should be broken up; if smegma behind the glans is found, or if at a future time evidence of its presence appears, it should be removed and measures taken to keep the parts clean. When the prepuce is abnormally long, or becomes so after the stripping of the glans, or the preputial opening is abnormally narrow, the child should be circumcised. The meatus urinarius should also receive attention, and if there is evidence of overgrowth of the mucous membrane at this point, sufficient to obstruct the urinary stream, it should be properly incised, but not indiscriminately and without care and judgment, thus preventing early irritation of the parts, which leads to handling, self orgasms, nervous derangements, and especially early prostatic hyperæmia.

These conditions are the essential factors in the causation of masturbation; and if they were not present with their constant irritation, I do not believe that the influence of the elder over the younger child would be what we must now accept from the history of these cases, as the cause of this vice; and if physicians can remove this factor, much will be gained for the future generation, and the principal cause of enlarged prostate, masturbation, will have been removed. But in a given case, when this habit has been practiced and, owing to proper advice or from fear of its results, it has been discontinued, unless at the same time the irritating cause has been removed, the mind. will continue to dwell upon lascivious fancies, keeping up the same chronic congestion or over distension of the prostatic vessels. When boys of this class are obliged to work hard, physically or mentally, with athletic training, leaving little time for solitude, some benefit will result; but a perfect normal, healthy condition cannot possibly result unless the original exciting cause has been eradicated.

Next in importance is the improper association of the sexes. The intense strain, prostatic and general, of the unsatisfied desire, etc., which results from the close association frequently allowed among the young and unmarried is often the cause of future ill-health and unhappiness, the misery of a hypertrophied prostate. This occurs while the person in his ignorance believes that no harm has been done, and that no commandments have been broken. Nature, however, has been outraged, and in time the penalty will have to be paid. I am therefore greatly impressed with the fact that medical men, as a rule, have been negligent in their duties to the unmarried men in their care in not giving them the proper admonition on this subject and advising the cultivation of the intellectual faculties, and not to indulge in carnal desires and diversions, and the reasons for such advice. This is especially true when we consider the tendency of the times, and the frequency with which our attention is called by the daily print to the actions of sexual perve-ts, etc.

We wish also to condemn the too frequent advice given by many to the young or older unmarried men that for their health they should practice male prostitution. They might as well. advise self-pollution or constant indulgence in sensual thoughts.

The effect on the prostate is the same, and we may add that the perverted sexual habits of married men, who for some reason do not desire the greatest of God's gifts-the family-has practically the same effect. A chaste mind and body are perfectly consistent with health. If abnormal irritations cause lust, remove the condition, but do not pamper to it, and allow your charge to ultimately suffer ill-health and life-long unhappiness. If he has urethritis, do not discharge him until the urine is free from epithelial and other shreds. When stricture, congenital or acquired, is present, give it the proper treatment, and if there is a stone in the bladder remove it. Should the saddle on the wheel they ride be improperly constructed, and it cannot be changed, have them discontinue the wheel, etc., etc.

Treatment.-When enlargement of the prostate has assumed some magnitude and causes distressing symptoms, we have many roads to follow. We should first use the milder means at our disposal before resorting to the more radical methods, and if fairly well directed and observed by the patient most cases may and do go along to the close of life with very little inconvenience. A warm, equable climate will be of great advantage. The body should be clothed summer and winter with flannel; when arising at night woolen slippers should be worn. Moderation in all things must be the constant guide. Over-excitement and drinking must be avoided; plenty of milk, however, should be advised; the bladder should never be allowed to become over-distended; horseback riding and wheeling should be interdicted, and mental and physical labor never carried to the point of fatigue. Counsel the patient to avoid straining when urinating, even when the desire is urgent. Doctor Hale has suggested in such cases that if the penis is grasped by the patient at the time of urination, obstructing the flow in the pendulous urethra and thus overdistending the membranous and prostatic urethra and then suddenly let go, the dam which is caused by the enlarged prostate will remain open and allow a good stream to flow, provided straining is avoided; and they may for years avoid the necessity of the catheter or operation. If, from chilling of the surface, over-eating, or neglect of the calls of Nature, retention occurs, warmth, and the indicated remedies, aconite, gels, should first be used. If these fail, try Dr. Bang's suggestion of placing the patient in bed with the pelvis elevated, giving a high rectal enema, and irrigate the urethra with a hot boric acid solution, to be repeated in an hour or two. This is sometimes followed by a spurt of urine, with evidence of relief on the part of the patient. Should these means fail, the catheter or aspirator are our only

resort.

