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extremities in the urethra of one or both the spermatic cords may be affected. Instead of being circular, and forming little nipplelike projections, their orifices may present a stretched chink, large enough to admit a goose-quill, and there may be erosion of a sort of sphincter which surrounds them. Ulceration may attack the mucous membrane. The lining membrane may present a villous alveolar inflamed appearance, or it may become of a yellow color. Instead of being the elastic free bodies they are, they may become cartilaginous or ossified, and they may have a tortuous crooked direction.” (Vol. i, pp. 11, 23.)
Fortunately for humanity, the appearances above described are rarely met with in practice. The most frequent morbid conditions of these parts depend upon inflammation attacking the vasa deferentia, consequent upon affections of the testis, and terminating in a closure, temporary or permanent, of one or both canals. In such cases the passage of the spermatic fluid is obstructed, and when the affection is permanent, sterility may be considered as beyond the control of surgery. In these cases, however, impotence, according to our definition given at page 154, does not necessarily follow. I believe that erection without subsequent emission is quite compatible with this state of occlusion of the vasa deferentia. When only one vas deferens is obstructed, of course neither sterility or impotence exists; for, as I have elsewhere stated, one perfect testis will be sufficient to carry on effectively the reproductive function, and it seldom happens that both testes become affected. Still, I believe that not unfrequently the vas deferens of one side is obstructed, and this gives rise to much local mischief, and in too many instances atrophy of the testis is the consequence, as there is no exit for the secreted semen except through the absorbent system.
TREATMENT.— The first consideration in dealing with any case of spermatorrhoea is to ascertain from which of its many causes the affection may have more especially arisen. Each patient may complain of some particular or well-marked symptom to the exclusion of all the others, though the affection itself may consist of a lesion of more than one function. It is, therefore, of great importance that this distinction should be clearly understood. According as one or other of the functions (e. g. erection, emission, or the character of the emitted semen) is in fault, so must the treatment vary; what may be good in one case, may not be applicable in another. Having heard what particular symptom the patient complains of, he should be desired to make water into a glass, which should be deposited at once in a stand, to be examined at leisure. It is well at the same time to pass an olivary bougie, in order to ascertain the susceptibility of the urethra—an excellent means of arriving at an accurate diagnosis of the local state of the mucous membrane. In order to cure the affection, it is of more consequence to ascertain the immediately inducing local cause than the primary cause which may have impaired the function or originated the lesion.
Before attempting the curative treatment, the preventive one should be commenced. It should be ascertained if bad habits exist, and if so, the patient should be told at once that unless they are left off it is useless for the surgeon to attempt to treat him. It should, however, not be concealed from the sufferer that the means about to be employed will speedily impart such power to the will that, by his own volition, he will be capable of correcting habits which were previously beyond his control. Moderation in sexual indulgence, if not abstinence, should be enjoined on the married, and a promise to that effect obtained. It should be next ascertained whether constipation exists, whether ascarides be irritating the rectum, or if the patient suffers from varicocele. If this latter complication be present, a suspensory bandage must be worn, or, what is still better, a varicocele-ring, which the surgeon should teach the patient how to put on.
The ring should be attached by a little piece of thread to the button of the drawers, otherwise it may readily slip off and be lost, and thus the testes be left without support during exercise.
The surgeon has next to determine whether the vesiculæ seminales are affected by any of the forms of irritation or inflammation spoken of in preceding pages, and, if so, whether the ev may not be kept up by some of the numerous causes which, as we have seen, produce or aggravate them. The patient must do his utmost to prevent emissions taking place, and, to effect this,
should have recourse to all the means spoken of at pages
231 and 236.
In the slighter cases of spermatorrhoa these remedies may alone suffice; and, as stated above, the occasional passage of an olivary bougie, or the glass tube of the instrument, hereafter to be described, will suffice to cure the patient. If, however, these plans do not succeed, and if the emissions occur, I have no hesitation in at once employing cauterization, a plan of treatment I will at once proceed to describe.
