHX, M. D., F. R. S., Professor of Anatomy and Physiology in Queen's College, Galway. A Directory for the Dissection of the Human Body. In one 12mo. volume of 178 pages. Cloth, 81.25. BELLAMY, EDWARD, F. R. C. S., Senior Assistant-Surgeon to the Charing-Cross Hospital, London. The Student's Guide to Surgical Anatomy: Being a Description of the most Important Surgical Regions of the Human Body, and intended as an Introduction to Operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, 82.25. HARTSHORNE'S HANDBOOK OF ANATOMY HORNER'S SPECIAL ANATOMY AND HISTOL- AND PHYSIOLOGY. Second edition, revised, j OGY. Eighth edition, extensively revised and In one royal 12mo. volume of 310 pages, with 220 ; modified. In two octavo volumes of 1007 pages, woodcuts. Cloth, Sl-75. with :!2(i woodcuts. Cloth, $6.00. 8HARPEY AND QUAIN'S HUMAN ANATOMY. \ HEATH'S PRACTICAL ANATOMY. From second Revised by Joseph Leidy, M. D., Prof, of Anat. in j London edition, with additions byW. W. Keen, Univ. of Penna. In two octavo volumes of about ! M. D. #In one 12mo. volume of 578 pages, with 1300 pages, with 511 illustrations. \ 247 woodcuts. 6 Henry C. Lea's Son & Co.'s Publications—Anatomy. ALLEX, HARRISOX, M. D., Professor of Physiology in the University of Pennsylvania. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. With an Intro- ductory Chapter on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to the Philadelphia Hospital. In one large and handsome quarto volume of about 600 double- columned pages, with 380 illustrations en 109 lithographic plates, many of which are in colors, and about 250 engravings in the text. In six Sections, each in a portfolio. Sect inn I. Histology (Just Ready). Section II. Bones and Joints (Just Beady). Section III. Muscles and Fascle [Just Heady). Section IV. Arteries, Veins and Lymphatics (Just Ready). Section V. Nervois System (In Press). Section VI. Organs of Sense, of Digestion and Genito-Urinaky Organs (In Press). Price per Section, 83.50. For sale by subscription only. extract from introduction. It is the design of this book to present the facts of human anatomy in the manner I.est suited to the requirements of the student and the practitioner of medicine. The author believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in addition to the text descriptive of the subject, a systematic presentation of such anatomical facts as can be applied to practice. A book which will be at once accurate in statement and concise in terms ; which will be an acceptable expression of the present state of the science of anatomy; which will exclude nothing that can be made applicable to the medical art, and which will thus embisue all of surgical importance, while emitting nothing of value to clinical medicine,—would appear to have an excuse for existence in a country where most surgeons are general practitioners, and where there are few general practitioners who have no interest in surgery. Among other matters, the book will be found to contain an elaborate description of the tissues; an account of the normal development of the body; a section on the nature and varieties of monstrosities; a section on the method of conducting post-mortem examina- tions ; and a section on the study of the superficies of the body taken as a guide to the position of the deeper structures. These will appear in their appropriate places, duly subordinated to the design of presenting a text essentially anatomical. A book like this is an ideal rarely realized. It ing the anatomist it will be of value to the will do, we have no doubt, what its accomplished author hopes: "make anatomy what unfortunately it rarely is—an interesting study." It has long been an opprobrium to America that ouranatomical text- books were all foreign, but this work will remove the stigma. It is a mine of wealth in the informa- tion it gives. It diflers from all preceding anato- mies in its scope, and is, we believe, a vast im- provement upon them all. The cjiief novelty practising physician. Such a work is certainly novel, and it will bring the greatest honor to the author. The illustrations of the bones are very fine. The names of the parts, muscular at- tachments, etc., are printed either on the figure or close beside, so that they are easily recognized. Dr. Allen'streatment of the jointsis admirab)e,and the illustrations made from the author's dissec- tions deserve the highest praise. They bear wit- about the book, and really one of the greatest ness to his skill witli the scalpel and to that of the needs in anatomy, is the extension of the text to cover not only anatomical descriptions, but the uses of anatomy in studying disease. This is done bv stating the narrower topographical relations, and also the wider clinical relations, of the more remote I arts, by giving a brief account of the uses el the artist with his pencil. They are well conceived and well executed, handsome artistically and clear anatomically. As the author points out, such a work as he has undertaken is necessarily encyclo- 1 sedic, and the result shows that he has brought to it a mind well prepared for the task by exten- variousorgans.and by quoting cases which illustrate sive reading, critical judgment and literary ability the "localization of diseased action." The plates are beautiful specimens of work by one who long since won a deserved reputation as an artist.—The Medical News, October 21,1882. It is to be considered a study of applied anatomy in its widest sense—a systematic presentation of such anatomical facts as can be applied to the practice of medicine as well as of surgery. Our author is concise, accurate and practical" in his statements, and succeeds admirably in infusing an interest into the study ii what is generally con- sidered a dry subject. The department of Histol- ogy is treated in a masterly manner, and the gn.und is travelled over by one thoroughly famil- iar with it. The illustrations are made with great care, and are simply superb. It would be impos- sible, except in a general way, to point out the excellence of the work of the author in the second We can cordially recommend the work to the pro- fession, believing that it is suited not only to those of scientific tastes, but that it will be of use to the practising physician.—Boston .Vulical and Surgical Journal, Jan. 11, 1883. It has fallen to the lot of the fortunate publish- ers to be able to bring out the best anatomy yet produced in America, and one which will prove much more useful to the general practitioner than the foreign works now accepted as standard. The descriptions are clear, tersely expressed and well up to date. The work, as a whole, shows a great amount of research, and reflects credit upon its author. Its pages teem with well-culled facts which cannot be found in the ordinary anatomical treatises. The lithographic plates are beautifully executed, and deserve unqualified praise. To the more advanced students in anatomy, as well as to Section—that devoted to the consideration of the the profession at large, it will prove a valuable Bones and Joints. There is as much of practical ' companion, and one olten referred to.—Arte York application of_anatomieal_ points to the every-day j Midieal Journal and Obstetrical iJeti'tu-, Nov. 1882. The distinguishing feature of this work is that, while a thorough treatise on human anatomy, it is neither prepared from the standpoint of the sci- entist without knowledge of or sympathy with clinical requirements, nor from the standpoint of the surgeon, who often disregards the wants of the student and physician. The purpose has been maintained throughout of adapting the work to the wants of the student, the surgeon and the physician. The Sections are admirably illustrated with plates of wonderful fidelity and beauty. The text is simple, concise, accurate and lucid.—Louis- wants of the medical clinician as to those of the operating surgeon. In fact, few general practi- tioners will read the work without afeeling of sur- prised gratification that so many points, concern- ing which they may never have thought before, are so well presented for their consideration. It is a work which is destined to be the best of its kind in any language.—Medical Record, Nov. 25,'82. The appearance of the book marks an epoch in medical literature. It is the first important work on human anatomy that has appeared in America; and, more than this, its scope is new and original. It is intended to be both descriptive and topograph- ical, scientific and practical, so that while satisfy- ville Medical ..Yews, Dec. 2,1882. Henry C. Lea's- Son & Co.'s Publications—Anatomy. GRAY, HEXRY, F. R. S., Lecturer on Anatomy at St. George's Hospital, London. Anatomy, Descriptive and Surgical. The Drawings by H. V. Carter, M. D., and Dr. AVestmacott. The dissections jointly by the Author and Dr. Carter. With an Introduction on General Anatomy and Development by T. Holmes, M. A., Surgeon to St. George's Hospital. A new American from the eighth enlarged and improved London edition. To Avhich is added the second American from the latest English edition of Landmarks, Medical and Surgical, by Luther Holden, F. E. C. S., author of "Human Osteology," "A Manual of Dissections," etc. In one magnificent imperial octavo volume of 993 pages, with 523 large and elaborate engravings on wood. Cloth 86.00; leather, raised bands, S7.00 ; half Russia, raised bands, S7.50. The author hsis endeavored in this work to cover a more extended range of subjects than is customary in the ordinary text-books by giving not only the details necessary for the student, but also the application of those details to the practice of medicine and surgery, thus rendering it both a guide for the learner and an admirable work of reference for the active practitioner. The engravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting- room. Combining, as it does, a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of great service to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. To the present edition has been appended the recent work by the distinguished anato- mist, Mr. Luther Holden—" Landmarks, Medical and Surgical"—which gives in a clear, condensed and systematic way all the information by which the practitioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illus- tration in anatomical study. It is difficult to speak in moderate terms of this [ gery as it has been heretofore to the student. As new edition of "Gray." It seems to be as nearly j regards completeness, ease of reference, utility, perfect as it is possible to make a book devoted : beauty and cheapness, it has no rival. No student to any branch of medical science. The addition j should enter a medical school without it; no phy- of Holden's " Landmarks" will make it as indis- sician can afford to have it absent from his library. pensable to the practitioner of medicine and sur- | —St. Louis Clinical Record, Sept. 1878. Also for sale separate— HOLDEX, EITHER, F. R. C. S., Surgeon to St. Bartholomew's and the Foundling Hospitals, London. Landmarks, Medical and Surgical. Second American from the latest revised English edition, with additions by AV. AV. Keen, M. D., Professor of Artistic Anatomy in the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. the student's and young practitioner's book.—Phy- sician and Surgeon, Nov. 1881. To the student or young surgeon this is prac- tically a most useful little book. We heartily recommend this work to all students and young practitioners, for whom it has been written, and who by its aid will readily be able to make thor- ough and intelligent examination, or in surgical operations to cut down upon any part with confi- dence.—Medical and Surgical Reporter, Sep. 3,1881. This little book is all that can be desired within its scope, and its contents will be found simply in- valuable to the young surgeon or physician, since they bring before him such data as he requires at every examination of a patient. It is written in language so clear and concise that one ought almost to learn it by heart. It teaches diagnosis by external examination, ocular and palpable, of the body, with such anatomical and physiological facts as directly bear on the subject, it is eminently DALTOX, JOHX C, M. D., Professor of Physiology in the College of Physicians and Surgeons, New York. The Topographical Anatomy of the Brain. In one very handsome quarto volume of about 200 pages of descriptive text. Illustrated with forty-nine life-size photo- graphic illustrations of Brain Sections, with a like number of outline explanatory plates, as well as many carefully-executed woudcuts through the text. Preparing. ELLIS, GEORGE VIXER, Emeritus Professor of Anatomy in University College, London. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. By George Atixer Ellis, Emeritus Professor of Anatomy in University College, London. From the eighth and revised London edition. In one very handsome octavo volume of 716 pages, with 249 illustrations. Cloth, S4.25; leather, $5.25. Ellis' Demonstrations is the favorite text-book special line. The descriptions are clear, and the of the English student of anatomy. In passing | methods of pursuing anatomical investigations are through eight editions it has been so revised and given with such detail that the book is honestly adapted to the needs of the student that it would I entitled to its name.—St. Louis Clinical Record, seem that it had almost reached perfection in this j June, 1879. Henry C. Lea's Son & Co.'s Publications—Physiology. DALTOX, JOHX C, M. D., Professor of Physiology in the College of Physicians and Surgeons, Sew York, etc. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. Seventh edition, thorouglily revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, $5.00; leather, sii.00 ; very handsome half Russia, raised bands, 80.50. The reputation which this work has acquired as si compact and convenient summary of the most advanced condition of human physiology renders it only necessary to stsite that the Author has sissiduously labored to render the present edition worthy a continuance of the marked favor accorded to previous issues, and that every care has been bestowed upon the typographical execution to make it, as heretofore, one of the handsomest productions of the American press. previous one, and will tend to keep the profession posted as to the most recent additions to our physiological knowledge.—Michigan Medical Xeics, April, 1882. One can scarcely open a college catalogue that does not have mention of Dalton's Physiology as the recommended text or consultation-book. For American students we would unreservedly recom- mend the edition of Dr. Dalton's work now before us. Let it suffice to state that revisions have been made to such an extent as to bring the volume as fully up to the present state of physiological knowl- edge as it is practicable for any author of a book to do.— Virginia Medical Mouth'u, Julv, 1882. The merits of Professor Dalton's text-book, his smooth and pleasing stylo, the remarkable clear- ness of his descriptions, which leave not a chapter obscure, his caution* judgment and the general correctness of his facts, are perfectly known. They have made his text-book the one most familiar to American students.—Med. Record, March 4, 1882. Certainly no physiological work has ever issued from the press that presented its subject-matter in a clearer and more attractive light. Almost every page bears evidence of the exhaustive revision that has taken place. The material is placed in a more compact form, yet its delightful charm is re- tained, and no subject is thrown into obscurity. Altogether this edition is far in advance of any FOSTER, MICHAEL, M. D., F. R. S., Professor of Physiology in Cambridge University, England. Text-Book of Physiology. Second American from the latest English edition. Edited, with extensive notes and additions, by Edward T. Reichert, M. D., late Demonstrator of Experimental Therapeutics in the University of Pennsylvania. In one handsome royal 12mo. volume of 999 pages, with 259 illnst. (loth, $3.25 ; leather, S3.75. A more compact and scientific work on physiol- preface that the abundant material, in spite of the ogy has never been published, and we believe our- moderate size, is not condensed to systematic selves not to be mistaken in asserting that it has ' shortness, but the whole is related in a narrative now been introduced into every medical college style. Further on he writes: "To give to students in which the English language is spoken. This arid physicians a book which is not intended work conforms to the latest researches into zoology merely for reference, but which, by its flowing, and comparative anatomy, and takes into consid- | lively style, invites the reader to go through it, is eration the late discoveries in physiological chem istry and the experiments in localization of Ferrier and others. The arrangement followed is such as to render the whole subject lucid and well con- nected in its various parts.