In the use of the catheter a large size is frequently successful, while the smaller one fails to pass. We may select or use, as indicated, the soft rubber velvet eye, the silver catheter with a long curve, the English catheter properly bent, or the Mercier. In this operation observe strict antisepsis and asepsis; always be surgically clean, and teach those who are about to take on a

catheter life the necessity of absolute cleanliness In the first catheterization it is best not to remove all of the urine, leaving some residual urine, as indicated in individual cases, always bearing in mind that the first catheterization is very frequently followed by urinary fever, etc.

The remedies most useful are pareira brava, sabal ser., caladium, sulph. cimicifuga, staphisagria., nux. vom., aloes, pulsatilla and antipyrine, which are, together with general hygiene, frequently all-sufficient. As an illustration, the following case is cited: Seen in consultation with Dr. Malcolm Leal, Mr. P., aged sixty-five; retired merchant; family history good; had been losing flesh and strength for some months; tongue red at the tip, food did not digest well, and many articles of food caused much distress and vomiting; the pulse was weak and feeble; the patient was occasionally annoyed with a dry cough; the lungs, larynx and pharynx on physical examination gave no evidence of disease.

of

The

For some years he had been troubled with frequent and painful urination; incontinence to such an extent that it necessitated the constant use of a urinal. At the time of consultation the desire to urinate occurred every five to twenty minutes, was very painful and unsatisfactory; there were twinging pains referred to the neck of the bladder, causing him to cry out, and preventing sleep; the patient said that he had not had fifteen minutes' sleep in four days. When he assumed a sitting posture he did so very carefully on account of the pain in the perineum produced by pressure. The amount of urine for the previous twenty-four hours was 2,160 c. c. Specific gravity 1,007; urea, 0.8 per cent.; albumen, I per cent.; reaction, alkaline; a large sediment of thick, viscid, ropy mucus composed apparently about one-third of the quantity passed. microscope revealed a large number of pus corpuscles, ammonio-magnesium phosphates, etc. Physical Examination. — Bladder contained about three ounces of residual urine; there was tenderness over the supra-pubic region, and the perineum was sore and sensitive to the touch. The prostate was about three inches in its lateral diameter, sensitive and hard to the touch, and the bladder walls were somewhat thickened. Constipation was complained of, the stool being accompanied with great pain. The muscular cramp or pain and irritability of the prostate were relieved, and a fair night's rest secured from the first day, by a threegrain dose of antipyrine at bedtime. This remedy was given nightly for two weeks, when it was discontinued on account of the improved condition of the patient. The specific remedies from May 3d, the time of the first consultation, to June 20th, were chimaphilla umbelatta and sabal. ser. Improvement was rapid, and on the last date urination was free from pain, occurring about every three hours; the urine was approximately normal in quantity and quality; the patient slept as well as could be expected at his time of life; had gained rapidly in strength; there was no pain on sitting, the prostate was reduced to two inches in lateral diameter, and was free from pain on manipulation. The only symptom left was an

occasional pain referred to the end of the penis. Examination gave no evidence of stone in the bladder, and the symptom was probably reflex from the prostatic urethra, and was relieved by clematis. No local treatment was used in this

case.

In the treatment of prostatic disease judgment and experience is required. There are cases that will not respond to remedial and hygienic treatment alone, but require local application, such as hot saline douches per rectum thrown against the prostate; heat or cold by the rectal psychophore; others do well on the introduction of a full sized conical steel sound every five to eight days. Postural treatment by elevation of the hips and rest in bed is frequently of great benefit.

