<■• OFFICE." KESIDEMCI^. Xo.3«3.^f&TsonSl>t.9th.& 10th.lt! yo.405Jfi|tBS)iuSt.,l)rt.lOth.itllth. ^.•^Swtton General's Office :,A:I» is, y ® r „ ecutm, &S&- No c/^^^i. N PRESENTED BY %CO^Oc;c.QOQG)QfOL j -- C;;.OrG^^ "y&gOXGj/ 4 « .,' >•.'• ly LALLEMAND ox SPERMATORRHOEA.. PRACTICAL TEEATISE CAUSES, SYMPTOMS, AND TREATMENT, SPERMATORRHEA: M. LALLEMAND, ». # FORMEST.Y PROFESSOR OF CLINICAL SURGERY AT THE UNIVERSITY OF MONTPBLL1ER i MEMBER OF THE ROYAL ACADEMY OF MEDICINE OF PARIS, &C. &C. TRANSLATED AND EDITED B* / HENRY J. McDOUGALL, MEMBER OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; FELLOW OF THE ROYAl, MEDICA?. AND CHIRURGICAL SOCIETY J AND FORMERLY HOUSE-SURGEON TO THE UNIVERSITY COLLEGE HOSPITAL, ^/v: t*£S4-Z. PHILADELPHIA: LEA & BLANCHARLX 18-48. WJA LI97J f~U-rn flic- 5'&eji '»P- 3 Gribos & Co., Priwtkrr. CONTENTS. PAGE Author's Preface ........ xiii Editor's Preface ........ xv CHAPTER I. Introduction . . .'......25 CHAPTER II. INFLAMMATION OF THE SPERMATIC ORGANS. Pathological Anatomy ....... 28 Cask I.—Blennorrhagia—Diurnal Pollutions—Hypochondriasis—Chro- nic affection of the Brain and its Membranes—Death. Autopsy— Right Kidney in a state of Suppuration—Prostate nearly destroyed. Ejaculatory Ducts ulcerated—Seminal Vesicles altered—Nothing remarkable in the other organs ...... 29 Case II.—Blennorrhagia—Spermatorrhoea—Hypochondriasis—Frequent attacks of Cerebral Congestion—Death. Autopsy—Suppuration in the Seminal Vesicles—Ossificdeposit in the Vasa Deferentia— Cystitis—Phlebitis—Old adhesions of the Arachnoid and Pleurae —Abscesses in the muscles of the Neck and Shoulders . . 34 Case. III.—Blennorrhagia—Retention of Urine, &c—Apoplexy—Death. Autopsy—Effusion of Blood into the left Ventricle of the Brain —Hypertrophy of the Heart—Gastro-enteritis—Abscess and Tubercles in the Kidney and Prostate—Stricture, &c. . . 3h Case IV.—Mental Derangement—Belief in a change of Sex—Death— Autopsy—Thickening of the Arachnoid—Great alteration of the Prostate—Atrophy and Obliteration of the Ejaculatory Ducts Summary of the preceding Observations.—Symptoms Lesions in the Prostate ...... In the Spermatic Organs ..... In the Orifices of the Ejaculatory Ducts 41 41 43 45 46 B CONTENTS. In the Ejaculatory Ducts In the Seminal Vesicles In the Qualities of the Semen In the Vasa Deferentia In the Testicles In the Urinary Organs Comparison of the Two Sets of Organs Resume ..... 46 47 47 47 49 49 50 53 CHAPTER III. CAUSES OF SPERMATORRHEA. Blennorrhagia ......... 54 Case V.—Lymphatic Temperament—Blennorrhagia—Orchitis—Nephri- tis—Nocturnal and Diurnal Pollutions—Abuse of Mercurials— Injurious effects of Cold and Tonics—Cure by means of Leeches, the Use of Flannel and Milk Diet—Fresh attack of Blennorrhagia —Same Treatment with the same Result . . . .54 Case VI.—Masturbation—Blennorrhagia—Diurnal Pollutions—Failure of the ordinary modes of Treatment—Cauterization of the Prosta- tic Portion of the Urethra—Rapid Recovery . . . .58 Case VII.—Abuse of Spirituous Liquors—Blennorrhagia—Nocturnal Pollutions—Impotency—Frequent discharge of Urine—Cauteriza- tion—Cure ......... 61 Case VIII.—Masturbation—Blennorrhagia, repeated Anti-venereal Treat- ment—Diurnal Pollutions—Increasing Weakness, especially of the Mental Faculties—Extreme Emaciation—Cauterization, and Cure after Sixteen Years—Venereal Excess, Relapse—Cauteriza- tion again Performed with Success . . . . .63 Case IX.—Blennorrhagia, followed by Excoriations of the Glans Penis —Spermatorrhoea—Cauterizationunsuccessful—Artificial Sulphur Baths—Cure ........ 66 Consideration of the Causes . . . . . .67 Mode of Action........69 Treatment of Spermatorrhoea following Blennorrhagia . . 71 Symptoms of Spermatorrhoea arising from Blennorrhagia . 72 CHAPTER IV. CAUSES OF SPERMATORRHOEA CONTINUED. Cutaneous Affections........ 73 Case X.—Itch during Ten Months, at about the age of Fourteen—Pain in the Epigastrium—Tumour of the Testicle—Chronic Inflam- mation of the Bladder—Diurnal Spermatic Discharges—Hy- pochondriasis. Cure by Cauterization at the age of Twenty-eight 73 CONTENTS. Ill Case XI.—Cutaneous Affections—Repeated Attacks of Urethritis—Ap- plication of the Nitrate of Silver—Cure . . . .75 Case XII.—Pruriginous Eruption around the Genital Organs—Two At- tacks of Blennorrhagia—Nocturnal and Diurnal Pollutions—Cure by means of Sulphuretted Baths . . • . .77 Case XIII.—Herpes Praeputialis, alternating in a remarkable manner with Irritation in the Prostatic Portion of the Urethra—Nocturnal and afterwards Diurnal Pollutions—Occasional Impotence—Re- establishment by Cauterization—Relapse—Cure by the Baths of Vernet .......•• 78 Case XIV.—Lymphatic Temperament—Various Cutaneous Eruptions alternating with other Affections—Habitual bad Health—Hypo- chondriasis—Spermatorrhoea undiscovered during Twenty-five Years—Cure by Sulphuretted Baths Consideration of Causes Mode of Action .... Irritation of the Rectum Treatment of these Cases 80 82 83 84 84 CHAPTER V. CAUSES OF SPERMATORRHOEA CONTINUED. Influence of the Rectum ....... 85 Case XV.—Spermatorrhoea from a Mechanical Obstacle to Defecation— Division of the Stricture—Rapid and Complete Cure . . 85 Case XVI.—Spermatorrhoea induced by Chronic Diarrhoea, and kept up by a Mechanical Obstacle to Defecation—Removal of a Schirrous Tumour from the Anus—Rapid and Perfect Cure . . . 8G Case XVII.—Hemorrhoids from the age of Puberty—Difficulty in evacu- ating the Rectum at the age of Twenty-eight—Spermatorrhoea— Cure..........89 Case XVIII.—Blennorrhagia, Constipation—Fissure of the Anus—Dis- charge of Semen at Stool—Profound Hypochondriasis—Desire of committing Suicide—Diarrhoea—Cure of the Fissure of the Anus —Disappearance of the other Symptoms . . . .90 Case XIX.—Horse Exercise — Constipation — Spermatorrhoea—Impo- tence—Frequent and violent Attacks of Cerebral Congestion—As- cending Douches—Cauterization—Sulphur Baths—Hot and Cold Douches on the Loins and Perineum—Cure . . . .92 Case XX.—Lengthened exposure to severe Cold—Incomplete Paralysis of the Rectum—Seminal Discharges during Defecation—Cure by the application of Galvanism ...... 97 Case XXI.—Intemperance—Lengthened exposure to Cold—Chronic In- flammation of the Bladder—Involuntary Seminal Discharges, &c. —Cauterization—Cure—Relapse—Same Treatment with the same Result—Remarkable influence of the Bladder on the Rectum 100 Case XXII.—Unsuspected Spermatorrhoea—Attacks of Cerebral Con- gestion—Disorder of the General Health—Asearides expelled from the Rectum, with immediate Recovery .... 103 IV CONTENTS. Case XXIII.—Masturbation at Nine Years of Age—Constant Nocturnal Emissions—Ascarides—Cure in Eight Days . . • 105 Case XXIV.—Hypochondriasis—Impotence—Attacks of Cerebral Con- gestion—Ascarides. Cure within Eight Days . • .106 Case XXV.—Nocturnal Pollutions resisting all modes of Treatment during Six Years—Great Physical and Moral Depression—Ex- pulsion of Ascarides with complete Relief .... 106 Case XXVI.—The habit of Masturbation contracted spontaneously at the age of Fifteen, and continued until the age of Twenty—Noc- turnal and Diurnal Pollutions—Increasing Disorder of the Health until the age of Twenty-nine—Frequent and prolonged Erections. Pain at the Margin of the Anus, &c.—Cauterization performed without Benefit—The expulsion of Ascarides followed by rapid Recovery . . . . . . . . .109 Case XXVII.—Masturbation at the age of Fifteen—Serious Disorder— the application of a Blister followed by Involuntary Nocturnal Emissions—Cauterization, Douches, &c, Unsuccessful—Expul- sion of Ascarides, followed by a rapid Recovery . . .111 Remarkable case of Urethral Discharge kept up by Ascarides. —Editor's Note to page . , . . . . 113 Case XXVIII.—Masturbation at the age of Ten—Seminal Emissions produced by Horse Exercise—Nocturnal, and afterwards Diurnal Pollutions—Constant Erections—Stools Relaxed, and containing abundance of Mucus—Burning at the Anus—Cauterization with slight Benefit—Expulsion of Ascarides followed by rapid and complete recovery . « . . , . .115 Resume.......... 117 CHAPTER VI. . CAUSES OF SPERMATORRHOEA CONTINUED. Abuse..........118 Case XXIX.—Masturbation—Nocturnal Pollutions—Palpitation and Dyspnoea simulating Cardiac Disease—Repeated Venesection fol- lowed by increased Disorder—Sulphuretted Baths and rapid Re- covery . . . . . . . . .118 Case XXX.—Masturbation at the age of Eight Years—At Twelve, very frequent Emission of Urine—At Sixteen, Coitus Impossible—Noc- turnal and afterwards Diurnal Pollutions—Cauterization at the age of Twenty-eight, followed by rapid Recovery . . . 119 Case XXXI.—Masturbation at the age of Seventeen, carried so far as to cause emission of Blood, but soon afterwards abandoned—In- creasing Debility during Four Years—Symptoms of Phthisis Laryngea and Chronic Gastritis—Extreme Prostration—Caute- rization followed by rapid Re-establishment .... 122 Case XXXII.—Masturbation from Twelve to Twenty-one Years of age —Melancholy—Inclination to Suicide—Serious alteration of the Health—Monomania—Unperceived Diurnal Pollutions—Caute- rization followed by perfect Recovery . . . .123 CONTENTS. V Oase XXXIII.—Abuse caused by sleeping on the Belly—Effects of •reading Erotic Works—Power of Habit—Alteration of the intel- lectual and moral Faculties—Impotence—Chronic Irritation of the Bladder—Nocturnal and Diurnal Pollutions—Cauterization fol- lowed by prompt Recovery ...... Case XXXIV.—Sexual Ideas at the age of Eight—Abuse at Thirteen— Various diseases in consequence, until the age of Thirty-two— Nocturnal and Diurnal Pollutions—Cauterization—Slow, but pro- gressive Improvement ....... Case XXXV.—Masturbation at Sixteen Years of age—At Twenty-one, compression of the Urethra during Ejaculation, followed by a sensation of Tearing, and acute pain—Urethral Discharge recur- ring frequently—Discharges of Semen during Defecation and the emission of Urine—Reciprocal Influence of the Discharges on the Digestive Organs—Chronic Catarrh of the Bladder—Caute- rization—Recovery after several Relapses Causes of Abuse ..... Internal or Pre-disposing Causes . External or Exciting Causes Varieties of Abuse ..... Effects of Abuse . . . Effects on Children and on Females Effects of Temperament, Idiosyncracy, &c. Urethral Discharges following Abuse Prostatitis ....... Cystitis . » . . . . Emissions of Blood . . - . Orchitis 127 129 131 134 135 135 140 145 147 150 150 151 151 151 151 CHAPTER VII. CAUSES OF SPERMATORRHOEA CONTINUED. Venereal Excesses . 153 Case XXXVI.—Nervous Temperament—Excessive Intercourse at the age of Twenty-one, continued during Eighteen Months—Increasing Derangement of Health—Symptoms of Gastritis, and of disease of the Heart—Repeated Abstraction of Blood—Nocturnal and afterwards, Diurnal Pollutions; Milk Diet, &e.—Acupuncture followed by perfect Recovery ...... Case XXXVII.—Robust Constitution—Venereal Excesses continued till the age of Twenty-four—Chronic Inflammation of the Bladder —Nocturnal and Diurnal Pollutions—Cauterization followed by perfect Recovery . . . . . . Cask XXXVIII.—Three Attacks of Blennorrhagia—Hypochondriasis— Danger of Suicide—Recovery—Marriage a few months after— Change in the moral Faculties—Disordered Digestion—Consti- 153 157 VI CONTENTS. pation—Agitation—Insomnia—Fits of Passion—Symptoms of Mental Derangement—Impotence—Nocturnal and Diurnal Pol- lutions—Cauterization followed by rapid Recovery—Excesses Repeated—Relapse ....... 158 Case XXXIX.—Strong Constitution—Masturbation at the age of Seven- teen—Serious disorder of the Health, until Twenty-six—Marriage —Rapid Improvement—Gradual Relapse after Three Years, not- withstanding the cessation of Coitus—Seminal Discharge during Defecation and the emission of Urine—Hypochondriasis—Inflam- mation of the Genito-urinary Organs—Cauterization—Rapid and complete Cure . . . . . . . . 162 Case XL.—Sanguineous Temperament—Masturbation from Fourteen to Eighteen Years of age—Marriage at Nineteen—Immediate im- provement in the Health—Afterwards disorder of the System— Hypochondriasis—Inclination to Suicide—Symptoms of Chronic Gastritis treated for Six Years with Leeches, Blisters, &c.—Noc- turnal and Diurnal Pollutions—Frequent Discharge of Urine— Cauterization followed by rapid and complete Cure . . 164 Case XLI.—Nervous Temperament—Delicate Health—Masturbation before Puberty—Urethral Discharge after Sexual Intercourse— Orchitis—Nocturnal Pollutions—Absolute Impotence—Injection with Solution of Nitrate of Silver Unsuccessful—Cauterization followed by rapid Cure ....... 165 Case XLII.—Masturbation—Venereal Excesses—ProlongedHorse Ex- ercise—Blennorrhagia—Nocturnal and Diurnal Poflutions—Two Cauterizations — Recovery — Premature Excesses — Relapse — Cure by another Cauterization ...... 167 Case XLIII.—Lymphatic Temperament—Early and long continued Masturbation—Horse Exercise—Infrequent Coitus—Urethritis— Repeated attacks of Inflammation in the Testicles—Frequent dis- charge of Urine—Pollutions during Defecation—Imperfect Ejacu- lation—Two Cauterizations followed by perfect Recovery . 169 Ca*e XLIV.—Lymphatico-Sanguineous Temperament—Coitus when nearly intoxicated, at the age of Twenty-two—Blennorrhagia— Pollutions during Defecation—Disturbance during Ejaculation— Band in the membranous portion of the Urethra—Cauterization— Cure by means of Antiphlogistics and Rest .... 172 Case XLV.—Coitus in a state approaching Inebriety—Gleet increased by a Journey—Diurnal Pollutions—Cauterization with rapid Im- provement—Relapse from premature fatigue of the Organs—Cure by means of Antiphlogistics and Rest. . 174 Resume ..... . 175 Characteristics of Venereal Excesses . 176 Age •...... . 179 Temperament .... . 179 Genital Instinct .... . 180 Differences of Genital Development . 180 Influence of Encephalic Organs . .....180 Accidental Influences . .....183 General Effects of Venereal Excesses .....184 Special Effects of Venereal Excesses .....184 CONTENTS. Vll CHAPTER VIII. CAUSES OF SPERMATORRHOEA CONTINUED. Action of Certain Medicines ...... 188 Astringents ......... 188 Case XLVI.—Intermittent Fever—Large Dose of Bark—Obstinate Constipation—Diurnal Pollutions—Symptoms of Chronic Gas- tritis, and of Disease of the Heart—The use of Douches followed by rapid Improvement ....... 188 Purgatives..........189 Narcotics .......... 190 Case XLVII.—Frequently repeated Narcotism at the age of Sixteen from the Vapour of Tobacco—Dilatation of the Pupils—Vomiting —Constant Headach—Constipation—Nocturnal and Diurnal Pol- lutions—Impotence—Cauterization at the age of Nineteen— Rapid Recovery . . . . . . . . 190 Case XLVIIL—Nervous Temperament—Repeated Narcotism from Smoking between the ages of Twenty and Twenty-two—Im- potence, &o. ........ 192 Cantharides.........193 Camphor .......... 194 Nitrate of Potass........194 Ergot of Rye.........195 Coffee . ..........195 Case XLIX.—Excessive use of Coffee—Frequent and profuse Dis- charge of Urine—Nocturnal, and afterwards, Diurnal Pollutions —Impotence,&c.—Cauterization—Sulphuretted Baths—Recovery 196 lea...........197 CHAPTER IX. CAUSES OF SPERMATORRHCEA CONTINUED. Action of the Cerebro-spinal System . . . . .198 Case L.—Masturbation—Extreme weakness of the Limbs and Senses— Erections excited by Percussion of the Occiput—Catheters left in the urethra—Rapid Recovery ...... 199 Case LI—Sickly Childhood—Nervous Temperament—Masturbation Rare—Coitus still more so—Symptoms of Aneurism and Gastri- tis—Nocturnal pollutions—Predominance of Erotic Ideas—Ten- sion at the Nucha—The application of cold Lotions to this Region followed by considerable Improvement ..... 200 Action of the Spinal Cord . . . . . . 203 vm CONTENTS. CHAPTER X. CAUSES OF SPERMATORRHOEA CONTINUED. Congenital Predisposition ....... 204 Sebaceous Matter ........ 205 Case LII.—Natural Phimosis—Frequent Nocturnal Pollutions from the age of Puberty.—Abundant and Fetid sebaceous Secretion between the Glans and Prepuce—Circumcision at the age of Twenty-three followed by immediate Relief ...... 205 Natural Phimosis........206 Case LIII.—Natural Phimosis—Erections at the age of Eight—At- tempts at Coitus at Nine—Vesical Catarrh—Diurnal Pollutions— Paraplegia, &c. ........ 206 Case LIV.—Very long Prepuce—Badly developed Genital Organs— Childhood Delicate—Incontinence of Urine—Sebaceous Discharge from the Orifice of the Prepuce at the age of Ten—Nocturnal Pollutions Increasing in Frequency—Hypochondriasis—Loss of Memory and failure of Intellect—Constipation—Diurnal Pollu- tions—Constant application of Lotions attended by Relief—Cir- cumcision at the age of Twenty-eight, followed by Cure . . 209 Case LV.—Very long Prepuce—Badly developed erectile Tissues— Abundant Secretion of Sebaceous Matter—Seminal emissions induced by Horse Exercise, and afterwards, by incomplete Inter- course—Marriage Unconsummated during Five Years—Diurnal Pollutions—Circumcision followed by rapid Cure . . . 211 Exuberant Prepuce ........ 212 Abundant and vitiated Secretion of Sebaceous Matter . . 213 Congenital Debility ........ 216 Case LVI.—Relaxed Genital Organs—Spermatic Cords Varicose— Few but debilitating Nocturnal Pollutions—Opposite effects of Coitus—Unsuspected Diurnal Pollutions—Constant Headach— Disordered Senses—Intellectual Debility—Hallucination—Tonic treatment at the age of Twenty-one, followed by Recovery . 216 Varicocele ......... 219 Case LVIf.—Hypospadias—Impotence—Frequent seminal Discharge 220 Case LVIIf.—Atrophy of one Testicle at the age of Eight—Nocturnal and afterwards, Diurnal Pollutions—Frequent desires of Micturi- tion, &c. . . . . . . . . 222 Casb LIX.—Lymphatic Temperament—Incontinence of Urine—Neither Masturbation nor Sexual Intercourse—More and more frequent Nocturnal Pollutions—Relaxation of the Sphincters of the Anus and Neck of the Bladder—Treatment Unsuccessful . . 223 Casb LX.—Sickly Childhood—Extraordinary Nocturnal Pollutions at Sixteen—Sometimes after, Pollutions during Defecation—Ejacula- tion impossible—Slow discharge of Semen after the subsidence of Erection—Urethra very slightly Sensitive—Prostatic Surface Hard and Cartilaginous ... , . 224 CONTENTS. IX Symptoms of Debility of the Genital Organs . . . 225 Symptoms Affecting the Urinary Organs during Childhood . 229 Incontinence of Urine.......229 Retention of Urine........231 Hereditary Transmission ....... 232 Case LXI.—Blennorrhagia at the age of Twenty-one—Pains in the Testicles—Pollutions during Four Years—Serious Gastric and Cerebral Symptoms occurring in Paroxysms—Hereditary Pre- disposition—Iced Milk—Cauterization—Acupuncture—Sulphu- retted Baths—Recovery ....... 232 Case LXII.—Nocturnal and Diurnal Pollutions occurring in Three Brothers...... . .236 Congenital increased Nervous Susceptibility . . . 237 Long-continued Continence...... 238 General Review of the Causes of Spermatorrhoea . . . 241 CHAPTER XI. SYMPTOMS OF SPERMATORRHOEA. Local Symptoms Nocturnal Pollutions . . 243 . 243 Diurnal Pollutions . 246 During Defecation During the Emission of Urine . 247 . 248 Appearance of Spermatic Urine Other Diurnal Pollutions . 248 . 250 Impotence .... . 251 Diagnosis of Spermatic Urine Chemical Analysis . Microscopic Examination Spermatozoa .... Appearances on Making Water in a Bal h . 251 . 252 . 252 . 254 . 256 Simplest mode of Detecting the presence jofS perma tozoa in the 258 X CONTENTS. CHAPTER XII. SYMPTOMS OF SPERMATORRHOEA CONTINUED. General Symptoms . . 260 Infecundity ..... . 260 Changes in the Characters of the Semen . 262 Fever ...... . 262 Symptoms Affecting the Digestive Organs . 262 Symptoms Affecting Nutrition . 266 Animal Heat ..... . 267 Symptoms Affecting Respiration . . 268 Symptoms Affecting the Circulation . 268 Symptoms Affecting Innervation . . 270 Mobility . 270 Sensation . 271 Symptoms Affecting the Special Senses . 272 Taste...... . 272 Smell ...... . 273 Hearing . 273 Sight...... . 273 Symptoms Affecting the Encephalon . 276 Sleep and Waking .... . 276 Cephalalgia . . . . 277 Cranial Congestion .... . 277 Alteration of Character .... . 279 Hypochondriasis . . . . 279 Memory ...... . 281 Intellect ...... . 282 Insanity ...... . 283 General and incomplete Paralysis of the Insane . 286 General Character of the Symptoms of Spermatorrhoea . 287 Effects of Masturbation on Children and Females . . 288 Progress of the Symptoms..... . 288 Spontaneous Recovery . 289 CONTENTS. XI CHAPTER XIII. TREATMENT OF SPERMATORRHOEA. Pollutions arising from Direct Causes.....290 Pollutions arising from Ascarides ..... 290 Pollutions excited by Cutaneous Eruptions v 293 Pollutions arising from altered or increased Secretion of the Sebaceous Glands.......294 Pollutions depending on Stricture of the Urethra . . . 295 Treatment of the various kinds of Stricture .... 295 Pollutions arising from Hemorrhoids.....297 Pollutions caused by Cicatrices in the neighbourhood of the Anus . "........298 Pollutions caused by Fissure of the Anus .... 298 Pollutions produced by Constipation.....299 CHAPTER XIV. TREATMENT OF SPERMATORRHOEA CONTINUED. Pollutions caused by Relaxation and Debility . . . 301 Pollutions arising from increased Nervous Susceptibility . 305 Acupuncture ......... 307 Pollutions kept up by Habit...... 308 Pollutions caused by Sleeping on the Back .... 308 CHAPTER XV. TREATMENT OF SPERMATORRHOEA CONTINUED. Pollutions caused by Irritation or Chronic Inflammation . 309 Diet ..........310 Cauterization.........311 • XH CONTENTS. Action of the Nitrate of Silver......315 Cauterization in Chronic Vesical Catarrh . . ... 316 ----Deviation of the Orifices of the Ejaculatory Canals . 317 CHAPTER XVI. TREATMENT OF SPERMATORRHOEA CONTINUED. Convalescence.........31 b AUTHOE'S PREFACE. During a period of fourteen years, I have collected more than one hundred and fifty cases in which involuntary seminal discharges were sufficiently serious to disorder the health of the patients considerably, and even sometimes, to cause death. Most of these patients have been sent to me on account of sus- pected cerebral affections of more or less standing. Hence, by a singular chance, it has been in consequence of the publication of my " Recherches Anatomico-Pathologiques, sur Pencephale et ses depen- dances," that I have obtained the most remarkable cases of diurnal pollutions; and I have correctly refused to acknowledge the presence of disease of the brain or its membranes in many cases where the existence of such disease had previously been considered indis* putable.' Many other of these patients were supposed to suffer from chronic gas- tritis, or gastro-enteritis; from aneurisms near the heart, the early symp- toms of phthisis, &c, &c.; and in other cases from nervous affections, and especially from hypochondriasis. These few words show how frequent, important, and difficult of detection, are involuntary seminal discharges, and to what deplorable errors of treatment they daily give rise ; it may be foreseen too, that their causes must be very varied, and their treatment present con- siderable difficulties. The Brochure of Wickmann and the commentaries on it by Sainte- Maria,* are the only writings we possess, on a disease that degrades man, poisons the happiness of his best days, and ravages society! Of the researches of these conscientious observers too, the profession are almost ignorant. They have nevertheless, done all in their power to call the atten- * Dissertation sur la pollution diurne involontaire; par Wickmann; traduction de Sainte-Maria.—Lyons, 1817. 2 XIV PREFACE. tion of practitioners to a subject of which they fully felt the impor- tance, and they have stated many valuable truths. Why is it then, that a more lasting impression has not been made on the medical world ? Doubtless because they have not supported their statements by a sufficient number of well detailed cases, and especially because those related are vaguely and generally stated. Although Wickmann and Sainte-Maria have stated facts which have not been appreciated, they have left numerous omissions to be supplied, and more than one serious error to be corrected. The materials I possess, permit me to hope that I shall be more successful; at all events, I consider it my duty to publish them. XV EDITOR'S PREFACE. In laying the following condensed edition of M. Lallemand's im- portant work on Involuntary Seminal Discharges before my profes- sional brethren in an English dress, I have beep actuated by the con- viction that the disorder treated of is little understood by the profes- sion generally in this country. The patients affected by it, are always hypochondriacal—indeed, the symptoms of hypochondriasis and men- tal derangement are generally by far the most prominently marked in them—and after the usual remedies for digestive disorder and liver disease have been had recourse to without benefit, the practitioner becomes tired of attending a disease which is at best obscure and does not yield to the usual remedies, and either treats his patient as a malade imaginaire, or leaves him a prey to the wretched balsam selling quacks, who are unfortunately permitted to pollute every pe- riodical publication with their disgusting advertisements. The subject of Spermatorrhoea is an uninviting one—especially to the fastidious—perhaps, too fastidious English taste;—hence, with very few exceptions, it has been generally avoided by regularly edu- cated practitioners in this country. An abstract of M. Lallemand's views was indeed published by my friend Mr. Phillips, in the Medi-4 cal Gazette in the year 1843, and about the same time some papers appeared in the Lancet on the same subject by Drs. Ranking and Dangerfield, and Messrs. Ryan, Chatto, and Dudgeon. These pub- lications however, from their transitory nature, were not calculated to remedy the want felt by the profession, of a systematic treatise on this important subject. Mr. Phillips indeed, in the conclusion of his paper in the Medical Gazette, takes occasion to remark: " Since the publication of the first part of this paper, I have been painfully im- pressed with the conviction, that the evil is more widely spread than I had before conceived; and that it will not be largely alleviated by the means I have adopted for advocating the relief of a particular remedy.....The pages of a strictly Medical Journal do not meet the eyes of the great mass of sufferers." In a notice also of M. Lallemand's work, in the British and Foreign Medical Review, the reviewer took an opportunity of pointing out the importance of the subject. Nevertheless, authors have always seemed to avoid the subject as dangerous ground, and with the exception of XVI PREFACE. an excellent chapter in Mr. Curlings's work on diseases of the testis, and some observations published by Dr. Smyth, in a work entitled "Miscellaneous Contributions to Pathology and Therapeutics," I believe the present to be the first attempt to render the profession familiar with this disorder, by any special work in the English lan- guage. Indeed, in Dr. Golding Bird's otherwise excellent book on urinary deposits, the author, although he admits that the spermatoza are fre- quently discovered in the urine by microscopic examination, takes occasion to express his opinion, that the subject of spermatorrhoea is one by no means deserving the importance attached to it. He adds, " it certainly is not very consistent with our national character, to dilate so freely on a subject which, in the great majority of cases, can be treated of only as the effects of a most degrading vice." That any physician should relieve himself from the investigation of a most afflicting disease, because the subject treated of is an unpleasant one, appears to me unworthy the general character of our profession. Had similar opinions been held respecing syphilis—a subject quite as repugnant to English feelings as spermatorrhoea,—what misery would have been entailed on the human race! Lecturers on surgery, while entering fully on other diseases of the urethra, appear either not to have been aware of, or by common con- sent to have omitted, spermatorrhoea from their oral lectures and text- books of surgery. Professor Miller of Edinburgh having given a short notice of spermatorrhoea in his " Practical Surgery " published in 1846, is, as far as I am aware, the only exception to this rule. At an early part of my professional life my attention was much en- gaged by two cases, which to me presented peculiar features of interest. One, the case of a near relative, since dead, proved particularly unfortu- nate. The other the case of a friend of about my own age—also study- ing medicine,—recovered after several relapses; and the patient is at present practising his profession in her Majesty's service. In both cases the best advice the West of England afforded was obtained without success, or indeed, even slight improvement, and in neither case was the cause of the disorder, which particularly affected the brain and digestive organs, recognised. The interest I took in these cases led me to suspect, from certain hints thrown out by the patients, that their disorders were somehow connected with the genital organs. Further experience has* con- vinced me that my suspicions were correct. A brief outline of these cases may not be uninteresting. R. H.-------, set. thirty-nine, passed the early part of his life in the country, and was in the habit of taking much and violent exercise. About the age of sixteen, he entered a banking establishment in Lon- don, in which by great diligence and steadiness of conduct he rose before he was twenty-five, to the post of cashier. The affairs of the house fell into disorder, and ultimately a bankruptcy occurred ; Mr. H-------, from the amount of confidence reposed in him by the » PREFACE. XV11 partners of the firm, was much harassed during these unfortunate pro- ceedings. Soon afterwards he became manager of a large mercan- tile establishment in the city, and about this time commenced some speculations in foreign bonds. From fluctuations in the share market he was a loser to a considerable extent; his mind was much harassed and he began to suspect those about him of dishonesty towards their employers. On investigation these suspicions were proved to be totally unfounded ; Mr. H-------gave way to great violence of con- duct, and resigned his situation. About this time his father died ; and Mr. H-------was much disappointed at finding that property, which he had incorrectly believed entailed and consequently his, as eldest son, was left by will to be equally divided between himself and the rest of his family. His conduct at this period was of the strangest description. He dreaded to go out into the streets of the town where his family resided, refused to join in their meals, and ultimately ab- ruptly left their house to return to London. In 1837, his state had be- come such that in consequence of his repeated letters, members of his family visited London, and on their return took him with them into Devonshire. About this time his mental disorder put on a decided aspect; and I had then, as well as later, ample opportunities of ob- serving his conduct; and frequently heard his eomplaints. Emissa- ries were constantly on the search for him to arrest him for unnatural crimes committed in London ; every one who met him in the street, read in his countenance the crimes he had committed ; tailors made his coats with the sleeves the wrong way of the cloth, in order to brand him with infamy; the sight of a policeman in the street alarmed him beyond measure ; and often, if a stranger happened to be walking for some little time in the same direction as himself, he would ex- claim that he was one of the emissaries sent to seize him. At other times he would lock himself in his room and weep by the hour. He never took his meals with the family, and never tasted food or drink, without first preserving a portion for chemical analysis, as he was con- vinced his friends were in a conspiracy to poison him slowly, in order to wipe out the memory of his crimes. These ideas haunted him night and day. His digestion was much disordered ; his sleep broken and restless, and his bowels excessively constipated. His face was flushed, and periodical attacks of cerebral excitement occurred, during which he complained of vertigo, noise in the head, loss of sight, &c. He complained also of loss of memory, and frequently of bodily weak- ness, and lassitude. The best medical advice the neighbourhood afforded was obtained, unavailingly; the opinions of the gentlemen consulted, were that Mr. H-------was labouring under aggravated hypochondriasis, complicated with moifomania. Various causes were suggested as giving rise to the disorder, but no previous case of in- sanity was recollected in any branch of the family. Mr. H------- now* began to talk of leaving England for America, in order to avoid his persecutors ; and to prevent this he was placed under the care of a private keeper. While with this person he frequently and bitterly coni- XViii PREFACE. plained of constant pollutions while at stool, with darting pain, and a sense of weight between the rectum and bladder. He had also urethral irritation attended with discharge, pains in his loins, and in one groin, weakness of his legs, thick urine, piles, and obstinate cos- tiveness. He kept a diary at this time, which is at present in my hands. Not a day is passed in this diary without mention of the dis- tressing seminal discharges from which he suffered. These were treated as of no importance by his medical attendants, although he never ceased to complain of them, and solicited aid so long as he con- tinued in confinement in England. When led away from his dis- order into any discussion on public matters, he was, however, a most amusing and instructive companion ;• as a man of business he was equally acute, and to a stranger as long as nothing was done to offend him he was, to all appearance, a man of observation and experi- ence in life. For about two years and a half he was under the care of various gentlemen, devoted to the insane, and at length he was discharge*d from an establishment near Bath, by the visiting magis- trates, as a person confined without due cause. His first act was to commence legal proceedings against his friends for his detention, and having gained his action, he immediately proceeded to London, and waylaid and violently assaulted a gentleman of high commercial standing in the city. After this offence he was confined for a con- siderable period in default of bail, and immediately on his liberation it is believed that he proceeded to America. From this time nothing was heard of him until September, 1843, when a letter was received by a gentleman who formerly attended him, in which he stated that the same course of persecution was pursued towards him in America, as had been followed in England. He complained of not being able to obtain efficient medical treatment, although he had applied to the most eminent practitioners at Cincinnati, and afterwards at Philadel- phia and New York. After this, nothing more was heard of Mr. H------- until the year 1845, when an American newspaper was forwarded to his friends by an unknown hand, containing an account of his death, and of an inquest held on him headed " Death of a Hermit in West Jersey." It was stated that he had lived on a small farm, entirely alone, with the exception of a dog, and that he had shunned all intercourse with his neighbours. He was taken suddenly ill, ap- plied to a neighbouring farmer for assistance, but died in the course of the following day. From information subsequently obtained by his friends, it is believed that he died of apoplexy, or perhaps, in one of the attacks of congestion of the brain, from which he frequently suffered before he left his native country. The symptoms of this unfortunate case strongly resemble those of the thirty-second and fifty-sixth cases related by M. Lallemand. It was more aggravated however, and presented the somewhat uncommon feature of the patient's discovering the frequent pollutions, and con- stantly complaining of them; these, unfortunately, were treated as matters of no importance. Mr. H-------'s insanity at first, constantly PREFACE. XIX had reference to his having either committed or been accused of com- mitting unnatural crimes, and this idea never entirely left him, although during the latter part of his life, his more prominent hallucinations had reference to imaginary persecutors constantly watching him, and endeavouring to ruin him by spreading false reports, and to poison him by adulterating his food, and infusing noxious gases into the air. There can be little doubt, on taking into consideration his complaints of weight between the rectum and bladder, with darting pains, &c, in the same region, that the pollutions arose from irritation in the neighbourhood of the prostate ; and I think, that if at an early period of his disease this had been relieved, there would have been con- siderable hope of his recovery from the hallucinations he manifested. The other case to which I have alluded as particularly attracting my attention, and which came under my notice about the same time, was that of a young man of high intellectual power and general talents, studying medicine. This gentleman was one of my most constant companions, when almost suddenly, a serious change came over him —he shunned society, especially that of females, was morose, taciturn, and frequently shed tears; he sat sometimes for hours in a kind of abstraction, and on being aroused from it, he could give no explana- tion of his thoughts and feelings; he constantly expressed to me his conviction that he should never succeed in his profession, and fre- quently exclaimed, that he was ruined both here and hereafter—body and soul—and by his own folly. About twelve months previous to this depression of spirits, he had a very severe attack of blennorrhagia, with orchitis and phimosis. This left a degree of irritability in the bladder, which required him to pass urine frequently. His digestion became so disordered that the simplest food would not remain on his stomach, and he had frequent eructations of fluid, which blazed like oil if spit out into the fire. This gentleman's father was a physician, and being naturally anxious for his son, obtained for him the advicej of many of the most eminent of the faculty. No improvement took place however. After he had been six months in this state, I had an opportunity of spending three weeks by the sea side, and my friend accompanied me. We slept in the same room, and he was scarcely ever out of my sight. Before our return, his health was almost re- established, and his spirits had returned to their natural condition. Twelve months later however, he again fell into the same state of despondency, and this time his condition was much worse than on the former occasion. He frequently remained in bed three parts of the day, and no threats or entreaties on the part of his father, could induce him to get up. His intellectual faculties were totally pros- trated, and a vacant stare which took the place of his natural lively expression, induced considerable fears of his ultimately becoming idiotic. I was the only person who possessed any influence over him, which may perhaps be attributed to his feeling that I was aware of the cause of his disorder. This state continued between three and four months, during which time I was with him as much as my other XX PREFACE. duties would permit, and frequently showed him the folly of the course he pursued. At the expiration of this time he gradually recovered. He has since had a slight relapse once only; he has pursued his pro- fessional studies with success, and is at present a medical officer in her Majesty's service. On this case, I need not only remark, that the symptoms did not arise from involuntary seminal discharges, but from excessive dis- charges caused by abuse. The various treatment recommended by the distinguished practitioners consulted, proved unsuccessful, be- cause the origin of the disorder was unrecognised, and the remedies consequently useless, while the habits of abuse were continued. Such were the two cases which first attracted my attention to the influence of the generative organs over the system generally, and the brain especially; and my suspicions once awakened, further observa- tions soon convinced me of their correctness, as well as of the frequent occurrence of such cases. I was soon convinced too, that the pro- fession generally, either