Cauterization.-In passing an instrument as above described, one of two conditions usually exists: either the instrument passes down to the vera-montanum without pain, when all at once excessive sensibility is felt in one or more spots; or the urethra is found large, patulous, and insensible, hardly seeming to feel the presence of the instrument; the former condition is, however, the one most frequently met with. Having explored the urethra, the surgeon should leave the patient quiet for that day, the only precaution taken, being that of administering a mild aperient, and desiring him to abstain altogether from stimulants or coffee. The sufferer usually prefers that the operation be performed at the surgeon's residence, and I have never found any objection to the patient returning home in a cab if the distance is not great. On the morning of the operation the patient may be allowed to eat a simple breakfast of bread, butter, or meat, but he must be strictly enjoined to abstain from fluid of any kind.
Before proceeding to perform the operation, I desire the patient to completely empty the bladder. I employ a syringe similar to the one here represented, which may be procured at Ferguson's, instrument
AUTHOR'S INSTRUMENT FOR CAUTERIZ.
ING THE URETHRA.
maker, Giltspur Street, Smithfield. It is made entirely of stout glass, to obviate breakage, and to avoid all decomposition of the solution of nitrate of silver. The lower part (A) can be taken off and on (at B), so as to fit into a case, thus making the instrument very portable. When put together and charged with fluid (containing a solution of ten grains of nitrate of silver to the ounce of distilled water), the instrument is passed down the urethra, the patient standing against a wall. No oil should be used, as it will interfere with the action of the caustic. The surgeon should take the precaution of folding a towel between the legs, in order to protect the trousers of the patient from being stained. The piston of the instrument is then to be forced down, at the same time that the finger and thumb of the operator's left hand compress the lips of the meatus firmly against the instrument, so as to prevent the fluid escaping from the urethra until the syringe is withdrawn, which is done as soon as the injection has been forced out of the instrument.' I may mention here that the syringe usually holds about two or three drachms. The pressure of the fingers on the urethra is then withdrawn, and the whole of the injected fluid passes out into the vessel which is placed to receive it. The patient may now sit or lie down in an arm chair, and remain there a quarter of an hour. The first result of the operation is to produce a warm pricking sensation at the end of the penis, which soon, however, subsides, and usually in ten minutes disappears gradually. In some cases an urgent desire to make water may come on, but as the bladder has been previously emptied, this is a fictitious want, and rapidly passes off, the patient being told to restrain the desire as much as possible. As to the pain felt after the operation, I have been over and over again assured that the suffering consequent on the application of the caustic has been much less than the patient anticipated, and in some instances it has been so slight that the patient doubts if any caustic can have reached the affected parts.
1 I should mention, that in exceptional instances I have met with some difficulty in emptying the syringe, in consequence of the strong contraction of the urethra : the fluid then, instead of passing forwards, is forced back behind the piston, and consequently does not come in contact with the mucous membrane. This, however, is of no consequence provided some of the fluid has come in contact with the morbid portion of the urethra.
Other patients say they have experienced none of that shock to the nervous system which interested individuals had led them to believe were sure to follow the injection of a solution of nitrate of silver, and which they had read that medical men had understated, in order to induce patients to submit to the operation. The first effect of the operation is to produce an oozing from the urethra, caused by the escape of a drop or two of caustic mixed with mucus, and hence a piece of linen or a folded handkerchief should be placed around the meatus to absorb the moisture, and protect the shirt from becoming stained. The patient within half an hour may be allowed to return home, but must not walk at all that day, and should swallow a copaiba capsule directly, repeating it every eight hours. Too strict injunctions cannot be given to abstain from drinking fluid of any kind until after making water, and not to pass urine until absolutely obliged. Some men can easily remain twelve hours without passing water; a space of time which allows the caustic solution to act on the mucous membrane. When the patient is no longer able to resist the desire of making water, say twelve hours after the operation, he may drink as much weak tea, soda-water, or diluents as he pleases. Immediately after the operation he may take his usual meals, abstaining, as before said, from fluid, and confining himself to an easy chair or sofa. During the few following hours some slight whitish discharge, like mucus, will flow from the urethra ; but there will be little or no pain. When the patient first makes water there is some scalding, but the urine passes without difficulty. In some few cases, where I have reason to suppose there is an extra amount of irritability of the bladder, I have prescribed opium after the operation, but this is very rarely necessary. When the patient has made water once, he may do so as often as he likes, and each time the slight scalding will diminish, until it wholly disappears. On the day following, a tinge of blood is sometimes noticed attending the last drops of urine, but this disappears in a day or two, the urine becoming again clear. On the second or third day the copaiba capsules