When the hypertrophy has an accompanying posterior urethritis and some shreds of epithelium are found in the urine, whether from a simple inflammation or are the remains of an imperfectly cured gonorrhoea of long standing, the deep urethral injections of nitrate of silver, I to 8,000 to I to 500; thallium sulphate, 3 to 6 grains to the ounce; Ultzman's solution of I grain each of alum, zinc sulph. and carbolic acid to the ounce of water, or a 5 per cent. solution of iodoform with sterilized sweet oil, every four to eight days, as indicated, may be of great benefit; as in case N. B., age fifty-five, married, occupation tinsmith, presented himself for treatment at my genitourinary clinic at the Metropolitan Post-Graduate School of Medicine, September 21, 1895; had always enjoyed good health, except that for some years he had been annoyed with painful urination, the act being painful at times and the stream smalĺ and hesitating, with all the other symptoms of prostatic hypertrophy. The diagnosis had been confirmed at the New York and Presbyterian Hospitals, where he had been advised that emasculation was his only hope. He had the desire to urinate every few minutes, but it was so painful that he was obliged to close the doors and windows to prevent the neighbors hearing his screams; during the act was obliged to press his head against the wall-frequently getting on his hands and knees-pain extended down the thighs and into the penis.

The prostate was about 2 inches in lateral diameter; the bladder walls were a little thickened; it contained no residual urine; pareira brava 2d was prescribed, with deep urethral injections of nitrate of silver, I to 2,000, administered every fourth day, gradually increasing to I to 500. One month's treatment relieved the pain and frequency of urination. The prostate was reduced to about two-thirds of its original size.

In the past, when mild methods failed, our only hope of making life endurable was median or lateral prostotomy or supra-pubic cystotomy and drainage, which, while relieving the pain and retention, caused inconvenience, annoyance and offensiveness to mind and body, with possible urinary abscess and sinuses; yet in selected cases there is no doubt that these operations are to be preferred to all other means. Electricity is sometimes, in special cases, of great benefit.

In 1893, Dr. White, of Philadelphia, stated to the

medical world that in his experience and from his studies the removal of the testicles would be followed by atrophy of the prostate, and relief of the distressing symptoms caused by its overgrowth, and that the death rate was smaller than that from prostotomy. The relief was as great or greater, and not followed by the constant reminder that an operation had been made and that the results were ever with them. His statistics of III cases to date are sixty-four greatly reduced in size, and in twenty-four more the relief of the general symptoms were such as to justify the belief that the prostate had grown smaller.

The cystitis was cured in fifty-two cases; there was 10 per cent. of apparent failures and a mortality of 7 1-10 per cent.

Unilateral orchotomy sometimes acts very satisfactorily. A case now under my care, where the left testicle was removed five years ago, resulted in almost complete atrophy of the prostate of the corresponding side, the right being somewhat overgrown; no urinary symptoms are now present.

But even in the very old there is a great antipathy to the thought of the removal of the testicles. All men feel the humiliation of being unsexed, and would prefer a considerable amount of pain and discomfort rather than relief with such loss. We all know that the nerve and blood supply of the prostate and testicle are of different origin; that the relation of the testicle to the prostate is one of function only. Emasculation discontinues the functional life, but it also eliminates from the system that power that the testes have of giving to man his masculinity, just as the ovaries give the feminine characteristics to the female; and we know that if they are removed early in life there ensues a complete change of character and development. This being the case, the resection of the vas deferens should give all the relief, and possess none of the disadvantages.

Parone, from a series of experiments regarding the difference in effect upon the prostate, of castration and excision of the vas deferens, found that both caused atrophy of the prostate, and that the anatomical changes as revealed by the microscope, differed in no appreciable manner.