were not aware of the immense importance of these discharges, or, that by a kind of common consent they ne- glected to recognise a subject certainly repugnant to delicacy. As a consequence, sufferers finding themselves neglected by their ordinary medical attendants, rush to find relief wherever there seems to them the slightest chance of its being obtained; and the ignorant and rapa- cious advertising quacks have a rapid and profitable sale for their injurious nostrums. Several cases of gross imposition by these Char- latans, have come under my notice, which it is my intention at some future period, to lay before the profession in one of our medical periodicals. Their introduction here would swell these prefatory observations to an inconvenient length. It now remains for me to make a few remarks on one or two points of my own experience respecting the symptoms and treatment of spermatorrhoea. One symptom which I have three times met with as the result of masturbation, is little more than alluded to by M. Lalle- raand—I mean epilepsy. Masturbation is admitted by most medical men to be a frequent cause of epilepsy; and I am surprised to find that M. Lallemand has related no cases in which epilepsy occurred. Two of the three cases to which I have alluded were simple uncom- plicated cases of epilepsy brought on by masturbation. In these, after the masturbation had been arrested the effect ceased. The third case however, was by no means so successful; it occurred in a lad of weak intellect, aged sixteen. The attacks of epilepsy frequently took place as often as twice in the day. He admitted that he was in the constant habit of practising masturbation, and even seemed aware of the influence the practice had in producing his fits. I have reason to believe that this lad corrected himself; but from the weakness of his intellect, much dependance could not be placed on his statements. As long as he continued to attend the dispensary at which I saw him, little improvement took place in his general health, and the epileptic paroxysms continued very frequent. I regret that I took no notes of PREFACE. xxi this case, and still more, that I lost sight of the patient, as I am in- clined to believe that the epileptic paroxysms might have been kept up by involuntary seminal discharges, after having been once excited by masturbation. This is a point which I earnestly recommend to the attention of the profession. Another very frequent symptom in cases of spermatorrhoea, is the occurrence of urethral discharge from very slight excitement. Several cases of this kind have come under my notice, the patients having consulted me on account of the discharge. These cases often give rise to distressing suspicions, and much family unhappiness, espe- cially as they often occur in married men. The symptoms are often alrrrost as severe as those of virulent clap, and the discharge is at- tended with great irritation in the neighbourhood of the prostate, and frequent desire, of micturition. The discharge came on in one case of a married man who consulted me, after taking a single tumblei of whiskey and water at night—this gentleman not having been in the habit of taking spirits for several years, on account of continued ill health. The discharge in these cases is thicker than that of ordinary clap, and sticks in patches on the linen. These patches may be scaled off, after which there is little mark left, and the discharge seldom penetrates through calico, so that on the opposite side of the shirt there is little or no appearance of stain. On wetting the linen, the discharge feels slippery, and it is washed off with difficulty. I am inclined to believe that these discharges are not contagious; but notwithstanding this, sexual intercourse should be avoided on account of the injury that may result to the patient himself. In most cases indeed, connexion is impossible during the first stages of the dis- charge, on account of the painful chordee to which excitement gives rise. I have generally, on questioning these patients, found that such discharges were connected more or less with deficiency of generative power. In the case I have above alluded to, impotence was almost complete; and in another similar case occurring in the person of a married surgeon, the powers had greatly declined. Both these pa- tients were in the prime of life, and both had in their youth, led very irregular lives. The irritation in these cases, I am inclined to believe, is situated in the posterior part of the urethra. Indeed, the surgeon whose case I have just alluded to, believed himself affected by enlarged prostate— many of the symptoms of which generally accompany the discharge I have described, especially frequent desire to pass water, anda feeling as though the bladder were never completely emptied, or as though two or three drops of urine were retained in the posterior part of the urethra. In the treatment of these cases, I have found the application of the solid nitrate of silver most effectual. The condition of the mucous membrane is immediately modified by it, within twelve hours the xxii PREFACE. patient experiences a degree of comfort to which, very frequently, he had long been a stranger. The condition of the membrane too, seems permanently altered by this treatment; and the discharge has never, as far as my experience goes, returned after subsequent excitement— a circumstance which is very apt to occur when the discharge has been arrested by other means. The involuntary seminal discharges often present in these cases, and to which the diminution of virile power is generally due, are also at the same time arrested, and the patient experiences a return of vigour wholly unexpected. This peculiar form of urethral discharge has hitherto, for the most part I believe, been confounded with contagious clap; indeed, many members of our profession are in the habit of setting down all dis- charges from the urethra, indiscriminately as the result of impure con- nexion, however positive the patient may be that such has not taken place. In all the cases I have hitherto met with however, the pa- tients have admitted that they had previously been affected with con- tagious clap—frequently on more than one occasion. The discharges I have described are, I am inclined to believe, from the number of eases I have met with since my attention was first attracted by the subject by no means uncommon, and certainly deserving the careful attention of the profession. The diagnosis of spermatorrhoea in aggravated or. long-standing cases, is by no means easy. When frequent diurnal pollutions have deteriorated the patient's health—discharge of watery semen taking place almost every time the patient makes water—the spermatozoa are often only distinguishable under the microscope, after a long-con- tinued and patient manipulation ; and perhaps for no researches con- nected with medical science is it more important to possess one of the best microscopes. When I first commenced the study of this subject, I was more than once tempted to give it up in despair, in consequence of my not possessing a perfect microscope. At present I use one of Powell's instruments, which I prefer to those constructed by Ross, on account of the greater convenience of the motions of the stage—a matter which will be found of much importance in all researches re- quiring delicate manipulation. The eighth of an inch object glass will be found almost indispensable in the study of these cases, al- though the spermatozoa in healthy semen can be perfectly well ex- amined with an object glass of a quarter of an inch focal length. M. Lallemand has described the operation of cauterization, as a very painful one, and its after effects as very severe. This by no means accords with my experience. In no case in which I have performed the operation has the pain been severe, or the subsequent inflammation violent; indeed, I have several times had difficulty in persuading the patients to remain twenty-four hours in bed after the operation—a precaution which I have thought advisable in all cases. At first I feared that sufficient inflammation had not been excited, and that the operation would require to be repeated—this has only hap- PREFACE. xxiii pened in my practice once however, and in that case I am inclined to think that the caustic was not properly applied to the surface of the prostate on the first occasion. The instrument commonly sold for the purpose of cauterizing the prostate, by instrument makers in this country, is in my opinion, ex- ceedingly defective. From its being made nearly straight, it is by no means easily introduced when the patient is lying down,—and in no other position ought the operation to be attempted—the irritability of the canal too, increases the difficulty of introduction, and conse- quently, every possible facility should be given to the operator, by having the instrument constructed of a convenient form. It is diffi- cult also, to measure the length of the passage exactly by applying a curved catheter to a nearly straight porte-caustique. I have therefore, had an instrument constructed of precisely the same curve as the catheters I generally use. This instrument is rather larger than those generally sold, being about the size of a No. 6 catheter, and its bul- bous extremity is two sizes larger, or as large as a No. 8 catheter; with this instrument many of the difficulties of cauterization are avoided. It can be easily introduced like an ordinary catheter while the patient is lying on his back; the moment when ^the bulb enters, the neck of the bladder is clearly distinguishable by the sensation communicated; and the caustic on account of the greater size of the cuvette, is more fairly applied to the whole of the inferior surface of the urethra, which is to a certain extent distended by its presence. With regard to the other precautions to be used, I quite agree with M. Lallemand. In translating the following pages I have endeavoured more to render the sense of the author in as few words as possible, than to give a full and literal translation. I must beg my readers to bear in mind that M. Lallemand's treatise consists of Three thick Octavo Volumes—these having been written at different periods, there are of course many repetitions, which I have as much as possible endea- voured to avoid. The total number of cases related by M. Lalle- mand is one hundred and fifteen. Of these I have selected sixty-two, which after mature consideration, appear to me to illustrate the sub- ject sufficiently. The same reason which induced me to omit so many of M. Lallemand's cases, has prevented me from inserting cases, from my own experience. As I have endeavoured to render this en- tirely a practical work—I have omitted M. Lallemand's interesting researches on the spermatozoa, except as far as they refer to the diagnosis of spermatorrhoea, as well as several digressions made by M. L. to topics of no practical interest in this country ; of these a dis- quisition on the character of J. J. Rousseau is one of the most re- markable. In speaking of spermatorrhoea arising from contagious urethritis, I have avoided the word gonorrhoea as being a misnomer—substituting for it blennorrhagia, which is certainly more correct in its derivation, although also liable to some objections. xxiv PREFACE. In conclusion, I must beg to express my thanks to M. Lallemand for the kind and complimentary manner in which he was pleased to grant me permission to undertake my task, as well as for the aid he has more than once afforded me in performing it. If through the medium of the following pages the profession become more fully ac- quainted with, and consequently better able to relieve, one of the most distressing disorders that affect mankind, I shall feel perfectly satis- fied in the conviction that the time I have appropriated to the subject has not been entirely misspent. 29, Berners Street. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT, 0? SPERMATORRHEA. CHAPTER I. INTRODUCTION. Involuntary discharge of the seminal fluid presents itself under various conditions, which differ much in their respective degrees of importance. When it occurs spontaneously during sleep in a healthy and con- tinent individual, it doubtless exerts a beneficial influence on the eco- nomy by freeing it from a source of excitement, the prolonged accu- mulation of which might derange the animal functions. In these cases it has an effect analogous to that produced by the epistaxis, common and beneficial during youth.. But the discharge may become excessive, or, from the condition of the parts, it may outlive the state that excited it; then, like repeated nasal hemorrhage, it gives rise to inconveniences proportioned to its frequency, its quantity, and the constitution of the individual. Involuntary seminaj. emissions may be caused by too great excitement of the genital apparatus, following venereal excesses or masturbation. A state of irritation remains in the spermatic organs after such excitement, which induces an increased secretion and hurried discharge of the secreted fluid, without com- plete erection, and almost without sensation. Lastly, the relaxation of the ejaculatory canals accompanying this state of irritation, may allow the expulsion of the semen without either erection or enjoyment, and this takes place especially during defecation and the expulsion of the » urine. The transition between these different stages of seminal eva- cuation is sometimes so insensible, that it is impossible for the patient, or even for the medical attendant, to specify its exact period. Every extreme evacuation of the spermatic secretion, in whatever 26 INTRODUCTION. manner caused, is capable of producing the same effects on the sys- tem. The different species of spermatorrhoea need not therefore be separated either in theory or in practice. Ordinary nocturnal emissions are easy of diagnosis and of cure ; I shall therefore pass them over, and only treat of those evacuations which are sufficiently serious to injure the health, or which are con- nected with discharges not ordinarily perceived. I shall use the expressions diurnal and nocturnal pollutions, because involuntary discharge of the spermatic secretion certainly occurs during the night without erection and without pleasurable sensations, as well as in consequence of lascivious dreams after sunrise. Neology is only to be excused when used for the prevention of errors; and I think no one will be deceived respecting the meaning of these ex- pressions which, indeed, are at present generally understood. In order, however, to avoid the repetition of many words, I shall express by the term spermatorrhoea, every excessive spermatic evacuation, from whatever cause it may arise. Diurnal pollutions are not always, as is generally believed, the result of venereal excesses, or of vicious habits. Many other varied causes, whose influence may be single, successive, or simultaneous, also give rise to them. Some of these causes are already understood, but of many others, the medical world is completely ignorant; and these are the most dangerous, because their influence is the most difficult of appreciation. In all sciences the study of causes is the most important and the most difficult. This is true of medicine, and especially of the affec- tion forming the subject of this work; for it is principally from the cause of the spermatorrhoea, that we learn its therapeutic indications. It is true that we must also in each case, take into account the parti- cular condition of the genital organs, and the constitution of the indi- vidual ; but these considerations are of little importance with respect to the treatment to be employed, and it is especially, in a practical point of view, that I wish to consider this disease. In consequence of not having properly distinguished its causes, explanations, as often false as true, have been published respecting spermatorrhoea, and modes of treatment have been recommended, whose general appli- cation has been sometimes useful, but more often injurious. It is, however, of great importance to study attentively the symp- toms of involuntary spermatic discharges ; they are little known, very varied, and capable of simulating a host of other affections; but their character is independent of the first cause of the disease, and they furnish few indications for the regulation of its treatment. On the other hand, the history of this affection is so much in its infancy, that I feel the necessity of proceeding as if I were treating an entirely new subject. I shall, therefore, relate many single cases, before I attempt to arrive at general conclusions. As these cases are very numerous, I must classify them according to some arrangement, and I shall place the causes first in this classification, since they are INTRODUCTION. 27 the most important part of it. Proceeding from the evident to the doubtful, and from the simple to the compound, I shall examine first the causes whose action is most direct and undoubted; and whilst studying the influence of each cause, I shall bring forward the cases in which its action has been energetic, isolated, and, when possible, proved by post mortem inspection, and I shall afterwards cite cases in which several causes have acted successively or simultaneously. After having examined many cases in this manner, I shall make a general resume, in the course of which, I shall comment on whatever relates to the symptoms of the treatment. I shall also pay attention to the analogous phenomena which may be observed in the female. I propose then to consider this affection of the genital organs in all its varied phases; I shall pass rapidly over what is already known; I shall, on the contrary, insist on the most remarkable errors, and com- ment fully on all that may seem doubtful or obscure. If I were to relate all the cases that have come under my notice, tiresome repetitions would result: I shall, therefore, choose only those which best show the characteristic features of the most important dis- tinctions.* * I have thought it advisable, on account of the great number and length of these eases, to select a few of the most striking only. In answer to a communication from me on this subject, M. Lallemand has favoured me with the following observation. " As regards the cases, their number may be reduced, now that facts are being daily multiplied in confirmation of those I hare related; it will be sufficient for you to gira the most characteristic."—[H. I. McD.] C 28 ) CHAPTER II. INFLAMMATION OF THE SPERMATIC ORGANS. Pathological Anatomy. Inflammation of the organs for the secretion and excretion of semen, is the most frequent and most active cause of spermatorrhoea. The influence of this cause may be very easily conceived, and its traces maybe detected in the organs after death; I shall therefore commence the subject by its consideration. Works on pathological anatomy have hitherto*afforded us very little information respecting this important and delicate matter; the omis- sion arises from several circumstances. Inflammation of the spermatic organs does not threaten life at its commencement; when the patient dies at an early period of the affec- tion, it is in consequence of some other more serious disease, which engrosses the care of the attendants, so that after death, examination of the spermatic organs is neglected. When the continued influence of this inflammation produces diurnal pollutions sufficiently serious to destroy life, the periods of their occur- rence are very distant; the symptoms are insidious, and their true cause, in many cases, is not even suspected. Whatever the care taken, then, in examining the body, it generally happens that every part is inspected except the genital organs; incomplete cases are thus published, which are received with the more confidence because the dissection of the viscera, generally, has been made with care. The situation of the prostate and seminal vesicles is another rea-" son why their examination is neglected. In order to inspect these parts with the minute care requisite, it is necessary to divide the crural arch near its centre, to remove the abduetor muscles of the thighs, to cut through the horizontal rami of the pubes, and the rami of the ischia, so as to remove the testicles, the vasa deferentia, the rectum, and the perineum undisturbed. It is by this means only that we can obtain a good view of the or- gans situated in the lower part of the pelvis, examine their relations with care, or observe their colour, consistence, and dimensions—cir- cumstances requiring attentive study—since serious symptoms may follow almost imperceptible lesions. Thus, for instance, the orifices INFLAMMATION OF THE SPERMATIC ORGANS. 29 of the ejaculatory ducts may have been rendered uneven by some slight ulceration ; their form may have been altered, or their size in- creased, of which I have met with several cases; and we can easily conceive the consequences which may result from even the partial destruction of their little sphincter muscles. The colour, firmness, and exact size of these canals also furnish information of much im- portance. The examination of all these parts requires considerable time, pa- tience, and skill; it is necessary to inspect them thoroughly, in order to appreciate all changes affecting them, and this is impossible if the removal of that portion of the pelvis, to which they are attached, be omitted. Thus the section I have described becomes in a measure indispensable; nevertheless, in general practice it is never had recourse to, except for the purpose of examining some rare affection of the bladder or prostate. In order to understand, thoroughly, the condi- tions of these parts when diseased, it is necessary, also, to have seen them very frequently while healthy; this is neglected even by men who devote themselves specially to the study of pathological anatomy. On this account I shall illustrate their pathological changes, by some cases which would under other circumstances be devoid of interest. CASE I. Blennorrhagia—Diurnal pollutions—Hypochondriasis—Chronic affec- tion of the Brain and its Membranes—Death. Autopsy.—Right kidney in a state of suppuration—Prostate nearly de- stroyed— Ejaculatory ducts ulcerated—Seminal vesicles altered. Nothing remarkable in the other organs. In the month of January, 1824,1 was requested to see M. De S----, affected with symptoms of cerebral congestion, from which he had suf- fered for some time. During several consultations I gathered the following facts. M. de S----was born in Switzerland of healthy parents, and his father died suddenly of affection of the brain. M. de S----, possessing a strong constitution and an active mind, received an excellent education, and at an early age turned his attention to the study of philosophy and metaphysics; he afterwards studied moral philosophy and politics. After having spent some years in Paris pursuing his favourite subjects, he was obliged to undertake the management of a manufactory, and to attend to details which wounded his pride. He became, by degrees, peevish and capricious—passed without apparent cause, from an extravagant gaiety to a profound melancholy—was irritated by the slightest contradic- tion—showed no pleasure at fortunate events—and gave way to anger on improper occasions; at length he appeared to feel disgust and fatigue at correspondence or mental exertion. At this period he married, and Dr. Butini of Geneva, his medical attend* ant and friend, wrote respecting him as follows:— " With this marriage the most happy period of his existence seemed to 3* • 30 INFLAMMATION OF THE commence; but soon the germs of the disease, which so many causes had contributed to produce, became rapidly developed. It was perceived that M. De S----wrote slowly and with difficulty, and his style presented signs of the decay of his faculties; he stammered and*expressed his ideas very imperfectly ; he experienced, also, at times, attacks of vertigo, so severe as to make him fall, without, however, losing sensibility, or being attacked by convulsions." One day an attack which frightened the patient seriously, and left a deep impression on his family, came on whilst writing an ordinary letter. His medical attendants attributed this attack, which left a weakness of the right side of the body, to apoplexy. Twenty leeches were applied to the anus, and the danger seemed at an end. Similar attacks, however, occurred at Geneva and Montpellier, and se- veral distinguished practitioners were consulted: some of these, struck by the misanthrophic irritability of the patient, and his solitary habits, regarded the affection as purely hypochondriacal or nervous; others, taking into con- sideration his digestive disorder, considered it an affection of the liver; but the greater number were of opinion that there existed a chronic affection of the brain, such as encephalitis, or chronic meningitis, arising from heredi- tary predisposition. This last opinion was held by Dr. Bailly, (of Blois.) At all these consultations, the necessity of abstaining from serious occu- pation, the utility of travelling—of various amusements, and of a strict re- gimen—and the importance of free evacuations from the bowels by means of purgatives and injections—were agreed on. Many of the practitioners recommended the frequent application of leeches to the anus, with milk diet, &c.; others thought that assafoetida, baths, and camphor, were indi- cated. None of these modes of treatment produced any considerable amendment; the leeches weakened the patient, and the milk diet disordered his stomach. His constipation continued. Cold plunge baths, and cold affusion to the head, relieved the insupportable spasms M. De S----experienced in his legs and face; the waters of Aix, in Savoy, and the use of douches also ap- peared to produce some improvement. Still M. De S----became more irritable, and at the same time more apathetic. His attacks were more frequent and more violent, and he ma- nifested greater indifference towards the persons and things he had before been partial to. The weakness of his limbs increased to such an extent that he frequently fell, even on the most level ground. His nights were restless, his sleep very light and often interrupted by nervous tremors, or acute pains accompanied with cramp. The cerebral congestion increased, and the imminent fear of apoplexy rendered leeches to the anus, venesec- tion in the foot, tartar-emetic ointment, blisters, mustard pediluvia, and the application of iee to the head, necessary. • Notwithstanding the employment of these energetic measures, another violent attack of congestion occurred. I was summoned on this occasion, and I found the patient restless, agitated, and incapable of remaining two minutes in the same place; his face was red, his eyes projecting, injected, and fixed, his physiognomy expressed extreme dread; his walk was uncer- tain, his legs bending under the weight of his body; his skin cold, and his pulse small and slow. The last circumstance attracted my attention, and I also recommended the application of leeches to the anus. M. De S-----immediately threw • SPERMATIC ORGANS. 31 himself into a violent passion and asserted that leechess had always weak- ened him without giving him any relief. I was too much afraid of the occurrence of apoplexy to pay attention to this assertion, and I succeeded in obtaining the application of six leeches. The next day I found the patient very pale, and so weak that he was unable to walk—a'source of much annoyance to him, as he manifested a constant desire for motion. An cedematous swelling of the parotid gland and of the right cheek followed, which was succeeded, a few days after, by a similar state of the left leg and foot. Sleep had become indispensable, and the patient was much reduced from the want of.it; he told me with tears in his eyes, that he had lost his appe- tite, and could no longer relieve his bowels. I also learned that he was habitually costive and flatulent; that he often had recourse to injections and purgatives in order to relieve his obstinate constipation; and, lastly, that his walks, and the evacuation of his bowels had lately become the sole objects of his thoughts and conversation. Having observed analogous symptoms in almost every person affected by diurnal pollutions, I made further inquiries respecting the attack, in which it was supposed that the right side had been paralyzed, and I was soon con- vinced that the intellectual powers had been wanting, and not the power in the hand which held the pen: both sides of the body had, in fact, retained an equal degree of strength. Struck by a remark of Dr. Butini's respecting the progress of the disease soon after marriage, I made inquiries of Mme. De S----, and learned that the character of her husband had become so uncertain, irritable, and tor- menting, that his friends thought he must be unhappy in his marriage. |* I then suspected that the origin of the patient's disease had been mistaken, and I requested that his urine might be kept for my inspection. The ap- pearance of the urine was sufficient to convince me that my suspicions were well founded; it was opaque, thick, of a fetid and nauseous odour, resembling that of water in which anatomical specimens have been mace- rated. By pouring it off slowly, 1 obtained a flocculent cloud, like a very thick decoction of barley; a glairy, ropy, greenish matter remained, strongly adherent to the bottom of the vessel, and thick globules of a yel- lowish white colour, non-adherent, like drops of pus, were mixed with this deposit. I was therefore convinced that spermatorrhoea existed, together with chronic inflammation of the prostate and suppuration in the kidneys. Notwithstanding the state of M. De S----'s intellect, I was able at a favourable moment to obtain further information. At the age of sixteen, he had contracted blennorrhagia; this he carefully concealed, and succeeded in curing by the use of refrigerant drinks. The following year the blennor- rhagia returned and was removed by astringents. Two years afterwards, from drinking freely of beer when heated, the discharge again appeared, and after some time it again returned, from the effects of horse exercise. Since that time, M. De S-----had felt little sexual desire, and had ab- stained from intercourse without regret. Ejaculation during coitus had always been very rapid. Fully convinced by combining all these circum- stances, I explained to M. De S----the nature of his disease, and he pro- mised me to observe carefully. The next day he called me aside, and told me that the last drops of urine were viscid, and that during an evacuation of the bowels, he had passed a sufficient quantity of a similar matter to fill the palm of his hand. 32 INFLAMMATION OF THE Eight days after, another attack of cerebral congestion occurred, fol- lowed by stertorous breathing, cold skin, and an inappreciable pulse; the patient fell into a kind of syncope, of which he died on the 1st of March, 1824. Post mortem inspection, twentv-six hours after Death.— The general emaciation of the body was extreme. Head.—Between the dura mater and the arachnoid several bubbles of air appeared, mixed with a viscid serosity; the vessels of the pia mater were slightly injected; the arachnoid was a little opaque near the falx, but neither thickened nor granular; two or three spoonfuls of limpid se- rum were found in the ventricles, without any apparent alteration in their serous lining; the brain was slightly injected and soft throughout, but with- out appreciable alteration in any one particular part; the cerebellum, also, was very soft, of natural size, neither more nor less injected than the brain, and without any particular alteration. Three or four spoonfuls of serum were found at the base of the brain and commencement of the vertebral canal. Chest.—Pleura pulmonalis every where adherent by a dense cellular tis- sue to the pleura costalis; lungs crepitant and pale, except at the posterior part; heart of the ordinary size, and firm. Abdomen, tympanitic, green, and exhaling a very fetid smell; liver of natural colour and very firm; a spoonful of bile in the gall bladder; spleen small and of a violet colour; stomach distended by gas; mucous membrane thin, soft, and of a brownish gray colour; small and large intestines equally distended by gas, pale, and thin in their structure, containing a small quan- tity of brown, excessively offensive, liquid, faecal matter, Left Kidney of the ordinary size, of a healthy red, and very firm. Right Kidney a third larger than natural, adherent by a dense, resistant cellular tissue to the surrounding structures; containing in its parenchyma about forty little abscesses, varying from the size of a pea to that of a nut, some of recent formation, and without cysts, others old and encysted, all containing thick and creamy pus; the structure of the kidney reduced in four-fifths of its extent to a dense coriaceous membrane, full of cloacae; the lining membrane of its pelvis red and villous; the ureter thin, distended, brownish, and much injected on its mucous surface. Bladder rising as high as khe umbilicus, and containing two pints of trans- parent urine. Its parietes thin; the muscular fibres weak and scattered; mucous membrane rose coloured and slightly injected, but thin and scarcely altered in appearance.* Prostate projecting three or four lines behind the neck of the bladder, over about an inch and a half in superficial extent. In the Trigone Vesicle there was an effusion of albuminous matter, half a line in thickness and about two inches in extent, uniting the seminal vesicles to the anterior wall of the rectum. The Lfft Seminal Vesicle small and brown, but in its normal position. The Right separated from the corresponding vas deferens, folded on the posterior border of the prostate, atrophied and surrounded by a very dense fibrous cellular tissue, which was very difficult of dissection. * In order to examine the genital organs with greater care, I removed the parti with the rectum, by means of the section before described. SPERMATIC ORGANS. 33 The Prostate double its normal size and projecting into the rectum; hard on the sides of the neck of the bladder, soft in the centre. Its fibrous envelope having been divided with a bistoury, an opaque, thick, ropy, elastic matter escaped, like pus in colour, and the mucus of the nostrils in consistence. There was a cavity occupying the whole of the anterior and middle parts of the prostate, about fifteen lines in size in every direction, when the purulent matter had been removed; the gelatinous mass was observed to divide into a number of filaments whieh became impacted in numerous small foramina; the canal of the urethra being closed, these filaments came out by the openings of the mucous follieles of the prostate. When this cavity was emptied it became evident that the two inferior thirds 6f the prostatic part of the urethral mucous membrane had been detached and had covered the cavity in the prostate in the same manner that the cribriform lamella of the ethmoid bone covers the nasal fossae in the dried skull. The openings of the Ejaculatory Ducts in place of being circular and nipple shaped, formed a long slit, which was ulcerated, especially on the side towards the bladder; two probes of considerable size introduced through the vasa deferentia passed easily through these openings. The ejaculatory ducts were long and thin, as though dissected, and formed part of the superior wall of the cavity in the prostate. The posterior border of the prostate was not destroyed but was pale, soft, and easily torn, like all the parts in the neighbourhood of the principal abscess. The Urethra presented no remarkable appearances. The Testicles were small, flaccid, and pale. I leave this case just as I wrote it when under impressions formed at the time, because its recital is well fitted to show those serious errors in diagnosis, which are much more common than might have been suspected. Now that we have seen the more obscure parts of this case cleared up by degrees, let us consider the chronological order of the facts:— An urethral discharge, badly treated in the beginning, reappeared from very slight causes, whose action, however, was easily appre- ciable. The follicles of the prostate from repeated attacks of inflam- mation, became disorganized; the ejaculatory ducts were laid bare, and their orifices became ulcerated; the inflammation extended to the seminal vesicles, and the peritoneum adjoining. Soon after, a new train of symptoms set in, which became much aggravated after the patient's marriage, in consequence of the unac- customed exercise of the disordered organs. Ejaculation was rapid, because the ejaculatory ducts were in a state of irritation. The erections were incomplete, and at length ceased altogether, because the semen was habitually expelled as soon as secreted. This dis- charge was considerable, for the testicles shared the irritation of the other parts. During all this time inflammation was creeping along the urinary apparatus, and ended by destroying the right kidney. Hence the symptoms observed previous to death; hence the very remarkable appearance of the urine, an excretion, to whose changes sufficient importance is not attached at the present day, from its exa- 34 INFLAMMATION OF THE mination having been once rendered ridiculous through the preten- sions of quacks. CASE II. Blennorrhagia— Spermatorrhoea—Hypochondriasis—Frequent attacks of cerebral congestion—Death. Autopsy.—Suppuration in (he seminal vesicles—Ossific deposit in the vasa deferentia—Cystitis—Phlebitis—Old adhesions of the arachnoid and pleurx—Jlbscesses in the muscles of the neck and shoulders. On the 25th of September, 1825, Professor Brousonnet granted me the examination of one of his patients who was supposed to have died from cerebral hemorrhage. Before commencing the post mortem I learnt the following particulars:— Francis Maurice, aged sixty-three years, formerly a soldier, had com- plained for some time of weakness in his legs; he staggered whilst walking as if he suffered from giddiness, and he would often have fallen if he had not been assisted. Occasionally he had attacks of congestion in his head; his face became red, he lost his senses, and experienced very varying spas- modic symptoms. After these his face became pale, and fainting occurred. These attacks had been treated by bleeding, derivatives, antispasmodics, and leeches. At length, on the 22d of December, a violent attack of congestion in the head occurred; his face became purple, and the next day he died. These symptoms seemed to indicate a chronic affection of the brain or its membranes, producing attacks of congestion, the last of which terminated in apoplexy. On inquiry I could not learn which side of the body had been paralyzed; but it seemed certain that no distortion of the face had ever existed. This circumstance made me suspect that the paralytic symp- toms had always been general. The cause of the disease was Attributed to some hidden care. The pa- tient had spoken little, and always presented a sad and silent appearance: he had complained of a host of different diseases, the greater number of which seemed imaginary, or, at least, much exaggerated. He complained of pain about the occiput, the neck, and the back; colic, distention of the lower part of his belly, and borborygmi affected him frequently. Notwith- standing his weakness he had a constant desire for motion: he could not remain quiet in bed, and often had recourse to the night-stool. He had an irritable manner; he tormented the nurses and snubbed the pupils, and was generally looked upon by the latter as a hypochondriac. I learnt also that he had experienced several attacks of retention of urine and I recollected having introduced a catheter for him a few days before his death. 7 I suspected, therefore, that the symptoms he had manifested arose from unperceived spermatorrhoea. The following are the results of the inspection of the body:— Head.—Cerebrum and cerebellum slightly softened throughout, but not more so in one part than in another; the cerebral substance slightly, but equally,injected,especially in the posterior lobes; several old cellular adhe- sions, five or six l.nes in extent, in the inferior occipital fossa?, intimately uniting the corresponding surfaces of the arachnoid; the cerebellum equally SPERMATIC ORGANS. 