—Chicago Medical Jour- nal and Examiner, August, 1882. Dr. Michael Foster's Manual, of Physiology has been translated into the Ui'iman, with a preface, by Professor Kiihiie. Kiihne points out in his always useful, especially when the contents, in- cluding numerous matters in a state of active dis- cussion in which physiology is now so rich, in- struct with truth and calm impartiality. Such the author has preserved throughout." The transla- tion of it into German is a well-merited compli- ment, since Germany is the especial home of physiology, and its literature is abundantly rich in text-books, monographs and periodicals on physi- ology.— American Med. Bi- Weekly, June 18,1S81. CARFEXTER, \V3I.B.,3I.d7, F. R. S., F. G. S., F. L. S., Registrar to the University of London, etc. Principles of Human Physiology. Edited by Henry Power, M.B., Loud., F. R. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the eighth revised and enlarged edition, with notes and additions by Francis G. Smith, AI. I)., late Professor of the Institutes of Medicine in the University of Pennsylvania. In one very large and handsome octavo volume of K),s3 pages, with two plates and 373 illus- trations. Cloth, S5.50; leather, 80.50; half Russia, 87. Without departing materially from the judicious arrangement which the author originally chose, the latest researches in physiology have been in- troduced, and with a careful hand. The Ameri- can editor has added what few paragraphs were necessary to bring the work up to the level of the science since the last English edition, and has the fullest sense of the word, is the production of a philosopher as well as a physiologist, brought it up fully to the -tundard of our knowledge of its Mibjeot at the present day. The additions by the American editor give to the work as it is a consid- erable value beyond that of the last English edi- c^iou^ y"^ vc ",,c"- *-""B"*>" cumui], anu nas tion. We have been agreeably surprised to find thus rendered it a thoroughly complete compen- the volume so complete in regard to the structure dium of physiology. Altogether there are few, if and functions of the nervous system in all its rela- any, treatises on th.- subject so well calculated to tions—a subject that in many respects is one of attract and instruct a student as this one.—Medical the most difficult of all, in the whole range of and Surgical Reporter, Dec. 2, l«7«. physiology, upon which to produce a full and satis- The editor.- have, with their additions to the factory treatise of the class to which the one be- only work on physiology in our language that, in fore us belongs.—Jl. of Xerv.and Ment. Dis., Apr.,'77. CARPENTER'S PRIZE ESSAY ON THE USE AND Abuse or Alcoholic Liquors in Health and Dis- ease. With a preface by D. F. (Vndie, M. D., and explanations of scientific words. In one small 12mo. volume of 178 pages. Cloth, GO cents. LEHMANN'S MANUAL OP CHEMICAL PHYS- IOLOGY. Translated from the German, with notes and additions, by J. Cheston Morris, M. D. In one octavo volume of 327 pages, with 4i illus- trations. Cloth, $2.25. HARTSHORNE'S ANATOMY AND PHYSIOL- OGY. Sec page 5. Henry C. Lea's Son & Co.'s Publications—Chemistry. 9 FOWXES, GEORGE, Fh. D. A Manual of Elementary Chemistry; Theoretical sind Practical. Revised and corrected by Henry Watts, B. A., F. R. S., Editor of A Dictionary op Chemistry, etc. A new American from the twelfth and enlarged London edition. Edited by Robert Bridges, M. D. In one lsirge royal 12mo. volume of 1031 pages, with 177 illustrations on wood and a colored plate. Cloth, S2.75; leather, §3.25. The book opens with a treatise on Chemical ! lous domain of organic chemistrv. In point of Physics, including Heat, Light, Magnetism and \ fulness the work is a Modern Dictionari/ of Chem- Eleetiieity. These subjects are treated clearly i tarry. In its explanations it is a clear and able and briefly, but enough is given to enable the stu- j treatise, embracing manv valuable tables from the dent to comprehend the facts and laws of Chemis- standard works of Graham, Miller and Gmelin.— try proper. It is the fashion of late years to omit Canada Medical Record, Sept. 1878. these topics from works on chemistrv, but their ' mu i • ± n i ± . • i. j omission is not to be commended. As was required I t The work is too wel known to American students by the great advance in the science of Chemistry ' &J15!d,?£y t 1? v n"tl.ee^'lffic,e 'V0 sa3j:l.hat of late years, the chapter on the General Principles i ^fJTT by. ^l16^1'*'1 edlt°r. j1"1 b*en f«th: of Chemical Philosophy has been entirely rew.it- I £"? d™*{, and that Professor Bridges has added ten. The latest views on Equivalents, Guantiva- 1 ?ome fr?sh £nd valuable matter, especially in the lence, etc., are clearlv and fullv set forth. This I '""'P" chemistry. The book has always been last editioA is a great improvement upon its prede- I £,& wJ ~V7 T"*trj> m lts;.new «haPe cessors, which is saying not a little of a book that ] brlds fa r *° ? a -V Alts T™er Jwwfij/e.-Awton has reached its twelfth edition.-O/a'c. Medical Re- \ Jourml <* ^emuTVy, Aug. 18,s. corder, Oct. 1878. When we state that, in our opinion, the present tv,o ct-.i^o^t ..,ui ..ni„<> *i,« „i«„,. „„j *.,ii „„„„„; ! edition sustains in everv respect the high reputa- hI«of Ph?£,Z fell ««,! tit Lfltr LtPJZ "on which its predecessors have acquired and en- lions ot Physical science, and the tabular form ot so I ; ,„_ j „_ „,.„„„„ *i,„„__,-*i, „.,„ *.,ii v„i:„* ;„ ;.„ many facts which are thus more readil/retained | \X&£ valSe as ateb^kan?^^ of refe^ in the memory. The medical practitioner will ; '„„'-!■!nn-rtn T,Lnal,,fPAmWtT Anir 1OTS turn with pleasure to its copious index for the ' ence-—A"Ul ica" Journal of J ha,macy, Aug. 1878. most recent facts in the somewhat hazv and nebu- ATTFIELD, JOHX, Fh. D., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. Chemistry, General, Medical and Pharmaceutical; Including the Chem- istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine smd Pharmacy. Eighth edition, specially revised by the Author. In one handsome roval 12mo. volume of 701 psiges, with 87 illustrations. Cloth, S2.50; lesither, s.'UKi. We have repeatedly expressed our favorable i the index contains three hundred new references opinion of this work, and on the appearance of relating to additional material.—Druggists' Circular a new edition of it little remains for us to say, ex- and Chemical Gazette, May, 1870. eeptthat we expect this eighth edition to be as in- This verv popular and meritorious work has dispensable to us as the seventh and previous edi- now reached its eighth edition, which fact speaks tions have been. While the general plan and ar- in the highest terms in commendation of its ex- rangement have been adhered to, new matter has cellence. It has now become the principal text- been added covering the observations made since book of chemistry in all the medical colleges in the former edition. The present differs from the the United States. The present edition contains preceding one chiefly in these alterations and in such alterations and additions as seemed necessary about ten pages of useful tables added in the ap- for the demonstration of the latest developments pendix.—American Journal of Pharmacy, May, '79. 0f chemical principles and the latest applications Each of these editions has been a decided im- of chemistry to pharmacy. It is scarcely necessary provement on its predecessor, until now the pres- for us to say that it exhibits chemistry in its pres- ent edition is as perfect as one could well expect a ent advanced state.—Cin. Med. News, April, 1879. work of this kind to be. It possesses the advan- The popularity which this work has enjoyed is tage over other chemical works intended specially owing to the original and clear disposition of the for medical students of being also quite complete facts of the science, the accuracy of the details, as a general chemical text-book. It is even more and the omission of much which freights many particularly serviceable to pharmaceutical students treatises heavily without bringing corresponding and apothecaries, as it "includes the whole of the j instruction to the reader. Dr. Attfield writes for chemistry of the U. S. Pharmacopoeia, of the Brit- , students, and primarily for medical students; he ish Pharmacopoeia and of the Pharmacopoeia of In- [ always has an eye to the pharmacopoeia and its dia."— Virginia Medical Monthly, May, 187!). ] officinal preparations, and ne is continually put- The author has bestowed arduous labor on the ! ting the matter in the text so that it responds to revision, and the extent of the information thus ! the questions with which each section is provided. introduced may be estimated from the fact that —Medical and Surgical Reporter, April 19,1879. BLOXAM, CHARLES L., Late Professor of Chemistry in King's College, London. Chemistry, Inorganic and Organic. New edition. In one very handsome octavo volume of about 700 psiges, with about 300 illustrations. In press. REMSEX, IRA, M. D., Fh. D., Professor of Chemistry in the Johns Hopkins University, Baltimore. Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. New edition. In one handsome royal 12mo. volume of about 250 pages. Preparing. Wohler's Outlines of Organic Chemistry. Edited by Rudolph Fittig, Ph. D. Nsit. Sc. D., Professor of Chemistry in the University of Tubingen. Translated bv IraRemsen, M. D., Ph.D., Professor of Physics and Chemistry in Williams College, Mass. In one 12mo. volume of 550 pages. Cloth, S3. BOWM VNS INTRODUCTION TO PRACTICAL I American from the sixth London edition. In CHEMISTRY, INCLUDING ANALYSIS. Sixth | one royal 12mo. volume, with illustrations. 10 Henry C. Lea's Son & Co.'s Publications—Chemistry. HOFF3IAXX, F, A.M., Fh.D., & FOWER, F.B., Fh.D., Public Analyst to the State of New York. Prof, of Anal. Chcm. in Phil. Coll. of Pharmaci/. A Manual of Chemical Analysis, as applied to the Examination of Medicinal Chemicals and their Preparations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Physicians, Druggists and Msinufacturing Chemists, and Pharmaceutical and Medical Students. Third, edition, entirely rewritten and much enlarged. In one very handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. Just ready. The first portion of this work, treating of operations and reagents, and giving a general account of the methods of chemical analysis, has been considerably enlarged and completed, so that now it affords an efficient and explicit guide in the practical execution of chemical analysis. Thsit on volumetric analysis has been correspondingly extended, and a new chapter on the separation and estimation of the alkaloids has been added. The second and main part of the work, containing the physical and chemical characteristics of medi- cinal chemicals and of the methods of establishing their identity, quality sincl purity, has been much enlarged and improved, new chemicals of recognized therapeutical value have been added, sind new tables and many additional illustrations, introduced. The methods for the quantitative estimation of many chemicals have also received an increased shsire of attention. Especially is this true in regard to the identification and separation of those of poisonous properties. The labors and results of pharmaeopoeial revisions both here and in Europe, as well as the kindred literature, have not been neglected ; so that the work will be found to correspond with the most recent advances in chemicsil knowledge. CLOWES, FRAXK, D. Sc, London, Senior Science-Master at the High School, Ncwcastle-under-Lyme, etc. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Spccisilly adapted for use in the Laboratories of Schools and Colleges and by Beginners. Second American from the third and revised English edition. In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, S2.50. The chief object of the author of the present work renders it unintelligible to the primary student was to furnish one which was sufficiently elemen- unless supplemented by copious verbal explana- tary in the description of apparatuses, chemicals, tions from the teacher. The Elementary Treatise modes of experimentation, etc., so as to "reduce of Dr. Clowes, examined with reference to the to a minimum the amount of assistance required above claims, is found to be a great improvement from a teacher." It is a generallv recognized fact on other elementary works. A student who care- that one of the most serious hindrances to the fully reads this text will scarcely need the assist- utility of many of the smaller text-books is the too ance of a tutor in following out any of the ex- great concisene-s of the language employed, which . periments described.— Va. Med. Monthly, Ap., 1SS1. GALLOWAY, ROBERT, F. C. S.9 Professor of Applied Chemistry in the Royal College of Science, Ireland, etc. A Manual of Qualitative Analysis. From the sixth London edition. In one handsome royal 12mo. volume, with illustrations. Preparing. CLASSEX, ALEX A XDER, Professor in the Royal Polytechnic School, Ais-la-Cliapelle. Elementary Quantitative Analysis. Translated, with notes and additions, by Edgar F.Smith, Ph.D., Assistant Professor of Chemistry in the Towne Scientific School, University of Pennsylvania. In one handsome royal 12mo. volume of 324 pages, with 3t> illustrations. Cloth," $2.00. Classen's work has for sometime been the labor- It is probably the best manual of an elementary atory companion of the student in mostof the first- nature extant, insomuch as its methods are the class schools of the continent of Europe, while it best. It teaches by examples, commencing with has been received with equal favor by practical single determinations, followed by separations, chemists in Fiance, Russia and Poland. Every and then advancing to the analysis of minerals and line in the book has practical stamped upon it. such products as are met with in applied chemis- Laboratory work alone can teach chemistry, and try. It is an indispensable book for students in Classen's Manual is the best guide to it we have chemistry.—Boston Journal of Chemistry, (u-t. 1*78. seen.—St. Louis Clinical Record, Oct. 1878. GREEXE, WILLIAM H, M. D., Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. A Manual of Medical Chemistry. For the use of Students. Based upon Bow- man's Medical Chemistry. In one royal 12mo. volume of 310 pages, with 74 illustrations. Cloth, Si.75. It is a concise manual of three hundred pages, giving an excellent summary of the best methods of analyzing the liquids and solids of the body, both forthe estimation of their normal constituents and the recognition of compounds due to pathological conditions. The detection of poisons is treated with sufficient fulness for the purpose of thestu- dentor practitioner.—Boston Jl. of Chem.,.hme, 'so. The author has availed himself of all the recent discoveries and advances in this important branch of medicine to bring his work fully up to the times. As a handbook for the busy practitioner who will necessarily be now and then called upon to make zoo-chemical analysis, this little work will prove invaluable.—Nashville Journal of Medicine mid Snrgiry, June, 1880. The above little book is concise, practical, and as thorough as the physician could desire. The meth- ods of examination are simple, require hut little apparatus, and are easily performed. The engrav- ings are fair and faithful. We recommend the book to our readers.—Am. Practitioner, June, 1**1. Henry C. Lea's Son & Co.'s Publications—Pharm., Mat. Med. 11 FARRISH, EDWARD, Late Professor of Materia Medica in the Philadelphia College of Pharmacy. A Treatise on Pharmacy. Designed as a Text-book for the Student, and as a Cuide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fourth edition, thoroughly revised, by Thomas S. Wiegand. In one handsome octavo volume of 985 pages, with 2S0 illustrations. Cloth, $5.50; leather, $6.50 ; half Russisi, $7.00. Perhaps one of the most important, if not the most important, book upon pharmacy which has appeared in the English language has emanated from the transatlantic press. " Parrish's Phar- mac\'" is a well-known work on this side of the equal value as a text-book for the student and as a guide for the pharmacist and physician, which has reached its fourth edition. A work which has gained such a hold upon the confidence of the pro- fession stands in no need of the recommendation water, and the fact shows us that a really useful , of the press. We have called the treatise an ency- work never becomes merely local in its fame. Thanks to the judicious editing of Mr. Wiegand, the posthumous edition of "Parrish" has been saved to the public with all the mature experience of its author, and perhaps uone the worse for a dash of new blood.—Lond. Pharm. Journal, Oct. 17, 1871 clopsedia as the name most descriptive of its char- acter—a work in which may be found all that the pharmacist or student of medicine need to know of pharmacy. On whatever point of pharmacy he may be seeking information, he will be fully instructed in this handbook, which is heartily rec- We have here an encyclopaedia of pharmacy, of I ommended.