The following case of resection of the vas deferens, from the genito-urinary ward in the Metropolitan Hospital, may be possibly instructive and give weight to the theories presented :

J. A., aged sixty-nine, married, born in Algeria, occupation, merchant; hereditary history, negative; has been a moderate drinker of whiskey and beer and used tobacco to a moderate extent; before present illness had always been comparitively healthy. Forty years ago had a slight eruption over the body; epitrochlear and cervical glands slightly enlarged, otherwise no history of syphilis. Present history: Two years ago suffered much gastric irritability and about this time. noticed much difficulty in passing his urine, there being abnormal frequency of desire, with the passage of only a very fine stream; this condition increased in severity, urination became painful and a catheter life was a necessity, which has been continued uninterruptedly for eighteen

months. He experienced slight pain on defecation. Has hydrocele on the right side, which has existed for about two years; previous to its appearance there had been marked oedema of the feet and ankles, but this condition was present only to a slight degree; complains of a considerable pain in the lumbar region; general condition feeble; temperature normal; pulse full and strong; moderate hypertrophy of the heart. Arteries atheromatous. Urinalysis: The amount of urine varied from forty-five to seventy ounces in twenty-four hours; specific gravity 1012; albumen, 16 by contact test. Sediment: Few hyaline and granular casts, moderate amount of pus cells; few round and flattened epithelium.

Rectal examination: Painful; prostate about the size of a large orange. In order to give relief from the painful catheterization and to make his last days comfortable, an operation, at his urgent request, was performed February 27, 1896. I was ably assisted by Doctors Curry and Newman, of the House Staff. Local anesthesia was made with a 4 per cent. cocaine solution by the infiltration method, as his kidney condition contra-indicated the use of ether. About one-half inch of each vas deferens was resected and tied with a silk ligature, and the ends knotted together. The operation was made about three-quarters of an inch below the external abdominal ring; the wound was closed without drainage and dressed antiseptically; little pain was experienced during the operation, nor was it followed by shock or reaction. Case Book gives the following history:

The

First day: Very comfortable; slight rise of temperature; considerable pain during the night. Second day: Wound dressed, union by first intention.

Third and fourth days: Has been catheterized every six hours up to this time; pain slight, temperature normal.

Fifth day: Patient able to pass his urine naturally.

Sixth day: Same conditions.

Seventh day: Again necessary to use the catheter.

Eighth day :* Stitches removed; wound healed. From this time on was able to pass the urine naturally, but his kidney condition grew worse, and being unable further to perform their functions, he died of chronic interstitial and cystic nephritis on the sixteenth day after the operation.

Autopsy: Body emaciated; costal cartilages ossified; right lung weighed 221⁄2 ounces, adherent at apex; interlobular adhesions between upper and middle lobes; pleura normal except at apex, where it was slightly thickened; crepitation present throughout; air vesicles greatly distended with air; anterior portions of lower and middle lobes congested; on expression a sero-sanguineous fluid exuded from the congested portions; left lung weighed 13%1⁄2 ounces, firmly adherent at apex; pleura normal except at apex, where it was greatly thickened; anterior portion of the lower lobe congested; numerous miliary nodules of a cheesy character existed at the apex. Heart weighed twenty-one ounces; muscles