35 adherent to the pia mater in the same situation, and incapable of being detached without injury to its structure. In the other parts of the interior of the cranium there was not the least local change that could be considered a result of recent disease. Thorax.—Lungs, healthy; a few old adhesions of the pleurae on both sides ; heart flaccid, of the colour of wine lees, and easily torn; the princi- pal veins without firmness, and of a dark violet colour; the iliac and crural veins presented the same conditions. Abdomen.—The mucous membrane of the stomach slightly injected; the small intestines in much the same state; nothing remarkable in the other abdominal organs; the kidneys and ureters healthy. Pelvis.—The bladder, which contained a large quantity of muddy urine, was united to the rectum by cellular adhesions; its mucous membrane was of a dark red, highly injected, and covered by small ecchymoses, from ex- travasation of blood in its structure; the prostate was of its natural size and firmness. The Seminal Vesicles were much dilated, their parietes were very thick and dense, and they presented no markings or inequalities. These organs were attached by strong and much injected cellular tissue to the neighbour- ing parts, and each of them contained about a spoonful of thick yellowish pus enclosed in three or four cavities communicating with each other and with the ejaculatory ducts. The inner surface of these abscesses was un- even, rugous, and lined by a sort of false membrane formed by a layer of thickened pus. The Vasa Deferentia were tortuous, and completely ossified for the ex- tent of about three inches, but not obliterated. They contained a slightly viscid fluid. T£ie mucous membrane of the urethra was much injected, especially from the bulb as far as the bladder; the mucous follicles much developed. The neck of the bladder, was thickened, of a reddish brown colour, without te- nacity and fissured by several recent lacerations. Some days after, the pupils, who were dissecting the muscles of this sub- ject, told me that they had found the subscapularis, and the supra- and in- fra-spinatus muscles on both sides, as well as several muscles of the neck in a state of suppuration. Some time after I succeeded in learning the following facts. Maurice whilst in service at the age of twenty-three years, contracted a violent blennorrhagia accompanied by orchitis and inflammation of the spongy tissue of the urethra, which he neglected after the relief of the most urgent symptoms. His character previously very gay, now changed by degrees ; he experienced attacks of profound melancholy, during which he imagined that every one disliked him; when these attacks were over he gave himself up to dissipation ; he drank freely, but when no longer excited he relapsed into melancholy, and often complained of pains in his head towards the oc- ciput. At first he experienced nocturnal pollutions, and soon after he perceived that in evacuating his bowels, especially when costive, he sometimes had a spermatic discharge. By degrees his digestion became much disordered, constipation became habitual, and the spermatic discharges at stool in- creased. He reformed and gave up drinking: his health was, however, ruined ; he took cold easily, and suffered from pain in his side and frequent pains in his limbs and loins; he was constantly tormented by flatulence, 36 .. INFLAMMATION OF THE colic, and diarrhoea or obstinate constipation. His legs were weak, and his body was frequently affected with tremors; yet he could not remain in bed, he was tormented night and day by a constant desire for motion, and be- ing very weak he frequently fell. After some time he had difficulty in supporting his head, and he com- plained of a constant pain in his neck and shoulders, accompanied by tender- ness in the vertebral column. The evacuation of urine, previously irregular and difficult, now became often impossible without the aid of a catheter. Latterly, he became subject to frequent attacks of cerebral congestion, during which his face was purple; he was insensible, convulsed, and ap- peared to be threatened with an attack of apoplexy. The practitioner, called under these circumstances, never failed either to bleed from the arm, or to apply leeches, and as the attack did not last long, he attributed its re- lief to the abstraction of blood. Immediately afterwards, even when bleeding had not been practised, the patient remained exceedingly pale; and at the close of one of these attacks he died. The same causes produced the same effects in this, as in the pre- ceding case ; the same symptoms led to the same errors in diagnosis: it was just as difficult to discover the truth, and the same appearances were found after death. Cases of this nature are not then so rare as might have been expected. Supposing that in these two cases, we had proceeded to examine the bodies, with the pre-convictions arising from an observation of the symptoms; it is clear we should have found nothing in the cranial cavity, which would have accounted for the cerebral symptoms, for a general and uniform softness of the cerebral matter is observed,after all chronic diseases, especially when decomposition has made any progress ; it is evident also that we should have found nothing more satisfactory in the other viscera: who knows then, to how many errors these observations might not have given rise ? Among the cases cited by the believers in nervous apoplexy, and special spasmodic affections, I am convinced that a great number arise from spermatorrhoea; but, from the non-examination of the genital organs, it has been impossible hitherto to prove the correctness of this opinion. I trust that soon all practitioners will be able to avoid such errors. But let us reconsider the case of Maurice:—at the age of twenty-three he had urethritis, accompanied by chordee and orchitis. As soon as the worst symptoms were relieved, he resumed his old habits, and gave himself up to excesses of all kinds. By degrees his health failed under the influence of nocturnal, and afterwards, of di- urnal pollutions; he became hypochondriacal, and notwithstanding his forced abstemiousness, he at length died in the same state as M\ De S---. Why did this patient resist the action of the disease longer than the first? Because the alterations were much less serious, and even the state of the pus found in the prostate seemed to announce that the inflammation had taken on an acute character, only during the last stage of the disease. SPERMATIC ORGANS. 37 Can diurnal pollutions sufficient to destroy life, exist at the age of seventy-three years ? Undoubtedly they can, since the vasa deferen- tia still contain at this age, a viscid secretion, consisting of badly formed semen : besides, the patient had told his friends shortly before his death, that in going to stool, he had passed semen in the palm of his hand. I have before said that Maurice passed for a hypochondriac, and that his diseases were considered imaginary, or at least very much exaggerated; nevertheless, we found in various organs, recent and old changes, to which we must refer his complaints. By degrees, as his health broke up, he became more easily affected; he complained of pains in his side—his lungs were attached to the walls of the chest by cellular adhesions; he often complained of pains in the head, fixed towards the occiput—the cerebellum was found ad- herent to the meninges at several spots, at the same time that the mem- branes were attached to each other: latterly, he complained of con- stant pains in the neck and shoulders—the subscapularis, and supra- and infra-spinatus muscles of both sides, together with several muscles of the neck, were found in a state of stfppuration: the patient was subject to attacks of retention of urine—the neck of the bladder, to- gether with the urethra and vesical mucous membrane, were thick- ened, and of a brownish red colour. I ought to add, that the principal abdominal, and even the femora veins, were softened, and of a violet hue, and presented traces of phlebitis. We see, therefore, that most of the disorders of which Maurice complained, depended on so many really existing local inflamma- tions. I know that many of the symptoms experienced by patients affected with spermatorrhoea are purely nervous, and that we find often after death, no trace of alteration in the organs which had been supposed to be diseased; but, I also know how the majority of post mortem examinations are conducted. We forget that the slow and progressive weakening of the consti- tution, following disordered digestion, causes an increased nervous susceptibility in hypochondriacs; and that a less energetic resistance of the different organs to the action of causes capable of altering their health also results from it; hypochondriacal patients are thus much more liable to every disease, at the same time that they suffer more from the diseases affecting them. A few words more on the other lesions: the vasa deferentia were ossified in several points; this ossific deposit was not the effect of age as might be supposed, for I have met with it under similar circum- stances in very young subjects: it must therefore be attributed to old standing inflammation. In the orchitis that follows blennorrhagia, the inflammation extends from the mucous membrane of the urethra to the testicles, by the ejaculatory ducts, seminal vesicles, and vasa deferentia; the latter 4 38 INFLAMMATION OF THi, are almost cartilaginous in their normal conditions; in chronic inflam- mation, therefore, they may easily become encrusted with phosphate of lime. The neck of the bladder was fissured by several recent splits. When the internes requested me to catheterize this patient, it was be- cause they had been unable to enter the bladder. I learnt that they had always used the smallest instruments; by, on the contrary, using the largest I could find, I reached the bladder without difficulty. CASE III; Blennorrhagia—Retention of Urine, $c.—Apoplexy—Death. Autopsy.—Effusion of Blood into the left ventricle of the brain—Hyper- trophy of the heart— Gastro-enteritis—Abscess and tubercles in the kidneys and prostate—Stricture, $c. Gojon, at the age of forty, contracted an acute blennorrhagia, with orchitis. Treated by irritating medicines, which produced diarrhoea and violent colic, it diminished, bRt did not entirely disappear, a slight urethral discharge continuing for ten years, with pain in the prostatic region and fossa navicularis. He was also annoyed by obstinate constipation. Be- tween the ages of fifty and sixty he experienced difficulty in discharging his urine, a feeling of uneasiness in the urinary apparatus, weakness of the body, difficulty of digestion, considerable loss of flesh, and a remarkable diminution in his intellectual powers. Still later he had frequent attacks of retention of urine, successfully treated by baths and demulcents, intolerable pain in the kidneys and bladder, hypochondriasis, a strong aversion to fre- quented places, melancholy, and serious debility. On the 1st of February, 1827, retention of urine occurred, for which leeches were applied to the perineum, and general baths and demulcents were employed without relief; active inflammation of the perineum and cellular tissue of the scrotum took place, for which fomentations were ap- plied. v On the 5th the skin of the perineum gave way in three places, and a large quantity of urine mixed with pus was discharged. On the 10th of February this patient was brought to the hospital. He was sixty-five years of age, his skin was warm, and his pulse full and strong; cheeks red, eyes watery, with pain under the orbits; ideas pretty clear, tongue red and dry, severe thirst and a desire for cold drinks ■ abdo- men sensitive on pressure, especially in the hypogastric region; attempts at cathetensm unsuccessful. Fomentations were ordered to the abdomen On the 11th an attack of apoplexy occurred, and on the 12th he died. POST mortem appearances. Head.— Considerable effusion of florid blood in the left lateral ventricle heart * gS crePitant- Hypertrophy of the left ventricle of the Abdomen.—Mucous membrane of the stomach red throughout its whole SPERMATIC ORGANS. 39 extent; covered by little spots of ulceration scattered here and there ; the injection of the intestines becoming more and more remarkable in the neighbourhood of the anus. Some ulceration in the rectum. Genifo-urinary organs.—From ten to twelve abscesses were found in each kidney; and in the left, crude tubercles, about the size of a bean, ex- isted. The ureters were dilated, and their lining membrane red and in- jected. Bladder hardened and columnar, an inch in thickness. Mucous membrane of a violet colour, thick, soft, and ulcerated in several points. Prostate three times its normal size; more developed under the neck of the bladder than towards the rectum; furnishing, by pressure, a very abundant purulent discharge, and containing about thirty little abscesses and as many crude tubercles. This prostate resembled the tissue of a lung full of tu- bercles, of which some are empty, others suppurating, and others immature. The seminal vesicles and vasa deferentia thickened. There was a circular stricture in the urethra, about half an inch in front of the prostate, formed by a tissue of a horny consistence, and scarcely per- mitting the introduction of a No. 2 catheter. An enormous dilation of the urethra was observed between the stricture and the neck of the bladder, and the mucous membrane of this portion of the canal was thickened, fun- * gous, and softened, and presented in its posterior part a fissure whence three fistula? took their origin. The cellular tissue of the perineum and scrotum was full of pus. The testicles were healthy. This patient died the day after his entry into the hospital, and during this short space, his state had not permitted us to think of in- voluntary spermatic discharges, always very difficult to detect in cases of this nature. The stricture was however, seated a little in front of the orifices of the ejaculatory ducts, and the prostatic mucous mem- brane was disorganized by inflammation; nothing is more common than spermatorrhoea under these circumstances. On the other hand the prostate was considerably altered, and the seminal vesicles and vasa deferentia were much thickened. It is then to be presumed that the loss of intellect, the great debility of the system, &c, arose, as in the preceding cases, from habitual spermatic discharges. Death was caused by a large effusion of blood in the left lateral ventricle. Was the hemorrhage the result of one of those cerebral congestions of which we have spoken in the preceding cases ? Analogy seems to indicate that it was. Hypertrophy of the left ventricle of the heart was present, however, and the influence, which the increased development of this organ exercises on the brain, is well known. If this hypertrophy were not the sole cause of the effusion, it had, without doubt, a large share in producing it. In obscure questions like that which occupies us we must only admit facts that are incontrovertible, and we must resist as much as possible the attraction of pre-conceptions. I have, therefore, reported this case, because it confirms what I have stated respecting the facility with which inflammation of the mucous membrane of the urethra extends to all the other mucous membranes connected with it. 40 INFLAMMATION OF THE The first disease was urethritis with orchitis. Thus, at the be- ginning the inflammation extended from the urethra to the testicles by their excretory ducts, and the manner of this extension cannot be doubted, because, twenty-five years afterwards the vasa deferentia and vesiculae seminales were still thickened. The extension of the inflammation in the direction of the urinary passages was still more evident, for not only the prostatic mucous membrane was thickened, fungous, and softened, but that of the bladder was thick and softened also, violet coloured and even ulcerated in several points; the ureters were dilated, and their inner surfaces red and injected ; lastly, each kidney contained ten or twelve abscesses, tubercles also existing in the left. The prostate is the principal seat of blennorrhagic discharges; be- ing situated at the junction of the urinary with the genital apparatus, it cannot fail to be affected by disorders which extend to tissues very far from their points of origin ; thus it was still more diseased than the kidneys. It was three times its normal size, and independent of the purulent matter furnished by its mucous follicles it contained about< thirty small abscesses and as many crude tubercles. I shall remark, as^I proceed, that the circumstances under which the tubercles of the prostate and left kidney were developed, and the existence of these tubercles by the side of recent abscesses, leave no doubt as to the cause of their formation. Before concluding these reflections, I must also notice that traces of acute gastro-enteritis and even of ulceration of the rectum were present. It is to this complication that we must attribute the redness and dryness of the tongue, the extreme thirst, and the sensitiveness of the abdomen to pressure—characteristic symptoms of inflammation of the digestive organs, which we must not confound with derange- ment of their functions, or with the gastralgia that so frequently accompanies spermatorrhoea; neither must we confound the hemor- rhage that caused death, with the cerebral congestions of which I have spoken in the two preceding cases. Unfortunately, these distinctions are very difficult to be established in some cases, as alterations of tissue often follow purely sympathetic functional derangements so suddenly, that it is impossible to specify the moment when the affection becomes really idiopathic. This is, above all others, the circumstance which has hitherto thrown so thick a veil over cases of spermatorrhoea; and which renders the minute examination of each case so necessary. SPERMATIC ORGANS. 41 CASE IV. Mental derangement—Belief in a change of sex—Death. Autopsy.—Thickening of the arachnoid—Great alteration of the prostate —Atrophy and obliteration of the ejaculatory ducts. I find the following particulars related by Professor Rech respecting an insane person who died under his care. " The intellect had been disordered for a long time; the patient believed he had changed his sex, and, thinking himself a woman, spent much of his time in writing to an imaginary lover: sometimes he fell on his kness and seemed to dig the ground for hours to- gether. He had entirely lost the power of vision in the left eye. His death took place from exhaustion after an obstinate diarrhoea. At the post mor- tem inspection, the dura mater was found healthy throughout; the arach- noid was thickened in several points, and opacities were found on its sur- face which obscured its transparency. The pia mater contained a consi- derable quantity of serosity, especially between the cerebral convolutions. The brain, cerebellum, and medulla oblongata were healthy in all their parts. The optic nerve of the right side was atrophied behind the commis- sure to the extent of half an inch, of a greyish colour and very soft. In the left eye, the retina was separated from the choroid by a considerable serous effusion; the vitreous humour, apparently atrophied, formed a reddish and irregular mass. The lungs and heart were healthy, but the latter was remarkable for its small size. " The mucous membrane of the intestines, from the ccecum downwards, was red and thickened; and this alteration increased in intensity near the rectum, in which numerous ulcerations existed. "The prostate projected into the bladder, and was nearly two inches in extent in its long, and fifteen lines in its transverse diameter; its structure contained three small abscesses. The ejaculatory ducts were softened, atrophied, and obliterated. The vasa deferentia, and the vesiculae seminales were on the contrary larger than ordinary." The patient died of a chronic diarrhoea, and the intestinal mucous membrane was injected, thickened, and ulcerated; he had lost his power of vision in the left eye, and this eye was extensively altered, as was also the right optic nerve, before its entering the optic com- missure; he believed himself to be a girl, and the functions of the testes must have been abolished, since the ejaculatory ducts were atrophied and obliterated. If this singular alteration of the genital organs were not the cause of the patient's derangement, it must at least have influenced its peculiar character. Summary of the preceding Observations. Symptoms.—In the first two patients only, were involuntary sper- matic discharges discovered, and their general symptoms well de- scribed. The other cases are hardly of importance, except in respect 4* 42 inflammation of the of their pathological illustrations. It is only m the first two cases that the progressive deterioration of the spermatic organs can be well followed, from the first blennorrhagia to the patient's death; and that the ever increasing influence of spermatorrhoea over the whole eco- nomy, but especially over the cerebro-spinal system, can be appre- ciated. The delusions produced in both patients by the last class of symp- toms, are well fitted to open the eyes of practitioners as regards cases of this nature. The consequences resulting from them in a thera- peutic point of view are so serious, that we cannot well attach too much importance to their due consideration. But how can extreme cases of spermatorrhoea so closely simulate affections of the brain, or of its membranes? and, by what characters can we distinguish their symptoms from those arising from idiopathic affections of the same organs ? In order properly to discuss questions of this kind, it is indispensable to have before us all the facts influ- encing them ; but in passing, we may hastily consider those with which we are already acquainted. In the first two cases, the cerebral symptoms were preceded during a long period, by a remarkable derangement of the other functions: thus, digestion was performed badly; the stomach no longer bore fermented drinks, spiced meats, or very nutritious food; stubborn constipation supervened ; the intestinal tube was habitually distended by flatus; sexual intercourse became more and more rare, the act more rapid, and at last entirely impossible. The patients, in these cases, discontented with themselves and their friends, and tormented by flatus, of which they want continually to relieve themselves, shun society and its trammels; they dislike every thing which recalls to them pleasures they are unable to share ; they become melancholic and irritable, misanthropic and hypochondriacal; ever occupied by the consideration of their health, they manifest the utmost indifference for all things which do not affect it. The cerebral functions are not more weakened than all the rest, but their disorder produces more serious consequences, and is more readily perceived. It is soon remarked that memory becomes im- paired, that the train of thought is easily interrupted, and that the least excitement of the intellect induces congestion towards the head. Difficult digestion, more obstinate constipation, and abdominal dis- tention by flatus, supervene in these cases, which end by attacks of congestion in the fatigued and weakened brain. But these congestions are accompanied with a remarkable feeble- ness of the pulse, chilliness of the limbs, general uneasiness, anxiety, agitation in every sense, and a remarkable desire for motion. They are immediately followed by pallidity of the countenance, general debility, and alarming faintness, without any one part of the body being more affected than the rest. Apoplectic congestions are never preceded for years by a progres- sively increasing weakness of the economy; the pulse is full, and there is a tendency to drowsiness. spermatic organs. 43 The patient whose case I have related in my third observation, died in consequence of an extensive cerebral hemorrhage, which came on suddenly in the left lateral ventricle of the brain; but this patient had hypertrophy of the heart, and the first attack promptly caused death; it is therefore probable that the congestion was not due to the same cause, and it certainly did not present the same characters as in the two preceding cases. The disorder observed in the ideas of such patients, cannot be con- founded with delirium ; whenever delirium, has been really present in these cases, true meningitis has been found to exist, of which, I have seen numerous examples. The state of the intellect in these affec- tions, manifests perhaps a greater resemblance to demency ; but de- mency commonly follows mental derangement; besides, it is always easy to obtain, in the cases I am considering, clear and connected answers. It is impossible also to confound the disorder of the digestive func- tions with the symptoms of inflammation of these organs; in all cases in which inflammatory symptoms are observed, gastro-enteritis is actually present. Lesions.—It is chiefly on account of the alterations discovered in the spermatic organs that the cases I have hitherto recorded, are of value. The influence of the urethra on all the organs which open l into it, is an important phenomenon in the history of spermatorrhoea. To have a clear idea of this influence, it is necessary especially to prove the facility with which inflammation creeps along the mucous membranes, to even their most distant continuations. Prostate.—Blennorrhagic discharge arises from the mucous follicles of the urethra, and of the prostate especially, where they are most developed and most numerous: the prostate, in fact, is formed of these follicles, united by cellular tissue. During the first days after contagion, a tickling in the urethra is felt, with itching heat and pain, especially during the emission of urine. The secretion of the canal is increased, and changes its ap- pearance, but it is not until the inflammation has reached the prostate, that the discharge acquires its greatest severity. It is then principally secreted by the prostate, and experienced patients seem to be aware of this, for in doubtful cases we see them compress the urethra from the perineum to the glans penis, in order to expel the secretion. Be- sides, post mortem examinations permit no doubt to remain on the subject. But the irritating matter which excites the disease is not deposited on the surface of the prostate, and it is not because this matter con- tains a contagious principle, that the inflammation is propagated so rapidly from the orifice of the urethra to the prostatic mucous follicles, for leucorrhcea, the menstrual discharge, or the lochia, are frequently sufficient to excite a profuse discharge, the seat of which is equally in the mucous follicles of the prostate. 44 INFLAMMATION OF THE It is not the passage of the irritating matter from one point of the mucous surface to another, that favours this propagation, for the dis- charge passes from behind forwards, and the inflammation extends in the opposite direction. However it may arise, the fact is constant, and it clearly explains the frequency of prostatic disease as a sequel to blennorrhagia. In the beginning of a very acute inflammation, the prostatic folli- cles are gorged with a thick adhesive pus, and form a firm and yel- lowish body like a scrofulous tubercle ; the cellular tissue surrounding them is so far, however, perfectly healthy, so that the follicles can be easily separated from one another throughout their extent, and the nature and seat of their changes can thus be proved. At a more advanced period of the disease, we find the prostate in- filtrated with pus or a pultaceous matter, which may be pressed out in the form of granules; the cellular tissue is now, therefore, attacked by the inflammation, but-suppuration is not yet well established. At a still more advanced period, by slightly compressing the pros- tate, pus may be made to exude from all its excretory ducts, and it contains besides, little abscesses from the size of a linseed to that of a pea. Here the suppuration of the cellular tissue has begun to form into distinct collections. In the third case I have related, the prostate was three times its normal size, and furnished on pressure, a very abundant purulent matter; it contained besides this about thirty little abscesses, and as many crude miliary tubercles. We observe here the same progress of the inflammation, but the abscesses, in place of discharging their contents, were transformed into tuberdles by the absorption of the fluid parts of the pus. In the first case I have reported, the prostate was partly destroyed, and contained in its fibrous envelope an elastic and purulent matter, which passed into the canal of the urethra, through a number of fora- mina in the mucous membrane. These foramina were the orifices of the mucous follicles whose parietes had been destroyed by sup- puration. We see by these observations, then, that the inflammation extends from the urethral mucous membrane to that lining the mucous folli- cles of the prostate, and afterwards to the cellular tissue uniting them ; that abscesses form, and either discharge their contents by the mouths of these follicles after having destroyed their parietes, or in other cases form tubercles, which end in the same way; that the prostate becomes destroyed by degrees, and is reduced to a fibrous envelope, quite perfect, and covered by a kind of perforated membrane, the foramina in which vary in form and size, according as the excretory orifices remain distinct, or are united together by the destruction of the intervening tissue which separates them. When the inflammation of the prostatic cellular tissue is less severe, in place of pus, an albuminous matter is deposited, which infiltrates SPERMATIC ORGANS. 45 * the part and gives rise to indolent engorgement, and if this be not dispersed promptly and entirely, induration of the prostate will result. I have seen many cases in which this has occurred. Spermatic Organs.—The frequency of orchitis arising from blen- norrhagia shows with what facility inflammation of the urethra extends to the testicles. This extension takes place by means of the mucous membrane. Injury, exposure to cold, &c, may indeed favour the development of orchitis; but its principal cause, often its sole cause, is the influence of the urethral mucous membrane over that lining the excreting organs of the semen. Both patients and practitioners are in many cases much puzzled to understand the appearance of orchitis, and they would be still more so if pre-conceived opinions did not facilitate its explanation. Some- times it is from having walked too far, or from having sat too long, sometimes from having worn too tight a pair of trousers, or from having bruised the testicles by crossing the legs, that the disease has arisen. But who is not exposed to the action of such causes? I admit that it is often immediately after a circumstance of this kind that the patient experiences for the first time, a more or less sharp pain in the testicle, which is soon afterwards followed by the other symptoms of orchitis; but those patients who observe carefully never fail to remark, that they first experienced a sense of weight in the inguinal region, and of dragging and pain in the spermatic cord. On examining the cord of the affected side, the vas deferens is then found to be swollen and very sensitive, and it even sometimes hap- pens that* the swelling of the cord is so great as to cause a kind of strangulation in the inguinal canal. When, afterwards, the inflammation extends to the body of the testicle, it is attributed to the first cause which drew attention to the morbid sensibility of the organ, and then it is that the urethral dis- charge diminishes or becomes suppressed, according as the new in- flammation is more or less severe. The suppression of the discharge makes the patient imagine that the affection itself has attacked the testicle, and many medical men even believe that the suppres- sion does give rise to orchitis. They are deceived by taking the effect for the cause ; but it is not the less true on this account, that the inflammation of the canal has originated that of the testicle; in- deed the succession of the symptoms ought to be sufficient to show the course the disease has taken. When both testicles have been affected, both ejaculatory ducts are found altered, and when both seminal vesicles or both vasa defe- rentia have been inflamed, the same alteration is remarked in both the ejaculatory ducts. When one only of the spermatic organs has been inflamed, I have always been able to trace the inflammation to the orifice of the corresponding ejaculatory duct, whilst the other has been found unaffected. ' I have also seen the inflammation spread without interruption as far as the tunica vaginalis of the testicle or of both tes- ticles, according as the disease has extended on one side or on both. 46 . INFLAMMATION OF THE This affection of the tunica vaginalis may be easily explained, since any alteration of the glandular tissue is readily partaken by its fibrous covering, which is intimately united with the serous tissue coating the gland. Inflammation of the seminal vesicles extends itself in the same man- ner in some cases, to the adjacent peritoneum. In the first case I have related, this inflammation was quite recent; the matter depo- sited on the surface of the serous membrane was still albuminous, soft, and unorganized; and in the second case, the bladder was united to the rectum by cellular adhesions, evidently due to the same cause. These observations are of greater importance than they appear; they prove that general peritonitis might easily arise from the diseases we have been studying. The old and circumscribed adhesions of peritonitis which sometimes line the bottom of the pelvis, ought also to be noted as being almost certain proof of old inflammation of the seminal vesicles; they may, therefore, assist much in explaining the symptoms observed during life, when the alterations of the spermatic organs have passed away, or do not leave any very apparent traces. However this may be, these alterations of the peritonaeum and of the tunica vaginalis prove that the inflammation is propagated by conti- guity of tissue. But it is necessary to examine a little more in detail the state of the different spermatic organs. Orifices of the Ejaculatory Ducts.—In the patient who was the sub- ject of the first case, the orifices of the ejaculatory ducts, in place of being circular, formed one elongated and irregular cleft. The ducts themselves were very large. This enlargement has been noticed by Stoll* in a case related by him; and it was still more remarkable in a body I once saw in the School of Medicine, in which the opening admitted a goose-quill. In all these cases still more serious lesions existed, but it is easy to conceive that the dilatation or ulceration of the sphincters which terminate the ejaculatory ducts, may alone "pos- sess great influence over the production of spermatorrhoea, and I should not be surprised if we should find sometimes no other lesion capable of accounting for it. The Ejaculatory Ducts generally share the alteration and dilatation of their orifices; besides which, they may be insulated, as though dis- sected, by the suppuration of the prostate, or thickened, hardened, and cartilaginous, or they may even contain osseous granules. These alterations, much more serious than those of their orifices, must dis- pose very much to the involuntary escape of the semen. The ducts having lost their elasticity, and even their power of contraction, are no longer able to drive back the semen into the seminal vesicles; or at least they are incapable of retaining it, however gently these reser- voirs may contract, or however little they may be compressed. * Pars prima rationis medendi. SPERMATIC ORGANS. 47 The pressure exerted on these ducts, by the swelled tissue of the prostate, may cause their atrophy or obliteration, whence, of course, ensues the more or less complete loss of their functions. Seminal Vesicles.—It would appear that pus formed in the seminal vesicles should be easily expelled; but these two receptacles, com- posed of ramified cells, are placed out of the direct course of the semen, to be used as reservoirs for it; and they only communicate with the vasa deferentia and the ejaculatory ducts, by a very narrow opening, in front of which the seminal fluid may pass to be discharged directly from the testicles into the urethra; it seems that the swelling produced by inflammation may so much lessen this opening as to form an obstacle to the exit of pus, for a shorter or longer period ; in one case which I had an opportunity of examining, the pus had acquired a considerable thickness, and that at the bottom of the cells was still more thickened, exactly resembling tuberculous matter. The resi- dence of the pus in this situation may be even still more prolonged, should the watery part be more completely absorbed ; in these cases we find only a yellowish homogeneous substance, soft, like plaster, or even chalky, the true origin of which has been entirely mistaken. It is almost unnecessary to notice that the presence of pus prevents the entrance of the semen into the reservoirs intended for it, and that it becomes, from this alone, an immediate cause of spermatorrhoea. We can easily understand also that after the expulsion of the pus, the parietes of the vesicles must be thickened, and that they may always remain hardened, altered in shape, thickened, cartilaginous, or even bony. In more favourable cases, also, their lining membrane must preserve, during a long time, an abnormal sensibility, the influence of which must be very injurious. It is not, kowever, necessary that such serious alterations should exist in the seminal vesicles in order to account for the irregular and spasmodic contractions of which they are sometimes the seat, or for their influence on the production of spermatorrhoea; but it is useful to understand fully the most striking changes, in order the better to appreciate the slighter ones. The qualities of the semen found in the seminal vesicles should also be carefully noticed; I have seen it resemble meconium in one of these receptacles whilst pus existed in the other; and it is probable that the alteration of the secretion of the one testicle was due to a similar influence which, in the same case, had acted still more evi- dently on the opposite organ. Vasa Deferentia.