—American Practitioner, July, 1874. GRIFFITH, R. EGLESFIELD, 31. D. A Universal Formulary; Containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- ists. Third edition, carefully revised and much enlarged, by John M. Maiscit, Phar. D., Professor of Materia Medica in the Philsidelphia College of Pharmacy. In one large and handsome octavo volume of 775 pages, with illustrations. Cloth, $4.50; leather, $5.50. A more complete formulary than it is in its pres- j be committed to memory by every student of entform the pharmacist or physician could hardly j medicine. As a help to physicians it will be found desire. To the first some such work is indispen- invaluable, and doubtless will make its way into sable, and it is hardly less essential to the praeti- | libraries not already supplied with a standard work tioner who compounds his own medicines. Much j of the kind.— The American Practitioner, July, 1874. of what is contained in the introduction ought to j HER3IAXX, Dr. L., Professor of Physiology in the University of Zurich. Experimental Pharmacology. A Handbook of Methods for Determining the Physiological Actions of Drugs. Translated, with the Author's permission, and with extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 illustrations. Cloth, $1.50. Just ready. TRANSLATOR'S PREFACE. The translation of Hermann's Manual of Pharmacology was undertaken to furnish the student with a work that would assist him in his studies of the physiological action of drugs, enabling him to make the experiments himself that would otherwise require the assistance of the instructor. The translator has attempted to elucidsite the text with a careful selection of illustrations; sind he trusts that his additions, which constitute nearly one-half of the entire volume, will render the work a more perfect guide to the student. This work is a text-book for students for their guidance in the physiological laboratory. To the translation the editor has added many original paragraphs, and he ha? introduced numerous illustrations from the larger volumes of Sanderson, Foster, Bernard and others. In size this work is much more handy than similar laboratory manuals, and must prove acceptable to the student in this department of study. If only such books are added to the literature of this advancing branch of medical research, we shall ere long have no reason to regret that the laws of Great Britain have closed their physiological laboratories only to open our own.—N. C. Medical Journal, Feb. 1883. 3IAISCH, JOHX3L, Fhar. D., Professor of Materia Medica and Botany hi the Philadelphia College of Pharmacy. A Manual of Organic Materia Medica; Beinjr a Cuide to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists and Physicians. In one handsome royal 12mo. volume of 451 pages, with 194 beautiful illustrations on wood. Cloth, $2.75. A book evidently written for a purpose, and not National Dispensatory, in a work for which students simply for the purpose of writing a book. It is of pharmacy should be grateful. The subject is comprehensive, inasmuch as it refers to all, or one in which the beginner needs the guidance of nearly all, that is of essential value in organic ma- ' a good classification in order to avoid the bewil- teria medica, clear and simple in its style, concise, i derment which follows the attempt to grasp a sub- since it would be difficult to find in it a superfluous ject having so many details. This condition the word, and yet sufficiently explicit to satisfy the , book fulfils, the classification adopted being a sim- most critical. The text is freely illustrated with pie and practical one; the notice of each drug is woodcuts, which cannot fail to be valuable in famil- brief and clear, non-essentials being omitted. It iarizing students with the physical, microscopic is fully illustrated by some two hundred woodcuts. and macroscopic appearance of drugs. The work —Boston Med. and Surg. Journal, Jan. 19,1882. is preceded by a table of contents and completed profesSor Maisch, in the work before us, has in with that without which no book shouId be consul- , as coneise a manner as seems consistent with clear- ered complete, i. e., an index. In tact, the little | ness jven us the origin habitat, botanical de- book is just what it pretends to be, and is worthy scrlption chemical constituents and medicinal of unqualified commendation\—Chicago Medical properties of the drugs of the vegetable kingdom. Journal and Examiner, Aug. 188A Thig book ig an a(jmn.able one indeed.—Michigan The above manual, by a well-known authority in Medical News, April 10, 1882. thi- department and one of the authors of the 12 Henry C. Lea's Son k Co.'s Publications—3Iat. 3Icd., Tlierap. STILLE, A., 31. D..LL.D., rf- 3IA1SCH. J. 3I.,Phar. T)., Professor of the Theory and Practice of Prof of Mot. Med. and Botany in Phila. Medicine and of Clinical Medicine in the College of J'harmacy, Sec'y to the. Ameri- University of Pennsylvania. can Pharmaciutical Association. The National Dispensatory: Containing the Natural History, Chemistry, Phar- macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of the United States, Gresit Britain and Germany, with numerous references to the French Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent imperial octavo volume of about 1G00 pages, with several hundred fine engravings. /// press. The publishers have much pleasure in announcing to the Medical and Pharmaceutical Professions that a new edition of this important work is in press, and that it will sippear in the shortest time consistent with the care requisite for printing a work of immeii-e detail, where absolute accuracy is of such supreme importance. Besides its revision on the basis of the U. S. Pharmacopoeia of 18S0, it will include all the advances made in its department during the period elapsed since the preparation of that work. To this end all recent medical and pharmaceutical literature, both domestic and foreign, h;is been thor- oughly sifted, and everything that is new and important has been introduced, together with the results of original investigations. The Therapeutical Index has been enlarged so that it contains about 8000 references, arranged under an alphabeticsil list of diseases, thus placing sit the dispossd of the practitioner, in the most convenient manner, the vast stores of therapeutical knowledge constantly needed in his daily practice. The work may therefore be justly regarded as a complete Encyclopedia of Msiterisi Medica and Thera- peutics up to ]SS.'!. The exhaustion of two very large editions of The National Dispensatory since 1879 is the most conclusive testimony as to the necessity which demanded its preparation and to the admirable manner in which that duty has been performed. In this revision the authors have sought to add to its usefulness by including everything properly coming within its scope which can be of use to the physician or pharmacist smd at the ssune time by the utmost conciseness and by the omission of all obsolete msitter to prevent undue increase in the size of the volume. No care will be spared by the publishers to render its typographical execution worthy of its wide reputation sincl universal use as the standstill authority. A few notices of the previous edition are appended. The authors have embraced the opportunity in all the necessary details, clear and lucid in its offered for a thorough revision of the whole work, explanations, and replete with references to the striving to include within it all that might have most recent writings, where further particulars been omitted in the former edition, and all that has can be obtained if desired. Its value is greatly newly appeared of sufficient importance during enhanced by the extensive indexes—a general the time of its collaboration and the short inter- index of materia medica, etc., and also an index val elapsed since the previous publication. After oftherapeutics. No practising physician can afford having gone carefully through the volume, we to be without The National Dispensatory.—Canada must admit that the authors nave labored faith- Med. and Surg. Journ., Feb. 1880. fully and with success in maintaining the high rny,^ «•..,+ o^;n„., „f *k;„ „..,„,(■ ...n_i. „„. «,,0j K»ti^ In im n " i U h, ul' iX.mLP™,£ shouId *nd Jt necessary to issue a second edition with Plarma^y Mfteria M^dicaand Therapeutics. ^U^^hS^^u&r^^S^ t -Am. Jour, of Pharmacy, Nov. 18,9. terial embodfed in the work 'js truly immense, as The authors have produced a work which for shown by the almost countless number of subjects accuracy and comprehensiveness is unsurpassed treated." It is now, undoubtedly, the most perfect by any work on the subject. There is no book in book of its kind in any language.—Buffalo Medical the English language which contains so much .and Surgical Journal, Nov. 1879. valuable information on the various articles of the I m, „ ...„„i, „„., u„ i__i.„j .___„__„ i.:„j „<•:„(.„.. materia medica. The authors have succeded in „J1''® ™rk mj*ya^M?tn ff?vnu\d£ll?£ producing a dispensatorv which is not only national, ! ^S^t?in „'l?ni. -mnh S P/S hdinbwgh Med. Jour., J\ov. 1879. ,ated tQ giye him Mnts RS tQ treatment arjd mo>it The National Dispensatory is beyond dispute ! suggestive as to remedies.—London Mnlicai. Timr* the very best authority. It is throughout complete j and Gazette. STILLE, ALFRED, M. D., LL. D., Professor of Theory and Practice of Med. and of Clinical Med. in the Unie. of Penna. Therapeutics and Materia Medica. A Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and Piistory. Fourth edition, revised and enlarged. In two large and handsome octavo volumes, containing 1936 page*. Cloth, $10.00; leather, f 12.00; very handsome half Russia, raised bands, $13.00. The rapid exhaustion of three editions and the universal favor with which the work has been re- ceived by the medical profession are .sufficient proof of its excellence as a repertory of practical and useful information for the physician. The edition before us fully sustains this verdict.— Ameiican Journal of Pharmacy, Feb. 1875. We can hardly admit that it has a rival in the multitude of its citations and the fulness of its research into clinical histories.and we must assign it a place in the physician's library; not, indeed, as fully representing the present state of knowledge in pharmacodynamics, but as by far the most com- plete treatise upon the clinical"and practical side of the question.—Boston Medical and Surgical Jour- nal, Nov. 5,1874. For all who desire a complete work on therapeu- tics and materia medica for reference in cases involving medico-legal questions, as well as for in- formation concerning remedial agent-, Dr. St die's is par excellence the work.—St. Louis M'dicol and Surgical Journal, Dec. 1874. rifcNKY v>. leas oon & co. s Publications—Tlierap., Histol. 13 FARQTJHARSOX, ROBERT, 31. D., Lecturer on Materia Medica at St. Mary's Hospital Medical School. A Guide to Therapeutics and Materia Medica. Third American edition, specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by Irank Woodbury, M.D. In one very handsome 12mo. volume of 524 pages. Cloth, 82.2->. Just ready. Dr. Farquharson's Therapeutics is constructed book, and predict for it a continued successful ca- upon a plan which brings before the reader all the reer.—Canada Medical and Surgical Journal, Dec. essential points with reference to the properties of 1882. drugs. It impresses these upon him in such a way The general arrangement, the excellent manner as to enable him to take a clear view of the actions i in which the individual articles are presented, the J^t ilnes a disordered conditions in eminently practical character together with the which they must prove useful. The double-col- i positivenessof expression in both the physiological umned pages—one side containing the recognized and therapeutical indications of special remedies, physiological action of the medicine, and the other ; and the fact that it is fully abreast with the most the disease in which observers (who are nearly al- . recent developments of scientific investigations, all ways mentioned) have obtained from it good re- I tend to make this little volume peculiarly valuable. suits—make a very good arrangement. The early j It is throughout complete in all the necessary de- chapter containing rules for prescribing is excel- j tails, clear and lucid in its explanations, and is not lent. We have much pleasure in once more draw- , only a handy little volume, but may be regarded as ing attention to this valuable and well-digested ! an authority.— The Southern Practitioner, Dec. 1882. GREEX, T. HEXRY73LD.~ Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, etc. Pathology and Morbid Anatomy. Fifth American from the sixth enlarged and revised English edition. In one very handsome octavo volume of about 350 pages, with about 150 fine engravings. Preparing. COATS, JOSEFH, 31. D, F. F. F. S., Pathologist to the Glasgow Western Infirmary. A Treatise on Pathology. In one very handsome octavo volume of about 900 pages, with 339 beautiful illustrations. In press. CORXIL, V.. and RAXVIER, L., Prof, in the Faculty of Med. of Paris. Prof, in the College of France. A Manual of Pathological Histology. Translated, with notes and additions, by E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia Hospital, and by J. Henry C. Simes, M. I)., Demonstrator of Pathological Histology in the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with 360 illustrations. Cloth, 85.50 ; leather, 86.50 ; half Russia, raised bands, 87. We have no hesitation in cordially recommend- ] welcome offering to all students of the subjects ing the translation of CornilandRanvier's "Patho- which it treats. The great mass of material is ar- logical Histology " as the best work of the kind in | ranged naturally and comprehensively. The any language, and as giving to its readers a trust- classification of tumors is clear and full, so far as worthy guide in obtaining a broad and solid basis the subject admits of definition, and this one chap- for the appreciation of the practical bearings of j ter is worth the price of the book. The illustra- pathological anatomy.—American Journal of the tions are copious and well chosen. Without the Medical Sciences, April, 1880. ] slightest hesitation, the translators deserve honest One of the most complete volumes on patholog- ■ thanks for placing this indispensable work in the ical histology we have ever seen. The plan of study ; hands of American students— Philadelphia Medical embraced within its pages is essentially practical. I Times, April 24,1880. Normal tissues are discussed, and after their thor- j Their book has been written in the laboratory ough demonstration we are able to compare any I beside the microscope. It bears the marks of per- pathological change which has occurred in them. I sonal knowledge and investigation upon every Thus side by side physiological and pathological ' page. Its translation has made it the best work in anatomy go hand in "hand, affording that best of pathology attainable in our language, one that all processes in demonstrations, comparison. The every student certainly ought to have.—Archives of admirable arrangement of the work affords facility Medicine, April, 1880. in the study of any part of the human economy.— , The best and most complete work ever issued on New Orleans Medical and Surgical Journal, June,1882. . the subject from the press of any country.—London This important work, in its American dress, is a i Medical Press and Circular. SCHAFER, EDWARD ALBERT, M. D., Assistant Professor of Physiology in University College, London. A Course of Practical Histology. Being an introduction to the use of the Microscope. In one handsome roval 12mo. volume of 308 pages, with 40 illustrations. Cloth, $2.00. It is a clear, practical guide for the student of ing him what to do, and explaining simply but histology, written by one who thoroughly under- thoroughly how to do it.—Boston Medical and Sur- stands not only his subject, but how to teach it. gical Journal, April 12,1877. We are, very much pleased with, the book, which ! This is a book which we do not hesitate to recom- teaches the student simply how to use his instru- mend to the profession. In these progressive ments and conduct his studies without going times, when many physicians are taking up the further into the microscopic anatomy of the tissues study, this is a book that is needed, and might be and organs than is absolutely necessary. What we appropriately named the study of microscopy and particularly praise in it is the way in which it histology without a teacher.—American Prartition- takes the student by the hand, as it were, show- er, June, 1877. GLUGE'S ATLAS OF PATHOLOGICAL HISTOL- plain and colored, and descriptive letter-press. OGY Translated, with notes and additions, by Cloth, $4.00. Joseph Lf.idy, M. D. In one volume, very large HORNER'S SPECIAL ANATOMY ANI> HIS- imperial quarto, with 320 copper-plate figures, TOLOGY. See page fl. 14 Henry C. Lea's Son & Co.'s Publications—Practice or Meti. FLIXT, AUSTIX, 31. D., Prof, of the Principles and Practice of Med. and of Clin. Med. in Bcllevue Hospital Mnlicai College, N. Y. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Prsictitioners of Medicine. Fifth edition, entirely rewritten and much improved. In one large and closely-printed octavo volume of 1150 pages. Cloth, 85.50; leather, 80.50; very handsome half Russia, raised bands, 87. We cannot conclude this notice without express- not merely a new edition. In making these altora- ing our admiration for this volume, which is cer- tions, Flint openly confesses that he has not been tainly one of the standard text-books on medicine; too careful to maintain a character for consistency, and we may safely affirm that, taken altogether, it but hits endeavored to give his reader his more exhibits afuller and wider acquaintance with re- matured, and, as he believes, more truthful views, cent pathological inquiry than any similar work careless of any discrepancy between them and with which we are acquainted, whilst at the same those he formerly advanced. Flint is right; only time it shows its author to be possessed of the rare in this wav could he produce a work worthy of be- faculties of clear exposition, thoughtful discrimi- ing looked upon as a standard.—Edinburgh Medical nation and sound judgment.—London iMncct, July Journal, June, 1S8J. 23> l881- This work is so widelv known and accepted as In a word, we do not know of any similar work the best American text-book of the practice of which is at once so elaborate and so concise, so full medicine that it would seem hardly worth while to and yet so accurate, or which in every part leaves give this, the fifth edition, anything more than a upon the mind the impression of its being the pro- passing notice. But even the most cursory exami- duct of an author richly stored with the fruits of nation shows that it is, practically, much more clinical observation, and an adept in the art of con- than a revised edition; it is, in fact, rather a new veying them clearly and attractively to others.— work throughout. This treatise will undoubtedly American Journal of Medical Sciences, April, 1881. continue to hold the first place in the estimation Flint's Treatise is the work of an accomplished of American physicians and students. No one of hospital physician, and is remarkable for its mas- our medical writers approaches Professor Flint in terly descriptions of disease. It is a work on clin- clearness of diction, breadth of view, and, what we ieal medicine embodying the experience of a regard of transcendent importance, rational esti- lifetime. It has been carefully brought up to the mate of the vsilue of remedial sigenN. It is tltor- Eresent day, and the additions'and alterations have oughly practical, therefore pre-eminently the hook een so great that it is virtually a new work, and . for American readers.—St. Louis Cm. flee, Mar.'81. HARTSHORXE, HEXRY, 31. D., Late Professor of Hygiene in tlic University of Essentials of the Principles and for Students smd Prsictitioners. Fifth edition handsome roysd 12mo. volume of 6tid pages, bound, 8-'!.0(). Just ready. The author of this book seems to have spared no pains to bring it up to the modern standpoint, for as we turn over it- pages we find many subjects introduced which have only lately been brought before the profession. Certainly amongst books of its cla-s it deserves and has obtained a good posi- tion. On the whole it is a careful and conscien- tious piece of work, and may be commended.— London Lanc.i t, June 24, 1882. Within the compass of (ioo pages it treats of the history of medicine, general pathology, general symptomatology,and physical diagnosis (including laryngoscope, ophthalmoscope, etc.), general ther- apeutics, nosology, and special pathology and prac- tice. With such a wide range, condensation is, of course, a necessity ; but the author has endeavored to make up for this by copious references to original Pennsylvania. Practice of Medicine. A Handy book , tboroughlv revised and rewritten. In one with 14-1 'illustrations. Cloth, 82.75; half papers, etc. Wc cannot but admit that there is a wonderful amount of information contained in this work, and that it is one of the best of its kind that we have seen.—Glasgow Medical Joiunal,'Nov. 1S82. An indispensable book. No work ever exhibited a better average of actual practical treatment than this one; and probably not one writer in our day had a better opportunity than Dr. Hartshorne for condensing all the views of eminent practitioners into a limo. The numerous illustrations will be very useful to students especially. These essen- tials, as the name suggests, are not intended to supersede the text-books of Flint and Bartholow, but they are tire most valuable in affording the means to see at a glance the whole literature of any disease, and the most valuabletreatmciit.—Chicago Medical Journal and Examiner, April, 18SJ. WOODBURY, FRAXK, 31. D., Physician to the German Hospital, Philadelphia; son College Hospital, etc. late Chief Assistant to the Medical Clinic in Jeffcr- A Handbook of the Principles and Practice of Medicine. For the use of Students and Prsictitioners. In one royal 12mo. volume, with illustrations. Preparing. BlilSTOWE, JOHX SYEJi, M. D„ F. R. C. F., Physician and Joint Lecturer on Medicine at St. Thomas' Hospital. A Treatise on the Practice of Medicine. Second American edition, revised by the Author. Edited, with additions, Iiv-James II. IIetchinsox, M.D., physieisinto the Pennsylvania Hospital. In one handsome octavo volume of 10S5 pages, with illustrations. Cloth, 85.00; lesither, 86.00; very handsome half Bussia, raised bands, 86.5(1. The second edition of this excellent work, like ' faithfully given pathologv of abnormal processes, the first, has received the benefit of Dr. Hutchin- have seldom been surpassed. He embraces many son's annotations, by which the phases of disease disease.-- not Usually considered to belong to theory which are peculiar to this country are indicated, and praetice,as skindiseasos, syphilisandinsanity, and thus a treatise which was intended for British but they will not be objected to by readers, as he has practitioners and students is made more practically studied them conscientiously and drawn from the useful on this side of the water. We see no reason life.—Medical and Surgical Reporter, Dec. 20,187!». to modify the high opinion previously expressed ...:iu ..-----j j.~ r\„ *>..:..♦.*...~'.........i- —"..«~*. l— -j.i with regard to Dr. Bnstowe's work, except by add- ing our appreciation of the careful labors of the author in following the latest growth of medical science.—Boston Medical and Surgical Journal, Feb. 1880. His accuracy in the portraiture of disease, his care in stating subtle points of diagnosis, and the The reader will find every conceivable subject connected with the practice "of medicine ably pre- sented, in a style at once clear, interesting and concise. The additions made by Dr. Hutchinson are appropriate and practical, and greatly add to its usefulness to American readers.—Buffalo Med- ical and Surgical Journal, March, 1880. himmci kj. jjea's Son & Cu.'s Publications—Practice of Med. 15 REYXOLDS, J. RUSSELL, 31. D., Professor of the Principles and Practice of Medicine in University College, London. A System of Medicine. AYith notes and additions by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, 85.00; sheep, 86.00; very handsome half Russia, raised bands, $6,50. Per set, cloth, 815; sheep, 81*; half Russia," 819.50. Sold only by subscription. Volume I. Contains General Diseases and Diseases oe the Nervous System. Voiume II. Contains Diseases of Respiratory and Cni51 pages. Cloth, 84.00; very handsome half Russia, raised lands, 85.50. A book which can give correctly and interest- I impress of a master-hand: and while the work is ingly, as well as scientifically, the method of thoroughly scientific in every particular, it pies -nts prescribing and the rationale of the best thera- i to the thoughtful reader all the charms and beau- peutics in the treatment of disease, is manifestly i ties of a well-written novel. No physician can just the work which each phvsician desires. It is ■ well afford to be without this valuble work, for its not extravagant eulogy to say that the physician , originality makes it fill a niche in medical litera- willfind in this work of Fothergill the guide which ture hitherto vacant.—Nashville Journ. of Med. and he seeks for his therapeutics; for not only is the : Surg., Oct, 1880. treatment which he seeks already indicated herein, j members of the profession will find but the rationale of the treatment is as clearly ex- , ^^ that should not on|yPbe read but care- pl&med.-Gaillard's Med. Journ., Sept. 1880. ; fu»y smdied u wi„ MBist them in tha proper The author merits the thanks of every well-edu- I selection and combination of therapeutical agents cated physician for his efforts toward rationalizing I best adapted to each case and condition, and the treatment of diseases upon the scientific basis ' enable them t<> prescribe intelligently and success- of physiology. Every chapter, every line, has the fully.—St. Louis Courier of Medicine, Nov. IKso. FLINT, AUSTIN, M. I). Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of Diseases. Designed for Students and Prsictitioners of Medicine. In one large and hand- some octavo volume of 799 pages. Cloth, 84.50; leather, 85.50; half Russia, $6.00. It is here that the skill and learning of the great of advanced medicine in this country as that ol clinician are displayed. He has given us a store- the author of two works of great mpnt on special house of medical knowledge, excellent for the stu- , subjects, and of numerous papers exhibiting much dent, convenient for the practitioner, the result of ! originality and extensive research.— The Dublin a long life of the most faithful clinical work, col- Journal, Dec. 1879. lected by an energy as vigilant and systematic as The great object is to place before the reader untiring, and weighed by a judgment nolessclear the latest observations and experience in diagnosis than his observation is close.—Archives of Mediant, and treatment. Such a work is especially valuable Dec. l*7'.i. to students. It is complete in its special design, To give an adequate and useful conspectus of the , and yet so condensed that they can by its aid keep extensive fieldof modern clinical medicine is a task | up with the lectures on practice, without neglect- of no ordinary difficulty; buttoaccomplishthiscon- i ing other branches. It will not escape the notice sistently with brevity and clearness, the different I of the practitioner that such a work is most valu- subjects and their several parts receiving the I able in culling points in diagnosis and treatment attention which, relatively to their importance, in the intervals between the daily rounds of visits, medical opinion claims for them, is still more dirti- since he can in a few minutes refresh his memory cult, This task, we feel bound to say, has been or learn the latest advance in the treatment of executed with more than partial success by Dr. diseases which demand his instant attention.— Flint, whose name is already familiar to students Cincinnati Lancet and Clinic, Oct. ii, 1879. By the Same Author. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 psiges. Cloth, $1.H8. FIXLAYSOX, JA3IES, 31. D., Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. Clinical Diagnosis. A Hsindbook for Students and Practitioners of Medicine. In one handsome 12mo. volume of o-ttl pages, with 85 illustrations. Cloth, 8--o3. The book is an excellent one—clear, concise, tractive from preface to the final page, and ought convenient, practical. It is replete with the very to be given a place on every office table, because it knowledge the student needs when he quits the! contains in a condensed form all that is valuable lecture-room and the laboratory for the ward and in semeiology and diagnostics to be found in sick-room, and does not lack in information that I bulkier volumes; and because of its arrangement will meet the wants of experienced and older men. and complete index it is unusually convenient for —Phila. Med. Tunes, Jan i, ls.79. ! quick reference in any emergency that may come upon the busy practitioner.—N. C. Mid. Journ., This is one of the really useful books. It is at- | Jan. 1879. FEXWICK, SAMUEL, 31. D„ Assistant Physician to the London Hospital. The Student's Guide to Medical Diagnosis. From the third revised and enlarged English edition. In one very handsome royal 12mo. volume of '.V2H pages, with 87 illustrations on wood. Cloth, 82.25. TAXXER, THOMAS HAWKES, 31. D. A Manual of Clinical Medicine and Physical Diagnosis. Third American from the second London edition. Revised and enlarged by Tilbcky Fox, M. D., Phy- sician to the Skin Department in University College Hospital, Ivondon, etc. In one small 12mo. volume of .'>o2 psiges, with illustrations. Cloth, 81.50. STURi.ES' INTRODUCTION TO THE STUDY IMPORTANT DISEASES; being a collection of OF CLINICAL MEDICINE. Being a Guide to the Clinical Lectures delivered in the Medical the Investigation of Disease. In one handsome Ward of Mercy Hospital, Chicago. Edited by l2mo. volume of 127 pages. Cloth. SI.2o. Frank H. Davis, M. D. Second edition. In one DAVIS' CLINICAL LECTURES ON VARIOUS royal 12mo. volume of 287 pages. Cloth, $1.75. Henry C. Lea's Son & Co.'s Publications—Electric, Prac, etc. 17 BARTHOLOW, ROBERTS, A. M., M. D., LL. D., Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. Second edition. In one very handsome octavo volume of 292 pages, with 109 illustrations. Cloth, 82.50. Just ready. FROM THE PREFACE TO THE SECOND EDITION. In the present edition I have made many additions and improvements to render the work more useful to those for whom it is intended. At the same time, in response to what seems to me an increasing desire for scientific treatment, I hsive developed more fully the modern methods of siscertaining and expressing current strength, tension, resistance, etc. I have also entered more fully into the polar method, and into the action and uses of the magnet. Notwithstanding an increase in the number of lines to the psige, and the con- densation of the matter new and old, the work has been enlarged by the addition of thirty pages. Thus improved, I msiv be permitted to hope that the new edition will continue to enjoy the favor so largely bestowed on the first. , The second edition of this work following so soon upon the first would in itself appear to be a sufficient announcement; nevertheless, the text has been so considerably revised and condensed, and so much enlarged by the addition of new mat- ter, that we cannot fail to recognize a vast improve- ment upon the former work. The author has pre- pared his work for students and practitioners—for those who have never acquainted themselves with the subject, or, having done so, find that after a time their knowledge needs refreshing. We think he has accomplished this object. The book is not too voluminous, but is thoroughly practical, sim- ple, complete and comprehensible. It is, more- over, replete with numerous illustrations of instru- ments, appliances, etc, is printed on tine paper, and handsomelv bound in cloth.—Medical Record, Nov. 15, 1882. It is, fortunately, not such an interminable trea- tise as most electro-therapeutists like to write. It is not burdened with a needlessly learned termin- ology, and is written more from the point of view of the physician than of the specialist. The second edition has been considerably increased over the first, and has been brought up to the most recent advances of the science. It can in every way be recommended to those who wish to read a lucid, manageable monograph on this form of therapeu- tics.—Med. and Surg. Reporter, Nov. 4, 1882. A most excellent work, addressed by a practi- tioner to his fellow-practitioners, and therefore thoroughly practical. The work now before us has the exceptional merit of clearly pointing out where the benefits to be derived from electricity must come. It contains all and everything that the practitioner needs in order to understand in- telligently the nature and laws of the agent he is making use of, and for its proper application in practice. In a condensed, practical form, it pre- sents to the physician all tfiat he would wish to rememberafterperusingawhole library on medical electricity, including the results of the latest in- vestigations. It is the book for the practitioner, and the necessity for a second edition proves that it has been appreciated by the profession.—Physi- cian and Surgeon, Dec. 1882. It is very evident that Dr. Bartholow was correct in his view that the profession desired a small, plain and complete work on the practical use of electricity. It is only about a year since the first edition of his book appeared. In preparing the second edition he has enlarged the book some- what, and has added some new matter, but not much. In truth, the work was so complete for its purpose as it first appeared that no considerable alterations or additions would be possible. Every physician who owns a battery should possess and study this book.