On

quite soft; the whole of the aorta from the valves to the diaphragm was inelastic and greatly thickened by calcareous plates; aortic valves thickened, especially about their base; mitral valves thickened to about % of an inch by calcareous plates, especially about their free border; tricuspid valves thickened; chordææ tendinæ shortened; pulmonary valves normal; liver weighed fiftyfive ounces; capsule smooth and glistening; substance tough, cut with extreme resistance, presented a nutmeg appearance; gall bladder, five inches in length and greatly dilated, containing twelve calculi, which were pyramidal in shape and about the size of chestnuts, one being the size of a walnut. These calculi were dark in color, except the largest, which was yellowish. The gall bladder contained but little bile; spleen weighed 7%1⁄2 ounces; surface rough and dark green; on section gave a gritty sensation and evidence of slight congestion. The right kidney with perinephritic fat weighed 13%1⁄2 ounces. the upper and outer surface a cyst the size of a lemon, with thin walls and filled with a serous fluid; there is an excessive amount of perinephritic fat, which was closely adherent to the capsule; capsule about 1-16 of an inch in thickness and closely adherent; kidney surface pale, the superficial vessels injected; on section the above mentioned cyst protruded through the kidney substance into the pelvis; on the upper and outer portion another cyst about the size of a chestnut was found, and throughout the substance numerous cavities of various sizes were found. The cortical substance was pale and from 1-16 to % of an inch in thickness; pyramids were obliterated by cavities and interstitial growth of fibrous tissue; pelvis contained no fat; it was greatly dilated and vessels were greatly congested; the walls tough and pale. The left kidney with perinephritic fat weighed 14 ounces; the great increase of perinephritic fat was here noticed, and closely adhered to the capsule, which did not differ from the capsule of the right side; surface of the kidney roughened, dumb-bell in shape, containing shape, containing numerous small cysts, which are also scattered throughout the substance of the kidneys. Cortex from to % of an inch in thickness; pyramids obliterated by these cavities of interstitial fibrous tissue; pelvis dilated, . presenting the same appearance as the right; ureters greatly dilated, and walls thickened; bladder walls thickened to about inch in diameter; mucous membrane lies in great folds of a deep red color; vessels congested and turgid; moderately distended with muco-purulent fluid. Prostate greatly enlarged, especially left lateral and middle lobe; the middle lobe projecting forward, distorting the prostatic portion of the urethra, and about the size of a large crab apple, 24 inches in lateral diameter.

The microscopical examination, made by Dr. E. D. Klots, curator of the Metropolitan Hospital, discloses proliferation of cells lining the tubules, and in many fatty degeneration or partial or complete disappearance. The muscular, and even the connective tissue, give evidence of great cell proliferation, that, probably in time, would result in

d. Connective tissue stroma showing proliferating cells.

In conclusion, all cases of prostatic hypertrophy must be individualized, and no operation should be undertaken without proper consideration of the present and probable future conditions of the patient.

In the well-to-do and those who will follow proper advice there is no doubt that many can be cured, and a large number relieved and life made comfortable with remedies, hygiene and local treatment. But there are cases where relief can only be procured by surgical methods, and then special care must be taken to properly choose the best operation for each individual case. If resection of the vas deferens or emasculation is decided upon,immediate results may be expected; that is, atrophy of the prostate, relief of pain on micturition, return of the expulsive power of the bladder and a clearing of the urine, in moderately recent cases, when the enlargement is due to an overgrowth of the glandular and muscular elements, closely resembling the normal; but if fibrous changes have taken place and the prostate is composed of dense, fibrous connective tissue elements and only a few remnants of the muscular and glandular tissue, the results will be correspondingly slow.

Pain, muscular cramps or spasms, due to straining and the symptoms of chronic cystitis are. usually ameliorated at once; all things being. equal, the less the patients are dependent upon their catheter the quicker and more satisfactory will be the relief. If a catheter life of two or more years has existed and the walls of the bladder are sacculated, the advisability of drainage rather than the separation of the function of the testicle and prostate will require careful consideration. Lastly, in favorable cases, we are of the opinion

that resection of the vas deferens will give all the relief that emasculation can possibly give, and without depriving the patient of his masculinity.

TALKS WITH YOUNG MEN UPON THE SEXUAL FUNCTION.

BY WALTER F. MORGAN, M.D., LEAVENWORTH, KAN.

PART I.

"He is a free man whom the truth makes free, and all are slaves beside."

I

AGREE with honest old Ben Franklin that "the sexual passion is difficult to control," and yet experience has taught me that it is not uncontrollable. Should the discussion upon which I now propose to enter seem at times to trench upon subjects of a foreign nature, I bespeak your patient forbearance. The great danger in such an investigation is that the horizon will be too narrow, the field of vision too limited. There is nothing on the earth beneath nor in the heavens above that is not related to man, or which may not be compelled to minister to his use and enlightenment. Do not be alarmed at this statement! We will try to be simple and honest towards each other, and as "life is short and art is long," we are obliged to be brief. At the close of my remarks, each one who honors me with his attention is expected to freely question and criticise, as our only object is to come as near to the Fountain of Truth as our limited faculties will permit.