—Pus formed in the vasa deferentia is not in all cases easily expelled; swelling of their walls may bring about complete obliteration of these vessels in one or more points, whilst in others they are distended by the accumulation of the pus, so that pouches, more or less dilated and separated by contractions, some- what resembling irregular chaplets, are formed. This disposition may extend itself to the epididymis, and to the corpora Highmoriana, the 48 INFLAMMATION OF THE mucous membranes of which are continuous with those of the vasa deferentia at one part, and with those of the secretory tubes at another. Pus thus separated and submitted for an indefinite time to the action of the absorbents, becomes more and more solid, and gives rise to deposits resembling those of tuberculous matter, the aspect and con- sistence of which may present every degree of alteration in the same individual, according to the age and size of the abscess. From this obliteration of the vasa deferentia, retention of the semen in the testicles also results, so that the generative power is lost; but it does not necessarily follow from this that the patients should be free from spermatic discharges. If the abscesses of the epididymis open ex- ternally we can understand that the semen will escape immediately through this rupture of the excretory canal, and that in this way a true spermatic fistula is formed ; and should this take place on both sides, it is clear that the patients would be exposed to the same phenomena as if they were affected by spermatorrhoea. If the obliteration of the excretory canal be not followed by rup- ture, it is probable that the secreting organ after having been a long time distended, swollen and painful, will in the end diminish by de- grees, and will become completely atrophied, as happens to other glands under the same circumstances. Thus certain cases of atrophy of the testicles, after very long and painful swelling of them, may be accounted for. When the vasa deferentia are felt hard and knotty there can be no doubt as to the cause of this atrophy; but sometimes the alteration takes place in parts where manual examination is impossible, and in these cases the state of the prostate will be likely to furnish important information; when it is found irregular, swollen, and*enlarged, the atrophy of the testicles must be regarded as the consequence of pres- sure on the ejaculatory ducts. In an officer whose case I treated, the testicles were not larger than those of a child of six years ; the patient had experienced a continued dull pain in them for a long time ; the prostate was much altered; his moral faculties had experienced the same changes that occur in cases of spermatorrhoea, but the physical man was not much weakened ; the reason of this is evident. Chronic atrophy of the testicles, following more or less acute pain in them, is by no means rare ; these pains are usually considered nervous, and the insensible wasting which follows them has not been as yet satisfactorily explained. All the patients of this kind whom I have had an opportunity of observing, had suffered previously from blen- norrhagia, of which I am convinced this atrophy was the distant but direct result. We often find the vasa deferentia thickened, hardened, cartilagi- nous, Or even quite ossified, in patients who have had orchitis. These cases confirm what I have stated respecting the mode of transmission SPERMATIC ORGANS. 49 of inflammation from the urethra to the testicles, for all these shades of induration are so many results of inflammatory action. Testicles.—Every surgeon knows how slowly enlargement of the epididymis and corpus Highmorianum, following orchitis, is dispersed. This fact alone is sufficient to prove that it is by the vas deferens that the inflammation reaches the testicles, because it is by means of the corpora Highmoriana that the secretory tubes open into the ex- cretory ducts. It is not then surprising that this part of the testicle should be the one most seriously altered, and often even the only one affected. Purulent collections formed in the testicle are not able, like those in the organs we have already considered, to empty themselves by the excretory canals, and the fibrous envelope which encloses the secretory vessels is very resistant; it must, therefore, often happen that slight and very circumscribed inflammations are arrested before suppuration has been able to appear externally. If in these cases complete absorption do not take place rapidly, the thicker part of the pus may form tubercles, the presence of which will in its turn, be a cause of new inflammation, and the vessels secreting the semen may, like the follicles of the prostate, be destroyed by degrees, so that the gland may become reduced to its envelope only. Other products besides pus may be formed in the cellular tissue of the testicle ; when the inflammation is slight but of long duration, or frequently recurring, a gelatino-albuminous matter is deposited which thickens and becomes a source of organic alterations like those in the prostate, and the first cause of these also may be usually traced to long neglected chronic affections of the urethra. I have attached much importance to the thorough understanding the mode of transmission of inflammation from the urethra to the tes- ticles, because the establishment of this point explains in the most simple way why the presence of a sound in the urethra, or the exist- ence of a stricture, so often excites congestion antLjnflammation of those organs, and even in some cases the development of hydrocele, as well as why the removal of the cause suffices generally to make the effect cease. The conciliation of all these circumstances is especially of impor- tance to the study of spermatorrhoea; and the intimate connexion of th# urethra with the testicles by means of the vasa deferentia should suffice to forewTarn us of the influence, which the condition of the mucous membrane surrounding the orifices of the ejaculatory ducts, must exercise on the secretion and expulsion of semen. Urinary Organs.—Analogous phenomena present themselves in the organs secreting and excreting the urine. The inflammation extends from the urethra to the kidneys by means of the bladder, and ureters; it is even easy to trace its progress, without interruption ; hence the violet coloured spots of congestion, the ecchymoses, and even ulce- ration of the mucous membrane lining these organs ; hence the swell- ing and injection of the kidneys; hence the abscesses of all sizes and 5 50 INFLAMMATION OF THE of all stages, encysted and non-encysted, and mixed with crude or suppurating tubercles, which have been found in the kidneys. As a sequel to these successive attacks of inflammation I have seen the tissue of the kidney destroyed like that of the prostate or of the testicle ; almost reduced, in fact, to its external fibrous envelope. There is then an exact similitude between these two classes of or- gans, and if the kidneys could be as easily examined as the testicles this resemblance would appear still more strikingly. Comparison of the two sets of Organs.—We often see after expo- sure to cold or excessive drinking, a blennorrhagia diminish or cease entirely, and the patient experience at the same time violent and deep- seated pain in the loins : the urine is scanty, high coloured, and some- times even bloody. If in these cases we could examine the kidneys as we do the testicles, we should,perhaps, find that attacks of nephri- tis following blennorhagia are nearly as frequent as those of orchitis. I am convinced that, in the cases I have seen, alterations of the kid- neys have been more frequent than those of the testicles. It is not only as a sequel to blennorrhagia or stricture that nephritis takes place, every inflammation of the urinary canals may extend to the kidneys ; and this is why acute or chronic cystitis, and the presence of stone in the bladder, are such common causes of inflammation of these organs ; this is why the kidneys are so often found disorganized when the bladder has been long irritated by the presence of extraneous matters, or by repeated attacks of retention of urine. I believe I have now more than sufficiently shown how easily acute inflammation of the urethra extends to the secreting organs of the semen and urine, by means of their excretory ducts, I have compared together the phenomena that occur in both classes of functions, be- cause they are presented at the same time, in very nearly the same degree, and with analogous characters. But this resemblance is not observed in cases of acute inflammation only; it is more easily shown in these cases,£pd on this account I have commenced with their con- sideration. Similar phenomena are, however, observed under the influence of less active causes. When the bladder is irrigated the secretion of urine is increased in quantity and altered in quality ; and at the same time that it becomes more abundant and more watery, it remains a shorter time in the bladder: the desire of micturition is felt oftener and more suddenly; however the patient may wish to retain the excretion, the sensation is so painful, and the bladder contracts so violently, that the urine is often expelled in spite of every effort, and before the patient has had time to prepare himself for its discharge. The fluid is passed each time in small quantity, the jet is short and feeble, and falls within a little distance of the patient's feet; should this state continue any length of time the muscular coat of the bladder becomes more de- veloped, the parietes of the organ are thickened, and its capacity di- minishes in the same proportion. Those who have noticed the coin- cidence of this limpidity of the urine with its frequent expulsion, have SPERMATIC ORGANS. 51 concluded that the more watery the fluid secreted the more it irritates the mucous membrane. But it is impossible for us to admit that the urine should irritate the bladder most when it contains least salts in solution. It is evident that the effect has here been mistaken for the cause. It is because the bladder is irritable that it cannot longer bear the presence of the urine, and this fluid is more watery, because the irritable kidneys secrete it in greater quantity, and it remains a shorter time in the bladder; that this view is correct, is proved by the vesical mucous membrane, when it possesses its normal sensibility, sub- mittting for a long time to the presence of a large quantity of watery urine, as occurs daily after meals. If this irritation be prolonged, it may produce in the end a kind of relaxation of the secreting vessels, and degenerate into diabetes. The urine entirely loses its chemical characters; the urea and uric acids are replaced by a saccharine matter, and the system wastes in con- sequence of furnishing so superabundant a secretion. Exactly the same phenomena are observed in the spermatic organs when they are submitted to the influence of a similar irritation ; the testicles secrete an increased quantity of semen because they are irri- tated, and their secretion is more watery because it is less perfectly formed, and remains a shorter time in its reservoirs before expulsion; it is more rapidly expelled because the seminal vesicles are more sensitive to the impression produced by its presence, and are more readily excited to action. The spasmodic contractions of which these organs become the seat, commence by producing ejaculation very rapidly either during sexual intercourse or after erotic dreams; this renders coitus rapid and in- complete, and nocturnal pollutions very frequent; afterwards, the weakness and irritability are increased, the semen becomes more abundant, and still more fluid, and the convulsive contractions of the seminal vesicles are more frequent; during this state the approach of a female, or even a lascivious idea may suffice to ex-eite ejaculation ; but the semen is no longer projected with energy, erection is never complete, and scarcely any sensation accompanies emission. These injurious contractions are at last excited even by still less distinct causes; the patients feel them come on when least expected, they dread their consequences and still they are quite unable to pre- vent them. Lastly, there are cases in which the debility of the genital organs is such that a true spermatic diabetes may be said to be pre- sent, as well by the quantity and quality of the secreted fluid as by the frequency of its emission. We have been unable to make the same chemical experiments on the altered semen that have been made on the urine of diabetic patients ; but the semen in such cases contains no more spermatozoa than the urine does urea. Let it not be thought that this statement is founded only on analogy; the fact really exists in practice. I have at this moment a patient under ray care, who is dying, worn out by the effect of diabetes with diurnal pollutions of the same nature. • 52 INFLAMMATION OF THE Here then we have from the action of the same causes, the kid- neys, testicles, bladder, and seminal vesicles affected in the same manner, and producing analogous results; and further, these affec- tions seldom occur singly ; thus, in stricture, the urinary passages are, indeed, chiefly affected, but I have seen cases in which the spermatic organs have been almost as much disordered ; it is not inflammation alone which may extend in both these directions, but even a simple irritation of the urethral mucous membrane. Diurnal pollutions are too little understood to have been generally noticed in these cases: they are always obscure, and the attention is fixed usually on another object; but.I have so often satisfied myself of their presence as a sequel to strictures, that I regard spermatorrhoea as the true cause of all the cases of hypochondriasis, ischuria, and debility, which are attributed to affections of the urinary organs. This position, is, I think proved by the weakness and rare occurrence of erection, the rapidity of ejaculation, and the increased fluidity of the semen observed in most of these patients. Cases of diurnal pollution uncomplicated with chronic catarrh or irritation of the bladder are somewhat rare: and this often renders diagnosis difficult, not only on account of the symptoms of catarrh being present, but also on account of the mucous secreted by the bladder and prostate. On this account when I see the urine cloudy, I always inquire respecting diurnal pollutions, so that I may not con- found mucus with semen. It is very remarkable also, that those who give themselves up to venereal excesses or masturbation, frequently experience a desire to micturate ; this fact gave rise to the saying of the ancients, " raro mingitur castus." I have ever been struck by the truth of this axiom ; and the fact proves how easily the urinary organs share the excitement of the spermatic. Another very important circumstance in the history of diurnal pol- lutions proves how correct is the analogy I have established between irritation of the bladder and that of the seminal vesicles. It is almost always at the end of the emission of urine that the semen escapes ; the bladder then contracts forcibly to expel the last drops of urine, and the seminal vesicles also enter into action, and expel with the urine a greater or less quantity of their contents. It has been wrong to attribute this viscid discharge to the prostate, because it does not present all the qualities of ordinary semen ; the evacuation is sometimes very abundant, and that it is semen, cannot, in these cases, be mistaken. Besides this, when the patients have their attention called to the circumstance, they know very well how to estimate the contractions of the seminal vesicles, which are even in general proportion to the extent of the evacuation. Most patients remark also that when they are threatened with a relapse, it is preceded by a more frequent and very sudden desire to micturate, whether this increased sensibility of the bladder arise from cold or from an excess either of drink or of coitus. This proves that the same -causes act at once on both sets of organs. • SPERMATIC ORGANS. 53 Persons affected by diurnal pollutions experience, generally, very injurious effects from the use of diuretics. Nearly all those who have taken squills, nitrate of potass, digitalis, &c, have noticed during their use a remarkable increase of the seminal evacuations, and a few, after having been cured during a longer or shorter period, have ex- perienced relapses which could not be attributed to any other cause, and which have spontaneously passed off" as soon as they have re- linquished the use of these medicines. It is also well worthy of notice that children subject to incontinence of urine, are particularly liable to nocturnal pollutions at the age of puberty; and at a later period, to diurnal pollutions. Lastly, I cannot conclude this parallel of the two sets of organs without mentioning that obliteration of the spermatic excretory ducts may be followed by the formation of spermatic fistulae, in the same manner that strictures of the urethra give rise to urinary fistula?. To resume:—All the mucous surfaces of the genito-urinary organs have the greatest analogy and the most intimate connexion with one another. It is by them that inflammation creeps by degrees to the secreting organs of the urine and of the semen. The portion of this membrane which lines the prostate, being in intimate connexion with that of the mucous follicles, with that of the ejaculatory ducts, and with that of the bladder—this portion then is the one, the different conditions of which have most effect on all the rest. This connexion takes place by means of the lining membrane of the ducts ; and is by no means to be considered the result of sympathy, such as exists be- tween the uterus and breasts. The excretory canal transmitting the inflammation, must neces- sarily share its influence. The seminal ducts and vesicles, then, cannot remain unaflected by the action they transmit to the testicles and this is an important consideration when-we recollect that these are as much the acting organs in the emission of semen, as the blad- der is the organ for the expulsion of urine. We shall often find it necessary to apply these facts to the study and treatment of diurnal pollutions, and in passing, it is as well to notice, that the influence of the excretory canals on the secreting organs is not an isolated phenomenon occurring only in the kidneys and testicles, but that it is the result of a general law, applicable to all glands. Suction excites the secretion of milk and changes its qualities; the first drops drawn from the nipple are watery, and the milk afterwards becomes more abundant and better formed in proportion as the suction continues. The introduction of extraneous bodies between the eyelids increases the lachrymal secretion, which some- times even is so changed, that it irritates and excoriates the skin of the cheeks. The presence of food in the mouth, especially when spiced and savoury, increases the secretion of the salivary glands. During digestion the liver and pancreas are excited; and the 54 CAUSES OF action of emetics and purgatives produces the same effects. The ejaculatory ducts open on the surface of the prostatic mucous mem- brane ; is then, the important part this membrane plays in the pro- duction of spermatorrhoea, a cause for wonder ? CHAPTER III. CAUSES OF SPERMATORRHOEA. Blennorrhagia. The first case of diurnal pollutions which I had occasion to treat occurred in a student of medicine, twenty years of age, who studied his disease with much care, and described its causes and symptoms with remarkable perspicuity. The following are the facts:— CASE V. Lymphatic temptrament—Blennorrhagia— Orchitis—Nephritis—Noctur- nal and diurnal pollutions—Abuse of mercurials—Injurious effects of cold and tonics—Cure by means of leeches, the use of flannel, and milk diet—Fresh attack of Blennorrhagia— Same treatment with the same result. M. N----, of lymphatic temperament, tall and thin, with a pale face, red hair, white, and habitually cold skin, narrow chest, and soft feeble voice, had never suffered from any diseases except those about to be described. In January, 1821, M. N---- contracted blennorrhagia which was treated by emollient drinks, general baths, and corrosive sublimate. In the month of April, several doses of Chopart's* mixture were taken and arrested the discharge, after a duration of four months. Six weeks afterwards he con- tracted a second blennorrhagia, and in September, swelling of the left tes- ticle occurred after horse exercise. This swelling was in a great measure dispersed, but a flaccid state of the scrotum remained, causing painful drag- ging pains in the spermatic cords, which were relieved, however, by the use of a suspensory bandage. At the commencement of 1822, the dis- charge still continuing, local astringents and mercurial frictions were em- ployed, with iodide of potassium and bichloride of mercury internally. * The following is the composition of Chopart's mixture :— Jjfc Balsam copaib., Alcoholis, sp. gr. 33°, Syrupi simplicis, Aq. menth. pip., Aq. flor. aurant., aa partes sexaginta, Sp. rather, nitr. partes octo; M. ft. mist cujus cochlear, minim, unum nocte maneque sumerfH. SPERMATORRHOEA. 55 Under this treatment the discharge diminished, but did not entirely disap- pear. Whilst taking these remedies, M. N----was exposed to severe cold. Cutaneous exhalation was suppressed, and pafti in the loins supervened. This was generally of a dull character, but was rendered acute on the least exposure to cold; about the same period M. N----'s digestion be- came impaired. He attributed this to weakness of the stomach, and sought to stimulate the organ by a generous diet, and by the use of rhubarb and wine. These means, however, only increased his disorder, and, about the month of June, 1822, it became very serious. As soon as food reached the stomach he felt an oppression at the praecordia, with difficulty of breath- ing, general lassitude, and sometimes a desire to vomit; his tongue was white and pasty; his bowels constantly distended with flatus, and he suf- fered from obstinate constipation, with occasionally, slight fainting fits; he was quite unable to fix his attention on any subject requiring mental exertion. Although without appetite, he forced himself to eat to keep up his strength, but his digestion became more difficult, and he felt himself much overcome by lassitude after meals. He endeavoured to assist digestion by the use of coffee, and with the same view he bathed every morning in cold water ; he was, however, unable to remain immersed more than a quarter of an hour at a time without shaking in all his limbs; no re-action took place after- wards, and he always remained a long time before he was able to regain a comfortable degree of warmth. He obtained relief from eating ices, how- ever, and took them frequently. A slight urethral discharge still continued, and on waking in the morn- ing he perceived a viscid pearly matter at the orifice of the glans. Part of this matter, remaining in the canal, was expelled with the urine, and re- mained suspended in the fluid like a cloud, which after some time was deposited on the bottom of the utensil. Towards the close of the year 1822, when the cold weather commenced, his bad symptoms increased; he became sad and absent, was unsettled, without fixed motives, and very timid. He became shivered on the least exposure to cold, the rigour commencing in the lower extremities, and ex- tending over the Whole body. He suffered severe pains in the loins, and passed urine frequently, and he now had difficulty in expelling the last drops, which were viscid and always partly passed on his shirt. He no longer had erections or sexual impulse. He often passed semen during sleep, without lascivious dreams or any turgidity of the penis, and he con- stantly felt an irresistible drowsiness. Towards the commencement of 1823 he perceived an abundant reddish sediment in his urine. About the end of February his state had become deplorable; he then ap- plied to me, and I ordered the following treatment,—twelve leeches to the anus, cold lotions to be applied to the scrotum and perineum three times a day, iced milk, flannel next the skin, very little wine to be taken with his meals, and, after a short time, complete abstinence from all fermented liquors. A few days after he felt a remarkable change; his digestion was performed better; the pain in his loins and the lassitude disappeared. He became less sad, less timid, and he applied himself to study with ardour; his genital organs acquired energy, and he threw aside his suspensory bandage; his urine no longer deposited a sediment, and erections re-appeared. Leeches were applied a second time, fifteen days after the first, and he continued 56 CAUSES OF the remainder of the treatment for two months. By that time—about the end of April—his health wa's re-established, and the warmth of summer proved sufficient to confirm it. In the month of July, 1823, however, he contracted a third blennorrhagia which did not affect his general health. A month after its appearance it was treated successfully by means of leeches and small doses of copaiba: but when he took the latter in too large quan- tities, he suffered acute pain in the loins. Sea bathing during the month of September contributed much to strengthen his genital organs. M. N---- was afterwards appointed, by concours, senior surgeon to a very important hospital, which proves that he was able to apply himself, after his recovery, to severe study. I have since seen him several times, and have learnt that his health continues excellent, but that he is obliged to guard carefully against the effects of cold, and against every over excitement of the diges- tive organs. He finds it necessary every winter to return to milk, with mild and light food, and to drink water with his meals. This patient while suffering under blennorrhagia used horse exer- cise ; soon afterwards orchitis occurred; painful dragging sensations were experienced in the spermatic cords, even a long time after the abatement of the inflammation. It was then by the vas deferens that the inflammation was transmitted from the mucous membrane of the urethra to the testicle. A short time after, from exposure to cold, perspiration became suppressed, and pain in the loins was experi- enced. This pain was probably situated in the secreting organs of the urine ; since, simultaneously, its emission became very frequent, the last drops were expelled with difficulty, and its composition was much altered. The inflammation then extended by means of the bladder from the urethra to the kidneys, in the same manner that it extended by the vasa deferentia to the testicles. The urine deposited an abundant gravelly sediment, and at the same time contained semen in suspension. The bladder had become more sensitive to the presence of urine, for the desire to empty it was often and very suddenly renewed. The seminal vesicles were exactly in the same condition, and the semen was passed without erection during sleep; in addition to which, the contractions of the bladder necessary for the expulsion of the last drops of urine caused contrac- tions in the seminal vesicles, and the fluid expelled was viscid and glairy. Both classes of symptoms ceased, re-appeared, and were cured at the same time; and they were evidently due to a state of inflammation, for the antiphlogistic treatment was the only one that succeeded in removing them. The injurious effects of cold were very evident in the case of M. N-----, and may be attributed partly to his lymphatic temperament; but we often find analogous phenomena in patients of a very different constitution. However this may be, I am convinced that without the habitual use of flannel next his skin, M. N-----would not have been able to preserve himself from further relapses, or permanently to strengthen his constitution. M. N----had undergone several courses of anti-venereal treat- SPERMATORRHOEA. 57 ment, although he had only suffered from blennorrhagia, and the effects of mercury were very injurious to him, as his constitution was little fitted to withstand its action. He fell also into other very com- mon errors, which are the ordinary result of an almost universal false reasoning on the part of the sick. Perceiving that he lost flesh, he eat heartily, and chose the most nutritious kinds of food: digestion being performed badly, and accompanied with the development of flatus, because the stomach shared the general weakness, he had re- course to rhubarb, generous wines, and spices. Hence frequently arise the attacks of chronic gastritis, which so constantly accompany old cases of spermatorrhoea. M. N----'s intellectual functions were weak in common with the rest; he was habitually drowsy, and he took coffee and tea to rouse himself. At length M. N-----, like many other practitioners, began to treat symptoms, and allowed himself to be influenced by the names given to medicines: his urine was thick, deposited a sediment, and was passed with difficulty; he took nitrate of potass as a diuretic, without reflecting that the increase of secretion which this medicine produces, is the result of excitement of the urinary organs, and that his were already too much irritated. His bowels being constipated, he took purgatives without seeking the cause of constipation, and without troubling himself about the effect which irritation of the rectum pro- duces on the bladder, the prostate, and the seminal vesicles. These are errors of daily occurrence. The abuse of cold in cases of nocturnal and diurnal pollutions is very common. By bathing in the river, M. N-----followed the ad- vice laid down by all writers on the Subject: it proved injurious to him, however, because the genito-urinary mucous membranes were too irritable not to receive a hurtful shock from immersion in cold water. The patient should have foreseen this result from the bad effects cold had always produced on him; besides this he was too weak to obtain a proper degree of re-action after bathing. I shall show by and by that cold baths employed without distinction in cases of spermatorrhoea, have done much more harm than good. Still the patient found that sea-bathing at a later period gave tone to his geni- tal organs, and he was unable to reconcile two effects of so opposite a nature ; yet nothing is more simple. When he took sea-baths he was cured; the irritation of the organs had passed off, and their normal condition had returned ; the first shock of the cold then was no longer injurious, and the consecutive re-action followed rapidly. It is true that considerable difference exists between sea and river bathing; but it is chiefly to the different states of the system that the two very op- posite effects of cold on this patient must be referred. From not having attended to this important distinction, general di- rections have been given respecting the use of these powerful agents,— directions which daily lead to the most disastrous results. 58 CAUSES OF CASE VI. Masturbation—Blennorrhagia—Diurnal pollutions—Failure of the ordi- nary modes of treatment—Cauterization of the prostatic portion of the urethra—Rapid recovery. Alexis Poit, aet. 20, short, stout, and of a sanguineous constitution, ap- plied at the Hotel Dieu, Montpellier, to be cured of a venereal taint, which, he said, existed in his system, in consequence of an attack of blennorrha- gia contracted three months previously, and cured in a few days by the simple use of dandelion tea. Nothing in the appearance of the patient confirmed this statement. He complained however of violent pain in his head, pain in his bones, frequent spasmodic tremors in his limbs, and a constant agitation which prevented his enjoying an instant's sleep; of stunning sensations and vertigo, with ringing in his ears; of a sense of suffocation with palpitation of the heart, and of itching in the skin: his eyes were injected, dry, and very sensitive to the impression of light. Out of all his symptoms, the ossific pain was the only one that could fa- vour the idea of a venereal taint; the patient said that he suffered most during the night, but his answers were very obscure and often contradic- tory. His skin however was hot and dry, and covered with pimples. I prescribed for him venesection, baths, and refrigerant drinks. The next and following days, discharges occurred, and he seemed still more satisfied that he laboured under a syphilitic taint. His constitution seemed strong, and his appearance proclaimed health. I thought there- fore, at first, that he had some motive for feigning various diseases, but as he did not eat, and seemed inclined to submit to moxas and other means of the same nature, I observed him more closely. The pupils looked on him as a hypochondriac or §, mSniac, because he complained of a fixed pain in the hypogastrium, although his tongue was neither red nor dry; and be- cause he said he heard a continual noise in his belly, and felt a hand of iron pressing on his intestines for several hours together, and then relaxing them suddenly. When this oppression came on, he felt something ascending from the epi- gastrium that almost suffocated him, and ceased suddenly on his passing flatus. He was habitually costive, his faeces were very offensive. He passed water very often, and complained of pain in the penis and bladder during micturition ; this he attributed to the suppression of the blennorrhagic discharge. Twelve leeches were ordered to the anus, with general baths, which relieved the pains in the bladder and penis. I advised the patient to get up and take exercise, but he pretended that his legs were unable to support him, and he spent all his time with his head under the bed-clothes, groaning and sighing. Having observed many of these symptoms in persons suffering from spermatorrhoea, I questioned Poit on this subject; but he had never noticed any discharge resembling semen, either while passing urine or faeces. He had never had intercourse with any female, except her from whom he had contracted blennorrhagia, and with her very rarely, and at very distant intervals. From the way he deplored the moment of folly to which he owed his SPERMATORRHOEA. 59 sufferings, I suspected that he had been addicted to masturbation; he denied it obstinately, however, before the pupils, but told me privately, that he had practised it from the age of ten, even five or six times a day; at first he ex- perienced a very lively tickling sensation, accompanied by discharge, and soon changing into a painful sense of burning. About the age of twelve, having perceived that these injurious practices injured his health, he became more careful; but about fourteen, he again gave himself up to the vice al- most madly. The irritation was now often carried so far as to produce pain; the veins of the spermatic cords swelled, and there existed in his whole body, especially in his loins and joints, a sense of debility attended by ob- tuse pain. He had continual vertigo, with noise in his ears, and his memory became impaired. From sixteen to eighteen he restrained himself by de- grees, and regained his strength and stoutness. At this time he first had sexual intercourse, soon after which, blennorrhagia came on. I requested the patient to preserve his urine, and to notice carefully what passed from the penis when he was at stool. I found the urine red, thick, and muddy, with a flaky cloud suspended in it; the sides of the vessel were lined by a brick-dust-like powder, and a glairy and tenacious sediment was adhered to its bottom. The patient noticed that the last drops of urine were thick and viscid, and were passed with sudden and involuntary con- tractions of the bladder. After passing faeces he found a thick, granular, and transparent matter at the orifice of the urethra. I prescribed for him milk three times a day, taken as cold as possible, and mixed with Eau de Spa or lime water; a vegetable diet; two cold hip baths daily, each of a quarter of an hour's duration; and a cold enema night and morning, to facilitate the passage of the faeces. These means, which I had seen recommended by Wickman and Saint Marie and which had succeeded in other cases, did not produce any im- provement in this. The patient became more restless and hypochondria- cal, and did not sleep an hour during the night. Emollients and leeches relieved his pain,but at the same time relaxed his system; he suffered less, but he passed much more semen. Tonics and cold diminished for a time the seminal discharge, but they increased the pain and irritation. After about three weeks of these fruitless essays, I gave up general means altogether, and as I was convinced that the spermatorrhoea arose from a state of chronic inflammation of the prostatic mucous membrane, the irrita- tion of which extended to the ejaculatory ducts and seminal vesicles, I con- sidered that by removing this state of the membrane by means of cauteri- zation, I should put an end to the irritation of the spermatic organs, and especially to the spasmodic contractions of the seminal vesicles. The beneficial effects which 1 had obtained from the use of nitrate of silver in analogous cases of irritation, made me littte dread the danger said to be attached to cauterization of the prostatic portion of the urethra, on account of its vicinity to the bladder. In order to empty the bladder, and to take the exact length of the urethra, I was obliged to introduce a catheter, which had scarcely entered an inch or two into the canal, when violent spasmodic contractions commenced, which prevented it from advancing, and almost made me suspect the existence of stricture; after a few seconds these spasms ceased, and the catheter passed as far as the neck of the bladder. Here the pain and spasms were redoubled, and the bladder seemed perfectly closed. At length, after a considerable time, I was enabled to introduce the point of the catheter 60 CAUSES OF into the neck of the bladder, and the instrument was immediately power- fully drawn into the vesical cavity, as though by a kind of suction. When untouched, the catheter was several timevS suddenly attracted and repelled alternately, by the convulsive action of the muscles of the perineum and bladder; and its extraction was almost as painful and difficult as its intro- duction had been, so firmly was it held by the neck of the bladder. The vesical contents were rapidly and forcibly discharged. All these circumstances confirmed me in the diagnosis I had formed re- specting the cause of the disease, and I immediately applied the solid nitrate of silver to the prostatic portion of the urethra. The application was rapid —lasting only long enough to incline the caustic to the right and left, so as to make it pass quickly over the inferior surface of the canal. During the first twenty-four hours, the patient suffered much while pass- ing urine. On the second day, the pain was much less severe, and on the third day, it was scarcely worth notice. During these three days, the urine was thick and muddy, and the last drops were streaked with blood. After this time it became transparent, and the patient was able to retain it much longer. Twelve days after the cauterization, the urine was quite normal, without either deposit or cloud—the last drops were expelled easily, and were as transparent as the first. The patient no longer experienced tension or un- easiness in the perineum, or involuntary contractions of the neck of the bladder; but when his bowels were confined,he still noticed a viscid matter at the orifice of the urethra. The first improvement noticed was in his sleep, which became sounder and longer; then the moral and physical man became more energetic; and lastly, the activity of the digestive organs returned. Within fifteen days erections re-appeared, and after some time the patient experienced noctur- nal pollutions, preceded by erotic dreams, and accompanied with lively sensations. The intellectual powers were the last to be entirely re-esta- blished ; but they did not appear to have ever been very active in this patient. At the expiration of a month, his health was quite perfect, and he wished to resume his former occupation. This patient was the first on whom I practised cauterization as a remedy for spermatorrhoea ; and I have related his case chiefly to show the active and painful contractions of the neck of the bladder and urethra which occur in such cases. These facts may give an idea of the extreme state of irritation of the urethral mucous lining, and of the influence which this condition must exercise over the seminal vesicles. The phenomena above described are very often observed in patients affected by spermatorrhoea, their study is therefore important in de- ciding on its treatment—thus, for example, I have noticed that the greater the state of irritation the more certain are the effects of cau- terization; in these cases also, tonics, ice, and cold hip baths, are by no means proper. In the case I have just related spermatorrhoea was, without doubt caused by the blennorrhagia, but the excessive mas- turbation to which the patient had been addicted, even before puberty SPERMATORRHOEA. 