—Columbus Medical Journal, Jan. 1883. The first edition of this work having been ex- hausted in less than a year, shows the great value in which it has been held by the profession. Only a work of unusually great merit could have met with such a rapid sale. It has been found to fill a want, notwithstanding having numerous competi- tors. It was the purpose of the author to prepare a work from the practitioner's rather than the merely scientific standpoint, and this he has cer- tainly" accomplished. — Cincinnati Medical News, Nov. 1882. This work seems to be written for physicians and is easily intelligible to every practitioner. It is concisely written, and the author's diction is simple and always comprehensible. The edition is larger than the first, and well represents the science of medical electricity at the present time. Every physician must use electricity in his prac- tice, and in doing so he can have no better guide and companion than this volume.—Gaillard's Med. Journ., Nov. 1882. RICHARDSON, B. W., 31.A., 3I.D., LL. D., F.R.S., F.S.A. Fellow of the Roi/al College of Physicians, London. Preventive Medicine. In one octavo volume of about 500 pages. In press. By Drs. E. In one very A CENTURY OF AMERICAN MEDICINE, 1776-1876. H. Clarke, H. J. Bigelow, S. D. (Jross, T. G. Thomas and J. S. Billings handsome 12mo. volume of 370 pages. Cloth, 82.25. This work appeared in the pages of the American Journal of the Medical Sciences during the year 1876. As a detailed account of the development of medical science in America, by gentlemen of the highest authority in their respective departments, the pro- fession will no doubt welcome it in a form adapted for preservation and reference. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With additions by D. F. Condie, M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. STOKES' LECTURES ON FEVER. Edited by John William Moore, M. D., F. K. Q. C. P. In one octavo volume of 280 pages. Cloth, 82.00. A TREATISE ON FEVER. By Robert D. Lyons, K. C. C. In one octavo volume of 354 pages. Cloth, $2.25. LECTURES ON THE STUDY OF FEVER. By A Hudson, M. D., M. R. I. A. Physician to the Meath Hospital. In one octavo volume of 308 pages. Cloth, $2.50. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological and Therapeutical Relations. In two large and hand- some octavo volumes of 1168 pp. Cloth, $7.00. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. -Cloth, $2.50. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. 8vo., pp. 103. Cloth, $3.50. 18 Henry C. Lea s Son & Co.'s Publications—Throat, Lin^s, «>t< SEILER, CARL, 31. D„ Lecturer on Laryngoscopy in the University of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. Second edition. In one handsome roysil 12mo. volume of "J'.>4 pages, with 77 illustrations. Cloth, SI.75. Just ready. BROWNE, LEXXOX, F. R. C. S., Ellin., Senior Surgeon to the Central London Throat and Ear Hospital, etc. The Throat and its Diseases. Second American from the second English edi- tion, thoroughly revised. With 100 typical illustrations in colors and V) wood engravings, designed anil executed by the Author. In one very handsome imperial octavo volume of about 350 pages. Preparing. FLIXT, AUSTIX, 31. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital M dical College, N. V. A Manual of Auscultation and Percussion; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand- some royal 12mo. volume of 240 pages. Cloth, 81.03. Just ready. By the Same Author. Physical Exploration of the Lungs by Means of Auscultation and Percussion. Three lectures delivered before the Philadelphia County Medical Society, 1NS2-S3. In one handsome small 12mo. volume of 83 pages. Cloth, Si.00. Just ready. By the Same Author. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octsivo volume of-391 psiges. Cloth, 84.50. By the Same Author. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis; In a series of Clinical Studies. In one handsome octavo volume of 442 payes. Cloth, 83.50. By the Same Author. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, 84. GROSS, S. D., 3I.D., LL.D., D.C.L., Oxov.. LL.D., Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, 82. FULLER ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Di- agnosis, Symptoms and Treatment. From the second and revised English edition. In one octavo volume of 475 pages. Cloth, $3.50. SLADEON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Second and revised edition. In one royal 12mo. volume, pp. 158. Cloth, $1.2.3. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. With an analysis of one thousand eases to exemplify its duration. In one octavo volume of 303 pages. Cloth, $2.50. SMITH ON CONSUMPTION ; its Early and Reme- diable Stages. 1 vol. 8vo., pp. 253. .*2.25. LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 pages. Cloth, $3.00. WALSHE o\ THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edi- tion. In I vol. 8vo., lb, pp. Cloth, 63.00. HABERSHOX, S. O., M. D., Senior Physician to and late Lect. on Principles and Practice of Med. at Guy's Hospital, London. On the Diseases of the Abdomen; Comprising those of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illustrations. Cloth, 83.50. This valuable treatise will be found a cyclopaedia the times, and making it a volume of interest to of information, systematically arranged, on all dis- the practitioner in every field of medicine and eases of the alimentary tract from the mouth to surgery. Perverted nutrition is in some form the rectum. A fair proportion of each chapter is associated with all diseases we have to combat, devoted to symptoms, pathology and therapeutics, and we need all the light that can be obtained on The present edition is fuller than former ones in a subject so broad aud general. Dr. Habershon's many particulars, and has been thoroughly revised work is one that every practitioner should read and amended by the author. Several new chapters and study for himself.—N. Y. Medical Journal, have been added, bringing the work fully up to April, 1879. PAWS TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one octavo volume of 238 pages. Cloth, $2.00. CHAMBERS' MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- some octavo volume of 302 pp. Cloth, $U.75. tlENRY U. LEA'S SON .. Cantab., Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, greatly enlarged and thoroughly revised by the Author sind Samcel W. Cross, A. M., M. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. In two large and beautifully-printed imperial octavo volumes containing 2.">s2 pages, illustrated by 1<>23 engravings. Strongly bound in leather, raised bands, 815; half Eussia, raised bands, 816. Just ready. The work as a whole needs no commendation. Many years ago it earned for itself the enviable rep- utation of the leading American work on surgery, and it is still capable of maintaining that standard. The reason for this need only be mentioned to be appreciated. The author has alwavs been calm and judicious in his statements, has based his con- clusions on much study and personal experience, ha« been able to grasp his subject in its entirety, and, above all, has conscientiously adhered to truth and fact, weighing the evidence, pro and con, accordingly. A considerable amount of new material has been introduced, and altogether the distinguished author has reason to be satisfied that he has placed the work fully abreast of the state of our knowledge.—Med. Record, Nov. 18,1882. We have purposely abstained from comment or In the present issue he has, in addition to his own great work, called to his aid Prof. S. W. Oro.-«, Drs. J. Solis-Cohen, George C. Harlan, Charles H. Burnett, William Thomson, Edward C. Seguin, Robert liattey. Lewis H. Sayre, Richard J. Dun- glison, and Surgeon-General Barnes, U. S. A. The author has conscientiously revised every page of the fifth edition, and in doing so has found it necessary to rewrite nearly every chapter, noting the extraordinary strides which surgery has made during the past fifty vear«.—Cincinnati Lancet and Clinic, Nov. 11, 1882. We regard Gross' System of Surgery not only as a singularly rich storehouse of scientific informa- tion, but as marking an epoch in the literary his- tory of surgery. The present edition has received the' most careful revision at the hands of the emi- nent author himself, assisted in various instam criticism of the book before us. It has formerly by able specialists in various branches. All depart- been noticed more than once in ourcolumns, and it is enough now to remark that the present edition fully maintains the reputation the work has ac- quired. Though Professor Gross' book is the out- come of his college lectures, the several parts have been extended, elaborated and amplified, till it has become a complete and systematic book of reference alike for the student and the practi- tioner.— The London Lancet, Jan. 27, 1883. ments of the vast and ever-increasing literature of the science have been drawn upon for their most recent expressions. The lute advances made in surgical practice have been carefully noted, such as the recent developments of Listerism and the improvements in gynsecological operations. In every respect the work reflects lasting credit on American medical literature.— Medical and Surgical Reporter. Nov. 11.1882. ASHHURST, JOHN, Jr., 31. D., Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. The Principles and Practice of Surgery. Third edition, enlarged and re- vised. In one large and handsome octsivo volume of 1060 pages, with 555 illustrations. Cloth, ^; leather, 87; very handsome half Russia, raised bands, S7.50. Jus/ ready. Dr. Ashhurst's Surgery is a condensed treatise "a condensed but comprehensive description of covering the whole domain of the science in one the modes of practice now generally employed in manageable volume. The present edition has had the treatment of surgical affections, with a plain a thorough revision. The novelties in surgical exposition of the principles upon which these practice and the recent observations in surgical modes of practice are based." In this he has so science have been incorporated, but the size oi the well succeeded that it will be a surprise to the volume has not been materially increased. The reader to know how much practical knowledge ex- author's arrangement is perspicuous, and his language correct and clear. An excellent index closes the work, and on the whole we consider it the best system of surgery in one volume which could be named as the product of an American tending over such a wide range of research is com- pressed in a volume of this size. This feature of the work must be its best claim for continued popularity with students and practitioners. In fact, in this respect it is without an equal in any author.—Medical and Surgical Reporter, Oct. 28, '82. language. In the present edition many novelties The author, long known as a thorough student in surgical practice are introduced, many modifi- of surgery, and one of the most accomplished cations of previous statements made, and several scholars in the coiintry, aims to give in this work new illustrations added— Med. Rec, Nov. 18,1**J GIBNEY, V. F., M. D. Orthopaedic Surgery. For the use of Practitioners and Students. In one hand- some octsivo volume, profusely illustrated. Preparing. ROBERTS, JOHN B., A. M.,* 31. D., Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. The Principles and Practice of Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 5<>0 psiges, with many illustrations. Preparing. STI3ISON, LEWIS A., B. A., 31. D., Prof, of Pathol. Anat. at the Univ. of the City of New York, Surgeon and Curator to Bellevue Huip. A Manual of Operative Surgery. In one very handsome roval 12mo. volume of 477 pages, with 332 illustrations. Cloth, $2.50. This volume is devoted entirely to operative sur- student should possess one. The preparation of gery, and is intended to familiarize the student this work does away with tne necessity of ponder- with the details of operations and different modes ing over larger works on surgery for descriptions of performing them. The work is handsomely of operations, as it presents in a nut-shell just illustrated, and the descriptions are clear and well what is wanted by the surgeon without an elabo- drawn. It is a clever and useful volume: every rate search to find it.—Md. Med. Journal, Aug. 1^78. Henry C Lea's Son & Co.'s Publications—Surgery. 21 BRYANT, THOMAS, F. R. C. S., Surgeon to Guy's Hospital. The Practice of Surgery. Third American from the third and revised English edition. Thoroughly revised and much improved, by John B. Roberts, A. M., M. D. In one large and very handsome imperial octsivo volume of 1009 psiges, with 735 illustra- tions. Cloth, 86.50; lesither, 87.50; very handsome half Russia, raised hands, 8*800, Without freighting his book with multiplied de- | plans of treatment, etc., to make the surgeon who tails and wearying descriptions of allied methods of procedure, he is ample enough for reference on all the departments of surgery, not omitting such strict specialties as dental, ophthalmic, military, orthopaedic and gynaecological surgery. Some of these chapters are written by specialists in these respective branches, and all are amply sufficient for anyone not himself aiming at special practice. The labors of the American editor deserve un- qualified praise. His additions to the author's text are numerous, judicious and germane. They add very distinctly to the value of the original treatise, and give a more equitable illustration of the part taken by American surgeons than the author was able to do.—Medical and Surgical Re- porter, Feb. 12,1881. It is the best of all the one-volume works on sur- gery of recent date for the ordinary surgeon, con- taining enough of pathology, accurate description of surgical diseases and injuries, well-devised follows the text successful in his diagnosis and treatment in any case in which success can be se- cured, according to the present state of the sur- gical art.— Virginia Medical Monthly, May, 1881. It is a work especially adapted to the wants of students and practitioners. It affords instruction in sufficient detail for a full understanding of sur- gical principles and the treatment of surgical dis- eases. It embraces in its scope all the diseases that are recognized as belonging to surgery, and all traumatic injuries. In discussing these "it has seemed to be the aim of the author rather to pre- sent the student with practical information, and that alone, than to burden his memory with the views of different writers, however distinguished they might have been. In this edition the whole work has been carefully revised, much of it has been rewritten, and important additions have been made to almost every chapter.—Cincinnati Medical. News, Jan. 1881. ERICHSEN, JOHN E., F. R. S., F. R. (. S., Professor of Surgery in University College, London, etc. The Science and Art Of Surgery; Being a Treatise on Surgical Injuries, Dis- eases and Operations. Carefully revised by the Author from the seventh and enlarged English edition. In two large and beautiful octavo volumes of 1944 pages, illustrated by 862 engravings on wood. Cloth, 88.50; leather, 810.50; half Russia, raised bands, S11.50. For the past twenty years Erichsen's Surgery has maintained its place as the leading text-book, not only in this country, but in Great Britain. That it is able to hold its ground is abundantly proven by the thoroughness with which the pres- ent edition has been revised, and by the large amount of valuable material that has been added. Aside from this, one hundred and fifty new illus- trations have been inserted, including quite a number of microscopical appearances of patholo- fieal processes. So marked is this change for the etter that the work almost appears as an entirely new one.—Medical Record, Feb. 23, 187s. Of the many treatises on surgery which it has been our task to study, or our pleasure to read, there is none which in all points has satisfied us so well as the classic treatise of Erichsen. His polished, clear style, his freedom from prejudice and hobbies, his unsurpassed grasp of his subject and vast clinical experience, qualify him admira- bly to write a model text-book. When we wish, at the least cost of time, to learn the most of a topic in surgery, we turn, by preference, to his work. It is a pleasure, therefore, to see that the appreciation of it is general, and has led to the ap- pearance of another edition.—Medical and Surgical Reporter, Feb. 2,1878. ES3IARCH, Dr. FRIEDRICH, Professor of Surgery at the University of Kiel, etc. Early Aid in Injuries and Accidents. Five Ambulance Lectures. Trans- lated by H. R. H. Princess Christian. In one handsome small 12mo. volume of loy pages, with 24 illustrations. Cloth, 75 cents. Just reidy. The course of instruction is divided into five i homes, to a medical man, or to a hospital. The sections or lectures. The first, or introductory illustrations in the book are clear and good, and it lecture, gives a brief account of the structure and ' will, we doubt not, command an extensive circu- ' , illustrated bv | lation.