The time of greatest danger to the young man is the age of puberty, when he suddenly discovers himself to be in possession of the sexual passions and power of a man without a man's judgment and experience to guide or restrain him. It is probable that the majority of young men, and, possibly also of those who have reached years of discretion without being discreet, yield to convenient temptation; but there are, fortunately, many exceptions to this rule-if indeed it be a rule-as shown by the following instances:

Two robust farmers' sons, æt. sixteen and eighteen respectively, being intimate, as their father's farms joined, once held this conversation:

A. said to B., " B., the old folks will not be at home to-night, and if you come to our house you can have some fun with the girls" (meaning his sisters). At the appointed hour B. went and found. the girls not in the least backward in responding to his advances. However, it suddenly occurred to B. that he was about to do a contemptible thing, and under this revulsion of feeling he rushed from the house, never again to enter it.

Years afterward, during which time A. and B. had not seen each other, they again met, and, after the usual salutations, A. said: "Well, B., I married a delicate girl, too unselfish to complain as she ought, and who, I regret to say, was seriously injured in health by my too frequent sexual demands. I at last learned, when too late, the true state of affairs. My wife died at forty-five, and her doctor said that with proper care she

probably might have lived to be three-score-andten. I hope, B., that you have no regrets on this score." "No," said B., "while I also married a delicate woman, and sometimes, especially when younger, I have wished her of a more amorous disposition, still her wishes have always controlled in this matter, and she is now near seventy years old, and the mother of a large family, and I doubt if I could have been so happy or contented with any other woman." Regarding A.'s amorous sisters it was learned that one had been in a house of prostitution, and the other in an asylum for the insane. While considering Nature's checks to the sexual appetite, one or two more examples will be offered. An over-ardent youth had been advised by his physician to marry-rather hazardous advice, by the way. Some ten years subsequently he became engaged to a farmer's daughter, and, conforming to a custom of rustic life, he visited his intended quite regularly on Sundays, and was frequently invited, during inclement weather, to remain until Monday morning. The wedding day was near at hand, and the ardent youth concluded, as a very convenient opportunity offered, that the pleasures of the nuptial bed might be anticipated.

The girl at first objected, but soon consented. Here conscience suddenly and unexpectedly intervened, accusing the youth of lack of self-control, and effectually putting to rout his desire. Explanations, however, did not satisfy his partner, who then pleaded for his embraces for her own sake. But conscience was firm, and desire did not return to the man until after the marriage was duly solemnized. A young physician of intellectual tastes was intimate with another young physician much devoted to Bacchus and Venus, who succeeded in inveigling the former into a house of illfame, but instead of arousing desire in him, as intended, an attack of nausea was the only result.

The first named gentleman is now the respected father of a large family; the second died of his excesses at the age of twenty-seven. A physician, now eminent, had frequently been importuned by his friend to accompany him to a maison-de-joie. He said: "I finally went with my friend, but after having connection with a courtesan, I left the house feeling that the burdens of the whole city rested upon my individual shoulders. This was my first and last experience of this kind." In my medical practice I have occasionally met husbands who, as soon as their wives began to suffer from the nausea of pregnancy, were invariably affected themselves in a similar manner, through sympathy. Were this more generally the case in this world, there would be more happy wives and healthy children!

Accepting the dictum that the chief duty of the physician is to teach people how to keep well, I do not intend to limit our discussion to the narrow field of drug prophylaxis. On the other hand, I consider that much more can be accomplished by carefully studying those beautiful and beneficent laws, the strict observance of which invariably tends to greatly increase our happiness and longevity. In considering the prevention of sexual disease, I wish to speak further of the