61 must have contributed much to produce this unfortunate disease, and, probably, from this circumstance it arose that a cure was impossible by the employment of the usual simple means. CASE VII. Abuse of spirituous liquors—Blennorrhagia—Nocturnal pollutions~-Im« potency—Frequent discharge of urine—Cauterization—Cure. J. D----at an early age accustomed himself to an excess of alcoholic drinks, but in other respects was remarkably abstemious ; at the age of twenty he contracted blennorrhagia which disappeared of its own accord at the end of about thrqe weeks. A short time after he noticed that noc- turnal pollutions occurred very frequently, sometimes happening eight or ten nights consecutively. The day following these discharges D----was depressed in spirits and suffered from headach, noise in the ears, and dazzling before the eyes; these symptoms induced him to submit to vene- section three times, and to apply leeches to the temples, after which D---- entirely lost all virile power. After the disappearance of the blennorrhagia a yellowish discharge from the anus came oh several times, and'was accompanied with a very trouble- some itching. Soon after this the patient had a tetter on the face, for which he took alteratives and mercurials. The skin disease disappeared but symptoms of irritation of the bladder supervened. In 1824, D----, aged twenty-four, came to the hospital of St. E!oi, in the following state. He was of the middle height, and well made, his skin was pale, his hair black, his face very red, his manner gloomy and taciturn ; he was fond of solitude, showed perfect indifference towards women, and great horror of masturbation. His intellect was dull, his digestion painful, and his limbs weak. He passed urine two or three times an hour during the day and five or six times in the course of the night, attended by scald- ing and pain in the canal. The introduction of a silver catheter of moderate size excited spasmodic contraction and acute pain in the neck of the bladder, which induced me to propose cauterization to the patient: he agreed to it without hesitation, and I performed it immediately. I introduced the caustic holder into the bladder so as to cauterize the parts near its neck, and I passed the caustic over the prostatic surface as well as over the membranous portion of the urethra in withdrawing it. Immediately afterwards there was a pressing desire to micturate, and blood passed with the urine. Baths and barley water were ordered. During the following night he experienced a painful seminal emission; he passed urine only once, but with an acutely burning pain. On the following day the patient only passed urine four times, but always with burning and a slight discharge of blood. On the third day he no longer passed any blood, and the scalding was very slight. On the fourth day the emission of urine took place every three or four hours only, and the discharge arising from the cauterization had ceased. On the following days emptying the bladder was performed less and less frequently; seminal discharge no longer followed; the patient regained his 6 62 CAUSES OF spirits; his health became perfectly re-established, and about the fifteenth day after the cauterization he left the hospital. In this patient the blennorrhagia had not been preceded by exces- sive sexual intercourse or masturbation; but the abuse of alcoholic stimulants is almost as pernicious in its effects on the genito-urinary organs : besides this he possessed a strumous habit, which showed it- self by the tetter on the face and the abscess at the margin of the anus. It is, especially in cases of this kind, that tonics, ice, and cold bathing fail, and are even injurious; happily, we possess a powerful remedy in cauterization. In this case the tetter on the face having disappeared, inflammation of the vesical mucous membrane occurred; this was very intense, the patient passing urine two or three times in the hour; from this time the urinary symptoms predominated, on which account catheterism was accompanied with acute pain in the prostatic region, and spas- modic contractions of the neck of the bladder. Not long since cauterization of the prostatic portion of the urethra was looked on as the extreme of rashness, so much was the introduc- tion of the least particle of the nitrate of silver into the bladder dread- ed ; although these fears were only founded on argument, they were generally received and seemed so natural that I was influenced by them for several years. I have stated in another place the means by which I shook off these foolish fears, and the successful results that have followed the application of the nitrate of silver to the mucous membrane of the bladder in catarrhal affections of that organ.* Since that time, whenever I meet with cases in which the affection of the prostatic mucous membrane extends to that of the bladder, I begin by cauterizing the latter, and I continue the application as far as the bulb of the urethra whilst withdrawing the instrument, by inclining it rapidly to the right and left. It is not to take the length of the canal that I introduce a catheter in these cases, but in order to empty the bladder completely, so that the nitrate of silver may act with more energy. We have just seen the effect of this treatment: a patient who previously passed urine two or three times in the hour was ena- bled to retain the excretion as long as is usual, and at the same time the spermatorrhoea from which he suffered was cured. This case also confirms in a remarkable manner what I have above stated respecting the relations that exist between the diseases of the urinary, and those of the spermatic, organs. * Vide Lejjons de Clinique, &c. SPERMATORRHOEA. 63 CASE VIII. Masturbation—Blennorrhagia, repeated anti-venereal treatment—Diurnal pollutions—Increasing weakness, especially of the mental faculties— Extreme emaciation—Cauterization, and cure after sixteen years. Venereal excesses, relapse—Cauterization again performed with success. M. V----, of spare habit and nervous temperament, was addicted to mas- turbation about the age of puberty, but abstained when he perceived his health affected. He again practised it as soon as his strength began to re- turn, and renounced it as soon as he perceived his health endangered. He again regained his strength and applied himself with diligence and success to the study of law. At the age of eighteen he contracted blennorrhagia, which was treated during six months with injections of acetate of lead, sulphate of copper, &c. The discharge disappeared after a journey on horseback—again came on soon after, and again stopped. Urethral discharge was afterwards often excited by very slight causes. Independently of tonics, injections, and astringents, which were pre- scribed for this patient without the least discretion, bichloride of mercury, mercurial pills, sarsaparilla, and friction with mercurial ointment, were re- commended. His health became more and more disordered; he was sub- ject to headach and pains in his limbs and loins, accompanied with debility, loss of sleep, and frequent attacks of fainting. M. V----attributed all these symptoms to the presence of a venereal virus in his system, and as they increased several times after sexual inter- course, he was persuaded that he had on each occasion received fresh in- fection. At length the care of his health became quite a kind of monomania. He abandoned the career he had followed for eight years, and came to Montpellier to study medicine for the sole purpose of arriving at the cause of his complaint, and finding a remedy for it. Returning always to the idea of a syphilitic virus, he submitted himself successively to all the anti- syphilitic modes of treatment he could discover recommended by authors, arfri combined them together in various ways. Still, however, his strength diminished by degrees; his digestion became painful and laborious; and he was annoyed by flatus and obstinate consti- pation, which he combated by the frequent use of purgatives. His intel- lect became so far weakened that he could not fix his attention during a lecture, and soon even he became unable to comprehend what he read. He attended the courses of the faculty, but he was unable to remain during half a lecture without experiencing fatigue and impatience: his head became congested, and he felt a constant desire to change his position, or to walk. Though formerly competent to argue with pleasure on the most abstract propositions, he was now unable to follow the simplest reasoning; and the most recent and important facts escaped his recollection. He was tor- mented by attacks of vertigo, loss of sight, and noise in the ears. The least intellectual excitement induced fits of heat in the head; and slight con- gestions were often excited by the digestive process, by flatulence, or by efforts at stool. The patient having his mind continually occupied by th^se symptoms at 64 CAUSES OF length persuaded himself that part of his cerebral substance had been absorbed, and that his cranium only contained the nerves of sense; he thought he could feel these bathed in serum, and he was obstinately of opinion that he was threatened with an attack of apoplexy. On the other hand his character became sad, variable, and unsociable; he disliked music of which he had previously been passionately fond; he slighted all his friends, and his misanthropy became so great that when he saw an acquaintance in the street he turned on his heel in order to avoid him. Tormented by a constant desire for motion, he was unable to remain long in the same place; and this restlessness, together with his love of soli- tude, made him wander constantly in all the by-ways of the neighbourhood of Montpellier. He was careless of every thing, and often in distress from having neglected his affairs. At length, after remaining seven years at Montpellier, M. V-----came to consult me. From the first words he said to me I suspected that he suffered from diurnal pollutions, and I questioned him closely on this head; but he had never noticed spermatic discharges either whilst passing urine, or faeces, and he persisted in the opinion that his disorder arose from a vene- real virus still existing in his system. A short time afterwards, to relieve an attack of cerebral congestion, he applied leeches to the anus, and was unable to leave his bed for three months. The observations he made during this period convinced him that my di- agnosis was correct, but he still wished to treat himself, and among other ' means, placed pounded camphor between the glans penis and prepuce, in order to act directly on the genital organs: a few hours after ongoing to stool, he passed a large quantity of semen, fainted, and remained some time before he was able to call assistance. I never witnessed a more repulsive sight than that I saw on reaching M. V—'s residence; the disorder and dirt that surrounded him evinced the most perfect carelessness. Muddy urine, of a fetid smell, filled a dirty ves- sel placed near the head of his bed on a chair covered with dust and clothes. He was extremely pale, and greatly emaciated ; he threw himself about on his bed like a person moribund, his limbs were cold, and his pulse weak and irregular. As soon as he was able to understand me, I proposed cauterization of the prostatic mucous membrane to him: he joyfully consented, and I per- formed it the same day. The moderate sized silver catheter which.I introduced first to empty the bladder, excited spasmodic contractions of the canal, and appeared to give considerable pain especially in the prostatic region—further confirming" me in my opinion that the prostatic portion of the urethra had been a longtime the seat of chronic inflammation. The application of the caustic presented nothing worthy of record. Two days after the operation, the patient experienced a'Teeling of vigour in the genital organs, and of general comfort which gave him hope. Soon after he regained his spirits, appetite and sleep returned; his voice acquired strength; he felt his taste for music return; he sought out his friends; his face entirely changed its expression, and his mirth became even boisterous. At the expiration of fifteen days from the operation he experienced vene- real desires, and erections were frequent and energetic. His appetite was good and his digestion acted with an unusual energy. SPERMATORRHOEA. 65 His health continued to progress favourably until, to hasten his restora- tion, he introduced a paste containing actftate of lead and copaiba into the urethra. After this the spermatic discharges re-appeared, inflammation ex- tended to the testicles, and^suppuration occurred in the left, notwithstand- ing active measures. An ounce of pus which seemed to me to be dis- charged from the tunica vaginalis, followed a puncture on tfle left side; after the escape of this, all the disorders disappeared by degrees, and con- valescence proceeded rapidly. Within a month, all M. V----'s functions were performed with a regularity which he had not enjoyed for twenty years previously. M. V----possessed considerable natural talents, and related the sensa- tions he had experienced, the opinions he had formed on his disease, and the motives of his most extraordinary actions, in a very lively manner. Two months afterwards, however, M. V----[came tome as sad as ever. He informed me that, being tormented by frequent erections he had more consulted his desires than his strength. This want of restraint had re-pro- duced in a fortnight all the irritation under which he had previously suf- fered, with the disorders following it. He had then broken off these habits, but his health had not become re-established.because diurnal spermatic dis- charges had re-appeared. I performed a second cauterization similar to the first and with an equally good result; and this time M. V----, having gained experience, became more moderate in his conduct and returned to his residence. This case ought to be placed by the side of the first two I have related in which the post mortem appearances are recorded. The symptoms were almost as severe, they presented the same characters, and gave rise to the same delusions as to the state of the brain. The rapid re-establishment of the intellectual functions in M. V----- proves that he had no greater cerebral disorganization than the other patients; it seems probable, however, that in the first cases the alte- rations of the spermatic organs had proceeded further than in the case just related. The obstinacy with which M. V-----continued to treat an imagi- nary venereal affection is remarkable; we have already seen an in- stance of it in the fifth case J have recorded. In neither case were there syphilitic symptoms efther primary or secondary. Such pre- convictions are very common in nervous patients and their surgeons sometimes share them. The wandering, dull, and deep-seated sensa- tions complained of are especially liable to be mistaken for the pain in the osseous system which follows syphilis. This case is well suited to show how difficult it is for patients to- discover those seminal discharges which take place whilst emptying the bladder and rectum. M. V-----had one only wish—to discover the origin of his disorder. To this desire he sacrificed every con- sideration, and for this end he came to Montpellier to study medi- cine ; he was not far from the truth, for he thought constantly of the blennorrhagia which had preceded the disease, yet after fifteen years of daily observation and seven years of application to medical studies, 66 CAUSES OF he had not even suspected the existence of involuntary spermatic dis- charges. * . Let us judge by this how many hypochondriacs owe their torments to the same cause. m CASE IX. Blennorrhagia, followed by excoriations of the glans penis—Spermator- rhoea—Cauterization unsuccessful—Artificial sulphur baths—Cure. N. B____, Lieutenant of Light Cavalry, affected with varicocele, con- tracted blennorrhagia in 1818. Emollient drinks and warm baths reduced this attack at the end of a month to a slight discharge, which soon after entirely ceased; excoriations, had however, previously appeared around the orifice of the glans penis. These excoriations healed in about twenty days, under the use of cold lotions: they reappeared four months after, and were cured by the same means; they afterwards showed themselves periodically every three or four months, and were not in any way affected by anti-venereal treatment of a very active kind, which the patient sub- mitted to. Each time their appearance was preceded by pain in the peri- neum and testicles, increased by the passage of faeces. After the expiration of five years, the excoriations ceased, and the pain, which had previously been relieved by their appearance, became permanent, and was accompanied by discharge of semen during defecation. The pa- tient suffered pain in the region of the kidneys, which became insupportable after remaining under arms for a few minutes; his urine deposited a whitish sediment. Sea bathing increased the pain in the perineum, and the difficulty of passing urine: fresh water bathing increased the pain in the loins: his diges- tion was disordered. When M. B----came to ask my advice, I at first suspected that a stric- ture existed, and endeavoured several times to examine the urethra with a soft wax bougie; each time, however, the instrument was arrested in a dif- ferent situation, and when withdrawn, presented a different form. After a few days' rest, I introduced an ordinary catheter into the bladder, without meeting with any permanent obstruction, but with severe pain to the pa- tient, especially in passing the bulb of the urethra. There was then, in this patient, only a state of extreme irritability of the urethral mucous mem- brane. I hope to cure this by means of cauterization with the nitrate of silver, as I had done before; but, on this occasion, no effect was produced. Recollecting then, that the disappearance of the excoriations on the glans penis, had been followed by an increase of the disease, I prescribed artificial sulphur baths, containing two ounces of sulphuret of potassium in each. At first, the baths produced an excellent effect, but afterwards, a severe irritation of the stomach, and the return of all the symptoms were occa- sioned. 1 discovered, however, that sulphuric acid had been added to the last baths: this was omitted, and as soon as the patient resumed the use of the baths containing sulphuret of potassium only, his state improved rapidly. At the expiration of a month, his pain had disappeared, his urine was transparent, and the passage of faeces was no longer accompanied by semi- nal discharge; digestion became active, and M. B----soon regained his strength and stoutness. SPERMATORRHOEA. 67 M. B-----, previously to the attack of blennorrhagia, had never suffered.from any cutaneous affection; from this date ulceration ap- peared periodically round the glans penis: this might be supposed to have arisen from a syphilitic affection, but it resisted the most active anti-venereal treatment. Its appearance put an .end to the pain in the- perineum and testicles: as soon as the sores healed, these symptoms returned, and diurnal spermatic discharges accompanied them. It seemed probable that the application of nitrate of silver would lessen the morbid irritability of the urethral mucous membrane; it produced no appreciable effect, however. Artificial sulphur baths were used with advantage when they con- tained only sulphuret of potassium ; when sulphuric acid was added, in order to increase their activity, all the symptoms re-appeared; on resuming the use of the sulphuret of potassium alone, the cure pro- ceeded with rapidity. It is remarkable, also, in this case, that river bathing always in- creased the pain in the loins, while sea bathing aggravated the pain in the perineum. Anomalies of this kind abound in the treatment of spermatorrhoea, and much careful research is often necessary to ex- plain them ; the relation of such cases will, however, put practitioners on their guard by furnishing analogies for their guidance. Baths containing sulphuret of potassium are especially indicated whenever a cutaneous affection co-exists with considerable sensibility of the mucous surfaces; but, when the irritation of the genital organs is very severe, they are often contra-indicated. In such cases, cau- terization, though it may not cure, at least will diminish the excessive sensibility.* Causes.—I have before stated that the cause of spermatorrhoea is a most important circumstance for our consideration. The truth of this becomes more evident as we proceed; but it often happens that several causes act simultaneously or successively, and that we are not able clearly to discover which of them exercises the greatest influence in the production of the disease. Blennorrhagia is the most active and the most direct, as well as the most easily appreciated, of all these causes, and this is why I have commenced by reporting cases in which it has played a principal part. When these cases are examined separately with some attention, we soon perceive that the discharge Has been preceded, accompanied, or followed, by some circumstances capable, by their own action, of giving rise to spermatorrhoea. It is necessary to pay attention to this point. In one patient I had occasion to treat, hereditary pre-disposition * M. Lallemand has reported many more cases of involuntary spermatic dis- charges following blennorrhagia; as, however, they differ very slightly from one ano- ther, and the same treatment was applied to all, 1 have thought it as well to omit the remainder of them. In fact, the connexion between blennorrhagia and involuntary ■permatic discharges, seems so well established by the cases above related, as to. re-. quire no further confirmation.—[H. J. McD.J 68 CAUSES OF probably existed, for his father had been also affected by spermator- rhoea ; others had a very marked lymphatic temperament, as in the fifth case I have reported. Many were naturally weak, delicate, and nervous; or their health had been injured by bad habits, or a too sedentary life; others again, suffered from tetters, hemorrhoids, or varicocele. By far the greater number of the patients who have come under my care, had committed excesses, either in coitus, masturbation, or the use of alcoholic stimulants. Blennorrhagia in many cases is neglected ; patients are too timid to mention it, or too careless, and too much occupied to pay attention to it; in other cases, the treatment is rendered useless by imprudence or excess; but, in many cases the inflammation produces injurious ef- fects by its simple presence for a short time. Many of my patients had had two attacks of blennorrhagia, and in one case as many as seven were experienced, before spermatorrhoea commenced ; but, I must remark, that in these cases, the recurrence of the discharge is not always due to a fresh infection, as the patients and many surgeons believe; the facility with which blennorrhagia often recurs without coitus, is sufficient evidence that it may return spontaneously, or, at all events, from very slight excitement. This disposition to a recurrence of the discharge maybe easily understood, if the increased development of the capillary system in the mucous follicles after repeated or continued attacks of inflammation be taken into consideration. These patients almost always in the end suffer from spermatorrhoea. In fact it is difficult to avoid, sooner or later, an extension of the in- flammation of the prostatic mucous follicles to the spermatic ducts. We must not, however, mistake for semen, the mucus which con- stantly moistens the urethral orifice in such persons; and, on the other hand, we must be careful to guard against repelling too lightly their apprehensions on this account, because chronic catarrh of the urethra often accompanies spermatic discharges, and is a sign of their presence by no means to be diregarded. In some of the cases I have seen, involuntary spermatic discharges seem to have been kept up by a venereal taint, and such have -been relieved by anti-venereal treatment; on the other hand, in some cases, the seminal discharges have not seemed to be influenced either by the venereal affection, or the means employed for its cure Anti-venereal treatment is frequently also employed in patients who have suffered merely from blennorrhagia, and in a very nume- rous class of cases it produces a serious increase of the irritation in the genital organs, and causes the appearance, or exasperates the ef- rects, ot involuntary spermatic discharges. Cases of this nature often present considerable difficulties of diag- nosis ; and the solution of these obscurities is always of much impor- tance m determining the treatment to be followed P Antx.venereals are not the only therapeutic agents which produce SPERMATORRHOEA. 69 such unfortunate effects; those which a blind routine of practice em- ploys in cases of blennorrhagia have not been less injurious; among these it is especially necessary for me to mention astringent injections, copaiba, cubebs, tonics, and bitters employed too soon, or in extreme doses. All these means act more or less by exciting the genito-uri- nary organs; it is therefore easy to understand that their untimely or immoderate use must favor an extension of the inflammation from the urethra to the mucous membranes which are continuous with it. I am far, however, from wishing to proscribe the use of these re- medies, and I willingly bear testimony to their beneficial effects, after the inflammatory symptoms have been subdued. A time arrives when the mucous membrane of the urethra, like all other membranes of the same class, requires the employment of tonics and astringents; but in the way they are daily prescribed, I am convinced more harm than good results from their use. Lastly, spermatorrhoea is often made worse by the very means em- ployed for*its removal, and among these may be ranked cold baths, ice, tonics, bitters, sulphur-baths, &c. In all the cases I have so far considered, blennorrhagia has exer- cised the chief influence in inducing spermatorrhoea; it is, however, rarely sufficient singly to bring on this fatal disease, and the causes, which in the cases I have related have been accessory only, may ex- cite, each by its own action, more or less serious involuntary seminal discharges. These accessory causes exercise too great an influence to be passed over in silence: they are numerous and various, and succeed or are combined with one another in different ways—two cases seldom occurring which resemble each other exactly. The further we advance the more plainly we shall see how neces- sary it is for the different forms of spermatorrhoea to be described as simple affections—how necessary it is to regard them in all their aspects, and to take account of all the circumstances which assist in producing them. In practice we find it indispensable to weigh well all the points connected with a case of spermatorrhoea, before deciding on our diagnosis, prognosis, or, especially, on our treatment. Mode of Action.—In all the cases I have related the urethra retained an excessive irritability, especially in the prostatic region; the patients felt constant pain, weight, heat, darting or painful tick- ling in this situation; and these sensations were increased by the passage of urine. Catheterism, though performed carefully, always produced acute pain and spasm, sometimes sufficiently violent to simulate stricture. The catheter was especially arrested at the neck of the bladder, and often it could only be passed on after waiting a considerable time. The patients felt as if the instrument had passed over spots of ulce- ration. They were convulsively agitated, and all the power of a determined will was often insufficient to restrain their expressions of agony. Their faces were distorted, and their whole bodies covered by a profuse sweat. As soon as the catheter was withdrawn a con- siderable quantity of florid blood was, in most cases, discharged. 70 CAUSES OF These different phenomena, which occur with more or less severity in every case, sufficiently indicate that the mucous membrane of the urethra possesses an extreme irritability, especially in the prostatic region. Several of the symptoms are even sufficient to make one suppose that it is granular, and very vascular or excoriated. A few of the patients I have treated experienced symptoms indicating still more positively an affection of the prostate, such as swelling of the organ, sense of weight in the rectum and perineum, darting pains in the neck of the bladder behind the pubes, &c, and, in one case, the inflammation of the prostate ended in suppuration. In many cases the testicles were swollen, inflamed, and painful (as in the fifth and ninth cases.) The spermatic cords also shared the condition of the testicles as in these cases. Lastly, in some patients who have con- sulted me, the seminal emissions contained blood or pus. Thus, in all such cases the blennorrhagia leaves great irritation and morbid sensibility in the urethral mucous membrane, most severe in the neighbourhood of the prostate, the principal seat of the primary disease. In many cases the inflammation extends its influence to the testicles by means of their excretory ducts, and this should make us suspect that the spermatic organs may retain the same irritability as the urethra. The same phenomena are manifested in the urinary organs; indeed their resemblance to the spermatic is remarkable in more respects than one. Many of my patients had experienced acute inflammation of the bladder, (as in the seventh case.) Others had suffered from symptoms of chronic inflammation of that organ. In a few, the inflammation seemed even to extend to the kidneys, if we may judge from the pain, spasm, and dragging felt in the loins, and the changes observed in the urine. These are the only circumstances which enable us to appreciate the state of the kidneys—organs out of reach of physical examination; but analogy confirms the results deducible from thern. After having unequivocally proved the presence of orchitis, under similar circum- stances we may well suspect the presence of nephritis, especially when we observe symptoms which are otherwise inexplicable Post mortem inspections have shown, in many cases, that these analogies do not deceive us, and I have found in the kidneys varied and serious infla'm'T" °f StmCtUre which could- only have been produced by All such patients, without exception, pass more urine during the twenty-four hours than natural: so that, although the kidneys may not be actually inflamed, it is evident that they are in a state of more or less active irritation, or, at least, of sufficient excitement conside- Sllc VnCreule th?ruaCti0n' The same edition obtains in the lr 1 ' 'I0' h.-U-gh -th?y may not be the seat of eith<* inflammation tLlf \ -fir fl™ y 1S,increased- ^e semen is not only expelled involuntarily, but it is also secreted in greater abundance than natural, SPERMATORRHOEA. 71 for unless the secretion were increased the seminal emissions would not be so frequent, and the weakening and exhaustion would not proceed so rapidly. The urine is not only more abundant but its nature is also changed, even after the pus and mucus contained in it have been removed. It is paler and more watery, and contains less urea and uric acid than natural. The semen also loses its peculiar odour, its colour, and its consist- ence ; it is, in fact, less perfectly formed than it ought to be. Lastly, all these patients experience a frequent desire to micturate, depending on the irritation of the bladder. Some are unable to hold their urine more than half an hour or an hour, (case seventh.) In all, the desire of micturition comes on suddenly and imperiously; the spasmodic contractions of the bladder overcome all the efforts of the will, and the emission takes place suddenly and convulsively. This phenomenon gives us an exact view of what passes in the vesiculae seminales during involuntary seminal discharge; some patients even feel distinctly the contractions which announce an emis- sion as inevitable, others have not sufficient practical knowledge to recognise them, but their statements show that the same phenomena are experienced, even when analogy would not lead us to admit their presence. The analogy is, however, very evident, for it is especially during the expulsion of the last drops of urine that the spermatic dis- charge takes place, and the two classes of symptoms are in general relieved or exasperated at the same time and by the influence of the same causes. This remarkable resemblance may be explained very simply by referring to the fact, that blennorrhagia has its principal seat in the prostate, where the spermatic and urinary apparatus meet, and the connection of the two classes of phenomena enables us still better to understand the causes and mechanism of spermatorrhoea. Treatment.—It is by no means astonishing that in this state the ap- plication of the nitrate of silver to the prostatic mucous membrane should produce effects more direct and powerful than those of any other re- medy. We know well how promptly and effectually nitrate of silver acts on tissues which are granular, injected or swollen from the effects of prolonged inflammation. Its results are especially evident in t he chronic ophthalmia of scrofulous patients. Soon after the nitrate has been applied, the tissues empty themselves, contract and become paler, and they retain an energetic action which preserves them from a relapse, to which the patients are often liable when a cure has been obtained by other means. On this account I have employed nitrate of silver in the chronic inflammation of the vagina and neck of the uterus, which keeps up leucorrhceal discharge in so many cases, and in chronic catarrh of the bladder, which is so difficult of cure by other means; and I have always had cause to be pleased with its action in these affections. The nitrate produces the same effects on the mucous membrane of the prostatic portion of the urethra; the organisation and sensibility of the membrane are considerably altered, and this change 72 CAUSES OF SPERMATORRHOEA. is soon felt by the organs which are immediately influenced by its condition. Hitherto relaxation of the ejaculatory ducts has been alone thought of in cases of spermatorrhoea, and this exclusive idea has been a cause of much malapraxis; but to attribute all cases of spermatorrhoea to irritation of the spermatic organs only, would be quite as erroneous and injurious. One patient 1 had occasion to treat was cured by tonics, another by antiphlogistics (case fifth ;) and I shall have to re- cord other cases of the same nature, but they are very rare. There exist almost always at the same time irritability and debility, extreme sensibility, and loss of tone in the spermatic organs. This state, however, we observe in the chronic affections of all mucous mem- branes ; indeed, we may even say as a general rule, that the weaker the organs or individuals, the more easily are'they excited. By acting on the surface of the engorged tissue, its morbid suscep- tibility is changed, and a contraction is afterward excited in it, which gives it energy. This is why one application of nitrate of silver gene- rally suffices to produce a perfect cure. But when the disease has existed a long time the genital organs share the general debility of the system, and after the chronic inflam- mation has disappeared, it becomes necessary to aid the relaxed tissues to resume their former energy; nothing now contra-indicates the exhibition of tonics of all kinds, which complete the cure com- menced by cauterization. This explains how cold and sulphur baths, ice, &c, are useful after cauterization to individuals who were injured by them at first, (case ninth.) Symptoms.—Whilst examining the mode of action of blennorrhacria m producing spermatorrhoea, I have already referred to the symptoms which occurred in the cases reported; in the other cases I have seen, the symptoms have been common to all kinds of spermatorrhoea, and I cannot notice them here without being exposed, by and by to use- less repetitions. I shall, therefore, only call attention at present to the insidious character of the general symptoms produced by these discharges, which often simulate the characteristic marks of cerebral affections, gastritis, diseases of the heart, urinary calculus, &c The real cause of the symptoms is very difficult of detection in cases of spermatorrhoea; some of my patients had studied medicine for many years, in the sole hope of discovering it (case eighth ;) we may judge from this how frequently cases of spermatorrhoea are mistaken for other affections. ( 73 ) CHAPTER IV. CAUSES OF SPERMATORRHOEA. Cutaneous Affections. The following case is that of a student of medicine who came under my care. At my request he put it into its present form for publication. CASE X. Itch during ten months at about the age of fourteen—* Pain in the epi- gastrium— Tumour of the testicle—Chronic inflammation of the bladder—Diurnal spermatic discharges—'■Hypochondriasis—Cure by Cauterization at the age of twenty-eight. " Up to the age of fourteen my health was very good, but at this period I was afflicted with psora, which continued for ten months in spite of various modes of treatment. Scarcely was this cured than I felt a sharp cutting pain in the epigastrium, after a time becoming dull and extended. The itching I had before felt over the whole body seemed to affect my head, and when I had been exposed to cold or damp, or had kept my head uncovered, the sdilp became covered with little pimples, which, when scratched, formed scabs. An induration of the left testicle of about the size and shape of a bean ' appeared, and continued during eight months. My digestion became de- ranged; my complexion darkened, and my shoulders became round; the epigastric region was so tender that I could not bear the weight of the bed- clothes, and when erect I seemed to have a weight suspended within me. At this time I was at school, but during the vacation I took an opportunity of consulting my family surgeon; he attributed all I felt to too rapid growth. Not being satisfied with this explanation, I consulted a bone setter well known in the neighbourhood, who said my breast bone was dislocated, pretended to replace it, applied a plaster, and sent me away as I came. This state of things continued till I was eighteen, when I experienced a slight pain in making water, and became very costive. The epigastric pain diminished, however, and I gained Heath At the age of twenty-two, after domestic trouble, and, perhaps also, from the effects of some slight excessses, 1 experienced the following symptoms;— Progressive emaciation; lassitude alter the least exertion; yellow, dry, and earthy skin; burning heat, especially in the palms of the hands and the soles of the feet; creeping sensation over all the body when I began to perspire; habitual sensation of internal heat; constant pain in the epigas- trium and right hypochondrium; obstinate constipation; difficult diges- tion attended with the secretion of flatus; acid eructations, smelling 7 74 CAUSES OF SPERMATORRHOEA. of putrid eggs; sometimes cold and clammy sweats, especially when I had taken any acrid or acid substance, or when I experienced the slightest contradiction, for SI had become very irritable; impossibility of enduring hunger; difficulty of holding my urine, with pain at the base of the glans penis, and spasm at the neck of the bladder during its emission; the urine presenting, when cold, a red muddy appearance, with an abundant brick dust sediment, and a cloud of flocculent matter in suspension; vene- real desires, with entire loss of the power of coitus; a discharge of a transparent and viscid matter after the least erection; an abundant discharge of a white, serous, slightly opaque matter from the urethra on going to stool; scurf and itching of the head; noise in the ears; loss of memory; feeling of discontent with myself; extreme timidity; dislike to all amuse- ments save solitary walks; deep melancholy without cause; loss of courage; sadness of countenance ; all these symptoms were aggravated after horse exercise. I consulted various practitioners all of whom considered my state as ner- vous, and told me I was hypochondriacal; some, however, recommended emollients, baths, a vegetable and milk diet with exercise and amusement; others prescribed bitters, tonics, alteratives, preparations of sulphur ex- ternally and internally, an issue, &c. All these modes of treatment were useless, or rather they increased my disorders, and in my painful condition I tried to contract a new itch, without success. I now, at the age of twenty-eight, came to consult you......The introduction of a catheter gave me violent pain, and caused spasm of the urethra, especially near the bladder. The application of the nitrate of silver dispersed the chronic inflammation which kept up the involuntary discharge of semen, and eight days after the cauterization I felt stronger, my limbs seemed more free, my urine beeame clear, and I began to hold it longer, my countenance appeared gay, and my complexion became fair. I had a nocturnal emission, a thing I had not experienced for a long time. At the expiration of three weeks I found myself in a perfectly new state; during a period of ten years I had never felt so well. The cerebral func- tions and those of the stomach, intestines, bladder, and genital organs were performed with an unaccustomed energy; my skin had lost its yellow and earthy appearance. The internal burning and the cutaneous tingling were removed. Nocturnal emissions, however, have since become very frequent, and from the fourth to this day, the twelfth of July, I have had four; never- theless my strength has continued to increase daily, and I hope that a second cauterization will remove altogether a disease which all previous treatment had only served to increase." I cannot now say whether I yielded to this patient's desire for a second application of the nitrate of silver, but I certainly did not share his uneasiness respecting the nocturnal emissions. When these follow involuntary diurnal discharges of semen they show a considera- ble improvement in the state of the genital organs; they prove, in fact, that the semen is no longer expelled as before in an almost con- tinuous manner. Indeed the patient experienced from this moment a rapid amelioration in all his functions, and an increase of strength -which would be inexplicable under other circumstances. The desire for a fresh cauterization was not alone due to the fear of nocturnal CUTANEOUS AFFECTIONS. 