—Medical Times and Gazette, Nov. 4. 1**2. organization of the human body, clear, suitable diagrams. The second teaches how to give judicious help in ordinary injuries—contu- sions, wounds, haemorrhage and poisoned wounds The third treats of first aid in cases of fracture This little book contains much of the greatest usefulness, and, were it generally read and remem- bered, the confusion and disorder that generally attend injuries and accidents would be dimin- and of dislocations, in sprains and in burns. Next, j jshed and the injured not only rendered comfort- the methods of affording first treatment in cases aDle at once, but preserved from further injury of frost-bite, of drowning, of suffocation, of loss of consciousness and of poisoning are described; and the fifth lecture teaches how injured persons may be most safely and easily transported to their The clear and lucid style of the great German sur- geon is readilv recognized in all parts of the trans- lation.— Nashville Journal of Medicine and Surgery, Feb. 1883. DRUITT, ROBERT, M. R. C. S., etc. The Principles and Practice of Modern Surgery. From the eighth London edition. In one octavo volume of 687 pages, with 432 illustrations. Cloth, 84.00 : leather, $5.00. _____________ SARGENT ON BANDAGING and OTHER OPERA- TIONS OF MINOR SURGERY. New edition, with a Chapter on military surgery. One 12mo. volume of 383 pages, with 187 cuts. Cloth, $1.75. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh edition. In one 8vo. vol. of 088 pages, with 340 illustrations. Cloth, $3.75. MILLER'S PRACTICE OF SURGERY. Fourth and revised American from the last Edinburgh edition. In one large 8vo. vol. of 682 pages, with 364 illustrations. Cloth, $3.75. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited bv John Neiix, M. D. In one 8vo. vol. of 784pp. with 316 illus. Cloth, $3.75. COOPER'S LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one 8vo. vol. of 767 pages. Cloth, $2.00. SKEY'S OPERATIVE SURGERY. In one vol. Svo. of 061 pages, with 81 woodcuts. Cloth, $5.25. GIBSON'S INSTITUTES AND PRACTICE OF SURGERY. Eighth edition. In two octavo vols. of 965 pages, with 34 plates. Leather $6.50. Henry C. Lea's Son & Co. s Publications —Surifcry, HOLMES, TI3IOTHY, 31. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. A System of Surgery; Theoretical and Practical. 1N TREATISES BY VARIOUS AUTHORS. American edition, thoroughly revised and re-edited by John H. Packard, M. I)., Surgeon to the Episcopal and St. Joseph's Hospitals, Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. In three large and very handsome imperial octavo volumes containing 3137 double- columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per volume, cloth, 86.On ; leather, 87.00; half Russia, 87.">0. Per set, cloth, 81S.O0; leather, 821.00; half Russia, 822.50. Sold only by subscription. Volume I. contains General Pathology, Morbid Processes, Injuries in Gen- eral, Complications of Injuries and Injuries of Regions. Volume II. contains Diseases of Organs of Special Sense, Circulatory Sys- tem, Digestive Tract and ( Jenito-Urinary Organs. Volume III. contains Diseases of the Respiratory Organs, Bones, Joints and Muscles, Disease- of the Nervous System, Ounshot Wounds, Operative and Minor Surgery, and Miscellaneous Subjects (including an essay on Hospitals). This great work, issued some years since in Pmgland, has won such universal confi- dence wherever the language is spoken that its republication here, in a form more thorouglily adapted to the wants of the American practitioner, has seemed to be a duty owing to the profession. To accomplish this, each sirticle has been placed in the hands of a gentleman specially competent to tresit its subject, and no hibor has been spared to bring each one up to the foremost level of the times, and to adapt it thoroughly to the practice of the country. In certain csises this has rendered necessary the substitution of an entirely new essay for the original, sis in the case of the articles on Skin Diseases and on Diseases of the Absorbent System, where the views of the authors have been superseded by the advance of medical science, and new articles have therefore been prepared by Drs. Arthur Van Harlingen and S. C. Busey, respectively. So also in the case of Anaesthetics, in the use of which American practice diners from that of England, the original hits been supple- mented with si new essay by J. C. Reeve, M. D. The ssime careful and conscientious revision has been pursued throughout, leading to an increase of nearly one-fourth in matter, while the series of illustrations has been nearly trebled, and the whole is presented sis ;i complete exponent of British sind American Surgery, adapted to the daily needs of the working practitioner. In order to bring it within the reach of every member of the profession, the five vol- umes of the original have been compressed into three by employing a double-columned royal octavo page, and in this improved form it is offered at less than one-half the price of the original. It is printed and bound to match in every detail with Reynolds' System of Medi- cine. The work will be sold by subscription only, and in due time every member of the profession will be called upon and offered an opportunity to subscribe. The authors of the original English edition are easy reach of American surgeons a work which has men of the front rank in England, and Dr. Packard been received with such universal favor on the has been fortunate in securing sis his American other side of the Atlantic as Holmes' System of coadjutors such men as Bartholow, Hvde, Hunt, Surgery. In the list of English contributors to the Conner, Stimson, Morton, Hodgen, Jewell and first volume we find the names of such well-known their colleagues. As a whole, the work will be I surgeons as Sir James Paget, Simon, Savory, Cal- solid and substantial, and a valuable addition to I lender, Barclay, and others equally distinguished; the library of any medical man. It is more wieldly ! while among the American revisers we recog- and more useful than the English edition, and with | nize men of no less celebrity. With regard to the its companion work—"Reynolds' System of Medi- mechanical execution of the work, neither pains cine''—will well represent the present state of our | nor money seem to have been spared by the pub- science. One who is familiar with those two works lishers.—Med. and Surg. Reporter, Sept. 14, 1881. will be fairly well furnished head-wise and hand- In the revision of the work for the American wise.— The Medical .~\i us, Jan. 7, lssii. edition not onlv has provision been made for a This work is cvclopsedic in character, and everv i;e«»S"itipn of tlie advances made in our knowledge subject is treated in an exhaustive manner. It is i dlu.'ln? Uie ten years since Us first publication, especially designed for a reference book, which i but also for a presentation of the variations in everv practising surgeon should have under hand Pra':n<,e .vvhlch characterize American surgery and in cases which require more than ordinarv knoul- ' distinguish " from that o Great Britain. The edge.—Chicago Med. Journ. and Exam., Feb. Ixsi "'ork is one which we take pleasure in com- mending to the notice of our readers as an enev- Great credit is due to the American editor and elopsedia of surgical knowledge and practice.— hi> co-laborers for revising and bringing within St. Louis Courier of Medicine, Nov. 1881. HOLMES. TIMOTHY, 31. A. Surgery, Its Principles and Practice. In one handsome octavo volume of 90s pages, with 411 illustrations. Cloth, sti.oo; leatlier, S7.00; half Russia, 87.50. Mr. Holmes is a surgeon of large and varied ex- | It will be found a most excellent epitome of sur- perienee, and one of the best known, and perhaps gery bv the general practitioner who has not the the most brilliant writer upon surgical subject- in | time to give attention to more minute and extend- England. It is a book for students—and an admi- • ed works, and to the medical student. In fact, we rable one—and for the busy general practitioner, know of no one we can more cordially recom- Itwill give a student all the knowledge needed to ' mend. The author has succeeded well in giv- |.a-s a rigid examination. The book fairly justifies I ing a plain and practical account of each surgical the high expectations that were formed of it. Its | injury and disease, and of the treatment which is style is clear and forcible, even brilliant at times, most commonly advisable. It will no doubt be- and the conciseness needed to bring it within its | come a popular "work in the profession, and espe- proper limit- has not impaired it- force and dis- i ciallv as a text-book.—('mem. Med. News April tinctness.—.V. }'. Med. Record, April 14, I87li. | 187G.' Henry C. Lea's Son & Co.'s Publications—Frac, Disloc, Ophthal. STI3ISON, LEWIS A., B. A., 31. D., Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator to Bel lev uc" Hospital, Surgeon to the Presbyterian Hospital, New York; etc. A Practical Treatise on Fractures. In one very handsome octavo volume of 598 pages, with 360 beautiful illustrations. Cloth, S4.75; leather, S5.7o. Just Ready. The author has given to the medical profession in this treatise on fractures what is likely to be- come a standard work on the subject. It is certainly not surpassed by any work written in the English, or, for that matter, any other language. Perfectly conversant with the American, English, French and German medical literature, the author tells us in a short, concise and comprehensive manner, all that is known about his subject. There is nothing scanty or superficial about it, as in most other treatises; on the contrary,everything is thorough. The chapters on repair of fractures and their treat- ment show him not only to be a profound student, but likewise a practical surgeon and pathologist. His mode of treatment of the different fractures is eminently sound and practical. We consider this work one of the best on fractures: and it will be welcomed not only as a text-book, but also by the surgeon in full practice.—N. 0. Medical and Sur- gical Journal, March, 1883. This practical treatise upon the subject of frac- tures of the various portions of the bony skeleton is a compendious exposition of the most recent as well as the best attested modes of treatment, but is not confined to this, as it also considers the pathol- ogy, etiology and mechanical principles involved in the different forms of fracture as well as the cause of delayed union, pseudo-arthrosis and other related topics. We have no criticism, but only commendation, for this excellent work.—College and Clinical Record, Jan. 15, 18s:s. HA3IILTON, FRANK H, 31. D.. LL. D., Surgeon to the Bcllevue Hospital, New York. A Practical Treatise on Fractures and Dislocations. Sixth edition, thoroughly revised and much improved. In one very handsome octsivo volume of 909 pages, with 352 illustrations. Cloth, 85.50 ; leather, 86.50 ; half Russia, raised bands, 87.00. The only complete work on its subject in the English tongue, and indeed it may now be said to be the only work of its kind in any tongue. It would require an exceedingly critical examination to detect in it any particulars in which it might be improved. The work is a mon- ument to American surgery, and will long serve to keep green the memory of its venerable author.— Michigan Medical News,'~Sov. 10, 1881. Dr. Hamilton is the author of the best modern work in his own or any language on fractures and dislocations.—Lond. Med. Times and Gaz. Nov. 19, '81. This edition, besides being carefully revised, has in part been entirely rewritten—for instance, the chapter on fractures of the patella—and a chapter on general prognosis has been added. The work as a whole is one of the very few medical books of American origin that are everywhere accorded a standard character. Its subject-matter unavoid- ably comes home to every general practitioner as a branch of our art in which he cannot afford to neglect the fullest and most practical information of such a character as it and it alone fumishe-.— New York Medical Journal, March, 1S81. WELLS. J. SOELBERG, F. R. C. S., Professor of Ophthalmology in King's College Hospital, London, etc. A Treatise on Diseases of the Eye. Third American from the third London edition. Thoroughly revised, with copious additions, by Chaui.es S. Bull, M.D., Surgeon and Pathologist to the New York Eye and Ear Infirmary. In one large smd very hand- some octavo volume of 883 pages, with 254 illustrations on wood, six colored plates, and selections from the Test-types of Jaeger and Snellen. Cloth, 85.00; leather, S6.00; half Russia, raised bands, S6.50. NETTLESHIF, EDWARD, F. R. C. S., Ophthalmic Surg, and Lect. on&phth. Surg, at St. Thomas' Hospital, London. The Student's Guide to Diseases of the Eye. New edition. With a chap- ter on the Detection of Color-Blindness, by William Thomson, M. D., Ophthalmologist to the Jefferson Medical College. In one royal 12mo. volume of 416 psiges, with 13S illustrations. Cloth, 82.00. Just ready. little work contains many additions and improve- ments on the former one. As it stands now the book forms one of the most complete, concise, and withal practical volumes in ophthalmology. The hailed by many a student whose preliminary sci- I principal additions that we recognize are an initi- entific lessons are fading from his mind. The ad- atory chapter on "Optical Outlines ' which is evi- vantage to all readers of having this rfisume of phys- dently introduced to supply a decided want in the ical principles thus readily at hand is manifest, preliminary education of every medical student. We confidently recommended the first edition; I Operations are desreibed stage after stage with we have only now to congratulate the author on j great clearness as becomes one who is himself m his assured success.—The Practitioner, Nov. 1882. the first line of operators.—Australian Medical The second edition of Mr. Nettleship's excellent ' Journal, Oct. 15, 1882. This new edition of an excellent handbook em- bodies several improvements. A brief but clear introduction to the principles of geometrical optics, so far as they concern the ophthalmist, will be BROWNE, EDGAR A., Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skin Diseases. HOW to Use the Ophthalmoscope. Being Elementary Instructions in Oph- thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 pages, with 35 illustrations. Cloth, 81.00. LAWSON ON INJURIES TO THE EYE, ORBIT AND EYELIDS: Their Immediate and Remote Effects. In one octavo volume of 404 pages, with !)2 illustrations. Cloth, $3.50. LAURENCE AND MOON'S HANDY BOOK OF OPHTHALMIC SUKGKRY, for the use of Prac- titioners. Second edition. In one octavo vol. ume of 227 pages, with Go illust. Cloth, 82.75. CARTER'S PRACTICAL TREATISE ON DISEAS- ES OF THE EYE. Edited by John Grkex, M. D. In one handsome octavo volume. 24 Henry C. Lea's Son & Co.'s Publications—Otol., I><»nt., I'rin. Dis. BURNETT, CHARLES H, A. 31., 31. D.. Aural Snrg. to the Presb. Hosp., Surgeon-in-charge of the Infir.for Dis. of the Ear, Philadelphia. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for tlie use of Medical Students and Practitioners. In one handsome octavo volume of 619 pages, with s7 illustrations. Cloth, 84.50; leather, 85.50: half Russia, raised bands, $6.00. The medical profession will welcome this new ful study of the book and a constant reference toits work on otology, which present- clearly and con- trustworthy pages.—Edinburgh Med. Jour. Aug. '78. eisely its present aspect, whilst clearly'indicating As the title of the work indicates, this volume the direction in which further researches can be treats of the anatomy and physiology of the ear as most profitably carried on. Dr. Burnett has pro- we|| as 0f jts diseases, ana the author has taken duced a work which, as a text-book, stands facile special pains to make this difficult and complicated princips in our language. To the specialist the matter thoroughly clear and intelligible. Both work is of the highest value, and his sense of grati- student and practitioner can study the work with tude to Dr. Burnett will, we hope, be proportionate a great deal of benefit. It is profusely and beauti- to the amount of benefit lie can obtain from the care- fully illustrated.