75 emissions; it arose partly from a kind of blind faith in a remedy which had produced such prompt and satisfactory results. The desire for a second application of the nitrate of silver is felt by many of the patients who have once experienced its effects, and I have often been obliged to resist it. We must only return to this remedy when much remains to be effected, and when all improvement has been arrested for some time; so long as progress is made, however slow it may be, there is reason for hoping that regimen, exercise, and a moderate use of the organs, will be sufficient to confirm the conva- lescence. The rapid cure of the hypochondriasis, treated for so long a time, and with such little success, by so many different means, sufficiently testifies that it originated in the involuntary loss of semen. But to what cause can we attribute the spermatorrhoea? After the disap- pearance of the cutaneous affection, symptoms of chronic inflamma- tion of the stomach, and afterwards of the bladder, appeared. Then a tumor arose in the left testicle. The connexion between irritation of the skin and that of the mucous membranes is well known, and I have shown the manner in which affections of the urethra extend to the testicles. It is then easy to understand the course by which irri- tation extendedto the spermatic organs, and excited spasmodic con- tractions of the seminal vesicles. The pain which the patient experienced in the neck of the bladder proves also, that the involuntary discharge was really kept up by chronic inflammation in that situation; the frequent desire of micturi- tion and the state of the urine, together with the sensation produced by catheterism, and especially the rapid cure effected by the nitrate of silver, are further evidences in support of this opinion. CASE XL Cutaneous affections—Repeated attacks of urethritis—Application of nitrate of silver—Cure. M. N----, of an irritable constitution and subject to frequent and varied cutaneous eruptions from his infancy, suffered during youth from several slight attacks of urethritis, which always passed off rapidly; at the age of twenty-one he married. Still, however, the "discharges re-appeared several times with various degrees of duration and intensity, alternating sometimes with tetters and at others with boils. The urethritis supervened once on an eruption of pimples on the head which had lasted very long and left cicatrices similar to those of small pox. At other times unyielding attacks of ophthalmia and violent rheumatic pains came on during the absence of the cutaneous affection. Several times slight excoriations became irritated in a remarkable manner, and a simple scratch on the leg kept the patient in bed for several months. In 1820 on an attack of numerous and large furuncles, a more intense and painful urethritis than usual supervened. I found M. N----in an extreme state of prostration and agitation, excited by harrassing suspicions as to the nature of this discharge, which was 76 CAUSES OF SPERMATORRHOEA. abundant and greenish and resembled in all respects that of an intense blen- norrhagia. As I knew my patient's constitution, I thought that the dis- charge depended on the general cause which had excited the former attacks, and therefore prescribed antiphlogistics and derivatives, to which it yielded. I afterwards advised emollients and alterative drinks, and still later the use of the warm sulphuretted springs; M. N----went successively to Cau- terets, Luchon, and Aries, near Perpignan. At the expiration of three years his general health was improved, but the attacks of urethritis re-appeared from time to time, especially in winter, when irritation no longer existed in the skin or any other organ; and he desired much to rid himself of these periodic discharges which embittered his existence. I had previously successfully used the nitrate of silver in substance in several cases of inveterate blennorrhagia, and I proposed its use to him with the hope of considerably modifying the action of the ure- thral mucous surface. He submitted to it with eagerness, and the results surpassed my most sanguine expectations. Twelve years afterwards, M. N----had not perceived the least trace of his distressing discharges, although he had travelled much, and had not restricted himself to any regimen or privation. But he soon perceived much more important changes. His venereal desires became more active and more imperious, his erections took on a new energy, and ejaculation no longer took place so precipitately as before; in fact he found himself at the age of fifty-five more vigorous in all respects, than he'had been at twenty. This single cauterization produced then a perfect revolution in the state of M. N-----'s genital organs, and its effects remained even after the expiration of twelve years. To obtain a correct idea of the importance of the change which had taken place in the urethral mucous membrane it is necessary to remark, that M. N-----remained subject to the same cutaneous erup- tions, and that they alternated as before with ophthalmia, attacks of gout, wandering pains in the breast, abdomen, &c, but that from this time the urethra was never the seat of the inflammation, which still continued to attack the other organs. Thus, although the first cause continued to act on the other organs, the part cauterized remained, after twelve years, free from its influence. On the other hand, if we may be allowed to judge by analogy with the preceding cases, and by the general symptoms which accom- panied the repeated attacks of urethritis, they must have produced spermatorrhoea, although the patient himself did not suspect it. This is the only way in which we can explain the increase of energy in the genital organs notwithstanding the effects of age, and the in- creased vigour of the whole economy in spite of more frequent sexual intercourse. In fact then, the nitrate of silver not only put an end to the dispo- sition to urethritis, but also destroyed a powerful and continually debilitating discharge, which was undermining the patient's consti- tution, without his being able to discover the cause of his weakness. CUTANEOUS AFFECTIONS. 77 CASE XII. Pruriginous eruption around Vie genital organs—Two attacks of'blen- norrhagia— Nocturnal and diurnal emissions—Cure by means of sulphuretted baths* M. L----, at the beginning of the year 1824, was attacked by a pruri- ginous eruption on the scrotum, which extended rapidly and covered the genital organs. After the least irregularity of diet, the surface of the scrotum assumed an inflamed appearance, and secreted a fetid discharge accompanied with violent itching. Baths, lotions of milk, decoctions of various kinds, and sulphur ointment, only gave temporary relief. In the month of June, 1824, four months after the first appearance of the eruption, M. L---- contracted an urethral discharge; the inflammation accompanying this was very slight, and the patient subdued it by baths and emollients. He attempted to take balsam of copaiba, but was soon obliged to leave off its use on account of the irritation it produced in the digestive organs. The urethral discharge diminished rapidly, but did not entirely disappear, a slight oozing of a viscid pearly matter remaining, which formed, at the orifice of the glans, a little crust which the patient was obliged to remove in order to give passage to his urine. This discharge he neglected,, and shortly after he noticed that semen was passed in large quantity during defecation. In the month of January, 1825, he contracted a second ure- thritis which was more severe than the first. Acute pain was present in the fossa navicularis, and after a time in the region of the prostate. In a few days the inflammation was accompanied by-general fever. The patient was then submitted to a rigid antiphlogistic treatment, and at the expiration of a week the local and general symptoms were much relieved; shortly after the discharge ceased entirely. In the month ©T February, M. L----rubbed in mercurial ointment m order to prevent a venereal contagion. This inunction entirely removed the cutaneous disease of the scrotum, but a few days afterwards the old discharge reappeared, accompanied with itching of the anus, and contrac- tion of the sphincter ani; feeling of arterial pulsation in the lower part of the rectum, especially after meals, when sitting, or during defecation; ob- stinate constipation; urine depositing a quantity of whitish fioeculi, which formed on cooling an abundant cloud suspended in the middle of the fluid; constant oozing of a fluid resembling semen, which formed a crust at the orifice of the urethra; abundant seminal emissions during defecation; noc- turnal emissions accompanied by pain of short duration, but sufficiently acute to arouse the- patient from a deep sleep-; extreme sensibility of the canal on the introduction of a catheter, with acute pain in the prostatic re- gion; the retina very sensitive to the effects of light; noise in the right ear, worse at night than in- the morning, and difficult digestion accompanied by abundant discharge of flatus. I ordered for this patient twenty-four sulphuretted baths, containing, at first, one ounce* then one oance and a-half, and afterwards two ounces of sulphuret of potassium* These means alone sufficed to perform a perfect cure at the expiration of two moaths. It is possible that both attacks of blennorrhagia in this patient were contracted, in. the ordinary manner, by contact with blenaoiihagic 7* 78 CAUSES OF SPERMATORRHOEA. virus; but at the same time this does not seem probable, because the suppression of the skin disease on the scrotum was followed by a re- turn of the discharge. The mucous membranes, too, seem to have possessed an extraordinary sensibility, since the balsam of copaiba given in the usual dose, induced great irritability of the digestive . organs after a few days administration. It is remarkable, too, that the cessation of the discharge followed the omission of the remedy. This susceptibility of the mucous membranes is very common in cutaneous affections, and explains the frequency of non-contagious attacks of urethritis in patients who suffer from them. The disappearance of the disease in the skin of the scrotum was followed by the return of the nocturnal and diurnal pollutions, but this time the irritation was more severe than ever, and was not con- fined to the mucous membrane of the genito-urinary organs; it ex- tended also to that of the rectum, and the patient experienced itching of the anus; spasm of the sphincter; and a feeling of pulsation in the lower part of the intestine.. This coincidence confirmed me still more firmly in the opinion that the previous urethral discharge had not been owing to blennorrhagic contagion, and led me to order sulphuretted baths; cauterization of the urethra would have produced no effect on the irritation of the rectum, and the latter would, alone, probably have sufficed to repro- duce involuntary spermatic discharges. The patient's rapid and per- fect cure shows that the indication followed was the correct one. CASE XIII. Herpes prseputialis, alternating in a remarkable manmr with irritation in the prostatic portion of the urethra—Nocturnal and afterwards diurnal pollutions—Occasional impotence—Re-establishment by cau- terization—Relapse—Cure by the baths of Vernet. M. B----, a magistrate, of a lymphatico-sanguine temperament, had occasionally practised masturbation, but had never committed any venereal excesses. He was attacked, for the first time, at the age of eighteen with an eruption on the prepuce which disappeared spontaneously, returned soon after, and again disappeared. This eruption was called by his medical attendant herpes praeputialis. From that time it continued to return at periods of increasing duration, and, at various times, presented circum- stances worthy of notice. The eruptions generally appeared on different spots, to the number of five or six, and were not, at first, larger than a pin's head, but were accompanied by violent itching; by degrees the spots in- creased in size and became united, after which they dried up, leaving only a degree of redness which soon passed off. The appearance of these erup- tions was always preceded, during three or four days, by a sensation of lassitude, and of weight at the root of the penis. During the eruption the lassitude left the patient entirely, and the sexual impulse and power were much greater than usual. The return of the eruption took place, at first, every two or three months, then every year, and after that every two years; and when M. B----consulted me it had not appeared for three CUTANEOUS AFFECTIONS. 79 years. As the eruption appeared more rarely it lost, also, much of its duration and intensity. It always yielded to lotions of cold water. Two years after the first appearance of the eruption M. B----had an ulceration on the penis. This was regarded as syphilitic. Still later he had two attacks of urethral discharge, after which a swelling at the anus supervened. All these symptoms were attacked by rigid and long conti- nued anti-venereal treatment. - During the twelve*years that M. B----has been married, he has very rarely had sexual intercourse, but he has generally experienced three or four nocturnal pollutions in the course of a month. For the last four years he has felt greater sense of weight 'at the root of the penis; spontaneous erections have disappeared; those which he has been able to excite have been very rare, and seldom perfect. Ejaculation has always been hurried, and sometimes even has preceded intromission. It has never been accompanied with acute sensation. Intercourse has been followed by sleeplessness, general prostration,'irritation and spasms in the stomach, especially if it has taken place in the evening. Nocturnal pollu- tions have been very abundant, have occurred almost without erection, and have been followed by much more serious symptoms than emission follow- ing coitus. For the last two years, nocturnal emissions have become gradually more rare, and M. B----has noticed, accidentally, on several occasions, that he has passed semen whilst at stool, although his bowels have not been constipated. On his arrival at Montpellier M. B----was forty-two years of age; his face was red, and he appeared in good health. But his digestion was badly performed ; his sleep was disturbed ; and he felt his memory and intellect much weakened. The progressive loss of power in the genital organs was a source of much regret to him. His urine was thick and very fetid, it contained a large quantity of mucous flocculi, and deposited a sediment of matter resembling semen. M. B---- told me this appearance had been present in it during twelve years. Thus the alteration in his urine dated from about the time of his marriage. On the sixth of May, 1836, I cauterized the urethra from the neck of the bladder as far as the membranous portion; the effect of the operation was prompt and very evident. Sixteen days afterwards the urine was perfectly transparent, and the general state very satisfactory. He was then compelled to leave Montpellier suddenly. Three months afterwards M. B----informed me that in spite of the irritation caused by travelling, his urine had continued transparent, and that his genital organs had acquired an unaccustomed energy. In fact M. B----found himself so well that he considered it unnecessary to use the mineral waters as I had recommended him. Two years afterwards M. B----had a slight relapse which yielded rapidly to the use of the sulphuretted waters of Vernet, near Perpignan. I shall not inquire here, whether there was really blennorrhagic con- tagion in this case. I shall only remark that the herpes appeared a long time before any sexual intercourse had taken place, and that its return was accompanied by violent pruritus, and increase of sexual impulse ; intercourse would in consequence take place more frequent- ly during the presence of the eruptions* The singular connexion of the skin affection, intermittent with at- tacks of blennorrhagia, is worthy of notice; it shows a continual 80 CAUSES OF SPERMATORRHOEA. metastasis of the irritation of the prepuce to the mucous membrane lining the prostate. As soon, therefore, as the eruption appeared, the habitual sense of weight in the prostatic region was relieved, and the activity of the genital organs increased ; the symptoms connected with the prostate re-appeared when the herpes was cured. ^ As the eruption diminished in frequency and intensity, and the intervals between its appearance became longer, the functions of the genital organs diminished, and at length, when the herpes had not come on for some time, the patient's impotence was complete. The urine was muddy from the period of the patient's marriage ; it seems pro- bable, therefore, that the greater frequency of sexual intercourse con- tributed to the production of diurnal pollutions. It is also worthy of notice, that as the nocturnal pollutions became rarer, the debility of the genital organs was shown in a more striking manner, and that • from this period, the' seminal discharges during defecation were suffi- ciently abundant to be remarked by the patient. M. B-----'s impo- tence was not absolute, because the involuntary discharges varied much in amount. This variation in the symptoms is a characteristic feature of slight cases of spermatorrhoea, and very probably explains the uncertainty of temper in such patients. In the case I have just re- ported it is not to be wondered at, when the intermissions of the Cu- taneous affection are taken into account. Another very remarkable ease in which blennorrhagia occurred several times as a consequence of the metastasis of cutaneous affec- tions, will be found in my 10th chapter. CASE XIV. Lymphatic temperament—Various cutaneous eruptions alternating with other affections—Habitual bad health—Hypochondriasis—Spermator- rhoea undiscovered during twenty-five years—Cure by sulphuretted baths, M. D----, of very lymphatic temperament, was subject, in his childhood, to chilblains and a cutaneous affection of the scalp; he had also many stru- mous abscesses in his neck. About puberty his health became better, but he was still subject to attacks, of ophthalmia, discharge from the ears, and frequent cutaneous eruptions of different kinds, which were very difficult Of cure, and alternated with sore throat or chronic affections of the different mucous membranes. He married at the age of twenty-one, and never committed excesses of any kind. He has had several children. About the age of thirty, tetters appeared on his face, neck, arms, legs, scrotum, and perineum; these were sometimes dry and squamous, and changed their situation very rapidly. They were often followed by little pimples which appeared in different parts of the body, causing great itch- ing ; at other times boils followed them and lasted for months. M. D____ underwent various modes of treatment in order to rid himself of these un- pleasant eruptions, but witho^success—some of the remedies even in- creasing his disease. By degrees his health became disordered in a more serious manner; he * experienced successively symptoms of pulmonary catarrh, of gastro-ente- CUTANEOUS AFFECTIONS. 81 ritis, and of chronic cystitis; he was also subject to frequent attacks of rheumatism, and was annoyed by obstinate constipation alternating with diarrhoea. His digestion by degrees became difficult and he was often attacked with flatulent colic; his bowels were, indeed, always distended by flatus, of which he was obliged frequently to relieve himself. When attacks of colic came on he seemed on the point of being suffocated; blood rushed to his head; his face became purple; but at length all passed off on the dis- charge of immense quantities of flatus, which often continued to escape for several hours. From this time he ceased to go into society and saw only his most inti- mate friends, and by degrees he became nervous and hypochondriacal. An excellent man naturally, he now was ill-tempered, peevish, and capri- cious, and he showed great weakness of character and morbid sensibility. A slightly interesting tale, or the recital of an instance of courage or devotion affected him, to a foolish degree, and he was particularly alive to any thing he considered an injustice. His face was often congested and he complained of stunning sensations, for the relief of which leeches were applied to the anus, and he used foot baths and other remedies without benefit. At length his legs failed, and he was obliged to give up the frequent walks he had previously taken. These symptoms were looked on as the forerunners of apoplexy. Leeches were again recommended to be applied to the anus, but the patient refused, because he had never been benefited by their application. Under these circumstances 1 was consulted, M. D-----being then fifty- six years of age. I was several days unable to discover the cause of these various symptoms, so long and complicated was the history of the com- plaint. At last the patient mentioned a tetter which had covered all the scrotum, and extended to the perineum and margin of the anus. I then inquired if he had ever experienced spermatic discharges during the passage of faeces, and I soon learnt from the details into which he entered that he had been subject to spermatorrhoea during twenty-five years without sus- pecting it. He had always thought that the urethral discharge during defecation consisted of mucus, and had never attached the least importance to it. These discharges were not habitual nor equally copious at all times, and he was often quite free from them during many months. As well as he could recollect these periods of immunity were when he was affected by cutaneous eruptions. He even thought that his "humours" escaped with the urine when he saw the spermatic discharges re-appear, and he then ex- perienced in the rectum and bladder a heat and irritation which he was only able to relieve by means of injections. From the first occurrence of these involuntary discharges his erections and sexual desire had constantly diminished, and had left him entirely for several years; this he attributed solely to the effects of age. His urine was often muddy and flocculent for a fortnight, and then became limpid during a variable length of time. All- these circumstances combined, were much too clear to leave the slight- est doubt as to the nature of the disorder; I therefore recommended him to take the natural sulphuretted waters, and he went to those of Vernet, near Perpignan. After seven or eight baths a lively itching came on in his skin, especially on the legs. Numbers of small pimples appeared, from which oozed for a month so considerable a quaajj^r of reddish serosity, that the patient was obliged to surround his limbs^rice a day with several folds of linen. At length this discharge gradually diminished and the epidermis came oftin patches over the whole surface of the body. 82 CAUSES OF SPERMATORRHOEA. During this time a complete change took place in the economy:—the fseces were passed easily and regularly; the appetite increased; the invo- luntary spermatic discharges disappeared; the stomach digested with equal facility all kinds of food, and bore the patient's taking wine; his erections re-appeared, and in fact M. D----at fifty-six years of age experienced almost a return to youth. In this case spermatorrhoea was unsuspected during twenty-five years, and the unhappy patient who thus suffered had passed during all the time for a hypochondriac. Enemas and medicines had been prescribed for him, without any attempt being made to seek the cause of his disease. I hope that these cases will in future receive more attention from medical men; although they do not speedily cause death, it must be admitted that they render existence wretched.. How was it that this patient could so long support so serious a dis- ease? Probably because it was not,constant. The spermatic dis- charges, in the commencement, seem only to have appeared when irritation occurred in the genito-urinary organs or rectum. At last, however, they threatened the patient's life and suspicions arose of the presence of cerebral disease, or at least of the danger of apoplexy. Causes.—The cases I have related are sufficient to show the inti- mate connexion that exists between the genito-urinary mucous mem- branes and the skin, especially that of the scrotum and perineum. I do not, however, mean to infer that the connexion between the mucous membrane and the skin is more intimate or special in the genito-urinary than in the* other organs of the body. It depends on the same cause, viz:—the analogy of function, between the mucous and the cutaneous tissues. In the tenth and eleventh cases which I have related, the genito-urinary organs were the last affected; the law, therefore, is a general one, but I can only here consider that part of it which relates to spermatorrhoea. Nevertheless, cutaneous affections alone have not, in most cases, been sufficient for the production of this disease, for I have already stated that its causes rarely act singly. It is, however, necessary to consider them singly when we wish to discover the influence due to each, and we ought to take into account all the circumstances which may contribute to produce so serious a disorder. I have reported in the preceding chapter an example (case ninth) of blennorrhagia complicated with cutaneous disease, for the cure of which it was necessary to employ special remedies; in the eleventh and twelfth cases, urethral discharges were present in more or less severity and frequency. It may appear that I should not have sepa- rated cases so much resembling each other, but I have been guided in so doing by the greater predominance of one or the other pre-dis- posing affection. There is certainly no reaso^why an individual affected by cutane- ous diseases should not expcH himself to the risk of blennorrhagic contagion, and there is on the other hand every reason why he should CUTANEOUS AFFECTIONS. 83 be easily infected by such exposure; I think, however, that we too generally confound the discharges, to which such persons are subject, with ordinary blennorrhagia, and if the patients speak of old cutaneous affections which have disappeared on the occurrence of the discharge, we too often smile, and without taking further notice prescribe the anti-blennorrhagic remedy which we are in the habit of using in all cases. Even well educated and experienced practitioners constantly act thus, from not having sufficiently considered special cases; these cases, nevertheless, occur often enough to merit serious attention. One of my friends, who had been affected for a long time by a pruriginous eruption, consulted an empiric, who ordered an ointment to be applied over all- his body for its cure. He was scarcely well when he married. A few days after, an abundant greenish discharge appeared from the urethra, attended by pain, and all the symptoms of violent blennorrhagia. At this he was much alarmed and consult- ed me. Knowing his history, I did not share his suspicions, but I recommended him to wear flannel from head to foot; in a few days the eruption re-appeared and the discharge subsided spontaneously. I have, at this time, under my care, a patient who at the age of fourteen, suffered from an eruption on the scalp; this disappeared about the age of nineteen and was followed by chronic inflammation of the pulmonary mucous membrane. After the cure of this affection, pain in the neck of the bladder accompanied with uneasiness, acute cutting pain, and weight in the rectum, came on without any evident causes; urethral discharge appeared; the spermatic cords and testicles became swollen and painful, and the patient is now the victim of spermatorrhoea with all its accompanying disorders. In another case for which I have been recently consulted, the patient had never had sexual intercourse. He suffered from cutaneous affec- tions in early life, and at the age of eighteen experienced inflammation of the testicles from excessive excitement caused by reading an ob- scene book, and two years afterwards, after unsuccessful attempts to obtain the favours of a female, a severe blennorrhagia occurred, which lasted nine months. After these facts we should think twice before we pronounce on the nature of an urethral discharge occurring in a person subject to cutaneous eruptions, especially when their suppression has previously been followed by inflammation of some other mucous membrane. Yet we must always bear in mind that these persons are liable, in common with the rest of mankind, to the occurrence of blennorrhagia, which would even put on, in their particular cases, greater virulence than usual, and must therefore greatly increase the pre-disposition of persons subject to cutaneous diseases to suffer from spermatorrhoea. We find in these cases, as in those recorded in the second chapter, that anti-venereal treatment is useless and frequently injurious. Mode of Action.—In what manner do cutaneous affections operate in producing spermatorrhoea? The cases I have reported are suffi- cient to show that they act by a metastasis to the mucous membrane 84 CAUSES OF SPERMATORRHOEA. of the genito-urinary apparatus. Thus the patients suffered from re- peated attacks of urethritis (as in the eleventh case,) acute or chronic cystitis (as in the tenth case,) active irritations of the bladder, inflam- mation of the testicles (tenth case,) or the prostate, and pains in the spermatic cords. We find then in these patients the same symptoms that are manifested by those in whom spermatorrhoea has arisen from contagious urethritis. The metastasis of cutaneous affections to the urethral mucous membrane, therefore, produces the same effects as the blennorrhagic virus, and the irritation extends in the same course along the seminal passages. Irritation of the Rectum.—Several of my patients have suffered from affections of the rectum of which I have given no account in the preceding chapters. These affections have consisted of a sense of heat, darting pains, uneasiness, and a feeling of pulsation extending more or less high in the intestine (as in the twelfth case.) These symptoms show that the cutaneous irritation had extended to the mucous lining of the rectum, as well as to that of the genito-urinary organs. Such a complication must increase greatly the chance of spermatorrhoea occurring, by provoking a spasmodic contraction of the rectum, whence results an obstacle to the passage of faeces, and a disposition to contraction in the seminal vesicles. In the next chapter I shall consider the causes of spermatorrhoea which are connected with the rectum, and I shall only now observe, in passing, that their symptoms must not be confounded with those arising from irritation of the prostate. In both cases, constipation and a sense of weight, heat, and uneasiness in the rectum may be present, but when these symptoms arise from an eruptive affection, an intolerable itching, and heat at the edge of the anus are felt, and on examining the parts, they are found red, excoriated, and wet; on drawing Out the folds of the skin, a mucous and sometimes a purulent discharge is perceptible, and the portions of mucous membrane which can be brought into view are seen to be in the same condition:—in a word, the margin of the anus presents unequivocal marks of cutane- ous disease. It is important to establish this distinction, because, in the first case, cauterization of the prostatic portion of the urethra may put an end to the chronic inflammation going on there ; but, in the second case, symptoms which have their seat in the rectum are due to a spe- cial affection of its mucous membrane. It is, indeed, true that this affection is similar to that of the urethra, and that it arises from the same cause ; but the cure of the urethral inflammation would have no effect on that present in the rectum, and we shall presently see that the latter may suffice to excite or keep up spermatorrhoea to a sufficient extent to alter the health seriously. Treatment.—The only means that have been successfully employed in cases of this nature, are cauterization and the use of the sulphuretted waters. ( 85 ) CHAPTER V. CAUSES OF SPERMATORRHOEA. Influence of the Rectum. I have hitherto examined those causes which influence the sper* matic organs by their direct action on the urethral mucous membrane. I now proceed to consider such as act on the sejninal vesicles by the mechanical and sympathetic influence of the rectum. CASE XV. Spermatorrhoea from a mechanical obstacle to defecation--■Division of the stricture—Rapid and complete cure. Nicholas G----, the guard of a diligence, of strong constitution, at the age of twenty-five contracted chancre, followed by bubi and warts. This attack of syphilis was treated with mercurials, without the patient giving up his employment, and, notwithstanding the fatigue consequent on his fre- quent journeys, at the expiration of six weeks all the symptoms had disap- peared. Shortly afterwards he experienced difficulty in defecation, which slowly increased, so that in the course of four or five years considerable efforts were necessary to evacuate the rectum. The faeces were flattened, like a riband, four or five lines in width and about a line in thickness. From this time G----*s health became gradually disordered ; his appe* tite diminished, his digestion was impaired, and accompanied with the de- velopment of flatus; he lost flesh, and his weakness increased daily; his memory was impaired, and the genital organs underwent the same changes in their functions. When he first consulted me he had scarcely any vene- real desires, his erections were imperfect, coitus was rarely possible, and ejaculation was long in taking place; sometimes it did not even occur at all, and it Was never accompanied by any lively sensation. The concurrence of all these symptoms convinced me of the presence o spermatorrhoea. The patient told me that for four years he had been i the habit of passing semen while at stool, and that its discharge in generp bore a proportion to the efforts necessary for the expulsion of the fasces on this account, in order to render them a3 fluid as possible, he had reduce himself to a vegetable and milk diet. He had often attempted to use ene mata but had been unable to succeed. The abundant spermatic discharges had so worn this patient out, that :■. the age of thirty-four he presented the appearance of a man aged sixty. On examination, I discovered, about two inches from the anus, a nearly circular obstruction, of about half a line in thickness, having an irregular opening in its centre which would barely admit the extremity of the fore- 8 86 CAUSES OF SPERMATORRHOEA. finger. This kind of diaphragm obstructed the passage of faecal matter; it was thin and soft, and felt like a cicatrix. I made transverse incisions through the obstruction, by means of a straight probe-pointed bistoury passed along the index finger. These in- cisions were of very trifling depth, and I afterwards dilated the opening by introducing my finger deeply, and pressing it forcibly in the direction of each wound, until by tearing I reached the walls of the intestine. Four loose flaps resulted from this operation, and I prevented their re-union by the frequent introduction of my finger. The operation was attended with very little pain or loss of blood. Some time afterwards I showed the patient how to introduce a rectum bougie, of sufficient size to dilate the portion of gut which had been operated on; this I advised him to practise daily for some time. This simple means proved sufficient to procure sepa- rate cicatrization of the four flaps, after which the expulsion of the faeces took place without difficulty, and the spermatic discharges ceased. All his functions were soon restored to their natural state, and Nicholas G----re- sumed his former occupation. This case gives a very clear view of the mechanical influence of constipation in producing spermatic discharge during the passage of faeces. The sole cause of the spermatorrhoea was the membranous ob- stacle above the sphincter; and the discharge was caused simply by mechanical pressure on the seminal vesicles during the violent efforts the patient was compelled to make in order to force the faeces through a narrow opening. As soon as the obstacle was removed, the sperr matorrhoea ceased, and all the symptoms arising from it disappeared. The effects of mechanical compression were in this case then quite un- mistakeable. Coitus was very long before ejaculation took place; sometimes even the completion of the act was impossible, and it was never attended by lively sensations. The cause of all this was that the seminal vesicles contained little and badly formed secretion; but these organs were not in a state of irritation, and the ejaculatory canals were neither irritable nor relaxed. In most cases of diurnal pollution, ejaculation is on the contrary, very rapid, because the spermatic organs are either irritated or relaxed, if they are not at the same time in both these conditions. CASE XVI. Spermatorrhoea inducedby chronic diarrhoea, and kept up by a mechanical obstacle to defecation—Removal of a scirrhous tumour from the anus__ Rapid and perfect cure. M----, of good constitution, entered the army at the age of seventeen, and served for eighteen years, during which he was exposed to considerable hardships. He also committed excesses of all kinds. His health, however, continued excellent. In 1814, M----, then aged thirty-five, contracted blennorrhagia which he neglected; the discharge diminished, but did not entirely cease before 1816, when he quitted the army. In 1820 M---- INFLUENCE OF THE RECTUM. 87 married, but did not indulge in any excesses. Some time afterwards, having been engaged as concierge to a club, he passed many nights almost without lying down. In 1824 he was suddenly seized with violent colic, which was relieved by means of emollient injections, repeated baths, and a severe regimen, but which did not entirely leave him. Two years afterwards he had a severe hemorrhage from the rectum, ac- companied with very painful tenesmus, during the violent spasms of which he noticed that he passed semen. This hemorrhage relieved the colicky pains he had suffered from, but a dysentery remained, which kept up the tenesmus and with it the involuntary seminal emissions, and caused the prolapse of several hemorrhoidal tumours with eversion of the mucous membrane of the rectum. From this period M----'s health became more and more disordered; he lost his habitual spirits together with his sexual appetite, and his sight as well as his memory and physical strength became weakened, so that in 1827 he was obliged to give up his occupation of con- cierge. During the years 1827 arid 1828, the chronic diarrhoea decreased in severity, and in 1829 it had become much less frequent. At length, in 1830, it was replaced by a very obstinate constipation, which in its turn also became the cause of spermatorrhoea, and increased the swelling caused by the hemorrhoids and the prolapsed mucous membrane of the rectum. This swelling was irreducible; it increased in hardness, was irritated by the friction of his clothes, and at last assumed a schirrhous consistency. Its presence alone formed a considerable obstacle to defecation. On the 28th of March, 1831, M----applied at the hospital St. Eloi, in the follow- ing condition. He was fifty-one years of age; extremely pale; his face pale yellow; skin woolly; hair black; weakness excessive; sensibility very great; profound melancholy; habitual hypochondriasis; digestion difficult, especially after the use of animal food; defecation rendered troublesome by a red hard swelling five or six lines in diameter across its base, projecting about an inch and occupying about half the circumference of the anus; in- voluntary discharges of semen during the efforts necessary to procure a faecal evacuation; the emission of urine followed by a discharge of a glairy, limpid, and sticky matter; no erections during a long period; absence of all sexual impulse; frequent attacks of vertigo; dazzling of the eyes; buzz- ing in the ears; attacks of heat towards the head from the slightest cause. The tumour, of which I have spoken, resembled a large cock's comb; con- tracted hemorrhoids were situated around it; and it seemed to have arisen from the prolapsus of internal hemorrhoids, which had brought down with them a portion of the mucous membrane of the rectum. The contraction of the sphincter ani had prevented the return of this tumour, and had in- creased its swelling, and the friction of the patient's clothes had caused re- peated inflammation and degeneration of its tissue. The base of the tumour occupied more than half the circumference of the anus, and extended above the sphincter ani. It was about six lines in thickness, and its feel was schir- rous; a sanious discharge exuded from its surface, some points of which had even begun to ulcerate. It was, therefore, evident that no time should be lost if it were intended to remove this tumour; the patient was anxious for the operation, and had previously asked several surgeons to perform it; but these gentlemen had refused on account of the depth to which the dis- eased tissue extended. By gentle "and gradual traction on the tumour I was able to bring it en- tirely through the sphincter, so as to bring the healthy mucous membrane 88 CAUSES OF SPER-VATORRHCEA. into view. On the 25th of March, therefore, I commenced its removal by an incision in the healthy mucous membrane, and to arrest the severe he- morrhage which ensued, I cauterized the bottom of the wonnd, with a fine heated iron. The tumour was then dissected out, the parts being touched with the actual cautery as they were divided. After the entire removal of the tumour, the greater portion of the wound ascended within the sphincter. Slight inflammatory symptoms supervened, which yielded to bleeding, &c, suppuration was established, and the cicatrization of the wound was com- pleted by degrees. The first few days after the operation, the patient was unable to void his urine without the use of the catheter, and for some time afterwards he micturated very frequently. On the first of May cicatrization was nearly completed, the faeces had regained their normal consistence and were passed daily without difficulty, their passage no longer giving rise to involuntary spermatic discharge. The patient regained his strength and spirits; his appetite returned, and his digestion was performed easily; his strength and stoutness increased daily. About the middle of the month his erections re-appeared during the night, and afterwards became more frequent and prolonged ; his cerebral functions followed the same course in their re-establishment; the dazzling of sight and xrebral congestions disappeared; and M----left the hospital on the 24th DfMay, perfectly restored to health. Three years afterwards, when I was summoned to Clermont to preside over a medical inquiry, M----called on me; I recognised him with diffi- culty, so much was his countenance changed. It is scarcely necessary for me to say, that he had resumed his conjugal duties, and his occupation of concierge. The cicatrix of the anus was thin and soft, and did not inter- fere with defecation. The latter part of this case exactly resembles the preceding one, and the results of the operation prove that the involuntary spermatic discharges were only kept up by the mechanical obstacle to defe- cation. But the diarrhoea which had caused the prolapse of the hemorrhoids, and the formation of the schirrous tumour, was also accompanied by frequent involuntary emissions. At this time, then, the seminal vesi- cles could not have been subjected to compression, as the faeces were liquid, and remained a very short time in the rectum ; we must, there- fore, admit that the seminal vesicles participated in the irritation of the rectum—that they were affected by the spasmodic contraction which took place in the gut—in a word, that they were influenced by the tenesmus. This case, then, presents a remarkable instance of the double in- fluence possessed by the rectum over the seminal vesicles ; in the be- ginning of the disease this influence was essentially vital,—at its ter- mination it was simply mechanical. Both phenomena produced the same results, but they were quite sufficiently distinguished from one another not to be confounded together. It was worthy of remark, also, that the patient, immediately after the operation, was unable to pass his urine without the assistance of a catheter, and that after a short time he experienced a frequent de- INFLUENCE OF THE RECTUM. 89 sire to micturate. These two phenomena show the intimate con- nexion that exists between the anus and the neck of the bladder. This case, then, exemplifies the influence of the rectum over the urinary organs, in both its different forms. CASE XVII. Hemorrhoids from the age of puberty—Difficulty in evacuating the rec- tum at the age of twenty-eight—Spermatorrhoea—Cure. M. A ■, of a sanguine temperament, at fifteen years of age was addict- ed to masturbation ; soon after he had a discharge of blood from hemor- rhoids, which he regarded as a consequence Of his injurious habit, and con- sequently abandoned it sufficiently early for his healjhto remain uninjured; but the hemorrhoids teased him much, especially when some time after he entered the army. They were relieved, however, after a campaign in Spain, where the patient suffered much from heat. By returning to his home and by leading a less active life, he hoped with care to rid himself of his troublesome affection ; the reverse happened, however—his diet being more stimulating and his habits being sedentary, the hemorrhoids increased in number and size. His stools were followed by a more or less abundant discharge of blood. The internal hemorrhoids were protruded and formed a voluminous and painful mass, which could only be reduced by long con- tinued pressure. After a time these hemorrhoidal tumours becoming irri- tated and swollen presented an obstacle to the discharge of faeces; a larger portion of intestine protruded and was returned with great difficulty. The patient now perceived that in his efforts at stool he passed a large quantity of semen, his health broke up by degrees, he felt debilitated, his digestion became disordered, bis sleep was broken and unrefreshing; his temper was soured, he often experienced sensations of stunning, vertigo, and sometimes even fainting fits. Emollient injections, baths, and demulcents appeared to benefit him at first, but he soon perceived that they increased the relaxation of the parts, and favoured both the prolapsus of the rectum and the spermatic dis- charges. This state had lasted four months, when the patient first consulted me. He was twenty-eight years of age and had the appearance of being forty ; his muscles were well developed, but he was, notwithstanding, without strength or energy. I first relieved the irritation of the rectum by lave- ments of decoction of poppy heads, and afterwards used slightly stimulating ointments containing balsamic applications, at the same time that quinine and preparations of iron were administered. Under this treatment the mucous membrane of the rectum by degrees regained its tone; the hemorrhoids became less sensitive and less volumi- nous and many of them withered away. The prolapsus of the rectum dis- appeared gradually, and the seminal discharges diminished, at the same time removing the symptoms that depended cm them. Hemorrhoids at the early age of fifteen ,are rare; I cannot, how- ever, believe that masturbation alone caused their appearance in this patient, but I think it probable that he had a considerable pre-dispo- 90 CAUSES OF SPERMATORRHOEA. sition to them. I do not suppose that the habit he practised for a short time in his youth had any influence in causing the spermator- .rhoea, for it is very easy to account for spermatic discharges in such a case without referring to very remote causes. We must then re- gard this case as another example of the influence which obstruction to the passage of faeces exercises on the seminal vesicles. CASE XVIII. Blennorrhagia, Constipation—Fissure of the anus—Discharge of semen at stool—Profound hypochondriasis—Desire of committing suicide— Diarrhoea—Cure of the fissure of the anus—Disappearance of the other symptoms. At the age of twenty-four F. B----- contracted blennorrhagia which was accompanied with weight in the region of the prostate. By leeches and baths the pain was relieved, and the discharge reduced to a slight gleet. Soon afterwards the left testicle became swollen and very painful, and the discharge increased in consequence of energetic and long continued erec- tions. The patient used leeches and hip baths, and the swelling of the tes- ticle diminished but the discharge continued. For three or four years this testicle continued very tender; it swelled on several occasions, and became painful in consequence of slight venereal excitement, the urethral discharge increasing at the same time. These phenomena returned every spring during four years. In order to cure these symptoms F. B----took the Rob de Laffecteur* after the second bottle of which, an obstinate constipation supervened. Defecation now became very painful and the fasces were covered with blood. The patient had recourse to enemata without benefit; during their administration he felt as if the " anus were torn by heated razors." This state had lasted several months when he experienced attacks of vertigo after going to stool, and sudden attacks of cerebral congestion passing off rapidly, either while walking or engaged in any kind of employment; his moral condition became affected; he fell by degrees into a deep melancholy; depressing thoughts arose before him incessantly; he seemed compelled to seek solitude and darkness; he felt a horror of suicide, but nevertheless he seemed always to be driven towards it. Wrapped up in his melancholy thoughts he spoke to no one, and if his friends endeavoured to attract his atten- tion he responded to them rudely; he felt his venereal desires constantly diminish; but this did not affect him so much as his moral position; he held suicide in abhorrence, yet he felt impelled towards it in spite of his will • his reason wandered until at length he believed himself possessed by the d'evil, and he spent hours together in praying to be delivered from his tempta- tions. A constant feeling of hunger annoyed him, though he ate often and greedily; his digestion was painful and laborious. Notwithstanding the Rob de Laffecteur is composed of a strong decoction of the Arundo Phragmitis, u J"Iru^.'™thrsarsaPan,Ia afld aniseeds, evaporated, and made into a Rob or syrup by the addition of sugar. To this a solution of the bichloride of mercury is afterwards added. INFLUENCE OF THE RECTUM. 91 repeated use of leeches, demulcents, and baths, these symptoms increased to a frightful extent; his sufferings indeed were generally greatest on quitting the bath. One day whilst at stool he noticed the evacuation of a quantity of whitish and viscid matter which he fancied was semen; from that time his attention being called to the fact, he observed that he seldom had an evacuation without more or less spermatic discharge; he noticed also that the matter in its passage produced a kind of tickling accompanied with heat in the urethra. After having passed six months in this deplorable condition, the patient suffered from a serious attack of indigestion, followed by a very copious diarrhoea that lasted a fortnight, and reduced him to an extreme state of debility; but after its relief the faeces regained, by degrees, their normal consistence, and were then passed without pain or streaks of blood; the spermatic discharges which had been excited by efforts at stool no longer took place, and all the moral and physical symptoms above mentioned were, by degrees, completely and spontaneously dissipated. Several years after- wards F. B----enjoyed excellent health, all his functions, without excep- tion, being perfectly performed. In this case the blennorrhagia caused inflammation of one testicle and developed the susceptibility of the genital organs; consequently, therefore, it pre-disposed them to the occurrence of spermatorrhoea; but the constipation brought on by the use of Rob de Laffecteur evi- dently was its immediate cause. The symptoms which ordinarily accompany fissures of the anus appeared soon after; and afterwards those arising from spermatorrhoea. The course of events was proba- bly as follows:—after prolonged constipation a hard copious motion distended the mucous membrane lining the anus, more than usual; it gave way ; from that date defecation having become painful the patient put it off as long as possible ; the hardened and accumulated faeces in their turn increased the fissure in the mucous membrane:—thus it is that fissures of the anus are usually produced and kept up. The diarrhoea, which lasted fifteen days, allowed the cicatrix in the mucous coat of the gut to become firm. It is easy, therefore, to account for the appearance and cessation of the seminal discharges, together with the anomalous symptoms from which the patient suffered during six months. I have already shown hypochondriasis, in many forms, as a conse- quence of spermatorrhoea, but in no case previously reported did it present characters like those in the case before us. This young man, naturally of a good disposition, was beset, during the whole course of his disease, by the most frightful propensities; he was so revolted by them that the loss of his health seemed nothing when compared with the mental torture they entailed on him. His reason was so shaken that he considered the intervention of the devil to be the only mode of explaining his evil impulses! To what must we refer an aberra- tion of intellect which might have produced such fatal results ? But to return to the consideration of fissures of the anus. This disease, without doubt, often excites spermatorrhoea. The silence of 92 CAUSES OF SPERMATORRHOEA. authors on the subject proves nothing, for, notwithstanding the acti- vity with which during years I have sought the causes of spermator- rhoea, I rarely, until lately, profited by the opportunities I had of ques- tioning patients on this point. When the violent efforts necessary to empty the rectum, the acute pain and spasmodic contractions of which it becomes the seat, and the disturbances which a very slight excoriation produces throughout the economy, are taken into account, I think, it will be readily allowed that fissures of the anus may fre- quently induce abundant spermatic evacuations. The patients fear to go to stool, on account of the pain the passage of the faeces produces ; these, therefore, accumulate and harden in the rectum; when, at length the irritable intestine contracts to expel its con- tents—their passage tears open the fissure; the sphincter irritated by this increase of pain, contracts spasmodically, and a contest is thus established, between the sphincter and the muscular walls of the in- testine, aided by the abdominal muscles. The efforts to evacuate the intestine are so violent and prolonged that respiration is suspended ; the face becomes injected and purple, and blood appears ready to start through the skin. It is difficult to conceive how the seminal vesicles can, under such circumstances, escape compression. We must, also, take into account the fixed pain at the verge of the anus, and the spasmodic state of contraction into which all the neigh- bouring muscles are thrown ; for these phenomena act more or less on the genito-urinary organs. Lastly, fissures of the anus are soon followed by changes in the physical and moral state of the patients, of too serious a nature to be attributed only to the pain they cause. I have seen young men arrive at the hospital in a condition of weak- ness and mental despondency, contrasting strongly with the size of their muscles, and the colour of their complexions. It is, especially after they have evacuated the bowels that such patients feel most worn out, broken spirited, and depressed ; they have generally lost all venereal desire; their erections are weak, rare, and incomplete. I regret that I have not recorded these cases, but I remember their circumstances perfectly, and all things conduce to make me attribute the symptoms to spermatorrhoea; however, this may be, it is a subject for further research to which I wish to call the attention of the pro- fession. CASE XIX. Horse exercise— Constipation— Spermatorrhoea— Impotence—Frequent and violent attacks of cerebral congestion—Ascending douches—Caute- rization—Sulphur baths—Hot and cold douches on the loins and peri- neum—Cure. M. De B----consulted me in the month of May, 1834, respecting a cerebral affection, on whose nature distinguished physicians could not agree, but which all regarded as very serious. He was of a middle height, with a large chest, and a well developed muscular system ; his hair brown and curly, his beard thick, his face full INFLUENCE OF THE RECTUM. 93 and deeply coloured. Notwithstanding these signs of apparent strength and health, I noticed that his knees were slightly bent, and that he was un- able to remain long standing without shifting the weight of his body from one leg to the other; his voice was weak and husky; the motions of his tongue seemed embarrassed, and he articulated his words in a confused manner; his attitude was timid, and his manner had something of incerti- tude and fear; he had been married fifteen days. His mother-in-law and his young wife, who accompanied him, informed me that within this period he had several attacks of congestion of the brain, during which his face was highly injected. At the first of these attacks the surgeon, called in the night, had bled him to the extent of three pounds, in order to prevent apoplexy ; repeated venesection, and the frequent ap- plication of leeches, had relieved such attacks of congestion, but had not prevented their recurrence. The patient had become subject to attacks of vertigo, and was unable to look upwards without feeling giddy; his legs had become so weak that he had fallen several times, even when walking on level ground; his ideas had lost their clearness, and his memory failed rapidly. These symptoms had spread consternation through both the family of my patient and that of his wife, especially as several practitioners of reputation were agreed as to the existence of some serious disease of the brain, al- though they could not decide as to its nature. Most of them, however, were inclined to suspect ramollissement. The countenance of the patient during this recital, the coincidence of the congestion, with the period of his marriage, and the bad effects of blood- letting, made me suspect the nature of the disorder, and induced me to question the patient separately. When we were alone he told me, stam- mering, that an unexpected occurrence, immediately after his marriage, had at first prevented any conjugal intimacy, and that afterwards he had found himself completely impotent. He attributed this misfortune to the attacks of cerebral congestion, and to the bleedings he had undergone. On further inquiry, however, I discovered that he was affected by diurnal pol- lutions. The following is the history I obtained from this 'patient by dint of ques- tioning :—at the age of sixteen, he possessed a very strong constitution, and an ardent and passionate character. At school he contracted the habit of masturbation, and at the end of three months he had frequent nocturnal pollutions, with pain in the chest, and troublesome palpitations, which warned him of the danger of the vice, and he renounced it forever. When he became free from the restraints of school, he subdued the ardour of his temperament, by the most violent exercises—especially that of the chase— and he attached himself to agricultural pursuits with much energy. This new mode of life so completely re-established his health, that he was tormented by energetic, and continual erections, to subdue which, he em- ployed river baths, even in the coldest seasons. He never committed ex- cesses of any kind, and had never suffered from any blennorrhagic or syphilitic affection. In 1831, the erections were slightly mitigated, but he became very much constipated, which he attributed to the constant use of horse exercise. In J 832, he experienced some numbness and creeping sensations in his feet and legs. In 1833, frequent dazzling of sight occurred with vertigo, difficulty of 94 CAUSES OF SPERMATORRHOEA. . vision, and flushes of heat, towards the.head and face, the patient attributed all these symptoms to the effects of his still increasing constipation. At the same time that these symptoms occurred, the patient's erections became rarer, less energetic, and after a time, incomplete; his fitness for intellectual labour diminished; the cerebral congestions became more fre- quent, and more severe; his face became habitually very red; his head burning; an almost constant fixed pain came on in the orbits, and his character became fickle and contradictory. His family physician, attributing all these disorders to a state of plethora, caused blood to be drawn several times, without benefit. In March, 1834, M. De B----engaged himself to a young lady, who lived about two leagues from his estate; and in order to visit her without neglecting the care of his property, he was obliged to make long and fre- quent journeys on horseback; shortly before 'his marriage, these journeys became so frequent, that he might be said to pass the greater part of his time on horseback. His constipation now increased to such a degree, that he passed forty days without fecal evacuation; during his efforts at stool he passed semen in large quantities, and in jets, although the penis remained flaccid. He had previously, several times, noticed the same occurrence, but as he attributed it to his long continued continence, he paid little atten- tion to the circumstance. His urine was constantly muddy; it was passed slowly, and with difficulty, and threw down a large quantity of thick and flocculent deposit. M. De B----awaited the period of bis marriage with a vague uneasi- ness, of which he could not imagine the cause; he was much attached to his betrothed, but, nevertheless, he experienced more embarrassment than pleasure in her society. I have already stated what occurred after his marriage, I should add, that having examined his genital organs, I found them, contrary to my expectations, of unusual development, the testicles were large and firm, but the scrotum was slightly relaxed. The patient experienced a strange tingling in the organs, and at times felt as if they were compressed by a hand of iron. These sensations increased when near his wife, and the penis diminished in size, and became retracted towards the pubes, in proportion as he endeavoured to excite erection. The union of all these circumstances could not permit any doubt to remain on my mind as to the nature of his disease; it became evident that all idea of cerebral affection must be abandoned, and that the diurnal pol- lutions, with all the symptoms of which they were the cause, must be referred to the patient's constipation. The first indication to be fulfilled, therefore, was to relieve the constipa- tion; indeed I hoped this was all that would be necessary: the youth of the patient, the development of his genital organs, and the strength of his constitution induced me to suppose that his cure would be prompt and easy. Things did not, however, follow so simple a course. The next day the patient began to use ascending douches; and was put on a vegetable diet, with iced milk. The first douches caused the evacuation of an immense quantity of faecal matter in lumps, as hard as bullets, and it was not until after the sixth douche that the faeces were of normal consistence; I then caused the tem- perature of the water to be lowered to 25° of Reaumur's* scale, and after- * About 88° of Fahrenheit INFLUENCE OF THE RECTUM. 95 wards to 20° Reaumur.* The last few douches were given at 16° Reaumur.t After the twelfth douche had been administered, they were omitted, the bowels having acted regularly every day, without the necessity for the slightest straining. By this time the patient's countenance had lost its purple tint, and pre- sented a more natural appearance: the stunning sensations of which he had complained diminished by degrees, and at length disappeared entirely; his legs regained their strength, and he was able to continue in a standing posture for a long time without fatigue, and to take long walks without inconvenience; his voice resumed its natural tone, his eye regained its expression, and all his motions acquired firmness. At the expiration of a fortnight the spermatic discharges during defeca- tion had ceased entirely; but his urine still continued thick. His erections had already acquired sufficient energy to make him believe himself cured, but ejaculation took place almost instantaneously. The use of ice and cold lotions did not ameliorate his condition. Such was M. De B-----'s state at the end of a month; when, in order to act directly on the orifices of the ejaculatory ducts, I determined to cau- terize the prostatic portion of the urethra. As soon as the inflammation had subsided, his erections became more perfect and energetic; yet ejacu- lation still took place too rapidly. The period for using the mineral waters having arrived, I sent M. De B----to Aix, in Savoy, where I visited him shortly after. He had experienced very little benefit from the use of the waters, either externally or internally. I now prescribed douches, alternately very warm and very cold, on the perineum and loins, the spout being changed when the sensation, either of cold or heat, became very intense. The bath was ended after about twenty or twenty-five minutes, by the cold douche, and the patient's skin remained highly injected for some hours afterwards. The effects of these douches were conclusive; after the first, the patient's erections acquired a degree of vigour and duration which remindedhim of his early torments. He continued the use of the douches for some days after his re-establishment; and when he left Aix the functions of his genital organs were perfect. Ejaculation was a good deal protracted by the use of the douches. I have entered into a somewhat lengthy detail of this case, because the subject affects gravely the most serious interests of society, as well as the happiness and peace of families. Besides, I confess that I was much interested by the unhappy position of a young man whose misfortune was undeserved, and could not have been foreseen, as well as by that of his wife—a young woman.scarcely of age, who was obliged to enter into the most unpleasant details. It is evident that in the case of M. De B-----, the constipation was the cause of the involuntary seminal discharges. The patient had practised masturbation it is true, and nocturnal emissions followed; but he had continued the vice only three months, and his health, * About 81° of Fahrenheit. t About 68° of Fahrenheit. 96 CAUSES OF SPERMATORRHOEA. though disordered for a short time, was soon re-established by the use of violent exercise. M. De B-----was even tormented during several years by erections, which must have been very energetic, if we may judge by the means he took to subdue them. From this time he had never committed any kind of excess, and he had never suffered from either blennorrhagia or syphilis. There is then no cir- cumstance in the history of his life, except his constipation, which would account for the involuntary discharges. But to what is this constipation to be referred ? After all I could learn from the patient concerning his mode of life, I could only refer it to his constant horse exercise. In fact, M. De B—— sometimes passed whole days on horseback, either for the purpose of hunting, or of superintending the management of his property. Shortly before his marriage his rides became more frequent and longer, and his bowels at this time did not act during forty days. The weakness of his legs, the stunning sensations, &c, increased in proportion as his costiveness became more confirmed. This case recals to my mind the well known observation of Hip- pocrates on the impotence of the Scythians, and I have no doubt that his opinion was founded on analogous facts. I shall treat this subject more fully in another place; but since at present I am considering the causes of spermatorrhoea which act on the seminal vesicles through the influence of the rectum, I report this striking case, showing the effects of long continued horse exercise. M. De B----was accustomed to nutritious food, and of a well marked sanguineous temperament; he had a large chest, powerful muscles, and a highly injected countenance; it is therefore by no means extraordinary that he should have been bled frequently for the relief of the cerebral congestions to which he was subject. On the night of his marriage the blood rushed to his head with greater force than ever, so that an attack of apoplexy was much feared; the weak- ness of the legs, the frequent falls, and the attacks of vertigo, were therefore afterwards attributed to an advanced stage of disease of the brain. This was a very natural opinion, but it was an incorrect one; I doubted it from the commencement, although the patient was brought to me in consequence of a supposed cerebral affection. I formed a different impression, because I had previously seen many analogous cases. There exists in all these patients something peculiar in the expression of the eyes, in the position, in the voice, and in the general appearance ; something oftimidity and bashfulness which I am unable to express, but which is instantly recognised by the experienced, although perhaps it is incapable of explanation. However this may be, the relation of the above case should draw attention to the sub- ject. I admit that venesections seemed to be clearly indicated in the case of M. De B——, but the loss of blood never produced good effects either immediate or remote; and by analysing the case carefully, his attendants would have seen that under this treatment the attacks in* INFLUENCE OF THE RECTUM. 97 creased in frequency. But pre-convictions throw a thick veil over the most acute perceptions. The ascending douches put an end to the constipation; but free- dom of faecal evacuation did not suffice to cure the disease. The seminal discharges, during the passage of faeces, diminished, indeed, or perhaps entirely ceased, but the patient's urine remained thick and muddy, and his erections were incomplete. The application of ice and of the nitrate of silver, and the use of sulphureous waters, were not sufficient to effect his cure; yet there could not have existed any organic change in his genital organs. We can therefore only attribute the continuance of the seminal discharge, during the emptying of the bladder, to relaxation of the ejaculatory canals, produced by their long habit of allowing the semen to escape in a passive manner— showing how necessary it is to put an end to the habit as early as possible. The alternate use of hot and cold douches on the loins and perineum produced a sudden and decisive change in this as in many analogous cases ; I shall therefore return to their consideration by and by. At present I must only remark, that they should never be employed so long as any irritation of the genital organs exists, as under such cir- cumstances they produce the most unfavourable effects. CASE XX. Lengthened exposure to severe cold—Incomplete paralysis of the rectum —Seminal discharges during defecation—Cure by the application of galvanism. M. V----, aged twenty-nine, a captain in an infantry regiment, had suffered from five or six attacks of blennorrhagia, and afterwards from a chancre, for the cure of which he took a considerable quantity of the bichlo- ride of mercury. At the end of the treatment, in 1822, he left Metz, to go to Spain. During his journey he was detained three weeks at Lyons, in consequence of a disorder of which the most prominent symptom was obstinate costiveness accompanied by fever. During the remainder of his journey he was obliged, for the first time, to support his left testicle, the veins of which were varicose. During the whole campaign he did not suf- fer from any other disease except occasional hemorrhoids. After having endured the fatigues of war without disorder, M. V----, whilst returning to France, was exposed during an entire night to ex- treme cold, being at the same time very lightly clothed. The next day he felt acute and darting pains in his legs, and these were soon followed by a feeling of cold, referred chiefly to the under part of the left hip joint, and to the hypogastrium. From this period a new train of symptoms appeared. The patient felt his legs daily becoming weaker; he was subject to obstinate constipation. It seemed to him as if the powers intended for the expulsion of the faeces, were paralyzed; and he experienced, moreover, in the distended intestine, a feeling of elastic re-action, rather than one of muscular contraction. Abundant seminal discharges attended his efforts at stool. Agitation gene- 9 "8 CAUSES OF SPERMATORRHOEA. rally followed the evacuation of any feces. The venereal impulse was nearly lost, erections occurred seldom, and were incomplete, and coitus was impossible, except under very extraordinary circumstances, and very rarely. The patient's digestion became difficult; flatus accumulated in the intes- tines, distended his abdomen, and caused pain in his epigastric and hypo- chondriac regions: his skin became habitually dry and harsh. He wished to take exercise to favour cutaneous transpiration, and was in a continued state of agitation as soon as he remained still for a few minutes; he was easily affected by cold, and his temper became very irritable. The suspensory bandage he wore, inconvenienced him, and he left it off before taking a long walk. Shortly after his return, a considerable swell- ing came on in the left testicle, to disperse which leeches were applied five times unsuccessfully. About this time bichloride of mercury was administered in solution for the treatment of some supposed venereal vegetations around the margin of the anus, but which, in reality, were only contracted hemorrhoids. The different means pursued, increased, to a great degree, the patient's weak- ness of the legs and digestive disorder. When Captain V-----came to the hospital of St. Eloi, I was struck by the pallidity of his countenance, and the flaccidity of all his tissues. His form was rounded, with the cellular tissue very abundant and slightly infil- trated with serum, especially in his legs; his skin was white, thin, transpa- rent, and habitually cold; his pulse small and feeble. The tumour of the left testicle was evidently only a common hydrocele. Taking into consideration the order of appearance, and the general character of the symptoms, I thought that the intense and lengthened action of cold had produced a deep and lasting effect on the inferior portion of the spinal cord, as I had before seen in a few cases. Weakness seemed to me to be the symptom predominating, no appearance of irritation being present, either in the rectum or the genito-urinary organs; and I conse- quently decided on submitting the affected parts to the action of galvanism. The first sitting took place on the 11th of February. The current was established, during twenty minutes, between the sacrum and hypogastrium; and afterwards, for the same period, between the hips. The shocks were very weak, only sixteen drops of sulphuric acid having been added to the quart of water; yet, on the following day, the patient experienced less sensa- tion of cold, less numbness in his left leg and in his genital organs, and less difficulty in emptying his bladder; besides which he had a stool. On the 12th a second sitting took place. The shocks were directed through the same parts, and applied during the same length of time; eighty drops of sulphuric acid being used on this occasion. On the 13th a third sitting was held, a hundred drops of acid being used. Stronger shocks were administered. Impressions were now more acutely felt, and the patient's improvement seemed progressively increasing. On the 14th, galvanism was again applied, a hundred and forty drops of sulphuric acid being added to the quart of water. The current was esta- blished occasionally between the loins and the perineum, and the surface of the hydrocele. The following day the patient had a free evacuation with- out enema; he experienced a feeling of power in the rectum, with less numbness in the lower extremities, from the pelvis as far as the knees; the legs and feet were in the same state as before; there was a considerable diminution in the size of the hydrocele; the patient's erections had become INFLUENCE OF THE RECTUM. 