—A'. }'. Hosp. Gazette, Oct. 15, 1877. FOLITZER, ADA3I, M. D., Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna. A Text-Book of the Ear and its Diseases. Translated, at tlie Author's re- quest, by James Patterson Cassells, M. I)., M. K. C. S. In one handsome octavo vol- ume of 800 psiges, with 257 original illustrations. Cloth, 85.5(1. Just ready. The name of Dr. Politzer is indissolubly associ- | Then follows a discussion of the diseases of the ated with the progress of aural surgery during this | several portions of the organ, the middle ear, the generation. The treatise which he has written on , mastoid process, the internal ear, etc. Injuries of this branch has long been a standard in Germany; | the organ and the relations of ear diseases to life and this translation of it, with the author's appro- j assurance are also treated of. The book closes with bation, and by one of the most eminent aurists of chapters on malformations of the ear, deaf-mutism, Great Britain, will certainly take rank as a stand- hearing instruments for the deaf and a satisfactory ard work of reference for years to come. The vol- j index. The text is elucidated by more than two ume begins with a complete exposition of the anat- I hundred and fifty illustrations.—Medical and Sur- omy of the ear and the physiology of audition. ! gical Reporter, Feb. 3, 188.'i. COLEMAN, A., L. R. C. F., F. R. C. S.. Exam. L. D. S., Senior Dent. Surg, and Lect. on Dent. Surg, to St. Bartholomew's Hosp. and the Dent. Hosp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised sind adapted to the use of American Students, by Thomas C. Stei.mvagen, M. A., M. D., I). I>. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome volume of 412 pages, with 331 illustrations. Cloth, 83.25. Just ready. This volume deserves to rank among the most deserves a place in the library of every dentist. important of recent contributions to dental litera- —Dental Cosmos, May, 1882. ture. Mr. Coleman has presented his methods of It should be in the possession of every practi- practiic, for the most part, in a plain and concise tioner in this country. The part devoted to first manner, and the work of the American editor has and second dentition and irregularities in the per- been conscientiously performed. He has evidently , manent teeth is fully worth the price. In fact, labored to present his convictions of the best modes price should not be considered in purchasing such of practice for the instruction of those commenc- a work. If the money put into some of our so-called ing a professional career, and he has faithfully en- standard text-books could be converted into such deavored to teach to others all that he has acquired publications as this, much good would result.— by his own observation and experience. The book Southern Dental Journal, May, 1882. GROSS, S. D., 31. D., LL. D., D. C. L., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third edition, thoroughly revised by Samiel W. Gross, M. D., Surgeon to the Philadelphia Hospital. In one octavo volume of 574 pages, with 170 illustrations. Cloth, 84.50. For reference and general information, tlie phy- sual advantage of being easily comprehended by sician or surgeon can find no work that meets their the reasonable and practical manner in which the necessities more thoroughly than this, a revised various subjects are systematized and arranged. edition of an excellent treatise. Replete with hand- —Atlanta Medical Journal, Oct. 1876. some illustrations and good ideas, it has the unu- ROBERTS, WILLIAM, 31. D., Lecturer on Medicine in the Manchester School of Medicine, etc. A Practical Treatise on Urinary and Renal Diseases, including Uri- nary Deposits. Fourth American from the fourth London edition. Illustrated by numerous engravings. In one large and handsome octavo volume. Preparing. TH03IFSOX, SIR HENRY, Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one .Svo. volume of 203 pp., with 25 illustrations. Cloth, 82.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Pistulae. From the third English edition. In one volume of 359 pages, with 47 cuts and 3 plates. Cloth, 83.50. LASH AM ON RENAL DISEASES: A Clinical I one 12mo. vol. of 304 pages, with 21 illustrations. Guide to their Diagnosis and Treatment. In | Cloth, S-2.no. Henry C. Lea's Son & Co.'s Publications—Venereal Dis., etc GROSS, SAMUEL W., A. 31., 31. D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. New edition. In one octavo volume. In a few da/s. A few notices of the previous edition are appended. The author has devoted much time to the hard- : The author is a clear and concise writer, and est study of this most trying class of diseases; and ; every page of his treatise gives evidence of his this labor, together with the fruit of laborious re-I thorough familiaritv with recent research, and search into the scattered literature of the subject, with the latest journal literature. The book is a constitutes the result of his investigations. We thoroughly scientific exposition of our present can earnestly commend it to the practitioner as j knowledge of the subjects treated of; its pages are the very best work upon the subject in the English j rich in information of high value to the practition- language.—Nashville Journal of Medicine and Stir- er, and, once read, will be freme it can only be accomplished by frequent and trior- has made its way into the library of every obstet- ough revision, he has spared no pains to make the ! rician and gynaecologist as a safe guide to "practice. present edition more desirable even than the pre- No small number of additions have been made to vious one. As a book of reference for the busy the present edition to make it correspond to re- practitioner it is unequalled.—Boston Medical and ' cent improvements in treatment.—Pacific Medical Surgical Journal, April 7,1880. and Surgical Journal, Jan. 1881. EDIS, ARTHUR W., 31. D.. Lond., F.R. C.F., 31. R. C. S., Assist. Obstetric Physician to Middlese.e Hospital, late Physician to British Lying-in Hospital. The Diseases of Women. Including their Pathology, Causation, Symptoms, Diagnosis and Treatment. A Manual for Students sind Practitioners. In one luindsome octavo volume of 576 pages, with 148 illustrations. Cloth, 83.00; leather, §4.00. It is a pleasure to read a book so thoroughly being fully explained. The descriptions of gynse- good as this one. The special qualities which are eological manipulations and operations are full, conspicuous are thoroughness in covering the . clear and practical. Much care has also been be- whole ground, clearness of description and con- j stowed on the parts of the book which deal with ciseness of statement. Another marked feature of diagnosis—we note especially the pages dealing the book is the attention paid to the details of | with the differentiation, one from another, of the many minor surgical operations and procedures, ! different kinds of abdominal tumors. The prac- as, for instance, the use of tents, application of titioner will therefore find in this book the kind leeches, and use of hot water injections. These j of knowledge he most needs in his daily work, and are among the more common methods of treat- he will be pleased with the clearness and fulness ment, and yet verv little is said about them in of the information there given.— The Practitioner, many of the text-books. The book is one to be ! Feb. 1883. warmly recommended especially to students and | it is an excellent manual—clear, decided, suffi- general practitioners, who need a concise but com- [ ciently comprehensive for a beginner, extremely plete risumt of the whole subject. Specialists, too, ; handy for anv practitioner, safe, cautious and pre- vvill find many useful hints in its pages.—Boston \ eiSe. The book reminds us constantly of Thomas' Med. and Surg. Journ., March 2, 1882. treatise, on which it seems to have been somewhat The greatest pains have been taken with the ! modelled. As a summary of existing knowledge, sections relating to treatment, A liberal selection empirical and other, it is really to be commended. of remedies is given for each morbid condition, ! —Archives of Medicine, June, 1882. the strength, mode of application and other details BARNES, ROBERT, M. D., F. R. ( . F., Obstetric Physician to St. Thomas' Hospital, London, etc. A Clinical Exposition of the Medical and Surgical Diseases of Women. In one handsome octsivo volume, with numerous illustrations. New edition. Preparing. GUSSEROW, A., Professor of Midwifery and the Diseases of Children at the University of Berlin. A Practical Treatise on Uterine Tumors. Specially revised by the Author, and translated with notes and additions bv Edmund C. Wkndt, M. D., Pathologist to the St. Francis Hospital, X. Y., etc., and revised by Nathan Bozeman, M. D., Surgeon to the Woman's Hospital of the State of New York. In one handsome octavo volume, with about 40 illustrations. Preparing. CHADWICK, JA3IES R., A. 31., 31. D. A Manual of the Diseases Peculiar to Women. In one handsome royal 12mo. volume, with illustrations. Preparing. WEST, CHARLES, 31. D. Lectures on the Diseases of Women. Third American from the third Lon- don edition. In one octavo volume of 543 pages. Cloth, $3.75; leather, 84.75. 2^ Henry C.Lea's Son &, Co.'s Publications—Dis. of Women, Mdy. E3I3IET. THOMAS ADDIS, 31. D., LL. D., Surgeon to the Woman's Hospital, New York, etc. The Principles and Practice of Gynecology; For the use of Students and Prsictitioners of Medicine. Second edition. Thorouglily revised. In one large and very handsome octsivo volume of 879 psiges, with 133 illustrations. Cloth, 85.00 ; leather, 86.00; very handsome half Russia, 86.50. No gynaecological treatise has appeared which ' ceived more attention than in America. It is, contains an equal amount of original and useful I then, with a feeling of pleasure that we welcome a matter; nor does the medical and surgical history work on diseases of women from so eminent a of America include a book more novefand useful, gynaecologist as Dr. Emmet. The work is essen- The tabular and statistical information which it tially clinical, and leaves a strong impress of the contains is marvellous, both in quantity and accu- author's individuality. To criticise, with the care racy, and cannot be otherwise than invaluable to it merits, the book throughout, would demand far future investigators. It is a work which demands more space than is at our command. In parting. not careless reading but profound study. Its value we can say that the work teems with original a> a contribution to gynaecology is, perhaps, ideas, fresh and valuable methods of practice, and greater than that of all previous literature on the is written in a clear and elegant style, worthy of subject combined.—Chicago Medical Gazette, April \ the literary reputation of the country of Longfellow o, lsso. and Oliver Wendell Holmes.—British Med. Journal, In no country of the world has gynaecology re- , Feb. 21, lsso. DUNCAN, J. MATTHEWS, 31.D., LL. D., F. R. S. E., etc. Clinical Lectures on the Diseases of Women; Delivered in Saint Bar- tholomew's Hospital. In one handsome octavo volume of 175 psiges. Cloth, $1.50. They are in every way worthy of their author ; stamp of individuality that, if widely read, as they indeed, we look upon them as among the most certainly deserve to be, they cannot fail to exert a valuable of his contributions. They are all upon i wholesome restraint upon the undue eagerness matters of great interest to the general practitioner. Some of them deal with subjects that are not, as a rule, adequately handled in the textbooks; others of them, while bearing upon topics that are usually treated of at length in such works, yet bear such a with which many young physicians seem bent upon following the wild teachings which so infest the gynaecology of the present day.—N. Y. Medical Journal, March, 1880. GYNECOLOGICAL TRANSACTIONS. Being the Transactions of the American Gynecological Somety for the Year 1881. VOLUME VI. Aw ready. Contains Essays by Doctors W. H. Byford, S. C. Busey, II. J. Garrigues, G. H. Lyman, Nathan Bozeman, E. Van de Warker, I. E. Taylor, W. Goodell, H. F. Campbell, T. G. Thomas, T. A. Reamy, A. II. Smith, A. D. Sinclair, J. W. Underhill, E. W. Jenks, LL. D., W. M. Polk, W. R. Gillette, C. C. Lee, F. P. Foster, E. W. Ssiwyer and B. B. Browne. With Indexes: (a) of Vol. VI., (6) of the Gynecological and Obstetric Literature of Countries for the year 1880, (c) of Obstetric and Gynecological Journals, and (d) of Obstet- ric and Gynecological Societies. The six volumes completing the series will be sent by mail postpaid on receipt of $30; or, if single copies are desired, they will be furnished at the rate of $5 each, excepting Vol. II., for the year 1877, the price of which is 86.50. HODGE, HUGH L., M. D., Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. On Diseases Peculiar to Women; Including Displacements of the Uterus. second edition, revised and enlarged. In one beautifully printed octavo volume of 519 pages, with original illustrations. Cloth, 81.50. By the Same Author. The Principles and Practice of Obstetrics. Illustrated with large litho- graphic plates containing 159 figures from original photographs, and with numerous wood- cuts. In one large quarto volume of 542 double-columned pages. Stronglv bound in cloth, $14.00. * * * Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. RA3ISBOTHA3I, FRAXCIS H, 31. D. The Principles and Practice of Obstetric Medicine and Surgery: In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., in the Jefferson Medical College of Philadelphia. In one large and handsome imperial octavo volume of 640 pages, with 64 full-page plates, and 43 woodcuts in the text, contain- ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. A-H WELL'S PRACTICAL TREATISE ON THE AND OTHER DISEASES PECULUR TO WO- DISEASES PKCULIAR TO WOMEN. Third MEN. In one 8vo. vol. of 164 pages ' Cloth ft-'50 American from the third and revised London MEIGS ON THE NATURE SIGNS AND TREA.T- edition. In one 8vo. vol., pp. 520. Cloth. $3.50. MENT OF CHILDBED FEVER In one 8vo CHURCHILL ON THE PUERPERAL FEVER volume of 34G pages. Cloth, $2.00.' Hkxry C. Lea's Son & Co.'s Publications—Midwifery. 20 FLA YFAIR, W. S., 31. D., F. R. C. F., Professor of Obstetric Medicine in King's College, London, etc. A Treatise on the Science and Practice of Midwifery. Third American edition, revised by the Author. Edited, with sidditions, by Robert P. Harris, M. D. In one handsome octavo volume of 659 psiges, with 183 illustrations. Cloth, $4; leather, 85 : half Russia, 85.50. The medical profession has now the opportunity i choose Playfair's. It is of convenient size, but of adding to their stock of standard medical works i what is of chief importance, its treatment of the one of the bast volumes on midwifery ever pub- ' various subjects is concise and plain. While the lished. The subject is taken up with a master discussions and descriptions are sufficiently elabo- hand. The part devoted to labor in all its various ! rate to render a very intelligible idea of them, yet presentations, the management and results, is ad- I all details not necessary for a full understanding mirably arranged, and the views entertained will of the -abject are omitted.—Cincinnati Medical be found essentially modern, and the opinions ex- News, Jan. 1880. pressed trustworthy. The work abounds with [t certainly is an admirable exposition of the plate-, illustrating various obstetrical positions; science and practice of midwifery. Of course the they are admirably wrought, and afford great additions made by the American editor, Dr. R. V. assistance to the student.—A". O. Medical and Snr- Harris, who never utters an idle word, and whose gical Journal, March, 1880. studious researches in some special departments If inquired of by a medical student what work ' of obstetrics aro so well known to the profession, on obstetrics we should recommend for him, par are of great value.— The American Practitioner, excellence, we would undoubtedly advise him to I April, 1880. KIXC. A. F. A., 3f. D., Professor of Obstetrics and Diseases of Women i/t the Medical Department of the Columbian Univer- sity, Washington, D. C., and in the University of Vermont, etc. A Manual of Obstetrics. In one very handsome 12mo. volume of 321 pages, with 5S illustrations. Cloth, 82. Though the book appears small externally, it lent obstetric dictionary, and well suited to the stu- contains a- complete a consideration of obstetric dent, it is also of value to the general practitioner, subject- a- many larger volumes, and this is who often desires to find a rfsumf of information chief!}' owiog to a directness of expression, and an upon a given subject. It will be of further value avoidance ot repetition and of waste of words, to the latter, as, in our opinion, the author holds The author endeavors to place theories, causes of most sensible views on practical matters. The disease and methods of treatment in that order book is admirably arranged for reference, being which, by weight of authority, they merit. His well paragraphed, with suitable sub-divisions, and excellent judgment has availed him well in this well indexed.—American Journal of Obstetrics, Aug. effort. While, in one sense, the book is an excel- 1882. TARXIER, S., and CHANTREUIL, G. A Treatise on the Art of Obstetrics. Translated from the French. In two large octavo volumes, richly illustrated. PAR-YIN, THEOPHILUS, 31. D., LL. D., Prof, of Obstetrics and of the Med. and Surg. Diseases of Women in the Medical College of Indiana. A Treatise on Midwifery. In one very handsome octavo volume of about 550 pages, with numerous illustrations. Preparing. BARNES. FAXCOURT, 31. D., and ROBERT, 31. D., Obstetric Phys. to St. Thomas' Hosp., Lond. Phys. to the General Lying-in Hosp., Lond. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For the Student and the Practitioner. The Section on Embryology contributed bv Prof. Milnes Marshall. In one handsome octavo volume, profusely illustrated. In press. BARXES, FAXCOURT, 31. D. A Manual of Midwifery for Midwives and Medical Students. In one royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, $1.25. PARRY, JOHXr S., 31. D., Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and Treatment. In one handsome octavo volume of 272 pages. Cloth, 8-.50. TAXXER, THOMAS HAWKES, M. D. On the Signs and Diseases of Pregnancy. First American from the second English edition. In one handsome ociavo volume of 490 pages, with 4 colored plates and 16 woodcuts. Cloth, $4.25. _________________________ WINCKEL, F. A Complete Treatise on the Pathology and Treatment of Childbed. For Students and Practitioners. Translated, with the consent of the Author, from the second German edition, by James Read Chadwick, M. D. In one octavo volume of 484 pages. Cloth, $4.00. MONTGOMERY'S EXPOSITION OF THE SIGNS I exquisite colored plates and numerous wood- AND SYMPTOMS OF PREGNANCY. With two | cuts. In one 8vo. vol. of 5G8 pp. Cloth, $3.75. 30 Henry C. Leas Son & Co.'s Publications—Midwfv., l>is. Childn. LEISH3IAX, WILLIAM, 31. D., Regius Professor of Midwifery in the University of Glasgow, etc. A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. Third American edition, revised by the Author, with additions by John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and very handsome octavo volume of 740 psiges, with 205 illustrations. Cloth, 8 i.5o ; leather, $5.50; very handsome half Russia, raised bands, 86.00. The author is broad in his teachings, and dis- preparation of the present edition the author has cusses briefly the comparative anatomy of the pel- made such alterations as the progress of ob-ietri- vis and the mobility of the pelvic articulations, cal science seems to require, and we cannot but The second chapter is devoted especially to admire the ability with which the task has been the study of the pelvis, while in the third the performed. We consider it an admirable text- female organs of generation are introduced, book for students during their attendance upon The structure and development of the ovum are lectures, and have great pleasure in recommend- admirably described. Then follow chapters upon ing it. As an exponent of the midwifery of the the various subjects embraced in the study of mid- i present day it has no superior in the English lan- wifery. The descriptions throughout the work are ! guage.—Canada Lancet, Jan. 1880. plain and pleasing It is sufficient to state that in ! To the American student the work before us this, the last edition of this well-known work, every i must prove admirably adapted. Complete in all its recent advancement in this field has been brought | pft,.tS) essentially modern in its teachings, and with forward.—Physician and Surgeon, Jan. 1880. demonstrations noted for clearness and precision, We gladly welcome the new edition of this ex- ! it will gain in favor and be recognized as a work cellent text-book of midwifery. The former edi- j of standard merit. The work cannot fail to be tions have been most favorably received by the I popular and is cordially recommended.—N. 0. profession on both sides of the Atlantic. In the Med. and Surg. Journ., March, 1880. S3IITH, J. LEWIS, 31. D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. A Complete Practical Treatise on the Diseases of Children. Fifth edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, with illustrations. Cloth, 84.50; leather, 85.50; very handsome half Russia, raised bands, $6. That a book professing to treat of diseases of impart the information desired by general praeti- children should have reached a fifth edition is in tioners on such questions as etiology, pathology, itself fair evidence of its worth, the more especially prognosis, etc., he has devoted more attention to as it has not the field to itself, but has to compete the diagnosis and treatment of the ailments which with several other excellent manuals. The chapter he so siccurately describes; and such information on Rachitis is excellent and well up to the day—a is exactly what is wanted by the vast majority of remark which may with equal justice be applied to '-family physicians."— Va. Med. Month/a, Feb. 1882. the chapter on Scrofula, which is one of the best it is a pleasure to peruse such a work as the one we remember to have read. The diseases of the before us, and as reviewers we have but one diffi- nervous system are well described, and so, for the culty—there is but little to find fault with. The most part, are those of the lungs. Dr. Smith would author understands what he writes about from a appear to be quite au courant with the work done practical acquaintance with the diseases incident on this side of the world, and refers freely to Eng- to infancy and childhood, and also thoroughly lishand foreign authors, as well as to periodicals comprehends their pathology and therapeutics. especially devoted to children's diseases.—British The work is full of original and practical remarks Medical Journal, May 6,1882. which will be particularly acceptable to the student There is no book published on the subjects of and young physician; but at the same time we can which this one treats that is its equal in value to with great sincerity commend it to the notice of the physician. While he has said just enough to the profession in general.—Edinb. Med. Jl., May, '*2. KEATIXG, JOHXM., 31. D., Lecturer on the Diseases of Children at the University of Pennsylvania, etc. The Mother's Guide in the Management and Feeding of Infants. In one handsome 12mo. volume of 118 pages. Cloth, 81-00. Works like this one will aid the physician im- Dr. Keating has kept clear of the common fault mensely, for it saves the time he is constantly giv- of works of this sort, viz., mixing the duties of ing his patients in instructing them on the sub- ' the mother with those proper to the doctor. There jects here dwelt upon so thoroughly and prac- is the ring of common sense in the remarks about tically. Dr. Keating has written a practical book, the employment of a wet-nurse, about the proper has carefully avoided unnecessary repetition, and food for a "nursing mother, about the tonic effects successfully instructed the mother in such details of a bath, about the perambulator versus the nurse's of the treatment of her child as devolve upon her. arms and on many other subjects concerning He has studiously omitted giving prescriptions, which the critic might say, "surely this is obvi- and instructs the mother when to call upon the ! ous," but which experience teaches us are exactly doctor, as his duties are totally distinct from hers. : the things needed to be insisted upon, with the rich —American Journal of Obstetrics, October, 1881. ' as well as the poor.—London Lancet, January J-, 1882. WEST, CHARLES, 31. D., Physician to the Hospital for Sick Children, London, etc. Lectures on the Diseases of Infancy and Childhood. Fifth American from the sixth revised smd enlarged English edition. In one large and handsome octavo volume of 080 pages. Cloth, 84.50; leather, 85.50. By the Same Author. On Some Disorders of the Nervous System in Childhood. In one small 12mo. volume of 127 pages. Cloth, 81-00. SMITH'S PRACTICAL TREATISE ON THE CONDIE'S PRACTICAL TKEVTISE ON THE WASTING DISEASES OF INFANCY AND DISEASES OF CHILDREN. Sixth edition, re- CHILDHOOD. Second American from the vised and augmented. In one octavo volume of second English edition. In one octavo volume ' TT.i pages. Cloth, $5.2"); leather, $1.25. of 2GG pages. Cloth, S2.50. Henry C. Lea's Son & Co.'s Publications—Med. Juris., Miscel. 31 TIDY, CHARLES MEYMOTT, M. B., F. C. S., Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. Legal Medicine. Volume I. Embracing Evidence, The Signs of Death, Iden- tity. The Causes of Death, The Post-mortem, Sex, Monstrosities, Hermaphrodism, Expec- tation of Life, Presumption of Death and Survivorship, Heat and Cold, Burns, Lightning, Explosives, Starvation. Making a very handsome imperial octavo volume of 664 pages, with 2 beautifully-colored plates. Cloth, $6.00; leather, $7.00. Just ready. He whose inclinations or necessities lead him to I The fact that the very numerous illustrative cases assume the functions of a medical jurist wants a are drawn from many sources, and are not limited, book encyclopaedic in character, in which he may j as in Casper's Handbook, to the author's own ex- be rea-onably sure of finding medico-legal topics I perience, and the additional fact that they are discussed win. judicial fairness, with sufficient I brought down to a very recent date, give them, completeness, and with duo attention to the most ! for purposes of reference, a very obvious value.— recent advances in medical science. Mr. Tidy's I Boston Medical and Surgical Journal, Feb. 8, 1883. work bids fair to meet this need satisfactorily. \ TAYLOR, ALFRED S., 31. D.. Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by John J. Ki:i:se, M. D., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one large octsivo volume of 937 pages, with 70 illustrations, (loth, 85.00; leather, $6.00; half Russia, raised bands, 86.50. # The American editions of this standard manual only have to seek for laudatory terms.—American have for a long time laid claim to the attention of Journal of the Medical Sciences, Jan. 1881. the profession in this country; and the eighth comes before us as embodying the latest thoughts and emendations of Dr. Taylor upon the subject to which he devoted his life with an assiduity and success which made him facile princeps among English writers on medical jurisprudence. Both the author and the book have made a mark too deep to be affected by criticism, whether it be censure or praise. In this case, however, we should This celebrated work has been the standard au- thority in its department for thirty-seven years, both in England and America, in both the profes- sions which it concerns, and it is improbable that it will be superseded in many years. The work is simply indispensable to every physician, and nearly so to every liberally-educated lawyer, and we heartily commend the present edition to both pro- fessions.—Albany Law Journal, March 2G, 1881. By the Same Author. The Principles and Practice of Medical Jurisprudence. Third edition. In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, 810; leather, 812. Just ready. The revision of the third edition of this standard work has been most happily con- fided to a gentleman who was during fourteen years the colleague of the author, and who therefore is thoroughly conversant with the methods of thought which have everywhere gained for the book an exalted position as a work of reference. The present edition, though not so large as its predecessor, contains si large amount of new matter which has been accommodated by a careful condensation wherever it was compatible with clearness. The chapters on poisoning have been in some parts entirely rewritten, a change demanded by the recent advances in this department of Forensic Medicine, and many illustrative cases have been added throughout the entire work. In its present form the work is the most complete exposition of Forensic Medicine in the English language. By the Same Author. Poisons in Relation to Medical Jurisprudence and Medicine. Third American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, 85.50 ; leather, 86.50. LEA, HEXRY C. Superstition and Force: Essays on The Wager of Law, The Wager of Battle, The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volume of 552 pages. Cloth, S2.50. This valuable work is in reality a history of civ- should not be most carefully studied; and however ilization as interpreted by the progress of jurispru- well versed the reader may be in the science of dence . In "Superstition and Force" we have a jurisprudence, he will find much in Mr. Lea's vol- philosophic survey of the long period intervening ume of which he was previously ignorant. The between primitive barbarity and civilized enlight- book is a valuable addition to the literature of so- enment There is not a chapter in the work that cial science.— Westminster Review, Jan. 1880. By the Same Author. Studies in Church History. The Rise of the Temporal Power—Ben- efit of Clergy—Excommunication. New edition. In one very handsome royal octavo volume of 605 pages. Cloth, 82.50. Just ready. TliAonthor is m-e-eminently a scholar. He takes primitive church traced with so much clearness, o • v tonic allied with the leading theme, and and with so definite a perception of complex or up eveij iop minutest detail with a wealth conflicting sources. The fifty pages on the growth traces u out i impal.t,jaiity of treatment that of the papacy, for instance, are admirable for con- ot Knowieage . f amount of information fineness and freedom from prejudice.—Boston erSssKo^hebook is extraordinary In no Traveller, May :,, 188.. X? single volume is the development of the Henry C.Lea's Son ,v Co. s Publication INDEX TO CATALOGUE. American Joiirnnl of the Medical Sciences American System of Gynsecology Allen's Anatomy " . ♦Ashhurst's Surgery Ashwell on Diseases of Women Attfield's Chemistry Barlow's Practice of Medicine Barnes' Midwifery ♦Barnes on Diseases of'Women Barnes' System of obstetric Medicine Bartholow on Electricity Basham on Renal Diseases Bellamy's Surgical Anatomy Blandford on Insanity Bloxam's Chemi-try Bowman's Practical"Chemistry *Bristowe's Practice of Medicine Browne on the (ophthalmoscope Browne on the Throat ♦Bryant's Practice of Surgery . ♦Bum-tead on Venereal Diseases ♦Burnett on the Ear Carpenter on the Use and Abuse of Alcohol ♦Carpenter's Human Physiology Carter on the Eye . Century of American Medicine Chadwick on Diseases of Women Chambers on Diet and Regimen Churchill on Puerperal Fever . Classen's Quantitative Analysis Cleland's Dissector Clowes' Practical Chemistry Coats' Pathology Coleman's Dental Surgery Condie on Diseases of Children Cooper's Lectures on Surgery . ♦Cornil and Ranvier's Pathological Histology Cornil on Syphilis .... Cullerier's Atlas of Venereal Diseases Dalton's Topographical Anatomy of the Brain ♦Dalton's Human Physiology . Davis' Clinical Lectures . Druitt's Modern Surgery Duncan on Diseases of Women . ♦Dunglison's Medical Dictionary Ed is on Diseases of Women Ellis' Demonstrations of Anatomy ♦Emmet's Gynecology . ♦Erichsen's System of Surgery Esmarch's Early Aid in Injuries and Accid'tS Far<|iiliarsoii'.- Therapeutics and Mat. Med. Fenu ick's Medical Diagnosis . Finlayson's Clinical Diagnosis . Flint on Au-cultation and Percussion . Flint on Phthisis .... Flint on Physical Exploration of the Lungs Flint on Respiratory Organs Flint on the Heart ♦Flint's Clinical Medicine Flint's Essays .... ♦Flint's Practice of Medicine . Foster's Physiology ♦Fothergill's Handbook of Treatment Fownes' Elementary Chemistry Fox on Diseases of "the Skin Fuller on the Lungs and Air Passages Galloway's Analysis i.iibuey's Orthopiedic Surgery . Gibson's Surgery .... g luge's Pathological Histology, by Leidy ♦Gray's Anatomy . . " . Greene's Medical Chemistry Green's Pathology and Morbid Anatomy Griffith's Universal Formulary. Gross on Foreign Bodies in Air-Passages Gross on Impotence and Sterility Gross on Urinary Organs ♦Gross'System of Surgery Gusserow on Uterine Tumors . Gynecological Transactions Habershon on the Abdomen ♦Hamilton on Fractures and Dislocations Hamilton on Nervous Diseases . Hartshorne's Anatomy and Physiology Hartshorne's Conspectus of the Med. Science; Hartshorne's Essentials of Medicine . Heath's Practical Anatomy Hermann's Experimental Pharmacology Hillier's Handbook of Skin Diseases . Hill on Syphilis .... Hoblyn's Medical Dictionary . Books marked * are Hodge on Women Hodge's Obstetrics Hoffmann and Power'- Chemical Analysis Holden"s Landmarks Holland's Medical Notes and Reflections '■Holmes' Surgery *IIolin *Mi Q3w do Aavaan tvnoiivn snioiosw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn 3n ■U LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE N/ i»v do Aavaan tvnoiivn 3nidio3w do Aavaan tvnoiivn 3nidiq3w jo Aavaan tvnoiivn 3n 3NiDia3w do Aavaan tvnoiivn snidiqsw jo Aavaan tvnoiivn snidiqsw jo Aavaan tvn 5 U^fC / I ^-^Mt NE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDI 3NiDia3w do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn 3nidici3w do Aavaan tvn< INE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDI ■j SNiDiasw jo Aavaan tvnoiivn snidicisw jo Aavaan tvnoiivn snidiqsw jo Aavaan tvnc INE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDI IVN 3NIDIQ3W JO AavaBIT TVNOIIVN 3NIDIQ3W dO AavaBIT TVNOIIVN 3NIDIQ3W dO AaVaaiT TVNC INE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDI I \s y&r~ "^ x ~o 3NiDia3w jo Aavaan tvnoiivn 3Nioia3w jo Aavaan tvnoiivn snidiqsw jo Aavaan tvi*