99 more energetic, and he was altogether more cheerful, notwithstanding the fatigue caused him by the violent shocks to which he had been subjected. He spoke of the galvanism with pleasure, but requested two or three days' rest before being again subjected to its action. From the 15th to the 19th galvanism was not employed. No improve- ment took place during these days. From the 20th to the 24th five sittings similar to the preceding took place; the quantity of sulphuric acid being increased on each occasion. After these the bowels were opened freely every day, without straining or seminal discharge. His urine was discharged easily, in a full stream. The liquid effused in the tunica vaginalis was completely absorbed. The patient's digestion became active; the intestinal flatulence disappeared, and the warmth and strength of the inferior extremities were restored. Shortly afterwards M. V---- rejoined his regiment, and resumed his duties as before. Four or five years afterwards I met with M. V----, who had attained the rank of general. He told me that his health had not undergone the least alteration. This patient had suffered from five to six attacks of urethritis, be- sides a chancre, and he had undergone many energetic courses of anti-venereals, of which one course only would have been useless, and even injurious. There are, therefore, many reasons why his case should have been placed among those of which I have treated in the third chapter. On the other hand, he had suffered, for a long time, from hemorrhoids, which were, on one occasion, even mistaken for syphilitic vegetations, a mistake by no means uncommon. The semi- nal discharges were, however, due to the distention of the rectum, (as in case fourteen) yet it seems probable that the other circumstances had some share in bringing on the disease, because Captain V----- had suffered from obstinate constipation, when at Lyons. These cir- cumstances must, therefore, be taken into account; but the deter- mining cause was, evidently, the extreme cold to which he was exposed during a whole night. This gave the disease a peculiar character, which is not otherwise met with. The first time I saw this patient I attributed the weakness of his lower extremities, his constipation, &c, to the seminal discharges; but on more mature reflection respecting the sudden effect of this lengthened exposure to cold, I recollected other cases of the same nature, in which cold had left a serious impression of debility in the parts which had chiefly suffered. I was struck by the general and truly characteristic state of the constitution, by the infiltration with serum of the affected parts, by the temperature of the skin, &c.; I concluded therefore that the pollutions arose from distention of the rectum, and that this was kept up by a kind of torpidity which the cold had produced in the nerves arising from the inferior portion of the spinal cord. This chain of reasoning led me to think of galvan- ism—a remedy, from the use of which, I had seen benefit arise in analogous cases. ' • The result proved this indication to be the right one, and the cure was even more rapid and decided than I had ventured to hope for. 100 CAUSES OF SPERMATORRHOEA. The hydrocele which existed in this patient, seemed to have been caused by the repeated attacks of urethritis; and the rapidity with which the effusion was absorbed under the use of galvanism, was very remarkable. This circumstance proves galvanism to have been the remedy best suited to the case. I shall relate here another case, illustrating the effects of cold; and which is also remarkable in other respects. CASE XXI. * Intemperance—Lengthened exposure to cold—Chronic inflammation of the bladder—Involuntary seminal discharges, SfC.—Cauterization— Cure. Relapse—Same treatment with the same result—Remarkable influence of the bladder on the rectum. G----, a soldier in the 4th regiment of light infantry, much addicted to intemperance, enjoyed pretty good health, with the exception of two or three slight attacks of blennorrhagia, until the age of thirty. At this age, however, when intoxicated and in an excessive state of perspiration, G---- plunged into cold water as far as his middle, and afterwards allowed his clothes to dry on his person. Shortly afterwards G----felt acute pain in the lumbar region, with weight in the hypogastrium, and a frequent desire to make water, which he passed with some little difficulty. Camphorated frictions on the loins, with rest, and an antiphlogistic regimen, gave him momentary relief; but G----soon perceived that he was more easily fatigued than before, and especially that his legs daily grew weaker. He continued to perform his military duties during eighteen months, though with great and increasing difficulty; and at length he became so weak that he was obliged to apply for his discharge. Having returned to his native town, he commenced business as a tailor, and he had not long followed this employment when he perceived that he passed semen frequently, without either erection or pleasure. These dis- charges grew more and more frequent, and were accompanied by an irresistible and frequent call to empty the rectum; his urine was passed with much difficulty, requiring efforts which were very fatiguing. During the years 1830 and 1831, the weakness of his legs continued to increase. His digestion was difficult, and his genital organs were much relaxed. In March, 1832, after a fit of intemperance, G----was seized by a com- plete retention of urine, for which baths, fomentations, and emollient drinks were prescribed. This state gave place to one of strangury, soon followed by incontinence of urine. In May, 1832, artificial sulphuretted baths Were employed without bene- fit, and in September, the baths of Balaruc with no better result. On the 4th of October, G----was admitted into the hospital of St. Eloi. Two moxas were applied to his loins, and shortly afterwards four issues lower down. On the 1st of November G----took some soup and wine, and the fol- lowing day acute irritation of the neck of the bladder came on, for which he was treated by leeches to the hypogastrium, baths and camphorated drinks. The pain diminished, but the passage of urine was preceded by a discharge of milky fluid. INFLUENCE OF THE RECTUM. 101 At this time the patient first came under my care. I found him in the following state. He was thirty-five years of age, of moderate stature; his skin white, face pale, hair black and scanty, voice feeble and rather husky, digestion difficult, especially after the use of animal food; he was frequently compelled to go to stool, the presence of a little faecal matter in the rectum inducing a painful feeling, which caused its involuntary expulsion. He passed urine every ten minutes or quarter of an hour, without being aware of its escape, and the fluid contained an abundant deposit of a greenish white colour, which appeared flocculent. The urine decomposed very rapidly. He had no venereal desires, and not the least appearance of erec- tions. His lower extremities were so weak as scarcely to support the weight of his body. His legs were the constant seat of osseous pains, and his feet were habitually cold. He seemed indifferent to every thing. On the 14th of November I performed a slight cauterization of the neck of the bladder, and of the surface of the prostate. The patient experienced little pain during the operation; there was no discharge of blood, and but little burning afterwards. On the 22d the urinary deposit had considerably decreased in quantity. By the 26th the deposit had entirely disappeared. On the 28th the urine appeared quite limpid, and the patient was able to retain it for half an hour, but it was still passed involuntarily. The feces were not passed so often, and the lower extremities were a little stronger. On the 29th I performed a second and more complete cauterization of the same parts. The pain was considerable, and followed by burning. Bloody urine was afterwards passed very frequently. On the 4th of December the patient was able to walk without the aid of crutches; his appetite and his spirits returned. On the following days the urine and feces were held longer. On the 11th of December a third cauterization was practised, beginning by the bladder, and ending at the bulb of the urethra. On the 18th, the patient was able to retain his urine, which was quite limpid, for an hour; animal food was well digested; his erections returned; his legs regained their normal strength; his face acquired colour and ani- mation, and his spirits had returned. The fseces were retained as long as in health. On the* 20th, the patient felt so well that he left the hospital; his con- valescence continued, and indeed seemed to make more rapid progress in proportion to the amount of exercise he took. In the month of February, 1833, G-----having occasion to take a long journey during very severe cold, drank a considerable quantity of wine. In the month of May he re-entered the hospital, in almost the same state as at first. I performed a fourth cauterization similar to the last, and with the same good effects. I afterwards prescribed tar-water and the use of the artificial sulphu- retted baths, and at the end of two months all the symptoms had disappeared, and the patient left the hospital quite re-established. A lengthened exposure to cold was followed in this, as in the pre- vious case, by diurnal pollutions, and by almost complete paralysis of the lower extremities. But here all resemblance between the two cases ceases. 9* 102 CAUSES OF SPERMATORRHOEA. In Captain V----- the cold had acted especially on the nerves which are given off by the lower portion of the spinal cord ; these had been affected with a loss of power, from which the rectum had chiefly suffered; hence, its distention by faeces, and the consequent compres- sion of the seminal vesicles. There was not the slightest appearance of irritation in the parts, and, for this reason, the galvanism produced such beneficial effects. In the patient G-----, the cold chiefly acted on the bladder, and the chronic cystitis resulting from it extended its influence successively to the seminal vesicles and the rectum. The extreme weakness of the lower limbs arose from the repeated seminal discharges, which wore the patient out. Hence cauterization was followed by the happiest results. I am convinced, that in this case, galvanism could not have been borne. It is easy to explain why, in the latter case, cold acted so directly on the bladder—the patient's intemperance pre-disposed that organ to disease. G-----was intoxicated when he went into the water; afterwards, when he experienced a rapid increase of his bad symp- toms, he had taken wide with his soup ; and still later, in the journey during the winter, which was the cause of his relapse, he had drank a considerable quantity of wine. It is, therefore, by no means easy to separate the effects of cold, in this case, from those of intemperance, the action of which on the urinary organs is easily explained. When considering the effects of blennorrhagia, I reported a case in which cold exercised considerable influence in the production of spermator- rhoea, (case fifth,) but this effect was shown by very different symp- toms. Strangely enough, the treatment which cured these three pa- tients was quite different in each case—showing the indispensable ne- cessity of observing numerous cases, and of examining minutely all their peculiarities. A phenomenon was present in the case of the patient G-----, which shows that the influence of the rectum on the genito-urinary organs, is quite equalled by that of the genito-urinary organs on the rectum. The mucous membrane of the intestine was, in this case, so irritable that the gut was unable to bear the presence of faecal matter; imme- diately that the faeces reached the level of the bladder, convulsive contractions of the muscular coat of the rectum were excited, causing their immediate and involuntary expulsion. The stools were not liquid, or mixed with mucus, as in diarrhoea, though in consequence of their-short stay in the rectum, they were by no means solid. No particular treatment was pursued for the removal of the irrita- tion of the rectum; it diminished after each cauterization, and disap- peared at the same time as the inflammation of the bladder. The longer the patient was able to hold his urine the less frequent his stools became, and both bladder and rectum seemed to return under the influence of the will at the same time. But if the inflammation of the bladder could produce such an effect on the rectum, it must have acted with still greater power on the seminal vesicles. What then was the cause of the patient's expe- INFLUENCE OF THE RECTUM. 103 riencing constant discharges of semen, both by day and night, with- out erection, without pleasure, and in the midst of the most perfect repose as regarded venereal excitement ? A certain quantity of the spermatic fluid having reached the seminal vesicles, produced in them, by its mere presence, involuntary and irresistible spasmodic contrac- tions, similar to those of the bladder and rectum ; the semen was ex- pelled in the same manner as the urine and the faeces, and without the characters which it would have acquired after a longer detention in the reservoirs destined for its reception. It is evident then, that an intimate relationship exists between all these parts, and that it is necessary to connect their phenomena in order to obtain a correct and perfect idea of their influence. It must by no means be thought that this effect of the genito-uri- nary organs on the rectum is of rare occurrence; it is, on the con- trary, habitual; but it is seldom so strikingly shown as in the pre- ceding case. I have not hitherto noticed it, because I wished to render the subject as simple as possible ; but it is to this intimate con- nexion that the sensation of uneasiness and weight at the margin of the anus, the habitual contraction of the sphincter, and the obstinate constipation, which are so often observed in patients affected by sper- matorrhoea, must be attributed. All those on whom I have practised cauterization of the neck of the bladder, have experienced a sudden burning at the margin of the anus, and a sensation of heat in the rec- tum immediately after the operation ; on the following day they have had greater tone in the rectum, and their stools have very soon be- come more free. I must not, however, at present, enter into further details on this subject. CASE XXII. Unsuspected spermatorrhoea—Attacks of cerebral congestion—Disorder of the general health—Ascarides expelled from the rectum with imme- diate recovery. M. C----, a Captain of Engineers, aged about thirty-two, nearly bald, very thin and pale, with sunken eyes surrounded by dark circles, a feeble shrill voice, and a timid embarrassed appearance, consulted me respecting his health on several occasions; I never attached much importance to his complaints, but always attributed them to the melancholy bias of his cha- racter. In 1824, however, his digestion became disordered in an alarming manner, and was always accompanied by the disengagement of much fla- tus ; even the ingestion of soup into the stomach was followed by oppres- sion in the epigastric region, and difficulty of respiration, which was espe- cially felt in the situation of the oesophagus, and terminated in the pharynx. This sensation diminished considerably as soon as the patient was able to pass flatus. He felt himself overcome by a sense of general debility, and especially experienced a feeling of weakness in his legs, which contrasted strikingly with his continual desire for motion, and his custom of taking long walks. He suffered from frequent attacks of giddiness, wit|j conges- tion in his head, especially when he stooped, or read, even for a few mi- 104 CAUSES OF SPERMATORRHOEA. nutes, and he consequently thought himself threatened by an attack of apo- plexy. His usual spareness of habit had increased; his testicles had di- minished sensibly in size, and his genital organs always felt cold. His pulse was weak and soft; his tongue pale and moist, and pressure on the epigas- trium did not give him the least pain. I could not participate in this pa- tient's fears respecting the probability of an attack of apoplexy, or the ex- istence of gastritis, for I attributed all his symptoms to excessive discharges of semen, although he would not admit the correctness of his opinion. He had abstained from coitus during a long time, from the fear of injuring his health, and expressed a horror of masturbation; he was not subject to nocturnal emissions, and he had never noticed any discharge of semen when passing urine, or at stool. I sent him for change of air, during the heat of the summer, to Vigan in the Cavennes, requesting him, at the same time, to watch himself carefully while at stool, and to send me an account of the appearance of his urine. A few days after his arrival at Vigan he sent me word that after each stool he had a discharge of thick whitish slightly unctuous matter, of a very weak spermatic odour, and which stained his linen a pale yellow. This discharge was especially abundant whenever his efforts at stool were very violent. It was not, however, during the actual passage of fecal matter that the discharges of semen occurred, but shortly afterwards; and he ex- perienced at the same time a sense of weight in the rectum, and a spasmodic contraction accompanied by itching and heat. The symptoms were then, as I suspected, really due to excessive spermatic discharges. Yet I did not attach sufficient importance to the singular circumstances which accompa- nied these discharges, and I was satisfied with prescribing cool injections, cold lotions, and vegetable and milk diet, with the intention of relieving the constipation, and of giving tone to the genital organs. These means pro- duced no remarkable change in the seminal discharges ; after a time I re- ceived another long letter, which was full of minute and uninteresting de- tails ; on the back, however, the patient had written a postscript, stating, that in one of his stools he had passed a number of little worms, and that he frequently felt an itching in the rectum, which he attributed to a herpetic affection. A slight discharge occurred from the rectum, and the feces were mixed with a good deal of purulent mucus. The parts surrounding the anus were gorged. This state had been present from 1818, and had first appeared after a violent intestinal inflammation, accompanied with colic and tenesmus, which latter re-appeared in 1822. The cause of the spermator- rhoea, now, was evident,'and I also understood how it was that the seminal discharge did not take place exactly at the same time as the passage of the faeces, but a little after; these discharges were not produced by mechanical compression arising from such passage, but they were the result of a state of irritation produced by the presence of worms; the sensation of pressure, the spasmodic contraction, the itching, and the heat, which were felt in the rectum, proved this. The patient took, fasting, on three successive mornings, four grains of calomel, and during the day three or four glasses of decoction of Corsican moss, and a tepid enema followed by a cold one; he once took a small enema of warm milk, and soon after a second composed of a strong decoc- tion of garlic. At the end of three days perceiving no more ascarides in his stocks, he left off treatment for a week, after which he took, at bed time, four grains of calomel, followed by six drachms of sulphate of magnesia, the INFLUENCE OF THE RECTUM. 105 next morning. Four copious stools were obtained, which presented no ap- pearance worthy of note. Soon after this, Captain C---- wrote to me stating that his strength had returned; that his stomach performed all its functions properly; that the spermatic discharges had ceased, together with the discharge from the anus, and the itching, &c, with which he had pre- viously been tormented. The ascarides re-appeared every year, however, at a stated period, and sometimes even twice a year, but the patient was able to treat himself, and immediately that any symptoms announced their presence, he got rid of them in two or three days—his health never becoming disordered. CASE XXIII. Masturbation at nine years of age—Constant nocturnal emissions— Ascarides—Cure in eight days. Henry B----, a Sergeant of Engineers, at the age of nine, was addicted to the vice of masturbation, which he continued to practise up to the age of fifteen, when he corrected himself. From this time he experienced frequent nocturnal pollutions. Loss of flesh followed, with pains in the chest and a fixed pain in the middle of the back. The whole nervous system was disordered, and the patient's eyes were injected and surrounded by dark circles. After the occurrence of a nocturnal emission, the patient often no- ticed that he had pricking sensations, as though he had been stung by ants, with acute pain in the lower part of his abdomen, and in his loins. He was completely overcome by fatigue in the morning, and felt, when he rose from bed as though his legs and arms had been bruised ; he com- plained also of oppression at his chest, and a sense of suffocation. He felt buzzing in his ears in the evening; he lost his memory, was unable to at- tend to his affairs, and performed his military duty with much difficulty. This state had continued for several years, and became daily more serious. Various modes of treatment had been employed by different medical men whom the patient had consulted; among other remedies used may be named quinine, oxide of iron, ferruginous water mixed with wine of Bor- deaux, lime-water in milk, and Hoffman's anodyne at night. River-bathing and cold enemata had also been tried, and the patient had applied, during the coldest season, snow and ice over his kidneys and genital organs. No advantage whatever was derived from all these means, and sal-ammoniac dissolved in water, to form a cold lotion, only irritated the skin of the penis an(l scrotum. Henry B-----was twenty years of age when he first consulted me; his face appeared coloured and healthy, and his form announced ljealth and vigour. It was therefore difficult to guess the cause of the deep melan- choly which his features showed. After much questioning, I at length learnt that he had been subject to worms from his childhood—that he passed them every time he went to stool, and that his feces were some- times quite covered with them. From the description he gave me, I was convinced that they consisted of oxyures, with perhaps a few trichocephali. I prescribed for him four grains of calomel night and morning, with half a drachm of mercurial ointment to be introduced into the rectum night and morning, and enemata composed of potentilla anserina in decoction. Eight 106 CAUSES OF SPERMATORRHOEA. days afterwards ho told me that his pollutions had ceased, and that his health was quite restored. CASE XXIV. Hypochondriasis—Impotence—Attacks of cerebral congestion—Ascarides —Cure within eight days. A-----, a gardiner of large and well-formed frame, and dark complexion, two years married, perceived, seven or eight months after marriage, that he lost by degrees his virile power; that his appetite at the same time became capricious, and his digestion difficult and accompanied with pain in the epigastrium, the development of flatus, and frequent attacks of vomiting. Pills containing cynoglossus, sedatives, and demulcents of all kinds, had been prescribed for this patient by a distinguished practitioner of Montpel- lier, in order to relieve the irritation of his digestive organs; but his general weakness, and that of the genital organs in particular, increased daily. A feeling of lassitude constantly came over him, he was habitually sleepy, and had frequent attacks of vertigo. These symptoms led other practitioners whom he consulted to fear the occurrence of apoplexy, and consequently venesection was prescribed: but the patient, notwithstanding his uneasi- ness, refused to be bled, saying that he was convinced he had no blood to lose. In 1833, A----consulted one of my pupils, who, after long ques- tioning, learnt that he suffered from obstinate costiveness, with troublesome itching in the rectum, and that he frequently passed a number of oxyures with his faeces. Believing that these oxyures were the cause of seminal discharges which the patient had not discovered, an infusion of mentha viridis was ordered for him, with aromatic enemata, and afterwards ene- mata of cold salt-water, sufficiently copious to distend the gut and to be expelled with some violence. These injections caused the expulsion of a rge number of entozoa. The patient's digestive disorder ceased almost immediately; his erections soon returned, and coitus took place a few days afterwards. He soon re- covered his strength; his spirits resumed their wonted gaiety, and he re- commenced his work with pleasure. This change was the result of only eight days' treatment. CASE XXV. Nocturnal pollutions, resisting all modes of treatment during six years- Great physical and moral depression—Expulsion of ascarides with complete relief. M. D----, the son of healthy parents, at the age of eleven, contracted, of his own accord, the habit of masturbation; but he soon discovered its per- nicious effects, and corrected himself: his strength returned, and up to the age of fourteen he continued in perfect health. At this period, after read- ing an erotic book, he relapsed into his former habits. He also formed a connexion with a female, who excited his passions without gratifying them. These sources of excitement so enervated him, that palpitation of the heart, and tremors in his limbs, supervened. Up to this period M. D----had never had an involuntary seminal emis- INFLUENCE OF THE RECTUM. 107 sion, and he still retained sufficient power over himself, only to practise masturbation once a week. The irritation he experienced in the genital organs was so great that he was often forced to plunge them into cold water for its relief. He was stout and tall, and his health was robust. On the 25th of October, 1816, on waking in the morning, M. D---- found that he had experienced a copious seminal emission unconsciously while asleep. On every one of the eight following nights he had several involuntary emissions. These discharges produced a remarkable state of weakness, and he lost flesh visibly; still he hoped that the 'discharges would cease spontaneously, and false delicacy prevented him from mention- ing his state. Absorbed in the consideration of his own condition, M. D----now withdrew himself from his companions, and occupied himself in devising means for the relief of the discharges. He attempted numerous ingenious contrivances to prevent the penis from becoming erect during sleep, but none of them succeeded; the disorder of his health continued to increase, until the year* 1820, when his condition was deplorable, and he came to Montpellier to place himself under my care. From his account of the sufferings he had endured, I at first thought that the involuntary emis- sions from which he had suffered, arose from a preternatural sensibility of the genital organs, increased by their premature use. Before commencing any plan of treatment, however, I caused M. D-----to draw up a history of his case, in order that I might have all the facts before me at one view. While reading this history, my attention was arrested by the mention of numerous small worms, which were passed with the feces, and which were looked on by the unfortunate patient as a sign of speedy dissolution. I examined the anus, and was unable to discover the eruption which he mentioned in his memoir, as giving rise to acute irritation in that neighbour- hood, besides which, this eruption would not have produced the itching of the nose of which he also complained. I suspected, therefore, that the invo- luntary emissions might be kept up by irritation from ascarides, and I drew the patient's attention to the circumstance. He told me, immediately, that he passed them habitually in his stools; and that frequently, from the vio- lent nature of the itching, he had been compelled to scratch until blood flowed, and even to introduce his finger nail within the margin of the anus, when on withdrawing it, he had removed a living oxyuris. About ten o'clock in the evening the oxyuris especially tormented him by descending into the lower portion of the rectum, and even within the contracted sphinc- ter. He had besides, a constantly acid taste in his mouth, and he passed a large quantity of saliva on his pillow, during the night. Of all the means prescribed for this patient, the administration of cold enemata, and the exhibition of calomel, were the most efficacious. The first injections were employed at a temperature of from 18° to 20° of Reaumer,* and they were afterwards used at 15° and even at 12° of the same scale.t Experience soon taught the patient, that he received most benefit from their administration about ten o'clock in the evening, at the time when the ascarides descended near the anus, of which he became aware, by the increased itching excited. He found also that in order to obtain the utmost benefit from the injections, it was necessary to throw a * Between 70° and 80° of Fahrenheit. t About 53° and 68° of Fahrenheit's scale. 108 CAUSES OF SPERMATORRHOEA. large quantity of water into the intestine, as high as possible, and after- wards to pass it suddenly so as to expel the ascarides inhabiting the upper part of the intestine, at the moment when they were benumbed. By these means large quantities of the entozoa were passed on several successive days; after their expulsion the involuntary emissions diminished rapidly and permanently, and all the accidents arising from them disappeared ; the patient's strength and embonpoint, especially, returned very quickly. The involuntary emissions, however, only ceased entirely under the influence of a natural exercise of the organs, with the use of cold bathing, and gym- nastic exercise. The patient had previously been obliged, on two occasions, to give up the use of the cold bath—once during the heat of summer, be- cause he was unable to obtain a proper reaction on quitting the water; yet immediately that his system had recovered a little strength, he found himself much benefited by cold bathing; indeed, after the expulsion of the ascarides, it produced more benefit than any other means employed, and he even continued the use of the cold plunge during the winter, with considerable advantage. Walking exercise was also very useful, and this perhaps it was that induced M. D----, after having completed his medical education at Mont- pellier, to turn his attention to the study of natural history. He has since undertaken long and dangerous travels in the service of science, and the works he has published bear the stamp of an observing mind, and a high range of thought. His labours have always been favourably received by the academy of sciences. M. D----'s health has been completely re-esta- blished twenty-five years. The history sent to me by M. D-----was full of interest; it showed a kind of fatality pursuing him, although he struggled with courage and perseverance against troubles which he had not deserved. It is necessary to have undergone such sufferings, and to write under their immediate influence, in order to relate all their circumstances with correctness. An uninterested observer would be unable to do justice to such a recital. How many such persons as M. D-----do we not meet with, constantly exposed to the relentless animadversions of society, when they ought to be regarded with pity, and to be relieved from their sufferings by the healing hand of the physician! Two of the patients, whose cases I have just related, (cases twenty- three and twenty-four) who suffered in infancy from ascarides, were addicted to masturbation, even before the age of puberty. They afterwards reproached themselves bitterly, and attributed all their misfortunes to this fatal habit. But it appears to me that in order to induce such a habit spontaneously, at so early an age, long before the full development of the genital organs, a degree of abnormal irritation must be present in them. The irritation caused by stone in the bladder, often excites, in male infants, premature erections, and pain referred to the fossa navicularis; this they relieve by elongating the penis, so that in such patients, as is well known, the prepuce is of unnatural length. These manoeuvres naturally lead them to habits for which they ought not, under such circumstances, to be held morally responsible. INFLUENCE OF THE RECTUM. 109 The irritation produced by ascarides in the rectum, constantly ex- cites the same phenomena, and I have frequently seen children two or three years of age affected with priapism, which could be referred to no other cause. This circumstance is so common, that it has been frequently mentioned to me by nurses, who even employ a popular remedy to relieve it, showing, at least, that the influence of the asca- rides is well known. Nurses introduce a suppository of lard into the rectum, under the impression that the ascarides come there in search of food, and that they will be able to remove them together with the lard, on withdrawing it. The cause of these premature erections cannot, therefore, be doubted. Such children must, in consequence of the irritation of the parts, possess an irresistible tendency to handle them, just as they have, under the same circumstances, to scratch and rub the nose; and the sensation resulting from the friction of the genital organs being very acute, is likely enough to form the basis of a more mischievous habit. When, on reaching puberty, reason assumes its empire, the patients often acquire sufficient command over themselves to renounce these fatal practices, and they then suffer from involuntary emissions arising from the same cause that excited the masturbation; that is to say, from the irritation of the genital organs by the worms inhabiting the rectum. Ascarides produce nearly the same effects in the female; I have seen many little girls of tender age, who were tormented by irresistible itching of the pudendum, and profuse leucorrhoea, often accompanied with redness and excoriation of the clitoris and labia minora, all arising from the same source of irritation. The involuntary emissions of semen which accompany defecation, in those patients who are affected with ascarides, cannot be attributed to mechanical compression of the seminal vesicles, for costiveness is not present, nor could constipation account for the nocturnal emis- sions; it appears to me that the titillation constantly exercised on the rectum and margin of the anus; by the ascarides, extends its influence to the genital organs, and excites spasmodic contractions of the seminal vesicles. CASE XXVI. The habit of masturbation contracted spontaneously at the age of fifteen, and continued until the age of twenty—Nocturnal and diurnal pollu- tions—Increasing disorder of the health until the age of twenty-nine— Frequent and prolonged erections—Pain at the margin of the anus, 4*c.—Cauterization performed without benefit—The expulsion of asca- rides, followed by rapid recovery. M. R----> a student of medicine, enjoyed good health in his childhood, but about the age of fifteen was tormented by frequent and prolonged erections. One evening, for the relief of the itching, of which the extremity of the penis was the seat, he rubbed the organ violently between his hands. This led to the establishment of masturbation as a habit or rather as a pas- 10 110 CAUSES OF SPERMATORRHOEA. sion, the patient practising it sometimes as often as eight or ten times a day. His health by degrees became so altered that one of his friends suspected his practices, and told him the dangers of his situation. By degrees he corrected himself, though not entirely before he had attained his twen- tieth year. On his renouncing masturbation, nocturnal emissions super- vened, and often occurred two or three times a night. They dimi- nished after a time, but without ceasing entirely, and seminal emissions during defecation and the emission of urine were added to them. Thus his health became daily more and more disordered for nine years, notwithstand- ing absolute continence, a severe regimen, and the use of sedatives, tonics, and anti-spasmodics. At length he grew incapable of any mental exertion. In 1837, he came to Montpellier, at the age of twenty-nine, in the following condition:—Extreme emaciation; face pale; appearance stupid and con- fused; intellect dull; reasoning powers much affected, the patient being in- capable of connecting two ideas on the most simple topic of conversation; loss of memory; constant headach referred to the forehead and temples, and increased by any mental excitement, being then accompanied by nervous tremors, and an almost idiotic state ; sleep broken and unrefreshing; con- stant sighing; frequent attacks of congestion of the head, especially at night; violent noise in the ears resembling the sound of a waterfall; vertigo; stun- ning sensations giving rise to a constant fear of apoplexy; timidity carried to a ridiculous extent; panics of fear even during the day; character gloomy, taciturn, restless, and irritable; horror of the least noise, and of all society; irresistible restlessness; great weakness; abundant sweats after very slight exertion ; almost constant coryza; frequent, dry and hard cough; pains in the base of the chest, the region of the heart, and along the spinal column; appetite voracious; dragging at the pit of the stomach; difficult digestion, accompanied with the development of flatus; grinding of the teeth during sleep; burning at the point of the tongue; darting pains in the bowels, especially in the rectum; obstinate constipation alternating with violent attacks of diarrhoea; stools containing much mucus, and sometimes streaked with blood; periodical pains at the margin of the anus, in the pe- rineum, penis, and testicles; urine passed in large quantities, and very fre- quently, always throwing down a whitish, thick, and very abundant deposit, involuntary emissions during defecation,both when constipated and relaxed; frequent and prolonged erections by day as well as by night; with constant presence of erotic ideas. On sounding this patient, I found the urethra very sensitive, especially towards the neck of the bladder, and I consequently thought that the noc- turnal and diurnal pollutions were kept up by a state of irritation arising from masturbation. I therefore proposed cauterization. This was performed on the following day, and produced the usual immediate effects, but its curative effects did not take place as I had anticipated. I then directed the patient to notice his faeces, and a few days afterwards he told me that he had observed numerous little worms passed in his stools. I now ordered enemata of cold water, and salt and water, which, however, produced only a momentary effect—probably because the ascarides inhabited the upper part of the intestine. A few doses of calomel, however, caused them to disappear without returning; and from this moment the involuntary diurnal emissions ceased entirely, the nocturnal emissions became more and more rare, and the patient's re-establishment progressed very rapidly. M. R----- returned to his studies with ardour, and long afterwards all functions were perfectly well performed. • INFLUENCE OF THE RECTUM. Ill It appears evident that the irritation caused by the ascarides, in the rectum, first led this patient to practise masturbation, and after- wards kept up involuntary seminal discharges. I did not discover this at first, because the history of his case, sent me by the patient, was so long, and was characterized by such disorder and want of clearness, that I was unable to arrive at any satisfactory conclusions from such a chaos ; 'his answers were still more vague and uncon- nected, so that my attention had been chiefly attracted to the state of his intellect, and the abuses he had committed. But after seeing the little success of cauterization, and again reading his notes, I paid more attention to the circumstances attending the commencement of his practising masturbation, and I noticed several symptoms to which I had not before attached importance, such as grinding of the teeth during sleep ; burning pain in the point of the tongue ; pain in the rectum, and at the margin of the anus; the stools always containing mucus, and sometimes being streaked with blood ; and especially the frequency and duration of the erections, and the constant presence of erotic ideas. When costiveness is present, the stools rarely contain any quantity of mucus; its presence alone, therefore, in such a case, would indi- cate that the rectum is irritated by ascarides. But a still more cha- racteristic point is, the long duration of the erections. When in- voluntary spermatic discharges are induced by any cause except this, the erections diminish in proportion as the disease advances, first be- coming incomplete, and afterwards disappearing entirely. When therefore energetic and obstinate erections continue, in spite of the great wasting of the body produced by them, they must be kept up by some other stimulus to the organs than the natural one, and I be- lieve irritation by ascarides to be the only cause capable of producing this effect. This, on the other hand, agrees perfectly with what I have already stated concerning their influence on the genital organs. CASE XXVII. Masturbation at the age of fifteen—Serious disorder—The application of a blister followed by involuntary nocturnal emissions—Cauterization, douches,